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Case Report

Supervisor :
dr. A. Yudho S. Akp, Sp.PD, FINASIM

By :
Tatit Fitri P. 111611101033
Inetia Fluida 121611101001
Alfin Tiara S. 131611101007
Akhmad Yusuf 131611101092

Faculty Of Dentistry Jember University

Departement of Internal Medicine
Balung General Hospital
May 18th 2018
Name Mrs. S
Age 48 y.o
Sex Male
Chief Complaint (S) Patient visited to emergency room RSD Balung
on Wednesday, 16th May 2018 with left angkle
swollen and burn sensatiton since four days
Clinical Observation Patient looks good but she can’t move her left
Temporary Diagnosis Osteoarthritis

Osteroarthtritis refes to a clinical syndrome of joint pain accompanied by
variying degrees of functional limited and reduced quality of life. Its common form of
arthritis, and one of leading cause of pain and disability wordlwide. The most commoly
affeced peripheral joints are the knees, hips, and small hand joints. Pain, reduce d
function and effects on a person’s ability to carry out their day to day activities can be
important consequences of orteoarthritis. Osteroarthtritis is caracterised pathologically
by localized loss cartilage, remodelling of adjacent bone and associated inflamation.
The treatments of osteoarthtritis usually use paracetamol or topical NSAID.
But both of them are insufficiet for people with osteoarthtritis, then the addition of
opioid analgesics should be considered. Topical NSAID for pain relief in addition to
core treatments for people with knee or hand osteoarthtritis. Consider NSAID and/or
paracetamol ahead of oral NSAID, COX-2 inhibitors or opioids. (NICE, 2014)
Adverse Effect of Nonsteroidal Antiinflammatory Drugs.
The mechanism of action of NSAIDs is actually inhibition of prostaglandin and
prostanoids biosynthesis by COX enzymes. Prostanoid including prostaglandins (PGs),
prostacyclins and thromboxanes are inflammatory mediators that are derived from
arachidonic acid in a series of reactions known as arachidonic acid casade. COX
isoenzymes are the first convert arachidonic acid to prostaglandin G2. Then, peroxidase
metabolizes PGG2 to PGH2 which is, in turn, converted by tissue-specific isomerases to
primary prostanoids including PGD2, PGE2, PGF, PG12 and tromboxane A2. Both
therapeutic and adverse effects of NSAIDs are cause through inhibition of COX enzyme
and consequent blocking of formation of PG and related compounds. Analgesic,
antipyretic, and antiinflammatory effects of NSAIDs are attributed to the reduction in
production of PGE2 and PGI2.
An inhibition of COX-2, the “inducible” enzyme blocks the conversion of
arachidonic acid to inflammatort PGs that is thought to be key to the beneficial
antiinflammatory effects of NSAIDs. An inhibition of COX-1, the “contitutive”
enzyme, on the other hand, results in altered cell intergrity that may gastrointestinal side
effects. A change in the balance between COX-1 and COX-2 activities i the body has
been suggested to influence, at least in part, the adverse effect including gastrointestinal
complication, reduced renal output, bleeding disorders and cardiogenic events.
NSAIDs have a range of adverse effect mainly effecting the gastrointestinal,
renal and cardio vascular system. These side effect may be relatively rare but can be
serious. In renal system NSAIDs can caused hypertension caused by electrolyte
retention, acute renal failure, glomerular filtrasion. In cardiovasculas, NSAIDs has risk
of cardiogenic stroke, thromboembolic, and also risk of elevated blood pressure and

What should we do if the patient consumed NSAIDs ?

Patient who consumed NSAIDs, visit the dentist and want a detal treatment like
extraction, endodontic treatment or dental surgery (kuretas, gingivectomi, odontectomy
etc), the first we should do is checking the blood pressure, cause NSAIDs has a risk in
cadiovascular system like hypertension.
NSAIDs may spread vasoconstriction in blood vessels, hypertension, and
thromboembolic. If performed dental treatment (retraction) will cause bleeding,
difficulty freezing blood, and stroke. The treatment are: Check the vital signs (blood
pressure), consul to internist until normal blood pressure. If the bleeding occurs when
the treatment is done, then we should control the bleeding by how to cope with the
emergency situation, looking for sources of bleeding and stop the bleeding. If the
bleeding is more than 1/10 the amount of body fluid (500cc) needs to be replaced in the
form of a 0.9% Nacl visiologic fluid, plasma whole blood packed cell. In the dental care
for bleeding when occurs, we can give the patient some of medication with adrenaline
(pehacaine), and vitamin K.

Osteoarthtritis Care and Management in Adults. NICE (National Institute for Health and
Care Excellence); 2014 .
Shoutherland J. H, Danielle G Gill, Pandu R Gangula, Leslie R Halpern, Cesar Y
Cardona, Charles P Moutson. Dental Management in Patients with
Hypertension Challenges and Sollution. Clinical Cosmetics and Investigational
Dentistry vol 8; 2016.
Harirfoorosh Sam, Waheed Asghar, Fakhreddin Jamali. Adverse Effect of Nonsteroidal
Antiinflamatory Drugs An update of Gastrointestinal Cardiovascular and Renal
Complication. J Pharm Pharm Sci 16: 2013.