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成年恒牙牙髓切断后牙髓钙化的X线片评价

X-ray evaluation of pulp calcification in adult permanent teeth after pulpotomy

雍颹 , ^{^*

钱锟

,
^{朱文昊

,
^{赵晓一

,
^{刘畅

,
^{and

潘洁}}}}}

雍颹

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钱锟

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朱文昊

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赵晓一

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刘畅

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潘洁

北京大学口腔医学院·口腔医院综合科，国家口腔医学中心，国家口腔疾病临床医学研究中心，口腔生物材料和数字诊疗装备国家工程研究中心，口腔数字医学北京市重点实验室，国家卫生健康委员会口腔医学计算机应用工程技术研究中心，国家药品监督管理局口腔生物材料重点实验室，北京 100081, Department of General Dentistry, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & NHC Research Center of Engineering and Technology for Computerized Dentistry & NMPA Key Laboratory for Dental Materials, Beijing 100081, China 北京大学口腔医学院·口腔医院综合科，国家口腔医学中心，国家口腔疾病临床医学研究中心，口腔生物材料和数字诊疗装备国家工程研究中心，口腔数字医学北京市重点实验室，国家卫生健康委员会口腔医学计算机应用工程技术研究中心，国家药品监督管理局口腔生物材料重点实验室，北京 100081, Department of General Dentistry, Peking University School and Hospital of Stomatology & National Center of Stomatology & National Clinical Research Center for Oral Diseases & National Engineering Research Center of Oral Biomaterials and Digital Medical Devices & Beijing Key Laboratory of Digital Stomatology & NHC Research Center of Engineering and Technology for Computerized Dentistry & NMPA Key Laboratory for Dental Materials, Beijing 100081, China MTA, mineral trioxide aggregate; iRoot, iRoot BP.Gender, n 0.1870.665 Male67 Female1614Average age/years, M (Min, Max)30.7 (16, 59)30.4 (21, 55)0.0930.926Jaw, n 1.1490.284 Upper1612 Lower69Tooth position, n 0.720.396 Premolar96 Molar1315

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2.2. 随访及临床成功率

术后1年随访时失访7例(其中MTA组3例，iRoot组4例)，失访率16%，而术后2年无新增的失访患者。

术后1年时，iRoot组中1例患者因有冷测一过性敏感，临床评价为有效，术后2年该患牙冷测正常，临床评价为治愈。两组1年随访时的成功率均为100%，治愈率分别为94.4% (iRoot组) 及100% (MTA组)，两组治愈率比较差异无统计学意义( P >0.999)。两组2年随访时的成功率和治愈率均为100%。

2.3. 牙髓钙化的X线片随访结果

除7例失访者，36例成功随访病例术前、术后1年和2年的钙化桥指数(DBI0、DBI1、DBI2)以及牙髓钙化指数(PCI0、PCI1、PCI2)分布频率见表 2 和表 3 。术后1年有38.9%的病例有钙化桥形成，术后2年该比例上升为55.6%，经秩和检验，差异均有统计学意义( P < 0.05)。术前的根管影像部分消失的初始比例为5.6%，术后1年为38.9%(包括1例根管影像完全消失的病例), 术后2年达到55.6%，经秩和检验，三组之间以及两两比较差异均有统计学意义( P < 0.05)。健康邻牙术前和术后1年、2年复查时，PCI指数变化差异无统计学意义。典型的前磨牙和磨牙牙髓切断后的钙化表现见图 1 和图 2 ，展示了钙化桥指数1~3级、牙髓钙化指数1~4级的典型表现。DBI及PCI的变化趋势类型及病例数分布见表 4 和表 5 ，术后的DBI和PCI评分呈现与术前持平(DBI占比44.4%、PCI占比25.0%)或逐渐增长(DBI占比55.6%，PCI占比75.0%)的趋势。

表 2

术前、术后1年、术后2年钙化桥指数(DBI)1~3级的分布

Percentage of dentin bridge index (DBI) from Level 1 to 3 before pulpotomy operation, 1-year and 2-year follow up

Level of DBI		Before operation (DBI0)		1-year follow-up (DBI1)		2-year follow-up (DBI2)
Level of DBI		Cases	Percentage	Cases	Percentage	Cases	Percentage
n =36, * P < 0.05, by rank sum test, the DBI difference among the three groups and between every two groups is statistically significant.
1	No dentin bridge	36	100	22	61.1 ^*	16	44.4 ^*
2	Thickness of dentin bridge < 1 mm	0	0	12	33.3 ^*	13	36.1 ^*
3	Thickness of dentinal bridge >1 mm	0	0	2	5.6 ^*	7	19.4 ^*

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表 3

术前、术后1年、术后2年牙髓钙化指数(PCI)1~4级的分布

Percentage of pulp calcification index (PCI) from level 1 to 3 before pulpotomy operation, 1-year and 2-year follow up

Level of PCI		Before operation (PCI0)		1-year follow-up (PCI1)		2-year follow-up (PCI2)
Level of PCI		Cases	Percentage	Cases	Percentage	Cases	Percentage
n =36, * P < 0.05, by rank sum test, the PCI difference among the three groups and between every two groups is statistically significant.
1	No calcification	12	33.3	0	0%	0	0
2	The root canal images become thinner but all of them exist	22	61.1	22	61.1 ^*	16	44.4 ^*
3	Part of the root canal images disappear	2	5.6	13	36.1 ^*	18	50.0 ^*
4	All of the root canal images disappear	0	0	1	2.8 ^*	2	5.6 ^*

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An external file that holds a picture, illustration, etc. Object name is bjdxxbyxb-55-1-88-1.jpg

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图 1

25牙髓切断术后根管钙化表现

Calcification of root canal before and after pulpotomy of the left upper second premolar

A, before pulpotomy operation, PCI0=level 1, DBI0=level 1; B, 1-year follow-up, PCI1=level 2, DBI1=level 2; C, 2-year follow-up, PCI2=level 2, DBI2=level 3.

An external file that holds a picture, illustration, etc. Object name is bjdxxbyxb-55-1-88-2.jpg

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图 2

47牙髓切断术后根管钙化表现

Calcification of root canal before and after pulpotomy of the right lower second molar

A, before pulpotomy operation, PCI0=level 3, DBI0=level 1; B, 1-year follow-up, PCI1=level 3, DBI1=level 3; C, 2-year follow-up, PCI2=level 4, DBI2=level 3.

表 4

钙化桥指数(DBI0、DBI1、DBI2)变化趋势类型及分布病例数

The types of dentin bridge index (DBI0, DBI1, DBI2) variation trend and number of distributed cases

Type	Before operation (DBI0)	1-year follow-up (DBI1)	2-year follow-up (DBI2)	Cases ( n =36)
1	1	1	1	16
2	1	2	2	8
3	1	1	2	5
4	1	2	3	4
5	1	3	3	2
6	1	1	3	1

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表 5

牙髓钙化指数(PCI)变化趋势类型及分布病例数

The types of pulp calcification index (PCI0, PCI1, PCI2) variation trend and number of distributed cases

Type	Before operation (CPI0)	1-year (CPI1)	2-year follow-up (CPI2)	Cases ( n =36)
1	1	2	2	10
2	2	3	3	9
3	2	2	3	7
4	2	2	2	4
5	3	3	3	2
6	2	4	4	1
7	2	3	4	1
8	1	2	3	1
9	1	3	3	1

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Mann-Whitney U 检验结果显示，按照盖髓材料、性别、牙列、牙位因素分别分组，钙化桥指数及其变化(DBI1、DBI2、DBI2 vs . DBI1)与牙髓钙化指数变化(PCI1 vs . PCI0、PCI2 vs . PCI0)的组间差异均无统计学意义( P >0.05)。

经Spearman非参数相关性分析检验，发现年龄与术前牙髓钙化指数(PCI0)正相关( P < 0.05)，但与术后1年、2年的钙化桥指数(DBI1、DBI2)、牙髓钙化指数(PCI1，PCI2)及其变化程度(DBI2 vs . DBI1、PCI1 vs . PCI0、PCI2 vs . PCI0)无相关性( P >0.05)。同样经Spearman非参数相关性分析检验，PCI0与PCI1 vs . PCI0 ( P =0.001)、PCI2 vs . PCI0 (PCI2-PCI0) ( P =0.007)呈高度负相关，但与DBI2 vs . DBI0无相关性( P >0.05)，而DBI2 vs . DBI0与PCI2 vs . PCI0有弱的正相关性( P =0.05)。

3. 讨论

本研究iRoot组与MTA组牙髓切断术均获得良好的疗效，2年的临床成功率均为100%，两者在促进钙化桥形成和牙髓钙化方面差异均无统计学意义。有55.6%的病例形成牙本质桥，同时75.0%的病例牙髓钙化加重。由于本研究样本量有限，以上结论有待大样本量的临床随机对照研究的进一步验证。

以往在对年轻恒牙牙髓切断后髓腔钙化情况的临床研究主要使用定性指标 ^{[

17

]} ，如是否有钙化桥形成、髓角消失、与同名牙相比是否髓腔钙化加重等。本研究改良了美国牙髓病学会的牙髓钙化分级 ^{[

20

]} ，提出DBI和PCI这两个指数的应用，方便将牙髓系统的钙化程度等级化，有利于比较分析。在对成年恒牙进行DBI评分时，发现单根管前磨牙容易测量，而多根管磨牙则易存在争议。因此在X线片评价者评分训练时，统一定义为磨牙钙化桥的测量是从盖髓剂与牙髓接触的位置起，向根管方向纵向测量，同时也向髓腔方向横向测量，钙化桥的厚度取任何一个方向上的最大值。而多根牙的牙髓钙化指数以钙化最重的根管来评价。DBI反映了与盖髓剂紧邻的牙髓组织的钙化程度，而PCI则反映了根管系统的弥漫性钙化趋势。本研究实验组患牙PCI在牙髓切断后2年内有统计学意义的显著增大，而健康邻牙则基本保持不变，说明本研究中PCI指标设置相对比较合理，可以反映牙髓系统加速钙化的趋势，正常的增龄性变化对其干扰较小。

高质量的钙化桥形成可以更好地封闭髓腔，保护牙髓组织，但临床研究发现活髓保存治疗中钙化桥是否存在并不影响成功率 ^{[

14

]} 。本研究也观察到44.4%的临床成功的牙髓切断病例并未形成钙化桥。

本研究DBI变化量与PCI变化量有弱的正相关性，这说明牙髓切断后根管系统弥漫性钙化有可能与钙化桥的形成同步发生。PCI的初始值(PCI0)与PCI的变化量呈高度负相关性，即PCI0越高则PCI的变化量越小，这提示根管钙化度较高的患牙，牙髓切断术后钙化加重的趋势反而较弱。但还存在另一种可能性，即这类患牙用本研究提出的PCI来反映根管钙化加重情况，敏感度不足。而PCI0与DBI及其变化量均无相关性，提示根管原始钙化程度对牙髓切断后牙本质桥的形成可能并没有显著性影响。

本研究年龄对根管系统的初始钙化程度是有影响的，年龄大的患者，初始的牙髓钙化指数(PCI0)较年轻人要高，但经牙髓切断后，牙髓钙化的最终程度和变化量则与年龄不相关。这一结果提示，牙髓切断术有可能打扰了成年恒牙根管系统增龄性钙化的自然进程，使钙化沉积的主体从继发牙本质变为第三期牙本质，客观上加速了根管钙化的进程。本研究发现钙化桥的形成率和厚度均可随复查时间延长而增长，牙髓钙化指数也随复查时间延长而增高，常见到远离盖髓剂部位的根管局部影像消失，甚至出现根管影像完全消失的病例，但本研究中这样的病例临床牙髓活力测试均有活力。成年恒牙牙髓切断后髓腔和根管的钙化趋势，可能是牙髓组织自我修复反应，其远期临床疗效有待进一步观察。本研究结果也提示牙髓切断后根管钙化的X线片表现并不宜作为根管治疗的指征。

综上所述，在本研究有限的样本中，MTA和iRoot BP成年恒牙牙髓切断2年临床成功率均达100%，X线根尖片显示部分病例根管系统有钙化加重的趋势，2年后有55.6%的病例形成钙化桥和根管系统较严重的弥漫性钙化。两种盖髓材料牙髓切断后钙化桥形成以及根管系统钙化程度未见有统计学意义的差异。

Funding Statement

北京大学口腔医院临床新技术新疗法项目(PKUSSNCT-17A14)

Funding Statement

Supported by the New Clinical Technology Program of Peking University School and Hospital of Stomatology (PKUSSNCT-17A14)

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Articles from Journal of Peking University (Health Sciences) are provided here courtesy of Editorial Office of Beijing Da Xue Xue Bao Yi Xue Ban, Peking University Health Science Center

成年恒牙牙髓切断后牙髓钙化的X线片评价

X-ray evaluation of pulp calcification in adult permanent teeth after pulpotomy

雍 颹

钱 锟

朱 文昊

赵 晓一

刘 畅

潘 洁

2.2. 随访及临床成功率

2.3. 牙髓钙化的X线片随访结果

表 2

表 3

表 4

表 5

3. 讨论

Funding Statement

Funding Statement

References

雍颹

钱锟

朱文昊

赵晓一

刘畅

潘洁