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TUGAS AKHIR : DIKERJAKAN BERKELOMPOK

Name/ NIM : Anggraeni Puspasari/ 10/KG/8642

Name/ NIM : Monica Dwi Anggraini/ 10/KG/8644

Name/ NIM : Tantia Cita Dewanti/ 10/KG/8646

Name/ NIM : Dhinintya Hyta Narissi/ 10/KG/8650

Name/ NIM : Herliena Dyah Indriani/ 10/KG/8652

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1. Tugas / pertanyaan : Cermati permasalahan pada lansia dibawah ini, baca pertanyaan-pertanyaan pada akhir

presentasi kasus dengan menyertakan sumber referensi !

CASE PRESENTATION

Mrs. Miriam Brodsky is an active 77-year-old female who presents to your dental office,

which is located in her winter place of residence, with a chief complaint of “I need a checkup.”

Description:

The patient’s last dental visit was three months ago at a private dental office in her home city

(1,500 miles away), where she resides approximately five months out of the year. She received

a dental prophylaxis and exam at that visit. Mrs. Brodsky reveals that although her niece is her

dentist at home and does provide a “friends and family discount of 10%,” she would like to see

whether she can receive treatment for a lower cost. Mrs. Brodsky is a private-pay patient and is

willing to pay for quality dental care but states she has limited discretionary resources available.

She also has more time available for continuous dental care in her winter residence. Mrs.

Brodsky’s primary physicians reside in her home city, although she does maintain an internist at

her winter residence for emergencies.

Medical History:

Illnesses: Cardiovascular disease, hypercholesterolemia, hypertension, cardiac arrhythmia, myocardial infarction 1998

Hospitalizations: 2001—Appendectomy, 1998—CABG x 4

Medications: Coumadin: 5mg x four days and 2.5mg x three days

Pravachol 40mg: once a day (OD)

Atenolol 25mg: twice a day (BID)

Hydrochlorothiazide (HCTZ) 25mg: two tabs once a day (OD)

Premarin 0.625mg: once a day (OD)

Ca++ 500 mg: twice a day (BID)

Multi-vitamin: once a day (OD)

Protonix 40mg: once a day (OD)

Allergies: No known drug allergies (NKDA)

Social History: Denies tobacco products and recreational drugs and drinks socially on occasion.

Family History: Married three times; four children

Father deceased at age 95, unknown cause

Mother deceased at age 93; history of cardiac disease and hypercholesterolemia

Vital Signs: BP: 135/85 Pulse 72R R: 14 T: 98.2 F

Clinical Exam:

Extraoral: No asymmetries, lesions, or growths noted; no lymphadenopathy; no TMD noted

Intraoral: Soft tissue: Generalized plaque; localized areas recession #6-10, #22-27; localized areas of gingivitis #22-27

Hard Tissue: Multiple missing teeth; long-span fixed PFM bridge work #2-14, #20-21, #28-31; distal composite #22; defective distal

composite #23; lingual endo access composites #24, 25, distobuccal decay #31

Periodontal probing reveals pocket depths no greater than three millimeters. Mobility: 3+ #24, 25

Radiographic examination reveals:

Missing teeth #1, 15, 16, 17, 18, 19, 30, 32

RCT #5, 6, 7, 8, 9, 10, 14, 24, 25, 28

PAP #24, 25

Generalized horizontal bone loss

Severe bone loss (80%) #24, 25

Moderate bone loss (50%) #6, 23

Radiographs:

Tugas / pertanyaan : Cermati kasus orodental di atas, kemudian atasi permasalahan pada lansia diatas dengan

mengacu pada learning issue berikut !

LEARNING ISSUES:

1. Prior to the rendering of dental treatment, what medical issues must first be addressed?

ANSWER:

Prior to the rendering of dental treatment, medical issues must be first addressed is Cardiovascular Disease. According to

the World Health Organization data back in 2006, cardiovascular disease or CVD has been announced as the leading factor of the

death in the women population. From the examination, Mrs. Brodsky is much likely to suffer from severe periodontitis. People who

suffer from periodontal disease share common risk factors with those who suffer from cardiovascular disease. Cardiovascular disease

can lead to health problems such as heart attacks and stroke. The list of common risk factors includes poor oral hygiene but other

factors such as age, gender, lower socio-economic status, smoking and stress have also been identified. Family history showed that

her mother died of CVD. This is could be the main major cause of Mrs. Brodsky having CVD. Sosiodemographic with the high risk

of lack of the nutrition and standard health of preventing system in developing countries, held the highest amount of CVD patients.

When the bacteria in dental plaque travel into the bloodstream they can cause infection of tissues anywhere in the body including

the cardiovascular network. Research has shown that these infections lead to inflammation of the blood vessels and there is a

modest association between periodontal disease and atherosclerosis, heart attacks, and stroke. It is important to maintain good oral

hygiene to protect the mouth and body against infection.The link between orodental health and CVD still not well known. But, the

manifestations of the drugs that the patients consumed, often led to gingival hyperplasia, xerostomia, and taste impairment (Hughes,

2010). As a caregiver, dental proffesional must be alert to the drugs and medication that your CVD patients has being consuming.

Complications could be occured because of the use of the medication that dentist may neglect. Serious problems, including the

death probability may happen whether dentist do not pay attention to the rules of systemic diseases and oral health connection

(WHO, 2006).

2. What is the proper medical management for patients taking the regiment of prescription medications that Mrs. Brodsky has been

prescribed?

ANSWER:

Geriatric patients usually have at least one age-related change and/or disorder that may affect patient management and

treatment planning. Clinical conditions, such as hypertension, anticoagulation therapy, and hypoglycemia, can trigger emergency

crises during dental treatment. Patients with diabetes often have cardiovascular diseases and are more susceptible to infection if the

disease is not properly controlled. Although controversial, antibiotic prophylaxis may be necessary for dental procedures in frail

elders to prevent infection of replaced joints and cardiac prosthetic valves. While dental health care workers provide their

professional judgment regarding these special conditions, consultations with other health professions are often required to optimize

patient care. All health care providers should be familiar with the treatment guidelines from professional organizations to facilitate

interaction among interdisciplinary care. Oral health providers, as part of the overall health care system, are often in the front line

in detecting age-related morbid conditions/diseases through routine oral examination. Medical history and evaluation, as well as

vital signs, temperature, respiratory rate, blood pressure, pulse rate and rhythm, as well as presence of pain or significant weight loss

should routinely be recorded for dental patients. The demonstration has been done that one-third of physician consultations

resulted in an alteration in dental treatment plans and 8% of consultations led to commencing medical treatment. While specific

health problem management during dental treatment of the elderly remains a real challenge for dentists, treatment of oral diseases

themselves is equally challenging. Many treatment modalities are still empirical. Cervical overhangs are a common problem for

interproximal restorations due to deep subgingival root caries. Dentists should be aware of advances in dental materials and new

treatment modalities for diseases commonly seen in geriatric patients (Ettinger, 2010).

Management of the dental patient on anticoagulant therapy involves consideration of the degree of anticoagulationachieved

as gauged by the PT/INR, the dental procedure planned, and the level of thromboembolic risk for the patient. In general, higher

INRs result in higher bleeding risk from surgical procedures. It is generally held that nonsurgical dental treatment can be

successfully accomplished without alteration of the anticoagulant regimen, provided the PT/INR is not grossly above the

therapeutic range and trauma is minimized. Greater controversy exists over the management of anticoagulated patients for oral

surgical procedures.

3. Which, if any, laboratory evaluations may be required prior to treatment?

ANSWER:

Due to the daily routine consumption of Coumarin, or anti coagulant, Mrs. Brodsky need to evaluate her coagulation phase

to avoid any certain conditions. There are a variety of common and less common laboratory tests that help to identify deficiency of

required elements or dysfunction of the phases of coagulation. The two clinical tests used to evaluate primary hemostasis are the

platelet count and bleeding time (BT). Normal platelet counts are 150,000 to 450,000/mm3. Spontaneous clinical hemorrhage is

usually not observed with platelet counts above 10,000 to 20,000/mm3. Surgical or traumatic hemorrhage is more likely with

platelet counts below 50,000/mm3. BT is determined from a standardized incision on the forearm. BT is usually considered to be

normal between 1 and 6 minutes (by modified Ivy’s test) and is prolonged when greater than 15 minutes. The skin BT test, thought

to identify qualitative or functional platelet defects, is a poor indicator of clinically significant bleeding at other sites, and its use as a

predictive-screening test for oral surgical procedures has been discouraged (Scully and Cawson, 2005).

Tests to evaluate the status of other aspects of hemostasis include prothrombin time (PT)/international normalized ratio

(INR), activated partial thromboplastin time (aPTT), thrombin time (TT), FDPs, specific coagulation factor assays (especially Fs VII,

VIII, and IX and fibrinogen), and coagulation factor inhibitor screening tests (blocking antibodies). The normal range of PT is

approximately 11 to 13 seconds. Because of individual laboratory reagent variability and the desire to be able to reliably compare

the PT from one laboratory to that from another, the PT test is now commonly reported with its INR. The INR is the ratio of PT

that adjusts for the sensitivity of the thromboplastin reagents, such that a normal coagulation profile is reported as an INR of 1.0.17

This test evaluates the extrinsic coagulation system and measures the presence or absence of clotting Fs I, II, V, VII, and X. Its most

common use is to measure the effects of coumarin anticoagulants and reduction of the vitamin K–dependent Fs II, VII, IX, and X.

Since the extrinsic system uses only Fs I, II, VII, and X, it does not measure the reduction of Fs VIII or IX, which characterizes

hemophilias A and B. Additionally, the PT is used to measure the metabolic aspects of protein synthesis in the liver (ADA, 2005)

4. What, if any, medical issues are impacted by Mrs. Brodsky’s oral condition?

ANSWER:

Mrs Brodsky has medical issues in Cardiovascular Disease (CVD) and its complication, so that she get and consume daily

routine of certain medications. Based on study by American Dental Association (2005), there are many medications can have side

effects that can negatively influence a person’s oral health, particularly older people. The commonest side effects of medications are:

dry mouth, changes in the gums and soft tissues of the mouth (such as swollen gums), alterations in taste, and excessive bleeding

after dental extractions. Some medicines can contain sugar that can contribute to tooth decay. It is therefore important to encourage

and help them with effective oral hygiene and a good diet. Limiting sugary food and drink to meal times and avoiding sugary snacks

between meals will help maintain good oral health for those taking medications. A major impact of systemic diseases on the oral

health of older adults is caused by the side effects of medications. With increasing age and associated chronic disease, the elderly are

prescribed an ever-expanding variety of medications. Besides the desired therapeutic outcome, adverse side effects may alter the

integrity of the oral mucosa. Problems such as xerostomia (dry mouth), bleeding disorders of the tissues, lichenoid reactions (oral

tissue changes), tissue overgrowth, and hypersensitivity reactions may occur as a result of drug therapy.

People who suffer from periodontal disease share common risk factors with those who suffer from cardiovascular disease.

Cardiovascular disease can lead to health problems such as heart attacks and stroke. The list of common risk factors includes poor

oral hygiene but other factors such as age, gender, lower socio-economic status, smoking and stress have also been identified. When

the bacteria in dental plaque travel into the bloodstream they can cause infection of tissues anywhere in the body including the

cardiovascular network. Research has shown that these infections lead to inflammation of the blood vessels and there is a modest

association between periodontal disease and atherosclerosis, heart attacks, and stroke. It is important to maintain good oral hygiene

to protect the mouth and body against infection (Kuo et al., 2008).

5. What concerns should a treating dentist have regarding Mrs. Brodsky’s living arrangements?

ANSWER:

Advances in medical science and in preventive dentistry have allowed patients to live longer and to retain their teeth while

doing so. Therefore, more geriatric citizens will seek dental care to maintain and restore their teeth as part of a desire for a better

quality of life. Many of these patients, like Mrs. Brodsky, will contend with at least one chronic disease and will take the required

medication(s). Dental treatment should only be undertaken for these patients when their medical conditions allow for a favorable

outcome. Similarly, medications that are prescribed for any aspect of dental treatment must be in harmony with any medication

that is prescribed for a chronic disease. Collaboration between the patient’s medical and dental care providers should be done if

there is any concern about the patient’s ability to undertake dental treatment, especially that of a surgical nature (Ettinger, 2010).

6. How might Mrs. Brodsky’s family history impact the dental treatment plans?

ANSWER:

As in general health care, prevention is a key factor in the dental care of aged people. Therefore, Scully and Cawson (2007)

said the most important considerations for dental professionals are how well the patient is compensated for his/her medical

condition and the exact dental intervention that will be performed. Noninvasive procedures in patients with minimal incapacity

carry less risk than do surgical procedures in ill people. Mrs. Brodsky’s has reported that her mother death is caused of CVD. This

linked between her non smoking and alcoholic habit due to the appearance of CVD of her own. Family history is an important

factor to consider when assessing CVD risk. Compared with the general population, the risk of a coronary event is approximately

doubled in individuals with a family history of clinically documented premature CVD (defi ned as CVD occurring before age 60 in a

mother, father or sibling). Similarly, the risk of ischaemic stroke is almost doubled in men with a family history of stroke. Older

patients with previous history of transient ischemic attack or a full-blown cerebrovascular accident, high blood pressure,

hyperlipidemia, smokers, affected by diabetes, overweight and with family history of stroke are at higher risk of developing a first

or recurrent cerebrovascular accident. All the aforementioned pathological conditions must be taken into account by the dentist at

the time of treatment. When treating geriatric patients with heart diseases, the dentist and all staff members must be aware of the

emergency protocol procedures. In general, patients with heart disease must be told to take their medications as usual on the day of

the dental procedure, and the dentist should keep on the patients’ records all medications in use as well as update this information

on each and every appointment (Meloto et al., 2008).

In patients with cardiovascular disease it is advisable to minimize the stress of visiting the dentist as well as to provide an

effective analgesic condition for treatment. The controversy as to whether or not to use a vasoconstrictor (adrenalin or

levonordephrine) with the local anesthetic solution is due to the vasoconstrictor’s effect on arterial pressure. The use of beta-

blockers as antiarrhythmic and antihypertensive medication is common in patients with heart disease. Therefore, it must be taken

into account that these medicines can delay peripheral plasma clearance of the local anesthetic, and that the prolonged use of

nonsteroidal anti-inflammatory drugs (NSAIDs), commonly occurring in elderly people, can reduce the antihypertensive effects.

Additionally, a visit to the dentist itself generates anxiety and provokes the release of endogenous catecholamines in amounts that

may exceed those administered with the local anesthetic solution. The association of a vasoconstrictor should thus be limited, taking

care not to exceed 0.04 mg of adrenalin.

Regarding hypertension, it is particularly important to avoid anxiety and pain in such patients and, ideally, the blood

pressure should be controlled before the dentist begins elective dental treatment. If the patient has a persistent hypertension, the

dentist should seek the opinion of the patient’s physician before initiating the dental treatment. In these patients, continuous or

periodic blood pressure monitoring is recommended. By the end of the dental session, aged patients under antihypertensive drugs

may suffer with orthostatic hypotension, and so the dentist should elevate the back of the dental chair to the upright position

slowly and in stages. If the patient’s blood pressure rises, the dentist should discontinue the dental treatment, place the patient in a

supine position, should allow the patient to rest and recheck the blood pressure after 5 min. If at that point the blood pressure is

consistently high, the dentist should call for emergency medical help (Coleman, 2002).

7. What recommendations for rational dental treatment might be presented to Mrs. Brodsky?

ANSWER:

In 1983, a flow diagram of decision-making, called the “rational dental care model,” was presented at a national meeting in

Chicago. Although the relative influence of the various modifying factors was unknown, it was hypothesized that this was the

mechanism by which dentists experienced in geriatric care made treatment planning decisions. It was suggested that this model

could be usefully incorporated into dental education, because it specified a thought process that would be helpful for diagnosis and

treatment planning for all patients. The model was modified in 1984.

Older adults do not tend to seek care unless they have a perceived problem. Therefore, when older people seek care, it is

important to try to resolve their chief complaints as quickly as possible when developing the treatment plan. This plan must take

into account the patient’s attitude, genetic predisposition to oral disease, lifestyle, socialization and the environments that influence

his or her health beliefs and behaviours. The 4 domains of dental need: function, symptomatology, pathology and esthetics. The

modifying factors that challenge dentists when prioritizing treatment interventions for elderly people are illness and frailty. When

planning the patient’s restorative and oral rehabilitative treatment needs, dentists must recognize, prioritize and balance the

influences of multiple age-associated, dental issues, the patient’s changing systemic health and psychosocial factors.

A case history to present the modifying factors believed to be identified to evaluate a rational treatment plan. If patients are

physically disabled or cognitively impaired, dentists need to understand their wider needs, such as how they function in their

environments with their medical problems, pharmacotherapy, their social support systems and the diverse sociologic variables, as

well as how oral health care fits into their environment. Clinical decisions in dentistry tend to be based on qualitative, subjective

estimates of the specific treatment needs of patients that will result in a net benefit to them. As we have shown, this subjective

restorative treatment plan is often based on the dentist’s personal clinical experiences rather than on evidence-based studies.

Successful dental care depends on good communication between dentists and patients, their families or significant others, as well as

other health care providers. Different older adults have different needs and their functional disabilities affect their ability to accept

and receive dental treatment. Also, treatment plans change over time with these older adults due to their illnesses, their finances

and their support systems

The 4 key areas of dental need to be considered when treating frail elderly (as mention above) are function, symptoms,

pathology and esthetics. These areas will require pragmatic modification based on fundamental issues such as illness and degree of

functional and cognitive impairment. The concept of “rational care” for medically compromised elderly patients, which can be more

appropriate than “technically idealized care”, was introduced in 1984. A key issue in rational dental care is the understanding of

what is an acceptable oral status for a particular patient, as opposed to a subjective estimate of need based on the dentist’s own

experience. “Oral impairment and disability are inevitable features of old age, but they do not necessarily have a negative impact on

one’s quality of life.”(MacEntee et al., 1997)

Rational dental care involves “individualized care with all modifying factors evaluated and considered” (Ettinger, 2010).

Factors include the patient’s ability to tolerate the stress of treatment, the possibility of reasonable and less extensive treatment

alternatives, how the patient’s dental problems affect his or her quality of life, as well as the patient’s ability to mainta in oral health

independently. The idea that “nothing less than idealized dentistry is secondhand, compromised care offered by bad dentists” has

been strongly refuted. Treatment for the “biologically compromised” older dental patient should ideally take place in shorter

appointments in a comfortable, supportive and positive environment with capable practitioners. Treatment plans may need to

evolve over time as treatment progresses and the patient’s situation changes.

Caries in frail older patients or patients with early dementia may often need to be managed by conventional hand

instruments and a slow-speed handpiece. For anterior esthetic restorations where moisture control is possible, a composite resin,

glass ionomer or glass ionomer/composite sandwich technique is appropriate. Where moisture control is less than optimal, the

material of choice will be glass ionomer — or even a temporary zinc oxide and eugenol material. For posterior restorations where

moisture control is less than optimal, the material of choice will be amalgam or glass ionomer, especially for subgingival locations

(Chalmers, 2006). Long-term temporary restorations using hard-setting zinc oxide and eugenol can also be extremely useful in

difficult management situations. Fractured teeth can be maintained simply by smoothing any sharp edges to ensure patient comfort.

For deep caries there is increasing evidence that the deepest layers of carious dentin in a vital tooth may not require

removal, or may be treated successfully through two-stage (stepwise) restorative management. Although management of a deep

carious lesion would normally involve 2-stage treatment using a temporary restorative material, an expedient, safe and pragmatic

technique for the biologically compromised older patient is to place a permanent restorative material at the first visit, leaving

deeper caries in appropriate situations (Chalmers, 2006) Avoiding exposure of the carious pulp will reduce the need for more

invasive treatment such as endodontic therapy or extraction.

The rate of total edentulism has steadily decreased over the past 50 years due to a combination of improved access to dental

care, diet and prevention. However, the rate of partial edentulism has increased, especially in the elderly. The demand for dental

prostheses to replace missing teeth is significant. For healthy older adults, fixed or removable partial dentures or implant-supported

crowns may be considered. For patients missing a limited number of posterior teeth, especially a single posterior unit, the best

option is often no treatment. A shortened dental arch limited to a combination of two opposing bicuspids and/or molars per side

provides adequate function at any age. When considering tooth replacement for frail older adults, the least intrusive and most cost-

effective means should be considered. A well-designed and constructed acrylic removable partial denture is often the best solution.

This prosthesis will require relining over time to compensate for residual ridge resorption, but has the advantage of easy conversion

to a complete denture if the remaining teeth are lost. All dental prostheses require reassessment and maintenance over time; the

removable partial denture in particular tends to collect plaque on surfaces in contact with teeth, making these teeth more

susceptible to caries and gingivitis.

8. What pharmacotherapuetic drugs may be used or avoided in postoperative management?

ANSWER:

Dentists should be cautious about the use of certain drugs with patients who have heart disease;

a. Nonsteroidal anti-inflammatory drugs (NSAIDs), if the patient uses them for more than 3 weeks, can impair the effect

of β-blockers and angiotensin-converting enzyme inhibitors.

b. Antimicrobial drugs can affect the function of cardiac drugs. Ampicillin, in prolonged use, reduces atenolol levels ;

erythromycin and tetracycline can induce digitalis toxicity; azole antifungals and macrolides such as erythromycin

and clarithromycin can interact with statins to increase muscle damage (rhabdomyolysis).

c. Antihypertensive drugs may lead to orthostatic hypotension, so the dentist should raise the back of the patient’s

reclined dental chair to the upright position slowly and in stages.

d. Warfarin (coumadin) therapy may put the patient at an increased risk of experiencing intraand postoperative bleeding

as well as internal or external bruising.

Dentists treating these patients should consult with the patients’ physicians to discuss the type of procedure and the level of

the patients’ international normalized ratio (INR). Dentists never should alter a patient’s anticoagulant treatment without the

agreement of the patient’s physician. The INR should be used as a guideline of hemostatic risk, and the dentist should check it on

the day of the invasive procedure or in the preceding 24 hours. Warfarin’s effect may be enhanced by many drugs such as aspirin

(acetylsalicylic acid) and NSAIDs, antibiotics and azole antifungal agents (Scully and Cawson, 2005).

Patients with stable ischemic heart disease receiving atraumatic treatment under local anesthesia can be treated in the

dental office. Prophylactic administration of 0.3 to 0.6 mg of nitroglycerine may be indicated if the patient has angina more than

once a week. The dentist should consult the patient’s physician before providing dental care for patients with unstable angina or to

those with history of a recent myocardial infarction, angioplasty or stent placement. During the first 6 months after an ischemic

episode, dental treatment should be limited to emergency situations aimed at providing pain relief.

Pharmacologically, the use of antiplatelet drugs (aspirin, clopidogrel, ticlopidine, dipyridamole), anticoagulants

(antivitamin K or the coumarins) and beta-blockers (mentioned above) deserves special attention. If discontinuation of

thrombolytic medication is required, the decision to provide dental treatment must be taken in coordination with the physician

supervising the patient medication. When the antiplatelet medication cannot be interrupted at the time of an invasive dental

treatment and a risk of bleeding is anticipated, local hemostatic measures must be applied such as sutures, platelet-rich plasma,

electric or laser scalpel.

Regarding hypertension, it is particularly important to avoid anxiety and pain in such patients and, ideally, the blood

pressure should be controlled before the dentist begins elective dental treatment. If the patient has a persistent hypertension, the

dentist should seek the opinion of the patient’s physician before initiating the dental treatment. In these patients, continuous or

periodic blood pressure monitoring is recommended. By the end of the dental session, aged patients under antihypertensive drugs

may suffer with orthostatic hypotension, and so the dentist should elevate the back of the dental chair to the upright position

slowly and in stages.

If the patient’s blood pressure rises, the dentist should discontinue the dental treatment, place the patient in a supine

position, should allow the patient to rest and recheck the blood pressure after 5 min. If at that point the blood pressure is

consistently high, the dentist should call for emergency medical help. Finally, another factor that must be considered is the risk for

infective endocarditis (IE). According to the American Heart Association revised guidelines for IE, individuals considered at the

highest risk for adverse outcome from endocarditis and to whom antimicrobial prophylaxis is advised are those with prosthet ic

cardiac valve or prosthetic material used for cardiac valve repair, previous IE, congenital heart disease and cardiac transplantation

recipients who develop cardiac valvulopathy.

A number of other cardiac conditions may pose mild to moderate risk for endocarditis. Reading the American Heart

Association guidelines for IE is strongly recommended. When treating patients who have undergone a Cardiovascular Accident

(CVA) episode, the dentist must pay attention to the possible complications that these patients might present. It is recommended

that the first post-stroke dental appointment is scheduled only six months after the CVA episode. At the time of the dental visit,

collecting information from the patient, the patient’s physician, family members and caregiver will help determining his/her

physical and mental status (Meloto et al., 2008).

For surgical procedures, physician consultation is advised in order to determine the patient’s most recent PT/INR leveland

the best treatment approach based on the patient’s relative thromboembolic and hemorrhagic risks.When the likelihood of sudden

thrombotic and embolic complications is small and hemorrhagic risk is high, coumarin therapy can be discontinued briefly at the

time of surgery, with prompt re-institution postoperatively. Coumarin’s long half-life of 42 hours necessitates dose reduction or

withdrawal 2 days prior to surgery in order to return the patient’s PT/INR to an acceptable level for surgery.147,154 For pat ients

with moderate thromboembolic and hemorrhagic risks, coumarin therapy can be maintained in the therapeutic range with the use

of local measures to control postsurgical oozing. High-risk cardiac patients undergoing high-bleeding-risk surgical procedures may

be managed most safely with a combination heparin-coumarin method, which allows maximal hemostasis with minimal

nonanticoagulated time (14–18 hours for a 2-hour surgery, as opposed to 3–4 days with the coumarin discontinuation method).

This technique, which requires hospitalization at additional cost, substitutes parenteral heparin, which has a 4-hour half-life, for

coumarin.

Coumarin is withheld 24 hours prior to admission. Heparin therapy, instituted on admission, is stopped 6 to 8 hours

preoperatively. Surgery is accomplished when the PT/INR and aPTT are within the normal range. Coumarin is re-instituted on the

night of the procedure and may require 2 to 4 days to effectively reduce the patient’s procoagulant levels to a therapeutic range.

Heparin is reinstituted 6 to 8 hours after surgery when an adequate clot has formed. Heparin reinstitution by bolus injection

(typically a 5,000 U bolus) carries a greater risk of postoperative bleeding than does gradual reinfusion (typically 1,000 U/h). Use of

additional local hemostatic agents such as microfibrillar collagen, oxidized cellulose, or topical thrombin is recommended for

anticoagulated patients. Fibrin sealant has been used successfully as an adjunct to control bleeding from oral surgical procedures in

therapeutically anticoagulated patients with INRs from 1.0 to 5.0, with minimal bleeding complications. In Europe, 4.8%

tranexamic acid solution used as an antifibrinolytic mouthwash has proven effective in control of oral surgical bleeding in patients

with INRs between 2.1 and 4.8.

Use of antifibrinolytics may have value in control of oral wound bleeding, thereby alleviating the need to reduce the oral

anticoagulant dose. Use of medications that interact with coumarin, altering its anticoagulant effectiveness as discussed above, is to

be avoided. The shorter-acting anticoagulant heparin is administered by intravenous or subcutaneous route. The most common

outpatient use of subcutaneous heparin is for the treatment of deep venous thrombophlebitis during pregnancy,161 with the goal

being regulation of the aPTT between 1.25 and 1.5 times control. In general, oral surgical procedures can be carried out without

great risk of hemorrhage when local hemostatics are used in a patient receiving heparin subcutaneously; however, on consultation,

the patient’s physician may recommend withholding the scheduled injection immediately prior to the operation. Continuous

intravenous heparin, with greater hemorrhagic potential than heparin delivered subcutaneously, is discontinued 6 to 8 hours prior

to surgery to allow adequate surgical hemostasis. If a bleeding emergency arises, the action of heparin can be reversed by

protamine sulfate.

Refferences :

American Dental Association. 2005. How Medications can Affect Your Oral Health, Journal of American Dental Association Vol 136:

831-877.

Chalmers JM. 2006. Minimal Intervention Dentistry: Strategies for Addressing Restorative Challenges in Older Adults, Journal of

Canadian Dental Association, Vol 72: 435-440.

Coleman, P. 2002. Improving Oral Health Care for The Frail Elderly: A Review of Widespread Problems and Best Practices, Geriatric

Nursing Vol 23(4): 189-197.

Ettinger, RL. 2010. The Development of Geriatric Dental Education Programs in Canada: An Update, Journal of Canadian Dental

Association, Vol 76(1): 234-249.

Hughes, P. 2010. Aging, Systemic Disease and Oral Health: Implications for Women Worldwide, Continuing Education Course, Vol

9(12): 531-533.

Kuo LC, Polson AM, Kang T. 2008. Associations between Periodontal Diseases and Systemic Diseases: A Review of The

Interrelationships and Interactions with Diabetes, Respiratory Diseases, Cardiovascular Disease and Osteoporosis, Public Health,

Vol 122: 417–433.

MacEntee MI, Hole R, Stolar E. 1997. The Significance of The Mouth in Old Age, Social Science Medicine, Vol 45(9): 699-701.

Meloto CB, Barbossa CMR, Gomes SGF, Custodio W. 2008. Dental Practice Implications of Systemic Diseases Affecting The Elderly: A

Literature Review, Brazilian Journal Oral Sciences, Vol 7(27): 1682-1690.

Scully C, Cawson RA. 2005. Medical Problems in Dentistry 5th Ed. Edinburgh : Elsevier Churchill Livingstone.

World Health Organization. 2006. Oral Health in Aging Societies: Integration of General Health and Oral Health. Geneva: WHO

Production Document Services.

Learning Objectives:

The student will be able to: 1. Reflect on the impact of living arrangements and geographic location on health care utilization.

2. Describe the living arrangement of the older adult population.

3. Understand the importance of proper medical history-taking in the older population.

4. Describe the physiology and presentation of age-related cardiovascular disease.

5. Describe the impact of peripheral and diminished blood flow, atherosclerosis, and plaque formation.

6. Describe the impact of concurrent medical conditions in the older adult.

7. Understand the pharmacology of the patient’s medication list as related to the provision of dental care.

8. Discuss adverse drug reactions, compliance behavior, and drug overutilization.

9. Discuss treatment planning and patient management in the context of social supports and coordination of multiple caregivers.

10. Discuss the relevance of the oral examination and past dental history to patient compliance and understanding.