Dental management of cardiac patients

1. Dental management of
cardiac patients
1

2. Intended Learning objectives (ILO’s)
• Recognize systemic diseases that need special
consideration before dental treatment.
• Collect data from patient to determine his
systemic problems.
• Differential diagnosis between cardiac &
cardiovascular diseases.
• Decide dental management for patients with
cardiovascular diseases.
2

3. ClassifiCation of PhysiCal status
ASA I : A patient without systemic disease; a normal,
healthy patient
ASA II : A patient with mild systemic disease
ASA III : A patient with severe systemic disease, that
limits activity, but is not incapacitating
ASA IV : A patient with incapacitating systemic disease,
that is a constant threat to life
ASA V : A moribund patient not expected to survive
24 hours with or without surgery
ASA E : Emergency operation of any kind, E precedes
the ASA number, indicating the patient’s
physical status
3

4. (1) modifying routine treatment plans by anxiety
reduction measures, pharmacologic anxiety
control techniques, more careful monitoring of the
patient during treatment, or a combination of these
methods (this is usually all that is necessary for
ASA class II);
(2) obtaining medical consultation
for guidance in preparing patients to undergo
ambulatory oral surgery (such as by preoperative
administration of oxygen and nitroglycerin for
patients with angina);
(3) refusing to treat the patient in the ambulatory
setting;
(4) referring the patient to an oral and maxillofacial4

5. Preoperative Investigations
1. Chest radiograph—Posteroanterior view
2. Electrocardiogram
3. Echocardiogram
4. Stress test
5. Blood investigations like lipid profile and
bleeding time, clotting time and prothrombin
time and index
6. (INR), in case the patient is on long term
anticoagulants.
5

6. Classification of cardiac diseases
Ischemic heart disease
1. Angina pectoris
2. Myocardial infarction
Non ischemic heart disease
1. Valvular diseases
2. Congestive heart failure (Left
ventricular dysfunction)
6

7. Ischemic heart disease
Coronary Artery Disease
• Myocardial ischemia will occur when the supply
of oxygen is inadequate to meet the demand for
oxygen.
• Myocardial oxygen need is increased when the
heart has increased rate or mass.
7

8. Etiology
Controllable
High blood pressure
High blood cholesterol
Smoking
Obesity
Physical inactivity
Diabetes
Stress*
Uncontrollable
Gender
Heredity (family history of CHD)
Age
8

9. Ischemic heart disease Coronary
Artery Disease
If the coronary arteries are critically narrowed by
fixed atheromatous lesions and/or spasm.
The blood supply (Oxygen) will be decreased to the
myocardium.
Symptoms of ischemia will occur and the heart may
respond with pain called Angina.
9

10. • The pain is usually felt in the chest or
sometimes in the left arm and shoulder.
(However, the same inadequate blood
supply may cause no symptoms, a condition
called silent angina.)
10

11. Myocardial infarction
Same management as
angina pectoris
However, dental TTT
should be postponed
for 6 months as much
as possible.
11

12. Dental management of ischemic
heart disease
Physician consultation.
Stop anticoagulants.
Nitroglycerin to be taken in the regular doses &
extra dose just before dental TTT.
Stress reduction protocol.
Return to anticoagulants after stopping of bleeding
due to dental surgery.
What about antibiotics?
12

13. • Some clinicians also advise giving no more
than 4 mL of a local anesthetic solution with a
1:100,000 concentration of epinephrine for a
total adult dose of 0.04 mg in any 30-minute
period.
13

14. 14

15. Treatment of angina attack
– Terminated dental treatment
– Sublingual nitroglycerin
– Make patient comfortable
– 100% oxygen
– Give nitroglycerin again if needed in 5 minutes up
to 3 tab.
15

16. Protocols for Treating the Patients on
Anticoagulants
1. Proper history—drug dosage, status of medical condition,
PTR and INR level. Proper antibiotic cover.
2. Schedule the appointment within 2 days, once desired
range of PTR and INR
A. PTR 1.5 to 2 and INR 2.0 to 3.0—do not stop or alter the drug
dosage
B. PTR 2.0 to 2.5 and INR 2.5 to 3.5—dosage may be altered
C. PTR > 2.5 and INR > 3.5—delay invasive procedure, until
dosage is decreased. Physicians should be consulted regarding
the dosage modification.
16

17. status of PTR and INR on the day of surgery.
5. Use atraumatic surgical technique. Control
postoperative bleeding by local measures.
6. Patients anticoagulant dosage can be
regulated back
in 48 to 72 hours in consultation with physician.
17

18. Non ischemic heart disease
• Valvular diseases
• Congestive heart failure
(left ventricular dysfunction).
Diseased cardiac valves pose two general risks:
*Precipitation of Cardiac failure
* Susceptibility to infective endocarditis.
18

19. 19

20. Infective Endocarditis
microbial infection of heart valves or
endocardium
20

21. Infective bacterial endocarditis
High-Risk Category: Prophylaxis Recommended;
Prosthetic cardiac valves
Previous infectious endocarditis
Complex cyanotic congenital heart disease
Moderate-Risk Category : Prophylaxis
Recommended;
Most other congenital malformations
Acquired Valvular dysfunction
Hypertrophic cardiomyopathy
Mitral valve prolapse with Valvular regurgitation.
21

22. Infective bacterial endocarditis
Negligible-Risk Category:
Prophylaxis NOT Recommended;
Coronary artery bypass graft
Mitral valve prolapse without regurgitation
Physiologic, functional, or innocent heart murmur.
Previous rheumatic fever without Valvular
dysfunction
22

23. Infective endocarditis
Oral Procedures in which Prophylaxis is
NOT Recommended;
Routine local anesthetic injection
Intra-canal endodontic therapy
Suture removal
Taking impressions
23

24. Preventative / Precautions:
1. Good oral hygiene.
2. Proper teeth cleaning, clorhexidine rinse prior to extractions to
decrease magnitude of possible bacteremia's.
3. Gingivitis, and, especially, periodontitis, increases the
frequency, intensity, and duration of bacteremia's.
4. Stress to the patient that they should take their prophylactic
antibiotic medication within the proper timeframe.
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25. Antibiotic Regimen for Prophylaxis of Infectious Endocarditis
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26. Rheumatic fever
is an inflammatory disease that can
develop as a complication of
inadequately treated strep throat or
scarlet fever. Strep throat and scarlet
fever are caused by an infection with
streptococcus bacteria
26

27. Rheumatic Fever –
Rheumatic Heart Disease
Considerations
– RHD presents risk of endocarditis
– RF without RHD - no medication needed
• General management
– Physician referral / consultation, ask for:
• echocardiogram results
• ECG (electrocardiogram or EKG)
• CXR (chest x-ray)
• Physical exam results
– Antibiotics
– Consider clorhexidine rinses pre-op
27

28. • Case Presentation
75 year female
patient with history
of RF over 30 years
ago with current
heart murmur but
no regurgitation.
MD stated no
antibiotics needed
28

29. There are no special
recommendations for
management treat her in a
routine manner for
restorative and other dental
needs.
Prosthetic valve disease;
Anticoagulants
Antibiotic (Same as
endocarditis)
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30. Heart Murmurs
• Considerations
– Organic disease is a problem
– Functional murmurs are NOT a problem
– Mitral Valve Prolapse with regurgitation is a
problem
• General Management
– Physician referral / consultation, ask for:
• echocardiogram results
• ECG (electrocardiogram or EKG)
• CXR (chest x-ray)
• Physical exam results
– Antibiotics according to American Heart Association
(AHA) 30

31. Heart Murmurs
Other Management Aspects
– Functional murmurs - no medication
– Pathologic murmurs - medicate according to AHA
– No treatment plan modifications
– No oral complications
– Childhood and pregnancy murmurs - no meds
– Medicate if unable to confirm nature of murmur ?
American Heart Association = AHA
31

32. Congestive heart failure (CHF)
Symptoms suggesting congestive heart failure
include dyspnea on exertion, paroxysmal
nocturnal dyspnea (PND), night-time cough,
and ankle swelling (pitting edema).
TTT;
Digitalis
Physician consult
32

33. What are the different classes of
drugs used in the treatment of
heart failure?
• Diuretics
• ACE
• Calcium channel blockers
• Beta blockers
• Digitalis
33

34. What are acidosis and alkalosis?
• Acidosis is the metabolic state when only
excessive quantltIes of metabolic acids are
produced or when the buffering systems or
renal function are abnormal.
• Alkalosis occurs when there is excessive
ingestion of a base (e.g., bicarbonate) or a
loss of excess acid (e.g ., hypovolemia,
vomiting).
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35. Mention causes of respiratory
acidosis?
• Chronic obstructive pulmonary disease (COPD)
• Chest wall or airway injury
• Drug effects
• Pulmonary edema • Central nervous system
(CNS) depression
• Cardiac alTest • Extreme obesity (e.g.,
pickwickian syndrome)
• Pneumonia
35

36. Treatment of angina attack
– Terminated dental treatment
– Sublingual nitroglycerin
– Make patient comfortable
– 100% oxygen
– Give nitroglycerin again if needed in 5 minutes up
to 3 tab.
36

37. Treatment of angina attack
– Terminated dental treatment
– Sublingual nitroglycerin
– Make patient comfortable
– 100% oxygen
– Give nitroglycerin again if needed in 5 minutes up
to 3 tab.
37

38. General Management
– medical consultation
– antibiotics required according to AHA
– avoid dehydration in CHF patient
– pre-op bleeding time, PT/INR, PTT
– CBC with differential & platelets count.
– stress-free appointments, often short in CHF patient.
American Heart Association = AHA
38

39. Other Management Aspects
– treatment plan modifications can vary significantly
– oral complications include:
• cyanosis (blue color)
• polycythemia (ruddy color), anemia (pale color)
• thrombocytopenia (petechiae)
• leukopenia
– avoid ASA, NSAID’s etc.
– in emergency treat with antibiotics, avoid surgery if
possible
until care defined by physician 39

40. Cardiac arrhythmia & pace maker
• Avoid dental ultrasonic scaler
• Physician consult
40

41. Hypertension
41

42. hypertension
Hypertension is considered to be the elevation of the
blood pressure greater than 140/90 mm of mercury.
Uncontrolled hypertension can have the following
surgical and anesthetic complications:
1. It reflects on the cardiac status of the patient,
thereby
increasing the anesthetic risk to the patient.
2. It causes excessive bleeding from the operation site,
thereby complicating the surgical procedure, as
well as significant blood loss for the patient.
42

43. Hypertensive patients
Blood Pressure
Category
Systolic (mm
Hg)
Diastolic (mm
Hg)
Normal less than 120
and
less than 80
Pre-
hypertension
120 – 139
or
80 – 89
High Stage
I
140 – 159
or
90 - 99
High Stage
II
160 or higher
or
100 or higher
43

44. Dental Management
• Stress and anxiety reduction
• Avoid sudden changes in chair position, sit
patient up slowly at the end of the procedure
(orthostatic hypotension)
• Avoid gag reflex
• Monitor vital signs
• Avoid vasoconstrictors
44

45. Preoperative Investigations
1. Chest radiograph—posteroanterior view for
detecting cardiac enlargement
2. ECG
3. USG of the kidneys
4. Ophthalmic evaluation for papilledema and
retinalhemorrhage
5. Renal function tests (blood urea nitrogen, serum
creatinine and serum electrolyte).
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46. 5-The Dental treatment for a
patient on dialysis should be
performed:
a) On the day of dialysis.
b) On the day between dialysis
appointments.
c) Without respect to dialysis time.
d) None of the above.
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47. 16- Which valve is unique in having
a different number of cusps than
the others
a) Mitral valve
b) Tricuspid valve
c) Pulmonary semi lunar valve
d) aortic semi lunar valve
47

48. 17- The thick ascending limb of
Henle is called the * diluting
segment* because :
1-NaCL is reabsorbed with a proportional amount of water
2-water is reabsorbed from the tubular lumen
3-water is secreted into the tubular lumen
4-NaCL is reabsorbed without water
5-NaCL is reabsorbed and water is secreted
48

49. 18------- Is the best overall
index of the kidney function:
a) CPR
b) TFR
c) APR
d) GFR
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