文献直达露髓后的牙髓止血效果能否用于准确

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PEDIATRICDENTISTRYV40/NO1JAN/FEB18

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露髓后的牙髓止血效果能否用于准确评估牙髓炎症程度？

原文标题：DoesAchievementofHemostasisAfterPulpExposureProvideanAccurateAssessmentofPulpInflammation?

原文作者：MerveMutluay,DDS,PhDVolkanAr?kan,DDS,PhDProf.SaziyeSar?,DDS,PhDProf.ü?lerK?sa,DDS,PhD

译 　　者：齐帅

校 　　对：汪　鹭　何本科　

审 　　阅：高艳霞

摘要

目的：本研究的目的在于探讨，龋源性露髓的乳磨牙中，露髓点和根管口处的牙髓止血效果是否能反映根管口处牙髓的炎症状态（炎症状态用细胞因子水平来测试）。

方法：本研究共纳入40例下颌乳磨牙深龋病例。将牙齿分为两组：A组牙齿的露髓点能在5分钟内止血，B组牙齿的露髓位点无法在5分钟内止血。在露髓点和根管口处采集血样，用ELISA法检测所有样本的细胞因子水平，包括IL-1β,IL-2,IL-6,IL-8,IL-10,TNF-α和前列腺素E2。

结果:A组露髓点的IL-6水平显著高于B组，但AB两组间根管口处血样的细胞因子水平差异无统计学意义。

结论：露髓点或根管口的止血效果并不能准确的评估牙髓炎症，若据此作出龋源性露髓的乳牙是否进行活髓治疗的治疗决策有误导可能。

关键词：细胞因子，ELISA（一种免疫方法），乳牙，龋源性露髓，牙髓炎症

Abstract：Purpose：Thepurposeofthisstudywastodetermineinprimarymolarswithcariousexposureswhetherhemostasisattheexpo-suresiteandpulporificereflectedinflammatorystatusofthepulpatthecanalorificebasedoncytokinelevels.Methods:Fortymandibu-larprimarymolarswithdeepcarieswereincludedinthestudy.Teethweredividedintotwogroups:groupAhadteethwherehemostasisattheexposuresitewasachievedwithinfiveminutes,andgroupBhadteethwherehemostasisattheexposuresitecouldnotbeachievedwithinfiveminutes.Bloodsampleswereharvestedfromtheexposuresitesandcanalorifices.CytokinelevelsforIL-1β,IL-2,IL-6,IL-8,IL-10,TNF-α,andPGE2weremeasuredusingELISAforallsamplesites.Results:TheIL-6levelsattheexposuresiteswerefoundtobesignificantlyhigheringroupAwhen 　　Pulpotomyisa 　　然而有相当多的文献报道称，临床症状、牙齿活力测试和影像学检查结果并不能提供牙髓状态的准确信息，目前尚没有关于乳磨牙牙髓炎症的定量标志物。在临床过程中，医生常常根据牙髓出血的色和量以及止血效果来判断根髓组织的状态，然而除止血效果外其余均为主观判断标准。此外，意见分歧还存在于应该在哪里评估出血状态。一些研究人员认为，露髓位点的出血能够有效反映牙髓病变，所以可以用来评估牙髓状态。一些人选择不考虑露髓位点，认为只应考虑牙髓切断部位的出血，还有一些人认为必须对这两个部位同时进行评估才能准确判断根髓的情况。这种认识上的不一致导致我们缺乏标准化的临床诊断策略。

　　However,thereisaconsiderableamountofliteraturere-portingthatclinicalsigns,sensitivitytests,andradiographicfindingsdonotprovideaccurateinformationaboutpulpalstatus,4-7andnoquantitativemarkerofprimarymolarpulpin-flammationiscurrentlyavailable.8Thestatusofprimarymolarradicularpulptissueisdiagnosedduringclinicalproceedingsbasedonthecolorandvolumeofbloodandtheachievabilityofhemostasis,allofwhich,withtheexceptionofhemostasis,aresubjectivecriteria.Moreover,thereisadivergenceofopinionastothesiteatwhichbleedingshouldbeevaluated.Someresearcherssuggestthatbleedingattheexposuresitereflectspulpalpathosisand,thus,canbeusedtoevaluatepulpalstatus.2,9,10Othersdisregardtheexposuresite,sayingthatonlybleedingattheamputationsiteshouldbetakenintoconsider-ation,11,12andstillothersclaimthatbothsitesmustbeevaluatedinordertoaccuratelydeterminetheconditionofradicularpulp.13,14Thislackofclarityhasalsoresultedinalackofstandardizationand,consequently,difficultiesin 　　美国儿童牙科学会(AAPD)的牙髓治疗指南建议，如果牙髓切断几分钟后出血仍无法控制，就需要行牙髓摘除术。然而一些作者认为机械性和龋源性露髓应该分开考虑，因为龋病的病因和龋的深度都会影响牙髓组织的病理变化。暴露部位周围的龋坏组织也被认为是细菌污染、牙髓炎和牙髓坏死的危险因素。由于炎症水平和活髓治疗的适用性难以客观测量，加上细菌污染和牙髓炎症存在的可能性，使得活髓切断术的预后难以预测。

　　TheAmericanAcademyofPediatricDentistry’s(AAPD)GuidelineonPulpTherapyre 　　Forteethwithcariousexposures,itisassumedthattheinflammationisconfinedtothecoronalpulp;hence,theseteethareconsideredtobesuitableforvitalpulpotomytreatment.1,2,18However,studiesreportcontradictoryresultsregardingthecon-ditionofthepulpinteethwithdeepcarieslesions.AccordingtoKassaetal.,19thecoronalpulpwasinflamedlongbeforethecariesreachedthepulpinprimarymolarswithinterproximalcariouslesionsgreaterthan50percentofthedentinthickness,andcariousexposurewasnotnecessarytocreatecoronalpulpalinflammation.Ontheotherside,AsgaryandEhsani20reportedthat,inpermanentmolarswithirreversiblepulpitisand(insomecases)apicalrarefaction,pulpotomyhadbetterout 　　本研究的目的是探讨乳牙牙髓暴露位点的止血效果是否能反映根管口牙髓的炎症水平。为了评估炎症严重程度，我们分别测量了牙髓露髓点和根管口的细胞因子水平。无效假设是牙髓暴露部位和根管口的细胞因子水平没有差异。

　　Thepurposeofthisstudywastoinvestigatewhetherhemo-stasisattheexposuresitereflectedthelevelofinflammationatcanalorificesofprimaryteethwithcariouspulpexposures.Formeasuringthelevelofinflammation,cytokinelevelsattheex-posuresitesandcanalorificeswereused.Thenullhypothesiswasthatcytokinelevelsattheexposuresitewerenotdifferentfromcytokinelevelsatthecanalorifices.

方法伦理学审批。本研究方案获得了土耳其Kirikkale大学临床研究伦理委员会的批准。所有参与研究的个体均获得了知情同意。研究目的及临床操作步骤已经向患者家长说明，并取得了家长及患者的书面同意。

Ethicalapproval.TheprotocolforthisstudywasapprovedbytheEthicalCommitteeforClinicalResearch,KirikkaleUniver-sity,Kirikkale,Turkey.Informedconsentwasobtainedfromallindividualparticipantsincludedinthestudy.Thepurposeandclinicalproceduresofthestudywereexplainedtothepatients’parents,andwrittenconsentsofparentsandassentsofpatientswereobtained.

患者选择。该研究包括38名5岁~9岁的儿童，他们在年4月至年3月期间由Kirikkale大学儿童口腔科招募。所有患者的病史均与炎症无关，且患者未使用过任何抗炎药物。根据下列临床和影像学标准纳入这些儿童的乳磨牙：(1)无临床症状或牙髓变性的证据(如叩痛、肿胀史或窦道)；(2)无自发性疼痛；(3)无内/外吸收、牙周膜间隙增宽或根分叉/根尖周透射影；(4)生理吸收不超过根长三分之一；(5)在去龋时可能发生牙髓暴露的深龋患牙。

Patientselection.Thestudyincluded38five-tonine-year-oldchildrenwhowererecruitedthroughKirikkaleUniversity’sDepartmentofPediatricDentistrybetweenAprilandMarch.Medicalhistoriesofallpatientswerenon-contributory,andpatientshadnotusedanyanti-inflammatorymedication.Primarymolarteethofthesechildrenwereincludedbasedonthefollowingclinicalandradiologicalcriteria:(1)noclinicalsymptomsorevidenceofpulpdegeneration(e.g.,painonpercussion,historyofswelling,orsinustract);(2)nospon-taneouspain;(3)noradiographicsignsofinternal/externalresorption,widenedperiodontalligamentspace,orfurcal/peri-apicalradiolucency;(4)physiologicalrootresorptionofnomorethanone-thirdtherootlength;and(5)adeepcarieslesionwithalikelihoodofpulpexposureduringcariesremoval.

　　这项研究计划对两组人进行；检测在双侧5%显著性水平和80%的检验效能下统计指标的差异，每组计划包含20颗牙齿。

Thestudywasplannedtobeconductedwithtwogroups;inordertodetectdifferenceswithan80percentpoweratatwo-sidedfivepercentsignificancelevel,20teethwereplannedtobeincludedineachgroup.

使用不含血管收缩剂的麻醉药进行局部麻醉(3%的Safecaine)，用橡皮障隔离牙齿，低速球钻去龋去腐，将在去龋过程中牙髓暴露的牙齿纳入研究，并排除在露髓部位周围有渗出物、脓或坏死牙髓组织的牙齿。

Followingadministrationoflocalanesthesiausingasolu-tionthatdidnotcontainavasoconstrictor(Safecainethreepercent;VemIlac,Istanbul,Turkey),teethwereisolatedwitharubberdam,alow-speedroundburwasusedtoremovecarioustoothstructure,andteethwithcariouspulpexposuresduringcariesremovalwereincludedinthestudy.Primarymolarswiththepresenceofexudate,purulence,ornecroticpulptissuearoundtheexposuresitewereexcluded.

　　将无菌棉球放置于露髓位点45秒以采集血样，之后将其取出，然后将一个潮湿的棉球放在患处，轻稍加压5分钟以止血。其中在5分钟内止血的牙齿纳入A组，止血时间超过5分钟的牙齿纳入B组（见示意图）。所有牙齿创建髓腔入路，用挖器去除冠髓。为了评估根管口的炎症标志物，用无菌棉球收集第二份血样，并将其放置在髓腔中根管口旁边45秒。之后同样换用一个潮湿的棉花球放在该处轻压止血。本研究排除了根管口在5分钟内不能止血的牙齿。本研究中的乳磨牙采用硅酸钙基材料进行活髓切断术，并用不锈钢冠修复。

Toassessinflammatorymarkersattheexposuresite,abloodsamplewascollectedbyplacingasterilecottonpelletonthesitefor45seconds.Thiswasremoved,andadampcottonpelletwasthenplacedonthesitewithslightpressureforfiveminutestoobtainhemostasis.PrimarymolarsinwhichhemostasisattheexposuresitewasachievedinfiveminuteswereincludedingroupA,andprimarymolarsinwhichhemostasisattheex-posuresitecouldnotbeachievedinfiveminuteswereincludedingroupB(Figure).Forallteeth,accesstothepulpchamberwascreated,andthecoronalpulpwasremovedwithaspoonexcavator.Toassessinflammatorymarkersatthecanalorifices,asecondbloodsamplewascollectedbyasterilecottonpellet,whichwasplacedinthepulpchamberadjacenttoallcanalori-ficesfor45seconds.Thiswasremoved,andadampcottonpelletwasplacedattheorificeusingslightpressuretocontrolhemor-rhaging.Teethforwhichhemostasisatthecanalorificecouldnotbeachievedinfiveminuteswereexcludedfromthestudy.Primarymolarsincludedinthestudyweretreatedwithvitalpulpotomywithacalcium-silicate-basedmaterial(Biodentine,Septodont,Saint-Maur-des-fossés,France)andrestoredwithstainlesssteelcrowns.

所有血样立即用0.08ml磷酸盐缓冲液(PBSpH=7.2)洗脱，并在-80℃保存直到开始分析。

　　Allbloodsampleswereimmediatelyelutedwith0.08mlphosphate-bufferedsaline(PBSpHequals7.2)andstoredat-80degreesCelsiusuntilanalysis.

图：根据穿孔位点和根管口的止血效果将牙齿分组

ELISA法分析。用ELISA法分析血样的IL-1β,IL-2,IL-6,IL-8,IL-10,TNF-α和前列腺素E2水平（pg/ml）。解冻后，将血样在四摄氏度下以克离心10分钟，然后取出棉球。细胞因子的浓度测定采用Invitrogen免疫检测试剂盒和双层三明治技术。

ELISA.PulpalbloodsampleswereanalyzedforIL-1β,IL-2,IL-6,IL-8,IL-10,TNF-α,andPGE2levels(pg/ml)usingEnzymeLinked-Immuno-SorbentAssays(ELISA).Afterthaw-ing,thebloodsampleswerecentrifugedat1,gfor10min-utesatfourdegreesCelsius,andthecottonpelletswereremoved.CytokineconcentrationsweremeasuredusinganInvitrogenImmunoassayKit(DIASourceImmunoAssays,Nivelles,Belgium)withadouble-sandwichtechnique.

统计分析。使用SPSS17.0进行数据统计分析。采用Mann-Whitney检验比较两组患者暴露位点和根管口炎症标志物水平的差异。用Spearman相关系数法检测各炎症标志物水平的相关性。P值小于0.05为差异有统计学意义，r值的说明见表1。

Statisticalanalysis.StatisticalanalysiswasperformedusingtheStatisticalPackagefortheSocialSciences(SPSS)17.0software(SPSSInc.,Chicago,Ill.,USA).Statisticaldifferencesbetweengroupsinthelevelsofinflammatorymarkersattheex-posuresitesandcanalorificeswereidentifiedusingtheMann-Whitneytest.CorrelationsbetweenthelevelsofinflammatorymarkersattheexposuresitesandatthecanalorificesforbothgroupswereidentifiedusingSpearman’scorrelationtests.AP-valueoflessthan0.05wasconsideredstatisticallysignifi-cant.ThervalueswereinterpretedaccordingtoTable1.29

结果

　　本研究样本数为：每组20颗牙齿，共40颗牙齿。取自38名儿童(27名男孩，11名女孩)，年龄为5岁-9岁(平均6.7岁)。A组(成功止血组)露髓孔的IL-6水平显著高于B组(P=0.;表2)，露髓位点的其他细胞因子水平差异无统计学意义(P0.05;表2)。

　　Thestudywasconductedwith20teethpergroup,foratotalof40primarymandibularmolarteethin38children(27boys,11girls)agedfivetonineyears(meanageequals6.7years).IL-6levelsattheexposuresitesweresignificantlyhigheringroupA(wherehemostasiswascontrolled)when 　　两组根管口处细胞因子水平的差异均无统计学意义(P0.05;表3)。

　　Therewerenostatisticallysignificantdifferencesinthelevelsofanyofthecytokinesmeasuredatthecanalorifices(P0.05;Table3).

　　A组和B组露髓点与根管口标记物水平的相关性。露髓位点与根管口的炎症标志物水平的相关性见表2(B组)和表4(A组)。

　　CorrelationbetweenmarkerlevelsatexposuresitesandcanalorificesingroupsAandB.ThedegreesofcorrelationbetweeninflammatorymarkerlevelsattheexposuresiteandinflammatorymarkerlevelsatthecanalorificesareshowninTable2(groupB)andTable4(groupA).

*差异显著（P=0.）

在这两个位点，A组和B组的IL-1β(r=0.,r=0.)和IL-6水平(r=0.,r=0.)均呈不相关或微弱的正相关。

IL-2水平的相关性在A组较低(r=0.)，在B组为中等(r=0.)。

IL-8水平在A组(r=-0.)和B组(r=0.)中均几乎无相关性。

IL-10水平在A组(r=-0.)几乎无相关性，在B组(r=0.)呈中等的正相关。

TNF-α水平在A组呈中度正相关(r=0.)，在B组几乎没有相关性(r=-0.)。

前列腺素E2水平在A组呈低度正相关(r=0.)，在B组几乎没有相关性(r=-0.)。

InbothgroupsAandB,negligibleorlowpositivecorrela-tionwasfoundforIL-1β(requals0.,requals0.)andIL-6(requals0.,requals0.)levels.IL-2levelsshowedlowpositivecorrelationingroupA(requals0.)andmod-eratepositivecorrelationingroupB(requals0.).IL-8levelsshowednegligiblecorrelationingroupA(requals-0.)andingroupB(requals0.).IL-10levelsshowednegli-giblecorrelationingroupA(requals-0.)andmoderatepositivecorrelationingroupB(requals0.).TNF-αlevelsshowedmoderatepositivecorrelationingroupA(requals0.)andnegligiblecorrelationingroupB(requals-0.).PGE2levelsshowedlowpositivecorrelationingroupA(requals0.)andnegligiblecorrelationingroupB(requals-0.).

比较两组间露髓点能在5分钟内止血的牙齿(n=26)和不能止血的牙齿(n=29),发现二者根管口的止血效果没有显著性差异(卡方=0.，P=0.51)。

Whenteethwherehemostasiscouldbeachieved(nequals26)andcouldnotbeachieved(nequals29)infiveminutes(Figure)attheexposuresiteswere 　　Whendecidingwhetherpulpotomyordirectpulpcappingisindicated,theextentofradicularpulpinflammationisparti-cularlyhardtodetermine.2,8,17Duringclinicalprocedures,theonlyoperativecriterionavailabletodeterminethetreatabilityoftheseteethishemostasis,8whichisacriterionthathasnotpreviouslybeenshowntodecisivelydeterminethelevelofin-flammationinradicularpulptissue.Moreover,thereisnoagreementastowhetherhemostasisshouldbeevaluatedattheexposuresiteoratthecanalorifice.2,9-12,30Inanattempttodevelopamoreobjectiveandaccuratecriterionforvitalpulptreatment,thisstudyaimedtoevaluatewhetherornothe-mostasisattheexposuresitereflectedtheinflammatorylevelasdeterminedbycytokinelevelsofpulptissueatthecanalorificesofprimaryteethwithcariouspulpexposure.Sinceonlyverysmallamountsofbloodcanbecollectedinprimaryteeth,especiallyattheexposuresite,ananestheticsolutionthatdidnotcontainavaso-constrictorwasusedforlocalanesthesiatoimprovecollectionofenoughamountsofbloodsampleforanalysis.

　　如今，从小样本中测量多个标记物从技术上是可以实现的。ELISA法是目前最常用的测定抗原-抗体反应的免疫学方法之一，经报道其准确性和敏感度都优于其他方法。因此，本研究采用ELISA法(免疫学检测方法中的金标准)检测血样中的炎症标志物水平。

　　Today,itispossibletomeasuremultiplemarkersfromsmallamountsofsamples.31ELISAisoneofthemost 　　IL-6是一种促炎细胞因子，由单核吞噬细胞、成纤维细胞和其他细胞在其他促炎细胞因子的作用下产生，它能够上调粘附分子并诱导血管生成，导致血管通透性增加和炎性水肿。据Wisithphrom和Windsor报道，IL-6水平增高后可以通过调节负责胶原降解的细胞而促进牙髓破坏。Barkhordar等和Zehnder等均报道了炎症性恒牙牙髓组织中IL-6水平的显著升高。但与此相反，Elsalhy等人的研究认为，露髓后提示行直接盖髓的恒牙与不可复性牙髓炎的恒牙之间，其IL-6水平无显著性差异，不过该研究中使用的样本仅来自露髓孔部位，考虑到冠髓和根髓的炎症状态本身就可能存在较大差异，特别是在龋源性露髓的牙齿中，这或许可以解释该研究和当前研究结果的差异。

Apro-inflammatorycytokineproducedbymononuclearphagocytes,fibroblasts,andothercellsinresponsetotheactivityofotherpro-inflammatorycytokines,39IL-6causesup-regulationofadhesionmoleculesandinducesangiogenesis,leadingtoanincreaseinvascularpermeabilityandinflammatoryedema.35WisithphromandWindsor36reportedthatincreasesinIL-6levelsincreasepulpaldestructionbymediatingthecellsrespon-sibleforcollagendegradation.BothBarkhordaretal.21andZehnderetal.23reportedsignificantincreasesintheIL-6levelsofinflamedpermanenttoothpulptissue.Onthecontrary,Elsalhyetal.26reportednostatisticallysignificantdifferencesintheIL-6levelsofpermanentteethwithcariesexposureindicatedfordirectpulpcappingandpermanentteethwithirreversiblepulp-itis.However,thesamplesusedinthatstudywereharvestedfromtheexposuresitesonly,which,giventhatinflammatorystatusofcoronalandradicularpulpmayvary,particularlyincariouslyexposedteeth,couldexplainthedifferenceinfindingsbetweenthatstudyandthepresentstudy.

Ozdemir等调查了龋源性露髓和意外露髓且具有活髓切断术指征的乳磨牙的IL-1α,IL-6和IL-8水平，他们发现与意外暴露的牙髓相比，龋源性露髓的牙髓组织中IL-6和IL-8水平显著升高，提示IL-6和IL-8水平有可能成为判断牙髓状态的指标，这将有助于提高判断活髓治疗预后的准确性。当前的研究显示，IL-6与水肿和炎症有关，且在止血时间小于5分钟的A组其水平显著高于止血时间大于5分钟的B组。

Ozdemiretal.40investigatedIL-1α,IL-6,andIL-8levelsincariouslyandmechanicallyexposedprimarymolarsforwhichpulpotomywasindicated.TheyreportedIL-6andIL-8levelstobesignificantlyhigherincariouslyexposedprimarymolarpulpwhen 　　Accordingtosomeauthors,chronicinflammationexistsinthecoronalpulpofprimaryteethwithdeepcaries,becausethestructuralcharacteristicsofprimaryteethprovoketheinitia-tionofaninflammatoryresponsebeforethecarieslesionreachesthepulp.3,12,41Ifthisisindeedthecase,whenthecarieslesiondoesreachthepulp,bacterialinvasionmayengenderanacuteresponse.Thus,theabilitytoachievehemostasisinteethwithhigherIL-6levelscouldbeexplainedbythechronicinflamma-tionofthecoronalpulpintheseteeth.ThehigherPGE2levelsintheseteeth,althoughnotstatisticallysignificant,supportsthisview,consideringthathighPGE2levelshavebeenreportedtobeassociatedwithchronicinflammation.3Ontheotherhand,concurrentincreasesinbothIL-6andIL-8havebeenobservedinthelatephaseofinflammation.23SincethepresentstudyfoundnosignificantdifferenceintheIL-8levelsofgroupsAandB,theincreaseinIL-6alonecannotbeconsideredastrongindicatoroflate-phaseinflammation.

根据本研究的结果，A组和B组根管口处的细胞因子水平没有显著差异。而且总的来说，露髓处和根管口处的细胞因子并无显著相关性(r＜0.50;表4和5)。这些结果表明露髓处的出血与根管口牙髓组织的病理状态没有直接关联，即在龋源性露髓的乳牙中，冠髓的炎症程度不能精确反映根管口牙髓组织的炎症程度和病理状态。

　　Accordingtotheresultsofthepresentstudy,therewerenosignificantdifferencesinthelevelsofcytokinesatthecanalorificesbetweengroupsAandB.Also,ingeneral,noneofthecytokinelevelsattheexposuresitesandatthecanalorificesshowedgoodcorrelationinbothgroups(r0.50;Tables4and5).Theseresultsindicatethatthereisnodirectrelationshipbetweenbleedingattheexposuresiteandthepathologicalstatusofpulptissueatthecanalorificesandthatthedegreeofin-flammationincoronalpulpdoesnotpreciselyreflectthedegreeofinflammationandpathologicalconditionofpulptissueatthecanalorificesincariousexposedprimaryteeth.

本研究的主要目的是探讨露髓部位的止血效果是否能反映根髓的病理状态。虽然在标准的活髓切断术中仅用根管口牙髓的止血效果作为适应症的参考，但一些研究人员认为露髓处的止血效果也应该纳入考虑范围。本研究的结果反驳了这一观点。此外，最近的一项系统综述表明，在乳牙中使用行直接盖髓术，其成功率与MTA活髓切断以及甲醛甲酚活髓切断术成功率相似。

　　Themainmotiveofthepresentstudywastoquestionwhetherthehemostasisattheexposuresitereflectedpatholog-icalconditionoftherootpulp.Althoughonlyhemostasisatthecanalorificesisusedinthestandardpulpotomyproce-dure,someresearchersarguethathemostasisattheexposuresiteshouldalsobeusedwhendecidingapulpotomyindication.2,9,10Theresultsinthepresentstudyrefutethisassertion.Also,arecentsystematicreviewsuggestedthatdirectpulpcappinginprimaryteethhassimilarsuccessrateswithmineraltrioxideaggregateandformocresolpulpotomy.42

然而本研究的结果表明，露髓部位的有效止血并不能完全证明根髓是健康的。由于露髓部位的出血不能准确反映根管口孔牙髓组织的病理状态，因此将其作为活髓切断术或直接盖髓术的诊断指引可能会产生误导。此外，根据本研究结果，露髓部位的牙髓与根管口牙髓的止血效果并没有显著相关性，为这场讨论又增加了新的热点：本研究的另一个有趣的发现是，在实验分组过程中，有6颗牙齿在牙髓露髓孔处可以止血，但在根管口无法止血。考虑到露髓孔处较靠近龋损组织，冠髓的炎症可能先于根髓存在，或许可以解释这种差异。当我们将上述发现与之前的研究的结果一同分析时，可以发现，牙髓止血效果与牙髓炎症状态之间尚缺乏直接联系，这与目前普遍接受的以止血效果作为判断牙髓状态指标的观念相反。

　　However,thefindingsofthepresentstudyindicatethatachievementofhemostasisattheexposuresitedoesnotdefi-nitivelyevidenceahealthyrootpulp.Sincebleedingattheex-posuresitecannotbesaidtoprovideaccurateinformationaboutthepathologicalstatusofpulptissueatthecanalorifices,usingitasacriterionfordiagnosisduringvitalpulpamputationanddirectpulpcappingcanbemisleading.Furthermore,accordingtotheresultsofthepresentstudy,therewasnostatisticallysignificantrelationshipbetweentheachievementofhemostasisattheexposuresiteandcanalorifices,andthisenhancesthepreviousargument.Anotherinterestingfindingofthisstudyisthat,duringallocation,hemostasiscouldbeachievedattheexposuresiteinsixteeth;however,itcouldnotbeachievedatthecanalorifices.Consideringthatexposuresiteisclosertothecariouslesion,presenceofinflammationwouldbeexpectedatthecoronalpulpbeforetheradicularpulp.Whentheafore-mentionedfindingsandtheresultsofpreviousstudies3,9areinterpretedtogether,lackofadirectlinkbetweenhemostasisandinflammatorystatusofthepulpcanbesuggested;thisisopposedtothecurrent