Download Cardiovascular Diseases and its dental implications

Cardiovascular Diseases
and its dental implications
Dr Elsanousi M Taher
BDS, MSc., FFDRCSI
E-mail: [email protected]
 Signs of cardiac diseases
– Cyanosis
– Finger clubbing
– Leg oedema
– Distended neck veins and elevated jugular
venous pressure
 Symptoms of cardiac diseases
– Chest pain:
 Angina pectoris
 MI
 Pericarditis
– Dyspnea (Lt. side heart failure is the most
common heart cause of it)
– Orthopnea
– Paroxysmal nocturnal dyspnea
– Palpitation
– Syncope and dizziness as a result of
failure to maintain an adequate circulation
to the brain
Distended neck veins in CVD occur in Rt. Side heart
failure and abnormalities of tricuspid valve when
Rt. Atrium contract against narrow or closed valve
Severe central cyanosis
Severe central & peripheral cyanosis
Central cyanosis may be seen in the
oral cavity
Drum stick
like finger
tips
Note the bluish discoloration of nail beds
Leg edema in cardiac patient
Bilateral pitting leg edema is indicative of heart
failure
Cardiovascular Diseases
Congenital heart diseases:
a) non cyanotic
b) cyanotic
What is cyanosis ?
 Non-cyanotic diseases which include:
 Ventricular septal defect (VSD):
– The most common (1l3 of all malformations)
– Lt to Rt. shunt
 Atrial septal defect (ASD):
– 10% of cases
– May be asymptomatic
– Cause arrhythmias
 Non-cyanotic diseases which include:
 Patent ductus arteriosus:
– is caused by failure of closure of the communication
between the pulmonary artery and descending aorta after
birth
– Cause continuous shunting from aorta to pulmonary artery
increasing the pulmonary venous return to the left heart to
increase Lt ventricular cardiac load and Lt heart failure
 Coarctation of aorta: narrowing of the lumen of the arch
of aorta distal to the origin of the left subclavian
artery:
– Cause secondary hypertension
– Delay between the radial and femoral pulses
ASD
VSD
Coarctation of aorta
Tetralogy of Fallot’s
 Cyanotic diseases:
 Fallot’s tetralogy:
– pulmonary stenosis
– VSD
– Right Ventricular hypertrophy
– Dextroposition of aorta to overlies the outflow tracts
of both ventricles
Rheumatic Fever

Is immunologically mediated disease caused by
cross reactivity between the antibodies formed
against M protein of the cell wall of the
Lancefield group A ß-hemolytic streptococci and
human connective tissues

It is usually follows sore throat and pharyngitis

Affects children (5-15 years old)

The patient usually hospitalized for many weeks
 After recovery, the patient will be kept
under antibiotic until he/she is no longer at
risk (early twenties)
 Its complicated sequel may result in
rheumatic heart disease (stenosis &
incompetence)
 60% of patients with caraditis develop
chronic rheumatic heart disease
Major criteria
 Revised Jones
criteria for the
diagnosis of
rheumatic fever
 (two major or
one major and
two minor)
- caraditis
- migratory
polyarthritis
- Sydenham’s
chorea
- erythema
marginatum
- subcutaneous
nodules
Minor criteria
-
fever
raised ESR
arthralgia
leukocytosis
characteristic
ECG changes
(prolonged P-R
interval)
Plus
- evidence of preceding streptococcal
infection: positive throat swab
culture and raised streptolysin O
Rheumatic Heart Disease
 Develops subsequently in at least 50-60% of patients affected
by rheumatic fever with caraditis
 The mitral valve is affected in > 90% of cases
 Many patients may not be aware that they have had rheumatic
heart disease, in that case, active inquiry must be made for
history of chorea, migratory polyarthropathy or growing pains
in childhood
 Patients with H/O rheumatic fever should be considered to have
rheumatic heart disease and at risk to develop infective
endocaraditis until proved otherwise
Heart murmurs
“Abnormal heart sounds that result from
vibrations caused by turbulent blood flow
through the valves or chambers of the
heart“

–
They are classified into:
II. Innocent, functional or physiological murmur:
–
–
as in children and pregnancy
no need for antibiotic cover
II. Organic or pathological murmur:
–
There is valvular or other cardiac abnormality
–
Need antibiotic cover
– Infective endocarditis (IE) is defined as an
infection of the endocardial surface of the heart
which may include one or more heart valves.
– Its intracardiac effects include severe valvular
insufficiency, which may lead to intractable
congestive heart failure and myocardial abscesses.
– If left untreated, IE is generally fatal.
– It is caused by infectious agents, or pathogens,
which are usually bacterial but other organisms
can also be responsible.
Infective Endocaraditis
• Its incidence is 10-50 cases per million
(uncommon)
• 50% of all endocaraditis occurs in normal
valves (acute course)
• At risk patients are 100 times higher
chance to get the disease than general
population after dental procedure
Risk factors for infective
endocaraditis


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






VSD
PDA
Coarctation of aorta
Rheumatic and other acquired valvular disease
Persistent murmur
ASD repaired with a patch
Hypertrophic cardiomyopathy
Mitral valve prolapse with regurgitation
Tetralogy of Fallot’s cases
Others
High risk patient for infective
endocaraditis
 H/O infective endocaraditis
 Prosthetic valve
Patients not at risk from
infective endocaraditis
 Pulmonary stenosis
 Mitral valve prolapse without a murmur/
regurgitation
 Six months after surgery for:
 ligated ductus arteriosus
 surgically closed atrial or septal defects
(without dacron patches)
Pathogenesis of endocaraditis







damage to cardiac endothelium: congenital or
acquired
circulating platelets adhere to the exposed
collagen
fibrin incorporated into the clot
bactermia
organisms adhere to the clot
vegetations grows and damage cardiac tissues
dissolution of the vegetations & occurrence of
embolic phenomenon
 only 5-10 % of endocaraditis cases are due to
dental causes
 65% are due to St. viridians and enterococci
 10% are caused by staphylococcal bacteria
 0-5% are due to anaerobic bacteria (G- bacilli)
 0-15 are due to other organisms (fungi, chlamydia
and rickettsia)
 it has 100% mortality rate if untreated and more
than 30% if treated
Infective endocaraditis
Clinical features: are mainly due to cardiac infection and embolic
phenomenon

General: night sweating, myalgia, joint pain,weakness, wt. Loss,
anemia, finger clubbing

Cardiac: failure, murmur and dysrrythemia

Eye: Conjunctival hemorrhage, Roth spots in retina

Lung: cough, dyspnea and bloody sputum

Skin : petechiae, splinter hemorrhage and Osler’s nodules (painful
pulp infarcts in fingers and toes)

Kidney: hematuria and acute renal failure
Infective endocaraditis
Infective endocaraditis
Splinter hemorrhage
Osler's nodules
Subcutaneous nodules
Diagnosis of infective
endocaraditis
– Blood culture: four sets of cultures should
be taken in the first 24 hrs
– CBC: normochromic, normocytic anemia,
leukocytosis, raised ESR
– CXR: cardiomegally
– ECG
– Echocardiography
– Urinalysis: hematuria and proteinuria
Infective endocaraditis
prevention
 Prevention depends on:
– Identification of at risk patients
– Deciding which dental procedure require
prophylaxis
– Giving appropriate prophylaxis at appropriate time
Procedures that require antibiotic
prophylaxis

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
Extraction and minor OS procedures
Incision of an abscess
Scaling, curettage and root planning
Full mouth periodontal probing
Implant placement
Placement and removal of orthodontic
bands (not brackets)
Procedures for which it may be prudent
to give antibiotic prophylaxis
 Root Canal Therapy !!!
Procedures that do not require antibiotic
prophylaxis
 Temporary or permanent restoration
 Adjustment of orthodontic appliance
 Placement of matrix band
 Exfoliation of primary teeth
Invective endocaraditis
prophylaxis
a) Preventive role:


Inform the at risk patient about importance of
his/her oral health
Advise regular checkups and maintaining of good oral
hygiene (to maintain healthy dentition for life)
b) Local measures


Use antiseptic like chlorhexidine gel (1%) or as mouth
wash (0.2%) 5 minutes before dental treatment
Use povidone iodine application if chlorhexidine is not
available
c) Systemic measures (prophylaxis regime)
Invective endocaraditis prophylaxsis
Basic principles:


Follow the recommended regime in your area (Libya, Europe,
USA, Australia)
The antibiotic must target the tissue before the
dissemination of the micro-organisms

The antibiotic must be used on the basis of the most likely
single organism to cause the infection

The antibiotic effect should be continued as long as the
contamination occurs

Allow 10 days to elapse before starting new coverage period

Plan treatment to minimize the number of antibiotic
administrations
Invective endocaraditis prophylaxis
– Carry as much treatment as possible during the 34 hrs after taking prophylaxis
– If multiple coverage periods are needed use
antibiotics in alternate, penicillin, clindamycin
– Advise the patient to recall if he notes any
abnormal fatigue, weight loss night sweatiness,
fever or arthralgia. etc.
– Consult the physician whenever possible
 Low risk patients no longer need prophylaxis
For dental procedure
Dental procedure associated with bleeding is
no longer exclusively indicated for prohylaxis
Only procedures associated with high degree
of baxcteremia can ve covered dental
procedures are proven cause of few cases of
IE
Adverse reactions to antimicrobials including
 In 2006 British Society for antimicrobial
Chemotherapy (BSAC) recommend
antibiotic prophylaxis in only three (high
risk) circumstance:
– Previous IE
– Prosthetic valves
– Surgically repaired defects with residual
patches
National Institution for clinical excellence
(NICE)
 NICE (2008) issued recommendations
removing the need for antibiotic
prophylaxis in relation to dentistry
(antibiotic prophylaxis is not recommended
for patients at risk of endocarditis
undergoing dental procedures) and advise
that such patient should receive high
standard of oral health
Infective endocaraditis prophylaxis regime
LA
Not allergic to
penicillin
3 gm amoxycillin, orally
start 1 hr PO
GA
allergic to
penicillin
600 mg*
clindamycin orally
start 1 hr PO
No special
risk
Special risk
Not allergic
to penicillin
Not allergic
to penicillin
allergic to
penicillin
1 gm IM
Amoxicillin + .5
gm orally 6 hrs
later
1 gm amoxycillin
IM + 120 mg
Gentamycin
0.5gm
amoxycillin
orally 6 hrs
later
1 gm
Gentamycin +
120 mg
vancomycin
IV
 The use of azithromycin syrup for
children who refuse tablets or capsules
or for patients who have dysphagia is
advocated by British national formulary
Ischemic heart disease
Ischemic heart disease

A long term decrease in oxygen delivery to the
heart leads eventually to the a condition known as
ischemic heart disease (IHD) or coronary artery
disease (CAA)

Atherosclerosis is the most common cause of IHD

Clinically IHD may be manifested as:

Angina pectoris

Myocardial infarction
 Acute coronary artery syndrome is a term
used to refer to clinical features
attributed to coronary artery
obstruction.
 It may take the form of:
– Unstable angina
– Myocardial infarction
ANGINA PECTORIS
 Ischemia is temporary and reversible, Constant short acting
chest pain or discomfort due to Coronary Insufficiency
 Lactic acid and other metabolites accumulate in the anoxic
myocardium
 Pain is retrosternal, lasts for few minutes and relieved by rest
and anti-anginal drug
 No enzymatic elevation in all types of angina
 Pt with H/O angina should be carefully assessed: stable or
unstable type of angina
Dental management and implications
of angina
– Consult the physician about unstable or untreated angina
– Reduce the anxiety and reassure the patient e.g. show concern and
worm approach, use of sedation
– You may need to ask the patient to take glyceryl nitrate before
treatment
– Have the antianginal drug readily available in the clinic to be used if
required ( 0.2 mg nitroglycerin sublingually)
–
?? Use LA with no adrenaline but make sure that the anesthesia is
profound and effective
– Adrenaline containing LA can be used with certain precautions like using
aspirating technique
– Adequate oxygen supply should be available for use ( 100 % O2 with
face mask and nasal cannula)
Direction of blood through the
heart with normal pressure in
each chamber
coronary artery angiogram with
stenosis
coronary artery bypass
Dental management and implications of
angina

Pts with unstable angina ( present at rest, becomes worse recently,
increase in frequency, poor response to treatment) are best referred
to a specialist for management

Short appointment and terminate appointment if patient got fatigued

If the patient develop angina stop the procedure and give glyceryl
nitrate sublingually

Anginal pain may be referred to the mandible

Drugs like nefidipine may be used in such patients and may cause
gingival enlargement

Anginal patients are susceptible to develop MI, so be ready to deal
with !!! by keeping up to date with practical skills to manage severe
angina and skills for cardiopulmonary resuscitation
Myocardial infarction (MI)
 Attack of severe chest pain is characterized by:
–
–
–
–
–
1. lasting more than half an hour,up to hours or days
2. Not relieved by vasodilators
3. Relieved only by morphine sulphate injection
4. Rapid and week pulse, pale face and cold (shock)
5. Acute myocardial infarction could be diagnosed by ECG
changes& elevation of serum enzymes :
–
–
–
–
–
creatine phosphokinase
C P K
serum glutamic oxaloacetic transaminase
SGOT
aspartate transaminase
AST
lactic dehydrogenase
LD
serum level of Tropinin T (myocardial fibrillar protein ) is
specific and rapid aid in diagnosis
Management of MI:
 Primary care
– Aim to get patient to hospital!
– Analgesia, Aspirin & reassurance
– Basic life support if required
 Hospital
– thrombolysis if indicated
– aspirin
– streptokinase (SK) and tissue plasminogen activator
(Altepase)
– drug treatment to reduce tissue damage
– prevent recurrence/complications
Complications of MI
 Death
 Arrhythmias
 Heart Failure
 Ventricular hypofunction & thrombosis
 Papillary muscle rupture - valve disease!
 DVT & pulmonary embolism
 Complications of thrombolysis
Dental implications of MI
– No routine dental treatment before six
months after attack
– Same measures applied as for angina
– Bleeding tendencies due to the use of
anticoagulants
– Note that patient might be hypertensive
HYPERTENSION
 Persistently raised blood pressure above the normal
range for age and sex
 The prevalence of hypertension is about 20%
 May be classified into:
 Essential hypertension: 80-90% of cases
 Secondery hypertension: Renal, endocrine, drugs, pregnancy
etc.
 Most of essential hypertension cases are insidious &
asymptomatic and to be discovered during routine
clinical checkups or later as a result of complications
Systems affected by hypertension:
– Cardiac: Lt. Ventricular hypertrophy and accelerated
coronary artery diseases, heart failure, dysrrhythmias
– Eyes: retinopathy, hemorrhages, exudates, papilloedema
and blindness
– Neurogenic: occipital headache on walking, dizziness,
blurred vision, vertigo, tinnitus, syncope and stroke
– Renal: arteriosclerotic changes, hematuria and proteinuria
 The hypertensive patient may or may not be under
medical treatment
 Whenever the patient gave a H/o hypertension or
you suspect it:
 Make the pt sit and relax
 Check the BP. If raised recheck after some time (15 minutes)
 The diagnosis of hypertension is the responsibility of the
physician

Diastolic BP is better indication of hypertension, so:
85 mm Hg diastolic is normal BP
85-89 mm Hg may be considered to be high normal
(borderline cases)
90-100 is mildly hypertensive
101-110 is moderately hypertensive
110 is severely hypertensive (only emergency dental
care can be carried out)
(malignant hypertension) is an emergency and need
immediate referral

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Systolic BP:
–
–
–
–
–
–
–
130 normal
130-139 high normal
140-159 mild hypertensive
160-179 moderate
180-209 severe
> 209 very severe (need immediate
referral)
<
Clinical features of hypertension:
 Most patients are asymptomatic
 Occipital throbbing headache
 Insomnia
 Disturbed vision
 Dizziness
 Palpitation
 Spontaneous epistaxis
 Ringing ear
 Weakness
Dental management of hypertensive patient
 When systolic and diastolic pressures fall into
different categories, the higher of the categories is
determined as the patient classification status
 With severe hypertension delay all surgical procedure
and consult the physician immediately
 Limit care to pain control and antibiotic therapy
 Start the dental treatment only after the BP is
under control
 Short appointments, sedative therapy and good pain
control may be necessary
Management of mild to moderate hypertensive
patients:
 LA is preferable whenever possible and aspirating syringes must be
used
 Reduce anxiety (5 mg diazepam the night before and one hour preop.) and reassure

the patient
 Use LA with no adrenaline (prilocaine + felypressin) or with
1:100.000 adrenaline + minimum dose ( 3-4 cartridges) +
aspiration and slow injection
 Extraction can be done under LA with one or two teeth and avoid
multiple extraction & trauma
 Minimize the waiting time
 Reduce pain & anxiety to reduce the sequels of increased
hypertension
 Do not change the Patient position abruptly to avoid postural
hypotension
 Take into account the management of the problems caused by
underlying disease or complications caused by hypertension e.g.
renal failure
 Systemic steroids may rise the BP
 GA potentiate the effect of antihypertensive drugs
 Be aware of the hypertensive drugs side effects such as:
– xerostomia,
– lichenoid reactions
– postural hypotension
– swelling and pain of the salivary glands
Oral complications of antihypertensive
drugs
 Xerostomia as in diuretics
 Lichenoid reactions: thiazide, methyldopa, propranolol
 Lupus- like reactions: hydralazine
 bleeding after surgical procedures if the patient is taking
anticoagulant or aspirin
 Swelling and pain of salivary gland
 THERE IS NO EVIDENCE THAT ADRENALINE IN
LA IS A HAZARD TO CARDIAC PATIENTS, IN
FACT THIS VASOCONSTRICTOR MAY ENHANCE
THE DURATION AND DEPTH OF LA, PROVIDE
GOOD PAIN CONTROL AND REDUCE THE RELEASE
OF ENDOGENOUS
Dysrrythemia
 Usually it is due to ischemic heart disease so manage as angina
case
 should be suspected in:




thyroid disease
open heart surgery
significant heart disease
hypertensive patient
 Dysrrhythmias may include:
 Tachycardia
 Bradycardia
 Atrial fibrillation:
– Is the commonest chronic dysrrythemias as it occurs in 4% of people above
the 65 years
– Increase the risk of intracardiac clot formation and systemic embolism
– These patients usually kept under aspirin and warfarin
 Ventricular fibrillation
 Cardiac arrest

These patients are at high risk of developing cardiac arrest

Patients with H/O palpitations, dizziness, angina, dyspnea and syncope
should be referred for medical consultations

Those with abnormal physical signs like irregular pulse, tachycardia,
bradycardia should be referred before dental treatment to determine
the need for a cover and confirm the medication/s being taken

If they are on anticoagulants manage accordingly

If they have a cardiac pacemaker:
 it is not contraindication to LA or GA
 no need for antibiotic cover
 avoid the use of electrocautery or diathermy, electric pulp
tester or ultrasonic scalar as the leakage of current may
affect the pacemaker function
Pace makers

Are devices use to supply an electrical stimulus to the heart to make
it contract at desired level (as there is problem with the conducting
system of the heart)

Inserted subcutaneously under left clavicle and connected to the heart
through subclavian vein

Used commonly to treat Bradyarrhythmias or less commonly to
suppress resistant tachycardia

Keep heart rate at a minimum level

Theoretical risk of electrical interference:
– electrical fields - MRI, electro-surgery/diathermy
– dental equipment THEORETICAL risk only
– avoid electrical scalers
Cardiac pacemaker
Implanted pace maker
Cardiomyopathy
 Is heart muscle disorder that is not
secondary to IHD, Hypertension,
congenital, valvular or pericardial diseases
 Classified into:
– Hypertrophic:
– Dilated:
– Constrictive:
Classified into:
– Hypertrophic:
 Hypertrophic cardiomyopathy (HCM) is a disease in which
the heart muscle (myocardium) becomes abnormally thick
(hypertrophied).
 The thickened heart muscle can make it harder for the
heart to pump blood
 Commonly hereditary but may occur sporadically cause
dyspnea, angina, palpitation and syncope
 It may be complicated by atrial fibrillation, emboli, heart
failure and sudden death in extraneous exercise
– Dilated:
 The ventricles are dilated and contract only poorly
 Causes:
– Viral & bacterial infection
– Alcohol
– Infiltrations like Sarcoidosis, amyloidosis and
hemochromatosis
– May present with signs and symptoms of heart failure ,
cardiomegally, fibrillation and emboli
– Constrictive:
 Due to endomyocardial stiffness
 Amyloidosis is the most common cause
Heart failure
 The heart is no longer act as a pump
to maintain sufficient cardiac output
to meet the demands of the body
despite the normal filling pressures
Classification:
1.Lt ventricular heart failure:
– Causes:

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IHD
HYPERTENSION
AORTIC & mitral valve disease
Anemia
Thyrotoxicosis
Cardiomyopathy

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



Excretional dyspnea
Orthopenea
Paroxysmal nocturnal dyspnea
Fatigue
Wheezing and cough
Hemoptysis
– Signs and symptoms
2. Rt. ventricular heart failure:
 Occur secondary to chronic lung disease (cor
pulmonale) e.g. COPD
 Signs and symptoms
– Pitting oedema
– Ascites
– Increased JVP
3.Congestive heart failure:
 Occur secondary to Lt Vent. Failure
 Cyanosis
 Fatigue
 Nausea swollen ankles
 Abdominal discomfort
 Treatment of heart failure
 Diuretics
 ACE inhibitors
 Nitrates
 Digoxin
Dental implications heart failure:
– In Poorly controlled or uncontrolled
patients only emegency treatment to treat
pain and infection can be carried out and
elective treatment should be deferred until
the medical condition is stabilized
– Appointment must be in late morning and of
short duration
– Pain and anxiety might precipitate angina,
dysrhythmia so good analgesia must be
given
– Take care of the underlying disease and
drugs including anticoagulants
Dental implications heart failure:
– Lidocaine and preilocaine can be used with
caution but bupivicaine should be avoided as
it is cardiotoxic
– Adrenaline should not be given in large
doses for patients taking B-blockers as it
might increase BP
– Gingival retraction containing adrenaline
should be avoided.
– Manage patient in upright position specially
for patients wit Lt. sided heart failure
General Principles Of Dental Management Of
Patients With Heart Disease
1. The chief hazards are likely to be:
a. Anxiety and pain which cause increased sympathetic activity and leads
to increased load on the heart and the possibility of inducing
arrhythmia
b. GA is particularly hazard and in general it is contraindicated in dental
surgery for such patients
c. Infective endocaraditis is hazardous for some cardiac patients
2. Routine dentistry is safe for most patients with heart disease
unless they are overanxious
3. Sedation using midazolam by SLAW INJECTION may be
helpful to reduce anxiety. Alternatively, nitrous oxide sedation
may be more pleasant and acceptable. Neither of these two
agents have significant adverse effects if competently given
4. Extraction under LA should be carried out with one or two at
a time and the blood loss of multiple extractions should be
avoided
5. LA is generally safe and should always be used in
preference of GA. The hazard of adrenaline in
LA used in sensible dose ( up to four cartridges)
is little more than theoretical
6. LA containing nor adrenaline are totally
contraindicated, as even in normal persons they
have caused fatal hypertensive attacks
7. GA is generally contraindicated in dental surgery and
it is particularly hazard in the following conditions:





After MI specially recent one
Angina specially recent and unstable
Severe hypertension
Intractable arrhythmia
Some congenital heart diseases
8. GA is a hazard because it may: depress cardiac
activity, aggravate or possibly precipitate heart
failure, cause dysrhythmias, dilate vascular bed
causing a full in BP, depress respiration and
oxygenation.