CBL IN ENGLISH

A 17-year-old man came to the dentist's office complaining of swelling in the gums around
the lower right molars, since one week ago. There is a known low-grade fever and the
patient has no appetite. Intra oral examination showed that 46 carious teeth reached the
pulp with a diagnosis of pulp necrosis, there was swelling in the vestibule of the 46 tooth
region, soft consistency, fluctuations (+). Previous medication has been given.

A. Problem Formulation
1. What is a diagnosis in the scenario?
2. What are the etiology and predisposing factor for abses?
3. What are the sign and symptom of the case?
4. What is the histological and radiographic picture of this condition?
5. What is this stage of examination cariried out by the patient?
6. What is the management of this case?
7. What are the different types of abses and which case are include?
8. What is the patofisiologi of this condition?
9. What is the relationship of fever in patient with abses?

B. Problem Analysis
1. What is a diagnosis in the scenario?
(Deylina)
Pulp Necrose with Vestibular Abses

(Mayang)
Pulp necrosis is a condition where the pulp has died, blood flow is no longer
there, and the pulp nerves no longer function.
vestibular abscess : there is painful swelling in the buccal vestibule near the
teeth

(Tecto)
Vestibular abscess is an infections that spreads to the vestibule area from a
necrotic tooth.

DIFFERENTIAL DIAGNOSIS :
There are several diseases that are almost similar to vestibular abscesses,
including submucosal abscesses, subperiosteal abscesses, cysts and
granulomas.
To be able to differentiate an abscess from a cyst or granuloma, an
examination with aspiration is needed to determine the type of fluid in the
lesion. if it is an abscess then it contains pus.

2. What are the etiology and predisposing factor for abses?

(Ratih)
- Abscesses in the oral cavity can be caused by 3 main factors, namely
organism, tissue anatomy and host factors.
 - Organism factors is from bacteria streptococcus mutans and
staphylococcus aerus.
- Surrounding tissue which has a major influence on the spread of
infection
- And immune factors of the host is greatly influence the spread of
infection.

Etiologic of this case .. organism factor is bactery streptococcus mutans

(Nazita)
Etiology abses vestibular: infection in a vestibular abscess can originate from
a dental infection and then penetrate the cortex and periosteum of the labial /
buccal bone into the soft tissue beneath the mucosal surface in the vestibule
area (muccobuccal fold)

(Deylina)
The most common odontogenic infection
often found originating from the periapical area of ​teeth that experience pulp
necrosis (25%). teeth that experience pulp nexosis due to caries that extends
to the pulp is a route for bacteria to enter the periapical tissue. The infection
that occurs can then spread in all directions and occur more often in parts of
the body with the lowest resistance. Infection can also spread through
cancellous bone to enter the cortical bone. The thin cortical bone will be an
entry point for bacteria into the surrounding soft tissue. The spread of
infection to other tissues depends on the source of infection, for example
infections of the teeth, pharynx, tonsils, paranasal sinuses and ears or due to
trauma.
3. What are the sign and symptom of the case?
(Annisa)
Signs: - Unclear boundaries - Redness - Soft consistency - Fluctuations on
intraoral examination - Swollen gums - Loose teeth due to loss of periodontal
structure - Experiencing purulent exudate - Swelling of the face
Symptoms: - Tenderness (when chewing or biting) - Fever - Bad breath -
Sensitive to hot/cold
Clinical symptoms of dentoalveolar abscess on intra-oral examination are
pain, swelling, localized erythema, pus at the apex extending to the alveolar
bone, and discoloration of the infected tooth enamel.
Intra-oral swelling varies greatly on the labial or buccal side, while abscesses
are very rare on the palatal side. Extra oral examination shows clinical
symptoms such as swelling with a soft consistency and tenderness on
palpation due to enlarged lymph nodes.
4. What is the histological and radiographic picture of this condition?
(Deylina)

5. What is this stage of examination cariried out by the patient?

(Indah)

6. What is the management of this case?

(Tecto)
The management of this case consists of 5 stages. The first stage is a
radiograph examination using periapical and panoramic techniques, to
determine the location of the focal infection. The second stage is giving
prophylactic antibiotics 1 hour before treatment with incision and pus
drainage. The third is the surgical stage with superficial incisions and pus
 drainage. The fourth stage is giving the patient medication with antibiotics,
analgesics, and roborantia to increase the body's immune system. The last
step is to instruct the patient for control after the patient's condition improves
so that the tooth can be extracted.

(Rista)
Vestibular abscesses usually originate from the maxillary premolars and
molars. Clinical examination usually reveals brightness and deep pain. The
buccal vestibule near the teeth causes this condition. Treatment consists of
opening the abscess, drainage, and elimination of the etiology. The main
incision must be vertical, this makes it easy to create a proper flap if it is later
needed to close sine.

(Nazita)
Incision and Drainage
1. Asepsis the area where the incision will be made using povidone iodine
2. Topical anesthesia with chlorethyl using a tampon
3. Incision in the lowest area from the peak of fluctuation, not in the necrotic
area using a perpendicular scalpel, blade
pointing towards the surface
4. Drainage with bent clamps, clamps are inserted closed, when inside they
are opened, repeat in all directions
until all the pussy comes out
5. Irrigation using NaCl using a syringe inserted into the cavity
6. Insert the drain (from a piece of latex) which was previously dipped in
povidone iodine
7. Then do suturing to fix the drain so it doesn't move
8. Medication → antibiotics
9. Control (replace drain 2-7 days)

(Annisa)
The aim of the incision and drainage procedure is to prevent the expansion of
the abscess/infection to other tissues, reduce pain, reduce the number of
microbial populations and their toxins, improve tissue vascularization
(because in abscess areas tissue vascularization is usually poor) so that the
body is better able to cope existing infections and administering antibiotics is
more effective, and prevents scarring due to spontaneous drainage of the
abscess. Apart from that, drainage can also be done by performing an open
bur and extirpation of necrotic pulp tissue, or by extracting the causative tooth
(Topazian et al, 1994). This procedure is generally carried out after local
anesthesia has been given first, so that the painful area will be numb.

(Deylina)
https://youtu.be/MiUiBHBcrOo?si=gaA7SS-E8dM20ax0

7. What are the different types of abses and which case are include?
(Annisa)
Tooth abscess is a bacterial infection that can occur around the root of the
tooth or in the gums. A tooth abscess can appear in several forms, depending
on the location and how severe the infection is. Some types of tooth abscess
include:

Periapical Abscess:
This abscess occurs at the tip of the tooth root and is the body's natural
response to infection in the tooth pulp. This infection can cause tissue death
around the root tip.

Periodontal Abscess:
Periodontal abscesses occur in or around the gums. This can be caused by
the buildup of plaque and bacteria around the teeth and gums, causing
infection.

Supraperiosteal Tooth Abscess:

This abscess occurs above the jawbone and under the mucous membrane.
Usually, this develops due to infection in the root of the tooth or the kidney of
the tooth that has abscessed.

Chronic Periapical Dental Abscess:

This is a form of periapical abscess that develops gradually. Sufferers may
not feel severe pain, but this abscess can last for a long time.

Acute Periapical Dental Abscess:

Acute periapical abscess is a form of tooth abscess that develops quickly and
can cause intense pain, swelling, and redness of the affected area.

(Nazita)

TYPES OF ABSCESS

1. Periodontal Abscess

It is an acute or chronic purulent inflammation that develops from periodontal

pockets. Clinically, edema is seen in the middle of the teeth accompanied by
pain and redness of the gums. The symptoms that arise are not as severe as
dentoalveolar abscess.

2. Acute Dentoalveolar Abscess

It is an acute purulent infection that develops in the apical part of the tooth in
the cancellous bone. Usually caused by bacteria originating from infected
teeth in both the maxilla and mandible. Typical symptoms are severe pain,
loose teeth, and the teeth causing them to feel elongated.

3. Subperiosteal Abscess
 Subperiosteal abscess is an abscess located between the bone and the
periosteum, both on the buccal, palatal and lingual surfaces of the tooth,
which causes infection. Symptoms include mild edema, pain due to pressure
on the periosteum and sensitivity to palpation.

4. Submucosal Abscess

This abscess is located directly under the buccal and palatal/lingual vestibular
mucosa of the toothwhich is the source of infection. Clinically visible mucosal
enlargement with fluctuations clear, sensitive to palpation, and loss of
mucobuccal folds in the area of ​infection.

5. Abscess on fossacanina

This abscess usually originates from the anterior teeth, and rarely from the
premolars. The most dramatic clinical signs include substantial swelling of the
upper region of the cheek, with pain located in the canine fossa region.

6. Vestibular abscess

Vestibular abscesses usually originate with the maxillary premolars and

molars. Clinical examination usually reveals painful swelling in the buccal
vestibule near the tooth causing the condition.

7. Sublingual Abscess

It is an abscess that forms in the sublingual space above the right or left
mylohyoid muscle. Usually caused by infection of the anterior teeth,
premolars, or mandibular first molars. The sublingual space is limited by the
mucosa of the floor of the mouth, mylohyoid muscle, mandibular surface,
mylohyoid bone and lingual septum.

8. Submandibular Abscess

The submandibular space is limited by the mandibular body, the anterior and
posterior venter of the digastricus muscle, the stylohyoid ligament, the
mylohyoid muscle and the hyoglossus muscle.

8. What is the patofisiologi of this condition?

(Arfiqa)
Odontogenic infections are commonly caused by bacteria native to
the oral cavity. They arise from either periapical or periodontal
sources. Periapical infections are the most common cause of
odontogenic infections. In periodontal infections, attachment loss of
the gingival fibers and destruction of supportive structures expose the
teeth and tissues to bacterial introduction. Periapical infections begin
with a carious lesion causing pulpal necrosis that introduces the pulp
 to microorganisms. The infection can quickly spread to periapical
tissues and may spread to other fascial spaces. Upon accessing the
periapical tissues, the process can remain localized to the bony
structures as a cystic lesion, granuloma, or focal osteomyelitis.
Periapical infection can also spread through cortical bone causing
cellulitis, localized and or deep-space abscess formation. After
inoculation of bacteria into deeper tissues, abscess development
progresses from cellulitis to abscess formation without early
intervention. Cellulitis is an acute disorder associated with warm,
diffuse, painful, indurated swelling of soft tissues that also may
present with erythema. Indurated swelling begins to soften as an
abscess develops represented by localized area of fluctuation. An
abscess is a collection of purulent material containing necrotic tissue,
bacteria, and dead white blood cells. Patients may present at varying
stages of the process. Bacteria responsible for odontogenic infections
have the ability to spread hematogenously due to the high vascularity
of head and neck structures allowing infections to present in distant
sites including the orbit, brain, and spine

(Ratih)

Pathophysiology of vestibular abscess :

- The bacteria that play a role in the abscess formation process are
staphylococcus aerus and streptococcus mutans.

- Streptococcus mutans has 3 main enzymes that play a role in the spread of
dental infections, one of which is the hyaluronidase enzyme which is
destructive.

- The hyaluronidase enzyme destroys bridges between cells whose function is

to transport nutrients and communication pathways between cells, as well as
building blocks and strengthening tissues. So if this bridge is damaged in a
major way, the pulp tissue which is composed of cells can die.

- After the pulp dies, these bacteria will spread to the deeper tissue, namely the
periapical tissue.

- The body will produce an inflammatory response to overcome the infection

that occurs. However, because the host condition is not very good and the
virulence of the bacteria is quite high, it will create conditions for an abscess
in the form of pus formation.
- Staphylococcus in the process of abscess formation has an active enzyme
called coagulase whose function is to deposit fibrin around the s-mutans
working area, to form a pseudomembrane known as the abscess membrane.

- This membrane will protect the abscess from inflammatory reactions and
antibiotic therapy, so to remove this pus can only be done by drainage.

9. What is the relationship of fever in patient with abses?

(Annisa)

When tooth decay has reached the pulp, infection will develop. Infection can
cause the formation of a pus-filled pocket on the tooth (dental abscess). In
severe cases, the patient will experience fever. Symptoms of fever occur as
the body's mechanism for fighting bacterial infections. With a hotter body
temperature, it will be more difficult for bacteria to survive. Fever can also
activate the immune system