CORNELL NOTE

Name/ NIM : Anggraeni Puspasari/

10/KG/8642

Name/ NIM : Monica Dwi Anggraini/ 10/KG/8644 TUGAS AKHIR : DIKERJAKAN BERKELOMPOK Name/ NIM : Tantia Cita Dewanti/ 10/KG/8646 Name/ NIM : Dhinintya Hyta Narissi/ 10/KG/8650 Name/ NIM : Herliena Dyah Indriani/ 10/KG/8652 Name/ NIM : 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 patients 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. Brodskys 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: 2001Appendectomy, 1998CABG 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). 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 dis eases 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

2.

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 Ivys 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 Kdependent 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) What, if any, medical issues are impacted by Mrs. Brodskys 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 persons 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). What concerns should a treating dentist have regarding Mrs. Brodskys 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 patients medical and dental care providers should be done if there is any concern about the patients ability to undertake dental treatment, especially that of a surgical nature (Ettinger, 2010). How might Mrs. Brodskys family history impact the dental tr eatment 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. Brodskys has reported that her mother death is caused of CVD. This

4.

5.

6.

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 (de ned as CVD occurring before age 60 i n 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 informatio n 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 vasoconstrictors effect on arterial pressure . The use of betablockers 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 patients physician befo re 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 patients 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 patients attitude, genetic predisposition to oral disease, lifestyle, socialization and the environments th at 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 frailt y. When

planning the patients restorative and oral rehabilitative treatment needs, dentists must recognize, prioritize and balance the influences of multiple age-associated, dental issues, the patients 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 dentists personal clinical experience s 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 in troduced 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 dentists o wn experience. Oral impairment and disability are inevitable features of old age, but they do not necessarily have a negative i mpact on ones 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 patients ability to tolerate the stress of treatment, the possibili ty of reasonable and less extensive treatment alternatives, how the patients dental problems affect his or her quality of life, as well as the patients 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 shorte r appointments in a comfortable, supportive and positive environment with capable practitioners. Treatment plans may need to evolve over time as treatment progresses and the patients 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 costeffective 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 -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 hyp otension, so the dentist should raise the back of the patients 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 patients anticoagulant treatment without the agreement of the patients 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. Warfarins 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 patients 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 patients 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 dru gs 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 patients 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 transpl antation 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 rec ommended 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 patients 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 patients most recent PT/INR leveland the best treatment approach based on the patients relative thromboemboli c 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 t he time of surgery, with prompt re-institution postoperatively. Coumarins long half-life of 42 hours necessitates dose reduction or withdrawal 2 days prior to surgery in order to return the patients 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 (1418 hours for a 2-hour surgery, as opposed to 34 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 patients 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 patients 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 p rior 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: 417433. 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. 2. 3. 4. 5. 6. 7. 8. 9. Reflect on the impact of living arrangements and geographic location on health care utilization. Describe the living arrangement of the older adult population. Understand the importance of proper medical history-taking in the older population. Describe the physiology and presentation of age-related cardiovascular disease. Describe the impact of peripheral and diminished blood flow, atherosclerosis, and plaque formation. Describe the impact of concurrent medical conditions in the older adult. Understand the pharmacology of the patients medication list as related to the provision of dental care. Discuss adverse drug reactions, compliance behavior, and drug overutilization. Discuss treatment planning and patient management in the context of social supports and coordination of multiple caregivers. Discuss the relevance of the oral examination and past dental history to patient compliance and understanding.

10.