47 - 通畅性：事实还是谬误？– 第47期

欢迎收听《内科学之声》，本节目由美国牙体牙髓病学会倾情呈现，我们邀请业内顶尖专家，共同探讨牙体牙髓治疗的艺术与科学，推动患者护理的最高标准。

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.

接下来，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.

能来到2023年美国牙体牙髓病学会年会的芝加哥现场，我们真的非常幸运。

We are so very lucky to be here in AAE twenty three in Chicago.

我是《内科学之声》的主持人，马库斯·约翰逊。

I'm your host, Marcus Johnson for Endo Voices.

每次能和同行、朋友，还有行业里的前辈们聚在一起，都特别开心。

It's always a pleasure to be amongst colleagues and friends and legends.

说到前辈，今天我们有一场堪称传奇的对话。

And speaking of, legends, we have a legendary conversation.

在座的各位，不管是牙体牙髓医生还是其他专业的，如果你没听过多梅尼科·里库奇的名字，那真是没怎么关注过文献，也没怎么接触过学术圈了。说到组织病理学，还有现在讲的牙髓治疗、生物膜，乃至根管治疗的病因和失败机制，你的名字几乎无处不在，里库奇医生。

For those of you who are endodontists and some of you who are not, if you do not know the name Domenico Ricucci, you must have been just not paying attention to any literature or have had any academic experience whatsoever because when it comes to histopathology and even now, I would say, pulp therapy, biofilms, you know, just the whole etiology of root canals and failures, your name is all over, doctor Ricucci.

我特别欢迎你今天来参加我们的节目，和我们聊聊关于根管通畅性的一些话题，真心感谢。

I just wanna welcome you and thank you so much for joining us today to just have some candid discussion about a few topics of patency.

谢谢。

Thank you.

谢谢。

Thank you.

能和你们还有《EndoVoices》这个节目一起交流，我感到非常荣幸。

It is my pleasure to be here with you and and the voices podcast.

感谢你邀请我。

Thank you for inviting me.

当然。

Of course.

对。

Yeah.

我想稍微提一下你的背景。

And and, you know, just to highlight a little bit about your background.

你是一位非常资深的研究者。

You know, you're you're an extensive researcher.

你发表了上百篇论文和著作，还撰写了多个章节和书籍。

You've published upwards of over a 100 articles and publications and written chapters and books.

我总是对咱们这个行业里这份热情感到由衷钦佩。

And so I'm always amazed at the passion that we have for our profession.

在正式开始讨论之前，能不能跟我们聊聊你的求学经历？你是怎么培养出对这份工作的热情，又如何达到如此高的专业水准的？

And so before we get into the discussion, maybe you can kind of just give us a little bit of history on your education and how you develop such a strong passion for what you do and how you do it at such a high level.

是的。

Yeah.

我得说明一下，我拿的是医学博士学位，主修全科医学，因为在我那个年代，牙科还只是医学的一个分支。

Basically, I'm I I need to tell you that I am an MD and graduated in general medicine because at my time dentistry was just a specialty of medicine.

所以你得先当六年全科医生，再学三年牙科，时间确实有点太长了。

So you had to be a general doctor six years before being a dentist another three years, which is too long probably.

可惜这些年来情况已经变了。

Unfortunately, things have changing over the years.

没错。

Right.

现在意大利也有了独立的牙科学院。

And now we have also in Italy a dental faculty.

不过这种体系也有好处，因为能打下扎实的医学和生物学基础，可能正是这些让我对牙齿的生物学，尤其是根管治疗产生了浓厚兴趣。

But it is good for the basis because you receive strong medical and biological basis and probably that was what prompted me to go deeper into the biology of the teeth and particularly about endodontics.

后来我遇到了我的导师，兰盖拉教授。

Then I met my mentor, Professor Langela.

我是在1987年认识他的。

I met him in 1987.

当时他正在意大利讲课。

He was lecturing in Italy.

那时他差不多就要退休了。

He was almost retiring.

后来我们成了朋友。

Then we became friends.

我多次去康涅狄格州拜访他的实验室，学到了制作组织切片的所有技术。

I visited Connecticut many times, his laboratory and I could learn I could learn all the techniques to produce histologic sections.

说到组织学这门科学，我认为这是其中一个关键方面。我们评估病例和治疗效果时，通常会从三个层面来看。

Well, know the science of histology is I think an aspect, know, we kind of look at cases and we look at the three different tiers of gauging outcomes or success.

首先是临床症状，比如有没有疼痛、肿胀这类情况。

Course clinical symptoms, absence of pain, swelling, things of that nature.

其次是影像学方面，我们有没有看到牙周膜、骨组织变化或者吸收这些迹象。

Radigraphic, you know, we're really are we seeing any changes in the PDL, osseous transformation, resorption, things of that nature.

当然，还有组织学层面。

And then of course, histological.

我觉得这正是我们特别欣赏你研究的原因——作为临床医生，我们平时很少关注这一点。

And I think that is one of the reasons why we love your literature is because that's an element that oftentimes as a practicing clinician, we don't consider too much.

没错。

Yes.

你说得很对，这很大程度上是因为你的医学背景，让你对整个生物学过程有了更深的理解。

And you're saying that a lot of it maybe is because your interest stems from your medical background and the understanding of that whole biological process.

没错。

Yes.

不过我得承认，对于牙医，尤其是普通牙医来说，组织学确实有点枯燥，也很难跟上。

Although I have to admit that histology for dentist and general dentists particularly can be boring and can be difficult to follow.

但那正是我的专长。

But that is, let's say, my specialty.

我的意思是，牙齿的组织切片，特别是经过根管治疗后的牙齿切片，应该看得明白才对。

I mean that histology, histologic sections of teeth or let me say, of endodontically treated teeth must be simple to read.

每个牙医都该懂，这样才能真正吸引人。

Everybody, every dentist should understand in order to be attractive.

其实组织学说白了就是组织形态学，看正常和病理状态下组织的形态结构。

But histology is nothing else than histo morphology, the morphology of the tissue in normality and in pathology.

所以，只要经过一点基本训练，每个牙医都能看懂组织切片，因为它们展现的其实就是形态。

So, after a minimum of training, every dentist should be able to follow the histologic slide because they show you just the morphology.

比如谈到感染，经过细菌染色的组织切片能清楚显示生物膜在根管系统复杂结构中的分布，包括主根管、分支和峡部这些关键位置。

For example, talking about infection, histologic sections stained for bacteria can show you the morphology of the biofilm where the biofilm is located in the complexity of the root canal anatomy, the epicenter, the ramifications and the isthmus.

所以理解起来并不难。

So it is easy to follow.

对的。

Yes.

没错。

Yeah.

通过染色，我能明白这确实能让结构变得一目了然。

With the staining, I can understand that it really kind of create makes it very clear.

说实话，这样的讨论很有意思，可惜我们没法展示相关的图片来辅助说明。

You know, having this discussion is interesting, unfortunately, we can't really have the visual aids to kind of support that.

但我们还是希望至少能理解一些有争议的观点，毕竟我们在这里是为了学习，为了用科学和生物学的方法更好地保留牙齿。

But we still want to just at least understand some of the concepts that have maybe have a controversial perspective, but we're here to learn and to look at ways that we can continue to save teeth through sound science and biology.

所以这让我想把话题引向‘通畅性’这个概念。

So that kind of brings me to I want to frame the discussion around the idea of patency.

对。

Yeah.

也许我们先简单回顾一下背景。

And maybe just kind of review the background.

在根管治疗或牙髓病学里，这个定义到底指的是什么？

What does that definition at least within root canal or within endodontics?

对你来说，‘根管通畅’到底意味着什么？

What does that really mean to you?

保持根管通畅这个概念。

The idea of having a patent canal.

是的。

Yes.

我先简单介绍一下，因为根尖通畅的问题与根管预备的终止位置和时间密切相关。

Let me make a short introduction because the problem of apical patency is strictly correlated to the problem of the apical termination of endodontic instrumentation and of duration.

可以说，牙髓治疗分为两个部分。

Let me say the endodontic work is split in two parts.

我称之为生物派，这一派的追随者通常会避免超出根尖的X光终点。

The let me call them biological a kind of biological school and, you know, the followers want to usually stay short of the radiographic apex.

还有一派则主张把所有操作都精确地做到X光下的根尖位置。

Then there is another part and people want to aim at finishing all the procedures at the radiographic apex.

最早提出这个观点的是西尔德教授，赫伯特·西尔德。

Was the first professor was Professor Schilder, Herbert Shilder

尽管从

Although from

西尔德的追随者后来逐渐调整了对根尖X光终点的理解，改用‘根管终端’这个说法，意思是根尖孔可能位于X光终点之前，他们就用这个术语来描述。

the followers of Shilder in time they have been modifying the concept of radiographic apex, they changed the terminology into the terminals of the canal, the apical terminals of the canal, meaning that the foramen can be anticipated, can be short of the radiographic apex and then they use this terminology.

所以根尖通畅性的问题密切相关——那些主张在X光根尖处完成预备的人，并不认为把器械和充填材料延伸到根尖孔、进入牙周膜组织是错误的。

So the problem of patents is strictly correlated because people who want to instrument the canal at the radiographic apex, they do not consider a crime invading with the tissue, with the instrument and with the obturation material the foramen, the foraminal part, which is already a part of the periodontal ligament.

而生物派则主张在根尖狭窄处终止操作，这个点始终位于X光根尖之前。

So on the other part, the follower of the biological school want to terminate the procedure at the apical constriction, which is a point located always short of the radiographic apex.

关于根尖通畅性的讨论，起源于1967年西尔德教授发表的关于三维感的论文，随后在1974年，他又发表了关于器械预备的第二篇论文。

So the story with patency originated with Professor Schilden in 1967 when his publication appeared about the three-dimensional feeling and then in 1974, there was the second publication about instrumentation.

所以，席尔德最初认为，对于没有经验的学生或牙医来说，当时还没有镍钛器械，他们在操作时会产生大量牙本质碎屑、粉末和碎块，这些都会堆积在根尖区域。

So, Schilder started with a consideration that students or dentists with no experience during instrumentation, at that time there were no nickel titanium instrument, they were producing mud, dentin muds, PQ's, dentin chips and these were packed in the apical portion.

于是他们一开始设定了一个工作长度，但后来发现这个长度太短，根本达不到根尖区域。

So they started with a certain working length and then after they realized that the working length was short because they couldn't reach the apical portion.

为了避免这种技术问题，席尔德开始建议用更小的器械反复回溯，一直通到工作长度，甚至超出一点。

So in order to avoid this technical accident, technical problem, Schilder started to think that it would be good to recapitulate, to insist with a smaller instrument going up to the working length and even beyond that.

所以，让一根细小的锉——叫作通畅锉——轻轻进入根尖孔，并不是什么问题，关键是防止碎屑堆积。

So, not consider a problem going with a small file, which was called patency file into the foramen and in order to prevent the package of debris.

这正是最初的设想。

That was the original idea.

但后来，布坎南对‘通畅’这个概念做了更精确的界定。

But then successively, Buchanan has been defining precisely the concept of patency.

再之后，美国牙体牙髓病学会也正式采纳了‘根尖通畅’这个术语。

And and then again also the American Association of Endodontist recognized the terminology, the apical patency.

所谓根尖通畅，就是使用一根细小的手动锉，比如8号、10号或15号，轻轻通过根尖狭窄区，不扩大狭窄区，目的是防止碎屑堆积。

So apical patency is the use of a small hand file, could be a number eight, ten, 15, which is passively moved through the apical constriction without widening the constriction in order to prevent debris accumulation.

这就是定义。

This is the definition.

所以在每次使用器械后，都要用通路锉进行清理。

So the patency file is used after each instrument during instrumentation.

我真的很喜欢关于通路锉的这段历史。在我们的根管治疗培训中，经常讨论放射学根尖和解剖学根尖之间的区别，你刚才其实也提到了这一点。根据研究，这个差距通常在放射学根尖附近0.5毫米，甚至可能达到1毫米。

Well I mean I love that history on the idea of the patency file and within you know our endodontic training we're often discussed the difference between the radiographic apex and the anatomic apex and I think you kind of touched on that and where that difference lies and we say usually based on the studies it lies usually 0.5 to maybe even one millimeter from the radiographic apex.

对。

Yep.

那么当我们谈到清除碎屑、保持通路时，还能不能用这种技术，同时又不损伤牙周膜或根尖组织呢？

And so when we're talking about debris accumulation and maintaining that patency, is it still possible to employ that sort of technique and not disrupt or cause damage to the PDL or the apical tissues?

可以。

Yes.

做根尖通路时，操作者本质上就已经进入了牙周膜区域。

It is a it is when you if you do apical patency, automatically the operator is invading the PDL.

完全是无意的吗？

Just automatically?

这是自动的，因为回到术语上，有些教材至今仍认为根管治疗的终止点应该是牙骨质牙本质界。

It's automatic because the you know, let me go back in terminology and you know that in some textbooks but still today the idle point were to terminate the endodontic procedure is considered the cementum dentin junction.

没错。

That's correct.

之所以这么说，是因为人们普遍认为牙髓组织与牙周膜的过渡区域位于牙骨质牙本质界。

This is in text because it is believed that the transition from the pulp tissue to the periodontal ligament is located at the cementum dentin junction.

但这种说法只对了一部分，因为根尖部的牙髓组织其实是没有成牙本质细胞的。

This is only partially true because the tissue in the apical pulp, the apical pulp is without odontoblast.

所以如果你在光镜下观察，根尖区牙髓和牙周膜的结构其实是完全一样的。

So if you look microscopically in the light microscope, the structure of the pulp in the apical portion and the periodontal ligament, they are the same.

它们都是纤维性结缔组织。

It is a fibrous connective tissue.

里面都有成纤维细胞和胶原纤维。

So you will find fibroblast and collagen fibrous.

因此，根尖部牙髓和牙周膜之间并没有明显的界限。

So there is not a clear difference between the pulp in the apical portion and the PDL.

但最重要的是，牙骨质-牙本质界只是一个组织学上的概念。

But the most important point is that the cementum dentin junction is a histologic point.

你只能在组织切片里看到它，实际操作中根本无法定位。

So you can observe it only in the histologic section, so it is impossible to do that practically.

所以我建议所有同行都别再用这个说法了，因为它根本没法实现。

So I would invite all colleagues to abolish, to forget this terminology because it cannot be realized.

还有另一个关键点。

And then there is another important point.

如果你沿着根尖孔做纵向切片，会发现牙骨质-牙本质界在一侧位于某个特定位置。

If you cut a longitudinal section through the foramen, you will see that the cementum dentin junction is located on one side at a certain level.

而在另一侧，它的位置却不一样，有时相差两到三毫米。

On the opposite side, it is located at a different level, sometimes two, three millimeters.

就算我们能临床识别这个界线，实际操作上依然行不通。

So even though, let's imagine that we could identify clinically the junction, but then practically still it would remain impossible.

所以，别再纠结这个了。

So please forget about that.

我们实际能用来作为终点的，只有根尖的X光影像终点、根管的X光影像末端，或者根尖狭窄处。

The only point that we can practically and realistically use as a termination are either the radiographic apex or the radiographic terminus of the canal or the apical constriction.

根尖狭窄处。

Apical constriction.

有些人也把它叫做最小直径，

Which is some people would call it minor diameter,

那不就是根管的尽头吗？

which Of is course, at the end of the canal?

是的，但我对‘解剖学根尖’这个说法有疑问，容易引起混淆。

Yeah, but I question the terminology anatomical apex because there could be confusion.

解剖学根尖并不等于根尖狭窄处。

Anatomical apex is not the constriction.

关键是要明白，从根尖狭窄处往根尖方向，会有一个向外敞开的空间。

So, is important to know is that from the constriction in an apical direction, you have a space which is open externally.

就像个漏斗一样。

It's like a funnel.

根尖孔？

The foramen?

对，就是根尖孔。

Yeah, the foramen.

它不是一个点，而是一个空间范围。

It is different, which is a volume and not a point.

有些临床医生说他们想把治疗终止在根尖孔，但根尖孔其实是一个区域。

So, some clinicians claim that they want to terminate the procedure at the foramen, the foramen is a volume.

根尖孔指的是大孔口和小孔口之间的这段区域。

The foramen is the part which is between the major foramen, the apical external opening and the minor foramen.

所以它是一个空间，不是单个点。

So it is a volume.

接下来我们得考虑一个问题：如今的电子根尖定位仪，真的能精确识别出根尖孔或者狭窄区的具体位置吗？

And also then we come to the point, can our electronic machine today, apex locators, can, you know, identify exactly what is the frame and or the constriction?

我们的设备其实已经非常精准可靠了，但关键是要会用，因为很多人对这些概念还存在混淆。

Because we have very good, really reliable machine, but we have to learn how to use them because there is a confusion.

我很高兴我们能讨论这个问题，把疑惑澄清一下。

I you know, I'm glad we're having this discussion to clear up the confusion.

接下来我们会从实际操作的角度来谈。

And we're gonna talk about all intents and purposes.

我们会重点讨论J区。

We'll think about the J.

玛莉塔，我们顺便也聊聊那些界限。

Marita just for any discussion on and talk about those lines.

我想再回过头强调一点，让听的人能彻底明白。

I wanted to get back to a point just so it's very clear for anyone listening.

在任何牙齿里，如果填充物到达了X光片上的根尖，就被认为是超填了。

Essentially, we fill to the radiographic apex within any tooth, it's considered long.

填充到根尖位置，就算超填，对吧？

The filling would be considered long, correct?

如果我们填充到X光片上的根尖位置。

If we fill to the radiographic apex.

没错。

Exactly.

你总是会系统性地超出根管的界限，但即使希尔德格在他的论文中也承认了这一点。

You are always systematically beyond the limits of the canal but even Schilder in his publication admitted that.

希尔德格说过，这样做会让器械稍微超出根管的末端边界。

Schilder said that by doing so the instruments are slightly beyond the limit of the root canal space.

但为什么他们非要死守根尖的十字路口，死守X光片上的根尖点呢？

But why should they insist that on the apical cross street, on the radiographic apex?

他坚持这一点，是因为这是你在X光片上始终能明确识别的定位点。

He was insisting because this is the point that you can always recognize in your radio Yes.

所以一切又回到了影像的问题上。

It's So all goes same back to imaging.

对。

Yeah.

正是因为影像的重要性。

Imaging for this reason.

所以他承认器械和材料会超出根管界限，但他认为从生物学角度看这并不重要。

So he admitted that the instruments and materials are beyond the limit, but he said that biologically this is not relevant.

这就是西尔德勒当时所说的话。

This is what Schilder said at that time.

我觉得，即使到现在，这种观点或学派依然存在——有人会说我们破坏了根尖解剖结构，但其实这根本无关紧要。

I I think even that that train of thought or that school of thought is still active today that maybe some would say we're destroying the apical anatomy but it's really not it's irrelevant.

这么说你能明白吗？

Does does that make any sense?

是的，说真的，问题在于，让我开个玩笑。

Yeah, know, the problem is let me joke about that.

我说，如果你在操作时觉得已经到达了根尖的放射学终点，甚至破坏了根尖狭窄区，你的病人也不会因此丧命。

I say that if you decide to instrument and feel that the radiographic apex and so destroying the constriction, you are not killing your patient.

病人不会死，只要没有感染，从放射学和临床效果来看，这些病例最终依然可以取得完全的成功，这一点你要特别注意。

So the patient doesn't die because radiographically and clinically the cases can be absolutely successful in time, pay attention in the absence of infection.

没错。

Yes.

所以关键就在这里。

So this is the point.

所以我们得从累积效应的角度来想，我们对牙周膜和细胞造成了什么影响。

So we have to think in terms of cumulative effect, what we are doing to the periodontal ligament to the cells.

机械损伤加上我们使用的冲洗液和填充或药物材料，共同引发了组织刺激。

So the mechanical insult, the mechanical damage together with the irrigation solutions and the material that we use for filling or for medication, we produce irritation of the tissue.

任何外科切口都会带来刺激，这再正常不过了。

Irritation is an obvious consequence of every surgical cut.

我们确实是在切削。

So, we are cutting.

问题在于，如果你只做到根尖狭窄处，组织被切断的范围很小，因为狭窄处本身创面就很小。

So, the problem is that if you stay at the apical constriction, you produce a severance of the tissue, you produce a wound which is minimal because of the constriction, the surface of this wound is minimal.

但如果你的器械到达了X光片上的根尖位置，情况就不同了。

It is different if your instrument and feel at the radiographic apex.

这意味着超出了狭窄区，因为你对组织造成的损伤更大了。

So means beyond because you are producing more damage to the tissue.

我再强调一遍，你并没有害了病人。只要没有感染，这种刺激感会慢慢消失，组织学上的炎症也会消退。

Now, I do repeat, you are not killing the patient because in the absence of infection in time, irritation disappear, histologic inflammation will disappear.

再假设一下，你用了氧化锌丁香油水泥作为封闭剂，配合牙胶尖。随着时间推移，丁香酚的刺激作用（因为它本身有刺激性）会消失。那从组织学角度看，时间久了我们会观察到什么？

And let's imagine you are using a zinc oxide eugenol cement sealer together with gutta percha and in time the irritant effect of the Eugenol because it is irritant will disappear and histologically what are we observing in time?

我们会看到一些慢性的炎症细胞

We are observing just some chronic inflammatory cells

围绕着

surrounding the

细胞残留的颗粒或牙胶碎片。

granules of the particles of the cell remaining and or gut patches.

它不会引起进行性加重的炎症和症状。

It is not progressively growing inflammation giving symptoms.

这属于亚临床水平。

This is at a subclinical level.

所以临床上牙齿可能没有症状，X光片上也看不到根尖病变。

So clinically, the tooth may be asymptomatic and radiographically you don't have any pediatric lesion.

所以我们把这些情况视为成功。

So we consider these cases successful.

但你知道，这是一条基本原则：单侧操作。

But you know, it's a basic principle of one ear.

外科手术的基本原则就是尽量让伤口越小越好。

Basic principle of surgery, keep the wound as small as possible.

对。

Yes.

微创根管治疗。

Minimally engaging endodontics.

没错。

Exactly.

我觉得这场讨论真的很有趣，待会儿我们再深入聊几个相关概念。

And I guess, you know, this is really fascinating discussion and we'll kind of touch on some more concepts in a bit.

不过既然我们谈到保持牙体解剖结构的自然形态，尽量缩小操作范围，那新型的先进冲洗技术又该怎么看呢？

But since we're talking about keeping the anatomy in its most natural form and keeping it as small as possible, What about the introduction of new advanced irrigation techniques?

GentleWave 和激光治疗。

GentleWave, lasers.

没错。

Yeah.

当我们用这种思路来处理时，目标是让根管尽可能保留自然的解剖形态，让狭窄部分尽量小。

You know, and when we're employing this within that sort of with that sort of thinking that we want to keep the canal represented by its natural anatomy and keep that the constriction as small as possible.

你对这些先进的冲洗技术有什么看法？

What are your thoughts on some of these advanced irrigation technologies?

这是个非常有趣的问题，很有意思。

This is a very intriguing question, interesting.

基于激光的新技术很有前景，很可能代表未来的发展方向。

New technologies based on laser are interesting and probably they will be the future.

唯一的问题是，目前还没有证据表明这些技术能彻底清理根尖区域的不规则空间。

The only problem is that there is no evidence concerning the possibility to completely debride the irregular spaces in the apical portion.

我说这一点时，每个根管治疗医生都明白，我们的难题在于近中根或下颌磨牙、上颌磨牙的峡部，还有吸收区域、侧支根管和分支结构。

And when I say this, every endodontist understands that our problem is isthmus as in mesial root or mandibular molars or upper molars and so on in resorption areas, lateral canals and ramification.

所以，这台设备和这些技术在清除这些区域的组织，特别是坏死和感染组织方面，可能大有帮助。

So potentially, this machine and these technologies can help a lot in debriding these spaces from the tissue, particularly from necrotic and infected tissue.

这正是我们的理想。

This is our dream.

但遗憾的是，目前还没有任何证据能证明这些效果确实存在。

But unfortunately, at the moment, we have no evidence that this really happens, this really occurs.

所以我一直强调，我们需要对根管治疗后的牙齿进行组织学研究，而这类研究现在根本缺乏。

So I always repeat that we would need histologic investigation of endodontically treated teeth and this is lacking today.

在美国和欧洲，由于伦理问题，做这种研究非常困难——在患者嘴里做这种实验，现在根本不可能。

Well, I would say in The US and in Europe, this is difficult for ethical problems because treating teeth, doing this experiment in the mouth of patient is today impossible.

在动物身上做这类实验，如今也同样行不通。

It is impossible also to perform these experiments in animals today.

对。

Yes.

不过我的建议是，可以把这些技术用在已经无法保留的牙齿上，比如牙周病晚期的牙齿，这样不会对患者造成伤害，反正牙齿也保不住了。

But, you know, my recommendation is to use them, know, periodontally terminal teeth, for example, because in those cases you are not abusing patient, the tooth is lost.

假设这颗牙出现垂直和侧向松动，已经丧失了。

The tooth test, let's imagine vertical and lateral mobility and is lost.

所以我觉得，或许可以尝试在牙周状况终末的牙齿上做这类实验，进行根管治疗操作，然后立即取出牙齿检查——这才是最终能证明这项技术是否彻底清除了根管内所有组织的证据。

So I think that maybe this can be attempted to do this kind of experiments and to do the instrumentation, the procedure in vivo and then immediately instruct the tooth because that would be the final evidence whether this technology is removing all the tissue from the endodontic space or not.

在缺乏活体研究的情况下，也可以用刚拔出的新鲜离体牙来做，虽然不完全等同，但至少能大致反映机器的实际效果。

This could be well, in the absence of in vivo studies could be done, these studies can be done also in extracted teeth, freshly extracted teeth, which is not the same, but still it is an approximation of what the machine really is doing.

但最终的验证，还是要靠组织学检查。

But still, the final investigation is the histological investigation.

需要对牙根做连续切片，最好的切面是沿根尖、中段和冠方的横断面。

So serial sectioning of the root and the best sections are the cross section along the apical, middle and coronal turn.

对。

Yes.

对。

Yes.

这一切都非常令人着迷，Ricucci医生。

And this is all very fascinating doctor Ricucci.

你知道吗，我觉得当我们开始研究你做的那些组织学研究时，如果我们理解了通路这个概念，同时逐渐放弃解剖性根尖这个想法，确实如此。

You know, I think one of the when we start to look at the studies that you've done with histology and if we're understanding the idea of patency and we're kind of getting rid of the idea of an anatomical apex and Yeah.

我们开始明白，到底该在哪儿停止根尖预备，怎样才能在每种病例中都保持一个一致的终点。

Kinda understanding where do we stop our apical preparation and how can we make that a consistent point with any within any case.

如果我们说通路这个概念其实并不成立，或者在很多情况下根本不需要考虑，那我们究竟该怎么确定根尖预备的终止点，又该怎么完成充填呢？

Because if we're saying that the the patency concept is really non existent or doesn't need to be applied to many cases, how exactly do we know where to stop our apical preparation and fill our cases?

所有遵循生物学理念的医生，目标都是找到根尖狭窄区。

The you know, all the the followers of the biological school, we aim at locating the apical constriction.

一旦你找到了根尖狭窄区，就不要再往更深的地方去。

Once you located the apical constriction without going beyond

是借助根尖定位仪来实现的吗？

With the with the use of the apex locator

你指的是用根尖定位仪？

you're suggesting?

通过根尖定位仪来操作。

With use of the apex locator.

没错。

Yes.

因为现在的设备和某些宣传手册或某些仪器上写的不一样。

Because the machine contrary to what is written in some brochures or some devices.

没错。

Yes.

现代的设备非常精准，能准确告诉你器械尖端何时离开根管。

The contemporary machines are very precise and they can tell you exactly the moment when the tip of an instrument is leaving the canal.

换句话说，它们能精确地告诉你器械尖端不再被牙本质包裹的那一刻。

In other word, they can tell you with precision the point where the tip of an instrument is no longer surrounded by dentin.

如今每台电子设备都能提供这个信息，只是设置方式不同而已。

Every electronic machine today can tell you this, although they are set in a different way.

所以，只要你了解自己诊室里那台设备的工作方式，并知道它提示的那个点就是狭窄区。

So if you know how your machine, the machine that you have in your office works and if you know that the machine is telling that point, this is the constriction.

尽管

Even though the

双频技术，也就是PDL频率之间的差异，当然还有

The dual frequency, the difference between the PDL, the frequency and of course the

这一点非常精准，因为设备会明确告诉你，此时已经脱离了牙周韧带的影响。

This is very precise because they tell you at this point you are independent of the ligaments.

所以你要在这里停止，精确记录这个点，然后用一系列尺寸逐渐增大的器械，在同一个位置进行操作。

You So know you stop there, you record precisely that point and you bring a series of instruments with increasing sizes at the same point.

这一点如今非常重要，因为根尖预备如果用手动器械完成，效果会更好。

So, is very important today because the apical preparation is better done if you use your hands instead of rotary instruments.

旋转器械固然不错，但每个临床医生都知道，要保持它的

So, rotary instrumentation is good but every clinician knows how difficult is it to maintain the

同样的操作非常困难，

same Very difficult,

是的。

yes.

因为有时候参考点会

Because sometimes The reference point is

确实容易往里拧过头了。

Yeah, tend to screw inside and go beyond.

你在同一个位置依次放入尺寸递增的一系列器械，逐步形成根尖部的形态。

You bring a certain number of instruments of increasing sizes at the same point and you are carving an apical cola at that point.

在填充时这样做非常有用，能帮助你避免超出根尖。

This is very useful in the moment of filling because it helps you to prevent overfilling.

你刚才提到超填的问题，尤其是生物陶瓷类封闭剂可能会对组织造成刺激。

Even you were saying overfilling considering bio ceramic sealers as being traumatic to the

是的，至少你的PDL...

Yeah, at least you PEL

作为

as

在那个位置控制好主尖后，我们就知道需要一种流动性的填充材料，比如传统封闭剂或者现代的生物陶瓷封闭剂。

can control your master point at that point we know then we need a fluid part of the filling which is a sealer, conventional sealer or the modern bio ceramic sealers.

而且我们知道，总会有一点点流动材料超出根尖孔。

And we know that a minimal amount of fluid material is always beyond the corner.

没错。

That's correct.

所以我们不认为这是什么严重问题。

So we don't consider this a tragedy.

问题在于，如果你使用热牙胶充填系统，比如加热的牙胶或类似技术，就会导致牙胶和封闭剂一起被挤出。

The problem is when you use, for example, warm good aperture or softened good for example, thermal field or similar systems and then you have extrusion not only with silhouette but also of gutta percha.

关键在于量的问题，因为传统氧化锌类封闭剂在糊剂中通常更容易、更快地被清除，而树脂类的就不行。

It's a problem of the amount because silhouette, conventional zinc oxide usually in silhouette are restored pretty easily and quicker compared to the resin based.

它们会长时间留在根尖组织里。

They remain in the periapical tissue for a long time.

如果长期残留，这就会成为问题。

And this could be a problem when they remain for a long time.

目前我们对生物陶瓷材料的了解仍然非常有限，而且它们现在比过去更难推广。

We know very little today about the bio ceramic, they are always sold less easily than in the past.

但问题依然存在。

But still the problem remains.

所以如果你能形成一个角落，也就是根尖处的硬组织屏障，这在临床上是个很大的优势。

So if you create a corner, an apical stone, this is a great clinical advantage.

这确实是个临床优势。

That is a clinical advantage.

说到不同的封闭材料，比如环氧树脂或者生物陶瓷，我们知道生物陶瓷确实更生物相容，收缩性也更小。

And when we talk about different sealers, you know, epoxy resin or any sort of the bio ceramic, we know that the bio ceramic, yes, is a little bit more biocompatible, you know, less shrinkage.

它具备很多我们看重的特性。

It has a lot of properties that we value.

有些人甚至认为它还有一定的促骨生成能力。

Some would even say it has some osteogenic, I guess, sort of capabilities as well.

不过，在活髓牙和坏死牙的情况下，我们在确定根尖预备终点时，有没有什么区别呢？

Is there a difference though when we talk about where to define our apical preparation in a vital case versus a necrotic?

也就是说，当我们根据牙髓活力测试或电活力测试来判断牙髓是坏死状态时，诊断结果会不会影响我们根尖预备应该停在哪个位置？

So when does the diagnosis, so to speak, if we're looking at diagnosis as necrotic pulp, vitality based on how we conventionally assess for vitality with our pulp testing or EPT, do we find that there is any difference in where we should stop our apical preparation based on the diagnosis of the tooth?

我们先从你提到的活髓牙说起。

Let's start with the vital cases that you mentioned.

当牙髓是活的时，从根管口到根尖方向，是没有细菌的。

When you have vital pulp from the orifice to go in an apical direction, you have no bacteria.

这对临床医生来说是个很大的优势，因为你不需要应对感染。

So this is a great advantage for the clinician because you are not facing infection.

所以当你到达根尖终止位置时，完全没有必要去破坏根尖部分的分支组织，因为那里的组织是活的。

So when you go to the apical to the apical termination, there is biological and not a single reason to destroy the tissue in the ramifications on the on or in a you know in the apical portion of the canal because the tissue is vital.

因此，制作

So producing

我能打断一下吗？

Can I stop you?

为了明确一下，我们希望保持牙周膜完整，以支持根尖三分之一的活组织。

Just to clarify, so we would we want to keep the PDL intact to support the vital tissue in the apical third.

是的。

Yes.

明白了。

Got it.

保持根尖孔及分支区域组织的活力。

To keep vitality of the tissue in the apical foramen or foramina and in the ramification.

所以在活髓情况下，保持根管通畅在生物学上是没有依据的——让我换个说法，这完全违背了生物学原理。

So in vital cases, patency is biologically against any let me rephrase, is against any biological evidence.

你没必要破坏这些组织，因为根尖分支和不规则区域的牙髓血供，其实是来自牙周膜的。

You don't need to destroy that tissue because you have to think that circulation for the pulp in the ramifications, in the irregularities, the circulation originates from the periodontal ligament.

所以血管是从外向内走的。

So the vessels go from outside to inside.

没错。

Yes.

只要没有感染，这种活力可以长期维持。

So the vitality maintained over the years in the absence of infection.

这一点非常重要，因为在根管治疗中，完全清除牙髓腔内100%的牙髓组织是不可能的。

And this is very important because removing completely 100% of the pulp tissue in the endodontic space is impossible.

这一点我们可以明确地说出来。

And we can say that loud and clear.

医生，您再说一遍。

Say it one more time, doc.

这真的不可能做到。

It's really impossible.

在活髓情况下，侵入根尖组织的预备操作是没有生物学依据的。

In vital cases to make an instrumentation which is invading the prefrontal tissue is not biologically based.

你现在肯定会问，那坏死的情况呢？细菌和感染已经到达根管根尖部分了，怎么办？

Now, obviously you ask me how about necrotic cases in which bacteria and infection can reach the apical portion of the canal.

我告诉你，长期以来，即使存在较大的根尖周病变，根尖区域的组织也可能是有活力的。

Let me tell you that for a long time the tissue in the apical portion, even when you have a large periapical lesion may be vital.

这一点普遍被误解，大学里也不教这个。

This is poorly understood in general and university do not teach that.

但原因很简单：当牙冠部或中1/3牙髓发生严重感染时，毒素、细菌及其代谢产物会通过结缔组织扩散到根尖区，引发免疫反应。

But the reason is very simple because when you have a severe infection in the pulp crown, in the coronal middle third, the toxins or bacteria and byproducts are transported, diffused through the connective tissue into the periapical space where an immune reaction is established.

所以从临床角度看，这其实是个很大的优势。

So practically, this is a great advantage for the clinician.

我们并不确定，但这确实是个很大的优势，因为即使坏死有时会蔓延到大量组织和根管空间，我们依然能在坏死病例中取得很高的成功率。

We don't know that, but it is a great advantage because despite necrosis can be sometimes invading a lot of tissue, a lot of the pulp space, we succeed, we have a high success rate also in necrotic.

没错，确实如此。

That's correct, yes.

原因就在这里：并不是所有坏死情况都会完全侵入根管系统，包括那些不规则的分支结构。

And the reason is exactly this, not in all cases necrosis has been reaching completely the endodontic space including irregularities and ramification.

明白吗？

Okay?

所以，这就是我们今天聚在这里的原因。

So this is the reason why we're here.

不过我得承认，在牙髓退变的最后阶段，坏死确实也可能波及到根尖分支。

But I do admit that in the final stages of the pulp degeneration process, the process can invade also apical ramifications.

这时候，假设你的通路锉能接触到其中一个分支，就有可能破坏那个分支里的生物膜。

And that then practically, let's imagine that you can reach with your patency file one of those ramifications and you can eventually also disrupt the biofilm present in that ramification.

但接下来的问题是，其他分支该怎么办？

But the question then comes in how about the other ramifications?

没错。

That's correct.

是的，根尖解剖结构的复杂性大家都知道。

Yes, the apical anatomy, the complexity of the apical anatomy is well known.

对。

Yes.

所以这大家都是清楚的。

So everybody knows that.

因此，你只清理掉其中一个侧支里的生物膜，

So it is meaningless that you disrupt the biofilm in one aromification and

却不清理其他地方，

not in

这没有意义。

the other.

是的，因为即使使用CBCT，临床上和影像上我们也很难察觉根尖弯曲区域解剖结构的复杂性。

Yes, because clinically and radiographically even using CBCT, are not aware of the complexity of the anatomy in the epical curve.

所以这并没有什么优势。

So still it is not an advantage.

但我得告诉你，还有另一个风险。

But let me tell you, there is another risk.

风险在于，这样做可能会穿透狭窄处，把牙管里的细菌和生物膜碎片推到根尖周围的组织里。

The risk is that by doing this, you penetrating through the constriction carries the risk of transportation of bacteria, pieces of bacteria by film from the canal into the perietic tissue.

我能打断一下吗？

And Can I stop you

就说到这儿。

right there?

这个观点很好。

That's a good concept.

细菌的迁移。

The transportation of bacteria.

不过我想确认一下，在你很多组织学研究和演示中，我们看到通常在牙齿冠方三分之二的区域，坏死组织里的细菌大多都集中在那里。

But just so I'm clear, in a lot of your histological studies and presentations we've seen that usually within I guess the coronal two thirds of the tooth, that's where most of the bacteria in necrotic tissue will be housed.

对吧？

Correct?

是的。

Yes.

你意思是，即使出现了我们所说的根尖病变，

And you're saying that even in the presence of what we call a periapical lesion

是的。

Yes.

这也是因为细菌代谢产物的扩散，而不是根尖病变本身被细菌感染了。

That occurs because of the transfusion of the byproducts of the bacteria, not necessarily that the actual periapical lesion is infected with bacteria.

不，没错。

No, yes.

我说的不是那种极端情况。

I'm not talking about this extreme cases.

所以如果你

So if you

如果那里还有活体组织，当你接触到活体组织时，医生通常能判断出来，因为当你从根管里提取出充满血液、连续的活体组织时，你就能识别出这是活体组织。

have if you have vital tissue there, when you reach the vital tissue usually the clinician is able to understand that because when you start to extract from the canal a tissue that is blood filled, continuous, you recognize the vital tissue.

这对医生来说是很重要的信息。

And this is an important information for the clinician.

但也会有一些长期坏死的病例，当你深入操作到达根尖部分并提取时，如果你观察器械尖端提取出的物质，你会发现有时组织已经坏死。

But there will be cases, cases with long standing necrosis where you go deeper, you reach the apical portion and you extract, if you observe on the tip of your instrument what you are extracting, you can see that the tissue is sometimes necrotic.

明白了

Got

这种情况。

it.

也就是说，坏死已经波及到了牙髓腔的8%。

Meaning that necrosis has already reached reached the 8% portion of the gland.

这类情况的风险在于，细菌可能突破牙髓腔的界限，引发根尖外的感染。

Those are the cases in which the risk can be seen carrying bacteria beyond the limit of the gland and creating an extra radicular infection.

不过，即使你把细菌推到了那里，也不一定会造成临床问题，因为可能会出现术后急性发作。

Now, if you push bacteria there, not always this is a clinical problem because you may have a flare up, you may have a postoperative flare up.

但有时候，免疫系统能处理这种情况。

But sometimes this is managed by the immune system.

但别忘了，有一种特殊的细菌叫放线菌，它们在根尖组织里特别顽强。

But don't forget that we have a particular species of bacteria, which is actinomyces bacteria, which are resistant when they live in periapical tissue.

这就是这类细菌的特点。

So this is the characteristic of those bacteria.

它们会形成菌落，能够抵抗吞噬作用。

They form colonies which can resist phagocytosis.

所以当它们存在于根尖组织时，不仅能存活，还能繁殖，这也是治疗失败的原因之一。

So when they are in the periapical tissue they can survive, multiply and this is one of the reason for failures.

我们称之为根尖外感染。

We call that extra radicular infection.

放线菌通常存在于根管内。

So actinomyces is usually present in the canal.

当你在坏死病例中清理到根管末端时，就有风险把它们带出来。

And when you do your patents in necrotic cases with necrosis up to final portion of the canal, you have the risk to query that.

我确实遇到过一个病例，通过组织切片才发现是放线菌病，这就是它特别顽固的原因。

You know, I actually have had a case, just through the histological sample where we found out that it was actinomycosis and that's why it was so resistant.

广告后马上回来，继续为您带来更多精彩内容。

We'll be right back with more after a quick word from our sponsor.

内科学实践伙伴团队在盐湖城与众多同行交流，非常开心。

The team at endodontic practice partners loved connecting with so many of you in Salt Lake City.

在那里，EPP的特雷尔·普罗珀医生

While there EPP's Doctor.

录制了一期《内科之声》特别节目，分享了她数十年来的领导经验。

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，收获洞见、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‘为最爱根管’T恤设计大赛中住院医师们提交的精彩作品了吗？

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

决赛作品可以在Instagram上关注@endopracticepartners查看。

You can check out the finalists on Instagram on the endopracticepartners Instagram page.