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欢迎收听EndoVoices，由美国牙髓病医师协会为您呈现。
Welcome to EndoVoices brought to you by the American Association of Endodontists.
这档节目旨在推动牙髓病学艺术与科学的发展，并与当今顶尖专家一起促进最高标准的患者护理。
The show where we are advancing the art and science of endodontics and promoting the highest standards of patient care with today's top experts in the field.
现在有请我们的主持人，医生。
Now here's your host, Doctor.
马库斯·D。
Marcus D.
约翰逊。
Johnson.
今天我们坐在这里，就在展览大厅里。
As we sit here today, we're on the exhibit floor.
我们即将录制一期Endo Voices节目，而我们现在就在阳光明媚的凤凰城。
We're about to shoot an episode of Endo Voices, and we live in sunny Phoenix.
能有几位特别的嘉宾和我在一起，真是太棒了。
And it's amazing just to have some special guests with me.
我们要讨论临床结果、仿生牙科，以及这些在牙髓病学领域里是怎么结合的。
We're gonna be discussing clinical outcomes, biomimetic dentistry, how that all fits within the space of endodontics.
我看到有些人可能想过来坐在观众席上。
I see some people here who may want to come sit in the crowd.
哦，他们都在排队了。
Oh, they're all queuing up.
他们都在排队。
They're all queuing up.
但是
But
这真的很棒，能有这样的合作。
this is fantastic, really, just to have the collaboration.
这是我们学习的最好方式，跨学科的讨论。
This is how we learn best, the interdisciplinary sort of discussion.
那么话不多说，让我先介绍一下，我们有医生。
So without further ado, let me at least introduce, we have Doctor.
沙农·帕特尔。
Shanon Patel.
你好。
Hi.
我们有医生。
We have Doctor.
戴维·阿勒曼二世。
Davey Alleman, Jr.
很高兴来到这里。
Happy to be here.
资深医生。
Senior Doctor.
戴维·阿勒曼。
David Alleman.
所以我们实际上就是在弥合牙髓治疗和修复牙科之间的差距。
And so we're really just kind of bridging the gap between endodontics and restorative dentistry.
我想我们就从这里开始，让Shanon先简单介绍一下自己，然后我再把话筒交给下一位。
And I think we'll just start there and kind of let Shanon share a little bit about himself, and then I'll pass the mic to the junior in
现场的那位。
the scene.
好的。
Okay.
嗯，我来自英国伦敦。
Well, I'm from London, England.
我在伦敦国王学院做兼职教育工作者，我是教授，同时也在诊所兼职，每周工作三到四天。
I'm a part time educator in King's College London, I'm a professor and I work part time in practice three to four days a week.
我做了很多临床研究，主要关注牙髓治疗结果、锥形束CT、牙根吸收和治疗计划。
I do a lot of clinical research on endodontic outcomes, cone beam CT, root resorption and treatment planning.
我是AAE的忠实粉丝，也是这两位——Alleman兄弟的忠实粉丝。
I'm a great fan of the AAE and I'm a great fan of these guys, the Alleman brothers.
Alleman兄弟。
The Alleman brothers.
我之前不知道他们是父子。
I didn't realize they were father and son.
我还以为他们是兄弟，不过算了。
Thought they were brothers, but anyway.
我想现在他们也是了，不过……
I think they have now too, but...
是的，先生。
Yes, sir.
对。
Yes.
没错。
That's right.
我们稍后再聊这个。
We'll get into that a little bit later.
我的另一个兄弟格雷格，他去世了。
My other brother Greg, he died.
那是开玩笑的。
That's a joke.
拜托别让我爸唱歌。
Please don't ask my dad to sing.
千万别让他
Please don't have
唱歌。
him sing.
那么，前辈，请先给我们讲讲你的背景吧。
And please, senior, go ahead and start us off with a little bit of background.
我刚跟我的……我们该怎么说来着？
So I just had a conversation with my valid, what do we call it?
就是那个毕业时成绩第一的人，对吧。
Somebody who graduates number one in your Yeah.
好像是叫致告别辞的毕业生代表吧。
Think it's a validatory.
对，没错。
Yeah, that's right.
1978年，我从牙科学校毕业。
In 1978, I graduated from dental school.
1978年，
1978,
你出生
you were born
在1978年。
in 1978.
1978年？
1978?
你还没出生呢。
You weren't born.
你还没出生呢。
You weren't born.
不过话说回来，史蒂夫·布坎南是我们的
But anyway, Steve Buchanan was our
哦，不错。
Oh, nice.
向他致敬。
Out to him.
他是先驱，是的。
He's a pioneer Yeah.
在我们这个领域，没错。
In our Correct.
总的来说。
General.
没错。
Correct.
所以史蒂夫在班上总是最优秀的。
And so Steve was always the best of everything in the class.
1978年，最聪明最优秀的人都去了牙髓科。
And the smartest and the brightest in 1978 went into Endo.
他确实如此。
So he did.
因为他的导师是史蒂夫·科恩。
Because his, mentor was, Steve Cohen.
对，没错。
Oh, yeah.
理查德·伯恩斯。
Richard Burns.
哇。
Wow.
所以，通往牙髓的路径。
So, pathways to the pulp.
我们在UOP有第一版《通往牙髓的路径》，但我们没有专科项目。
So we had the first edition of Pathways to Pulp at UOP, and we didn't have a specialty program.
所以我们
So we
都做了磨牙根管治疗
all did molar endo
在本科阶段。
Undergraduate.
所以根管治疗占的比重很大。
So it was heavy on endo.
而史蒂夫，就像我说的，后来成了明星。
And Steve, like I say, went on to become a star.
而我，就只是个牙医。
And me, I just was a dentist.
按照UOP教我的方法做了十七年牙科之后，我发现那些东西在五年、十年、十五年后开始出问题。
After seventeen years of doing dentistry the way they taught me at UOP, I saw that stuff started failing at five, ten, fifteen years.
没有一样能撑过十五年。
Nothing has lasted more than fifteen years.
不过话说回来，做了十七年传统牙科之后，归根结底就是这样。对。
But anyway, the bottom line after seventeen years of doing traditional dentistry Yep.
我是说，我受过牙髓治疗的训练。
I mean, was trained at endo.
史蒂夫教了我怎么做更好的牙髓治疗，但我所有的病例最后都变成了牙髓问题。
Steve trained me how to do better endo, but all of my stuff was going to endo.
所以我放弃了牙科。
So I quit dentistry.
我就是不干了。
I just quit.
哇。
Wow.
但六个月后，我听说有个在加州讲课的人，叫雷·贝托洛蒂，他有一种粘接牙齿的方法，他称之为粘接牙科。
But then but then, after six months after six months, I heard of this guy who was lecturing in California named Ray Bertolotti who had a a way to adhesively bond teeth, and he called it adhesive dentistry.
在八十年代，粘接牙科在业内是有的，但在后牙上完全不起作用。
Well, during the eighties, adhesive dentistry was in the profession, but none of it worked at all on posterior teeth.
我的意思是，那简直就是失败。
I mean, it was just like failure.
所以
So
那是不是就是不管用，只是
And and was it not working just
因为有很多……
because It was lots of...
有很多。
There's much.
有很多。
There's a lot.
有很多。
There's a lot.
但是
But
总之，因为我遇到了雷·贝托洛蒂，他从日本引进了新技术，我开始做文献综述。
anyway, because I met Ray Bertolotti who was bringing in new technology from Japan, I started to do, a literature review.
那花了我大约四年的时间，每天三到五个小时，持续了四年。
And that took me about, four years, about three to five hours a day for four years.
那时候，我是粘接牙科领域的专家，我发明了一种用粘接方式修复牙齿的方法，完全避免了做牙冠。
And at that time, I was an expert in adhesive dentistry, and I had created a way to fix teeth adhesively that prevented crowns, completely eliminated crowns.
没错。
That's right.
而且90%的情况下，牙齿都能保持活力。
And 90% of the time, a tooth would stay vital.
活力。
Vital.
对牙齿友好的牙科。
Teeth friendly dentistry.
那。
That.
但后来，我在自己的诊所里做了五年，然后我就想，为什么不是每个人都这么做呢？
But then, after I did it in my own practice for five years, then I said, why isn't everybody doing this?
这让我很开心。
This makes me happy.
我修好一颗牙，它就一直保持修复状态。
I fix a tooth, it stays fixed.
它不会变成需要根管治疗。
It doesn't go to endo.
现在我还有其他做过根管治疗的牙，那我在那里该怎么办呢？
Now I still have other teeth that are endodontically treated, but then what do I do there?
所以，从几十年来成功修复活髓牙，到将其应用于死髓牙，这个过渡就是我们所说的第七课。
And so the transition between fixing vital teeth for decades successfully, and then moving that into non vital teeth, that's what we call lesson seven.
这就是我们过去十五年一直在做的事情。
And that's what we've been doing for the last fifteen years.
在过去的十五年里，我们一直在使用纤维。
For the last fifteen years, we've used fibers
为了确保根管治疗后的牙齿的粘接强度。
To ensure the bond strength into the endodontically treated teeth.
这些是带状材料。
These are the ribbon stuff.
带状材料，还有一种叫Everex的纤维，它们很不一样。
Ribbon, there's another fiber that's called Everex, are very different.
不错。
Nice.
所以基本上，传统牙科、牙髓科和仿生牙科之间的结合，现在正在发展。
So basically the marriage between traditional dentistry and endodontics and biomimetic dentistry, now is evolving.
所以我们有，我儿子明天早上演讲，他会讲如何不用牙冠修复根管治疗后的牙齿。
So we have, my son speaking tomorrow morning and he'll be talking about how to restore endodontically treated teeth without crowns.
几天？
How many days?
这很有趣，因为现在我们看到牙髓学内部发生了一个范式转变，几乎可以说是修复性牙髓学。
This interesting because now we see a paradigm shift within endodontics to what we almost say is, restorative endodontics.
而且，你知道，真正去理解，文献里有很多相关内容。
And, you know, really just understanding, you know, the literature is replete.
明确说了，根管治疗后的牙齿修复，其重要性不亚于根管治疗本身，甚至更重要。
It's unequivocally stated that the restoration of the endodontically treated tooth is as important, if not more, than the endodontics.
我们可以引用很多相关的研究。
And we can quote a lot of studies regarding that.
但让我们请戴维来谈谈，我想，这个范式转变，还有粘接性，以及你父亲刚才解释的那些好东西。
But let's bring in Davey to talk about, I guess, the paradigm shift and bondability and all these good things that your father just explained.
让我真正对牙科产生热情的，是看到我父亲从一个不开心的牙医，变成了一个充满热情的牙医。
So what really got me passionate about dentistry was seeing the the change from my dad being an unhappy dentist to a passionate dentist.
那时我大概12岁，我会……
And I was about 12 years old where I would...
我注意到他不喜欢工作。
I noticed that he didn't like work.
然后有一天，他突然喜欢工作了，他一直在读那些非常无聊的论文。
And then one day, all of a sudden, he liked work, all he was doing was reading really boring papers.
好的。
Okay.
不是关于体育的。
It wasn't about sports.
也不是关于政治的。
It wasn't about politics.
就像是
It was like
图片不多。
Not many pictures.
没有图片。
There was no pictures.
但是
But
他更开心了，所以一个更开心的爸爸通常会让孩子们更开心，因为我们可以继续
he was happier, and so a happier dad usually leads to happier kids because we could keep
或者晚一点的门禁。
Or a later curfew.
爸，我今天出门了。
Dad, I'm leaving for the day.
看看能不能回来。
We'll see if get back.
对。
Exactly.
其实重点在于，当你真的能看到父亲的变化时，那种感觉是很有吸引力的。
Well, that's what it's about is when you can actually visualize the change in your father, that is something that's kind of attractive.
那这是什么？
Well, what is this?
挺有意思的。
It's kind of intriguing.
显然，你站在这里，某种程度上算是他的接班人，这多棒啊？
Obviously, you stand here, his protege in a sense, and how fantastic is that?
那我们来说说你吧。
So let's kind of discuss you.
你之前提到你的病例都失败了。
You were talking about your cases were failing.
你在牙科学校学做病例的方式，
The way that you learned how to do cases through dental school,
对吧？
correct?
对，太平洋大学，就像所有牙科学校一样，都觉得自己是全世界最好的牙科学校。
Yeah, University of Pacific, like all dental schools felt like they were the best dental school in the world.
我们去了，
We went,
你知道，
you know,
国王学院说
Kings College says the
国王学院也是。
same Kings College is
确实是的。
actually Yeah.
最好的东西其实无所谓。
The best thing in doesn't matter.
每个学校都觉得自己很了不起，但你知道，我进入私人诊所后。
Every, you know, they're all, every school, you know, is full of themselves, but you know, it's like, I go into private practice.
我在海军待了三年，做常规牙科，主要是补牙，用银汞合金，还有一些前牙的复合树脂，还有牙冠。
I was in the the navy for three years in the navy doing regular dentistry, mostly fillings, amalgams, some composites, on the anterior and then some crowns.
不过，在军队里我做了很多根管治疗，很多口腔手术，各种都做。
But anyway, started to a lot of endo in in the military, a lot of oral surgery, everything.
但当我进入私人诊所后，病人最需要的其实是补蛀牙或者修复断牙。
But when I got into private practice, what patients really needed mostly was to get their cavities or their broken tooth fixed.
所以我修好了，但那些我重新治疗的牙齿，我就想，他们没上过太平洋大学。
And so I'd fix it, but all these other teeth that I was retreating, I just said, well, they didn't go to the University of Pacific.
你知道吗？
You know?
所以十年来，我知道我的东西比那些坏掉的东西要好，我或者把病人转给牙髓专科医生，或者自己动手做。
So for ten years, I knew that my stuff was superior to the stuff that was falling apart, and I was referring to the endodontists or doing it myself.
但就在整整十年后，也就是十年零一天的时候，我十年前修复的那个病人出现了和其他牙齿一样的问题，那些问题我十年来一直在修。
But at ten years to the day, like ten years and one day, my patient who I had restored ten years ago had the same problems that I had been fixing on other teeth for ten years.
我突然意识到，我过去十年做的一切都会失败。
And it hit me like everything that I have just done for ten years is gonna fail.
于是我开始参加更多的牙髓治疗培训，比如跟史蒂夫·布坎南学，我的牙髓治疗技术变得非常熟练。
Now I started taking more endo training, like, from Steve Buchanan, and I got really good at endo.
但后来发现，这些牙髓治疗失败并不是因为牙根部分，而是因为边缘渗漏或者顶部断裂。
But then there's the other thing is that this endo was not failing from the root portion of the tooth, but from leakage, marginal leakage, or fracture on the top.
所以我做了完美的牙髓治疗。
So I do a perfect endo.
我做了完美的牙冠。
I do a perfect crown.
七年后，那颗牙断了。
Seven years later, the tooth has broken off.
嗯，你知道，我觉得这里正好可以请Shanon来聊聊，我们讨论一下为什么牙齿会失败，或者根管治疗后的牙齿为什么会失败。
Well, you know, I I think that's a good place to maybe bring in Shanon and discuss when we talk about why teeth fail or endodontically treated fail.
你在病变里真正看到的是什么？
What are you really seeing in the lesion?
我觉得需要区分的一点是，你的很多研究都是在自己的诊所里做的。
I think that what's important to a distinction to make is that a lot of this research that you conduct is in your own practice.
所以他是个临床经验丰富的医生，不只是做桌面上的染料渗漏研究。
So he's a wet handed clinician It's not just like desktop dye leakage studies.
我们在伦敦国王学院做了很多研究，既在诊所也在大学里，研究结果和预后因素。
We've done a lot of research at King's College London, both in practice and in the university looking at outcomes and prognostic factors.
我在同一个诊所已经待了二十三年了。
I've been in the same practice for twenty three years.
所以就像你一样，头几年一切都很顺利，但最终失败会回来，你会想，这到底是怎么回事？
So like you, everything works first few years, but then eventually you get your failures coming back and you're like, what's going on here?
如果你看文献的话，会发现根管治疗失败的牙齿，原因往往是蛀牙或者无法修复的牙齿，还有一点是垂直根折。
And if you look at the literature, it appears that the reason root treated teeth fail is caries or unrestorable teeth, vertical root fractures, a little bit.
根管本身的问题很少。
It's hardly endo.
大概只有百分之十是根管问题。
It's about ten percent endo problems.
没错。
That's right.
但那些根管失败的案例，如果当初做得规范，很可能就不会失败。
But those endo failures, if they were done properly, chances are they wouldn't fail.
现在我觉得很多其实是垂直根折。
Think a lot of it now is vertical root fractures.
我们对副功能习惯更了解了。
We're more aware of parafunctional habits.
病人磨牙的情况很多，尤其是疫情之后。
Patients are grinding their teeth a lot, especially since the pandemic.
疫情之前，他们就像在三档上跑。
They were in third gear before the pandemic.
现在全都挂到五档、六档了。
Now they're all in fifth gear, sixth gear.
这种情况我见得太多了。
I see a lot of those.
你得考虑咬合的问题。
You have to think about the occlusion.
但修复失败其实不算是修复本身的问题，我觉得更多是病例选择不当。
But also the restorative failures aren't really, I don't think restorative failures, they're poor case selections.
他们是在治疗一颗实际上已经无法挽救的牙齿。
They're treating a tooth that's actually not salvageable.
所以，根管治疗本身其实挺直接的。
So, endo is a straightforward bit.
牙髓专科医生什么都能重新治疗。
The endodontist can retreat anything.
但是转诊的牙医能不能在那颗牙上做出好的边缘呢？
But can the referring dentist put a good margin on that tooth?
还有一件事，大概十年前，我刚开业的时候，经常有人拿着牙冠来找我，里面带着一个大桩核和一点牙齿。
And the other thing I noticed up to about ten years ago is when I first started in practice, you get these guys coming in with crown in their hand with a big core in it and a bit of tooth.
但现在我们不再这么做了。
But we don't do that anymore.
我们现在做的是微创嵌体，或者像你那样的直接复合树脂修复。
We're doing minimally prepped onlays or like you direct composite restorations.
所以你不会再看到那种失败了。
So you don't get those sorts of failures anymore.
所以我觉得再过十年，我们不应该再看到那种修复失败。
So I think in another ten years, we shouldn't get those sorts of restorative failures.
但我认为最大的问题会是垂直根折，这些必须得处理。
But I think the killer will be the vertical root fractures and those have to be managed.
很高兴你提到这个。
Glad you mentioned that.
所以二十年前，我在接受了史蒂夫·布坎南的培训后，买了我的第一台显微镜。
So twenty years ago, I bought my first microscope after I got trained by Steve Buchanan Excellent.
那是在俄亥俄州立大学的一个牙髓病学课程上。
In an endodontic course at Ohio State.
然后用了显微镜做牙髓治疗后，我就说，嘿。
And so after using, you know, microscope for doing endo, I said, hey.
我也要买一台。
I'm gonna get one of these.
所以我买了一台……
So I bought a rock...
买了一台显微镜，然后突然之间，我看到了裂纹。
Bought a a microscope, and all of a sudden, I was seeing Cracks.
断裂。
Fractures.
到处都是。
Everywhere.
看到那些裂纹了吧。
See those cracks.
是的。
Yes.
我有一些朋友是工程师。
I I have, friends who are engineers.
有个朋友修喷气式飞机，就是美国政府战斗机的。
One friend fixes, jet planes, United States government fighter jets.
那些是纤维复合材料的。
They're fiber composite.
如果机翼上出现裂纹，他们很清楚裂纹多长之前机翼会脱落。
And if a crack happens on a wing, they know exactly how long a crack can be before the wing falls off.
所以他们看到裂纹就会修，不会等到它变成七英寸，因为七英寸……
So they look at it and then they repair it before it becomes seven inches because seven inches...
如果裂纹到了七英寸，你就没命了。
If you have a crack seven inches, you're gonna die.
所以有些飞行员得带着裂缝飞一阵子，但最终你还是得修。
And so some of the pilots have to go with the crack for a while, but eventually, you gotta fix it.
所以我就说，丹尼斯，我朋友丹尼斯·格罗尔说，飞机上的裂缝你们怎么修？
So I said, so Dennis, my friend Dennis Grohl, says, how do you fix the cracks on the airplanes?
他说，拿一个圆头钻头，把裂缝钻掉。
He says, you take a round ended drill and you drill it out.
把裂缝去掉，直到露出完好的碳纤维。
You remove the crack until you get to sound carbon fiber.
那我也能用在牙齿上，对吧？
I could do that on a tooth, couldn't I?
他说，对。
He says, yeah.
所以二十年前，我开始用显微镜研究丹顿的牙齿裂缝。
So I started to dissect cracks on Denton twenty years ago with my microscope.
突然之间，那5%让我头疼的牙齿……
All of a sudden, the 5% teeth that I was having problems with...
因为我当时已经用了五年的仿生学方法。
Because I had developed the Biomimetic approach for five years.
我一直在用这个方法。
I've been using it.
但一旦我有了显微镜，我立刻就去处理裂纹了。
But as soon as I got a microscope, all of a sudden, I went after cracks.
然后另外那5%的敏感、牙髓问题，全都消失了。
And then the other 5% sensitivity, endo, everything stopped.
所以当我这么做的时候，我查阅了文献。
And so when I did this, looked around the literature.
关于裂纹解剖的文献完全没有。
There's no literature on crack dissection.
零。
Zero.
裂纹解剖，对，这确实是……
Crack dissection, yeah, it's...
当我们谈论牙髓治疗中的牙裂，以及在仿生牙科领域里，可能得注意到有些分歧或者一些区别点。
When we talk about, I guess, cracked teeth within endodontics and also, I guess, amongst the space of biomimetic dentistry, maybe we have to note that there is some discrepancies or some, points of distinction.
所以当我们看Keith和Krell、Keith Krell和Rivera的经典研究时，我们知道牙裂后大约有百分之二十的几率会发展成有症状的不可逆牙髓炎或牙髓坏死。
So when we look at maybe the classic studies by Keith and Krell, Keith Krell and Rivera, and we know that there's probably about a twenty percent chance when you have a cracked tooth that it's gonna go on to become symptomatic irreversible pulpitis or necrotic.
我们必须考虑到这一点，但根据症状，我们知道……
We have to consider that, but based on the symptoms, we're knowing...
假设牙齿确实裂了。
Assuming that the tooth is cracked.
但你说你已经意识到牙齿裂了。
But you're saying that you've already realized the tooth is cracked.
我们是在裂纹刚过牙釉质本质界的时候发现的。
We are finding cracks when they're just past the DEJ.
刚过牙釉质本质界。
Just past the DEJ.
当裂纹超过牙釉质本质界半毫米或一毫米时，解剖它有多难？
When the crack is a half millimeter, a millimeter past the DEJ, how hard is that to dissect it?
小菜一碟。
Piece of cake.
连牙科学生都能学会怎么做。
Even a dental student could learn how to do that.
但他们得能看见才行。
But they have to be able to see it.
他们得能看见。所以，戴维，当——
They have to be able So see Davey, when
他上牙科学校的时候，第一年拿到他的工具包，你想讲讲这个故事吗？
he went to dental school, first year getting his kit, the, you wanna tell the story?
他们问我，好吧。
They asked me, okay.
你会拿到你的两倍半放大镜。
You're gonna get your two and a half loops.
我说，太好了。
I'm like, great.
我……
I...
那个可以直接扔进垃圾桶。
That can be put right in the trash.
所以我就问，我能找哪位代表谈谈，买一个我真正能看清东西的？
So I ask, who's the representative that I can talk to to buy something that I can actually see something with?
那就升级呗。
So Upgrade.
然后我就跟那个代表聊了，她说，你可以过来看看。
So I talk with the representative, and she's like, well, you can come over.
她说，我现在没有六号或者四号半的可以给你看，但今晚会有。
Like, I don't have any sixes or four and a halfs that you can look at, but I will tonight.
于是我和一个同学就去了她的办公室。
And so me and a classmate, we went to her office.
她给我们看了六号和四号的，比我们工具箱里给的那个二点五号好多了。
She shows us the sixes and the fours, and they're a lot better than the two and a halfs that they gave us in our kit.
然后她说，你确定要往这个坑里跳吗？
And she's like, are you sure you want to go down this rabbit hole?
你确定要六号的吗？
Are you sure you want sixes?
我不想卖给你你用不上的东西。
I don't wanna sell you something that you're not gonna use.
我就说，女士，我非常确定我要六号的。
And I just said, ma'am, I'm absolutely positive I want sixes.
如果能弄到显微镜，我早就弄了。
If I could get a microscope, I would.
没错。
Exactly.
因为……
Because I...
如果我看不见东西，我就没法处理它。
If I can't see something, I can't treat it.
如果我没法治，那结果就完全靠运气了。
And if I can't treat it, my outcomes are gonna be completely Yeah.
全凭运气。
Luck of the draw.
然后她说，好吧。
And so she said, well, alright.
这是个自由的国家。
This is a free country.
所以我给了她700美元升级到六倍镜，然后她……
So I gave her the $700 to upgrade to to sixes, and she...
刷完卡后，她说，我只卖出去过一个六倍镜，买家是个牙髓病医生。
After she ran the card, she she said, I've only sold one other sixes, and that was to an Endodontist.
你完全在正轨上。
You're right on track.
我的意思是，我们只能治疗我们能看到的东西。
I mean, we can only really treat what we see.
所以我们经常开玩笑说，在CBCT出现之前，牙髓病医生都是在黑暗中操作，当然现在有了引导成像和动态导航这些技术，情况已经大不一样了。
That's why we oftentimes joke that before CBCT, endodontists, do it in the dark and of course it's now guided imaging and things of that nature, dynamic guidance, things have changed.
所以当我们谈到牙裂的时候，Shanon，我们不妨聊聊你在实际中看到的失败和进展，至少在你那个领域里。
So when we talk about cracked teeth, Shanon, let's maybe talk about what you're really seeing in terms of failures and progression, at least within your space.
是不是主要因为密封不当？
Is it more or less due to just improper seal?
我看到的情况是，如果牙髓治疗做得好的话，我遇到的失败案例，或者转回来的病例，大多数都是垂直根折。
I see if it's a good endo, the majority of failures I see or my endos coming back, which are generally quite good, is vertical root fractures.
垂直根折通常发生在磨牙的近中根，或者上颌磨牙的近中颊根。
Vertical root fractures of mesial roots of molar teeth or MBs of upper molar teeth.
然后你回去检查他们的咬合，会发现有大的磨耗面，磨损面。
And then you go back, you look at their occlusion, you've got big facets, wear facets.
很多人失去了尖牙引导，所以他们真的在猛烈撞击那颗牙。
A lot of them have lost their canine guidance, so they're really knocking that tooth.
在很多情况下，我会回顾与转诊牙医的沟通，我会说，看，这个病人有副功能习惯。
And in a lot of cases, I go back to the communication I've had with the referring dentist and I've said, Look, this patient's got parafunctional habits.
你能谈谈怎么把尖牙垫高吗？
Can you please discuss ramping up the canine?
就在尖牙的腭侧粘上一些树脂。
Just put some bonding on the palatal aspects of the canines.
让患者恢复尖牙引导。
Give the patient back the canine guidance.
也许给他们做个咬合垫。
Maybe make them a splint.
有些情况下，这些都没做。
In some cases, that hasn't been done.
结果患者失去了一颗好牙，或者需要对近中颊根做根切来多撑一阵子。
The patient loses a good tooth or needs to have a root resection of the MB to keep it going for a bit longer.
如果当时处理了副功能习惯，那颗牙现在还能保住。
Whereas if they'd managed the parafunctional habits, that patient would still have their tooth.
明白了，明白了。
Gotcha, gotcha.
然后更大的问题，抱歉，是……
And then the other bigger picture, sorry, is a...
所以如果他们失去了牙齿，就做种植牙。
So then if they lose their tooth, have an implant.
如果咬合问题没有解决，种植牙也会失败。
If the inclusion isn't sorted out, that implant will fail as well.
这就引出了另一个关于咬合的讨论。
And that brings us to another discussion about the occlusion.
所以当我们谈到，也许你可以帮我分解一下，我觉得可能是六步法。
So when we talk about, and I'll have you maybe break it down, I think it's the six step approach maybe.
六课。
Six Lessons.
六课。
Six Lessons.
很高兴你问这个问题。
Glad you asked.
还好我提了这个话题。
I'm glad I brought in.
我们开始吧。
We got the adventure.
那这怎么融入进来？我们继续。
So how does that factor So into here we go.
我分析了文献，大概有400篇文章，我对它们都有相当的了解。
So as I analyzed the literature, and it it grew to about 400 articles that I had pretty much a working knowledge of.
然后我把这400篇文章开始分类，最后分成了六类。
And those 400 articles, I started to put them into groups, and they came into six groups.
其中对临床成功最重要的一类就是去龋。
And the group that was the most important as far as clinical success was caries removal.
去龋。
Caries removal.
第一。
Number one.
对。
Yes.
我是说
I mean
所以去除龋齿所需的技术就是龋齿龋齿
So the technology with caries removal that you needed was caries caries
染色指示剂。
dye indicators.
对。
Yes.
我我让你等一下。
I I risked you a second.
第二组
The second group
就像香农说的，是裂纹。
Like Shanon says, was cracks.
而且还有……
And there's...
人们研究裂纹研究了很久，但最后得出的结论就是做全冠修复。
People have been studying cracks forever, but all they came up with put full coverage on
对。
it.
但并不是每次都有效。
But that didn't work every time.
不是每次都有效。
Not every time.
好的。
Okay.
显微镜才是突破性的技术。
Microscope was the breakthrough technology.
嗯，六……
Well, six...
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如果你是牙科学生，六倍放大就够了。
If you're a dental student, six power.
好的。
Okay.
然后第三个是实际的粘接，大多数人认为这是最重要的。
Then the third was the actual bonding, which most people think is the most important.
但是牙齿的即刻牙本质封闭，以及我们所说的树脂涂层，也就是在即刻牙本质封闭上面覆盖的半毫米复合树脂，这是八十年代末从日本传来的，效果差异非常显著。
But the immediate dentin sealing of the tooth and what we call resin coating, which is the first half millimeter of composite on top of your immediate dentin sealing, that came out of Japan in the late eighties, and it showed a huge difference.
但关于强度的数据，我们直到大约2005年才真正拿到。
But the numbers, we didn't have until about 2005, really, for the strengths.
但基本上，如果你把龋齿处理好了，把裂纹处理好了，再用所谓的金标准粘接系统做好即刻牙本质封闭，那么你唯一需要担心的就是所谓的C因子，而这是个很大的问题。
But basically, if you got caries right, if you got cracks right, if you got your immediate dentin sealing with what's called the gold standard bonding system right, then the only thing you had to worry about, which was a big one, which was called c factor.
而C因子，没有人，唯一……
And C factor, nobody, the only...
我本人亲自走访了美国36所牙科学校，当时是为了招募医生来教授这六课。
So I visited personally 36 of the dental student, dental schools in The United States when I was recruiting to teach doctors the Six Lessons.
我每到一个学校，都会去毕业班问：你们用不用龋齿检测染料？
And I'd go to each school and I'd go to the senior class and say, okay, do you guys use caries detecting dye?
不用。
No.
你们了解裂纹吗？
Do you guys know anything about cracks?
不了解。
No.
你们知道即时牙本质封闭吗？
Do you know anything about immediate dentin sealing?
不知道。
No.
不知道。
No.
然后我讲到第四课，问：你们了解C因素吗？
And I go to lesson four, do you know anything about C factor?
有一位牙医，是塔夫茨大学牙科学院的大四学生。
One dentist, dental student, senior at Tufts University dental school.
他说，C因子是粘接面与非粘接面的比例。
He said, C factor is a ratio of bonded and unbonded surfaces.
他说，看，这就是尼奥，你知道，这是给戴维的，他刚开始上牙科学校，但总会有一个真正优秀的学生，我可以
He's like, here he is Neo, you know, this is for Davey who started dental school, but there'll be one, you know, true student that I can
带
bring
出来。
up.
然后我问，那他们教你们怎么克服C因子带来的应力了吗？
And then I said, so what did they teach you about how to overcome the stresses of C factor?
他说，哦，我不知道。
And he says, oh, I don't know.
我打算当牙髓病医生。
I'm going be an endodontist.
他聪明，这让人高兴。
Happy that he's smart.
在这种事情上。
On the stuff like this.
马库斯总是很聪明。
It's always smart one, Marcus.
总是最聪明的那个。
Always the smart one.
他想在那门牙科材料课上拿A的唯一原因，就是为了能专攻某个方向。
Only reason he wanted to get an A in that dental materials class is so he could specialize.
但归根结底，这是可以学到的科学。
But the bottom line is that this is it's learnable science.
这并不容易。
It's not easy.
上周一，我们在Zoom上教了30位医生。
Last Monday, we taught 30 doctors on Zoom.
这就是我们每周一做的事情。
That's what we do every Monday.
所以我们在全球有三个小组，每组十个人，我们教他们C因素。
So we have three groups of 10 around the world and we taught them the C factor.
这是粘接面和非粘接面的比例。
It's a ratio of bonded, un bonded surfaces.
怎么克服C因素呢？
How do you overcome C factor?
这就是秘诀。
This is the secret.
大家都在听吗？
Everybody listening?
我们有一个了。
We got one.
你明白了吗？
You got it?
我们有一个了。
We one.
好的。
Okay.
秘诀是什么？
What's the secret?
你们没关注我的Instagram吗？
Haven't been following me on Instagram?
我已经把秘诀公布出去了。
I've already put the secret out there.
秘诀就是，在给粘接剂光照进行即刻牙本质封闭时，前五分钟内厚度不要超过1.5毫米。
The secret is you don't get thicker than 1.5 millimeters in the first five minutes after you put your light on your adhesive for your immediate dentin sealing.
我的意思是，这就是秘诀，而且是免费的。
I mean, that is the secret and it's free.
好吧，其实这要花12000美元，但这是最值得的12000美元。
Well, really it costs you $12,000, but it's the best $12,000.
现在没有秘密了。
No secret anymore.
不再是秘密了。
Not a secret anymore.
但关键在于，分子要么很笨，要么很听话，你得自己判断。
But the idea is that if you can get molecules are stupid or they're very obedient, you have to decide.
在自由基聚合中，分子只会做它们该做的事，而且它们会移动。
Molecules only do what molecules do in free radical polymerization, and they move.
换句话说，当两个分子连接在一起时，它们会靠得更近。
In other words, when you have two molecules, when they connect, they get closer.
这就是所谓的收缩。
That's what's called shrinkage.
而这种收缩会带来一些后果。
And so that shrinkage has consequences.
但如果复合树脂层能单向移动，那只会让混合层更坚固，甚至比真正的牙本质还要强。
But if you have a unidirectional movement of the composite layers, then it only strengthens the hybrid layer and it becomes stronger than actual dentin.
所以我们创造出了所谓的超级牙本质。
So we create what's called super dentin.
这样你就有了一毫米半的坚不可摧的牙齿结构，把修复体和牙根连接起来。
So you have a millimeter and a half of indestructible tooth structure connecting your restoration to the root.
但你必须让这一毫米半的结构成熟五分钟。
But you have to let that millimeter and a half mature for five minutes.
我们只要求这么多。
That's all we're asking.
三十分钟更好，但五到三十分钟这个窗口期能让你把应力降低百分之七十，甚至百分之八十。
Thirty minutes is better, but five to thirty minutes is that window that allows you to decrease the stress 70%, maybe 80%.
现在这成了我的想法了。
It's my brain now.
确实如此。
It is.
嗯，我很喜欢你刚才的讲解，你其实是在说让分子朝一个方向移动。
Well, I love how you broke that down and really just about you're saying allowing the molecules to move in a unilateral direction.
我们很快休息一下，听听赞助商的广告。
We're gonna take a quick, break to hear from our our sponsors.
牙髓治疗实践伙伴团队很高兴在盐湖城与这么多朋友见面。
The team at Endodontics Practice Partners loved connecting with so many of you in Salt Lake City.
在那里，EPP的医生
While there, EPP's Doctor.
特雷尔·普罗珀录制了一期特别的《牙髓之声》节目，分享了她几十年经验中的领导力心得。
Terrell Proper recorded a special episode of Endo Voices, sharing leadership lessons from her decades of experience.
这期节目将于6月19日上线，记得收听，获取见解、灵感，还有不少笑声。
That episode is available June 19, so be sure to tune in for insight, inspiration and a few laughs.
你看到今年“为你最喜欢的T恤投票”比赛中，住院医生们提交的那些超棒的牙髓主题设计了吗？
Have you seen the incredible Endo theme designs submitted by residents for this year's Root for Your Fave T shirt contest?
你可以在Instagram上查看决赛作品，就在Endo Practice Partners的Instagram页面。
You can check out the finalists on Instagram on the Endo Practice Partners Instagram page.
获胜的T恤将在圣路易斯的APICES会议上分发。
The winning T shirt will be distributed at APICES in St.
路易斯，前三名的设计将获得资金，用于他们的住院医师项目，满足住院医师的需求。
Louis and the top three designs will win funding for their residency program to use for resident needs.
EPP 与各种规模的牙髓病医生合作，在人员配备、薪资、IT、认证和运营方面提供支持，这样你就可以专注于提供优质的患者护理。
EPP partners with endodontists of all sizes, providing support in staffing, payroll, IT, credentialing, and operations so you can focus on delivering excellent patient care.
他们还帮助住院医师找到合适的诊所，让他们有信心开始职业生涯。
They also help residents find the right practice to start their careers with confidence.
请访问 endopracticepartners.com 了解更多信息。
Visit endopracticepartners.com for more information.
牙髓病实践合作伙伴。
Endodontic Practice Partners.
支持牙髓病医生，赋能诊所，塑造职业生涯。
Supporting endodontists, empowering practices, shaping careers.
好的，非常感谢。
Okay, thank you so much.
所以当我们谈论牙本质时，你知道，Shanon 提到了我们见过的垂直根折。
So when we talk about dentin, you know, Shanon brought in the conversation of we've seen vertical root fractures.
在牙科领域，我们正看到一种范式转变，就是尽量保留牙颈周围的牙本质。
Within dentistry, we're seeing the paradigm shift that we're really trying to conserve peri cervical dentin.
所以当你说你创造了一种更强的粘接，如果我说牙齿本身，那个超级牙本质……
So when you're saying you're creating a bond where it's even stronger, if I'm saying that the tooth itself, the super dentin
那是个来自日本的专业术语。
That's a technical term that came out of Japan.
所以，你知道，谁……
So, you know, who's
就像超级马里奥那样。
Like, super Mario.
你会怎么说？
Would you say?
谁是……
Who is...
你读牙髓专科的时候，谁是牙髓领域的权威人物？
Who was like the guru in endo when you went to endo residency?
罗恩·约翰逊还在那里吗？
Was Ron Johnson still there?
还是说不是。
Or is that No.
不是。
No.
史蒂夫·布坎南，他是其中之一吗？
Steve Buchanan, was he one of them?
你知道，太多了。
You know, there's so many.
太多了。
There's so many.
我们就
We'll just
弗兰克·瓦恩。
Frank Wine.
你认识弗兰克·瓦恩吗？
Did you know Frank Wine?
史蒂夫·科恩，你大概认识。
Steve Cohen, you probably do.
你知道吗？
You know?
太多了。
There's so many.
嗯，这些粘接牙科领域的名字，有一半来自日本。
Well, these names in adhesive dentistry, half of them come out of Japan.
是的。
Yes.
在美国根本没人知道他们。
Nobody in The United States even knows them.
我是说，他们都是我的私人朋友。
I mean, are my personal friends.
我不会说日语，但他们说英语。
I don't speak Japanese, but they speak English.
其实，我们讨论的关于日本血管再生的文献，你知道，也是来自日本。
Well, mean, even we talk about the literature on, revascularization at Japan, you know, came out of Japan.
爱荷华。
Iowa.
我
I
忘了。
forgot.
你说。
You go.
岩谷。
Iwaya.
对。
Yes.
继续
Keep
说下去。
going.
还有更多。
There's more.
然后还有星野小林。
And then there's Hoshido Kabayashi.
小林。
Kabayashi.
你知道，我们一直在
Know, we've been
所有这些名字。
all these names.
连在一起。
Bonding.
是叫小林吗？
Kabayashi, was it?
小林？
Kabayashi?
嗯，不是。
Well, no.
也许是中林。
Nakabayashi perhaps.
他是……嗯，混合腿。
He's Well, hybrid leg.
他叫中林。
He named Nakabayashi.
中林。
Nakabayashi.
抱歉。
Sorry.
他去年去世了。
He died last year.
安息了。
Rested.
好吧。
Alright.
我喜欢这个关于直接顶部的想法，我想也许请戴维来谈谈，那个叫什么来着？
I like this idea of the of the immediate ceiling, I wanna maybe bring in Davey, talk about the, what is it?
中央停止区。
The central stop zone.
马库斯很敏锐。
Marcus is sharp.
他确实很敏锐。
He he is sharp.
所以当我们看牙齿时，应该明白活髓牙比死髓牙更好。
So so when we look at teeth, we should understand that a vital tooth is better than a non vital tooth.
是的。
Yes.
这是生命的基本原理。
That is the fundamental basics of life.
所以每个牙髓专科医生都应该以保留每一颗牙髓为使命。
So every endodontist should have this mission to preserve every pulp.
对，这样就不需要做根管治疗了。
Yeah, so it doesn't have to have a root canal.
我同意。
I agree.
就像每个普通牙医都应该把预防性牙科作为首要目标，这样就能防止患者在人生的某个阶段失去牙齿。
Just like every general dentist should have the idea of preventative dentistry as a forefront in terms of You know their goal so they can prevent the tooth being lost at some point in the patient's life.
你通过保住牙髓来获得报酬。
You get paid for saving the life of the pulp.
每个牙医、每个牙髓专科医生都应该这样做。
Every dentist, every endodontist should be saved.
好，我们开始吧。
Hey, here we go.
所以当我们谈论粘接牙科时，它与无龋边缘封闭区的概念紧密相关。
And so when we talk about adhesive dentistry, it's closely connected to this idea of a caries free peripheral seal zone.
我喜欢这个说法。
Love that.
如果我们能有一个无龋边缘封闭区，并且通过理解复合材料的移动和收缩来维持封闭，那么在很多深龋情况下，神经就能愈合。
And if we can have a caries free peripheral seal zone and we can maintain the seal by understanding composite movement and shrinkage, then the nerve can heal in a lot of these deep caries situations.
所以如果你不理解这一点，嘿，如果我能给牙齿一个机会，也许结果会不同。
And so if you don't understand that, hey, if I can give the tooth a chance, maybe I'll have a different outcome.
那么你突然意识到，你在牙科学校学到的关于完全去除龋坏的内容现在是不适用的。
Then all of a sudden you have to realize what you were taught in dental school in terms of complete caries removal is now contraindicated.
所以中央停止区或靠近牙髓处留下所有感染或受影响牙本质的概念，以及因为你理解粘接的层级而维持封闭，是的。
And so the idea of a central stop zone or a place where you just leave all infected or affected dentin near the pulp and you maintain the seal because you understand the hierarchy of bondability Yeah.
你给牙齿一个机会。
You give the tooth a chance.
所以我们支持保留受影响的牙本质。
So we're in support of leaving affected dentin.
还有感染的，还有感染的。
And infected And infected.
这真是个有趣的概念，因为……
Now that's an interesting concept because
拉库齐可不喜欢这个。
Racuzzi doesn't like that.
如果你说意大利语，就别提这个了。
If you speak Italian, don't even go there.
那如果我们提到像马涅这样的名字呢。
Now if we talk about maybe a name like Magne.
马涅。
Magne.
对于牙髓病医生来说，我们现在真的在拥抱修复方面的理念，我们试图抵制香农所说的那种情况，抵制垂直根折，以及那些无法挽救的牙齿。
And for endodontists, we're seeing now where we're really embracing the restorative aspects is we're trying to resist what Shanon was saying, resist against vertical root fractures and those teeth being, unsalvageable.
那这种互动和交叉性怎么体现呢？就是生物仿生牙科，但现在这颗牙需要做根管治疗，然后我们还要做深边缘提升这类操作。
How do we have that interplay, that intersectionality between Biomimetic dentistry, but now the tooth needs to be root canal, and then we're doing deep margin elevation sort of practices.
这个你支持吗？
Is that something that you support?
这是我发明的。
I invented it.
我很想听这个。
I love to hear that.
这正是我想听的。
That's what I wanna hear.
这正是我想听的。
That's what I wanna hear.
对。
Yes.
就像……
It's like...
在我做之前，这从来没发生过。
It never happened before I did it.
我确实支持深边缘提升。
I do support deep barge elevation.
有人想聊聊这个吗？
Anybody wanna talk about that?
我们来聊聊这个吧，因为这是个很有争议的话题……
Let's talk about that because it's such a controversial sub...
因为它有点像，比如说，生物学宽度。
Because it's something like, for instance, biologic width.
它不只是……
It's not just like It's
一个
a
神话。
myth.
不是
It's not
很多。
a lot.
这很遗憾。
It's sad.
我一直这么说。
That's what I've been saying.
就是……
It's...
它会有变化，因为我们都有非常……
It has variation because we all have very...
2.04可能对高年级学生来说不错，但它……
It made two point o four maybe good for the senior, but it...
1.5可能对戴维来说不错。
1.5 maybe good for Davey.
我是说，我们真的得好好想想这个问题。
I mean, we gotta really think about it.
这个……
This...
你知道，很明显，我是个老头子了。
You know, obviously, I'm an old man.
我离死不远了，你知道，但我很享受这个过程。
I'm close to death, you know, but I'm enjoying this.
所以我也一直在享受这个过程。
So I'm I've been enjoying this.
但这可能是我第一次做深边缘提升，那是在1998年。
But this could be the first time that I did deep margin elevation was nineteen ninety eight.
我这么做的原因是因为我在三年的学习中积累了一些粘接牙科的技术。
Get The out of reason I did that is because I had some skills on adhesive dentistry that I'd developed in three years of studying.
而且，要成为一个好的牙髓病医生，这是我当时想做的，你知道，我是由史蒂夫·布坎南培训的，不是史蒂夫·布坎南，你知道，我在做我该做的事。
And so one of the problems to be a good endodontist, which I wanted to do when, you know, I was trained by Steve Buchanan, not Steve Buchanan, you know, I'm doing what I do it.
你必须做好隔离。
You've got to isolate.
我的意思是，你不能把漂白剂注射到病人嘴里，橡皮障也不是万能的，你必须做好隔离。
I mean, you're not going to be, you know, injecting bleach into the patient, you know, rubber dam doesn't, you know, you gotta isolate.
隔离就是一切。
Isolation is everything.
所以如果你有一个深的、深的、深的窝洞，嗯。
So if you have a deep, a deep, a deep box Uh-huh.
如果它已经龋坏了，你首先得把它隔离好。
That's decayed, you first have to isolate it.
我唯一能做到这一点的方法就是粘接牙科技术。
The only way I could do that was with adhesive dentistry.
所以我先把窝洞重建起来，做了磨牙的根管治疗，然后做完之后，我在想，接下来怎么办？
So I built up the box, did the molar endo, and then after that's done, I'm going, what next?
当然，这正是戴夫明天早上要讲的内容。
And of course, that's what Dave is going be speaking on tomorrow morning.
但我的想法是，我绝不会按照传统教条，回到健康的牙体组织上去做牙本质肩领，然后依靠健康的牙体组织，因为那种粘接，那种东西已经用了五年了。
But the idea is that there's no way in the world I would do the dogma of going back to sound two structure to develop my ferrule and to rest on sound two structure because that bond, that stuff is doing it for five years.
它不会消失。
It's not going away.
它不会消失。
It's not going away.
所以，你知道，那时候我拍了照片。
And so, you know, at that point, I took pictures.
然后我第一次见到帕斯卡尔·马涅是在2004年或2005年，他在南加州大学，我开车去那里，那个病例就是我给他看的。
Then the first time I met, Pascal Magne in two thousand and four, five, you know, he was at USC and I drove down there and that's a case that I showed him.
他说，这个还没发表过。
And he said, that hasn't been published.
我说，我知道，因为所有文献我都读过。
And I go, I know, because I've read all the literature.
这个……
This...
其实那篇论文是他导师在同一年发表的，就是1998年，但太冷门了。
It actually had been published by his mentor the same year that I did it, 1998, but it was so obscure.
插图质量太差，没人看懂Dietschy当时在做什么。
The illustration was so poor that nobody understood that Dietschy was, doing that.
不过话说回来，这可以追溯到大约二十五年前。
But anyway, so it goes back to, basically twenty five years ago.
二十五年？但现在……
Twenty five years But now
我们在法国有长达十三年的研究数据，
we have thirteen year studies out of, France,
法国、荷兰……
France, Holland
荷兰，还有Dole's之后的。
Holland and, and after Dole's.
是的。
Yes.
北欧国家总是很棒的，是的。
Scandinavian countries always have great, Yes.
很棒。
Great
所以，不管怎样，我们有十三年的研究，来自日本、法国、荷兰，成功率都在百分之九十五左右。
So, but anyway, we have thirteen year studies and, they come from Japan, they come from France, they come from Holland and it all has like ninety five percent success.
没有生物学宽度侵犯。
There's no biologic width invasion.
没有，而且有根管
There's no And there's a root
治疗的牙齿？
canal treated teeth?
对，根管，根
Yeah, root canal, root
管，你的边缘会在骨下四毫米。
canal where your margin would be four millimeters Subcrest.
骨下...
Sub...
不是，不是骨下。
Not not subcrest.
骨下。
Subcrest.
四毫米的...
Four millimeters of...
从牙骨质界往下。
From the CEJ down.
牙骨质界。
The CEJ.
骨嵴顶。
Crestal.
对。
Yes.
即使是牙槽嵴顶的骨情况也是这样的。
Even crestal bone situations are are things like that.
所以附着就变成了长上皮附着，但结缔组织附着完全没问题。
So the the the attachment becomes a long epithelial attachment, but the, the connective tissue attachment is perfectly happy.
它不出血。
It doesn't bleed.
我的意思是，如果你把探针伸到九毫米深的地方，然后
I mean, if you put your probe down nine millimeters and go
到
to the
骨头，你会碰到一些。
bone, you'll get some.
但那里有一种附着，只要你不去破坏它，就没事。
But there is an attachment that if you don't violate it, it's just fine.
没事。
It's fine.
我跟你说，这几年最让人惊叹的就是现在能买到的各种成型系统，让操作变得简单多了。
I'll tell you what's amazing the last few years is the type of matrix systems you can get now, which make things so much easier.
你当年做的时候，肯定更难，因为那时候几乎没什么系统能帮上忙。
When you were doing it, it must have been even twice as hard because there Well, were hardly
当时确实没什么人做出真正能帮我推进工作的系统，后来有个叫Dentsply Automatrix的。
was any one making a system that really helped me make progress and that was called the Dentsply Automatrix.
我现在还在用。
I still use
因为它够硬，你可以用力推。
Because that it stiff enough that you could push on it.
但现在我们发明了一种新技术，明天Dave会展示，就是在自动成型系统或者Garrison成型系统里加一个铜制成型片。
But now we've invented a technique that Dave will show tomorrow with a copper matrix within an auto matrix or within the Garrison matrix.
Garrison的。
The Garrison.
所以，你大概两天前做过一次提升术吧。
And so you, I mean, you did an elevation about two days ago.
那个挺好的，是九毫米的。
That was a good was a nine millimeter.
九毫米。
Nine millimeter.
哇。
Woah.
你发到IG上了吗？
You posted that on IG?
还没呢。
Not yet.
哦，好的。
Oh, okay.
但是当你在牙槽嵴顶的时候，你知道，这种情况可以通过牙周医生的传统冠延长手术来处理。
I But when you're at Crestal Bone, you know, that's a situation where you can treat that with traditional crown lengthening surgery from a periodontist.
有一本2016年意大利出版的书，展示了二十年的成功案例，全粘接牙科，但他每个病例都用了冠延长手术……
And there's a book that was published in 2016 by out of Italy that showed, twenty year successes, total adhesive dentistry, but he used crown lengthening on every...
几乎每一颗牙都是这样。
Almost every tooth.
他当时有一位牙周病医生合作。
He had a periodontist he was working with.
然后旁边的牙齿现在也……
And then the adjacent tooth was now
但这是个问题。
But that is a problem.
这就是问题所在。
That's the problem.
但是明天你会看到戴维展示的技术，基本上我们已经有……
But with the technique that you'll see tomorrow from Davey, you'll see that basically we haven't done any crown lengthening surgery for
十八年……
eighteen years.
没做过牙冠延长手术了。这种技术创伤小，微创，
It's minimally invasive, it's trauma,
创伤更小。
less invasive.
而这些正是我们
And those are the type
真正希望看到的结果。
of outcomes we really wanna see.
我们谈到牙髓治疗和修复，目前我们看到哪些预后因素？
We talk about endodontically restorative, what are some of the prognostic factors that we're seeing?
好问题，马库斯。
Well, it's good question, Marcus.
传统因素包括已有的根尖周病变、牙髓治疗的质量、牙髓治疗的长度，以及冠方封闭和通畅性。
So the traditional factors existing periapical lesion, quality of the endo, the length of the endo and the coronal seal and patency.
这些显然都围绕感染，因为我们所做的就是消除感染并预防感染。
And that all revolves around infection, obviously, because that's all we're trying to do is eliminate infection and prevent infection.
但我们用锥形束CT做了更多预后研究，它在发现早期病变方面更敏感。
But we've done some more prognostic studies with cone beam, which is more sensitive at picking up early lesions.
我们发现，实际上——这也是我今天下午三点要讲的——我们确认了磨牙的失败率更高。
We found that actually, and it'll be my presentation at 03:00 today, that we've identified that actually molar teeth have a higher failure rate.
其实这在文献里之前没被提到过，但这很明显。
Actually, it hasn't been shown in literature before, but it's a no brainer.
因为解剖结构复杂。
Complex anatomy.
所以，是牙髓治疗的失败，不是修复的失败。
So, are endo failures, not restorative failures.
磨牙，还有剩余牙本质少于30%的后牙。
Molar teeth and also posterior teeth with less than 30% residual dentin left.
对。
Correct.
牙本质是关键。
The dentin is key.
所以我们做了一项研究。
So we've done a study.
我们有一位研究生，他回到了伊拉克，NASA，他是和Monocci教授、我自己还有Rupert Austin一起做的这个研究。
One of our postgraduates who's come back to Iraq, NASA, he did it with Professor Monocci, myself, Rupert Austin.
他通过体积测量来计算剩余牙齿结构的量。
He measured volumetrically the amount of residual tooth structure.
而且我觉得如果牙齿结构少于30%，失败率会高出两倍半。
And I think there's a two and a half times higher failure rate if there's less than 30% tooth structure.
所以这就回到了你如何修复牙齿的问题上。
So this goes back to how you restore the teeth.
你不想做全冠修复。
You do not want full coverage crowns.
如果你有Davey's Caries直接进入的技术，你更想做浅表嵌体，甚至直接复合树脂修复。
Want superficial onlays or even direct composite restorations if you've got the hands of Davey's Caries directed access
还有类似这样的东西。
and things of this And
然后另一件事基本上就是常识了。
then the other thing is basically common sense.
每次拍X光片，或者看片子的时候，都要换手套。
Every time you take a radiograph, interpretive radiograph, change your gloves.
你把橡皮障框架放回去，开始摆弄你的锉刀，手指上全是唾液。
You put the rubber dam frame back on, you start fiddling around with your files, your fingers are covered with saliva.
所以你在给根管消毒，结果又不小心把它重新污染了。
So you're disinfecting the root canal and then you're inadvertently recontaminating it.
这些都是常识性的东西。
It's just common sense stuff.
保持无菌，同时尽量少磨牙。
Keep it all sterile and also minimally prepare the tooth.
如果要做牙尖覆盖的高嵌体，我们只有在替换旧牙冠的时候才会建议做全冠。
And if you need to put a cuspal coverage onlays, I mean, only time we advocate putting a crown on a tooth is if you're replacing a crown.
没有其他情况需要做全冠。
There's no other indication.
所以通常你不推荐间接修复，对吧？
So no indirect, it's not your recommendation usually?
嗯，不是的，如果需要间接修复的话，就用高嵌体。
Well no, indirect if you have to, onlays.
只要你有
As long as you
仿生学的思路，那就有意义。
have a biomimetic approach, so that means something.
所谓仿生学修复，就是追求牙齿外层粘接强度达到大约30兆帕或更高。
So what it means to do a biomimetic approach is that you're shooting for a bond strength of around 30 MPa or more in the outer layers of the tooth.
上面可以是陶瓷、复合树脂或者金，但基本上必须有一个直接复合树脂的基底。
And that could be ceramic, it could be composite, it could be gold on the top, but basically you have to have a composite direct base.
所以每个仿生修复都包含直接修复的部分。
So every biomimetic restoration has a direct component.
而过分关注间接修复，比如漂亮的陶瓷什么的，那方向就错了。
And the the focus on an indirect, you know, beautiful ceramic, whatever, you know, that's just looking the wrong way.
这有点像，哦，又回到了老路子上。
And that's kind of like, oh, giving back to where six piles.
所以前三个桩，然后第四个桩，C因素是最难理解的概念。
So the first three piles and then the fourth pile, the c factor is the most difficult to concept.
但然后你有顶部，那是牙釉质替代，然后六个，对。
But then you have the top, which is enamel replacement, and then six Yep.
是咬合。
Is occlusion.
所以在我开始这个探索之前，咬合就像是解决所有问题的关键，但结果它是最不重要的。
And so before I started this quest, occlusion was like the solving of all the problems, but it turned out to be the least important.
如果你有了这五个，你仍然可能会有咬合问题。
If you got these five, you still can have problems with occlusion.
你必须处理那个，但你必须先确保打好基础。
You have to deal with that, but you have to make sure that you get to the bottom first.
所以我们说仿生学是从底部到顶部。
So we say Biomimetic is a bottom to top.
系统性的方法。
Systematic approach.
从下到上的系统方法。
Systematic bottom to top.
我很喜欢你刚才分解的那个层级结构，因为在牙髓病学里，当我们谈到马克，保存那个
I love that hierarchy that you kind of broke down because within endodontics, when we talked about Mark, saving that
他一直在做研究，我还没有
he's been doing his research, I hasn't
喜欢这个保存天然牙的理念，我们考虑的是层级结构
love this Saving stuff, you the natural teeth, we think about the hierarchy of
也许我们会让他再当一次全科牙医。
Maybe we'll get him in to be a general dentist again.
我
I'm
不过我最关心的是保存牙髓。
all about saving the pulp though.
我有个故事要告诉你。
I got a story I gotta tell you.
来听听这个故事吧。
Let's hear this story.
这些年来，我们培训了六位牙髓病专科医生。
So we've had six endodontist specialists that we've trained over the years.
不。
No.
六个不算多，但都是好样的，他们给我们的反馈水平很高。
Six isn't very much, but six good ones, they give you feedback that is at a great level.
我们培训的第一个，大概是六七年前，叫泰勒·博斯。
So the first one that we trained six, seven years ago is the name Tyler Boss.
他是科罗拉多斯普林斯人。
He's from Colorado Springs.
天哪。
Oh, man.
他做了很多事。
Does so much.
我爸爸还活着。
My dad lives.
大声喊出来
Big shout
科罗拉多那边跟TDO有关，还有你知道的，跟Gary Carr一起。
out Colorado associated with the TDO and, you know, with Gary Carr.
我们去了Gary Carr的实验室。
We went down to Gary Carr's, lab.
我花了一天时间
I spent a day
用扫描电子显微镜。
scanning electron microscope.
我跟其中两个一起待着。
Two of them I was hanging out with.
我在做透射电镜切片，然后我说，你告诉我这些切片有100纳米厚。
I was doing TEM slices, and I'm going, you tell me that these slices are a 100 nanometers thick.
我什么都看不见。
I can't see any
一个都看不见。
of them.
不过，反正，这就是
But, anyway, it's
一个故事。
a story.
但是泰勒·博斯，他接到了科罗拉多斯普林斯最好的修复科医生的电话。
But Tyler Boss, so he gets a call from the best prosthodontist in Colorado Springs.
她说，我有个病例，我觉得自己处理不了，但我觉得你能行。
And she says, I've got a case that I I don't feel like I can treat, but I think you can.
真的吗？
Really?
所以这位修复科医生就把这个病例转介了过来。
So this is the prosthodontist referring this case
转给牙髓科。
To the Endodontics.
这个病例是从一位全科牙医那里转来的，他说这个病人有26颗牙。
Comes from a referral of general dentist who said, this patient has 26 teeth.
全都烂掉了。
They're all bombed out.
我唯一能想到的办法就是全部拔掉，然后种牙，好吧。
The only thing I can think is just take them all out, implants all on Okay.
所以这位修复科医生看了看，像一位好的修复科医生那样，她做了牙髓活力测试。
So the prosthodontist looks at it, and like a good prosthodontist, she endo tests for vitality.
只有六颗牙是死髓牙，其他的虽然烂了，但还有活力，她说，我觉得你可以修复这些牙，但我做不到。
Only six of the teeth are non vital and the others are bombed out, but still, you know, she says, I think you can restore this, but I can't.
所以她转诊了，这位修复科医生把整个口腔的病例都转了过来。
So she refers, the prosthodontist refers the full mouth.
他做了六次根管治疗。
He does the six endos.
他处理了其他18颗牙。
He does the other 18 teeth.
总共涉及24颗牙。
There's 24 teeth involved.
他用仿生学方法处理了其他18颗牙，完成了全口病例，费用只是传统种植体支持修复的一小部分。
Does the other 18 teeth biomimeticly full mouth case at a fraction of what any traditional implant does supported prosthodontics.
总之，这是个故事。
Anyway, this is a story.
他准备开始到处讲这个讲座了。
He's going to start giving that lecture around.
你看，另一件事是回到马库斯说的，保存牙齿，保存牙髓。
You see, the other thing is going back to what Marcus was saying, saving teeth, saving pulps.
因为如果你开始做激进的治疗，比如根管治疗，有时候相当激进，那么那颗牙最终会在15年、20年、25年后失败。
Because if you start doing aggressive treatment, which is an endo, is fairly aggressive sometimes, then that tooth is going to eventually fail in fifteen, twenty, twenty five years time.
但让我
But let me
停一下，所以你说得对，要尽可能拖延时间。
stop So you right won't delay as long as possible.
但我们得聊聊它们为什么会失败。
But we have to let's talk about why they fail.
我的意思是，你刚才暗示了垂直根折。
I mean, you kind of hinted at it a vertical root fracture.
我觉得那大概就是
To I think that's what
我们发现
we find
基本上就是结构性的失败。
more or less is the structural failure.
哦，完全正确。
Oh, absolutely.
没错。
Absolutely.
但是，
But the
问题是，你想尽可能推迟拔牙和种植牙，因为种植牙也不是万无一失的。
thing is you want to delay an extraction and an implant for as long as possible because implants aren't bulletproof.
它们的失败率很高，我觉得百分之三十到四十的人会在几年内出现种植体周围炎。
They have a high, I failure think thirty percent, forty percent have peri implantitis within a few years.
你想把它当作你的王牌。
You want that as your joker in your pack.
所以你需要种植牙，但你会活到大约九十岁。
So you will need an implant, but you're going live to be about 90.
所以推迟根管治疗，如果需要做，就用一种非常微创的方式来做。
So delay that endo, and if you need the endo, do it in a really minimally way.
你通过模仿来修复它。
You restore it by memetically.
然后可能……
And then may...
也许十五、二十年吧。
Maybe fifteen, twenty years
两千块。
two time thousand.
他需要重新做根管治疗。
He needs a re endo.
哦，你太厉害了。
Oh, you base.
选择性到达。
Selectively reaches
我是说，看到一颗根管治疗做得相当不错的牙齿，牙髓病医生肯定会心疼。
I mean, it has to break an endodontist heart to see a tooth where the endo is actually done fairly well.
完美。
Perfect.
而且还有一些好的牙体结构，可以让这颗牙再撑五年、七年，甚至十五年。
And there's still some good tooth structure that you could give this tooth another five, seven, maybe fifteen years.
但全科医生就直接做了那个，哦。
But the general practitioner just makes the Oh.
直接跳到了种植牙，对。
Makes the jump straight to the implant Yeah.
而不是，太疯狂了。
Instead of Crazy.
你知道，把自己埋进土里，真正给这颗牙一个机会。
You know, digging themselves in the dirt and actually giving the tooth a chance.
或者有时候，开髓洞太大，把那么多重要的颈部牙本质都磨掉了。
Or even sometimes when the access is just so aggressive that you removed so much that important peri cervical dentin.
所以当我谈到牙髓治疗时，我们现在说微创牙髓治疗，但我说的是微接触。
And so when I talk about endodontics, I mean, now we say minimally invasive endodontics, but I say minimally engaging.
我喜欢这个说法。
I like that.
微接触牙髓治疗。
Endodontics.
而且，你知道吗，我其实得引用我在意大利的好朋友詹卢卡·贡贝里尼的话。
And, you know, I actually, have to quote my good buddy Gianluca Gomberini in Italy for that.
当我去和他一起玩的时候，
When I went to go hang out with him and
贡贝里尼是在帕斯卡那里受训的。
Gomberini was trained in Pascal.
没错。
Exactly.
在帕斯卡受训。
Trained Pascal.
看看这个。
Look at this.
他是第三代。
He's a third generation.
差不多。
Pretty close.
那我现在得来找你培训了。
So now I need to come get trained by you then.
所以这就是
So that's
你觉得我为什么在这儿？
Why do you think I'm here?
我们有产品要卖。
We have a product to sell.
它可能会改变整个世界。
It could change the whole world.
总之，对。
Anyway Yeah.
我们明天再弄这个。
We'll do that tomorrow.
所以这真是一场很有意思的讨论，你知道，时间总是不等人。
So so this is really fascinating discussion, you know, and, time is always not an ally.
所以我觉得如果你们每个人想简单说两句，我们就收尾吧。
So I think if there's any just a quick point that each one of you wanna make, we'll wrap it up.
但我真的很期待你们再来，因为你们是播客的朋友，牙科行业也需要你们。
But I definitely look forward to having you all back because you're friends of the podcast and dentistry needs you all.
嘿。
Hey.
这才是重点。
This is where it's at.
而且我们老板住在纽约。
And our boss lives in New York.
你知道吗？
Did you know that?
我们公司的CEO，不是，我们的老板。
Our not CEO know of our company.
我们有八个员工。
We have eight employees.
戴维和我就是八名员工中的两个。
Davey and I are one of the eight employees.
太棒了。
Love it.
太棒了。
Love it.
但我们的首席执行官住在纽约市。
But the CEO lives in New York City.
她在那里当音乐老师。
She's a music teacher there.
小妹妹。
Little sister.
我最小的孩子。
My youngest child.
哦，真好。
Oh, lovely.
然后就是
And it's like
这是一家人的事。
It's a family affair.
她是老板。
She's the boss.
她让我们去哪儿，我们就去哪儿。
We we go where she tells us to go.
希望可能会
Hopefully, might be
在那里。
out there.
十月份去印度参加两场实操课程。
Go do two hands on courses at Indian in October.
好的，我们会回到纽约，我肯定会安排很多人来参加那个课程。
Well, we'll come back to New York and I'll I'll definitely have a lot of people lined up to to sit We'll in on that do that.
百分之百。
100%.
太好了。
So great.
好的。
Alright.
那么，谢谢你，马库斯。
So Thank you, Marcus.
这次真是太棒了。
This has been fantastic.
非常感谢。
Thank you much.
戴维，戴维，真的很感谢你们。
Davey, Davey, really appreciate you guys.
谢谢你们邀请我们。
Thanks for having us on.
非常感谢。
Thank you very much.
太好了。
Excellent.
谢谢。
Thank you.
很高兴见到阿勒曼兄弟。
It's great to meet the Alleman brothers.
那个
The
阿勒曼兄弟。
Alleman brothers.
阿勒曼兄弟。
The Alleman brothers.
嘿，在你们走之前，我想特别感谢一下我们的赞助商。
Hey, before you go, I'd like to give a special thanks to our sponsor.
牙髓病实践合作伙伴提供有益的商业资源，以支持和促进我们每个牙髓病诊所的发展。
Endodontic Practice Partners provides beneficial business resources to support and grow each of our endodontic practices.
我们的使命是成为牙髓病医生、他们的员工和患者的可信赖服务伙伴。
Our mission is to be the trusted service partner for endodontists, their staff, and their patients.
我们将为所支持的每个诊所增加价值，并为我们的医生所有者创造有意义的财务回报。
We will add value to every practice we support and create meaningful financial returns for our doctor owners.
感谢您收听本期《牙髓之声》。
Thank you for listening to this episode of Endo Voices.
别忘了订阅，这样您就能收到我们所有即将推出的节目，涵盖牙髓病学最热门的话题。
Don't forget to subscribe so you can catch all of our upcoming episodes covering the hottest topics in endodontics.
一如既往，我们欢迎您提出问题、评论，以及对未来节目主题和嘉宾的想法。
As always, we welcome your questions, comments, and ideas for future show topics and guests.
请发送邮件至endovoicesaae.org，并访问aae.org了解更多关于美国牙髓病医师协会的信息。
Email us at endovoicesaae dot org and visit aae.org for more information on the American Association of Endodontists.
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