ENDODONTIC
EMERGENCIES
drg. Irfan
Dwiandhono
REFERENSI
Walton, R.E., Torabinejad, M. 2002.
Principles and Practice of Endodontics.
3rd ed. W. B. Saunders. London
Grossman, L.I., Oliet, S., Rio, C.E.D.
1995. Ilmu Endodontik Dalam Praktek.
EGC. Jakarta
Ford, T.R.P., Rhodes, J.S., Ford, H.E.P.
2002. Endodontics Problems-Solving
Clinical Practice. Martin Dunitz. London.
Chong, B.S. 2010. Harty’s Endodontics in
Clinical Practice. 6th ed. Elsevier. London
PAIN….
✓Physiological
✓Psychological
EVALUATION OF THE CASE SEVERITY
•
Regular daily activities : Sleep, meals, work, etc
•
Symptons began
•
Take pain killers
•
Drug inefficacy / short lasting analgesia
•
Systemic symptoms / signs : fever
•
The patient perspective : Emotional condition, pain
tolerance
KEDARURATAN VS
KEGAWATDARURATAN
•
DARURAT
Keadaan sulit (sukar) yang tidak
disangka-sangka yang memerlukan
penanggulangan segera
•
GAWAT
Kritis / Genting / Berbahaya / Dekat
dengan kematian
ENDODO
NTIC
“The condition associated with
EMERGE
pain and/or swelling which
NCIES
requires immediate diagnosis and
Perawatan kedaruratan endodontik adalah perawatan yang
treatment”
bersifat sementara dan bertujuan untuk mengurangi atau
menghilangkan rasa sakit bagi penderita.
TRUE EMERGENCY VS LESS CRITICAL
EMERGENCY
• True Emergency
The condition which requires unscheduled visit with
diagnosis and treatment at that time
• Less Critical Emergency
Less severe problem in which next visit may be
scheduled for mutual convenience of both patient as
well as the dentist
ETIOLOGI ENDODONTIC
EMERGENCIES
• Kelainan dalam pulpa
• Kelainan dalam periradicular
• Cedera Traumatik
ENDODONTIC
EMERGENCIES
Pre Treatment
Intra Appointment
Post Obturation
SISTEM
PENEGAKAN
1. Pemeriksaan
Subjective
DIAGNOSA
Chief Complaint
Present Illness
Past Dental History
Past Medical History
Family History
Social History
SISTEM
PENEGAKAN
1. Pemeriksaan
Subjektif
DIAGNOSA
2. Pemeriksaan Objektif
Extra Oral
Intra Oral
Asimetri wajah
Vitalitas
Luka
Perkusi
Kondisi fisik
Palpasi
Gaya berjalan
Mobilitas
SISTEM
PENEGAKAN
1. Pemeriksaan
Subjektif
DIAGNOSA
2. Pemeriksaan Objektif
3. Pemeriksaan Penunjang
Diagnosa
Rencana
Perawatan
PULPAL
PERIRADICULAR
PULP ORIGIN VS
PERIODONTAL
ORIGIN
Periodontal Origin
Pulp Origin
•
•
If thermal stimuli lead to
severe explosive pain
The patient is unable to
localize
•
Thermal test
•
Electric pulp tester
•
If pain occurs on mastication or
when teeth are in occlusion
•
The patient is able to localize
•
Periodontal probing
•
Palpation over the apex
•
The mobility of tooth
•
Selective biting on the object
KLASIFIKASI KEDARURATAN
ENDODONTIK
• Pulpitis Ireversibel akut
• Periodontitis apikalis akut
• Abses Alveolar Akut
• Abses Periodontal Akut
• Acute flare-up
• Fraktur mahkota
• Fraktur akar
PULPITIS IRREVERSIBEL AKUT
• Nyeri spontan dan tajam, kadang
persisten selama beberapa menit
• Nyeri timbul bila kena rangsangan
termal (dingin atau panas), bertahan
dari detik sampai menit meskipun
rangsangan telah dihilangkan
PULPITIS IRREVERSIBEL AKUT
PEMERIKSAAN KLINIS
• Extensive atau recurrent
caries
• Gigi dengan restorasi
yang besar dan dalam
• Gigi crack atau fraktur
PULPITIS IRREVERSIBEL AKUT
PULPITIS IRREVERSIBEL AKUT
THE CHALLENGE
•
Identification of the
responsible tooth
•
Obtaining an
adequate anaesthesia
•
Finding the canal
orifices because
bleeding
PULPITIS IRREVERSIBEL AKUT
Adequate anaesthesia
•
Infiltrasi labial / palatal
•
Block anaesthesia
PULPITIS IRREVERSIBEL AKUT
Adequate anaesthesia
•
Intrapulpal injection
•
Periodontal ligament
injection
PULPITIS IRREVERSIBEL AKUT
Treatment :
•
Extirpation of the pulp from the
chamber
Emergency treatment
•
Root canal treatment
•
Extraction
•
Medication : analgesic
EXTIRPATION OF THE PULP
PULPITIS IRREVERSIBEL
AKUT
Treatment :
•
Apabila tidak mempunyai
banyak waktu untuk
menyelesaikan eksterpasi
pulpa & preparasi saluran
akar
Pulpotomi
(debridement, pengeringan,
dan penutupan kamar pulpa
dengan suatu dressing yang
telah diberi obat
PULPOTOMI
PULPITIS IRREVERSIBEL AKUT
• Root canal treatment
PERIODONTITIS APIKAL
AKUT
•
Inflammation of periodontal ligament
caused by tissue damage usually from
extension of pulpal pathosis or occlusal
trauma
• Pressure on tooth (occlusion / percussion)
is transmitted to the fluid which pushes on
nerve ending in the periodontal ligament
PERIODONTITIS APIKAL
AKUT
•
Bacterial invasion
Pulp necrosis
•
Development of a complex biofilm
•
Interaction with periapical tissues at
foraminal areas
•
Conflict between bacterial
proliferation and host defense
mechanisms
PERIODONTITIS APIKAL
AKUT
•
Release of inflamation mediators
•
Immune and inflamatory reactions in the
periodontal space
•
Exsudate infiltrates the periodontal ligament
space
•
Pressure increases on periodontal fibers,
already sensitized by inflamatory mediators
PERIODONTITIS APIKAL
AKUT
Symptoms :
•
Intense pain caused by masticatory
movement
•
Sensation of supraocclusion
PERIODONTITIS APIKAL AKUT
Examination :
• Color alteration
• Caries or restoration
• Tenderness to touch
• Percusion positive
• Non vital
• Enlargement of the Periodontal Ligament space
PERIODONTITIS APIKAL AKUT
Treatment :
•
Open bur / Trepanasi
treatment
•
Occlusal grinding
•
Root canal treatment
X
Emergency
PERIODONTITIS APIKAL AKUT
• Root canal treatment
ACUTE APICAL
ABSCESS
•
Formation of a periapical abscess implies
the breakdown of body immune system
because it contain microbes inside the root
canal system
•
Large number of bacteria get past the apex
into the periradicular tissues resulting in
local collection of purulent exudates
ACUTE APICAL ABSCESS
•
Bacteria pass the
foramen in large
numbers, invading the
apical periodontium
•
Release of chemotactic
factors (PMN
leucocytes)
Release
of lysosomic enzymes
ACUTE APICAL ABSCESS
SYMPTOMS :
•
Pulsating pain
•
Swelling
•
Pain to chewing
•
Sensation of supraocclusion
•
Mobility
•
Systematic feature (Fever & Malaise)
ACUTE APICAL ABSCESS
EXAMINATION :
•
Non vital
•
Percussion positive
•
Enlargement of periodontal ligament space
•
Radiolucent diffuse
PHASE ACUTE APICAL
ABSCESS
• Initial abscess
•
Subperiosteal abscess
•
Final phase abscess
ACUTE APICAL ABSCESS
1. INITIAL ABSCESS
• Pulp necrotic
• No swelling
• Canal contain bacteria, biofilm,
and PMN (Leucocyte)
• Leucocyte release lysosomic
enzim
Production pus
• Acumulate pus
high
pressure on periapical tissues
ACUTE APICAL ABSCESS
2. SUBPERIOSTEAL ABSCESS
• Swelling
• High pressure on both the periapical tissues
and the periosteum
• Emergency treatment : Drainage the purulent
exsudate
ACUTE APICAL ABSCESS
2. SUBPERIOSTEAL ABSCESS
ACUTE APICAL ABSCESS
3. FINAL PHASE ABSCESS
• The pus break the periosteum and accumulate
in the sub mucosa
• Swelling on the buccal or lingual aspect of the
alveolar bone
• Fluctuation
• Emergency treatment : Drainage
- Access cavity
- Incision in the fluctuation zone
ACUTE APICAL ABSCESS
3. FINAL PHASE ABSCESS
ACUTE APICAL ABSCESS
Perawatan :
1. Tindakan untuk meredakan kondisi
akutnya, meliputi drainase (open
bur(trepanasi)/insisi), occlusal
grinding, debridement
(pembersihan dan pembentukan
saluran akar secara sempurna)
2. Bila pembengkakan luas, lunak,
dan menunjukkan fluktuasi
diperlukan suatu insisi melalui
jaringan lunak
3. Antibiotik diberikan setelah
dilakukan drainase
ACUTE APICAL ABSCESS
Tujuan Drainase :
1. Mencegah terjadinya perluasan
abses/infeksi ke jaringan lain
2. Mengurangi rasa sakit
3. Menurunkan jumlah populasi mikroba dan
toksinnya
4. Memperbaiki vaskularisasi jaringan
5. Mencegah terjadinya jaringan parut akibat
drainase spontan dari abses
ACUTE APICAL ABSCESS
• Root canal treatment
ABSES PERIODONTAL AKUT
Tanda dan Gejala :
•
Rasa sakit dan bengkak
•
Dapat timbul pada pulpa vital maupun nekrotik
•
Probing helps in differentiating endodontic from
periodontal disease. These abscesses occasionally
communicate with the sulcus and have a deep
probing defect
•
Etiologi : Pembentukan nanah di dalam infrabony
poket yang dalam
ABSES PERIODONTAL AKUT
Treatment:
๏ Pada pulpa vital
✓ Dilakukan kuretase, debridement, drainase
melalui sulkus, dan insisi jaringan lunak
✓ Bila gagal : PSA
๏ Pada pulpa non vital
✓ Dirawat seperti abses alveolar akut
PSA
ABSES PERIODONTAL AKUT
ACUTE FLARE-UP DURING
TREATMENT
• The occurence of pain, swelling or the combination
of these during the root canal therapy
• Etiology :
- NaOCl accident
- Perforation
- Over instrument
- Extrusion
ACUTE FLARE-UP DURING
TREATMENT
NaOCl accident
•
Serious severe situation
•
Immediate, sudden and violent pain
•
Swelling and prolonged bleeding in
the canal
•
Lack of control in the irrigation
ACUTE FLARE-UP DURING
TREATMENT
NaOCl accident
•
Treatment :
-
Wash with saline or distilled water
-
Medication : Analgesic
-
Consider the need to refer to a hospital
ACUTE FLARE-UP DURING
TREATMENT
Perforation
•
Proximal, buccal, floor
•
Bleeding in root canal
•
Treatment : Closure with MTA
ACUTE FLARE-UP DURING
TREATMENT
Overinstrumentation
•
Uncontrolled enlargement of the foramen
•
Mechanical agression to the periapical
tissues
•
Debris are pushed out
•
Overobturation
•
Medication : Analgesic
FRAKTUR MAHKOTA
• Nyeri tajam, nyeri yang menusuk
terutama sewaktu mengunyah
• Transluminasi dapat digunakan untuk
menyingkap garis retak pada gigi
FRAKTUR MAHKOTA
Treatment :
•
Bila segmen mahkota terbelah dan pulpa
tidak terbuka (rasa sakit biasanya akan
menghilang)
Pulp capping
Restorasi
•
Bila pulpa terbuka
•
Occlusal grinding
PSA vital/non vital
FRAKTUR MAHKOTA
FRAKTUR AKAR
Prognosis tergantung :
❖ Lokasi dan arah garis fraktur
✓ Fraktur horizontal pada servikal / apeks (++)
✓ Fraktur vertikal (-)
❖ Vitalitas pulpa
✓ Vital (++)
✓ Non vital (-)
FRAKTUR AKAR
FRAKTUR AKAR
Tissue response following intra-alveolar
root fracture:
1. The coronal & apical fragments
become reunited by mineralized origin,
which may be of dentinoid or
cementumoid (a)
2. The fragments of root don’t reunite, but
the coronal portion of tooth is retained,
with the fracture line occupied by soft
connective tissue (possibly periodontal
ligament) (b)
FRAKTUR AKAR
Tissue response following intraalveolar root fracture:
3. Bone and soft connective tissue
(possibly periodontal ligament),
4. Granulation tissue representing an
inflammatory response to either
pulp or gingival interaction, and
with associated expansion of the
fracture line and lateral
radiolucencies
FRAKTUR AKAR
Treatment :
✓ No displacement & the crown is not mobile
repositioning & splinting
✓ Displacement & sufficient bone to support the
coronal fragment
traumatic occlusal
repositioning & avoid
✓ Repositioning or mobile teeth should be stabilized
with flexible splint (wire & composite resin)
FRAKTUR AKAR
Treatment :
✓ Pulp breakdown in the coronal element (non vital,
radiolucency at the fracture line)
treatment
root canal
✓ During RCT
instrumentation and root canal filling
should be limited to the fracture line only. Apical pulp
retains vital function
✓ If apical periodontitis develops on the apical fragment
Apex resection
FRAKTUR AKAR
FRAKTUR AKAR
ENDODONTIC EMERGENCY
• Stressful situation
• We must to keep and show
calm
• The knowledge and skill in
various aspects of
endodontics are required to
achieve successful outcome
of endodontic treatment
TERIMA KASIH
irfandrg@gmail.com
08155277884
irfandwiandhono
irfandwiandhono