LBM 1 BLOK 17

STEP 7

1. Apakah makna difus radiolusen pada apical gigi 11 diameter 3mm di distal ?
The first way is with is an infection inside, in the living pulp tissue. You either get tooth decay or severe irritation of the inside. Ordinarily, when you have an infection, your body responds by sending white blood cells and antibodies to kill the bacteria. The tissue will then swell and turn red. However, there is no room inside your tooth for the tissue to swell. Thus, this natural defense mechanism breaks down. Antibiotics will not stop an infection inside your tooth. So, unless you address the decay or the tooth irritation in time, the pulp tissue of the tooth will die and the infection begins to spread into the surrounding bone. This is what is called a tooth abscess. It can cause a painful toothache, it can cause the tooth to be just tender to pressure, or sometimes you won't even notice it. Once the infection is in the bone, your body can fight it. Depending on how aggressive the bacteria are, your body may be able to wall them off and you can live for years with a tooth abscess.

2. Apa yang menyebabkan di buccal fold terjadi kemerahan dan sakit saat ditekan ?
In addition to an abscess, an infection in the root canal of a tooth can cause:

Swelling that may spread to other areas of the face, neck, or head Bone loss around the tip of the root

http://www.webmd.com/oral-health/dental-root-canals

3. Mengapa gigi 12 juga ikut merasakan sakit ?

Karena pada gigi 11 mengalami pelebaran lig. Periodontal , akar 11 bengkok ke distal sehingga daerah mesial 12 terkena infeksi dari 11 dan mngenai saraf skitar dan mrasakan sakit

4. Apakah penyakit sistemik mempengaruhi keparahan dari gigi 11 ?

Ya , missal diabetes : memperparah keadaan penyakit dan sulit dalam penyembuhan luka. Bila ada penyakit sistemik mempengaruhi imunologi manusia

5. Apakah gigi 11 itu vital ?

Tidak , karena pada saat open bur sudah muncul bau tidak sedap dan juga sudah menembus periapikal dan gigi sdah mngalami diskolorisasi

6. Apakah perawatan dan bagaimana prosedur perawatan yang cocok untuk gigi 11 ?
PSA
1. The first step in the procedure is to take an X-ray to see the shape of the root canals and determine if there are any signs of infection in a surrounding bone. Your dentist or endodontist will then use local anesthesia to numb the area near the tooth. Anesthesia may not be necessary, since the nerve is dead, but most dentists still anesthetize the area to make the patient more relaxed and at ease. 2. Next, to keep the area dry and free of saliva during treatment, your dentist will place a rubber dam (a sheet of rubber) around the tooth. 3. An access hole will then be drilled into the tooth. The pulp along with bacteria, the decayed nerve tissue and related debris is removed from the tooth. The cleaning out process is accomplished using root canal files. A series of these files of increasing diameter are each subsequently placed into the access hole and worked down the full length of the tooth to scrape and scrub the sides of the root canals. Water or sodium hypochlorite is used periodically to flush away the debris. 4. Once the tooth is thoroughly cleaned, it is sealed. Some dentists like to wait a week before sealing the tooth. For instance, if there is an infection, your dentist may put a medication inside the tooth to clear it up. Others may choose to seal the tooth the same day it is cleaned out. If the root canal is not completed on the same day, a temporary filling is placed in the exterior hole in the tooth to keep out contaminants -- like saliva and food -- outbetween appointments. 5. At the next appointment, to fill the interior of the tooth, a sealer paste and a rubber compound called gutta percha is placed into the tooth's root canal. To fill the exterior access hole created at the beginning of treatment, a filling is placed. 6. The final step may involve further restoration of the tooth. Because a tooth that needs a root canal often is one that has a large filling or extensive decay or other weakness, a crown, crown and post, or other restoration often needs to be placed on the tooth to protect it, prevent it from breaking, and restore it to full function. Your dentist will discuss the need for any additional dental work with you.

http://www.webmd.com/oral-health/dental-root-canals

7. Apakah ada perawatan lain yang dilakukan pada akar bengkok ?

Pada akar bengkok, preparasi akses dilakukan dengan tekhnik step-down menggunakan bur Gates. Kemudian, instrumen dibengkokkan sampai ke panjang kerja dan dilakukan tekhnik step-back menggunakan file yang fleksibel

Masalah utama yang sering ditemui pada saluran akar bengkok adalah preparasi yang tidak sempurna. Jarum file dapat memotong dentin apabila permukaan file tersebut menyentuh seluruh bagian dentin. Ketika file sudah terasa longgar, maka file secara otomatis akan berusaha untuk meluruskan diri dan akan berkontak dengan bagian tertentu saja. Hal ini menyebabkan kesalahan prosedur seperti, pembentukan ledge, transportasi bakteri dari foramen, perforasi atau patah instrumen pada saluran akar bengkok. Untuk mencegah terjadi kesalahan ini, maka dapat diatasi dengan: 1. Pembengkokkan file File yang dibengkokkan lebih dapat memyesuaikan bentuk saluran akar yang bengkok daripada file lurus. 2. Penggunaan file dengan nomor lebih kecil. Instrumen dengan nomor yang kecil dapat mengikuti bentuk lengkung saluran akar oleh karena daya fleksibilitasnya. Instrumen lebih digunakan hingga nomor file yang lebih besar dapat masuk ke saluran sesuai panjang kerja akar tanpa hambatan. 3. Penggunaan file intermediat Pada beberapa bentuk saluran akar bengkok, dapat dilakukan pemotongan 0,05 mm panjang file untuk memperbesar diameter instumen sebanyak 0,01 mm. Hal ini memungkinkan adanya transisi instrumen sehingga menghasilkan preparasi yang lebih halus pada lengkung saluran akar. 4. Penggunaan file yang fleksibel. File yang fleksibel dapat mempertahankan bentuk lengkung dan mencegah terjadinya kegagalan prosedur preparasi seperti pembentukan ledge, siku, atau patah alat. 5. Modifikasi bidang potong intrumen Bidang potong instrumen untuk saluran akar bengkok dapat dimodifikasi dengan menumpulkan alur potong instrumen, yaitu pada bagian luar sepertiga apikal dan bagian luar sepertiga tengah akar. Untuk menumpulkan alur potong dapat digunakan bantuan file diamond.

Gambar 1. Menumpulkan alur potong file dengan bantuan file diamond.

8. Mengapakah setelah dilakukan open bur sakitnya berkurang ?

Karena pada saat open bur, jringan nekrotik terbuang dan jaringan nekrotik tersebut mrukan sumber rasa sakit trsebut, Bau mulut juga terkadang timbul sebagai pertanda adanya kelainan yang serius baik lokal dalam rongga mulut ataupun sistemik sehingga bisa diwaspadai untuk selanjutnya merupakan langkah awal pemeriksaan kelainan di dalam mulut atau tubuh secara umum. Pada orang yang sehat, bau mulut umumnya berasal punggung lidah, karena bentuknya yang berupa papila (tonjolan-tonjolan kecil), memungkinkan sisa makanan tertinggal. Juga adanya plak (deposit lunak pada permukaan gigi yang mengandung berbagai koloni bakteri yang dapat menyebabkan peradangan gusi dan jaringan periodontal) yang tertinggal di gigi. Sisa makanan ini dipergunakan oleh bakteri anaerob (bakteri yang hidup tanpa membutuhkan udara) seperti Fusobacterium, Veillonella, T.denticola, P. gingivalis, Bacteroides and Peptostreptococcus untuk berkembang biak dan menghasilkan gas sulfur yang mudah menguap (VSCs=Volatile Sulfur Compounds). Gas ini antara lain Hidrogen Sulfid (H2S), Metil Merkaptan (CH3SH), Dimentil Sulfid [(CH3)2S], Sulfur Dioksid (SO2) bertanggung jawab dalam menyebabkan bau mulut, sedangkan zat bukan sulfur yang dapat menyebabkan bau adalah kadaverin, putresin, indol dan skatol. Pembentukan gas VSCs mudah terjadi pada pH alkalin (7,2) dan terhambat pada pH asam (6,5). Adanya glukosa (0,02M) juga dapat menghambat pembentukan VSCs. Penilaian bau mulut dapat dilakukan secara obyektif melalui penilaian langsung (analisa organoleptik). Cara ini diperkenalkan oleh Rosenberg dengan suatu skala organoleptik (nilai 0-5). Cara lain adalah dengan Gas Kromatografi dan fotometri (dapat mendeteksi jenis VSCs, kadaverin, putresin, skatol). Namun cara ini mahal dan sulit. Penilaian dengan Sulfidmeter/Halimeter lebih mudah dan tidak mahal dan juga dapat mendeteksi VSCs meskipun tidak dapat dibedakan jenis sulfurnya, (bau metil merkaptan 3 kali lebih berbau daripada hidrogen sulfid). Kelemahan lain adalah metode ini dapat terganggu dengan adanya minyak tertentu, alkohol dan perlu dikalibrasi ulang dari waktu ke waktu karena sensitivitas alat lama kelamaan makin berkurang. Metode yang tidak langsung (indirek) adalah hidrolisis BANA (N-benzoil-DL-arginin-naftilamid) yaitu senyawa tripsin sintetik. Metode ini mudah untuk digunakan. Sushma Nachnani, MS, Oral Malodor, A Detailed Review

9. Mengapa bibir atas dan lubang hidung kanan sakit saat ditekan ?
Karena disitu daerah apeks gigi 11 adanya inflamasi yang sudah meluas dan trjadi vasodilatasi sehingga saat ditekan akan mrasakan sakit dan terdapat tanda inflmasi

10.
-

Apa yang menyebabkan ligament periodontal melebar ?

Adanya abses

11.

Patofisiologis terjadi penyakit yang ada di scenario ?

Bakteri + karbihidrat makanan + Kerentanan permukaan gigi + waktu Karies superfisialis

Karies Media

Karies Profunda

Radang pada pulpa (Pulpitis)

Pembusukan jaringan pulpa (ditemukan gas-gas indol, skatol, putresin)

Bau Mulut

Keluar Gas H2S, NH3

Gigi non vital (Gangren pulpa)

12.
-

Apakah diagnose dari penyakit di scenario ?

Abses periapikal (harusnya ada swelling) Kista periapikal (harusnya ada krepitus , dan gigi bergerser) Akut Apikal periodontitis

Abses alveolar akut Periodontitis apikal akut Eksaserbasi akut Abses alveolar kronis Granuloma Kista radikular Osteoitis memadat

13.

Apakah etiologi dari penyakit di scenario ?

Bakteri + karbihidrat makanan + Kerentanan permukaan gigi + waktu

14. Mengapa dokter memilih perawatan saluran akar padahal ada kontraindikasi PSA ?
Karena kita harus melihat akarnya bengkok seperti apa dan juga mungkin bisa menggunakan tekhnik retrogat bukan retrogat tapi retrofill The most common surgical procedure is called root end resection. We usually cut off the very tip of the root and place a filling at the end of the root to help seal the root structure. This used to be called apicoectomy and retrofill or "apico" and "retro". The American Association of Endodontists decided that apicoectomy was not very patient friendly so it retermed the procedure root end resection. They feel it describes the procedure better.

Gum Tissue Opened Tissue Removed. Gum tissue is reflected near the tooth to give access to the tissue at the end of the root. Then the inflammed and/or infected material is removed.

Root End Resected Root End Filled. The end of the root is removed since it is usually the problem area. Sometimes the end of the root may have embedded bacteria in the rooth structure or branching of canal system which was untreatable with current techniques. A filling helps seal the end. I usually use MTA or Mineral Trioxide Aggregate which is really sterilized for medical use portland cement. It is one of the most biologically compatible materials ever devised for use in dentistry. This material was very difficult to place until I designed a set of carriers to place it.

Bone Healed. Over a period of months, sometimes years, bone heals around the end of the root. This means after the surgery is completed,

http://www.endodovgan.com/Endoinfo_SET.htm

Risk of Apicoectomy Nerve Damage

Depending on where the damaged tooth is located, specific risks can appear. The roots of teeth located on the back of the lower jaw are very close to major nerves, such as the mandibular nerve. These nerves are at risk of being damaged during the procedure. However, dentists are aware of these risks and, if they see on the X-ray that the nerve is too close, they do not recommend the procedure. One might experience symptoms similar to those of nerve damage due to the swelling and the inflammation close to the nerve. These disappear gradually as the area heals.

Sinus Infection
If the damaged tooth is located on the upper jaw, the infection can spread to the sinuses. Your dentist will prescribe antibiotics and decongestants to treat the secondary infection. http://www.dentalfind.com/go/root-canals/article/risks-apicoectomy-root-endsurgery.html#ixzz1fxE8q5AI

15. Apakah perawatan lanjutan setelah PSA pada gigi anterior ?

For the first few days following the completion of a root canal, the tooth may feel sensitive due to natural tissue inflammation, especially if there was pain or infection before the procedure. This sensitivity or discomfort usually can be controlled with over-thecounter pain medications such as ibuprofen(Advil, Motrin) or naproxen (Aleve). Most patients can return to their normal activities the next day http://www.webmd.com/oral-health/dental-root-canals

KLINIS Satu minggu pasca root canal treatment Subjektif o Ada atau tidak keluhan sakit Tes perkusi o Ada atau tidak rasa nyeri Tes palpasi o o o o Ada atau tidak rasa nyeri Kegoyahan Kesehatan gingival Ada atau tidak fistula

RADIOGRAFIS Satu minggu pasca root canal treatment Skor periapikal index untuk melihat hermetical seal o o Mouth Guard Skor 1 : obturasi sempurna dan tidak ada area radiolusen Skor 2 : area radiolusen di periapikal 1 mm (sama sebelum perawatan)

Fillings
Fillings are typically recommended for small cavities, when the root canal is performed on one of the front teeth. However, even for the front teeth, if the cavity is larger, a crown will be recommended (as it will protect the tooth). Fillings may also be an option if the patient cannot afford to get a dental crown. However, this solution should be only temporary, as the tooth can get damaged or fractured, being no longer as resistant as before the root canal procedure.

Crowns or Caps
Crowns or caps are typically recommended for teeth that have undergone a root canal procedure. The crown will be placed on the tooth, but this will have to be fixed with a filling and peeled so that the crown can be fitted in place. If a lot of the tooth is missing, a post or a metallic rod may also be needed, which will help maintain the position of the tooths core.

Veneers and lumineers

Veneers and lumineers are dental products which are placed on the external part of the tooth in order to correct tooth imperfections. In case of root canal treatments, veneers or lumineers can also be used to reinforce the tooth and provide a better look.

If the devitalized tooth is located in the back of the mouth, dentists recommend full crowns. However, if it is located in the front, veneers or lumineers are also a good option. The decision on whether to use a crown or veneers/lumineers is made taking into consideration the position, the health and the integrity of the tooth. Ultra- thin Lumineer veneers are custom designed to give you a beautiful smile you've always dreamed of. Unlike traditional porcelain veneers, there are no shots, no drilling of sensitive tooth structure, and no pain. Lumieers are ultra thin (approximately 0.2mm) and highly translucent, allowing them to replicate the natural appearance of tooth enamel. http://www.dentalfind.com/go/root-canals/article/can-root-canal-combined-other-dentaltreatments.html#ixzz1fxEVUYmN

Medication after root canal therapy: a. 600 mg dose of ibuprofen which is available OTC (Motrin, Advil) within 4 hours after root canal treatment is performed. Dose should not exceed 800mg. Dentist may also prescribe oxaprozin or ketorolac (Prescription only) after root canal treatment. Codeine is given in case of severe pain and has to be used for short term. Pain meds will provide relief and will reduce the swelling. b. Amoxicillin or clindamycin antibiotic may also be given after root canal therapy. When to consult a dentist or endodontist If pain is acute or if pain persists for more than 2weeks, then patient should visit his dentist to get the root canal treated tooth evaluated. Pain persisting for long time can be because of root canal failure.

16. Mekanisme timbulnya bau tidak sedap yang keluar dari gigi saat open bur ?
Bau mulut juga terkadang timbul sebagai pertanda adanya kelainan yang serius baik lokal dalam rongga mulut ataupun sistemik sehingga bisa diwaspadai untuk selanjutnya merupakan langkah awal pemeriksaan kelainan di dalam mulut atau tubuh secara umum. 3 Pada orang yang sehat, bau mulut umumnya berasal punggung lidah, karena bentuknya yang berupa papila (tonjolan-tonjolan kecil), memungkinkan sisa makanan tertinggal. Juga adanya plak (deposit lunak pada permukaan gigi yang mengandung berbagai koloni bakteri yang dapat menyebabkan peradangan gusi dan jaringan periodontal) yang tertinggal di gigi. Sisa makanan ini dipergunakan oleh bakteri anaerob (bakteri yang hidup tanpa membutuhkan udara) seperti Fusobacterium, Veillonella, T.denticola, P. gingivalis, Bacteroides and Peptostreptococcus untuk berkembang biak dan menghasilkan gas sulfur yang mudah menguap (VSCs=Volatile Sulfur Compounds). Gas ini antara lain Hidrogen Sulfid (H2S), Metil Merkaptan (CH3SH), Dimentil Sulfid [(CH3)2S], Sulfur Dioksid (SO2) bertanggung jawab dalam menyebabkan bau mulut, sedangkan zat bukan sulfur yang dapat menyebabkan bau adalah kadaverin, putresin, indol dan skatol. 3

Pembentukan gas VSCs mudah terjadi pada pH alkalin (7,2) dan terhambat pada pH asam (6,5). Adanya glukosa (0,02M) juga dapat menghambat pembentukan VSCs. Penilaian bau mulut dapat dilakukan secara obyektif melalui penilaian langsung (analisa organoleptik). Cara ini diperkenalkan oleh Rosenberg dengan suatu skala organoleptik (nilai 0-5). Cara lain adalah dengan Gas Kromatografi dan fotometri (dapat mendeteksi jenis VSCs, kadaverin, putresin, skatol). Namun cara ini mahal dan sulit. Penilaian dengan Sulfidmeter/Halimeter lebih mudah dan tidak mahal dan juga dapat mendeteksi VSCs meskipun tidak dapat dibedakan jenis sulfurnya, (bau metil merkaptan 3 kali lebih berbau daripada hidrogen sulfid). Kelemahan lain adalah metode ini dapat terganggu dengan adanya minyak tertentu, alkohol dan perlu dikalibrasi ulang dari waktu ke waktu karena sensitivitas alat lama kelamaan makin berkurang. Metode yang tidak langsung (indirek) adalah hidrolisis BANA (N-benzoil-DL-arginin-naftilamid) yaitu senyawa tripsin sintetik. Metode ini mudah untuk digunakan.

17. Apakah jenis antibiotic dan analgesic yang dipilih dokter untuk menangani penyakit di scenario dan mengapa dipilih ?
Analgesic : non narkotik (mis : kombinasi asetaminofen , ibuprofen) Antibiotik : penicillin , clindamycin

Bila sudah ada radang periapikal berikan antibiotik Amoksisilin 500 mg 3 x sehari selama 5 hari, bila terjadi alergi amoksisilin gunakan antibiotika pilihan kedua, eritromisin atau kotrimoksazol. Pada kasus yang berat : penisilin prokain 600.000 IU/hari selama 3 hari. Kalau perlu diberi parasetamol 500 mg 3 x sehari.

18.
KEUNTUNGAN -

Apakah keuntungan dan kerugian melakukan PSA ?

Untuk mempertahankan gigi Mencegah masuknya MO ke saluran akar melalui koronal Mengembalikan fungsi gigi Biar tidak terjadi fokal infeksi

KERUGIAN Mahal Perlu beberapa kali kunjungan

More than the normally anticipated number of root canals in a tooth (leaving one of them uncleaned) An undetected crack in the root of a tooth A defective or inadequate dental restoration that has allowed bacteria to get past the restoration into the inner aspects of the tooth and recontaminate the area A breakdown of the inner sealing material over time, allowing bacteria to recontaminate the inner aspects of the tooth
Swelling after root canal Pain after Root Canal

http://www.identalhub.com/article_complications-and-care-after-root-canal-therapy106.aspx

Bacterial Infection A root canal treatment involves opening the canal for cleaning. While this is done, the air which enters the canal might stimulate bacteria to grow and develop in the canal. During the cleaning process, bacteria can be pushed through a hole from the blood vessels. Blood vessels reach the pulp through a hole located at the tip of the root and if bacteria are pushed through that hole, they can infect the tissue surrounding it. This causes pain and inflammation. Bacterial inflammation and infection have to be treated with painkillers, anti-inflammatory medication and antibiotics. If you feel pain after a root canal, you should consult your dentist so that proper treatment is administered. Puncture of the Root Canal The tools dentists use for a root canal procedure are flexible and they bend respecting the form of the canal. However, if a canal is curved or difficult to find, it can be punctured. If the hole resulting after the puncture allows saliva to enter the tooth, it has to be filled. Sometimes this is not possible and the tooth needs to be removed. If the punctured is deep, under the gum, the hole might heal on its own without causing any further complications. Infected Canals There are cases when finding all root canals is extremely difficult. Canals may have branches which might be impossible for the dentist to reach and clean. Part of the infected pulp tissue can still remain in the tooth if the canals are not cleaned all the way to the bottom due to incorrect measurement. In all these cases, the infection will persist and the treatment needs to be repeated. Broken File The instruments dentists use such as the file are typically reliable. However, there might be cases when the files tip breaks inside the root canal. If the canal has already been cleaned, the broken part can be left inside the tooth. If the canal still needs cleaning, the tip of the file has to be removed. If it cannot be taken out through the opening of the canal, it might need a minor surgical procedure called apicoectomy. This means that the dentist cuts into the gum and reaches for the file from the bottom of the canal.

19.
INDIKASI -

Apakah indikasi dan kontraindikasi dari PSA ?

Adanya abses periapikal Keadaan OH pasien baik Keadaan sistemik baik

- Saluran akar lurus, tidak bengkok - Tidak ada obliterasi saluran akar - Saluran akar jelas - Kerusakan belum mengenai bifurkasi

Severe toothache pain upon chewing or application of pressure Prolonged sensitivity/pain to heat or cold temperatures (after the hot or cold has been removed) Discoloration (a darkening) of the tooth Swelling and tenderness in the nearby gums A persistent or recurring pimple on the gums

KONTRAINDIKASI Gigi tidak dapat direstorasi Akar dari gigi terlalu bengkok dan terdapat modifikasi akar Adanya fraktur vertical Adanya resorbsi internal eksternal tulang alveolar yang luas An undetected crack in the root of a tooth

A defective or inadequate dental restoration that has allowed bacteria to get past the restoration into the inner aspects of the tooth and recontaminate the area
1. When the tooth in question does not have adequate bone support and the bone supporting the tooth shows resorption and tooth is mobile, then that tooth cannot be saved by root canal treatment. 2. When the tooth which has to be treated by root canal treatment has inadequate tooth structure and can not be restored after wards

3. When the general resistance of the patient is poor in that case root canal treatment is not indicated. 4. If the root is fractured then also the tooth cannot be saved by root canal treatment.

20. Faktor apakah yang mempengaruhi keberhasilan dan kegagalan PSA ?

KEGAGALAN Diagnose salah Merawat gigi dengan prognosis buruk Preparasi dan sterilisasi kurang baik Kualitas bahan pengisi saluran kurang baik Tekhnik pengisian kurang baik Keadaan patologis gigi nya sendiri Kesalahan dalam perencaan perawatan

Tahap praperawatan

1. Diagnosis yang keliru 2. Kesalahan dalam perencanaan perawatan 3. Seleksi kasus yang buruk 4. Merawat gigi dengan prognosis yang buruk Tahap slma pratan 1. Kesalahan Pembukaan Kamar Pulpa a. Perforasi prmukaan akar b. Pruskan dasr kmar plpa c. Prparasi saluran mlali tnduk pulpa d. Mmbuat pmbukaan trllu kcil e. Prepras pmbukaan mlebar kearah dsar kmar plpa 2. Kesalahn slama preparasi a. Instrumntasi brlebih / kurang b. Prprasi brlebih/kurang c. Terbentuknya birai / ledge d. Instrumen ptah e. Kslahan pda wktu irgasi dan strilisasi 3. Kslhan saat pngsian

a. Pngsian tdak smpurna b. Pngsian dlkukan pda saat yg tdak tpat c. Pngsian dlkukan pdda saat tdak steril 4. Fktor psca prwatan a. Restorasi yg kurang baik b. Trauma dan frakturtr c. Trkenanya jaringan periodontal Tanda kgagalan 1. Secara klinis (Walton & Torabinejad, 1996; Mardewi, 2003) Rasa nyeri baik secara spontan maupun bila kena rangsang. Perkusi dan tekanan terasa peka. Palpasi mukosa sekitar gigi terasa peka. Pembengkakan pada mukosa sekitar gigi dan nyeri bila ditekan. Adanya fistula pada daerah apikal. 2. Scara radiografis o Perluasan daerah radiolusen di dalam ruang pulpa (internal resorption). o Pelebaran jaringan periodontium. o Perluasan gambaran radiolusen di daerah periapikal. 3. Secara histologis

Adanya sel-sel radang akut dan kronik di dalam jaringan pulpa dan periapikal. Ada mikro abses. Jaringan pulpa mengalami degeneratif sampai nekrotik

Serpihan dentin pada 1/3 apikal, irigasi kurang Kesalahan pemilihan teknik preparasi Penggunaan alat preparasi yang kurang tepat ledging Hasil preparasi S.A. kurang halus Ukuran bahan pengisi (master cone) terlalu besar

Sebab-sebab terjadinya kegagalan tersebut dapat dikatagorikan dalam tiga hal, yaitu (Tarigan, 1994) : 1. Iritasi apikal oleh cairan jaringan yang terinfeksi pada saluran akar yang diisi tidak hermetis adalah 63,46 %. 2. Kesalahan-kesalahan selama dilakukan perawatan, misalnya perforasi, pengisian yang berlebih, instrumen patah, adalah 14,42 %. 3. Kesalahan pada waktu diagnosis, 22,12 %.

What to do if root canal treatment fails In case of root canal failure, root canal re-treatment, Apicoectomy or tooth extraction is done. Root canal re-treatment and Apicoectomy is done to save the tooth and to remove the infection from the tooth. Procedure for root canal re-treatment is similar to root canal treatment and is mainly performed by endodontist. Apicoectomy is surgical removal of root apex to remove infection. If

prognosis of root canal re-treatment or Apicoectomy is poor, then tooth extraction may also be required. After tooth extraction, patient can get the missing tooth replaced with either dental implants or dental bridge. Retreatment. This is a nonsurgical approach. It basically consists of redoing the root canal and is a second chance on maintaining the tooth Endodontic Surgery. This is a Surgical approach. Treatment depends on the cause of failure and still another chance on maintaining the tooth. The most common surgery is root end resection with root end filing also known as 'apico' or apicoectomy and retrofill. When the failure is on a lower molar, surgery may not be an option. Not only are the roots of these teeth difficult to get to surgically, but they also lie very near the nerve that goes to the lower teeth and the lip. Surgery that risks damage to this nerve may not be wise. . Apicoectomy is more difficult to perform in posterior teeth because of difficulty in vision, surgical access and the complexity of multi-rooted teeth. Extraction. This is where the tooth is removed. Commonly some type of replacement is needed, otherwise teeth may shift causing a problem with biting

The Retreatment Process

Step 1: A opening is into the restoration and the build up material from the previous endodontic therapy is removed. If a post is present, it is exposed for removal. A microscope can be very helpful during this part of the procedure since it allows substaintially better vision.

Step 2: Post and other intracanal obstructions are removed. Typically, either a post remover or an ultrasonic handpience is used to vibrate the post lose. Sometimes both are used in more challenging cases.

Step 3: The old root canal filling material is removed sometimes with the help of a softening agent. Tiny instruments are used to clean the root canals and to shape them to a form that will be easy to fill. Instruments are worked to the very tip of the root if possible and widen the canal to remove debrie along the walls which may have been missed with the initial treatment. Irrigants are used to disolve and flush debrie. If this step is not completed in one visit, medication will be placed in the canals and a temporary will be placed in the opening to protect the tooth between visits. X-rays are taken periodically during the cleaning process to check if the instruments are cleaning near the end of the root. Step 4: When thoroughly cleaned the root canals are filled with a rubber like compound called gutta percha. A cement is also used to help seal the canals to prevent bacteria from reentering. In many cases, the opening in the crown of the tooth is sealed with a temporary filling. Sometimes by request of your dentist, or when we feel it's appropriate, the access opening in the crown is filled with a build up restoration as pictured. The restoration is matched for color if possible. After endodontic treatment, X-rays are taken to verify that cleaning and filling of the canals is close to the end of the root.

KEBERHASILAN (triad endodontic) Preparasi akses Preparasi saluran akar / cleaning and shaping Pengisian saluran akar

Anatomical factors Several anatomical and histological studies have demonstrated the complexity of the anatomy of the rootcanal system, including wide variations in the number, length, curvature and diameter of root canals; the complexity of the apical anatomy with accessory canals and ramifications; communications between the canal space and the lateral periodontium and the furcation area; the anatomy of the peripheral root dentine. This complex anatomy must be regarded as one of the major challenges in root canal preparation and is reviewed in detail elsewhere in this issue.
Microbiological challenges Both pulp tissue and root dentine may harbor microorganisms and toxins (2633). A detailed description of the complex microbiology of endodontic infections lies beyond the scope of this review, this issue recently has been reviewed by rstavik & PittFord (34), Dahlen & Haapasalo (35), Spangberg & Haapasalo (36) and others.

Zip Zipping of a root canal is the result of the tendency of the instrument to straighten inside a curved root canal. This results in over-enlargement of the canal along the outer side of the curvature and under-preparation of the inner aspect of the curvature at the apical end point. The main axis of the root canal is transported, so that it deviates from its original axis. Therefore, the terms straightening, deviation, transportation are also used to describe this type of irregular defect. The terms teardrop and hour-glass shape are used similarly to describe the resulting shape of the zipped apical part of the root canal Elbow Creation of an elbow is associated with zipping and describes a narrow region of the root canal at the point of maximum curvature as a result of the irregular widening that occurs coronally along the inner aspect and apically along the outer aspect of the curve. The irregular conicity and insufficient taper and flow associated with elbow may jeopardize cleaning and filling the apical part of the root canal Perforation Perforations of the root canal may occur as a result of preparation with inflexible instruments with a sharp cutting tip when used in a rotational motion (Fig. 8). Perforations are associated with destruction of the root cementum and irritation and/or infection of the periodontal ligament and are difficult to seal. The incidence of perforations in clinical treatment as well as in experimental studies has been reported as ranging Apical blockage Apical blockage of the root canal occurs as a result of packing of tissue or debris and results in a loss of working length and of root canal patency (Fig. 10). As a consequence complete disinfection of the most apical part of the root canal system is impossible.

21.

Bagaimana indicator PSA dinyatakan berhasil ?

Removal of vital and necrotic tissue from the main root canal(s). Creation of sufficient space for irrigation and medication. Preservation of the integrity and location of the apical canal anatomy. Avoidance of iatrogenic damage to the canal system and root structure. Facilitation of canal filling. Avoidance of further irritation and/or infection of the periradicular tissues. Preservation of sound root dentine to allow longterm function of the tooth.

Obturasi sempurna Tidak ada keluhan sakit Tidak ada radiolusensi yang membesar Gingiva normal Skor periapikal index = 1 Tidak ada fistula

22.

Apakah medikamen pada PSA ?

Bahan pengisi pilihan kombinasi GUTTA-PERCHA dengan SILER * karena dapat mengisi dan melengkapi kekurangan masing masing

According to research by Dr. Boyd Haley of the University of Kentucky, 75% of root canal teeth have residual bacterial infections remaining in the dentinal tubules. - Gutta-percha berbentuk Kon (conus) sebagai bahan pengisi utama. Ukuran gutta- percha pengisi yang sama dengan ukuran jarum endodontik, dari besaran 15 sampai 140, sesuai dengan standard ADA dan ISO, guttap percha ini dapat disterilkan dengan alkohol 70%, chlorhexidine 2%, atau sodium hipoklorit (5%). Guttap point ISO dengan penambahan diameter keruncingan 2% per mm. Guttap point protaper dengan penambahan keruncingan 4%, 6%, 12% per mm. Namun demikian masih banyak sistem keruncingan yang berbeda karena tergantung pada merek misalnya: core filler guttap percha, guttap percha point, yang menggunakan inti dari resin. Siller atau pasta saluran akar, sebagai bahan perekat guttap point pada dinding saluran akar, agar kedap terhadap cairan maupun udara. Siller ini harus dapat menyatu dengan jaringan gigi dan tidak merangsang jaringan apeks. Siller yang mnengandung resin dapat mengeras sehingga kebocoran periapeks dapat dicegah. Konsistensi bentuk cair seperti dempul. Dua metode yang populer untuk memasukkan ke dalam saluran akar adalah dengan metode penyuntikan dan penggunaan jarum lentulo. Metode penyuntikan dilakukan dengan semprit dan jarum khusus. Pasta dicampur dan dimasukkan ke dalam tabung, tangkai yang disekrup dipasang dan diputar sehingga pasta keluar melalui jarum khusus. Jarum dimasukkan sejauh mungkin ke dalam saluran akar. Pasta disuntikkan sambil jarum ditarik perlahan-lahan. Metode dapat dilakukan dengan cara menggunakan lentulo. Jenis bahan yang dipakai misalnya oksida seng adan egenol yang dicampur membentuk campuran murni (tanpa aditif) yang kental. Jenis lain adalah formula campuran dengan aditif. Misalnya : AD seal, endomethason, AH plus. Konsep pemakaian pasta saluran akar bersama-sama bahan utama adalah untuk mendapatkan pengisian yang hermetis dan apeksifikasiannya dapat setipis mungkin.

23.

Bagaimana sifat bahan yang ideal untuk PSA ?

1. Antimikroba 2. Tidak merangsang jaringan periapikal 3. Membantu proses penyembuhan

4. Tidak menimbulkan toksisitas sistemik 5. Flow yang baik 6. Adaptasi/adhesif baik 7. Tidak ada perubahan dimensi 8. Tidak larut 9. Bersifat radiopak 10. Mudah dimanipulasi dan ditempatkan 11. Tidak menyebabkan pewaarnaan 12. Harganya cukup murah 13. Mudah dikeluarkan kembali/perawatan ulang

24.
-

Bagaimana keadaan normal daerah periapikal ?

Lebar jaringan lig. Periodontal (0,1-0,3 mm)

25.

Mengapa gigi yang di PSA mengalami diskolorisasi ?

After the root canal treatment as the tooth looses its vitality, it becomes discolored. This discoloration can be taken care of either by bleaching or by giving dental crown on root canal treated tooth.

26.
-

Mengapa menggunakan foto rontgen periapikal ?

Karena untuk melihat gigi dari mahkota sampai apeks Pada anak-anak bisa pake panoramic karena dibutuhkan melihat benihnya juga

27.
Sikat gigi Flossing

Bagaimanaka pemeliharaan gigi setelah PSA ?

Harus menjaga OH 6 bulan sekali ke dokter gigi Selama perawatan dilarang makan makanan keras

Care after Root Canal Treatment 1. Patient should avoid eating from side of root canal treated tooth. 2. To reduce swelling after root canal treatment, ice pack application over that area can be done. Ice pack application should be done for 10-15 minutes every hour. 3. Take the pain meds as directed and complete the course of antibiotics. Pain meds should be taken before the effect of local anesthesia wears off. 4. Patient should sleep with head at slightly elevated position. 5. Patient should take soft foods at least for 2 days after root canal treatment. Very hot or cold foods should be avoided after root canal treatment. 6. Avoid smoking, drinking or stressful exercises as it will affect the healing

28. Apakah pada gigi nekrosis masih ada lig. Periodontal ? Masih