牙髓活力保存治疗与全科医生的根管治疗 essentials，特邀 Dr. Judy McIntyre

嘿。

Hey.

欢迎收听《牙科文摘》。

Welcome to Dental Digest.

我是主持人梅丽莎·塞伯特医生，帮你走在循证牙科的前沿。

I'm your host, doctor Melissa Seibert, helping you to stay on the cutting edge of evidence based dentistry.

你碰到一个深部龋损，已经到牙髓了。

You're into the pulp on a deep lesion.

它在出血，你得决定这颗牙是需要根管治疗，还是能保住牙髓。

It's bleeding, and you have to decide whether that tooth needs a root canal or can stay vital.

朱迪·麦金太尔医生

Dr.

详细讲解了她是如何做这个决定的。

Judy McIntyre walks through exactly how she makes that call.

从为什么做牙髓切断术时金刚砂钻头比碳化钨钻头好，到次氯酸钠棉球，再到后面的生物陶瓷封闭剂。

From why a diamond beats a carbide for a pulpotomy to the sodium hypochlorite pellet and the bioceramic sealer that follows.

然后她做了锥形束CT扫描。

And then she gets in a cone beam.

为什么她现在每个病例都要扫描，那两个根管的犬牙让她吃过亏，以及为什么全头颅扫描不等于牙髓治疗的精细扫描。

Why she now scans every case, the two canal canines that burned her, and why a whole head scan isn't an endo resolution scan.

我们今天的嘉宾是朱迪·麦金太尔医生，她以优异成绩毕业于哈佛牙医学院，并在北卡罗来纳大学教堂山分校完成了牙髓病学住院医师培训。

Our guest today is doctor Judy McIntyre, an endodontist who graduated magna cum laude from the Harvard School of Dental Medicine and completed her endodontics residency at the UNC Chapel Hill.

她发表过关于牙外伤和儿童牙科及牙外伤学中特殊牙髓切断术的论文。

She has published on traumatic dental injuries and the spec pulpotomy in pediatric dentistry and dental traumatology.

她曾担任美国牙髓病学会董事会成员，并在全国范围内就牙外伤、牙根吸收、儿童牙髓病学和三维影像进行讲座。

She served on the AAE board of directors and lectures nationally on dental trauma resorption, pediatric endodontics, and three d imaging.

好了。

Alright.

我们开始吧。

Let's jump in.

你有没有觉得在这个行业里很孤立无援？

Do you ever feel like you're on an island in this profession?

你会不会觉得不知道该去哪里找高质量的继续教育，也不知道该相信谁？

Do you feel unclear on where to find quality CE and who to trust?

或者你有没有遇到过，在某个病例上卡住了，不知道该找谁帮忙的时候？

Or have you ever felt unsure about where to turn when you hit a wall on a case?

我懂那种感觉。

I know the feeling.

这正是我创办ELEVATED GP的原因。

That's exactly why I created ELEVATED GP.

这是一个面向想追求卓越的全科牙医的虚拟学习俱乐部。

It's a virtual study club for general dentists who want to be excellent.

我们每月两次聚会，进行继续教育。

We meet twice a month for CE.

还有一个完整的点播课程库，你可以随时学习。

There's a full on demand course library you can work through anytime.

而我最喜欢的部分是，一个活跃的社区，我们每天都在交流，互相解答问题，互相推动，一起进步。

And my favorite part, a live community where we're talking every single day, getting each other's questions answered and pushing each other to the next level.

你不再感到孤单，而是觉得自己有了教育和伙伴的支持。

You stop feeling alone and you start feeling equipped with the education and the people to back you up.

如果你想加入，就来 theelevatedgp.com 找我们，拼写是 the，elevatedgp.com。

If you want in, come join us at theelevatedgp.com, spelledthe, elevatedgp.com.

希望在那里见到你。

I hope to see you there.

顺便说一下，我有一个关于二类修复的短期课程。

By the way, I have a short course on class two restorations.

你介意花点时间给我们留个评价吗？

Would you mind taking a moment to leave a rating?

如果你把评价的截图发到 Dr.

If you send me a screenshot of your rating at Dr.

Melissa Seibert 的 Gmail 邮箱，我们就会给你课程访问权限。

Melissa Seibertgmail dot com, we'll give you access to the course.

感谢你的支持。

Thank you for supporting us.

这对我和我家人来说意义重大。

It means a lot to both me and my family.

随着最近活髓治疗越来越受重视，生物陶瓷材料也大量涌现，普通牙医在遇到成熟恒牙深龋时，到底该怎么实际决定是做活髓切断术、直接盖髓术，还是直接做完整的根管治疗呢？

With the recent shift toward vital pulp therapy and the explosion of bioceramic materials, how should general dentists realistically decide between performing a pulpotomy versus direct pulp capping versus committing to a full root canal on a mature tooth with deep caries?

这个问题问得很好。

So a great question.

在牙髓病学里，其实在整个牙科领域，关键是要清楚自己真正的能力，并且对自己的能力有信心。

For everything in endodontics and for everything really in dentistry, you know, the important part is knowing what your, like, your true abilities are and being confident in those abilities.

所以，显然，活髓治疗有禁忌症，也有非常理想的情况。

So, obviously, for vital pulp therapy, there are a list of contraindications and then a a list of short, like, these are very optimal.

先说说禁忌症。

So just addressing contraindications.

很明显，活髓治疗的一大禁忌症就是术前没有症状，但说实话，深龋往往……

So, obviously, one big contraindication for vital pulp therapy is the absence of preoperative symptoms, which frankly, like, having deep caries is kind...

通常都会伴随术前症状。

Like, goes hand in hand with preoperative symptoms.

不过，这种情况是存在的。

However, it is...

这种情况确实存在，而且经常发生，尤其是在儿童病例中，或者很多年纪较大的牙齿，它们修复得很重，但牙髓仍然有活力，却没有术前症状。

It can exist, and it often does, especially in pediatric cases or, you know, a lot older teeth, right, that are heavily restored where it's still vital but they don't have pre op symptoms.

所以，这就是活髓治疗主要适用的两大类情况。

So those are the, like, kind of the two big main categories that Vital Pulp Therapy is, like, working in under.

很多临床医生，甚至牙髓专科医生，都会在术前症状很少或不明显的情况下进行活髓治疗。

A lot of clinicians do do vital pulp therapy, even endodontists, with, like, few or scant, like, meaning, like, not impressive pre op symptoms.

比如，只是有点冷刺激敏感。

So, like, well, it's a little cold sensitive.

那就试试吧。

Let's try it.

不过，这只是我个人的看法，一旦你决定做活髓治疗，你就失去了将来进行冷测试的能力。

However, and this is just my personal opinion, once you're committing to a vital pulp therapy, right, you're losing the the ability to perform a future cold test.

所以，如果这颗牙要失败或者失败的时候，真的，你基本上没有办法测试这颗牙的健康状况，直到出现根尖周透射影。

So if the tooth is going to fail or when it fails, right, really, you don't have really any way to test the health of this tooth until there's a periapical lucency.

而且，要穿过MTA或者你用来盖髓的材料去找到根管，对牙髓专科医生来说都非常困难，更别说普通牙医了。

And, also, getting to that, right, through MTA or whatever you've capped it with is really, really difficult for an endodontist, let alone a general practitioner.

要可靠地找到原来的根管，还不造成医源性损伤，真的非常非常难。

It's very, very difficult to predictably find your way back and not create an iatrogenic defect.

所以说实话，活髓治疗我做得很多。

So to be very honest, vital pulp therapy, I do it a lot.

但我觉得牙科里经常发生的问题，我们都有责任，就是太着急了。

But what I think happens a lot in dentistry, and we're all guilty of it, but it's the rushing.

我们没有跟患者解释清楚，比如你必须六个月后回来复查。

So when we're not explaining to patients, like, you've got to come back in six months.

你必须一年后回来，否则可能会脸肿或者更严重，甚至可能失去这颗牙。

You've got to come back in one year, or, you know, you could end up with a jaw swelling or something worse and may even lose this tooth.

因为我们通常面对的是深龋。

Because we're talking about deep caries most often.

所以这些患者本身就不是那种依从性很好的病人。

So these these aren't really dentally compliant patients to begin with.

所以这一切真的非常棘手。

So all of that is really, really tricky.

所以，在没有匆忙和时间压力的前提下，进行这些推心置腹的谈话，对于活髓治疗的成功案例来说，超级重要。

So having these really heart to heart conversations without the pressure of rushing and time is super important for the successful viral pulp therapy cases.

你提到了很多关于活髓治疗的重要考量。

You're breaking up a lot of really important considerations with Vital Pulp Therapy.

有些我们甚至不常想到，因为我觉得这算是比较新的，或者至少现在大家对它的关注度更高了。

Things that sometimes we don't even always think about because I would consider this relatively new, or at least there's a lot more awareness around it.

那我们先倒回去一点。

So let's actually backtrack for a second.

你想解释一下什么是活髓治疗，以及它不是什么吗？

Do you wanna explain what Vital Pulp Therapy is and perhaps what it's not?

所以它……

So it...

它其实涵盖了很多方面。

It's actually a lot of things.

最初，活髓治疗，你知道的，是为有深龋和根尖未闭合的孩子设计的。

Originally, Vital Pulp Therapy, you know, was designed for, I I believe, like, a child with deep caries and an open apex.

对吧？

You know?

所以就像，好吧。

So it's like, okay.

比如，你知道的，三十年前的老式牙髓治疗，他们会做根尖诱导成形术。

Like, you know, old school endodontics thirty years ago, they would have done, you know, apexification.

但我们从文献和临床案例中知道，那些治疗失败率很高。

But we know from the literature and from clinical cases that those are so high in failure.

比如处理一个很大的开放根尖，尤其是在过去的二维影像下，真的非常困难。

Like, managing a huge open apex, especially historically in two d, has been really, really hard.

所以开放根尖和孩子的好处在于他们的愈合能力。

So the great thing about open apices and kids is their ability to heal.

而且，显然，对于开放根尖，根尖区域有那些好东西，比如还在发育中的干细胞。

And, obviously, with open apices, you have all those great things apically like stem cells that are still in development.

所以活髓治疗的目标，对吧，比如说，一个根尖未闭合的下前磨牙，就是把龋坏去掉，然后做牙髓切断术。

So the goal of vital pulp therapy, right, and let's just say, like, the the the lower premolar with an open apex is to get the caries out and then ottomy.

做牙髓切断术时，通常强烈推荐用金刚砂车针，而不是碳化钨车针，因为碳化钨会把整个牙髓都带出来。

So pulpotomy the pulp until with a usually highly recommended a diamond burn, not a carbide because the carbide will pull the entire pulp out.

它会缠住牙髓。

It'll engage it.

所以用碳化钨车针，你几乎是在一片一片地切牙髓。

So with a carbide, you're literally almost amputating slices and slices.

想象一下肉铺里的屠夫……

Think of the the butcher at the meat...

在熟食店市场里。

At the deli market.

你就像切肉一样，一片一片地切牙髓，直到得到一个稳定的牙髓环境。

So you're amputating slices of the pulp until you get a stable, pulpal environment.

那这到底是什么意思呢？

Now what does that mean?

你要看的是，牙髓不应该大量出血。

What you're looking for is the pulp should not be gushing blood.

它不应该像火山爆发一样出血，搞得一团糟，很难控制。

It should not be a volcanic hemorrhagic site that's just a mess to maintain.

而且，当然，天哪，这很容易。

And, of course, dammit, it's easy.

全部在橡皮障隔离下进行。

All under rubber dam isolation.

所以你就用金刚砂钻头这样操作，直到像你八岁时受的那种伤一样。

So you're doing this with the diamond bur until, like, you know, like a wound, like, when you were eight years old.

你知道吗？

You know?

就像，哇。

Like, wow.

你……

You're...

就像你膝盖上缺了一块肉，你能看到血，但它没有渗出来。

A chunk of your knee is missing, and you can see the blood, but it's not oozing.

就是很多新鲜的、裸露的皮肤。

Like, it's just a lot of, like, fresh, raw skin.

看起来就应该是那样。

That's what it should look like.

然后从那里开始，你用棉球蘸次氯酸钠消毒，放在上面两到五分钟，用温和但稳定的压力。

And from there, you place cotton pellets with sodium hypochlorite to disinfect, and you put it on from anywhere to two to five minutes, you know, with gentle firm pressure.

然后拿下来，快速用无菌生理盐水冲洗一下。

And then you take it off and, you know, a a quick, you know, sterile saline rinse.

然后放一些生物陶瓷材料，比如膏状的那种，或者如果是前磨牙或前牙就用白色的MTA，或者MTA在……

And then you place something bioceramic, a putty, or a a white if it's, you know, premolar or anterior MTA or MTA on...

如果是磨牙的话，但我们说的是前……

If it's a molar, but we're talking about pre...

这个理论上的开放根尖的前磨牙。

This theoretical open apex premolar.

我可能会给孩子用白色的，然后你要么修复它，要么临时...

I would probably do white on the child, and then you would either restore it or temper...

用更硬的材料临时修复它。

Temporarily restore it with something firmer.

我个人喜欢Coltine的Duo Temp。

I personally like Duo Temp by Coltine.

它有点像IRM，但是双固化树脂增强的。

It's kind of like an IRM, but dual cure resin reinforced.

所以它真的...

So it's it's just a really...

切割起来很方便。

It's nice to cut into.

当你重新处理它时，它不会变得黏糊糊的。

It doesn't get all goopy when you go get back into it like have it.

所以这就是真正的、历史上的活髓治疗。

So that is the true, like, historical vital pulp therapy.

到了现代，我们……

Now modern day, we...

现代的话，咱们直接快进一下。

Modern day, like, let's fast forward.

你知道，现在孩子们经常出现牙根尖闭合的情况。

And, you know, kids often present with closed apex teeth.

或者，比如说，一个年纪大点的病人，有颗牙补得特别多……

Or, you know, there's a heavily restored molar that on an older patient...

我就举两个例子，就是那种牙髓还活着，但没有任何症状的情况。

I'm just gonna give two examples where, you know, it's still vital, but there's an absence of symptoms.

所以为了避免做根管治疗，你还是要再做一次冷测试，然后过几个月，你觉得合适的时候再补上就行了。

So to avoid root canal therapy, you're going to, again, cold anymore, and then you can restore it, you know, however many months down the line that you feel necessary.

所以这就是活髓治疗的实质，真的是非常非常……

So that is Vital Pulp Therapy in essence, which is super, super, super...

听起来好得有点不真实，而且特别简单，但历史上对于这些牙根尖未闭合的牙齿来说，它真的是一个很好的替代方案，因为根尖诱导成形术真的不容易做，效果不可预测，长期来看也不是很成功。

Sounds like almost too good to be true and very easy, but it's a great, great alternative historically for these open apex teeth, whereas the epaxification was really not an easy procedure, not predictable, and not that successful long term.

所以这就是活髓治疗。

So that is Vital Pulp Therapy.

那在成人恒牙列中，牙根尖闭合的情况下呢？

Now what about in adult dentition with a closed apex?

比如说，一个12岁的孩子，六龄齿牙根尖已经闭合，或者一个年纪更大的患者，牙齿上……

So for the, you know, the 12 year old kid on a six year molar with closed apices or the older patient on...

有大量修复体的前磨牙或磨牙。

That has a heavily restored whatever premolar molar.

同样，在没有症状的情况下，你会做完全相同的事情，然后，你知道，希望一切顺利。

Again, in the absence of symptoms, you would do the exact same thing and just, you know, again hope for the best.

而且，你要进行非常清晰和坦诚的沟通，说明这需要定期复查。

And, you know, again, have that very clear and frank discussion that that this should be followed up routinely.

你提到了一个我们经常忽略的非常有趣的点，那就是……

So you bring up the most interesting consideration there, though, that we don't oftentimes think about is...

所以，是的，现在因为髓腔里填充了生物陶瓷，我们不能再进行测试了。

So, yeah, now because the chamber's been filled with a bioceramic, we can no longer test

它。

it.

所以我们真的只能等到看到根尖病变。

And so we have to wait really until we see an apical lesion.

我是说，希望这不会发生，对吧。

I mean, hopefully, right, that doesn't happen.

但是……

But...

所以大家都应该清楚，这可能会发生，第一点。

So everybody should be clear that that may, number one.

所以，合理的期望总是成功的关键。

So proper expectations is always the key to success.

但在这里，在私人诊所环境中，这更考验你的系统执行力。

But, also, here's where, like, it gets in the private practice setting a little bit more highly executional in terms of your systems.

因为我总是考虑系统。

Because I'm always thinking about systems.

所以你是在给牙科保健员授权。

So you're empowering your hygienist.

嘿。

Hey.

你知道，苏珊三个月后会来。

You know, Susan's gonna be in in three months.

我们拍一张根尖片吧。

Let's take a PA.

你可以直接去。

You can go ahead.

她会来找你做清洁。

She'll be in to see you for her cleaning.

请确保你拍一张根尖片。

Please make sure that you take a PA.

而且，你知道，她可以，牙科保健员可以叩诊，然后你也可以叩诊。

And, you know, she can, the hygienist can percuss, then you can percuss also.

所以应该对叩诊敏感。

So it should be percussion sensitive.

应该对触诊敏感。

It should be palpation sensitive.

显然冷测试会是阴性。

It obviously will be cold negative.

然后，你知道，你的洁牙师或团队拍的X光片应该显示健康的牙周……

And then, you know, that X-ray that that your hygienist, your team takes should show a healthy peri...

牙周

Peri

顺着这个思路，你是不是……

Along those lines as well, are you...

你建议做过根管治疗的牙齿每年都拍新的根尖片吗？

Do you recommend that teeth that have been endo treated every year get a new PA?

我在空军的时候，这是我们诊所的实践指南之一。

When I was in the air force, that was part of our clinic practice guidelines.

这是我做过的事情。

It was something I did.

我很乐意做这件事。

I appreciate doing it.

那真是纯粹的对牙髓治疗的热爱，而且我很喜欢那些军队系统。

That's that's pure endo love, and I love, like, some of those military systems.

比如说，那正合我意，因为，对……

Like, that's right up my alley because, right...

我的意思是，我总把自己想成是平安夜来看病的病人。

I mean, I always think of myself as the Christmas Eve patient.

所以我指导病人的时候，就是这么说的。

So when I coach patients, that's what I say.

就像，这就是我的生活。

Like, this is my life.

我有三个孩子。

I have three kids.

墨菲定律总是让我倒霉。

Murphy's Law just backfires on me all the time.

所以我不喜欢过那种赌博和冒险的生活。

So I don't like to live a a life of gambling and risk.

比如说，我可不想在平安夜或者他们休假的时候去看牙髓科医生。

Like, you know, I don't wanna come into the Endodontist on Christmas Eve or Christmas Eve or when they're on vacation.

所以我会更主动一些。

So I am more proactive.

所以我特别注重预防措施。

So I'm all about systems to prevent.

再说一遍，记住，牙髓病学，我们要预防或治疗根尖周炎。

And, again, remember, endodontics, we prevent or treat apical periodontitis.

所以我们不希望它最终变成病变。

So we don't want it to end up in a lesion.

我们希望通过第一次就做对来预防这种情况。

We wanna prevent that by doing it right the first time.

所以，当然，我确实很喜欢那个系统。

So, absolutely, I I do love that system.

更重要的是，反过来，我强烈建议在戴牙冠之前做根尖片和测试，这样我们就能……

And more importantly, conversely, I highly recommend PAs and testing before crowns are placed so that we...

知道，就像我们在ELEVATED上聊过很多次那样。

Know, like, we've talked about this on ELEVATED a ton of times.

但人们会忘记，而且，你知道，保险不覆盖这个，因为，对，就像全景X光片每五年才拍一次，这太荒谬了，因为如果你要给一个……

But people forget and, you know, insurance doesn't cover it because, right, like, FMX is every five years, which is so ridiculous because if you're placing a crown on an...

用……

With...

用四年前的全景X光片来戴牙冠，那上面可能已经有根尖周透射区了。

From an FMX that's four years old, like, there might be a perioglucency already on it.

你懂吗？

You know?

说得太好了。

Phenomenal point as well.

咱们换个话题，聊聊CBCT吧。

Let's pivot a little bit here and talk about CBCTs.

你给Elevatedgp做过一个关于三维成像和CBCT的精彩讲座。

You gave a phenomenal lecture to Elevatedgp about, like, three d imaging, CBCTs.

我想稍微聊聊这个。

I wanna talk about that a little bit.

现在CBCT在全科诊所里越来越常见了。

So CBCTs are becoming much more common in general practice.

确实，它的普及率大幅上升了。

Really, the adoption of it has dramatically increased.

那么，对于自己做根管治疗的全科医生来说，有哪些具体的警示信号或临床情况，会让你觉得需要拍一张根尖片……

So for a GP doing their own Endo, what are the specific red flags or clinical scenarios where you'd, you'd say taking a per...

抱歉。

Sorry.

不好意思。

Excuse me.

你觉得在哪些情况下，术前拍CBCT是必须的？

Where you'd say taking a preoperative CBCT is mandatory?

好的。

Okay.

顺便说一句，谢谢你的夸奖。

So thank you, by the way, for that compliment.

你太客气了。

That was very kind.

我确实很喜欢CBCT。

I do love CBCTs.

我觉得我喜欢上CBCT的原因，是因为我在没拍CBCT的时候吃了很多亏，那种滋味我可不喜欢。

And I think the reason during my journey to loving CBCTs is because I've eaten a ton of that humble pie from not taking CBCTs, and I don't like that taste.

所以，在我的经历中，回答你的问题，我真的发现有时候我根本预测不了。

So, you know, on my journey and to answer your question, I've really come to the conclusion that sometimes, for me, I can't predict.

我不知道什么时候会需要它，因为我被坑过太多次了。要知道，在我完全、完全、完全接受并开始使用CBCT之前，我已经干了十多年了。

I don't know when I'm going to need it because I've been burned so many times because, remember, I was practicing for a good ten plus years before I fully, fully, fully adopted and started using CBCT.

所以，你知道，这其中有部分原因是，我做这行已经很多年了。

So, you know, there's part of this, like, I've been doing this for many years.

我做了很多根管治疗，都没用CBCT。

I've done tons of root canals without it.

我为什么需要它呢？

What do I need it for?

但正是那些让你难受的意外和惊吓，让你变得谦卑，也让你……

But it's those hard gulps and surprises that humble you that make...

让我彻底转向了100%使用CBCT。

Have made me move to a 100% CBCT.

所以，如果拿我的专科诊所来说，就是全科医生转给我的那些病例，然后应用到你的问题上，我会说……

So if I take, right, like, my specialist practice, right, like, the the things that general dentists send me and then apply it to your question, I'll say.

对于前牙，我很难说门牙一定要用，除非我在二维影像上看到非常非常奇怪的东西，这个我待会儿会再提到。

So anteriors, I would say, like, I'm hard pressed to say on incisors unless I see something very, very funny on two d, and I'm gonna come back to that.

尖牙，其实我在尖牙上栽过跟头，我想我在演讲里也分享过这个。

Canines, actually, I've been burned on canines, and I think I shared that on the presentation.

其实有很多犬齿是双根双管的。

Like, there are a lot of two rodent and two canal canines out there.

我的一些正畸医生朋友，因为他们会拍CT或者全景片，他们就会在白天直接发给我。

And some of my orthodontist friends will, like, you know, because they scan or pano, and they'll just send me in the middle of the day.

其实有很多犬齿是双根双管的。

Like, there are a lot of two rooted two canal and canines out there.

所以，对于全科医生来说，如果你们觉得要做犬齿和前牙，记住它们可能会有分叉，尤其是下前牙。

So, again, for the GP that thinks like, man, I'm gonna do canines and incisors, Just remember, they can have fast breaks, especially the lower anteriors.

所以，当你……

So so so when you...

我想回到这个话题。

I wanted to come back to it.

所以当你看二维影像的时候，你真的必须非常仔细地看，这很花时间，而全科医生常常抱怨他们的日程里没有那么多时间。

So when you're looking at two d, you really have to start with looking at two d very, very critically, which takes a lot of time, which general dentists complain they don't have a lot of time in their schedule.

所以这真的很难，因为我不是全科医生，很难想象白天那样工作是什么感觉。

So it's really, really hard, again, because I don't practice as a general dentist, to imagine running like that during the day.

所以这是我的建议。

So here are my recommendations.

第一，给你的团队赋能。

Number one, empower your team.

给你的牙科保健员赋能，让他们做得更好，并找到时间真正仔细看那些二维X光片，寻找那些快速断裂，寻找那些可能隐藏着巨大吸收缺陷的小小透射影，所有这些都需要时间。

Empower your hygienist and get better and find the time to really stare at those two d X rays for those fast breaks, for that little, little, little radiolucency that may be hiding a huge resorptive defect, all of those things, that takes time.

只有通过仔细看二维片子，你才能更好地判断哪些需要用三维扫描。

And from the staring at the two d, only then can you get better at discerning what needs to be scanned with three d.

明白了吗？

Does that make sense?

我建议所有磨牙，显然，所有再治疗病例，所有根尖手术，以及有快速断裂的前磨牙。

I would recommend all molars, obviously, all retreatants, all apicoes, and then the premolars with the fast breaks.

对我来说，我喜欢用三维，而且用得挺高级的。

For me, I love it and use it pretty sophisticated.

所以我会规划我的工作长度。

So I plan my working length.

我会规划我的开髓入口。

I plan my access.

还有任何弯曲，我……

And any kind of curve, I...

在二维影像上，你能看出来。

On two d, you can appreciate.

它是往这边弯还是往那边弯？

Is it curving this way and that way?

你明白我的意思吧？

You know what I'm saying?

所以我想确切知道我的锉针会面临什么。

So I wanna know exactly what is expected of my file.

否则，如果……

Otherwise, if...

特别是如果有两度弯曲，对吧，就像这样，然后你知道，它又向颊侧或舌侧、腭侧转折，那就会给我的锉针带来压力，还会增加锉针分离的风险，这会让我非常恼火。

Especially if there's a two degree curve, right, right, like this way and then, you know, pivots buckly or lingually, palatally, then that's gonna stress my file, and that's gonna risk file separation, which makes me really grumpy.

所以任何弯曲、任何急转弯，这些都会……

So any kind of curves, any kind of fast breaks, which, again, are gonna...

你得盯着二维影像，而且始终要保持高度警惕，这样才能慢慢建立起自己的判断系统，知道什么时候该用三维影像。

You're gonna be clued in by staring at your two d and being very, very suspicious always on two d, then you can start to develop your own systems with when to take the three d.

关于这一点，还有一个注意事项。

And to that, one more caveat.

记住，很多全科牙医的诊所里只有全头颅锥形束CT，没有EndoRes。

Remember, a lot of general dentists have whole head cone beam in their offices and not EndoRes.

所以，你懂的，这就像拿苹果和橘子比，不太一样。

So, you know, you're kind of comparing apples and oranges here.

我不一定会……

I wouldn't necessarily do...

就是……

Be...

我不会仅凭全头颅CBCT就放心做根管治疗。

I wouldn't be confident doing Endo based on a whole head CBCT.

我需要EndoRes CBCT，特别是针对吸收、快速断裂，以及观察MB2根管走向的情况。

I need EndoRes CBCT, especially for resorption, especially for fast breaks, especially to visualize an m b two and where that's going.

比如，它是不是一个独立的出口？

Like, is it a separate portal of exit?

它会不会汇合？

Does it join?

这些细节，全头锥形束CT是看不出来的。

All of those kind of details, you're not gonna get on full head cone beam.

EndoRes。

Endo res.

给我多讲讲这个。

Tell me more about this.

所以，你知道，通常呢……

So, you know, usually, it's...

全头CT，对吧，显然拍的是整个头部。

So whole head, right, obviously takes the whole head.

EndoRes通常只是分辨率更高，大概在80到90微米之间，我记得是这样。

Endo res is usually just a higher resolution, you know, somewhere between 80 to 90 microns, I believe.

我不是口腔放射科医生。

I'm not an oral radiologist.

这个我没专门研究过。

I didn't study up on this.

但你知道，显然就是剂量稍微高一点，分辨率更高，然后就能让你看到所有细节。

But, you know, obviously, you know, just a a little bit of a higher dose, higher resolution, and then, you know, allows you just to see everything.

真的太神奇了。

It's just so magical.

所以这其实是……

So it's actually...

这个问题在我们群里讨论过一阵子。

This is a question that comes up in our group chat for a bit.

但用哪种CBCT呢？

But what CBCT?

你喜欢哪种？

What do you like?

你现在用的是什么？

What are you using?

再说一遍，这期节目不是赞助的，但大家喜欢听实际的。

Again, this is not a sponsored episode at all, but people like to get practical.

我是说，我喜欢非常实际的。

I mean, I like to be very practical.

好问题。

Great question.

在我诊所里，我之前用的是Dexus。

So in my office, I had Dexus.

以前是Gendex CBCT，我很喜欢它。

Used to be Gendex CBCT, which, you know, I loved.

其他用Merida或Carestream的牙髓科医生经常夸它的清晰度。

I always got a lot of compliments from other endodontists that were using Merida or Carestream about the clarity.

所以当我展示我的锥形束CT演示时，很多牙髓病医生——他们可是很挑剔的一群人——如果他们对设备很熟悉、看过很多图像的话，都会特别称赞图像的清晰度。

So when I would present my cone beam presentation, a lot of endodontists in, right, were a picky bunch, would really complement the clarity, if they had a lot of views and familiarity with their machines.

他们会问，为什么这个这么清晰？

They're like, why is it so much clearer?

所以我确实相信，DEXIS的CBCT机器做得很好。

So I do believe that, you know, DEXIS makes a great CBCT machine.

而且，市面上大多数传感器都是DEXIS的。

Also, most sensors on the market are DEXIS sensors.

所以如果你熟悉DEXIS传感器，你在CBCT上也会得到同样可预期的图像。

So if you're familiar with DEXIS sensors, you're gonna get that same predictable image on the CBCT.

话虽如此，我最近也对Carestream的产品更熟悉了。

That being said, I've also recently become more familiar with the Carestream product.

我……

I'm...

你知道，牙髓病医生并不是他们……

You know, Endodontists are not they...

我们都是有习惯的动物。

We are creatures of habit.

所以适应起来挺难的，但我正在学着用Carestream。

So it's been difficult, but I am learning the Carestream.

我对Merida不太熟悉。

I don't have any familiarity with Merida.

我看过Merida的图像。

I've seen Merida images.

我也看过Vault Tec的图像。

I've seen Vault Tec images.

虽然我不想贬低任何产品，但我想说的是，我个人不喜欢滤镜。

And while I don't wanna bad mouth any product, what I will say is I personally do not like filters.

所以，就像很多……

So, like, a a lot...

你知道，就像Instagram那种滤镜。

You know, like, you know, filters like Instagram.

所以……

So...

当然，我们很看重滤镜。

And, of course, we value filters.

但是，我不希望我的图像上有滤镜。

However, I don't value them on my images.

就像，我想……

Like, I wanna...

我是在非常原始地看数据和图像，我想放大，想看清楚，不希望它有任何改动。

Like, I am looking at the data and the images so rawly that I wanna zoom in and I wanna see, and I don't want it to be altered in any way.

而且很多……

And a lot of...

有些锥形束CT的制造商会在他们的算法里加入滤镜。

Some of the cone beam manufacturers will, in their algorithms, include the filters.

所以有时候我就像，几乎像，吱吱吱，你懂的，或者还记得九十年代的《独领风骚》吗？

So sometimes I'm just, like, almost, like, squeak squeak, you know, or or remember Clueless from the nineties?

就像，哦，这太莫奈了。

Like, oh, that's so Monet.

你知道吗？

You know?

我想把莫奈效果关掉。

I I want the Monet off.

我就想直接看原始图像，不过这只是我太较真了。

Like, I wanna just see the raw images, but that's me just being a total nerd.

这有什么原因吗？

Is there a is there a reason for that?

我是说，你是不是……

I mean, are you...

加滤镜会扭曲图像质量吗？

Is it distorting the image quality when you put a filter on it?

你知道，再说一次，我不是口腔放射科医生。

You know, again, I'm not an oral radiologist.

我就是有时候不太喜欢那种……

I just I just don't like it sometimes when...

如果我在纠结出口通道这种细节，我几乎想把那个……

If I'm, like, splitting hairs over a portal of exit, it's almost like I wanna take the...

滤镜关掉。

That filter off.

所以我就想……

So I just wanna...

我不想怀疑自己看到的东西，我觉得有些滤镜确实会让人这样。

I I don't wanna question what I'm seeing, and I feel like some of the filters do.

不过，回到你刚才说的第一点，我觉得这些滤镜本意是好的，是为了帮助刚开始学CBCT的新手医生。

However, to your first point, I think that it's supposed to be helpful and designed to be helpful for the average new practitioner learning CBCT.

但话说回来，我也不确定。

But, again, I don't know.

梅丽莎，我还真没问过那个好问题。

I've never asked that great question, Melissa.

但也许ELEVATED上的某位口腔放射科医生能在我们继续之前详细讲讲这个。

But maybe one of the oral radiologists on ELEVATED can can expound on this before Mhmm.

稍后再说。

Later.

跟我们聊聊微创牙髓治疗，这些微创的牙齿开髓。

Talk to us about minimally invasive endo, these minimally invasive tooth accesses.

你知道，这是不是一种增值服务？

You know, is that a value add?

因为我觉得很多全科医生都听说过这个，他们说，你知道，我不知道怎么做这个。

Because I think a lot of GPs are hearing about this, and they say, you know, I don't know how to do this.

那我是不是就再也不该提供牙髓治疗了？

So should I just never offer endo again?

所以我觉得，跟你第一个问题很像，关键是要了解自己的能力。

So I think, like, very similar to your first question, it's about knowing your ability.

再说一次，我比较保守，但有很多同事就是喜欢尝试各种新东西。

Now, again, I'm pretty conservative, but there are a lot of our colleagues that just kind of like to try a lot of new things.

而且，你知道，他们会试着突破自己的极限。

And, you know, kind of flex and push their limits.

那也挺好的。

And that's cool too.

我们都是需要共处的人，而且每个人都有不同的性格。

We're we're we're all a bunch of people that have to, right, coexist, and we all have different personalities.

我不做那种忍者式的操作。

I don't do ninja.

比如说，所以……

Like, so...

比如说，我不会做那种忍者式的开髓。

Like, I won't do the ninja accesses.

我真的很羡慕那些会做的同事。

And I'm so jealous of my colleagues who do.

真的，说真的。

Like, serious.

就是那种怕错过的感觉。

Like, FOMO.

我希望我能做到，但那只是我知道自己的极限。

Like, I wish I could, but that's just me knowing my limit.

那我会做微创吗？

Now will I do minimally invasive?

有好几次，我在Instagram上炫耀过一些特别小的切口，因为它们真的很小。

There's been several, like, you know, accesses that I flaunted on Instagram because they're so small and tiny.

但当我感觉到我的锉刀插入，我的系统，对吧，我的触觉反馈。

But the moment that I feel that my my file insertion, my, you know, system, right, like, my tactile feedback.

当我感觉到它扭转得有点过头时，我就知道我需要调整我的切口，而且我快达到自己的极限了。

When I feel it torquing a little too much, that's when I know I need to modify my access, and I'm reaching my own limitation.

这不是...

It's not...

所以我需要扩大那个切口，为了我自己，为了我的舒适度。

So I need to enlarge that access for me, for my comfort level.

再说一次，每个人都不一样。

Again, everybody is different.

所以我喜欢这个运动吗？

So do I love the movement?

我喜欢这个理论上的运动，就是保留更多的牙本质。

I love the theoretical movement of saving saving more dentin.

你知道，它……

You know, it...

一直以来都是关于保留牙齿和保留更多的牙齿结构，这是肯定的。

It's always been about saving teeth and saving more tooth structure for sure.

但是，再说一次，如果你为了追求微创或者微创牙髓治疗而弄断每一根锉，那肯定得有所妥协。

However, again, if you're breaking every file trying to ninja or MIE, then something has to be compromised.

我觉得指出这一点真的很好，也很有建设性。

I think that's really good and really constructive to point out, though.

你知道，这个我在播客里也稍微聊过一点。

You know, this is something I talked a little bit about on the podcast.