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Drg. Desak N. Ari Susanti, M.

Kes

RESTORATIVE DENTAL EMERGENCIES


PROBLEM :

pain
swelling

Structural integrity (crack, fracture)

Filling

prothesa
DOKTER GIGI DIHARAPKAN MAMPU :
Mendiagnosa dengan tepat
melaksanakan perawatan darurat yang
efektif dan dengan cepat
Presenting Structure Condition Causes
complaint involved
Pain Tooth (pulp) Sensitivity Caries
Pulpitis Crack or fracture
Wear (abrasion,
attrition, erosion and
abfraction)

Failing restoration
Gingival recession
iatrogenic, e.g.
scaling,whitening,
over-preparation,
overload, galvanic
pain,
composite shrinkage
Periodontium Acute gingivitis and Infection (periodontal
periodontitis or pulpal)
Abscesses Trauma, e.g.
ANUG occlusion,
impacted food and
foreign bodies
Iatrogenic, e.g.
over-instrumentation
of root canals or root
surface, overhangs,
impinging denture
clasp

Infection-related
Prosthesis-related,
e.g.
ill-fitting denture
Stomatitis
Mucosa
Bone For example,
inflammatory bony
Conditions

Referred pain from


Other another tooth or
structure
Neurological, e.g.
Trigeminal nerve
neuralgiaa
Psychologic pain,
e.g. atypical facial
Pain

Periapical or
periodontal
abscess

Swelling Mucosa Infection


Tooth Tooth Chipping Trauma (impact or
structural Cracked tooth occlusal)
integrity syndrome Caries
(cracks, Fracture Internal resorption
fractures, and Over-p
mobility) Preparation

Marginal leakage
Caries
Fillings Loosening, Construction errors
Prosthesis debonding,
decementation Trauma (impact or
Fracture occlusal)
Periodontal
disease
Periodontal Dislocation and
avulsion Trauma
Loss of Pathology, e.g.
Attachment cysts,
neoplasms

Bone Fracture
Bone loss
A. PAIN MANAGEMENT
1. Dentin Hypersensitivity
- nyeri pendek, tajam
- Karena rangsangan dingin, panas, osmotic,
dll
- Dapat terjadi di permukaan gigi, cervical
- Terapi dengan
- desensitising agents such as fluoride as
sodium or stannous fluoride
- Potassium nitrate can be applied
- topically as a gel or aqueous solution.
- Sealants in the form of adhesive resins
applied to the areas of sensitive dentine to
occlude open tubules may be used
- In home: non-abrasive dentifrices,
desensitising toothpastes, fluoride
mouthwashes
2. Reversible Pulpitis
- Sakit bila terkena dingin, panas, dan manis

- Sakit pendek, tajam

- Sakit hilang bila rangsangan dihentikan,


sering sulit menentukan lokasi sakit
- Electric Pulp Test (EPT) batas normal s/d
sakit
- Tes perkusi batas normal

- Radiografi ; tampak caries or an extensive


restoration.
Management :
- Check the occlusion

- Bersihkan karies dan beri sedatif dressing ex.


calcium hydroxide (liner) + GIC
- Sarankan untuk segera tumpat permanen
3. Irreversible pulpitis
- Pain with hot, cold and sweet stimuli
- Pain is persistent, Lasts minutes or hours
after the stimulus has been removed.
sakit spontan, throbbing /berdenyut , can
disturb sleep, is often difficult
to localise, eased with analgesics.

In advanced cases, cold can ease the pain


and heat will make it worse.
There is no pain if the dentine is cut if the
coronal pulp is non-vital.
Percussion tests are within normal limits.

Radiographs may show deep caries or large


restorations and occasionally
early widening of the apical periodontal
membrane space.
B. INFECTIONS AND SOFT TISSUE
PROBLEMS
1.Abses periapical akut
- Irreversible pulpitis acute apical
periodontitis acute periapical
periodontitis
- Radiografi tampak membran periodontal
yang melebar
- Gigi mungkin ekstrusi, mobilitas gigi
meningkat, gigi dapat menjadi non vital
- Ada pembengkakan jaringan lunak
Management ;
DRAINASE ..!
- Gigi (open bur)

- Insisi intra oral (bila terdapat abses yg


fluktuatif)
- Extra oral , celulitis s/d mengancam
nyawa rujuk BM
Akut apikal
periodontitis
Abses periapikal
2. Abses Periodontal Akut
- kerusakan jaringan periodontal
- Pus/nanah
- Infeksi dari sulcus,, bukan dari pulpa
- Diawali dari adanya poket periodontal
- Secara klinis : edema, kemerahan, sakit,
terdapat poket, gigi extruded, mobile, kel lympa
membesar/ teraba
- Diagnosa : hystory, pemeriksaan klinis,
radiografi : lateral aspek jelas
bukal,/ palatal/lingial kurang
jelas
Differential diagnosa ;
- Mirip dengan akut apikal periodontitis

Apikal periodontitis/ abses Periodontal Abses


periapikal

Gigi non vital Gigi vital

Vertikal perkusi + Lateral perkusi ++

caries No caries

No pocket pocket

Ro apek radiolucency Lateral Radiolucency

No/minimal mobility mobility


Treatment (gingival dan periodontal abses) :
- Anastesi

- Debridement, pocket curettage , incisi


(gingival abses)
- Semprot larutan saline

- Antibiotik dan analgetik (periodontal abses)

- Kontrol hari berikutnya, cek kondisi, ex.


perlu tindakan bedah/ tidak
3. Acute Gingivitis

Treatment of gingivitis takes three forms:


(1) Physical removal of plaque by efficient
toothbrushing, or professional
mechanical tooth cleaning.
(2) Chemical inhibition of bacterial plaque
formation using mouthwashes containing
chlorhexidine solution.
(3) Dental health education and oral hygiene
instruction to correct deficiencies
in cleaning techniques are important.
4. Acute Periodontitis
- gingivitis periodontitis
- Bone loss
- Periodontal attachment rusak
- Penderita DM, kerusakan lebih cepat

Complications of gingivitis
Gejala awal : gusi berdarah, halitosis,
spontaneus bleeding + loss of bone
period attch loss teeth loss. Juga dpt
beresiko terjadi infeksi dp membran period
periodontal abses
Bisa jadi serius ok barrier function jaringan
gingiva berkurang toxin dan bakteri
pembuluh darah mll ggv

Dampak serius :
- Bakteri dental plak pembuluh darah
atheromatous plaques dlm arteri acute
myocardial infection juga stroke
- Px bermasalah dg paru-paru meningkatkan
infeksi
- Ibu hamil BBLR ok. Plak cervic/uterus
inflamasi
Gingival problems and dental implants

Terkadang terjadi keradangan pada jaringan


sekitar implan cek OH, bersihkan
Calculus should be removed from titanium
abutments with instruments that will not
damage the surface of the implant.
Ultrasonic instruments and steel-tipped
instruments are contraindicated.
Amati dengan cermat, cari penyebab :
adaptasi yg kurang baik dr crown diatas
implan, kebocoran tepi
memastikan tidak ada kelebihan residu
semen dari sendi implan / mahkota.
5. ACUTE NECROTISING ULCERATIVE
GINGIVITIS (ANUG)

Inflamasi akut pd ggv dg karakter ; sakit


sangat, bengkak, ulcer, jaringan mati yg
mengelupas , biasanya pada papila interdental
Rasa sakit , panas, bau

Mikroorganisme :Prevotella intermedia,


alphahaemolytic streptococci, Actinomyces
species and spirochaetes
Treatment : menghilangkan sakit dan sepsis
scaling to remove necrotic debris and
calculus plus irigasi dg clorhexidine
Antibiotik ; metronidazole, Amoxicillin dpt
digunakan bila metronidazole tdk bekerja
Obat kumur chlorhexidine atau 6% hydrogen
peroxide mouthwash
Analgetic ; Pct, ibuprofen
6. STOMATITIS
Denture stomatitis (chronic atrophic
candidosis, denture sore mouth)
- Oral Candidasis
- Penggunaan denture 24 jam /hari
- Tidak terawat
- Tidak tepat / longgar
- Kemerahan, edema
- Lebih banyak pada RA
Management :
- Mengurangi pemakaian denture, lepas saat
tidur
- Denture should be cleaned and soaked
overnight in either a weak hypochlorite
solution or chlorhexidine. Denture berbasis
metal kontraindikasi dg hypochlorite stain
- Antifungal ; Topical treatment is often the
first-line therapy. Clotrimazole cream may be
applied to the fitting surface of the denture
and the denture refitted. Fluconazole may be
indicated.
Perhatikan kemungkinan kasus sistemik : DM
tipe 2, immunodeficiency disorders, HIV or
antibiotic therapy
7, ANGULAR CHEILITIS
- Luka / inflamasi pada sudut bibir, biasanya
bilateral
- Sakit saat membuka mulut

- susceptible to infection with Candida albicans


or other pathogens such as staphylococci
- decreased vertical dimension either from the
loss of teeth or ill-fitting dentures.
- nutritional deficiencies and iron deficiency
anaemia, zinc deficiency, poor diet and
medications that can dry
the skin.
8. TRAUMATIC SOFT TISSUE LESIONS
- ill-fitting prostheses,
- sharp teeth or restorations,
- cheek biting,
- parafunctional habits or
- thermal burns.

Dx ; evident from the history (anamnesa) and


examination (pemeriksaan klinis)
Tx ; sesuai dg penyebab
Cheek biting

Thermal burn
C. CRACK, FRACTURE AND MOBILITY OF TEETH
AND DENTAL RESTORATIONS

1. The cracked tooth syndrome


- incomplete fracture of enamel or dentine
- lower molars, followed by upper premolars and
molars,
- age range of 3060 years
Dx; sulit
careful history and assessment of the symptoms,
in particular that of cold sensitivity and sharp
pain on biting hard or tough food, which starts
on the release of pressure, is an important
indicator. Symptoms may vary according to the
depth and orientation of the crack.
Investigations ;
- Kaca pembesar, sinar light cure pd
dental unit
- Probe / sonde yg tajam
- The removal of existing restorations may also
help to reveal fracture lines.
- The use of stains to highlight fracture lines
such as gentian violet or methylene blue.
- The use of the so-called bite tests to mimic
the symptoms associated with
incomplete fractures of posterior teeth.
- Vitality tests (biasanya masih vital)
- Radiographs tend to be of limited use

Emergency treatment for cracked tooth


syndrome
Aim of treatment is to prevent crack
propagation and to relieve the associated
symptoms.
Treatment options :
- Occlusal adjusment

- Removal of a pre-existing restoration: This


should be done to assess the full extent of
the fracture.
- Immobilisation of segment: An extra-coronal
circumferential splint may
be applied. This may take the form of a copper
ring or a stainless steel orthodontic band.
- Direct composite splint
cracked
Fracture
2. Fracture and mobility of restorations
- Ditched (hilang/terbuang) , fractured, dislodged
(lepas) or lost fillings may complain of pain or
sharp edges (irritation to the side of tongue or
the cheek potentially leading to an ulcer).
- The pain symptoms, caused by dentine
exposure underneath the filling,
- could present as hypersensitivity, pulpitis or
even as periodontal/periapical abscess
symptoms in advanced cases.
Emergency management :
- Pain management depends on the diagnosis

- dokter perlu menentukan antara mengganti


mengisi komposit retak dengan komposit
atau menumpat sementara dengan GIC.
- The material : replacement of a porcelain or
gold filling. Therefore, the filling should be
removed and replaced by another
temporarily, atau komposit
Fracture and mobility of fixed prostheses
- Patients with loose crowns usually complain
of dental hypersensitivity, tampak buruk,
khawatir akan lepas saat mengunyah.
- Some will also report gingivitis or a
periodontal abscess
- re-prepare the abutment and to take a new
impression
Fractured and loose temporary crowns
3 hal yang harus diperhatikan :
a. Strength of the temporary crown

b. Strength of the cement

c. Occlusal forces
Fractured and loose permanent crowns and
bridges
Most likely reasons for loose permanent
crowns and bridges
(1) Crown decementation, which in turn could be due to:
a. non-retentive preparation;
b. secondary caries;
c. weak (or dissolved) cement (or loosening of the crown
retention screw on an implant);
d. excessive occlusal forces.
(2) Crown fracture
This can be seen with porcelain but not metal crowns. It could be due
to:
a. insufficient porcelain thickness as a result of tooth underpreparation;
b. excessive occlusal forces.
(
(3) Abutment fracture, because of:
a. secondary caries;
b. excessive occlusal forces.
(4) Fracture/decementation of a post or
loosening of the abutment screw on an
implant as a result of:
a. dissolved cement/secondary caries;
b. use of weak post;
c. excessive occlusal forces.
Single Crown ;
- Bersihkan semen

- Cek karies/ fraktur

- Crown di bersihkan

- Cek marginal, cek preparasi

- Cek oklusi, lateral, protrusif

- Cek tekanan

- Desain

- Recementing dg semen yg lebih kuat


Bila crown tidak bisa digunakan lagi, buatkan
crown baru,
Lindungi abutment dg temporarry crown atau
gunakan crown yg lama di semen dg
temporrary crown
rencana pengobatan baru bila diperlukan :
perawatan saluran akar, restorasi inti
abutment, penggantian pos retak, atau
bahkan ekstraksi gigi abutment.
Bridge

- Kerusakan bridge lebih sering daripada


crown
- Clinicians should beware of radiopaque
crowns and bridges hiding caries
radiographically
- Management perbaikan crown berbeda
dengan bridge :
- a. Sectioning the intact cemented retainer
and making a new fixed bridge
b. Sectioning the bridge between the pontic
and loose retainer, and leaving
the remaining units as a cantilever bridge.
The loose retainer will be then
recemented or remade
c. Attempting to recement the loose retainer.
This technique has been recently described
but not followed-up in the long term. The
method comprises
making a hole in the loose retainer to inject a
resin cement.
Fraktur sering terjadi pada konektor antara
pontik dg retainer.
Harus diputuskan apakah bridge yg patah dpt
digunakan as it comprises of a separate
cantilever bridge one side and a retainer on
the other
Alternatively, the two sections could be
removed and soldered, or the bridge remade
Whatever the choice, careful examination of the
bridge design, the span length and occlusal
forces is vital to avoid further failure or
additional complications.
Fracture of the porcelain veneer of a porcelain-
fused-to-metal crown

- repair of the fractured veneer with


composite.
- The alternative option to remove the crown or
bridge in order to fix them in the laboratory
or for replacement could prove very
difficult,costly and risky to the abutment
tooth
LEARNING TASK

1. Pasien wanita 40 tahun datang ke praktek


dokter gigi dengan keluhan sakit saat
mengunyah pada daerah rahang atas dimana
terdapat jembatan pada gigi 15,16 dan 17. Test
perkusi (-), tekan (+). Dokter gigi lalu
melakukan ronsen foto dan ditemukan
gambaran sbb
GAMBARAN RONSEN :
a. Apa diagnosa kasus tersebut? Jelaskan
alasannya
b. Tindakan emergency apa yang sebaiknya
dilakukan oleh seorang dokter gigi dalam
menangani kasus tersebut? Jelaskan
2. Pasien wanita 35 tahun datang ke praktek
dokter gigi dengan keluhan ngilu pada gigi
geraham atas kanan, ngilu dirasakan bila
pasien minum dingin atau panas, dan rasa
ngilu terasa lama dan tajam. Pemeriksaan
klinis tampak gigi 15,16 terdapat tumpatan
amalgam seperti gambar berikut
a. Tindakan apa yang harus dilakukan oleh
dokter gigi tersebut? Sebutkan dan
jelaskan dengan sistematis
b. Apa diagnosanya? Jelaskan alasannya
3. Pasien laki-laki datang dengan keluhan
seperti gambar dibawah ini.
Crown beserta post/dowelnya terlepas pagi
tadi. Apa yang akan anda lakukan untuk
menangani kasus tersebut ? jelaskan
4. Pasien wanita 65 tahun datang ke praktek dokter gigi
dengan keluhan denturenya patah karena terjatuh 3 hari
yang lalu
saat membersihkannya. Apa tindakan yang akan anda
lakukan untuk menangani masalah tersebut? Jelaskan
5. Sebutkan perbedaan abses dengan celulitis
6. Jelaskan alasan mengapa sebagai dokter
gigi perlu mempelajari dental emergencies?
7. Tampilkan video yang menayangkan
tindakan emergencies yang dapat dilakukan
di tempat praktek ex.membongkar
crown/bridge yg rusak, membuat temporarry
crown dll (masing@ kelompok 1 video )