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Contents ...........................................................................................................................................1 Preface..............................................................................................................................................2 Chapter 1 : Introduction ...................................................................................................................3 Chapter 2 : Odontogenic Infection, Patients Management, and Farmacology ...............................6 2.1 Odontogenic Infection ............................................................................................................6 2.2 Treatment Plan and Patient's Management ...........................................................................9 2.2.1 Extraction ....................................................................................................................9 2.2.2 Medication : Antibiotics and Analgesics ..................................................................24 2.3 Medically Compromised Patients ......................................................................................27 2.3.1 Gastrointestinal and Hepatic Disorders ....................................................................27 Chapter 3 : Narasumber .................................................................................................................30 Chapter 4 : Conclusion...................................................................................................................35 References ......................................................................................................................................37


This paper is written to provide information about the diagnostic procedure and step of the treatment plan in non-specific odontogenic infections. In this paper we will give information about the mechanism of spread infection, how to diagnose the infections, and how we treat odontogenic infection especially for medically compromised patient. In this scenario, the patient has problem with her liver and gastrointestinal that in doing the treatment plan, we should aware to some considerations in treating medically compromised patient. There are several data that we needed to confirm the systemic disease is really occurred in patient that we can collect from laboratory investigation that later will be describe in this paper. This paper describe about pathogenesis of non-specific odontogenic infection, diagnostic procedures, treatment plan that includes: anesthesia, indication and contra indication of extraction, instrument and technique of extraction, medication.

CHAPTER I INTRODUCTION Scenario 1 : Mellinda, 35 years old woman, came to RSGMP FKG UI with her daughter, 6 years old Dee. She wants to have a comprehensive treatment on her tooth because she frequently suffers from toothache on that tooth, and she took ponstan that makes the pain disappear. Because of the pain on that tooth, she couldnt sleep eat all on the night before she came to RSGMP. When she woke up, there are reddish swelling on the left side of her face extending to the under of her left eye, when the pressure applied to swelling, it is tender and she feels pain. She frequently feels a sting/pain on her stomach and a bloated belly. Several months ago she was sick and suffers a several symptoms such as, her whole body looks yellowish, she feels extremely weak and nausea. Melinda said Dee, have a big hole on her upper right back tooth, the surrounding gingival is sometimes swollen. The extra oral examination shows no abnormalities. The intra oral examination shows that her 54 tooth had a pulp caries (sondase, percussion, palpation: negative), a gingival swelling on the palatal side of 54 region, palpation: tender, when the pressure applied to the swelling, there are a liquid coming from those area she doesnt feel any pain. Keywords: Melinda 1. Female, 35 years old 2. frequently suffers from toothache, complains about a radix on upper left back tooh 3. several months ago, she took a ponstan to make the pain disappear 4. because of the pain, she couldn't sleep 5. when she woke up, there are reddish swelling on the left side of her face extending to the under of her left eye. pressure applied to the swelling --> tender and pain 6. frequently feels sting/pain on stomach and bloated belly 7. several months ago, she was sick and suffers several symptoms such as her body looks yellowish, feels extremely weak and nausea Dee 1. Female, 6 years old 2. big hole on her upper right back tooth, the surrounding gingival is sometimes swollen

3. Extraoral examination: there are no abnormalities 4. 51 have a pulp caries (sondase, percussion, palpation: negative) 5. gingival swelling on labial side of 51 region, palpation: tender 6. pressure applied to the swelling --> liquid coming from those area, no pain 7. ulcer on the labial side near the root of 51 area 8. the tip of 51 tooth can be seen on the labial gingival

Questions: 1. What causes the pain in Melindas tooth? 2. What is the reddish swelling on the left side? 3. Why does she feel tender and pain when pressure applied? 4. Are there any relation of the tootache to her general condition? 5. Why does the tooth pain recurrent? 6. What is the reddish swelling and the pain indicates? 7. How does the pain killer work? 8. What kind of pain killer we should use? 9. Is antibiotic needed in treating Melinda's case? What kind of antibiotic we should use? 10. Related to systemic condition, what things has to be considered? and what information or data should be taken? 11. How to formulate the diagnosis/DD based on IO, EO, radiographic, and laboratorium report? 12. How can we treat the patient? Can the tooth be conserved or extracted? 13. Indication and contraindication of extraction? 14. How is the procedure of extraction? 15. What are the instruments of extraction? what are the techniques of extraction? 16. How is the anaesthetic technique and done? 17. Is there any consideration in treating medically compromised patient? 18. Is there any modification?

Hypothesis: 1. Melinda suffers from odontogenic infection from the unextracted radix and systemic disease (Liver and gastrointestinal disease) 2. We should consider that Melinda has to be reffered to the internist and get laboratory investigation 3. The proper treatment plan for Melinda and Dee are: emergency care, remove pathologic condition and medication (antibiotic, analgesic)

Learning Issues: A. Diagnostic Procedure 1. Anamnesis 2. Extraoral and intraoral examination 3. Supporting examination radiograph 4. Diagnosis and differential diagnosis 5. Prognosis 6. Treatment plan a. Indications and contraindications of extraction b. Medication (pre and post) c. Procedures d. Instruments e. Complications and management of complications B. Pathogenesis 1. Inflammation 2. Infection how it spreads C. Patient referral and laboratory investigation Considerations of dental management in medically compromised patients


2.1 Odontogenic Infection

Terminology Inoculation is characterized by the entry of pathogenic microbes into the body without disease occurring. Infection involves the proliferation of microbes resulting in triggering of the defense mechanism, a process manifesting as inflammation. Inflammation is the localized reaction of vascular and connective tissue of the body to an irritant, resulting in the development of an exudate rich in proteins and cells. Inflammation Inflammation may be caused by, among other things, microbes, physical and chemical factors, heat, and irradiation..The manifestation of inflammation is typical and is characterized by the following clinical signs and symptoms: rubor (redness), calor (heat), tumor (swelling or edema), dolor (pain), and functio laesa (loss of function). Depending on the duration and severity, inflammation is distinguished as acute, subacute or chronic. Acute Inflammation. This is characterized by rapid progression and is associated with typical signs and symptoms. If it does not regress completely, it may become subacute or chronic. Subacute Inflammation. This is considered a transition phase between acute and chronic inflammation. Chronic Inflammation. This procedure presents a prolonged time frame with slight clinical symptoms and is characterized mainly by the development of connective tissue. The natural progression of inflammation is distinguished into various phases : Serous Phase. Lasts approximately 36 h, and is characterized by local inflammatory edema, hyperemia or redness with elevated temperature, and pain. Serous exudate is observed at this stage, which contains proteins and rarely polymorphonuclear leukocytes. Cellular Phase. Characterized by massive accumulation of polymorphonuclear leukocytes, especially neutrophil granulocytes, leading to pus formation. If pus forms in a newly developed cavity, it is called an abscess. If it develops in a cavity that already exists, e.g., the maxillary sinus, it is called an empyema. 6

Reparative Phase. Begin almost immediately after inoculation. With the reparative mechanism of inflammation, the products of the acute inflammatory reaction are removed and reparation of the destroyed tissues follows. Repair is achieved with development of granulation tissue, which is converted to fibrous connective tissue.

Infection of orofacial region The cardinal causes of orofacial infections are non-vital teeth, pericoronitis (due to a semi-impacted mandibular tooth), tooth extractions, periapical granulomas that cannot be treated, and infected cysts. Rarer causes include postoperative trauma, defects due to fracture, salivary gland or lymph node lesions, and infection as a result of local anesthesia. 1. Classification of Infections of the Orofacial Region a. Based on the organism causing the infection: bacterial, viral, mycotic, parasitic b. Based on the tissue affected: odontogenic, non-odontogenic c. Based on the route of entry: pulpal, periodontal, pericoronal, fracture, tumour, iatrogenic, opportunistic d. Based on the clinical presentation: acute, chronic e. Based on the deep fascial spaces of the head and neck infiltrated by the infection: canine, buccal, infraorbital, submandibular, submental, sublingual, submassetric, pterygomandibular, lateral pharyngeal, retropharyngeal, carotid, parotid, infratemporal, temporal, peritonsillar, pretracheal, or mediastinal space 2. Physiology of the Infection and Inflammatory Response Sequels of inflammation: a. Vasodilatation of the arterioles causing hyperemia b. Extravasation of plasma rich in plasma proteins, antibodies and nutrients into the surrounding tissues c. Collection of leucocytes d. Leucotoxin, increases permeability allowing polymorphs into the area e. Exudate forming fibrin, walling the region f. Macrophages phagocytosis of bacteria, dead cells

3. Mechanism of Spread of Infection Oral infection may originate in: (a) the pulp of the tooth and extend via the root canals into the periapical tissues and may become dispersed through the spongy bone; or (b) the periodontal tissues and spread to the bones.

The infection may become localized or extend diffusely. In the bone, it might perforate the cortical plate and discharge pus via a sinus on the outer skin surface of might remain confined within the bone.

The type and virulence of the microorganisms involved and the immunological condition of the patient influence the degree of spread of the infection.

4. Routes of Spread a. Direct Spread 1) Spread into the superficial soft tissues may: Localize as a soft tissue abscess Extend through the overlying oral mucosa or skin, producing a sinus linking the main abscess cavity with the mouth or skin Extend through the soft tissue to produce cellulitis

2) Spread may occur into the adjacent fascial spaces, following the path of least resistance 3) Infection may extend into deeper medullary spaces of alveolar bone producing a spreading osteomyelitis b. Indirect Spread 1) Lymphatic routes to regional nodes in the head and neck region. Usually involved nodes are tender, swollen and rarely may suppurate requiring drainage. 2) Hematogenous routes to the other organs, such as brain. 5. Stages of Infection a. During 1 to 3 days the swelling is soft, mildly tender and doughy if consistency. b. Between 5 to 7 days the centre begins to soften and the underlying abscess undermines the skin or mucosa making it compressible. The underlying pus may be seen through the epithelial layers making it fluctuant. c. Finally, there is resolution of the abscess that may be spontaneous or after the surgical drainage. During the resolution phases, the involved region is firm on palpation due to the process of removing tissue and bacterial debris. 6. Clinical Features of Infection in the Oral Cavity a. Rubor or redness b. Tumour or swelling c. Calor or heat d. Dolor or pain e. Loss of function f. Pyrexia 8

g. Lymphodenopathy h. Presence of halitosis 7. Factors Affecting the Spread of Orofacial Infection a. Systemic Factors 1) Microbial factors: level of virulence, number of organisms introduced into the host, body sites pathogen targets for invasion 2) Host factors: general state of health, integrity of surface defenses, capacity for inflammatory and immune response, level of immunity, impact of medical intervention 3) Combination of both factors b. Local Factors 1) Alveolar bone and periosteum 2) Neighboring soft tissues, muscles 8. Principles of Management of Odontogenic Infections a. Treatment of Causes b. Incision and Drainage c. Excision of Sinus d. Antibiotic Therapy e. Complementary Medical Care f. Supportive Therapy

2.2 Treatment Plan and Patient's Management

2.2.1 EXODONTIA (TOOTH EXTRACTION) Exodontia is a branch of dentistry dealing with extraction of a tooth from its socket in the bone. 1. INDICATIONS FOR TOOTH EXTRACTION 1. Deeply carious tooth with pulpal pathology 2. Teeth with apical pathology 3. Non-vital teeth 4. Teeth with periodontitis 5. Malpositioned and overerupted teeth 6. Impacted 7. Retained deciduous teeth 8. Tooth in the line of fracture 9. Teeth with fractured root

10. Orthodontic purpose 11. Prosthetic purpose 12. Certain teeth before radiation therapy 13. Prophylactic extraction 14. Root fragments 2. CONTRAINDICATIONS FOR TOOTH EXTRACTION 1. Systemic contraindications a. Absolute contraindications: Patients with uncontrolled diabetes, leukaemia, renal failure, cirrhosis of liver and cardiac failure. b. Relative contraindications: Patients with diabetes, hypertension, cardiac disease, patients on steroid therapy, pregnant women, patients with blood dyscrasias, patients on anticoagulant therapy, toxic goiter, jaundice, fever of unexplained origin, nephritis, medically compromised patients and extraction of teeth in recently irradiated patients 2. Local factors 3. INSTRUMENTS OF EXTRACTION 1. Forceps Types of forceps a. Mandibular forceps The beaks are oriented at more of an angle to the handle. The beaks of mandibular forceps are always symmetrical and the handle is vertical handle. For the molar, the beak is symmetrical with central points or tips on each beak intended to fit or engage the bifurcation or buccal / lingual root grooves. Mandibular anterior forceps Shape : beak, joint, handle has a 90 shape, with open and round end Function : to extract mandibular anterior teeth

Mandibular premolar forceps Shape : beak, joint, handle has more than 90 shape due to its location at the angle of the mouth and near the cheek, with open and round end

Function : to extract mandibular premolars teeth

Mandibular molar forceps Shape : beak, joint, handle has a 90 shape, with bifurcation shape et the end of the beak Function : to extract mandibular molars teeth

Mandibular posterior radix forceps Shape : beak, joint, handle has a 90 shape, with close and round end

b. Maxillary forceps The beaks are oriented closer to parallel in relationship to the handles. Bayonet-designed handles are used only with maxillary forceps. Maxillary anterior teeth forceps


Shape : beak, joint, and handle perform a straight line. The beak has open and round end

Maxillary premolars teeth forceps Shape : beak, joint, and handle perform s reversed. The beak has open and round end

Maxillary posterior teeth forceps Shape : beak, joint, and handle perform s reversed. The beak has open and has bifurcation end. If bifurcation end at the left, its for maxillary right molars visa versa. Function : extract 1st and 2nd maxillary molars


Maxillary 3rd molar forceps Shape : beak, joint, and handle perform bayonet. The beak has open and round due to fused root.


Maxillary posterior teeth radix Shape : beak, joint, and handle perform s reversed. The beak has open and has bifurcation end. If bifurcation end at the left, its for maxillary right molars visa versa. Function : extract root of maxillary premolars and molars


Elevators They are oriented with the concavity of the blade directed toward the tooth to be extracted Function :

Separate gingiva attachment Luxate the tooth Remove radix Separate tooth at the bifurcation


3. Cryer (root elevator) / elevator with T-shaped handles 4. Cryer is used for the mandibular posterior teeth only due to uncontrol force if apply to the maxillary teeth. Cryer can remove radix of posterior teeth if the other root already removed.



1. Extraction of Maxillary Central Incisors The beaks of the forceps are adapted to the tooth, and the beaks must be parallel to the long axis of the tooth. The initial extraction movements are gentle, first in a labial direction, and then palatal.After the initial force is applied to the tooth, motions gradually become greater and the final extraction force is applied labially. Because the root of the central incisor is conicalin shape, its removal may also be achieved using rotational forces. More specifically, the tooth is rotated first in one direction and immediately afterwards in the other direction, until the periodontal fibers are completely severed. The tooth is then delivered from the socket using slight traction.


2. Extraction of Maxillary Lateral Incisors The extraction movements for removal of the lateral incisor are labial and palatal. Because the lateral incisor has a thin root and there is usually curvature of the root tip distally, rotational force is not allowed. Slight rotational motions maybe employed only in the final stage, with simultane oustraction of the tooth from the socket.

3. Extraction of Maxillary Canines Maxillary canines present some degree of difficulty due to: (1) their firm anchorage in alveolar bone, and (2) their long roots and frequent curvature of the root tip.


Also, the labial surface of the tooths root is covered by thin alveolar bone, and if due consideration is not given during movements, there is a risk of fracturing the alveolar process. The extraction movements are labial and palatal, with gradually increasing intensity. Because the canine has a flattened root and the root tip is usually curved distally, rotational motions are not permitted, or if they are used, they must be done so very gently and with alternating buccopalatal pressure. The final extraction movement is labial.

4. Extraction of Maxillary Premolars As for the first premolar, because it usually has two roots, buccal and palatal pressure should be gentle and slight. If movements are vigorous and abrupt, there is a risk of fracturing the root tips. If one of the root tips does break, it may be removed easily, since they are not very curved and the tooth has already been mobilized during the extraction attempt. Rotational motions are not allowed due to the tooths anatomy. Extraction of the second premolar is easier, because the tooth has one root. Movements are the same as those for the first premolar. The final movement for both teeth is buccal.


5. Extraction of Maxillary First and Second Molars The maxillary first molar has three diverging roots the palatal, which is the large stand most widely divergent toward the palate, and the two buccal roots, which are often curved distally. The tooth is firmly anchored in the alveolar bone and its buccal surface is reinforced by the extension of the zygomatic process. This tooth therefore requires the application of strong force during its extraction, which may cause fracture of the crown or root tips. To avoid this from happening, initial movements must be gentle, with buccopalatal pressure and an increasing range of motion, especially buccally, where resistance is less. The final extraction movement is a buccal upwards curved motion, following the direction of the palatal root. Because the root tips are close to the maxillary sinus, their removal requires careful consideration, due to the risk of oroantral communication. Extraction of the maxillary second molar may be accomplished in the same way as for the maxillary first molar, because the teeth have similar anatomy. Extracting the second molar, however, is considered to be easier than extracting the first molar, because there is

less resistance from the buccal alveolar process and relatively little divergence of the roots. Quite often the roots of this tooth are fused together in a conical shape. In this case, extraction of the tooth is even easier.

6. Extraction of Maxillary Third Molar The maxillary third molar is the smallest of all molars and varies greatly in size, number of roots, and root morphology. It has three to eight roots. It most commonly has three roots just like the other maxillary molars, but smaller and converging. They are usually fused together in a conical shape, curved distally. Extraction of the tooth depends on its location, as well as on the number and shape of the roots. If the third molar has erupted completely and its roots are fused (conical shape), its extraction does not usually present any difficulty and it may be removed with only buccal pressure. The risk of fracturing the palatal alveolar process is avoided this way, which would otherwise occur if force were applied palatally (the palatal bone is thinner and lower than the buccal bone). When the tooth has three or more roots, though, its extraction is accomplished by applying buccal pressure and very gentle palatal pressure. The final extraction movement must always be buccal. Root anatomy of the third molar permitting, extraction is easily accomplished using the straight elevator. The elevator is positioned between the second and third molars and the tooth is luxated according to the direction of its roots.

7. Extraction of Mandibular Anterior Teeth Mandibular incisors have narrow f lattened roots, which are not very firmly anchored in the alveolar bone. These teeth have one root and are curved at the root tip, especially the lateral incisor. Their extraction is easy, due to their morphology and the thin labial alveolar bone surrounding the root. Extraction pressure is applied labially and lingually, gradually increasing in intensity. Due to the flattened roots of the teeth, only slight rotational force is permitted. Mandibular canines usually have only one root. Seventy percent of these teeth have a straight root, while 20% present distal curvature. Compared to incisors, canines are more

difficult to extract, due to the long root and frequent curvature of the root tip. Extraction movements are the same as those employed for central and lateral incisors. The final extraction movement for all anterior teeth is labial, curved outwards and downwards. Damage of maxillary teeth by the forceps is thus avoided.

8. Extraction of Mandibular Molars The mandibular first molar usually has two roots, a mesial and a distal one. The mesial root is larger, more flattened than the distal root and usually is curved distally. The distal root is straighter and narrower than the mesial root, and more rounded. The mandibular second molar has a morphology similar to that of the first molar. Even though this tooth is surrounded by dense bone ,it is removed more easily than the first molar, because its roots are smaller and less divergent, and they are often fused together.


The extraction technique is the same for both molars. More specifically, the forceps are adapted to the tooth as apically as possible, beneath the cervical line of the tooth, with the beaks parallel to the long axis of the tooth. Initially the movements are gentle with buccal and lingual pressure. After the tooth is slightly mobilized, force is gradually increased and the final extraction movement is buccal, taking care not to damage themaxillary teeth with the forceps.

9. Extraction of Mandibular Third Molar The mandibular third molar usually has two roots, whose morphology is similar to that of the other molars. They are smaller, though, and usually are fused in a conical shape, widely diverging distally. Buccolingual pressure is applied and th range of motion depends on the morphology of the buccal and lingual alveolar bone. The lingual alveolar bone is very thin compared to the buccal alveolar bone, which is unyielding in the third molar area; therefore, the force that mobilizes the tooth must be applied in the lingual direction. Afterwards,

pressure must be applied very carefully, so as to avoid fracture of both the tooth, due to excessive buccal force, and the lingual plate of bone. If the third molar has one root or if the roots converge and are curved in the same direction, the extraction may be accomplished using the straight elevator alone. In this case the elevator is positioned at the mesial surface of the tooth, which is delivered according to the direction of curvature of the roots.


Extraction of Deciduous Teeth The extraction technique for deciduous teeth is similar to that used for permanent teeth.

The dentist must pay particular attention when extracting deciduous molars because of the risk of simultaneously extracting the bud of the subjacent permanent tooth. More specifically, because the crown of the deciduous molar is short, the beaks of the forceps may accidentally grasp the crown of the bud of the underlying permanent tooth as well and remove both. This is why the beaks of the forceps must be positioned on the mesial or the distal area of the tooth and not the center (root bifurcation), underneath which is the permanent tooth. When the roots of the deciduous tooth embrace the crown of the subjacent premolar, the deciduous tooth must be removed by surgical extraction. If the root of the deciduous tooth breaks during the extraction procedure, it may be removed using narrow elevators, taking care to avoid contact with the permanent tooth. Extraction of deciduous teeth is much easier than that of permanent teeth, especially if their roots are resorbed. Deciduous teeth are difficult to extract when root resorption is incomplete. The subjacent tooth then erupts partially, causing thinning of the roots instead of total resorption. These thin root remnants are interposed between the crown of the permanent tooth and the bone, and fracture easily during the attempt to extract the deciduous tooth. This extraction is deemed necessary because the deciduous tooth is not shed spontaneously due to incomplete resorption of the root or roots.


5. COMPLICATION FROM EXTRACTION a. Perioperative complications Fracture of the crown of the adjacent tooth or luxation of the adjacent tooth Soft tissue injuries Fracture of the alveolar process Fracture of the maxillary tuberosity Fracture of the mandible Broken instrument in tissues Dislocation of the TMJ Subcatenous or submucosal emphysema Hemorrhage Displacement of the root or root tip into soft tissues

Displacement of an impacted tooth, root or root tip into the maxillary sinus Oroantral communication Nerve injury

b. Postoperative complications Trismus Hematoma Ecchymosis Edema Postextraction granuloma Painful postextraction socket Fibrinolytic alveolitis (dry socket) Infection of wound Disturbances in postoperative wound healing.

2.2.2 MEDICATION ANTIBIOTIC USE FOR ODONTOGENIC INFECTION1 Despite the high incidence of odontogenic infections, there are no uniform criteria regarding the use of antibiotics to treat them. Treatment should be provided in some acute situations of odontogenic infection of pulp origin as a complement to root canal treatment, in ulcerative necrotizing gingivitis, in periapical abscesses, in aggressive periodontitis, and in severe infections of the fascial layers and deep tissues of the head and neck. They do not recommend antibiotic treatment in chronic gingivitis or periodontal abscesses (except in the presence of dissemination). Antibiotics should be used to assist the dentist in treating patients with infections. Surgical treatment of the infection remains the primary method of treatment in most patients; antibiotic therapy plays an adjunctive role. Antibiotics are especially important in patients who have infections that cannot be adequately treated by surgery alone (e.g., cellulitis) and in patients who have some compromise of their host defense mechanisms. When antibiotic therapy is to be used for a routine odontogenic infection, empirical antibiotic therapy is recommended, because the microbiology of odontogenic infections is well known and usually consistent from patient to

Pallash, Thomas J., Antibacterial and Antibiotics Drugs.


patient. The antibiotic of choice for odontogenic infections is still penicillin. Penicillin is bactericidal; has a narrow spectrum that includes streptococci and the oral anaerobes, which are responsible for approximately 90% of odontogenic infections; has low toxicity; and is inexpensive. Although many Prevotella are resistant to penicillin, when used in conjunction with adequate surgery, penicillin almost always results in cure. An alternative drug is clarithromycin, which is a useful medication for patients who are allergic to penicillin. Clindamycin is also a useful alternative, but its increased toxicity make it most useful in special situations in which resistant anaerobic bacteria are suspected. The oral cephalosporins are excellent choices when the patient has a history of mild allergy to penicillin and in whom bacteria other than the normal oral flora are suspected. Both cefadroxil and cephalexin are good choices, but cefadroxil is given twice daily instead of four times daily for cephalexin. Tetracycline, especially doxycycline, is a good choice for mild infections. Metronidazole may be a useful adjunct when only anaerobic bacteria are involved. Although slightly more than one third of all odontogenic infections are caused by only anaerobic bacteria, this cannot be predicted reliably; therefore the use of metronidazole alone in acute infections should be somewhat limited.2 Precaution - Pregnancy - Kidney failure Many antibiotics are actively eliminated through the kidneys. The presence of impaired renal function requires reduction of the drug dose in order to avoid excessively elevated plasma drug concentrations that could lead to toxicity. dose adjustment can be carried out by reducing the amount administered in each dose or by increasing the interval between doses (without modifying the amount of drug). Neither approach has been shown to be superior3. - Liver failure Some antibiotics are metabolized in the liver, followed by elimination in bile. In patients with liver failure, the use of such antibiotics should be restricted in order to avoid toxicity secondary

2 3

Pederson G. W., Oral Surgery, W,B Saunders Co, 1988. Livornese LL Jr, Slavin D, Gilbert B, Robbins P, Santoro J. Use of antibacterial agents in renal failure. Infect Dis Clin North Am 2004;18:55179.


to overdose. Erythromycin, clindamycin, metronidazole and anti-tuberculosis drugs are antibiotics requiring dose adjustments when administered to patients with liver failure. Regardless of the above considerations, some antibiotics are potentially hepatotoxic. As a result, and whenever possible, they should be avoided in patients with some active liver disorder. Specifically, tetracyclines and anti-tuberculosis drugs should be avoided 4. ANALGESIC USE FOR PAIN MANAGEMENT5 Aspirin It is a peripherally acting, non-steroidal analgesic. Indicate for pain with a significant inflammatory component (e.g. postoperative pain after dental surgical procedures). Also used in the management of musculoskeletal pain, headache, and dysmenorrhoea, as an antipyretic, and for its antiplatelet actions in the prophylaxis for cerebrovascular disease or myocardial infarctions. It cannot be prescribed to asthmatics (can precipitate bronchoconstriction), patients with a history of peptic ulceration, uncontrolled hypertension, patients suffering from gout, patients with disorders of haemostasis (aspirin reduces platelet aggregation, therefore increases bleeding time), or patients with known hypersensitivity to the drug.

Mefenamic acid Its a peripherally acting, non-steroidal anti-inflammatory analgesic. It reduces pain and inflammation associated with musculoskeletal disorders, e.g. rheumatoid arthritis, osteoarthritis, and ankylosing spondylitis, dysmenorrhoea and menorrhagia. Patients on long-term NSAIDs such as mefenamic acid may be afforded some degree of protection against periodontal breakdown. This arises from the drugs inhibitory action on prostaglandin synthesis. The latter is an important inflammatory mediator in the pathogenesis of periodontal breakdown. Rare unwanted effects of mefenamic acid include angioedema and thrombocytopenia. The latter may cause an increased bleeding tendency following any dental surgical procedure.

Douglas LR, Douglas JB, Sieck JO, Smith PJ. Oral management of the patient with end-stage liver disease and the liver transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:55-64. 5 E.S. Troullos, D.M.D., R.D. Freeman, D.M.D.t R.A. Dionne, D.D.S., Ph.D. Review Journal: The Scientific Basis for Analgesic Use in Dentistry. 1986.


Paracetamol Its a non-opioid analgesic. Its for mild to moderate pain (e.g. headache) and to reduce pyrexia. Patients with renal failure, since chronic use of paracetamol and overdose can cause both papillary and tubular necrosis. The problem of renal failure is compounded when paracetamol is combined with centrally acting analgesics. Paracetamol can cause bronchoconstriction in asthmatics, although the incidence is much lower than for aspirin or other NSAIDs. Paracetamol is hepatotoxic in overdose and should be avoided in patients with liver failure.

Ibuprofen (Brufen, Nurofen, Fenbid) It is a peripherally acting, non-steroidal anti-inflammatory analgesic that is derived from propionic acid. Its for pain management with a significant inflammatory component (e.g. postoperative pain after dental surgical procedures). Also used in the management of musculoskeletal pain, dysmenorrhoea, and to reduce fever. Ibuprofen is avoided in patients with a history of allergy to aspirin or any other NSAID. The drug should not be prescribed to asthmatics or patients with a history of angioedema and urticaria. Ibuprofen should not be prescribed to patients with active peptic ulceration or to patients with hemorrhagic disorders since it will affect platelet aggregation. Ibuprofen should be used with caution in patients who exhibit renal, cardiac or hepatic impairment since the repeated use of the drug can result in deterioration in renal function.

2.3 MEDICALLY COMPROMISED PATIENTS 2.3.1 GASTROINTESTINAL AND HEPATIC DISORDERS A. HEPATITIS 1. Viral hepatitis Hepatitis A Caused by the hepatitis A virus (HAV), which is an RNA-type virus. Serologic test for HAV and its antibodies are available. Transmitted almost exclusively by fecal contamination of food or water. Common sources include contaminated wells or water supplies, food sources. Transmission is also enhanced by poor personal hygiene. Occurs primarily in children and young adults.

No vaccine is currently available and recovery usually conveys immunity against reinfection.

Hepatitis B Caused by the hepatitis B virus (HBV), which is DNA-type virus. HBV is composed on an outer shell which is Hepatitis B surface antigen (HBsAg) and its antibody is anti-HBs and the inner core is hepatitis B core antigen (HBcAg) with corresponding antibodies anti HBc and IgM anti HBc. And the third particle is the hepatitis B e antigen (HBeAg). One of the more significant features of hepatitis B is the existence of a chronic carrier state that can persist for variable periods after resolution of acute disease. A carrier is defined as an individual in whose serum the HBsAg persists and is detectable for longer than 6 months. Hepatitis C Type C hepatitis is similar to type B in behavior and characteristics. Transmitted primarily parenterally and is the major etiologic agent of posttransfusion non-A non-B hepatitis. Signs and Symptoms There are classically three phases of acute viral hepatitis: a. The prodormal (preicteric) phase Usually precedes the onset of jaundice by 1 or 2 weeks. Consists of aneroxia, nausea, vomiting, fatigue, myalgia, malaise, fever. b. The icteric phase is heralded by the onset of clinical jaundice Many of the nonspecific prodormal symptoms may subside, but gastrointestinal symptoms (e.g. aneroxia, nausea, vomiting, and right upper quadrant pain) may increase, especially early in the phase. Usually lasts 6 to 8 weeks. c. Convalescent or recovery (posticteric) phase The symptoms disappear but hepatomegaly and abnormal liver function values may persists for a variable period. Can last for weeks or months. The usual sequence is for recovery to be complete 4 months after the onset of jaundice.


2. Non-infection hepatitis (drug induced, alcohol, etc) A very careful operative technique and system for sterilization of instruments is required to protect surgery staff and other patients. All staff should be advised to be immunized against the hepatitis B virus as unrecognized carriers of the antigen may present for treatment.

B. DISEASES OF GASTROINTESTINAL TRACT 1. Gastroesophageal Reflux Disease Medical aspects During gastroesophageal reflux, gastric contents passively move up from the stomach into the esophagus. Heartburn is the cardinal symptom of GERD and is defined as a sensation of burning or heat that spreads upward from the epigastrium to the neck. Oral health considerations Patients who experience gastric reflux disease complain of dysgeusia foul taste), dental sensitivity, erosion and/or pulpitis. 2. Hiatal hernia Oral health considerations If a hiatal hernia is treated with medications that cause xerostomia, the dose or drug type may need to be altered by the patients physician. Class V caries or root caries are sequelae of dry mouth. 3. Duodenal ulcer disease Oral health considerations Oral manifestations of peptic ulcer disease are rare unless there is anemia from gastrointestinal bleeding or persistent regurgitation of gastric acid as a result of pyloric stenosis leading to dental erosion, typically of the palatal aspect of the maxillary teeth. 4. Ulcerative colitis Oral health considerations Pyostomatitis vegetans, a purulent inflammation of the mouth may occur.



Narasumber drg. Dewi Fatmah : 1. Kaitan dg gangguan sal. cerna -hepar: obat apa saja yg hepatotoxic? -pilih obat yg ga mengiritasi saluran cerna 2. Kasus malinda hrs pakai antibiotik karena infeksinya sudah menjalar. Terapi : causa & symptom 3. Dee. Bila sudah mengetahui causanya misalnya radix tsb, kita tidak perlu memberikan antibiotik, cukup cabut saja. 4. Kapan butuh antibiotik sebelum operasi? 5. Pilih obat yg memberi manfaat lebih besar daripada risknya. 6. Pain killer ada 3 golongan, yakni: NSAID, OPIOID, ANASTESI LOKAL.

Narasumber drg. Ronny : 1. Sebelum proses cabut gigi, melakukan anestesi lokal (baik infiltrasi maupun blok). 2. Cabut gigi sukses: - posisi pasien - tinggi pasien - posisi operator - pemilihan alat yang tepat (tang esktraksi, elevator/bein, root elevator/cryer - untuk ekstraksi) - tehnik penggunaan alat tsb di gigi (penempatan, gerakkan, sedalam apa) 3. Komplikasi dalam cabut gigi dan cara penanganannya misalnya: tulang alveolar ikut tercabut, akar tertinggal 4. Prinsip: kalau kita melakukan tindakan ekstraksi, kita harus yakin dapat mengeluarkan gigi tsb serta menangani komplikasinya 5. INSTRUMEN alat, cara pemakaian cabut gigi punya 3 gerakan standar:

1. Luksasi --> bucal - lingual 2. rotasi --> di putar (hanya dipakai untuk gigi yang berakar tunggal) 3. ekstraksi --> mencabut (Gigi RA ektraksi ke bawah, gigi RB ekstraksi ke atas) 6. Penempatan tang penting di perhatikan! 7. Instrumen untuk ekstraksi - tang cabut gigi - alat bantu (bein & cryer) 8. Perbedaan dalam mencabut gigi dewasa dan anak salah satunya adalah ukuran tang. 9. Tang cabut memegang gigi di daerah akar gigi bukan di mahkota agar tidak patah. 10. Jika yang tersisa radiks, maka gunakan bein untuk melepaskan komponen gigi dari tulang alveolar. untuk akar tunggal bisa dilakukan ekstraksi dgn tang, untuk akar ganda bisa di separasi terlebih dahulu. tang khusus radiks juga ada. 11. Bein arahnya ke apeks, jangan sejajar karena bisa tergelincir melukai bagian mulut yang lain. 12. KOMPLIKASI intra- operative pasca- operative 13. Perdarahan --> intra (kena pembuluh darah), pasca (pasien menggunakan obat pengencer darah). 14. Kalau pendarahan mengenai arteri bisa muncrat darahnya, kalau kapiler merembes darahnya. 15. Perdarahan : jika sepanjang tulang? jika di jaringan lunak? jika terkena kanalis? - - klem jika dalam tulang , stop cut digunakan utk di dalam tulang, jahit jika di jaringan lunak. 16. Patah: gigi yang dicabut, atau gigi tetangga, tulang rahang, atau tulang alveolarnya. 17. Root displacement (intra operative) membuat hubungan antara sinus maksilaris dgn rongga mulut krn akar terdorong ke sinus. komunikasi ontroaral ini harus di tanggulangi. tes nya: pasien buka mulut, tarik nafas, dan keluarkan lewat hidung. letakan kaca mulut di bawah soket, jika dari sinus angin keluar ke kaca mulut maka menandakan terjadi hubungan ontroaral.

18. Cabut gigi RA jangan terlalu besar force nya. bein usahakan jangan di gerakkan ke atas, bertumpu pada tulang alveolar namun cungkil ke bawah. M1 akar palatal paling dekat dengan sinus maksilaris. 19. Masa bekuan darah= ? 20. Jika lebih dari 1 jam pasien masih berdarah perdarahan primer --> potong, darah keluar perdarahan intermediat --> selama sejam perdarahan sekunder --> lebih dari sejam 21. Pasca ekstrasi Pencabutan Gigi bisa sampai infeksi, bisa terjadi abses atau dry socket. dry socket (alveolitis / alveolagia / localize osteomyelitis / dolor post extraction) = gejala klinisnya warna abu2, tidak ada bekuan, kosong pada soket gigi, biasanya terjadi 2-5 hari. penanganannya berikan anestesi lokal, soket dibersihkan (kuret hinga menemukan bekuan darah yang sehat), tutup dengan gingipack, dan diberi antibiotik

Narasumber drg. Siti Alijah : The point to know whether the patient has hepar disease or not: To prescribe medication/drugs. To know the infection transmission. To know further complication on that patient. (Especially on non-infection patient).

How do we know someone is infection / non-infection? Infection: Fever (Body will give reaction) The reaction is kind of swelling. Five systems of swelling are: Tumor (Swelling) Regional Lymph Gland (First swelling), Dolor (Pain / dizzy / stiff), Calor (Heat), Rubbor (Reddish), Fungsilaisa (Disturbance of function). Non-infection: From his/her habits (Alchololic, drug user, medication). The disturbance is not clear. Drugs It can be Hepatitis B or C (C is the most). We have to know the patient is high risk or low risk. a. High risk patient: Clear symptoms Clinical lab shows antigen (+)

Thats why we have to work sterilely. All kinds of invasive treatment must be delayed until the condition is stable (we have to refer to the internist). If it is urgent, we can only give premedication, but not until extract. Drug of choice, non-hepatotoxic drugs.

Feses merah bata, urin berwarna gelap, anoreksia, mual, muntah, malaise, etc. Jaundice (Ikterus) on palatum and tongue, reddish on palm of hands, b. Low risk patient The symptom is unclear He/she had been suffered from hepatitis before. Lab result Antibody (+); Antigen (-) We can work it directly, but we have to beware, and work sterilely.

There is also window period In fact he is not suffering from hepatitis (symptoms is gone), but there is still virus in his/her blood. Hepatitis in healing period. When the lab result is (-) from hepatitis, after 6 months he has to check again to laboratory, if he is still (-), then the patient is stated totally recovered from hepatitis .All hepatoxic drugs can not be given to hepar sufferer. If there is no alternative, it can be given but after eating, or after drinking hull coating (antacid). Ex.: Steroid users, we have to give antacyde first before he takes the steroid. Laboratorium procedure SGPT, SGOT (Ask drg. Niniarty) Transmission of Hepatitis B & C Blood (Injection / Transfusion / Scar) Transmission of Hepatitis A Faecal Oral (Ex.: Food, drinking by the same glass)

What important in learning this kind of patient is how to treat patient with hepatitis background. Dia akan memberika ulceraci disepanjang saluran pencernaan termasuk rongga mulut.

Narasumber drg. Niniarty : Patients with medically compromised condition are easily subject to dental treatment complication since their immune response are compromised. In treating patient with medically compromised condition, doctors should be careful in doing surgical treatment and other treatment that causes bleeding. In treating these patient, we should be more selective in choosing medicine for these patients.


1. As a dentist we have the right to chose some examination that related to the symptoms of the patient. 2. For examination with gastrointestinal disorder, we use clinical or endoscopic examination. 3. Hepatitis type B and C will never be cured. While hepatitis type A will be healed in a range of period if the immune system is good. 4. One of the symptoms of hepatitis disease is a yellowish skin color. The skin become yellow because of too much Bilirubin in the blood and the Bilirubin is dissolved in human bodys liquid. 5. It is better not to compare the result of examination of one lab to the other, because each lab has its own method and tools to examine the patient. 6. Liver disease disturbance of blood coagulation because factor of blood coagulation are built up in the liver.


Melinda, 35 years old 1. Diagnosis: Dentoalveolar abscess with acute exacerbation et causa radix. Management: a. Incision of abscess and drainage b. Extraction of radix c. Medication: Amoxicillin/clavulanic acid 2,000/125 mg one hour prior to starting the surgical intervention, followed by 2,000/125 mg every 12 hours for 5-7 days. Paracetamol 500 mg to treat post surgical pain.

2. The dental management for Mrs. Melinda should be done carefully considering her medical conditions.

Dee, 6 years old 1. Diagnosis: Chronic dentoalveolar abscess et causa radix perforation. The root of 51 that is seen on the labial gingival region is a root perforation that can happen in all primary teeth. The crown is not there, it has been lost and leaving a radix inside the socket. The radix has a root canal that is become a tunnel for the remaining food / bacteria from the oral cavity to the apex of the root. The process continues and the bacteria infects the apex of the root and causes inflammation. Seems like the products of the bacteria (toxin) cannot flow out of the radix back to the oral cavity, so that the accumulation of the toxin makes an inflammation on the apex of the root and produces pus. It is called Dentoalveolar Abscess because it involves the dental (radix) and the alveolar bone. The products of the abscess is pus, when the pus is produced, the gingival is swollen, when pressed, the pus goes out through the gingival margin. But because the radix is not taken out, the process is going on and on, the pus is formed and goes out again. The effect of this continuous process is the alveolar bone is then wrecked. In the age of 6, the tooth 51 is still in the process of root resorption but the root will not perfectly resorbed until the age of 7 or 8. The resorbed root of 51 is making the root sharp35

edged in the labial side. Because the bigger resorption is on the palatal side, due to the position of the permanent tooth of 11 that is on the palatal side. The force from the tooth 11 is also making the sharp-edged root of 51 forced to the labial side, because the alveolar process has been wrecked, the tip of the root is going through the labial mucosa. The sharp-edged root that is going through the labial mucosa makes the labial mucosa traumatized and an Ulcus decubitus is emerged. Ulcus decubitus is signed by the gingival swelling on the labial region, the shape is round, like a crater , redden outer layer , and the middle is yellowish orange in color. 2. Management: The therapy or treatment for this is an extraction of the 51 radix. After the extraction, a space maintainer should be used to maintain the space of the premature loss of 51. Before the extraction, an anesthetic procedure should be done. Firstly is the topical anesthesia in the labial region of 51, when the drug is working, insert needle for an infiltration on the labial gingival approximately half the length of the root, after the anesthetic drug is working, make another infiltration in the interdental side, mesial and distal, but more to the palatal than the labial, so that the palatal side is also anesthetized. After all the anesthetic drug works, start the extraction process using only the pedo forceps for anterior maxillary teeth. For 51 root, the movement is rotation because of the conical shape of the root.


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