切换至 "中华医学电子期刊资源库"
高级检索
中华口腔医学研究杂志(电子版)

中华口腔医学研究杂志(电子版) ›› 2019, Vol. 13 ›› Issue (04) : 193 -199. doi: 10.3877/cma.j.issn.1674-1366.2019.04.001

所属专题： 口腔医学； 文献；

中青年专家笔谈

活髓保存治疗中的微创理念
刘奕雯1, 蒋宏伟1,†()   
  1. 1. 中山大学光华口腔医学院·附属口腔医院，广东省口腔医学重点实验室，广州　510055
  • 收稿日期:2019-05-12 出版日期:2019-08-01
  • 通信作者: 蒋宏伟

The minimally invasive theory in vital pulp therapy

Yiwen Liu1, Hongwei Jiang1,†()   

  1. 1. Guanghua School of Stomatology, Hospital of Stomatology, Sun Yat-sen University, Guangdong Provincial Key Laboratory of Stomatology, Guangzhou 510055, China
  • Received:2019-05-12 Published:2019-08-01
  • Corresponding author: Hongwei Jiang
  • About author:
    Corresponding author: Jiang Hongwei, Email:
  • Supported by:
    Natural Science Foundation of Guangdong Province(2017A030313713)
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

刘奕雯, 蒋宏伟. 活髓保存治疗中的微创理念[J]. 中华口腔医学研究杂志(电子版), 2019, 13(04): 193-199.

Yiwen Liu, Hongwei Jiang. The minimally invasive theory in vital pulp therapy[J]. Chinese Journal of Stomatological Research(Electronic Edition), 2019, 13(04): 193-199.

牙体牙髓病科最常见的疾病是龋病和牙髓根尖周病，其有效治疗手段是及时去除龋坏或感染坏死牙髓组织并进行严密无菌的充填，在阻断病变发展的基础上最大限度地保留健康牙体组织，尽可能提高患牙的远期保存率。随着现代诊疗设备的革新、新材料的应用，牙髓生物学基础和临床研究日益深入，其中牙髓炎症状态的判断、活髓牙的治疗策略、活髓保存治疗的预后分析这三方面更是提出了不同以往的一些新理念。基于此，我们通过此笔谈阐述牙体牙髓病中活髓保存微创治疗理念的重要意义，以进一步指导相关活髓保存技术在临床的应用。

关键词: 龋齿, 牙髓, 牙周疾病, 微创牙髓治疗, 活髓保存治疗, 牙体保存

Dental caries, pulpitis and periapical diseases are the most common diseases in the Endodontics. Correspondingly, the effective treatment is to remove the structure of caries or infections in time and to fill or restore them with aseptic methods strictly. On the basis of stopping the development of the disease, the healthy tooth tissues will be preserved as much as possible to improve the long-term preservation rate of the affected teeth. With the innovation of modern diagnostic and therapeutic equipments, the application of new materials and the study of basic research on vital pulp therapy, together with the application of this minimally invasive theory in the field of vital pulp therapy have been further realized. This article reviews the minimally invasive theory in the vital pulp therapy by briefly introducing these three parts: the diagnosis of dental pulp under the guidance of the new concepts and methods, the treatment strategies for the vital pulp, the evaluation and prognosis of vital pulp therapy.

Key words: Dental carries, Dental pulp, Periodontal diseases, Minimally invasive treatment, Vital pulp therapy, Preservation of tooth structure
表1 牙髓治疗决策思路（Wolters WJ，2017）
阶段 临床症状 治疗
初期牙髓炎 冷测一过性敏感，叩诊（-）； 间接盖髓术/直接盖髓术
? 无自发性疼痛 ?
轻度牙髓炎 冷、热测持续敏感，可持续20 s；叩诊（-/+）； 间接盖髓术/直接盖髓术
? 无自发性疼痛； ?
? 对应的组织学显示：局部炎症局限于冠髓 ?
中度牙髓炎 冷热测持续敏感，可持续数分钟；叩诊（+/++）； 部分/完全冠髓切断术
? 自发性钝痛但可被止痛药缓解； ?
? 对应的组织学显示：炎症在冠髓中广泛存在 ?
重度牙髓炎 冷热测持续敏感，持续时间长，叩诊（++/+++）； 视出血情况行冠髓切断术
? 夜间剧痛，自发性疼痛； 或根管治疗
? 对应的组织学显示：冠部牙髓炎症可能延伸到根部 ?
[1]
Gluskin AH, Peters CI, Peters OA. Minimally invasive endodontics：challenging prevailing paradigms[J]. Br Dent J，2014，216(6):347-353. DOI：10.1038/sj.bdj.2014.201.
[2]
樊明文，周学东.牙体牙髓病学[M].北京：人民卫生出版社，2000：170-174.
[3]
Gutmann JL. Minimally invasive dentistry（Endodontics）[J]. J Conserv Dent，2013，16(4):282-283. DOI：10.4103/0972-0707.114342.
[4]
蒋宏伟.微创牙髓治疗的理论与实践[J].中华口腔医学杂志，2016，51(8):460-464. DOI：10.3760/cma.j.issn.1002-0098.2016.08.004.
[5]
Caplan DJ, Cai J, Yin G，et al. Root canal filled versus non-root canal filled teeth：a retrospective comparison of survival times[J]. J Public Health Dent，2010，65(2):90-96. DOI：10.1111/j.1752-7325.2005.tb02792.x.
[6]
Hargreaves KM, Berman LH. Cohen′s pathways of the pulp[M]. 11th. St Louis：Elsevier Inc，2016：849-858.
[7]
da Rosa WLO, Piva E, da Silva AF. Disclosing the physiology of pulp tissue for vital pulp therapy[J]. Int Endod J，2018，51(8):829-846. DOI：10.1111/iej.12906.
[8]
Taha NA, Ahmad MB, Ghanim A. Assessment of Mineral Trioxide Aggregate pulpotomy in mature permanent teeth with carious exposures[J]. Int Endod J，2017，50(2):117-125. DOI：10.1111/iej.12605.
[9]
Asgary S, Verma P, Nosrat A. Treatment Outcomes of Full Pulpotomy as an Alternative to Tooth Extraction in Molars with Hyperplastic/Irreversible Pulpitis：A Case Report[J]. Iran Endod J，2017，12(2):261-265. DOI：10.22037/iej.2017.51.
[10]
Ricucci D, Loghin S, Siqueira JF Jr. Correlation between clinical and histologic pulp diagnoses[J]. J Endod，2014，40(12):1932-1939. DOI：10.1016/j.joen.2014.08.010.
[11]
Wolters WJ, Duncan HF, Tomson PL，et al. Minimally invasive endodontics：a new diagnostic system for assessing pulpitis and subsequent treatment needs[J]. Int Endod J，2017，50(9):825-829. DOI：10.1111/iej.12793.
[12]
Hashem D, Mannocci F, Patel S，et al. Clinical and radiographic assessment of the efficacy of calcium silicate indirect pulp capping：a randomized controlled clinical trial[J]. J Dent Res，2015，94(4):562-568. DOI：10.1177/0022034515571415.
[13]
Pigg M, Nixdorf DR, Nguyen RH，et al. Validity of Preoperative Clinical Findings to Identify Dental Pulp Status：A National Dental Practice-Based Research Network Study[J]. J Endod，2016，42(6):935-942. DOI：10.1016/j.joen.2016.03.016.
[14]
Bender IB. Reversible and irreversible painful pulpitides：diagnosis and treatment[J]. Aust Endod J，2010，26(1):10-14. DOI：10.1111/j.1747-4477.2000.tb00144.x.
[15]
Niraj LK, Patthi B, Singla A，et al. MRI in Dentistry-A Future Towards Radiation Free Imaging-Systematic Review[J]. J Clin Diagn Res，2016，10(10):ZE14-ZE19. DOI：DOI：10.7860/JCDR/2016/19435.8658.
[16]
Drǎgan OC, Fǎrcǎşanu AŞ, Cǎmpian RS，et al. Human tooth and root canal morphology reconstruction using magnetic resonance imaging[J]. Clujul Med，2016，89(1):137-142. DOI：10.15386/cjmed-555.
[17]
Assaf AT, Zrnc TA, Remus CC，et al. Early detection of pulp necrosis and dental vitality after traumatic dental injuries in children and adolescents by 3-Tesla magnetic resonance imaging[J]. J Cranio-Maxillofacial Surg，2015，43(7):1088-1093. DOI：10.1016/j.jcms.2015.06.010.
[18]
Nakashima M, Iohara K, Murakami M，et al. Pulp regeneration by transplantation of dental pulp stem cells in pulpitis：a pilot clinical study[J]. Stem Cell Res Ther，2017，8(1):61. DOI：10.1186/s13287-017-0506-5.
[19]
Schuurmans TJ, Nixdorf DR, Idiyatullin DS，et al. Accuracy and Reliability of Root Crack and Fracture Detection in Teeth Using Magnetic Resonance Imaging[J]. J Endod，2019，45(6):750-755.e2. DOI：10.1016/j.joen.2019.03.008.
[20]
Iohara K, Fujita M, Ariji Y，et al. Assessment of Pulp Regeneration Induced by Stem Cell Therapy by Magnetic Resonance Imaging[J]. J Endod，2016，42(3):397-401. DOI：10.1016/j.joen.2015.11.021.
[21]
Cankar K, Nemeth L, Bajd F，et al. Discrimination between intact and decayed pulp regions in carious teeth by ADC mapping[J]. Caries Res，2014，48(5):467-474. DOI：10.1159/000358068.
[22]
Di Nardo D, Gambarini G, Capuani S，et al. Nuclear Magnetic Resonance Imaging in Endodontics：A Review[J]. J Endod，2018，44(4):536-542. DOI：10.1016/j.joen.2018.01.001.
[23]
Gazelius B, Olgart L, Edwall B，et al. Non-invasive recording of blood flow in human dental pulp[J]. Endod Dent Traumatol，2010，2(5):219-221. DOI：10.1111/j.1600-9657.1986.tb00148.x.
[24]
Liao Q, Ye W, Yue J，et al. Self-repaired Process of a Traumatized Maxillary Central Incisor with Pulp Infarct after Horizontal Root Fracture Monitored by Laser Doppler Flowmetry Combined with Tissue Oxygen Monitor[J]. J Endod，2017，43(7):1218-1222. DOI：10.1016/j.joen.2017.03.001.
[25]
Zanini M, Meyer E, Simon S. Pulp Inflammation Diagnosis from Clinical to Inflammatory Mediators：A Systematic Review[J]. J Endod，2017，43(7):1033-1051. DOI：10.1016/j.joen.2017.02.009.
[26]
Zehnder M, Wegehaupt FJ, Attin T. A First Study on the Usefulness of Matrix Metalloproteinase 9 from Dentinal Fluid to Indicate Pulp Inflammation[J]. J Endod，2011，37(1):17-20. DOI：10.1016/j.joen.2010.10.003.
[27]
Mente J, Petrovic J, Gehrig H，et al. A Prospective Clinical Pilot Study on the Level of Matrix Metalloproteinase-9 in Dental Pulpal Blood as a Marker for the State of Inflammation in the Pulp Tissue[J]. J Endod，2016，42(2):190-197. DOI：10.1016/j.joen.2015.10.020.
[28]
Aaminabadi NA, Parto M, Emamverdizadeh P，et al. Pulp bleeding color is an indicator of clinical and histohematologic status of primary teeth[J]. Clinical Oral Investig，2017，21(5):1831-1841. DOI：10.1007/s00784-017-2098-y.
[29]
Morotomi T, Washio A, Kitamura C. Current and future options for dental pulp therapy[J]. Jap Dent Sci Rev，2019，55(1):5-11. DOI：10.1016/j.jdsr.2018.09.001.
[30]
da Rosa WLO, Cocco AR, Silva TMD，et al. Current trends and future perspectives of dental pulp capping materials：A systematic review[J]. J Biomed Mater Res B Appl Biomater，2018，106(3):1358-1368. DOI：10.1002/jbm.b.33934.
[31]
Ricucci D, Loghin S, Niu LN，et al. Changes in the radicular pulp-dentine complex in healthy intact teeth and in response to deep caries or restorations：a histological and histobacteriological study[J]. J Dent，2018，73:76-90. DOI：10.1016/j.jdent.2018.04.007.
[32]
Mattos J, Soares GM, Ribeiro Ade A. Current status of conservative treatment of deep carious lesions[J]. Dent Update，2014，41(5):452-454,456. DOI：10.13140/2.1.2853.4401.
[33]
Iranzo-Cortés JE, Terzic S, Montiel-Company JM，et al. Diagnostic validity of ICDAS and DIAGNOdent combined：an in vitro study in pre-cavitated lesions[J]. Lasers Med Sci，2017，32(3):543-548. DOI：10.1007/s10103-017-2146-5.
[34]
Schwendicke F, Frencken JE, Bjørndal L，et al. Managing Carious Lesions：Consensus Recommendations on Carious Tissue Removal[J]. Adv Dent Res，2016，28(2):58-67. DOI：10.1177/0022034516639271.
[35]
Iwami Y, Yamamoto H, Hayashi M，et al. Relationship between laser fluorescence and bacterial invasion in arrested dentinal carious lesions[J]. Lasers Med Sci，2011，26(4):439-444. DOI：10.1007/s10103-010-0798-5.
[36]
Matsuo T, Nakanishi T, Shimizu H，et al. A clinical study of direct pulp capping applied to caries-exposed pulps[J]. J Endod，1996，22(10):551-556. DOI：10.1016/S0099-2399(96)80017-3.
[37]
韦曦，刘红艳，韩雨晴. Nd：YAG激光和Er：YAG激光在牙体牙髓病治疗中的应用[J].口腔疾病防治，2019，27(4):212-218. DOI：10.12016/j.issn.2096-1456.2019.04.002.
[38]
Stefanova VP, Tomov GT, Tsanova STs. Morphological Study Of Border Area Of Pulp-Capping Materials And Er：YAG Laser Prepared Hard Dental Surface[J]. Folia Med（Plovdiv），2015，57(1):49-55. DOI：10.1515/folmed-2015-0019.
[39]
Odabaş ME, Bodur H, Bariş E，et al. Clinical，radiographic，and histopathologic evaluation of Nd：YAG laser pulpotomy on human primary teeth[J]. J Endod，2007，33(4):415-421. DOI：10.1016/j.joen.2006.12.013.
[40]
Bürklein S, Schäfer E. Minimally invasive endodontics[J]. Quintessence Int，2015，46(2):119-124. DOI：10.3290/j.qi.a33047.
[41]
Qureshi A, Soujanya E, Nandakumar，et al. Recent Advances in Pulp Capping Materials：An Overview[J]. J Clin Diagn Res，2014，8(1):316-321. DOI：10.7860/JCDR/2014/7719.3980.
[42]
Mente J, Geletneky B, Ohle M，et al. Mineral trioxide aggregate or calcium hydroxide direct pulp capping：an analysis of the clinical treatment outcome[J]. J Endod，2010，36(5):806-813. DOI：10.1016/j.joen.2010.02.024.
[43]
Lee SJ, Monsef M, Torabinejad M. Sealing ability of a mineral trioxide aggregate for repair of lateral root perforations[J]. J Endod，1993，19(11):541-544. DOI：10.1016/S0099-2399(06)81282-3.
[44]
Rodrigues EM, Cornélio ALG, Mestieri LB，et al. Human dental pulp cells response to mineral trioxide aggregate（MTA）and MTA Plus：cytotoxicity and gene expression analysis[J]. Int Endod J，2017，50(8):780-789. DOI：10.1111/iej.12683.
[45]
Parirokh M, Torabinejad M, Dummer PMH. Mineral trioxide aggregate and other bioactive endodontic cements：An updated overview-Part I：vital pulp therapy[J]. Int Endod J，2017，51(2):177-205. DOI：10.1111/iej.12841.
[46]
Zhou HM, Shen Y, Wang ZJ，et al. In vitro cytotoxicity evaluation of a novel root repair material[J]. J Endod，2013，39(4):478-483. DOI：10.1016/j.joen.2012.11.026.
[47]
Jiang S, Wu H, Zhang CF. Partial pulpotomy of immature teeth with apical periodontitis using bioceramics and mineral trioxide aggregate：a report of three cases[J]. Chin J Dent Res，2016，19(2):115-120. DOI：10.3290/j.cjdr.a36182.
[48]
Nosrat A, Seifi A, Asgary S. Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate：a randomized clinical trial[J]. Int J Paediatr Dent，2013，23(1):56-63. DOI：10.1111/j.1365-263X.2012.01224.x.
[49]
Asgary S, Hassanizadeh R, Torabzadeh H，et al. Treatment Outcomes of 4 Vital Pulp Therapies in Mature Molars[J]. J Endod，2018，44(4):529-535. DOI：10.1016/j.joen.2017.12.010.
[50]
Zanini M, Hennequin M, Cousson PY. A Review of Criteria for the Evaluation of Pulpotomy Outcomes in Mature Permanent Teeth[J]. J Endod，2016，42(8):1167-1174. DOI：10.1016/j.joen.2016.05.008.
[1] 叶长缨, 谢静, 丁桂聪. 乳牙龋病的过渡性治疗研究进展[J]. 中华口腔医学研究杂志(电子版), 2023, 17(05): 365-370.
[2] 张艺山, 莫丹, 蒋依玲, 邓思成, 吴冬燕, 黄华, 邱荣敏. 广西百色市壮、汉族儿童口腔健康行为比较及风险因素分析[J]. 中华口腔医学研究杂志(电子版), 2023, 17(03): 172-179.
[3] 张东敏, 李臻, 梁珊珊, 杜民权, 江汉. 学龄儿童第一恒磨牙龋综合干预2年效果评价[J]. 中华口腔医学研究杂志(电子版), 2023, 17(03): 167-171.
[4] 王军辉, 胡颖, 刘芳, 王飞, 陈宇江, 王小竞. 浓缩生长因子用于年轻恒牙根尖周炎再生性牙髓治疗2例及文献复习[J]. 中华口腔医学研究杂志(电子版), 2023, 17(02): 81-88.
[5] 廖心敏, 李月梅, 陈婵婵, 丁桂聪. 全身麻醉下乳牙牙髓治疗研究进展[J]. 中华口腔医学研究杂志(电子版), 2023, 17(02): 128-132.
[6] 尹娟, 杨兴, 李平, 徐旻馨, 鲍玉, 张志鹏, 薛慧. 低强度脉冲式超声波在脂多糖诱导的RAW264.7巨噬细胞分化中的抗炎和抗氧化作用[J]. 中华口腔医学研究杂志(电子版), 2023, 17(01): 26-36.
[7] 陈孟竺, 韦小浪, 陈文霞. 神经肽P物质对人牙髓干细胞生物学行为的影响[J]. 中华口腔医学研究杂志(电子版), 2022, 16(06): 343-351.
[8] 毛学理, 施松涛. 牙髓干细胞与牙髓再生[J]. 中华口腔医学研究杂志(电子版), 2022, 16(06): 333-342.
[9] 王涛, 朱顶贵, 郭世梁, 张心宇, 邢向辉. 三种方法治疗年轻恒牙根尖周病的效果分析[J]. 中华口腔医学研究杂志(电子版), 2021, 15(06): 341-347.
[10] 廖莹, 邢向辉. 南京市视力障碍儿童患龋状况、龋活跃性和口腔卫生习惯调查及相关性分析[J]. 中华口腔医学研究杂志(电子版), 2021, 15(04): 222-227.
[11] 王浩然, 管俊杰, 王映, 李娜, 王静秋, 葛良玉, 孟箭. 经皮穴位电刺激对不可逆性牙髓炎患者下牙槽神经阻滞的影响[J]. 中华口腔医学研究杂志(电子版), 2021, 15(02): 85-91.
[12] 蒲东全, 刘锐, 胡凯凯, 刘莉, 张琳, 杨琴, 周霞. 上颌侧切牙腭根遗漏、钙化伴侧壁穿孔显微根管外科手术一例[J]. 中华口腔医学研究杂志(电子版), 2021, 15(01): 34-39.
[13] 曾凯密, 韦曦, 黄湘雅, 伍婉翠. 不同镍钛系统结合触控启动技术预备模拟弯曲根管的成形效果研究[J]. 中华口腔医学研究杂志(电子版), 2021, 15(01): 6-12.
[14] 郁莹, 张皓, 曾晓莉, 江一巍, 易芳羽, 翁清清, 张颖. 基于风险评估的6岁儿童龋病分级管理临床效果评价[J]. 中华口腔医学研究杂志(电子版), 2020, 14(06): 345-352.
[15] 董霞, 杨卫国, 王明华. 血清维生素D及双歧杆菌水平与儿童重症龋齿的关系分析[J]. 中华临床医师杂志(电子版), 2022, 16(05): 442-446.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号