38 - 根管治疗中的神经血管损伤 – 第38集

欢迎收听EndoVoices，由美国牙髓病学协会为您呈现。在这个节目中，我们推动牙髓病学的艺术与科学发展，并携手当今顶尖专家，促进最高标准的患者护理。

Welcome to EndoVoices, brought to you by the American Association of Endodontists, 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.

我是说，今天我们能在凤凰城相聚，参加AAE 2022，真是太幸运了。

I mean, what a blessing that we are here today in Phoenix, AAE 2022.

这一刻我们期待已久。

This has just been so long awaited.

你知道，每个人都在不同程度上经历了新冠疫情的考验。

You know, everyone has dealt with COVID on so many different levels.

而自从我们在蒙特利尔首次推出Endo Voices以来，这是我们第一次回到线下会议。

And here we are back for our first in person meeting since Montreal when we first launched Endo Voices.

我是你们的主持人，马库斯·约翰逊医生，能在这里真的非常高兴。

I'm your host, doctor Marcus Johnson, and it's really just, just a pleasure to be here.

我们有一大串很棒的播客嘉宾阵容。

And we have a great lineup of, whole host of podcast guests.

但今天，我们特别要跟保罗·克鲁西医生聊聊，当然还有艾伦·加恩医生。

But today, specifically, we are going to be talking with, Doctor.

保罗·克鲁西医生，当然还有艾伦·加恩医生。

Paul Cruci and of course, Doctor.

艾伦·加恩医生。

Allen Gaon.

希望我没念错名字。

I hope I got that right.

来吧。

Go on.

开始吧。

Come on.

我希望刚才说得没错，不过呢，我当然也得真心感谢一下AAE的工作人员，特别是Hoffman、Tanya Kinsman，还有好多其他人，当然还有音响团队。

I hope that was, right on point, but, of course I would be remiss if I were not to send out a sincere hand of thank you to the AAE staff, more specifically, of course, Hoffman, Tanya Kinsman, and so many of individuals and of course this the sound team.

我们这里有Mike，还有我的好哥们Joel，他们真的促成了很好的合作，帮我们在疫情期间让信息一直流通，还给了我们这个漂亮的录音室，观众就在旁边。

We got Mike here and my good buddy, Joel, who really just allowed a strong collaboration to help us, you know, keep the information flowing throughout the pandemic and gave us this beautiful studio with the audience built in right there.

兄弟，最近怎么样？

How's it going, buddy?

挺好的。

Good.

那就好。

Good.

所以真的很开心。

So it's just a pleasure.

那么，在我们正式开始之前，我想先让你们做个简单的自我介绍。

And so, before we really get into it, I guess I'll let you guys to say a little introduction about yourselves.

我们要讨论的是神经损伤，你们马上有个演讲，而且非常感谢你们从英格兰飞过来，飞了大概十一个小时。

We're gonna be discussing nerve injury and you have a presentation coming up and thank you so much for making that long flight from England things at around eleven hours.

但你知道，这个话题在神经血管损伤中非常重要。

But you know it's a topic that is so important during with neurovascular injury.

作为牙髓病医生和牙医，我们都害怕，不想给病人造成任何伤害，但我们知道，有时候那些意外情况确实会发生。

Know we're all afraid as endodontists and dentists We we don't wanna cause any harm to our patients, but we do know that sometimes, those untoward situations can occur.

那么，话不多说，有请克鲁奇医生。

So, without further ado, doctor Cruci, please.

好的，谢谢你，马库斯，也非常感谢委员会给我们机会来到这座美丽的城市，表达我们的想法。

Well, thank you, Marcus, and thank thank you very much to the committee for allowing us the opportunity to come out to a beautiful city and to, yeah, express our thoughts.

我们之前就有了这个项目的想法，因为我们在讨论同事转诊给我们的病例时，发现很多都是高风险牙齿，比如下颌第二前磨牙、第二磨牙，这些牙齿已经开始了治疗，但在操作风险方面似乎存在盲区，特别是它们与下牙槽神经的接近程度。

So we had the idea of this project a while ago because we were discussing cases that were referred to us by colleagues and we found that quite a lot of them were high risk teeth, so mandibular second premolars, second molars that had had treatment initiated, but there just seemed to be a blind spot in terms of the procedural hazards that these teeth presented in terms of their proximity to the ID nerve.

我们经常讨论这个问题，觉得在评估方面没有指导框架，同事们也很难真正意识到他们什么时候可能会遇到麻烦。

And we were talking about this a lot and thought that you know there's no there's no structure for guidance in terms of assessment and for our colleagues to really recognize when they're potentially getting into trouble.

没有正式的评估标准。

There's no formal assessment criteria.

所以我们想试着想出一个主意，聚在一起，看看能不能想出解决办法。

So we thought we would try and sort of hatch an idea and get together and see if we could work something out.

我们俩都在白金汉郡那边执业，就在伦敦北边，大概三十英里。

So we're both in practice in a place called Buckinghamshire which is just North of London, about 30 miles north of London.

他工作的那个地方，比我的更有历史底蕴，环境也好得多。

He he works in a much nicer area than than mine in terms of historical interest.

他在沃里克。

He's in Warwick.

他在阿默舍姆。

He's in Amersham.

阿默舍姆。

Amersham.

对。

Yes.

阿默舍姆。

Amersham.

好的。

Okay.

我们俩都是在沃里克受的教育。

We both educated in Warwick.

哦，在沃里克受的教育。

Oh, educated in Warwick.

好的。

Okay.

太棒了。

Fantastic.

但是，对，就像你说的，有一个评估风险的方法，然后制定一个流程图，这有多重要呢？

But, yeah, just like you said, I mean, how important is it just to have a a way to assess risk and and and develop a flowchart?

我觉得你说得完全对。

I think you're absolutely right.

我是说，到目前为止，我们听到的都是“近距离接触”这种说法。

I mean, up to now, what we hear is the sentence in close proximity.

我们就是紧挨着，或者离得很近。

We we're bang on top of or we're close to.

我觉得重要的是能够筛选出接近程度和风险，并且能够把这些信息传达给同事和病人，这样我们就能以连贯的方式表达信息，而且这些信息是可以转移的。

And I think it's important to be able to sift out proximity and risk and be able to communicate that to colleagues and to our patients so that we can express the information in a coherent manner and it's transferable.

一旦信息可以转移，就意味着它可以被标注，风险评估也能做得恰当。

Once it's transferable it means it can be annotated and the risk assessments can made properly.

当然，同意是一个大问题，如果你不能恰当地评估风险，你就不能恰当地获得病人的同意。

Consent is a huge issue of course and if you can't risk assess properly you can't consent a patient properly.

当然，这是我们每天都很熟悉的事情。

And of course, that's something we're all familiar with on a day to day basis.

我们需要向病人传达信息。

We need to communicate information to our patients.

对，就像你说的，要有一个标准化的方法。

Yeah, and have a standardized approach like you said.

没错。

Correct.

我觉得把这个带到这次会议上非常棒。

I think that's very brilliant to bring that to this meeting.

这对我们临床医生来说非常宝贵，当我们评估风险以及如何向患者传达这些信息时，让他们真正从自己的角度理解，保留这颗牙齿的相对风险是什么，以及我们需要考虑哪些因素？

And it's so valuable to us as clinicians, when we assess risk and how we kind of communicate that to patients as well so that they can really understand from their perspective what is the relative risk considering saving this tooth and what are the considerations that we have to kind of bring into play?

对。

Correct.

而且还要建立一种我们专业人士之间可以沟通的语言。

And also just creating a language that we can communicate amongst professionals.

所以我们提出了这个分级结构，一级、A级、B级、C级，反映了不同的风险。

So we came up with this tiering structure of Tier one, Tier A, Tier B, Tier C, which reflected various risks.

如果我们能在内部使用这种语言，我们就能通过转诊、向患者传达以及知情同意过程来传递这些信息。

And if we can use that language amongst ourselves, we'd be able to then communicate that information both across referrals but also to patients and through the consent process.

我很喜欢，是的。

Love that, yeah.

我们接下来会深入探讨这个系统以及你们是如何开发的。

And we'll get into a little bit more of that system and how you all develop that.

但对于那些可能对这个话题不太熟悉的人，你们是如何定义神经损伤的？

But just for those who may not be too familiar with the topic in itself, how do you kind of define nerve injury?

具体来说，就是针对做过根管治疗的牙齿。

Specifically talking about endodontically treated teeth.

嗯，我们的研究主要关注的是顺行根管治疗带来的神经损伤风险。

Well, I mean, our study has been focused on the risk of nerve injury posed by orthograde endodontic treatment.

所以不涉及外科根管治疗。

So it doesn't include any reference to surgical endodontics.

这个区分很重要。

Great distinction.

基本上就是任何由器械推出或主要是神经毒性物质溢出引起的神经血管或神经损伤。

It's basically any neurovascular or neural injury that's caused either by extrusion of instrumentation, but mainly what we're talking about here is extrusion of some neurotoxic substance.

比如冲洗液、封闭剂，或者程度较轻的牙胶尖。

So either an irrigant or a sealer or to a lesser extent, gutta perch.

但主要是化学性神经毒性，一旦溢出就来不及了。

But mainly it's a chemical neurotoxicity that is by the time it's extruded, it's too late.

对。

Yes.

这不像你能取出来的固体东西，比如断针碎片或者牙胶尖之类的实物。

It's not like something you can retrieve that's a solid object like a file fragment or, gutta perch or something, some physical object.

等它已经进去之后，你就……

By the time it's gone and it's in there, you've...

你知道，已经太晚了。

You know, it's too late.

听起来那时候就不可逆了。

Sounds like irreversible at that point.

所以是不可逆的损伤，我们对此有明确的界定。

So irreversible damage, and we qualify that.

我们在演示中从解剖学的角度定性分析了……

We we we we qualitatively look at that in the presentation in terms of the anatomy of the...

神经的微观解剖结构，以及外层、内层，这种神经毒性物质会遇到什么，它如何损伤神经，以及这可能如何影响后续的恢复。

The micro anatomy of nerves and the exterior layers, the interior layers of what this neurotoxic substance is going to encounter and how it might damage the nerve, and how that might influence recovery, later on.

所以为了我们这次对话的目的，我们真的不会涉及任何鼻窦并发症或者溢出到上颌窦的情况，主要就是……

And so just for the intents of this conversation, we're really not going to get into any sinus complication or extrusion into the scientists mainly with the...

这关乎

It's about the

能力

ability of

就是……

just...

不，我觉得这样挺好的。

No, think that's good.

你刚刚又为我们发表了一篇论文。

You've just launched another paper us.

你刚刚又发表了一篇论文

You've just launched another paper

为我们。

for us.

确实是的。

I have indeed.

请把我列入参考文献。好的，约翰逊等人，是的。

Please include me in the work cited Okay, Johnson et yeah.

我觉得这很重要。

I think that's important.

所以当我们真正讨论神经毒性和神经的接近程度时，让我们把它放在一个合适的角度，当我们谈论前磨牙、磨牙、第一和第二磨牙时。

So when we're really discussing that neurotoxicity and proximity to the nerve, Let's just kind of put it into perspective when we're talking about premolars, molars, first and second.

我们在文献中看到，大多数这些损伤发生在哪里？

What are we kind of seeing in the literature as to where most of these injuries...

首先，说实话，我觉得这不太常见，对吧？

First of all, think it's not too common to be honest, right?

神经血管损伤，并不是极其常见，但不幸的是，一旦发生，会降低患者的生活质量，还有很多其他因素。

Neurovascular injury, it's not like extremely common, but unfortunately when it does happen, decreases a patient's, just quality of life and so many other factors.

它影响深远。

It has an extensive, impact.

但让我们谈谈我们看到的这些损伤的实际发生率。

But let's just kind of maybe talk about what we're seeing in terms of the actual prevalence of these sort of

事故。

mishaps.

这真的取决于你看谁的资料，但根据文献来源不同，大约在牙髓治疗程序的百分之一到百分之七之间。

Depends who you read, really, but depending on the literature source, it's somewhere between one to seven percent of endodontic procedures.

这要么是第一或第二阶段的，历史上有些研究也涉及神经影响。

That's either first or second stage historically, and some of the studies have had neural impact.

所以，大概在百分之三点五左右，差不多这样。

So, know, somewhere between say three point five percent, something like that.

听起来不多，但如果你不幸遇到这样的损伤，对患者来说后果真的很严重。

It doesn't sound a lot, but the sort of gravity of what actually happens to the patient if you're unlucky to get enough and lucky enough to get an injury like that.

对患者来说可能是毁灭性的，对我们来说也一样。

It can be pretty devastating for the patient and pretty devastating for us as well.

要知道，这真的是很严重的事情。

Know, it's really serious stuff.

律师们也会抓住不放。

The lawyers get their teeth into it.

我们会谈到一些诉讼问题，但你知道，光是心理上、情感上，当然还有身体上，对病人来说都是创伤。

We'll get into some of the litigation, but you know, just the the trauma just from a mental standpoint, emotional, and of course, physically for the patient.

这对双方来说都很难处理，也很难从中恢复过来。

It's difficult to, you know, manage and kind of recover from that from both parts.

我们来聊聊，当这种情况真的发生时，处理流程是什么？

Let's kind of talk about, you know, when that does happen, what is the protocol?

你知道，我们应该遵循什么样的路径？

You know, what's the path that we should sort of follow to?

嗯，我们很幸运，在伦敦有一位学术型的口腔外科医生，叫塔拉·伦顿教授。

Well, we're lucky that we've got, an academic, oral surgeon in London called Professor Tara Renton.

我知道她之前在美国牙髓病学会讲过课，她是一位了不起的女士，在处理这些病例方面做了很多工作，其中很多患者都有严重的永久性神经病变问题。

I know she's spoken at the AAE previously, and she's, an amazing lady who's done a lot of work on management of these cases, a lot of whom have got, you know, some serious permanent neuropathic issues.

所以，这确实伴随着很多社会和心理上的影响。

So I mean, there's a lot of sort of social and emotional impact that goes with this.

这些患者中有很高比例的人患有慢性抑郁症，变得焦虑，当然还有诉讼问题。

High numbers of these patients have chronic depression, become anxious, litigation obviously as well.

但这些人的生活非常痛苦。

But life is awful for these people.

他们不能接吻。

They can't kiss.

他们不能把玻璃杯或杯子放到嘴边。

They can't put a glass or cup to their lips.

说话也很困难。

Speaking is difficult.

有意思的是，在我们出发之前，一位同事给我发了一篇他刚发表的论文的文稿，里面有一个非常悲惨的案例。

Mean, it's interesting before we came away, a colleague sent me a transcript of a paper he's just published with a really tragic case in it.

我把这个案例放进了我的演示文稿里，想给大家看看。

And I've got that in my presentation just to show.

这几乎是最糟糕的情况，但如果对神经离根尖有多近这类简单的事情不够了解，这种情况很容易发生。

I mean, it is almost a worst case scenario, but it's an easy scenario to have happen if one isn't aware of simple things like how close the nerve is to root APCs.

而这个案例几乎包含了所有高风险因素。

And in this case, every element of high risk is encapsulated in this case.

这是一个年轻人。

It's a young person.

是一位年轻女性。

It's a young female person.

术前影像显示，下颌七号牙远中根尖正好压在神经上。

There's preoperative evidence of the apex of the distal root of a lower seven being absolutely on top of the nerve.

所有条件都具备了。

Everything's in place.

再加上操作技术不够熟练，或者牙齿位置不好操作，有人会超出自己的能力范围去尝试。

Then a lack of procedural clinical ability, maybe an inaccessible tooth, someone who's pushing the edge of the envelope of their skill set.

这种情况很容易发生，患者期望很高，你又在赶时间，患者还疼着。

Easily happen patient with high expectation, you're rushing, someone's in pain.

我能一次就诊就完成这个病例吗？

Can I finish this as a single visit case?

这很关键。

It's vital.

是的，我可以。

Yes, I can.

然后突然一切都出问题了。

And then suddenly everything goes wrong.

当你提到那个病例时，我们会尽可能详细地讨论你能分享的具体情况。

When you mentioned that case, and we'll get into the specifics as much as you can share.

当然。

Sure.

如果能理解影像的价值，以及在那个病例中术前使用了什么样的影像，比如三维、二维，以及我们如何正确评估这些，那就太好了。

It'd be nice to kind of understand the value of imaging and what imaging was maybe employed in that case preoperatively when we're talking about three d, two d, and and how do we properly assess that and I

我觉得你说到点子上了。

think you've hit the nail on the head there.

影像至关重要。

Imaging is critical.

作为牙医，我们通常从根尖片开始，也就是标准的根尖周X光片，通常是一张好的根尖片，采用平行投照技术。

We always start as dentists with the IOPA, standard periapical view, usually a good IOPA, paralleling technique.

这通常在普通牙科诊所里做。

That's usually in general practice.

在转到我们专科诊所之前，一般都会先做这个。

It happens before it comes to our practices in specialty.

我们需要帮助普通牙医理解和解读这些X光片。

We need to help general dentists understand and interpret those radiographs.

比如，如果他们看不到下牙槽神经管和牙根尖的关系，他们就得想想，它是不是在那里？

If they can't see, for example, the ID canal in relation to the apices of teeth, they need to think perhaps, is it there?

是不是在附近？

Is it somewhere close?

有没有更好的影像能帮我达到目的，也就是找到下牙槽神经管的走向或形态。

Is there a better image that I can take to achieve what I'm trying to do, which is identify the pathway or the laminarature of the ID canal.

所以有时候我们会建议拍垂直角度根尖片。

So sometimes we recommend taking vertical periapicals.

在下颌六号和七号牙区域稍微难一些，但那些技术我们都学过。

A little more difficult in the lower six and seven regions but there are techniques that we've all learned to do.

我们也知道拍X光片是有风险的，需要注意很多方面。

We also understand that radiography is risky and we have to be mindful of a lot.

尽量使用最少的辐射量。

Uses a little radiation as practical.

所以在对这些患者进行风险评估时，同时兼顾这些因素非常重要。

So it's very important to have all these balls in the air when we're risk assessing these patients.

现在一切都数字化了，几乎全数字化，我们有集中的信息系统，也许可以调出患者以前拍过的影像。

Beautifully now, everything is digital, pretty much all digital, we have centralised information systems, we can perhaps draw on past images that have been taken from the patient.

这些影像可能不是最新的，但可能有旧的扫描，或者旧的OPG、OPT。

It may not be necessarily contemporaneous, but we may have an old scan, we may have an old OPG, OPT.

所以我们可以利用这些信息，我们有责任做一些研究来帮助评估这些病例的风险。

So we can bring in information and it's our responsibility to be doing a little bit of research to try and help risk assess these cases.

是的，这就是二维影像。

So yeah, that's two d imaging.

我们的规程指出，在高风险病例中，三维影像至关重要。

Our protocol says that three d imaging is critical in high risk cases.

不过，我们并不希望所有人都一直做CBCT。

However, we don't want everybody to be taking CBCTs all the time.

那是不合适的。

That's not appropriate.

我们项目的一部分是与颌面放射科医生合作的。

Part of our project here worked with maxillofacial radiologists.

我们把他们请进来，因为我们意识到这对研究至关重要。

We brought them on board because we realised this was a critically important element to the research.

他们明白，LARA在评估病例中非常重要，而不是让全科牙医对每个病例都做CBCT。

And they understood that a a LARA was really important in assessing cases, not letting GDPs taking...

不要对每个进诊所的病例都随意做CBCT。

Take perhaps injudicious CBCTs of every single case that comes into their offices.

所以我们现在在方案中明确了信息传递的流程，以及何时、如何做CBCT，以及选择哪种CBCT扫描。

So we have now created within the protocol the transfer of information and when and how to take a CBCT and which particular CBCT scan.

小视野、高分辨率的CBCT，针对我们需要的区域，我们还会讨论如何评估和报告扫描结果。

A small field of view, high definition CBCT of the area that we want and we're going to be talking about how to assess and report on the scan as well.

所以这是一个过渡。

So it's a transition.

在普通诊所里，用的是二维影像。

In general practice, it's two d imaging.

如果情况复杂，就找专家要第二意见。

If it gets complicated, get second opinion from a specialist.

这里有很多专家，恐怕我们的指南相当保守，这意味着我们这些专家要处理更多复杂和棘手的病例。

There's a lot of specialists here and I'm afraid that our guidelines are quite risk averse and it means that we as specialists are going to be doing a lot more complicated and scary cases.

但这其实是好事，因为我们可能更有能力处理这些病例，也能应对万一出问题时的后续情况。

But that's good because we're probably better positioned to handle these cases and also to deal with the the potential sequelae if something goes wrong.

嗯，从培训的角度和知识基础来看，确实是这样。

Well, definitely from a a training standpoint and just knowledge base.

而且当我们评估风险时，必须非常明确地设定护理标准，而不一定是实践标准。

And when we do assess that risk, we have to be very clear about setting a standard of of care and not necessarily practice.

所以听起来，在这个分级系统里，你们已经发展出了这样的标准，并且能够展示出来。

So it sounds like within this tiered system, you all have kind of developed that and been able to present that.

当我们真正讨论神经血管损伤的细节时，比如说，有没有一个设定的距离，我们说的是，当我们越来越接近，两毫米、三毫米左右，就有更多的

When we really discuss the nuances of a neurovascular injury, just for instance, is there a set distance that we're saying this is, as we get a little bit closer, two millimeters, three millimeters or so, there's more of

风险？

a risk?

或者我们能不能

Or can we kind

谈谈这个。所以我认为我们考虑的是三毫米的安全边际。

of talk about just So I think we're looking at a safety margin of three millimeters.

所以任何在良好的平行投照根尖片上明显可见的，没有过度缩短或过度拉长的。

So anything anything that's demonstrably on a good paralleling periapical view where you've not got full shortening or full lengthening.

如果你能识别出来，最好，你知道，还有其他因素，比如中间的骨质质量。

If you can identify preferably, you know, there are other factors as well such as the intervening bone bone quality.

任何距离和屏障，都是我们希望在根尖和神经之间看到的。

Anything that anything that distance and barrier is what we wanna see between the root apex and the nerve.

距离。

Distance.

我们希望能看到距离。

We wanna see distance.

我们希望看到骨质的屏障。

We wanna see a barrier in terms of bone.

如果我们能看到下牙槽神经管上缘的皮质化，那是另一件我们……

If we can see cortication of the superior board of the IDC, that's another thing that we...

能看到就太好了。

It it would be good to see.

但就这个项目而言，标准是三毫米。

But for the sake of the project, it's it's three millimeters.

三毫米相当安全，前提是没有牙根吸收，而且有中间……

Three millimeters is pretty safe if if it's supported by a lack of root resorption, by inter...

中间有骨质，理想情况下下牙槽神经管上缘也有皮质化，还有颏管。

Intervening bone, ideally some cortication in the superior border of the IDC as well in ferrodental canal.

真正模糊的区域是在一到三毫米之间。

Where you're sort of up for a gray area is really between one and three millimeters.

其中一些病例在普通诊所里可能也能处理，前提是有其他因素支持，比如没有牙根吸收，还有我提到的这个屏障效应。

Some of those cases may be treatable in general practice if they're supported by the other factors, lack of root resorption, and I say this barrier effect.

我想在这个范围内，我们最想发挥影响力的地方，实际上就是行为和治疗方法的选择。

And I guess within that margin, that's where we're trying to have the most influence and actually I guess behavior and treatment.

所以你的意思是，在那个时候建议做CBCT，还是说在评估完CBCT之后再做建议？

And so maybe you're saying making a recommendation at that time to take a CBCT or you're saying after you evaluate the CBCT.

所以这个分级结构正好说明了这一点。

So the tier structure highlights exactly that.

如果你处于安全区域，也就是A级，这意味着在IDC和离治疗牙最近的牙根尖之间有足足三毫米的优质骨质，没有吸收，那就可以放心进行治疗了。

If you're in a safe zone, tier A, which suggests that there is a good three millimeters of good quality bone, no resorption between the IDC and the apex, the closest apex of the treatment tooth, you should be in good stead to proceed with treatment.

当然，前提是还要考虑其他因素，比如病例控制和评估，因为可能还有其他并发症，需要专科医生来处理。

Subject to all the other caveats about a case control and case assessment because of course there may be some other complications that suggest it should be seen by a specialist.

但是，如果距离越来越近，比如牙齿已经失去活力，根尖有透射影，靠近眼管，而且中间没有足够的骨小梁来阻止任何挤出物——不管是液体还是材料——的移动，那就要小心了。

However, if you're getting closer and, for example, it's a non vital tooth with a periapical lucency, a radiographic lucency at the apex, you're getting close to the eyelid canal and there's not much intervening bone trabeculation that's going to stop movement of any extruded material, whether it's liquid, whether it's material.

所以你得开始意识到，这已经变得危险了。

So you have to start thinking this is getting dangerous.

我们现在需要寻求专科医生的意见，并且可以和患者讨论这个问题。

We now need to seek a specialist opinion and we can discuss this with our patients.

这就是分级系统的妙处。

That's the beauty of the tiering system.

你建立了一个可以和患者沟通的结构。

You're creating a structure that you can have a conversation with the patient.

患者不会说，你不知道自己在做什么，就把我转给专科医生。

The patient's not going to say, You don't know what you're doing, you're sending me to a specialist.

牙医会说的是，这是一个高风险或者较高风险的病例。

What the dentist is going to say is, This is a high risk case or a higher risk case.

我会建议你去找专科医生，因为这需要特别熟练的技术来处理，可能他们自己还没有这方面的经验。

I'm going to recommend that you seek specialist pin because it needs to be managed in a particularly skilful way, which perhaps they may not have that experience with.

所以，正如保罗所说，你要看接近程度，看吸收情况，还要看中间骨质的质量。

So, as Paul said, you're looking at closeness or proximity, you're looking at resorption and you're looking about the quality of the intervening bone.

所以如果中间没有骨质，而且距离还是三毫米，我会认为那是相当危险的。

So if there's no intervening bone and it's still three millimeters, I would consider that quite dangerous.

然后我们就把这个病例转给专科医生，我想建议的是，我们和英国的放射科医生一起决定的是，那时候才做CBCT，而不是提前做。

And then we move that to the specialist and I would suggest and what we decided with the radiologist in The UK and we were working with was that is when to take the CBCT, not in advance.

这样牙医或者专科医生就可以根据需要拍CBCT，按照他们需要的清晰度来拍，然后他们就能针对即将进行的治疗进行具体的报告和评估。

So that the dentist can take, specialist can take the CBCT that they require, of the definition that they need, and they'll be able to report and assess it specifically for their forthcoming treatment.

所以这是非常有针对性的。

So it's very, very targeted.

对，我觉得问题在于，如果你遇到一颗B类牙，处于这种灰色地带，而且有神经血管损伤的风险，无论你怎么跟患者沟通知情同意，除非你把风险强调出来，让患者意识到这个风险，否则……

Yeah, I think the problem, if you've got a B tooth where you've got this sort of grey area and there is a neurovascular injury risk, however well you consent the patient, unless you've heightened that risk and brought that awareness of that risk to the patient, then the...

基本上，这个知情同意就不……

Essentially, the consent isn't...

可能是无效的。

Could be invalid.

你知道，我觉得，这个风险……

You know, I think I think the raise...

强调神经血管损伤的风险，在知情同意方面真的非常重要。

The raising of neurovascular injury risk is really important consent wise.

我们可能会在法律上让自己处于不利地位，你知道的。

We could be opening ourselves up to vulnerability legally, you know.

所以我们想强调这一点。

So we want to stress that.

嗯，要想着患者安全，这是整个医疗和医学的基础。

Well, think patient safety, that's the foundation of just health and medicine in general.

我们常提到希波克拉底誓言中的“首先，不伤害”。

We talk about the Hippocratic First do no harm.

首先，不

First do

对，没错。

no Exactly.

我们稍作休息，听一下赞助商的广告。

We're going to take a quick break to hear from our sponsors.

牙髓病诊所合作伙伴团队很高兴在盐湖城与这么多朋友交流。

The team at Endodontics Practice Partners loved connecting with so many of you in Salt Lake City.

当时，EPP的医生也在场。

While there EPP's Doctor.

Terrell Proper录制了一期特别的《Endo Voices》节目，分享了她几十年经验中的领导心得。

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，顺便乐一乐。

That episode is available June 19 so be sure to tune in for insight, inspiration and a few laughs.

你们看过今年“Root For Your Fave”T恤大赛中，住院医师们提交的那些超棒的Endo主题设计吗？

Have you seen the incredible Endo theme designs submitted by residents for this year's Root For Your Fave T shirt contest?

大家可以去 Endo Practice Partners 的 Instagram 账号上看看入围决赛的作品。

You can check out the finalists on Instagram on the Endo Practice Partners Instagram page.

获胜的T恤将在圣路易斯举办的 APICES 大会上发放。

The winning T shirt will be distributed at APICES in St.

前三名的设计将获得资金支持，用于满足住院医师项目的需求。

Louis and the top three designs will win funding for their residency program to use for resident needs.

EPP 与各种规模的牙髓专科医生合作，在人员配置、薪资、IT、资质认证和运营方面提供支持，让你能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.

他们还帮助住院医生找到合适的诊所，让他们自信地开启职业生涯。

They also help residents find the right practice to start their careers with confidence.

更多信息请访问 endopracticepartners.com。

Visit endopracticepartners.com for more information.

牙髓病实践伙伴——支持牙髓病医生，赋能诊所，塑造职业生涯。

Endodontic Practice Partners Supporting endodontists, empowering practices, shaping careers.

好的，非常感谢。

Okay, thank you so much.

所以，能够把这种风险传达清楚，让患者真正在某个层面上理解它。

And so being able to communicate that risk so that the patient can actually understand it at a level

这也延伸到我们该如何带着高风险意识进行对话，讨论最佳治疗方案，并把它带给患者。

And it translates over into how we should be having conversations with high risk in mind about what the best treatment is and bringing it to the patient.

这总是很困难。

It's always difficult.

患者被转诊来做牙髓治疗。

Patients are referred for an endodontic procedure.

他们被转诊过来，预期是要做根管治疗的。

They get referred in the expectations they're going to have a root canal.

但你知道，我们常说，有时候我们的工作就是知道什么时候不该做某些事。

But, you know, sometimes we always say sometimes our job is about knowing when not to do things.

对。

Yes.

而且，你知道，病人来找我们，就是因为知道什么时候不该做。

And, you know, that's why patients come to us is knowing when not to.

就像英国有位学者说的，有些人手里拿着锤子，看什么都像钉子。

As a particular academic in England who says, Some people for whom when they have a hammer in their hand, everything looks like a nail.

我们有些同行就是这样。

Some of our colleagues.

对，没错。

Yeah, exactly.

我们可不想变成那样。

We don't want to be going there.

关键是要知道什么时候该建议说，这颗牙可能更适合拔掉。

It's knowing when to maybe suggest that this is a tooth that's better replaced.

你知道吗，有意思的是看到这怎么融入到……

You know what's interesting is to see how this would into...

在AAE，我们有一个风险评估表，专门用来评估这颗磨牙是不是让新手、普通牙医或者牙髓专科医生都觉得好处理，它分了好几个等级，能指导你下一步该怎么做。

At the AAE, we have a risk assessment form just for assessing is this molar something that maybe a novice a general dentist or endodontist feels comfortable treating there's different tiers which kind of direct you as to, what to do next.

所以当我们真正谈到神经血管损伤时，那就像是另一个层面、另一个组成部分，我们可以把它加进那个风险评估表里。

So when we actually talk about neurovascular injury, that's like another layer another component that we can actually filter into that risk assessment sheet.

所以，你知道，当我们谈到这个的时候，你有没有也考虑到这一点？

And so, you know, when we talk about that, did you consider that as well?

是的，先生。

Yes, sir.

根管本身的复杂性？

The complexity of the root canal itself?

我觉得这正是我们想引入的，把它作为另一套评估参数的一部分。

I think that's I think exactly that we want to introduce it as part and parcel of another series of parameters for assessment.

每个病例当然都要全面评估，但设立这个特定的分级真的很重要。

Every case should be assessed of course in its entirety but creating this specific tier is really important.

另外，在AAE发布的指南和声明里也有提到。

Also in the guidelines, in the statement that has been published by the AAE.

那是一份很棒的文件，但我希望在下一版里能看到神经血管撕裂的内容。

It's an excellent document, but I'd like to see Neurovascular Tearing perhaps in the next iteration.

那会非常好。

It would be wonderful.

如果真是这样，我会感到非常荣幸。

Be very honored if that was the case.

我觉得我们需要那种合作。

I think we'll need that collaboration.

我想这就是计划。

Think that's the plan.

我们看到了……

We saw...

我注意到的一点是……

I mean, one thing I did pick up there was the...

他们说得挺对的，用注射器来输送封闭剂或氢氧化钙，因为不好控制，在这些情况下相对不可控。

I mean, they quite rightly make the point that using a syringe able delivery for a sealer or calcium hydroxide is, you know, because it's uncontrolled, relatively uncontrolled in these cases, to be used.

但也许可以考虑用螺旋输送针。

But you should maybe consider using a lentilospiral.

这让我有点发怵，因为我担心那个，因为那种针太细了。

Well, that made me go a bit cold because I worry about that because one of the problems with those is they're so thin.

如果加个橡胶限位器，你怎么确定深度呢？

How you're gonna depth orientate them if you put a rubber stop on it.

那是一种非常细的金属丝，而且它还在转。

It's it's a really skinny little gauge of wire, and this thing's going around.

所以它可能上下移动。

So that thing can move up or down.

很容易理解，在关键病例中，你原本在螺旋输送针上设定的深度标记可能会出大问题，那个限位器可能会移动。

It's really easy to see how that that that depth orientation that you'd have on your lentil, though, in a critical case could go badly wrong and that stop could move.

所以，也许委员会可以考虑在建议方面做些修改。

So, maybe that's something that the committee might think about modifying in terms of advice.

说实话，这确实让我有点担心。

It just did worry me a bit, I must admit.

你知道，这引出了另一个关于材料的话题。

You know, that that brings up another point when we discuss materials.

现在我们看到了很多关于生物陶瓷封闭剂的文献和支持。

And now we've seen so much, literature and just support for bio ceramic sealers.

我们对此感到高兴，因为它膨胀有限，而且非常稳定。

And we celebrate it because the limited expansion and, you know, it's very stable.

而且它往往更生物相容，神经毒性也更低。

But also it tends to be more biocompatible and not as neurotoxic.

那么，当我们查看文献时，我们看到哪些类型的封闭剂或材料涉及这些神经血管损伤事故？

So when we look at the literature, what sort of sealers or materials are we seeing that are involved in these neurovascular injury, accidents?

嗯，所有东西都有神经毒性。

Well, everything's neurotoxic.

我的意思是，你看，从丁香油酚到树脂再到生物陶瓷，什么都有。

I mean, you choose, look at everything from Eugenol to resins to bio ceramics.

你什么都不想要。

You don't want anything.

任何东西都会引起神经毒性，所以你什么都不想要。

Anything is going to cause neurotoxicity, so you don't want anything.

最近有一个……

There's a recent...

有一篇我们在文章里提到过的论文，在……

There's a there's a paper we made reference to in the article in the...

抱歉，在文章里，还有明天讲座里提到的，关于生物陶瓷风险增加的问题，因为某些技术中使用的量更大了。

I'm sorry, in the article and in the lecture tomorrow about the increased potential risk of bio ceramics because of the increased volume that's used in some of the techniques.

所以，你知道，这些东西的固定性到底有多强。

So, it's it's, you know, how fixotrophic are these things.

所以当你开始给它们施加压力时，它们会不会更容易被挤出？

So when you start putting pressure on them, do they become more extrusible?

我觉得，这还是要看医生自己用着顺不顺手，你愿意用多少封闭剂？

Think I think it's it's it's it's what what works in that practitioner's hands, you know, how how how much sealer are you happy using?

你想让它在那里面到处流动吗？

Do you want it glooping around in there?

那你就……

Then you...

我会选更……

I'd go for much...

你知道，保罗，这……

Know, Paul, it's it's...

我就……

I'm like...

我告诉你一个秘密。

I'm going to let you into a secret.

我们要分享这个秘密。

We're gonna share the secret.

分享这个秘密吧。

Share the secret.

你知道吗？

You know what?

保罗，我脑子里一下子冒出好多想法，而且很有意思的是，随着牙髓病学领域的范式转变，牙本质保存和更多基于封闭剂的充填方式出现，随之而来的就是更多封闭剂的溢出。

It's just so many things come to mind Paul and it's interesting because as we have see a paradigm shift within endodontics, dentin conservation and more sealer based obturation and with that comes the extrusion of more sealer.

所以我想我们应该预料到会有更多的神经毒性。

So I guess we should expect to see more neurotoxicity.

这基于……

It based on...

我觉得关键是要识别它。

I think it's recognizing it.

我觉得是要学习处理根尖三分之一的技术。

I think it's learning techniques to manage the apical third.

这就是我要说的秘密。

And this is the secret I was going

来展示一下。好的，你说得对。

to show Okay, you right

是的，你真是个非常好的主持人。

so yeah, you're a very good host.

你真的……

You've really...

嗯，你

Well, you

明白了。

got it.

Adieu 非常……

Adieu is very...

我们不想透露太多秘密，但我们正在努力开发一个实用的方案，帮助牙医以技术性的方式管理这些高风险病例。

We don't want to give away too many secrets, but we're working very hard on trying to develop a practical protocol to assist dentists in managing these high risk cases in a technical way.

记住，预防才是关键。

Remember, it's all about prevention.

所以我们要尝试处理根尖，特别是在感染病例中，会有一些吸收的情况，我们需要设计某种捕捉系统，一个根尖捕捉区，并且非常非常小心地处理它。

So we're going to try and manage the apex, particularly in cases that are infected where there's going to be some element of resorption, where we're going to have to design some form of capture system, an apical capture zone, and manage that very, very carefully.

我们讨论的是锉针放置的位置，如何管理锉针的长度，以及如何确定锉针的长度。

Talking about where to place files, how to manage the length of files, how to length determine files.

控制就是一切。

You've control is everything.

完全正确。

Absolutely.

是的。

Yes.

还有测量的问题，你知道，最大的问题是紧密弯曲的根管，你通常使用带槽的锉针，K型锉，来尝试测量你的根尖孔直径。

And the issue of gauging, you know, the big problem, tight radius curves, you're using a fluted file, a K file in most cases to try and gauge, you know, your AF diameter.

它们的问题在于它们是有锥度的。

The problem with them is that they're tapered.

所以，你知道，在紧密弯曲的根管中，很难获得触觉反馈，因为可能有更多的冠方摩擦阻力。

So, you know, very often it's very difficult to get a tactile feedback around a tight radius curve where there could be more coronal frictional binding.

那你得到的这种反馈，这种触觉反馈，到底有多准确呢？

So how faithful is that feedback that you're getting, that tactile feedback Yeah.

就是器械本身，在末端停下来的时候，那种感觉。

Of of the, the file actually, you know, having a stop at at the terminus?

在牙体较长、根尖弯曲半径又小的情况下，有多少感觉其实是来自冠方的束缚？

And how much of that is potentially coronally binding in a long tooth with a tight radius apical curve.

所以我们对此有一些想法，也许器械制造商可以考虑一些方向，来减少那种假阳性反馈——就是器械在冠方被卡住时你得到的那种感觉，而实际上你想得到的是……

So we've got some thoughts on that and maybe directions that instrument manufacturers might like to consider in terms of reducing the the sort of false positive feedback that you're getting from an instrument that's binding more coronally in terms of trying to get that...

我好像没解释清楚。

I'm not explaining this very well.

不。

No.

你解释得很清楚。

You're explaining it very well.

你知道吗，我刚才在想，你刚才讨论的时候，我们其实在聊封闭剂、材料和超充，但你也提到了冲洗。

You know, I I was I was just thinking, when you're discussing that right now we're kind of discussing sealers and materials and extrusion, but you also mentioned irrigation.