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Pharmacology
Drugs That Alter Dental Treatment
Cardiovascular Drugs
Module #6A
Chapter 15
Cardiovascular Drugs
Cardiovascular Diseases
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Hypertension
Angina pectoris
Congestive heart failure
Myocardial infarction (MI)
Cerebrovascular accident (stroke)
Contraindications to Dental Care
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Clients with the following conditions are
ASA IV and generally are not scheduled
for elective dental treatment.
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Recent acute MI (6 months)
Unstable (or recent onset) angina pectoris
CHF – uncontrolled
Uncontrolled cardiac arrhythmias
Significant uncontrolled hypertension
Implications for Dental Treatment
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Vasoconstrictor Limit
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Use of epinephrine in the local anesthetic
agent
Cardiac dose 0.04 mg maximum
Infective endocarditis
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Rheumatic heart disease or valvular problems
Antibiotic premedication
Implications for Dental Treatment
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Cardiac pacemakers & defibrillators
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Consult with medical provider
No premedication necessary
Periodontal disease
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Increased risk
Link between perio and CVD
The Oral-Systemic Health Connection
Congestive Heart Failure
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Heart cannot meet the needs of the body
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Inadequate output
Not enough oxygen
Symptoms
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Pulmonary edema- failure of left side of heart
Dyspnea- difficulty breathing
 Orthopnea- difficulty breathing when lying flat
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Peripheral edema- failure of right side
CHF Treatments
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Drugs
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First line of therapy
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ACE inhibitors- (Angiotensin-converting enzyme
inhibitors)
Second line of therapy
Cardiac glycosides
 Digoxin (Lanoxin) (digitalis)
 Narrow therapeutic index
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Angiotensin-converting Enzyme
Inhibitors
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(ACE inhibitors)
1st line therapy for CHF
Improve symptoms
Decrease hospitalization
Prolong survival
Digoxin
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Pharmacological effects:
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Increases force/ strength of heart contraction
Increases volume of output
Decrease heart rate & size
Reduces edema
Uses
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CHF
Arrhythmias
Digoxin cont.
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Adverse effects
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Narrow TI- possibility of toxicity
GI- Nausea and vomiting
Arrhythmias- can progress to vent. fibrillation
Neurologic- headache, green/ yellow vision
Oral- increased salivation, increased gag
reflex
Digoxin Drug Interactions
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digitalis & epinephrine > additive, increase
risk of arrhythmias
digitalis & diuretics > hypokalemia may
lead to arrhythmias
Dental Implications- Digoxin
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Narrow TI
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Watch for overdose
side effects such as
nausea, vision
changes and excess
salivation
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Avoid triggering gag
reflex
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Helps with difficulty
breathing
Monitor pulse @ each
appointment
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Nausea
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Semireclined position
Check for bradycardia
Epinephrine in LA
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Cardiac dose limit
Review Book Question
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Which of the following is NOT a
pharmacologic effect of digitalis (a
cardiac glycoside)?
a.
b.
c.
d.
e.
Improves myocardial contractile force
Increases ventricular rate
Increases cardiac output
Decreases venous pressure
Decreases blood volume
Cardiac Arrhythmias
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Causes
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Abnormal impulse generation
Abnormal impulse conduction
Myocardial anoxia, ateriosclerosis, heart
block
Symptoms
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tachycardia
bradycardia
dysrhythmia
Cardiac Arrhythmias
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Drugs
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Sodium channel blockers
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Beta blockers
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Quinidine and procainamide
propanolol
Calcium channel blockers
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verapamil
Antiarrhythmic Agents
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Narrow therapeutic index
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Possibility of toxicity
Difficult to manage
Only used when necessary for proper heart
functioning
Antiarrhythmic Agents- Adverse
Effects
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Gingival enlargement
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Xerostomia
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Calcium channel blockers
procainamide
Nausea & vomiting
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quinidine
Board Review Question
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Quinidine is used to treat which of the following
conditions?
a.
b.
c.
d.
e.
Cardiac arrhythmias
Cardiac insufficiency
Congestive heart failure
Hypertension
Hypotension
Angina Pectoris
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Insufficient oxygen for body’s demand
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May be precipitated by stress (physical or
emotional)
Symptoms
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pain in chest
Radiates to left arm and shoulder
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May also radiate neck, back, and lower jaw
Angina Pectoris Treatment
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Drugs:
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Nitroglycerin
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Nitrostat, Nitro-dur
Calcium channel blockers
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Verapamil, nifedipine
Nitrogylcerin
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Pharmacological effects
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Uses
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Vasodilation
Treatment of angina attacks
Prevention of angina attacks
Adverse effects
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Hypotension
Fainting/ headache
Interaction with drugs used for ED
Dental implications- Nitroglycerin
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Prevention of angina attack
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Acute MI
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Can be taken before symptoms start
If pain does not go away, send patient to ER
Storage of nitroglycerin
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Avoid heat and moisture
Keep in original brown glass container
After opened, discard after 3-6 months
Pilot Board Question
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Which of the following BEST represents
the reason that nitroglycerin is effective
in treating anginal pain?
a.
b.
c.
d.
e.
Causes general vascular dilation
Possesses central analgesic actions
Produces specific coronary vasodilation
Increases efficiency of the myocardium
Has a negative inotropic effect on the heart
Hypertension
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Most common CVD
High blood pressure
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Essential (primary)
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Unknown cause (90% of cases)
Secondary
Cause is identifiable (endocrine, renal disease)
 Related to drug therapy (steroids, NSAIDs, ect.)
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Malignant
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Very high BP, rapidly rising, retinal/ renal damage
Classification of Blood Pressure
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Normal <120/80 mm Hg
Pre-hypertension 120-139/ 80-89
Stage 1 hypertension 140-159/ 90-99
Stage 2 hypertension >160/100
Managing Hypertension (fig 15-4)
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Lifestyle modifications
Initial drug choices
Not at goal BP- combination drug therapy
Lifestyle Modifications
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Weight reduction, physical activity, healthy
diet low in saturated fat, sodium restriction,
moderate alcohol intake, smoking cessation
Hypertension Treatment
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Stepped-care
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1 – lifestyle changes
2 – use 1 of big 5
3 – mix drugs;  dose
4 – use 2-3 drugs
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Big 5
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Diuretics
Beta-blockers
Ca channel blockers
ACE inhibitors
ARBs
Anti-hypertensive Drugs
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Diuretics
Beta-blockers
Calcium channel blockers
ACE inhibitors
ARBs- angiotensin receptor blockers
Diuretics
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3 main types
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Thiazides
Loop
Potassium (K) sparing
Thiazide Diuretics
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Most commonly used- HCTZ
Act on kidney tubule to increase water
excretion
Adverse reactions
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Hypokalemia- potassium loss
Arrhythmias- avoid epinephrine (cardiac dose
of vasoconstrictor in LA)
Interactions with NSAIDs- decreased diuretic
effect with ongoing use
Loop Diuretics
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Furosemide (Lasix)
Acts on loop in kidney tubule
More potent than Thiazides
Also cause hypokalemia
Used for CHF and hypertension
Potassium Sparing Diuretics
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Spironolactone and triamterene
Increase sodium excretion but retain K
Weak compared to Thiazides and Loops
Combined with other diuretics to combat
side effects
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Drug combo example:
Dyazide= thiazide and triamterene
Beta-Blockers
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Examples: propanolol, atenolol, labetolol
Uses
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Decrease BP by decreasing cardiac output
Consideration
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Orthostatic hypotension
When a person stands after being in the supine
position, blood flow to brain is reduced
 Causes dizziness and potential fainting
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Calcium Channel Blockers
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Examples: Verapamil, nifedipine
Lowers BP by reducing cardiac output
Oral side effects:
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Xerostomia
Dysgeusia
Gingival enlargement
Gingival Enlargement
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Calcium channel
blocker
 Nifedipine
(Procardia)
Nifedipine Gingival Enlargement
Gingival Enlargement
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Nifedipine
Gingival overgrowth
and ulceration in a
patient taking
nifedipine for
hypertension
ACE Inhibitors
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Examples: captopril, enalapril, lisinopril
Lower BP by reducing peripheral vascular
resistance
Side effects:
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Cardiovascular
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hypotension (dizziness, fainting)
CNS- dizziness, headache
Respiratory- cough
Oral-dysgeusia
ARBs
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Examples: losartan (Cozaar)
Lowers BP by causing vasodilation
Very similar to ACE inhibitors (more
specific site of action) and have fewer side
effects
Patient management:
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Possibility of leg cramps
NSAIDs interference
Video- YouTube
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Review of Cardiac Drugs
https://www.youtube.com/watch?v=2Vv1y
ed_urs
https://www.youtube.com/watch?v=SU7Ef
mXZLDc
General Adverse Effects of Antihypertensive Drugs
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Orthostatic hypotension
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Xerostomia
CNS sedation
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Sit patient up slowly
Additive with other CNS depressants
Dysgeusia
Gingival enlargement
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CCBs
Review Book Question
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Which drug does NOT cause gingival
hyperplasia?
a.
b.
c.
d.
Phenytoin
Cyclosporin
Nifedipine
Inderal
Anti-hyperlipidemics
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Used for treating high cholesterol
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Risk factors
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Untreated hypertension, smoking, obesity, alcohol
use
Review
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HDL- good cholesterol
LDL- bad cholesterol
VLDL- very bad cholesterol
Treating High Cholesterol
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Non-drug therapy
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Exercise
 saturated fat
 dietary cholesterol
 total fat
Drug therapy
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HMG Co-A reductase
inhibitors
“statin’s”
HMG Co-A Reductase Inhibitors
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Mechanism of action
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Inhibit LDL cholesterol synthesis
Adverse reactions
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GI upset
Hepatoxicity- liver testing
Niacin
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B Vitamin
Large doses inhibit synthesis of VLDL
Causes skin flushing in many patients
Anti-coagulants
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Interfere with blood clotting
Purpose of anti-coagulant therapy
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Reduce intravascular clotting and prevent lifethreatening situations
Embolism- blockage of a BV by an embolus
Mechanism of action of anti-coagulants
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Vitamin K antagonist – interferes w/ synthesis
of clotting factors
Warfarin (coumadin)
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narrow TI
many drug interactions
Dental considerations
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Bleeding
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Consult physician to determine whether the drug
needs to be discontinued prior to dental procedure
Analgesic choice
NO aspirin- increased risk of hemorrhage
 NSAIDs also contraindicated- inc risk of bleeding
 Use APAP or opioids for pain relief
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Warfarin Drug Interactions
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ASA -  effect of warfarin
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Prone to excessive bleeding, hemorrhage
vitamin K -  effect of warfarin
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Prone to clotting, may form embolus
INR
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International Normalized Ratio
Should be 2-3
Prosthetic heart valve 2.5- 3.5
Ranges from 1 (no drug effect) to 4
(overdose- too much drug effect)
Clopidogrel (Plavix)
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Inhibits platelet aggregation
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Increased bleeding risk
Has no effect on PT or INR values
Penny Purple
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What are the
classifications of drugs
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Lanoxin – cardiac
glycoside
ASA – analgesic
Advil – NSAID
Need to consult?
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Yes – why taking Lanoxin,
ok to treat, epi?
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Time of day
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Position
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Morning
Upright
Anesthesia
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No epinephrine –
mepivacaine or priliocaine
plain
Charlie Cherry
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Clarify
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heart attack
reason for Quinora
Needed info.
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OK to work on him
epinephrine OK
Classification
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Quinora – IA
antiarrhythmic
Vital signs
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Emergency?
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pulse
BP – possible hypotension
syncope
Pacemaker
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ultrasonic, EPT,
iontophoresis,
electrosurgery
Board Review Question

Which of the following is the most common of all
cardiovascular diseases?
a.
b.
c.
d.
e.
Coronary artery disease
Stroke
Angina
Hypertension
Cardiac arrhythmia