Perawatan Endodontik

Pada Anak
Drg. Fajar Dwi Anggono MDSc

PAEDIATRIC ENDODONTIC
INTRODUCTION
Princip goals of paediatic endodontic:
to prevent the extension of dental
disease & to restore damaged teeth
to healthy function.
KEY POINTS
Disadvantage of unplanned in the primary & mixed
dentitions:
- loss of space, promoting mal occlusion
- reduced mastication function( post. teeth)
- impaired speech development ( ant, teeth)
- psychology disturbance ( ant, teeth)
- anaesthetic & surgical traumas

The dental pulp:

Soft tissue structure:
Resides in coronal pulp chamber
Root canals ( primary & permanent)
Histologically
connective tissue
continous layer of specialized secretory cell
odontoblasts
The pulp primary & permanent teeth
blood vessels & nerves
lateral / accesory root canals
incomplete apices. great healing capacity
have a very rich blood supply
generally respond well to treatment aimed & at preservation
sensory fibres of ( N- V ) the pulp in large numbers

THE MATURED TEETH

Two types of sensory neurons:
A. myelined : 1. fast reacting
2. most numerous
3. stimulating is low
communication the charac.sharp. stabbing pin
associated with dentin sensitivity &reversible
inflammation
B. The unmyelined
1. higher threshold of stimulation
2. convey dull, intense pain charac, of
advanced irrever. pulp inflamm

PULP PATHOSES
The coronal dentine & pulp of sound newly
erupted teeth to prevent from injury
Breakdown of the barrier occur must
commonly in children due to caries, trauma, a
variety of chemical, physical, microbial agent.
1, Reversible pulpitis
sensitivity to hot, cold, sweet stimuly
no symptom
2. Irreversible pulpitis
throbbing pain spontaneously, interrupt
sleep
not unusual for few / no symptoms

A PAIN HISTORY
1. Primary teeth;
a pain history rarely, provides clear
information, but the report of
spontaneous pain correlates well with
advanced irreversibles pulpitis
2. Permanent teeth
Give more information of diagnostic
value

KEY POINTS
Pain history helpful information
area involved
what the affected tooth feels like
duration of the problem
precipitans and relieving factors
duration of pain
spontaneous or precipited by
external stimuli
analgesic required

VITAL PULP THERAPY

Pulp capping:
strict selection criteria are applied
- deep lesion in a vital . symptom free

KEY POINTS
Pulp capping:
not recommended for primary teeth
not recommended for permanent
teeth
if there sign and symptom of pulp
path.
best prognosis within 24 h in
permant.
teeth exposed to trauma

PULP AMPUTATION ( PULPUTOMY)

Preserving the vitality and function of
the remaining portion.
Differences in the ways pulp
amputation procedure are conducted
for primary and young permanent
teeth.
Pulp amputation in primary teeth
poor candidat for direct capping
choice medicament

Formocresol pulpotomy

VITAL PRIMARY PULP

MEDICAMENTS
1. Formocresol (buckleys formocresol)
Concentrated stock solution:
Formaldehyde 19 ml
Tricresol 35 ml
Glycerol 15 ml
Water 31 ml
Diluent solution:
Glycerol 3 parts
Water 1 part

2. Glutaraldehyde :
Tissue fixative , Uninflamed pulp, Local toxicity is low,
Have minimal carciogenic

3. Analytical-grade:
As effective as traditional aldehyde preparations
Without the fears of local or systemic toxicity

The effects of formocresol (5 min & > 14 days)

PULP AMPUTATION (APEXOGENESIS)

Indication and principe of treatment
apexogenesis immature permanent teeth:
1. extension of direct pulp caping
2. irreversible inflamed
3. coronal pulp tissue is removed.
4. to preserve the vitality & funtion of
radiculair
This procedure may be the treatment of choice:
1. following pulp exposure bleeding cannot
be easily cntrolled.
2 following trauma the pulp has been
expose , to the mouth for more than 24 H.

APEXOGENESIS PROCEDURE

NON VITAL PULP THERAPY

PRIMARY TEETH

PULPECTOMY PROCEDURE
First visit
a. caries removal
b. caries is eliminated and access made to the pulp
( irrigation with NaOCl O,5 1,O %
c. disinfection of the canal system

cotton wool barely moistened in formocresol for 7 10

days is sealed in the pulp chamber.
Second visit:
c.. reopened irrigation % drying
mixture of slow setting zinc oxide eugenol cement packed
into the canal with a cotton wool pledget.
e. the pulp chamber is packed with accelerated zinc oxide
eugenol cement before definitive restoration of the tooth,

 KEY POINT: non vital pulpotomy

predictable treatment if infection is
controlled and the canal sealed
bacteria tight.
control of intracanal infection by
irrigation & disinfection.
no need for vigorous canal
enlargement, which risks perforation
and failure
resorbable material is used for canal
obturation.

ENDODONTIC MANAGEMENT OF
NON VITAL IMMATURE PERMANENT
TEETH
INTRODUCTION
Immature permanent, teeth special difficult
Premature loss of pulp vitality a thin &
relatively weak tooth structure
Technical difficulties for the controlled
condensation of root filling material
A root end closure procedure apical calcific
barrier against which filling materials
Monitor barrier formation 12 30 months

Operative procedure for root end closure

(apexification)

Access
Caries removal
Ioose debris should be removed from the
Pulp chamber with hand instrument.
Irrigation with Na Cl ( 1 2% )
Canal preparation
Cleaning
To free the root canal system of organic debris,
M.O. Toxins
Shaping, to modify the form of the existing canal
Cleaning is achieved primarily by the use of
irrigants & dressing

 Canal entrance
Gates glidden drills should not be used deep in
the canals of immature teeth create a trip
perforation
Deeper preparation is continued with hand files
Working slowly in an apical direction files are
directed around the canal walls

In the curved canals of molars

Special care to avoid over cutting on the thin
furcal walls
damaging strip perforation

Instrumentation - high volume

- low pressure irrigation
- Ultrasonic units at size 15 or 20 endosonic k file
- Usually a point some 2 or 3 mm short of the ro
apex
- Working length establish 1 mm short of the ro apex

Dresing the rootcanal

A non setting Ca(OH)2 pasta
High pH calcification root end closure
(e.g pulpdent paste)
- Antimicrobial
- Mild tissue solvent activity continue to
cleanse the canal
- Calcium hydroxyde powder with sterile
saline
- A 3 mm thickness of GIC or composite resin
to provide a bacteria tight seal

MONITORING ROOT END CLOSURE

-

Review appoint 3-6 monthly intervals

The Ca(OH)2 washed from the canal
Ro to assess the progress of barrier formation
If the canal is closed obturation
If the canal is not complete redressed for 3-6 months
Calcification barier formation complete with in 12-18 months
Using mineral trioxide aggregate(MTA) to create an
artificial root end barirer at a single visiting
Packed in to the canal with pluggers
creating an
immediate, sealing, biocom partible barrier for obturation
with in minutes

OBTURATION
-

With gutta percha & sealer

Cold lateral condensation of gutta percha
Techniques succesfully combines the lateral adaptation of
gutta percha in apical portion of the canal cold lateral
condensation

FINAL REST
Controlled canal obturation
The root end closure procedure
The canal wall thickness or
Mechanical strength of immature teeth

Dentine bonded comp. resins

helpful in setting if extended several
millimeters in to the root canal to
provide internal splinting
Periodic clinical & ro

KEY POINT :
Root end closure
Gives predictable results if infection is
controlled and the canal sealed bacteria
tight
Infection is controlled by irrigation &
disinfection
Canal is encharged only to allow irrigate
alless and dense obturation
It adds nothing to the strength of the tooth
Coronal restoration is critical to long term
success

ALTERNATIVES TO THE ROOT END

CLOSURE
PROSEDURE
I. The almost complete apex
- Ca(OH)2

1-2 mm

- MTA

II. Failure of the root end closure procedure or

patient unable to undergo lengthy treatment
- The wide canals where the root end closure has
failed
- The patient is unable or inwilling to attend be
created for repeats appointments
- Irretrie vable overfill

OBAT INTERKANAL DALAM

PSA

 Keberhasilan PSA:
-pembuangan jaringan nekrotik dan
bakteri
-irigasi saluran akar
-bahan pengisi saluran akar yang
hermitis

ket:
1.intrumen dengan reamers dan file
menurunkan jumlah bakteri 1000 kali
2.irigasi dengan NaCl menurunkan
jumlah bakteri 50%
3.pemberian bahan dressing:
antiseptik yang kuat, biokompabilitas
tidak mempunyai side efek

Mikrobiologis saluran akar

Perjalanan penyakit infeksi:
#Karies gigijar. Pulpa mati inflamasi
gigi mati
Ket.: m.o jaringan nekrotik
Kolonisasi
Membanyak diri
Infeksi masuk ke tubuli dentinalis dan jar.
Apikal
Bakteri anerob masuk ke SA

 Reaksi bakteri terhadap jar. Pulpa:

- hilangnya sirkulasi udara di daerah
nekrotik
- sistem pertahanan tubuh (inflamasi,
imunitas tidak berfungsi)
- sistem saluran akar menjadi lebih
khusus dan sangat ideal untuk
mikroorganisme lebih berkembang
( membentuk ekosistem mo. dalam
saluran akar)
- mikrosistem ini dan inflamasi
periapikal akan tetap bertahan bila
infeksi tidak dikeluarkan

Intrumentasi saluran akar

Pengambilan jaringan nekrotik : cleaning and shaping
dengan K-file, H-file, Ni-Ti file, reamers dengan
metode towspeed
Akar bengkok? saluran akar tertutup oleh chip
dentin
Metode : dekalsifikasi sebagai profilaktik dengan
EDTA (berfungsi sebagai Ca)
- K-file dibasahi dengan EDTA masukan ke SA dengan
diputar
- irigasi dengan NaOCl yang berfungsi sebagai:
1. meningkatkan permeabilitas
2. melepaskan Oksigen
3. menetralkan efek EDTA

IRIGASI SALURAN AKAR

Metode cleaning and shaping
Efektif dengan NaOCl 0,05% yang
berfungsi sebagai melarutkan debris
pelumasan memperkuat efek
antimikroba obat
Cara : manual, ultrasonik

INTRAKANAL SALURAN AKAR

METODE:single visit and multiple
visit
Alasan: keterbatasan waktu
saluran akar basah
infeksi periapikal/drainage

 Bahan dasar obat

1. fenol : toksik, antigenik, efek jangka
pendek, contoh : eugenol, Champh.para
Chlorfenol, monochlorfenol, thymoll,
cresol,creosote, cresatin
2. Aldehide : sifat fiksasi, antimikroba kuat,
hasil tidak efektif untuk membunuh bakteri,
contoh : formokresol, glutaratdehid
3. steroid : pemakaian berdiri sendiri atau
dicampur dengan antibiotik. Tidak ada
indikasi dengan bahan berisi antibiotik.
Bahan berisi kortison, side efect dapat
penurunkan dadaya tahan tubuh

4. bahan dasar logam berat : berisi

perak, Cu, merkuri. Efect :
mengkoagulasi protein dan berfungsi
sebagai inhibitor enzim dan bersifat
toksik. Contoh: N2 (jarang
digunakan)
5. bahan dasar halogen : NaOCl dan
campuran klorin (toksisitas rendah)
6. bahan dasar iodine : iodine
potassium, iodide memiliki anti
mikroba yang baik, toksisitas rendah,
iritasi jaringan rendah

7. bahan dasar kalsium hidroksida Ca(OH)2

- ditemukan Herman tahun 1920

- untuk pulpa kaping, pulpotomi, pulpektomi,
gigi sulung, apeksifikasi
- ditambah barium sulfat untuk visualisasi Ro
- obat harus berkontak dengan dinding saluran akar
- Ph obat mendekati Ph jaringan
- aplikasi lentulo dengan plugger
- Ca(OH)2 + air = baik
- Ca(OH)2 + CHKM = tidak menambah anti bakteri
- obat keluar apeks dapat diabsorbsi dengan cepat
- makin lama dalam jaringan makin baik untuk
regenerasi. 1 minggu regenerasi tulang 50% sampai
12 minggu 100% regenerasi jaringan dan aposisi
semen

ANTIBIOTIKA
Pembelian antibiotika selama perawatan
PSA: secara oral tidak diperlukan
Infeksi saluran akar dihilangkan
dengan :
- drainage
- debridemen
- irigasi
- medikasi dressing

 Kasus : tidak diperlukan antibiotika

- pulpitis
-periodontitis apikal
-drainage saluran sinus
-pembengkakan lokal
Kecuali : medical compromize seperti
remautik, penyakit jantung bawaan,
diabetes tidak terkontrol, gangguan
imunologi