dental management of the cardiologically compromised patient

8/6/2019 Dental Management of the Cardiologically Compromised Patient

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Dental Management of the

Cardiologically

Compromised Patient

By

AbhisekChatterjee

Final Year B.D.S



Physical Evaluation and Risk Assessment

Dentistry today is far different from what was practiced only a decade or two

ago, not only in techniques and procedures but also in the types of patients

seen. As a result of advances in medical science, people are living longer and

are receiving medical treatment for disorders that were fatal only a few years

ago.

For example, damaged heart valves are surgically replaced, occluded

coronary arteries are surgically bypassed or opened by balloons, organs are

transplanted, severe hypertension is medically controlled, and many types of

malignancies and immune deficiencies are managed or controlled.

Because of the increasing numbers of dental patients, especially among

the elderly, who may have chronic medical problems, the dentist must remain

knowledgeable about patients· medical conditions.

Patients with various forms of cardiovascular disease are especially

vulnerable to physical or emotional challenges that may be encountered

during dental treatment.

Main Questions are:

� W hat do we do in the course of providing dental care that can

affect the health and well being of a patient?Potential for the

Occurrence of Adverse Events

� Can we provide routine dental treatment to this patient

without endangering their (or our) health and well being?

&

� Is the benefit of having dental treatment worth the risk to the

patient?



W hat do we do in the course of providing dental care that

can affect the health and well being of a patient?

y Instill fear

y Inflict pain

y Inject local anesthetic solutions

y Inject potent vasoconstrictors

y Cause bleeding

y Control body position

y Expose to radiation

y Expose to dental materials

y Prescribe medications

y Alter oral function

y Alter appearance

y Dependent upon:

The medical condition of the patient (diagnosis, severity, stability,

control)

The cardiopulmonary reserve which the patient has to be able to

respond to physical/emotional challenges (METs; oxygen utilization)The

emotional stability of the patient (fear, anxiety)

The type of dental procedure (invasiveness, length of procedure, blood

loss, type of anesthesia, use of vasoconstrictor)



Can we provide dental treatment to this patient without endangering their(or our) health and well being?

y Yes. No problems are anticipated, and treatment can be delivered in

the usual manner.

y Yes. The potential for problems exists; however, modifications can be

made in the delivery of treatment that reduces risk to an acceptable

level.

y No. Potential problems exist that are serious enough to make itinadvisable to provide elective dental treatment.

Physical/Emotional

-stability

-control

-tolerance -reserve

Dental Procedure

-invasiveness

-trauma

-blood loss

-duration



Most Common Medical Emergencies in Dental

Practice:

� Syncope

� Mild Allergic Reaction

� Angina Pectoris

� Postural Hypotension

� Seizures

� Asthmatic Attack

� Hyperventilation

� Epinephrine Reaction

� Insulin Shock

� Cardiac Arrest

� Anaphylaxis

� Myocardial Infarction

Many of these events are preventable, or at least the chances of

them occurring can be lessened.

� Medical history (questionnaire/ interview)

� Physical examination (general survey, face, eyes, skin, etc.)

� Laboratory tests (screening, confirmation)� Medical consultation (physician, dentist, pharmacist)



� Printed questionnaire, paper or electronic (patient must be literate,

competent, of legal age)� Follow-up dialogue/research; make notes on questionnaire

� Use ink - not pencil

� Patient, student, and faculty signature, date

� Update regularly

� Inquire at each appointment about any changes in health or

medications since previous appointment and include this in your

progress note; ´no change in health historyµ

� New questionnaire completed (every 1-2 years)

� Review the Medical History and note positive responses

� Interview the patient to gain more information about those positive

responses; write in the margins of the history form

� Innocuous or insignificant problems can be disregarded

� Potentially significant disorders OR unfamiliar disorders require

further thought and/or investigation

� General appearance

� Behavior

� Vital signs� Head and neck

� Oral tissues

� Radiographs



� Determine coagulation status (von Willebrand·s, hemophilia)

� Determine level of anticoagulation (coumadin)� Screening for blood glucose (periodontal disease, burning mouth)

� Screen for infectious disease (hepatitis C, A IDS)

� Screening for liver function (hepatitis C, cirrhosis)

� Screening for kidney function (renal failure)

� Complete blood count with differential [CBC with diff] (burning mouth,

unexplained oral lesions)

� Purpose:

± V erify or clarify information

± Determine risk for doing dental treatment on the patient

± Determine if any changes are required in the delivery of

dental treatment

� Be brief and to the point

� Letter, FAX, phone call

� Response should attached to or recorded in the patient·s chart

� If not, proceed with treatment in the usual manner

� If yes then«..

W e need ´Dental Treatment Modificationsµ

Examples of Treatment Modifications

� Limit treatment to specific times (e.g. hemodialysis; pregnancy)

� Preoperative anticoagulation level; blood pressure



� Preoperative antibiotics (e.g. prosthetic heart valve)

� Provide pre-operative or intra-operative sedation (e.g. unstable

cardiac patient; fearful patient)

� Minimize the intraoperative use of epinephrine in local

anesthesia, (e.g. unstable cardiac patient)� Avoid the administration or prescription of certain drugs (e.g.

erythromycin for patients taking certain lipid-lowering drugs)

� Make position changes slowly (e.g. BP medications)

� Ensure a comfortable chair position (e.g. heart failure,

emphysema, pregnancy, arthritis)

� Provide postoperative antibiotics (poorly controlled diabetic

with dental abscess)

Cardiovascular Problems Related to Dentistry and

their Management:

Questions should refer to known medical problems,

past history and present general fitness.

� Is there a history of heart valve surgery,rheumatic fever or murmurs,

which might necessitate prophylactic antibiotic cover

� Is the patient aware of any heart disease or hypertension?

� Does the patient suffer from palpitations, swellingof the ankles and

dizziness?

� Can the patient lie flat without breathlessness?

� What is the patient's general fitness? For example, can the patient

climb stairs without breathlessness or chest pain?



Congenital and rheumatic heart disease

Valvular anomalies and damage may predispose to colonization and

subsequent potentially fatal infective endocarditis following a bacteremia

caused by dental treatments such as subgingival periodontal therapies or

surgical procedures including dental extraction. Providing antibioticprophylaxis for such dental procedures should reduce this risk.

Antibiotic protocol for prevention of endocarditis from dental

procedures

� Local or no anesthesia

Oral amoxicillin 3 g 1 hour before procedure Or if allergic to penicillin or

have had more than a single dose in previous month: oral clindamycin 600mg 1 hour before procedure Or patients who have had endocarditis:

amoxicillin and gentamycin, as under general anesthesia

� General anesthesia: no special risk

Amoxicillin 1 g intravenous at induction, then oral amoxicillin 500 mg 6

hours later Or oral amoxicillin 3 g 4 hours before induction then oral

amoxicillin 3 g as soon as possible after procedure Or oral amoxicillin 3 g and

oral probenecid 1 g 4 hours before procedure� General anesthesia: special risk

Patients with a prosthetic valve or who have had endocarditis are at special

risk Amoxicillin 1 g and gentamycin 120 mg both intravenous at induction,

then oral amoxicillin 500 mg 6 hours later

� General anesthesia: penicillin not suitable

Patients who are allergic to penicillin or who have received more than a

single dose of a penicillin in the previous month need different antibiotic

cover Vancomycin 1 g intravenous over at least 100 minutes then intravenous

gentamycin 120 mg at induction or 15 minutes before procedure Or

teicoplanin 400 mg and gentamycin 120 mg both intravenous at induction or

15 minutes before procedure Or clindamycin 300 mg intravenous over at least

10 minutes at induction or 15 minutes before procedure then oral or

intravenous clindamycin 150 mg 6 hours later



A cardiologist should have confirmed the presence of valve damage. There is

lack of consensus on the precise clinical conditions that indicate a need for

antibiotic cover.Indeed, it is now suggested that the risk of endocarditis may

actually be very small following dental treatment. However, there is clear

evidence that the risks are greatest with patients who have prosthetic heart

valves. The recommendations of the Working Party of the British Society for

Antimicrobial Chemotherapy are presented in the British Dental

Practitioners' Formulary.

HypertensionThe risk of stroke and myocardial infarction associated with G A is known to

be increased when the diastolic pressure is persistently above 110mmHg.

Local anaesthetic (L A) solutions containing adrenaline (epinephrine) may be

used safely providing that aspirating syringes are used to reduce the

incidence of intravascular injection (which may cause hypertension,

arrhythmia or trigger angina in susceptible patients).

Treatment� Blood pressure should be controlled before sedation/G A for elective

treatment and patients should continue to take their antihypertensive drugs

up to and on the day of sedation/G.A .

� Blood pressure should be monitored during treatment involving conscious

sedation techniques.



Cardiac failure

Diuretics are the usual treatment. Cardiac failure should be controlled before

sedation/G A.

Exercise tolerance gives useful information about the severity of the disease.

Arrhythmias

The patient may give a history of palpitations or have irregular pulse, but

arrhythmias are only diagnosed accurately from an electrocardiogram.

Treatment

� Arrhythmias should b e controlled before sedation/G.A, for example atrial

fibrillation treated with digoxin.

�Additional monitoring and supplemental oxygen therapy are required when

using conscious sedation techniques.

Angina and myocardial infarction

About 5% of patients have a myocardial infarction during G A if they have

already had a myocardial infarction in the past. The death rate of myocardial

infarction associated withG A is 50%.

G A is particularly dangerous for

patients who have had an infarction in the previous 6 months. Angina should

be controlled before sedation/G A.

L A solutions containing adrenaline (epinephrine) may be used safely.

Aspirating syringes are recommended to reduce the incidence of

intravascular injection, which may theoretically lead to an increase in

hypertension.

Treatment

Preoperative glyceryltrinitrate should be considered for patients with angina

receiving treatment under L A. Patients m ay be treated using conscious

sedation techniques but require additional monitoring and should receive

supplemental oxygen therapy.

dental management of the cardiologically compromised patient

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