Download Congestive Heart Failure

Disease/Medical Condition
HEART FAILURE
Date of Publication: January 27, 2017
(also known as “HF”, “congestive heart failure”, and “CHF”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated? Yes, in patients/clients
with undiagnosed, untreated, or poorly managed HF.
■ Is medical consult advised? Yes, for patients/clients with symptoms of HF (i.e., decompensated heart failure – NYHA1
class II, III, or IV). As well, an initial consultation with the patient/client’s physician (cardiologist or primary care
physician) is indicated to establish the level of HF control and the underlying cause(s), which will inform subsequent
dental/dental hygiene management.
Is the initiation of invasive dental hygiene procedures contra-indicated?** Yes, in patients/clients
with undiagnosed, untreated or poorly managed HF. A major risk in providing treatment for a patient/client with symptomatic
(decompensated) HF is that signs/symptoms could suddenly worsen with resultant acute pulmonary edema, a serious arrhythmia,
unstable angina, stroke, or myocardial infarction.
■ Is medical consult advised? .......................................... See above.
■ Is medical clearance required? ..................................... – Yes, for patients/clients with symptoms of HF (i.e.,
decompensated heart failure – NYHA class II, III, or IV). Many patients/clients with NYHA class II HF and some with class III
may undergo routine treatment in an outpatient setting after clearance by their cardiologist. Supplemental oxygen and/or
vasodilatory drugs such as sublingual nitroglycerin may be part of the dental/dental hygiene treatment plan.
– Yes, if there is the potential for equipment-related electromagnetic interference of a cardiac implantable electronic device
(CIED). Patients/clients with HF may have pacemakers and/or implanted cardioverter defibrillators (ICDs).
– Yes, if the patient/client has received a heart transplant.
■ Is antibiotic prophylaxis required? ................................. No, in the absence of cardiac valvular pathology or atrial
fibrillation.
■ Is postponing treatment advised? .................................. Yes, for patients/clients with symptoms of HF (i.e.,
decompensated heart failure – NYHA class II, III, or IV), who are generally not candidates for elective dental/dental hygiene
care. For such persons, treatment should be postponed until medical consultation has been obtained, medical management
has been optimized, and medical clearance has been given. Patients/clients who have a history of HF but who are
asymptomatic (i.e., have compensated HF, designated NYHA class I) are at intermediate risk for a serious event; with good
functional capacity and reserve, as demonstrated by ability to climb a flight of stairs, they generally can safely receive
routine outpatient dental/dental hygiene care.
Oral management implications
■ HF often goes undiagnosed, with patients/clients not knowing that they have the condition. Therefore, the dental hygienist
should be particularly aware of signs and symptoms.
■ Patients/clients with untreated or poorly managed HF are at elevated risk during dental and dental hygiene treatment for
complications such as myocardial infarction, cardiac arrest, and stroke. Even asymptomatic HF patients/clients (NYHA class I)
are at intermediate risk of the occurrence of a serious event due to potential decompensation.
1
Severity of heart failure is often gauged according to the New York Heart Association (NYHA) classification system of functional capacity. In
Class I, there are no symptoms (i.e., no limitation of physical activity, and no dyspnea, fatigue, or palpitations with ordinary physical activity).
In Class II, symptoms occur with ordinary activity (i.e., slight limitation of physical activity, with patients/clients experiencing fatigue,
palpitations, and dyspnea with ordinary physical activity but being comfortable at rest). In Class III, symptoms occur with less than ordinary
activity (i.e., marked limitation of activity, but patients/clients are comfortable at rest). In Class IV, symptoms are present at rest or with any
minimal activity, with any physical exertion exacerbating the symptoms.
cont’d on next page...
Disease/Medical Condition
HEART FAILURE
(also known as “HF”, “congestive heart failure”, and “CHF”)
Oral management implications (cont’d)
■ At each dental hygiene appointment, determination of HF severity and level of control is indicated. In particular, the dental
hygienist should ensure that the patient/client is taking prescribed HF medications properly, because the most common
reason for decompensation during a dental/dental hygiene procedure is medication non-compliance.
■ The HF-associated medical emergency most likely to occur in the dental hygiene setting is acute pulmonary edema (APE).
Although the onset of the emergency is sudden, careful questioning of the patient/client at the beginning of the appointment
will likely reveal that the HF has been worsening in recent weeks (e.g., increasing shortness of breath and cough). Dental
hygiene procedures should be postponed until medical treatment has been optimized and medical clearance obtained.
■ Close monitoring of the patient/client, as appropriate, and being prepared for an emergency are prerequisites for dental
hygiene treatment. In particular, blood pressure should be monitored, because it may significantly increase or decrease in
patients/clients with poorly controlled HF.
■ Stress/anxiety reduction techniques may be indicated, particularly for patients/clients with untreated or poorly controlled
HF, who may appear anxious and are at risk of a cardiac crisis. Ultrasonic instrumentation in such patients/clients should be
limited so that fluid does not back up in the oral cavity; this will minimize anxiety and facilitate breathing. Appointments
should be brief (i.e., ideally less than 30 minutes).
■ While chair positioning is not usually an issue if the patient/client has compensated (i.e., NYHA class I) HF, the dental
hygienist should be alert for orthopnea (i.e., positional dyspnea experienced while in recumbent or semi-recumbent
position), particularly in persons with decompensated HF. Furthermore, a patient/client who has pulmonary congestion or is
becoming hypotensive and syncopal from cardiac stress may not tolerate the supine position; semi-supine or upright chair
position is indicated.
■ When orthopnea and paroxysmal dyspnea are severe, the patient/client may require supplemental oxygen 24 hours a day.
Such patients/clients typically carry portable O2 cylinders with a nasal cannula.
■ Orthostatic hypotension may result from drug treatment of HF, including diuretics2, angiotensin-converting enzyme inhibitors
(ACEIs)3, angiotensin receptor blockers (ARBs)4, beta-blockers5, and vasodilators6. Therefore, the back of the dental chair
should be raised slowly from the supine/semi-supine position, and the patient/client should be allowed to sit upright for a
few minutes before standing.
■ Nausea and vomiting are risks in patients/clients taking digitalis-derived drugs7, who are also prone to accentuated gag
reflex. Procedures that may trigger gagging should be performed with extra care.
■ Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided, because they can exacerbate symptoms of HF.
■ Excessive bleeding may occur in patients/clients with HF if their medical regimen includes anticoagulants 8 for management of
commonly coexisting atrial fibrillation.
■ Epinephrine and other vasoconstrictors should be used cautiously, and they should be avoided in patients/clients with class III
or IV HF without prior physician consultation.
■ Nutritional counseling (to decrease sodium intake and hence alleviate fluid retention) and smoking cessation (to decrease
further cardiac damage) should be recommended, as appropriate.
2
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4
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7
8
Diuretics include furosemide, hydrochlorothiazide, chlorthalidone, amiloride, and spironolactone.
ACEIs include captopril, enalapril, lisinopril, and ramipril.
ARBs include candesartan, irbesartan, losartan, telmisartan, and valsartan.
Beta-blockers include atenolol, metoprolol, propranolol, and timolol.
Vasodilators include hydralazine and isosorbide dinitrate.
Digitalis glycoside drugs include digoxin and digitoxin, which are used to improve myocardial contractility.
Anticoagulants include warfarin, clopidogrel, apixaban, rivaroxaban, and dabigatran.
cont’d on next page...
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Disease/Medical Condition
HEART FAILURE
(also known as “HF”, “congestive heart failure”, and “CHF”)
Oral manifestations
■ Mucous membranes may be grayish-blue in patients/clients with more severe heart failure. There may also be cyanosis (bluish
tinge) of the lips and ashen-gray appearance of perioral (and other) skin. Frothy pink sputum can occur in HF-associated
acute pulmonary edema. Otherwise, there are no oral manifestations of HF per se, but drug treatment can cause oral signs/
symptoms.
■ Xerostomia is a side effect of diuretics.
■ Angioedema of the lip, face, or tongue; taste changes; and burning mouth may result from ACEIs.
■ Lichenoid lesions9 may occur with ACEI and beta-blocker use.
■ Increased gag reflex and hypersalivation may occur with digitalis-derived drugs (e.g., digoxin and digitoxin, which are used to
improve myocardial contractility).
■ Lupus-like oral lesions may infrequently result from hydralazine.
Related signs and symptoms
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■
■
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More than 600,000 Canadians live with heart failure, and 50,000 persons are newly diagnosed each year. Given that heart
failure is the end result of many cardiovascular diseases and is primarily a condition of the elderly, these numbers are
increasing as more persons survive myocardial infarctions and other cardiovascular events and as the population ages.
Heart failure is serious and progressive syndrome in which the heart muscle has been damaged or weakened by disease 10. This
results in a decreased ability to eject blood, especially during increased activity or under stress. In addition, the cardiac
muscle may not relax enough to accommodate the flow of blood back from the lungs to the heart. These abnormalities can
result in fluid back-up (“congestion”) in the lungs (systolic dysfunction known as left-sided ventricular heart failure) and fluid
accumulation (“congestion”) in peripheral tissues (diastolic dysfunction known as right-sided ventricular heart failure). In
addition, HF may result from a variety of other cardiac conditions – including disorders of heart rhythm or rate – or by states
in which the heart is unable to compensate for increased metabolic requirements or increased peripheral blood flow.
Right-sided heart failure is usually preceded by failure of the left ventricle, even if overt signs/symptoms of left-sided HF are
absent. Emphysema (a form of chronic obstructive pulmonary disease usually secondary to smoking) is the most common
cause of pure right-sided HF.
Dyspnea (perceived shortness of breath) and fatigue (especially muscular) are the cardinal manifestations of left-sided HF.
The dyspnea results from congestion of blood in the pulmonary vessels. Inspiratory “crackles” can be heard upon stethoscope
auscultation of the bases of the lungs.
Peripheral dependent edema (e.g., swelling of ankles and feet, which “pits” upon depression with a fingertip) and systemic
venous congestion (including distended neck veins) are outcomes of right ventricular failure.
Other signs/symptoms of HF are: weakness; paroxysmal nocturnal dyspnea (which awakens patient/client from sleep); acute
pulmonary edema (manifesting as progressive dyspnea or cough); exercise intolerance (e.g., inability to climb a flight of
stairs); weight gain and/or increased abdominal girth (from fluid accumulation, including ascites); right upper quadrant
abdominal pain (liver congestion); rapid, shallow breathing; Cheyne-Stokes respiration11; nausea, vomiting, decreased
appetite, and constipation (due to bowel edema); heart murmur; pulsus alternans12; jaundice; cold hands and feet; cyanosis;
and clubbing of fingers.
9 Lesions similar in appearance to lichen planus, typically manifesting intraorally on the buccal mucosa.
10 The most common causes of heart failure are hypertension; ischemic heart disease resulting in myocardial infarction; cardiomyopathy; cardiac
valvular disease; myocarditis; infective endocarditis; congenital heart disease; pulmonary hypertension; pulmonary embolism; and diabetes
mellitus. Other causes include chronic obstructive pulmonary disease (COPD), severe anemia, hyperthyroidism, rheumatic fever, and excessive
use of alcohol or certain drugs.
11 Abnormal pattern of breathing characterized by hyperventilation followed by a gradual decrease culminating in apnea, with each cycle
typically occurring over 30 seconds to 2 minutes.
12 Alteration of strong and weak pulse beats (associated with left-sided heart failure).
cont’d on next page...
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Disease/Medical Condition
HEART FAILURE
(also known as “HF”, “congestive heart failure”, and “CHF”)
Related signs and symptoms (cont’d)
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■
■
■
■
Compensated HF (NYHA Class I) means that a variety of physiological responses to HF (including increases in heart rate,
myocardial contractility, and efficiency in oxygen utilization by tissues) have eliminated symptoms (at least temporarily).
Decompensated HF (NYHA Classes, II, III, and IV) means that HF is symptomatic.
The prognosis for patients/clients with heart failure is poor, with 50% dying within 5 years of diagnosis (including 20% within
the first year). Sudden death occurs 6 to 9 times more frequently than for the general population.
Abnormal pattern of breathing characterized by hyperventilation followed by a gradual decrease culminating in apnea, with
each cycle typically occurring over 30 seconds to 2 minutes.
Alteration of strong and weak pulse beats (associated with left-sided heart failure).
References and sources of more detailed information (cont’d)
■ Canadian Cardiovascular Society http://www.ccs.ca/images/Guidelines/Guidelines_POS_Library/HF_CC_2006.pdf
(CCS Consensus Conference Recommendations on Heart Failure 2006: Diagnosis and Management)
http://www.onlinecjc.ca/article/S0828-282X(12)01379-7/fulltext#sec1.1 (The 2012 CCS Heart Failure Management
Guidelines Update: Focus on Acute and Chronic Heart Failure)
■ Heart and Stroke Foundation (Canada)
http://www.heartandstroke.com/site/c.ikIQLcMWJtE/b.3484065/k.9224/Heart_failure.htm
http://www.heartandstroke.com/atf/cf/{99452d8b-e7f1-4bd6-a57d-b136ce6c95bf}/2016-HEART-REPORT.PDF
■ Mayo Clinic http://www.mayoclinic.org/diseases-conditions/heart-failure/basics/tests-diagnosis/con-20029801
■ WebMD http://www.webmd.com/oral-health/dental-care-heart-disease#1
■ Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
https://healthit.ahrq.gov/sites/default/files/docs/resource/
James_Fricton_IQHIT_Q1_HP_Recommendations_for_Preventing_Complications_for_Chronic_Illnesses.pdf (Dental
Recommendations)
■ RDH Magazine, Dentistry IQ Network http://www.rdhmag.com/articles/print/volume-16/issue-2/columns/periodontics/drug
-therapy-for-congestive-heart-failure-poses-several-risks-during-dental-treatment.html
■ Cruz-Pamplona M, Jimenez-Soriano Y, Sarrión-Pérez MG. Dental considerations in patients with heart disease. J Clin Exp
Dent. 2011;3(2):e97-105. http://www.medicinaoral.com/odo/volumenes/v3i2/jcedv3i2p97.pdf
■ Darby M (ed.) and Walsh M (ed.). Dental Hygiene: Theory and Practice (4 th edition). St. Louis: Elsevier Saunders; 2015.
■ Little JW, Falace Da, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (8th edition). St.
Louis: Elsevier Mosby; 2013.
■ Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.
*
Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
**
Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling
teeth and root planing, including curetting surrounding tissue.
Date: October 24, 2016
69 Bloor St. E, Suite 300, Toronto, ON M4W 1A9 t: 416-961-6234 ● tf: 1-800-268-2346 ● f: 416-961-6028 ● www.cdho.org
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