- 學位論文
高雄醫學大學附設醫院保存科2000至2009年根尖手術回溯性病例分析
A retrospective study of apical lesion with surgical endodontic treatment at Chung-Ho memorial hospital Kaohsiung Medical University
摘要
研究目的：持續的根管內感染常會導致根尖周圍炎的產生，進而造成牙根尖周圍組織破壞。大部分病例可藉由非手術性根管治療成功，但因根管解剖構造複雜、根尖外感染或病灶本質的差異等，會導致持續性根尖周圍炎。一般而言，手術性根管治療會於病例無法以傳統根管治療解決時介入。本篇報告統計高雄醫學大學附設中和紀念醫院保存科十年來接受根尖手術的病例，藉由流行病學的調查，來探討本科進行根尖手術的可能原因，並對年齡、性別分佈、手術區域分佈，以及術後的組織病理報告做進一步分析。此外藉由術前X光根尖片的判讀，病歷的調閱，進一步探討不同根尖病變之差異性。期望對術前診斷與傳統根管治療的預後，提供更完整的資訊。 材料與方法：收集高雄醫學大學附設醫院保存科接受根尖手術之患者資料。總共有848位因無法實施傳統根管治療，傳統根管治療失敗或有持續根尖病灶等原因而接受手術性治療。術中取得根尖軟組織樣本送往高醫口腔病理診斷科進行組織病理檢查。選定2007年元月至2009年底共253個根尖手術病例，進行回溯性流行病學調查。調閱病歷資料與X光片，主要紀錄手術的原因、臨床症狀、放射線學影像型態、根尖病變大小。 結果：在十年中，高醫保存科共有848人次接受根尖手術以及送檢之病例。平均年齡為42.5±15歲，最小10歲，最老為86歲，以40~50歲之年齡層最常接受手術治療。上下顎比為3.74：1；男女比為1:1.75。包含1014顆牙齒，手術牙位以上顎側門齒最多，共有280顆，佔全部牙齒的27.6%。口腔病理報告主要分為根尖肉芽腫(periapical granuloma)、根尖囊腫(radicular cyst)、疤痕組織(periapical scar)、以及其他，根尖肉芽腫佔最多數，共596個病例約佔70.3%。根尖囊腫194個病例，盛行率為22.9%。疤痕組織共54例，盛行率為6.4%。其他病變共4例，佔0.5%，包括odontogenic keratocyst、cemento-ossifying fibroma、myxoma、actinomycosis。手術原因方面，以持續性腫痛(41.90%)跟瘻管不消(39.10%)為最主要手術原因。而手術原因與病變種類並無相關性。根尖病變表面積大小方面，樣本數共有192顆牙齒。表面積大小平均值為54.04±57.36mm2。在0~100 mm2的病變中，根尖肉芽腫占比率為72.78%。根尖囊腫佔19.62%，疤痕組織佔7.59%。而在100~200mm2中，根尖肉芽腫占比率為62.07%。根尖囊腫佔37.93%，疤痕組織佔0%。而大於200mm2共五例。統計發現，根尖囊腫的表面積大小顯著大於其餘兩組（F ratio=15.697；p＜0.05）。 結論：近十年高醫保存科根尖848人次手術病例中。男女比為1:1.7，平均年齡為42.5歲。最常接受手術的牙齒為上顎側門齒。根尖病變中以根尖肉芽腫佔最多數，約佔70.3%。根尖囊腫盛行率為 22.9%。疤痕組織6.4%。其他非發炎性病變共4例，佔0.5%。此外根尖囊腫的平均年齡小於根尖肉芽腫。不同根尖病變臨床症狀與病變種類並無關係，無法作為鑑別診斷之依據。最常見的手術原因是疼痛與持續的瘻管形成，其中操作失誤與疤痕組織的發生在統計上有相關性存在。X光透射區表面積方面，根尖囊腫顯著大於其他病變，說明術前X光檢查對於非手術性根管治療之預後評估有一定之參考價值。
並列摘要
Objective Periapical periodontitis is the most frequently diagnosed apical odontogenic lesions for human teeth. The etiologic factor is the presence and colonization of microorganisms within the pulp canal system. However, the host defense system may help to attack the invading microbes and block the entrance of bacteria to the root canal of the teeth with necrotic pulps. As a consequence, the inflammatory response results in the formation of various types of periapical lesions. The cystic periapical lesion has been cited as a factor that may compromise the outcome of root canal treatment. There has been a prolonged debate about the management of large cystic lesions, with some authors maintaining that they can only be treated successfully by surgical intervention. On the other hand, endodontists believe that a large majority of cysts will heal after non-surgical root canal treatment. The aim of this retrospective study was to evaluate a population of periapical lesions treated with periapical surgery in a teaching hospital southern Taiwan. Materials and methods This study comprised a cohort of 848 endodontic surgical cases performed by the staff of the Department of Conservative Dentistry, Kaohsiung Medical University Hospital (KMUH) between 2000 and 2009. Details of age, sex, operative site, symptoms, etiologies of failure, and pathological diagnoses were recorded. The radiographic dimension of the lesion (area in mm2) before surgery was also measured. Results Of the 848 cases, the female to male ratio was 1.75:1, the average age was 42.5 years old ranging from 10–86 years old. We found that 70.3% of the samples were apical granulomas, 22.9% were radicular cyst, 6.4% were apical scar tissue and 0.5% was non-inflammatory apical lesion including odontogenic keratocyst, cemento-ossifying fibroma, odontogenic myxoma and actinomycosis. A total of 1014 teeth were involved with a predominant proportion of maxillary incisors (n=538). Persisted pain (41.90%) and sinus tract (39.10%) were the main reasons for surgery, but not significantly related to different lesion types. For surface area between 100~200mm2, periapical granuloma accounted for 63.3%, radicular cyst for 36.7%, and scar tissue for 0%. Five lesions with lesion area >200mm2 in which four were radicular cysts with remaining one was periapical granuloma. The surface area of the radicular cyst was greater than the other two groups. The lesions of periapical granuloma had no significance difference to the periapical scar. Conclusion: In our cohort of periapical surgery cases, the most common apical lesion were periapical granuloma (about 70.3%).The incidence of radicular cyst and periapical scar was 22.5% and 6.4% respectively. Others non-inflammed apical lesions were 0.5%. The radiolucence of apical lesion of cysts was significant larger than other types of apical lesions. The value of pre-surgery radiographic finding was important for the prognosis of non-surgical root canal treatment. Persisted Pain and sinus tract were the two most common reasons for periapical surgery.