Cardiovascular diseases & Dental Management

CARDIOVASCULAR
DISEASES
Dr.Priyanka Sharma
1st year MDS
Dept of Public Health Dentistry
1

CONTENTS
1) Introduction
2) Diagnosis of Cardiovascular
diseases
3)Causes of cardiovascular diseases
4) Hypertension
5) Coronary Artery Diseases ( ischemic)
2

6) Angina pectoris
7) Myocardial Infarction
8) Rheumatic fever
9) Rheumatic heart diseases
10) Heart Failure
11) Cardiac Arrhythmia
12) Oral Health Consideration & Oral Manifestation
13) Oral Procedures & Need For Antibiotic Prophylaxis
To Minimise Risk Of Bacterial Endocarditis
3

14) Pregnancy and cardiovascular diseases
15) Congenital Cardiovascular diseases
16) Studies involving cardiovascular diseases
and dentistry
15) Summary & Conclusion
15) References
4

Introduction
 Cardiovascular diseases (CVD) comprise of a group of
diseases of heart and the vascular system.
 30.5% of all deaths takes places globally according to the
global and regional estimates for 2008.
 Compared with all other countries, India suffers the
highest loss, due to dealths from CVD in people aged 35-64
years.
 The prevalence of CVD is 2-3 times more in urban than
rural.
5

On the Indian subcontinent and in Africa, it is
predominantly due to rheumatic fever, whereas
calcific aortic valve disease is the most common
problem in developed countries.
 With over 3 million deaths owing to CVD
every year, India is set to be the “ HEART
DISEASE CAPITAL OF THE WORLD” in
few years, said doctors on the eve of WORLD
HEART DAY (Sept. 29th 2010).
6

Prompt recognition of the development of
heart disease is limited by two key factors:
1) Firstly, it is often latent.
2) Secondly, the diversity of symptoms
attributable to heart disease is limited.
7

CVD
Hypertension
Coronary Artery
Disease
Myocardial
Infarction
Acute coronary
Syndrome
Rheumatic heart
disease & fever
Cardiac Arrythmia
Angina Pectoris
Stroke
Congenital CV
Disease
Congestive Heart
Failure
8

DIAGNOSIS
OF
CARDIOVASCULAR
DISEASE
9

SCHEME OF HISTORY TAKING
1) Symptoms and history of presenting illness
2) Past history
3) Family History
4) Personal History
10

SYMPTOMS AND HISTORY OF
PRESENTING ILLNESS
1. Dyspnoea
2. Chest Pain
3. Palpitation
4. Syncope
5. Cough With Expectoration And Haemoptysis
6. Cyanosis
11

7. Right Hypocondrial Pain, Swelling Of Feet And
Decrease In The Urine Output
8. Gastrointestinal Symptoms Like Anorexia,
Fullness Of Abdomen And Vomiting
9. Fatigability
10. Fever
11. Diabetes Mellitus And Hypertension 12

PAST HISTORY
1. Rheumatic Fever
2. Cyanotic Spells
3. Recurrent Respiratory Infections Since Childhood
4. Detection Of Murmur/Cardiac Lesion At School
5. Recent Dental Extraction, Genitourinary
Instrumentations
6. Hypertension, Diabetes Mellitus, Ischaemic Heart
Disease Or Any Other Significant Medical Illness
7. Nifedipine- Gingival Hyperplasia
13

FAMILY HISTORY
1. Hypertension
2. Ischaemic Heart Disease
3. Congental Heart Disease
4.Rheumatic Heart Disease
5. Sudden Death
14

PERSONAL HISTORY
1. Appetite
2. Weight Loss
3. Disturbed Sleep
4. Bowel And Bladder Disturbances
5. Habits- Smoking And Alcoholism
6. Exposure To Syphilis
15

APPROACH TO A
PATIENT OF CARDIAC
DISEASE
16

ANALYSIS OF PRESENTING
SYMPTOMS
DEFINITION:-
 Abnormal awareness of breathing with discomfort.
 Dyspnoea is a significant manifestation of cardiac
failure.
 Dyspnoea is more commonly due to left-sided
cardiac failure than due to right heart failure.
17

SEVERITY (GRADING) :
FUNCTIONAL GRADING OF DYSPNOEA
GRADE I : No limitationn of any physial activity but
dyspnoea occurs on more than ordinary (unoccustomed)
exertion.
GRADE II: Dyspnoea on ordinary daily activity
GRADE III : Dyspnoea on less than ordinary daily
activities.
GRADE IV : Limitations of all activities( dyspnoea at rest)
18

Mechanism underlying dyspnoea :
During Heart Failure  Interstitial pulmonary
edema  stimulates the J receptors  reflex 
rapid and shallow breathing.
Respiratory muscle fatigue
Bronchial mucosal edema
Increased bronchial mucosal production
19

 Paroxysmal Nocturnal Dyspnoea (PND)
 This is an attack of severe shortness of breath and
coughing usually occurring at night.
 Awakening the patient from sleep.
 Persist after sitting upright.
 May be due to depression of the respiratory centre at
night.
 Reduced adrenergic stimulation to the myocardium
at night.
20

Definition:
 Dyspnoea that occurs usually on lying down/ recumbent position.
Characteristic features:
 Usually occurs within minutes of assumption of recumbency.
 Occurs when a patient is awake.
 Indicates the presence of severe left heart failure (pulmonary
oedema).
 Manifests later than PND. (in slowly progressive left heart disease).
21

 Dyspnoea occurs on sitting (upright) rather than on
lying down position.
 Example: left atrial myxoma, left atrial ball valve
thrombus.
22

Occurs on breathlessness only when lying down
in lateral/decubitus position.
May be due to ventilation perfusion relationship
alteration in certain body position.
Occur in patients with pathology of one lung
and chronic congestive heart failure.
23

There is severe periods characterised by alternating
hypopnoea and hyperpnoea follwed by periods of
apnoea sign of severe heart failure.
The patient lies motionless for 10-20 seconds and
again the cycle is repeated.
Conditions associated : HF, Increased intracranial
pressure, Uraemia, Severe pneumonia, Chronic
hypoxia, Narcotic drug poisoning, Cerebral trauma
and haemorrhage, Normal subjects living at high
altitudes. 24

 Bluish dicoloration of skin and mucous membrane.
 Resulting from increased amount of reduced
haemoglobin.
 Cyanosis appearing in infancy indicates the presence of
congenital cardiac anomalies with right to left shunt
(teratology of fallot).
 Cyanosis beginning to appear after 6 weeks of age may be
an indication of VSD with slowly progressive right
ventricuar outflow obstruction.
 History of cyanosis in a suspected patient of congenital
heart disease between the age of 5-20 years indicates
reversal of left to right shunt (Eisenmeger Syndrome). 26

 Right heart failure causes systemic venous
congestion with increased hydrostatic
pressure in the lower limb veins. This results
in the transudation of fluid causing edema.
 Ankle edema is more common in ambulatory
patients. Bed-ridden patient develop sacral
edema.
28

 This is due to enlarged and congested liver and stretching
of its capsule, as in congestive heart failure.
 Cardiac pain may occasionally present as upper
abdominal pain.
 Pain from a dissecting abdominal aortic aneurysm is
usually most marked in the back and may originate in the
chest and spread down the legs. Other arteries can have
aneurysms and bleed.
29

 In the presence of cardiac failure due to decreased cardiac
output, renal blood flow decreases with decrease in the
glomerular fitration rate, this causes decrease of urine
output in patients with cardiac failure.
 Transient loss of consciousness with postural collapse.
 Expectoration (coughing up) of blood or of blood-
stained sputum.
 Suggests uncomfortable awareness of heartbeat, which
may be unpleasant.
30

EXAMINATION
OF
CARDIOVASCUAR
SYSTEM
31

1) General examination
2) External markers of cardiac disease
3) Examination of peripheral cardiovascular
system
4) Examination of precordium
5) Examinations including various other signs
6) Examinations of face
7) Examinations of mouth
8) Examinations of ear
9) Examinations of eyes
10)Examinations of fingers 32

GENERAL EXAMINATION
1. Build
2. Nourishment
3.Pallor
4.Cyanosis
5. Clubbing
6. Jaundice
7. Pedal Odema
8. Lymphadenopathy
33

PALLOR
 Severe anemia may be associated with:
1. Chronic CCF
2. Infective endocarditis
 Severe anemia can itself cause- cardiac failure or
aggravate the underlying heart disease.
 Patients with cyanotic congenital heart disease may
have polycythemia with suffused conjunctiva.
34

CYANOSIS
 Central cyanosis occurs in:
[Decreased atrial oxygen saturation]
1. Cyanotic congenital heart disease
2. Reversal of left to right shunt (Eisenmenger’s syndrome)
3. Tetralogy of Fallot
4. Pulmonary edema (left heart failure)
 Peripheral cyanosis occurs in:
[Diminished peripheral blood flow = Reduced Cardiac
output]
1. Congenital cardiac failure
2. Peripheral vascular disease
3. Shock 35

Differential cyanosis:
• Feet and toes are blue but hands and fingers are
not cynosed.
• e.g. PDA with pulmonary hypertension with
reversal of shunt.
Reverse differental cyanosis:
• Fingers are more cyanosed than toes.
• e.g. Transposition of great vessels with
pulmonary hypertension with preductal
coarctation with reversed flow through PDA.
36

CLUBBING
CARDIAC CAUSES:
1. Cyanotic congenital heart disease
2. Reversal of left to right shunt
3. Infective endocarditis
 Clubbing of fingers also known as drumstick fingers and watch-glass nails.
 Clubbing develops in five steps:
1) Fluctuation and softening of the nail bed.
2) Loss of the normal <165° angle (Lovibond angle) between the nailbed and the
fold (cuticula).
3) Increased convexity of the nail fold.
4) Thickening of the whole distal (end part of the) finger (resembling a
drumstick).
5) Shiny aspect and striation of the nail and skin. 37

JAUNDICE
Following cardiac conditions may be associated
with jaundice:
1. Congestive cardiac failure with congestive
hepatomegaly
2. Cardiac cirrhosis
3. Pulmonary infarction
38

PEDAL EDEMA
Pitting edema of feet can occur in:
1. congestive cardiac failure
2. constrictive pericarditis
3. tricuspid valve disease
LYMPHADENPATHY
 Condition associated with generalized
lymphadenopathy may involve the
cardiovascular system.
 e.g. lymphoma, SLE etc.
39

EXTERNAL MARKERS OF
CARDIAC DISEASE
VITAL SIGNS
• Pulse
• Blood Pressure
• Respiratory Rate
• Temperature
RADIAL PULSE
• Rate
• Rythm
• Volume
• Character
40

EXAMINATION OF
• The Carotids & Jugular Venous Pulse And
Pressure
• Peripheral Signs Of Infective Endocarditis
• Peripheral Signs Of Rheumatic Fever
41

EXAMINATION OF THE PRECORDIUM
INSPECTION
1. Precordial Bulge
• Position Of Apical Impulse
Pulsations In The:-
A. Left Parasternal Region
B. 2nd Left Intercostal Space
C. 2nd Right Intercostal Space
D. Epigastric Pulsation
E. Suprasternal Pulsation
F. Engorged Veins Over The Chest
G. Spine(kyphoscoliosis)
45

PALPATION
• PERCUSSION
1) Right Cardiac Border
2) Left Cardiac Border
3) Left And Right 2nd
Intercostal Space.
46

AUSCULTATION
• Mitral, Tricuspid, Aortic, Pulmonary And
Other Additional Areas For:-
A) 1st And 2nd Heart Sounds
B) Additional Sounds
C) Murmurs
47

EXAMINATION OF FACE
Following Features May Be Indicative Of Underlying Cardiac
Abnormality While Examination Of Face :
ABNORMALITIES CLINICAL
MANIFESTATIONS
CONDITIONS
ASSOCIATED
ELFIN FACIES Receding jaws,
Flared nostrils,
Pointed ears
Supraventricular
aortic stenosis
HIGH ARCHED
PALATE
Marfan syndrome
MITRAL FACIES Malar flush and
pinkish purple
patches over the
cheek
Mitral stenosis with
decreased cardiac
output and Systemic
vasoconstriction
48

MALAR FLUSH
MARFAN
SYNDROME
TERATOLGY OF
FALLOT
49

Acute macroglossia:
The tongue is diffusely enlarged and
bright red along its lateral portion. The
patient had bleeding into the tongue
while on anticoagulants.
Acute macroglossia
Due to Enalapril: this 75-year-old Black female
developed acute swelling of tongue and lips after
being on enalapril for 2 days. She was unable to talk
or swallow (upper photo).
In lower photo, 2 days after stopping enalapril, the
tongue and lips have returned to their normal size.
EXAMINATION OF MOUTH
50

GUM HYPERPLASIA
Due to dilantin. similar findings
may be seen in patients on
nifedipine
TANGIER DISEASE OF THE
TONSILS:
The tonsils are enlarged with
bright orange yellow streaks
(“tiger stripes”) (premature cad).
51

EXAMINATION OF EYES:
• Exopthalmus: associated with thyroid artery
disease.
• Blue sclera: Osteogenesis imperfecta with aortic regulation.
• Opthalmic fundus: looks for
a. Arteriosclerotic changes
b. Hypertensive retinopathy
c. Roth’s spots( of infective endocarditis)
d. Cork screw arteries- coarctation of aorta.
BLUE SCLERA
ROTHS SPOT
52

EXAMINATION OF FINGER
CLUBBING
CLUBING
NEGATIVE
53

OSLERS NODE IN ENDOCARDITIS
SUBUNGAL HAEMORRHAGES
JANEWAY LESIONS
54

CAUSES
OF
CARDIOVASCLAR
DISEASE
55

1. MYOCARDIAL
A. Overload Secondary To Hypertenson Or Valve
Disease
B. Coronary( Ischaemic) Heart Disease
C. Cardiomyopathies
2. ENDOCARDIAL
A. Rheumatic Heart Disease
B. Congenital Anomalies
C. Infective Endocarditis
3. PERICARDIAL
A. Pericarditis
B. Pericardial Effusion
C. Functional Disorders
56

 DUE TO HYPERTENSION
 DUE TO ABNORMALITIES IN HEART RATE
A. Tachycardia
B. Bradicardia
C. Other Dysrthymias
 CHANGES IN CIRCULATORY VOLUME
A. Hypovoloemia (Shock Syndrome)
B. Hypervolaemia ( Circulatory Overload)
C. Others
 CONGENITAL ABNORMALITIES :
1) Patent ductus arteriosus
2) Ventricular septal defect
3) Arterial septal defect
4) Tetralogy of Fallot , etc. 57

NYHA CLASSIFIACTION
FUNCTIONAL CAPACITY
OBJECTIVE
ASSESSMENT
CLASS I. Patients With Cardiac Disease But Without Resulting
Limitation Of Physical Activity. Ordinary Physical Activity
Does Not Cause Undue Fatigue, Palpitation, Dyspnea, Or
Anginal Pain.
A. No Objective
Evidence Of
Cardiovascular
Disease.
CLASS II. Patients With Cardiac Disease Resulting In Slight
Limitation Of Physical Activity. They Are Comfortable At
Rest. Ordinary Physical Activity Results In Fatigue,
Palpitation, Dyspnea, Or Anginal Pain.
B. Objective Evidence
Of Minimal
Cardiovascular
Disease.
CLASS III. Patients With Cardiac Disease Resulting In Marked
Limitation Of Physical Activity. They Are Comfortable At
Rest. Less Than Ordinary Activity Causes Fatigue,
Palpitation, Dyspnea, Or Anginal Pain.
C. Objective Evidence
Of Moderately
Severe
Cardiovascular
Disease.
CLASS IV. Patients With Cardiac Disease Resulting In Inability
To Carry On Any Physical Activity Without Discomfort.
Symptoms Of Heart Failure Or The Anginal Syndrome May
Be Present Even At Rest. If Any Physical Activity Is
Undertaken, Discomfort Is Increased.
D. Objective Evidence
Of Severe
Cardiovascular
Disease.
58

CONTENTS OF HYPERTENSION
 Definition
 Classification
 Types
 Other risk factors
 Effects of hypertension
 Complications
 Symptoms
 Oral manifestations
 Diagnosis
 White coat hypertension
 Dental management
 Treatment of hypertension
 Oral medications used
 Conclusion 60

HYPERTENSION
Hypertension is known as Silent Killer of mankind.
Most of the sufferers (85 %) are asymptomatic and
hence early diagnosis is a problem.
 Normal or optimal blood pressure (BP) is defined as
the level above which minimal vascular damage
occurs. There is a continuous, consistent, and
independent relationship between elevated BP and risk
of cardiovascular events.
61

Definition
• Hypertension is usually defined by the presence of a chronic
elevation of systemic arterial pressure above a certain threshold
value.*
• According to Davidson :
• Hypertension is defined as having systolic blood pressure (SBP)
>/= 140mm of Hg .
(or)
Diastolic blood pressure (DBP) >/= 90mm of Hg.
(or)
As having to use antihypertensive medications.
* Thomas D. Giles et al.Definition and Classification of
Hypertension: An Update ; Emerging concept : 2009,
11:611–614.
62

CLASSIFICATION
The Seventh Joint National Committee Criteria
(JNC VII) classifies hypertension for adults aged
18 years and older into following stages:
Blood Pressure Classification SBP(mm Hg) DBP(mmHg)
•Normal <120 & <90
•Pre hypertension 120-139 & 80-89
•Stage I hypertension 140-159 & 90-99
•Stage II hypertension >/=160 & >/=100
•Isolated Systolic hptn. >140 & <90
63

• “For individuals 40-70 years of age, each increment of
20 mmHg in systolic BP or 10 mmHg in diastolic BP
doubles the risk of CVD across the entire BP range
from 115/75 to 185/115 mmHg”. [JNC VII. JAMA
2003;289:2560-2572 ]
Classification according to WHO
• Grade I: Hypertension without damages to the end
organ.
• Grade II: Hypertension with damages to the end
organ (e.g.. fundus hypertonicus (Grade I and
II), plaque formation in the larger blood vessels)
• Grade III: Hypertension with
manifest cardiovascular secondary diseases
(e.g. angina pectoris,heart attack, stroke)
64

TYPES
PRIMARY (or)
ESSENTIAL
HYPERTENSION
• Which develops
gradually over many
years & has no
underlying cause.
• 90% of people have this
type of hypertension
SECONDARY
HYPERTENSION
• Which has an
underlying cause such as
renal disorders, endocrinal
disturbances, neurologic
causes etc.
• 10% of people have this
type of hypertension.
65

Other Risk Factor of Hypertension
•Lack of exercise
•Increased salt intake
•Family history
•Too little potassium
•Alcohol
•Smoking
•Stress &
•Age
66

Effect of Hypertension
The common target organs damaged by long
standing hypertension are:
•Brain
•Heart
•Kidneys
•Eyes &
•Peripheral arteries.
67

Complications of hypertension
Left ventricular hypertrophy
Heart failure
Cerebral hemorrhage
Renal insufficiency
Aortic dissection
Atherosclerotic disease
68

Symptoms
Symptoms due to hypertension:
1. Headache - usually in morning hours.
2. Dizziness
3. Epistaxis
Symptoms due to affect over target organs:
1. CVS:
a. Dyspnea on exertion
b. Anginal chest pain
c. Palpitations
69

2. Kidneys: Hematuria , nocturia , polyuria .
3.CNS:
a. Transient ischemic attacks ( TIA or Stroke)
b. Hypertensive encephalopathy(headache ,
vomiting etc.)
c. Dizziness, Tinnitus & syncope.
4. Retina:
a. Blurred vision or
b. sudden blindness.
70

Diagnosis
• Physical Examination
• Laboratory and Additional Testing – it includes
Routine laboratory procedures like
hemoglobin, urinalysis, routine blood
chemistries and fasting lipid profile.
• Electrocardiography & Electroencephaloghy
• Ambulatory BP Monitoring
• Plasma renin activity testing
• Radiologic testing
71

WHITE COAT
HYPERTENSION
‘’White coat hypertension’’ is a
phenomenon in which individuals
present with persistent elevated BP
in a clinical setting but present with
non-elevated BP in an ambulatory
setting.
•20% of mild hypertensive
individuals may present with white
coat hypertension.
72

Dental Management
• Measure and record BP at initial visit
73

Recheck :-
•Every 2 yrs for patient with BP <120/80 mm
Hg.
•Every 1 yr for patient with BP 120-139/80-89
mm Hg.
•Every visit for patient with BP >140/90 mm
Hg.
•Every visit for patient with established
coronary artery disease, diabetes mellitus or
chronic renal disease with BP >135/85 mm Hg.
•Every visit for patient with established
hypertension.
Before initiating dental care:
•Assess presence of hypertension
•Determine presence of target organ disease
•Determine dental treatment modifications
74

1. Asymptomatic BP <159/99 mm Hg, no history of target
organ disease
• No modifications needed
• Can safely be treated in dental setting
2. Asymptomatic BP 160-179/100-109 mm Hg, no history of
target organ disease
• Assessment on an individual basis with regard to type of dental
procedure BP>180/110 mm Hg, no history of target organ disease
• No elective dental care until BP is controlled.
3. Presence of target organ disease or poorly controlled
diabetes mellitus
• No elective dental care until BP is controlled , preferable below 140-90
mm Hg.
75

TREATMENT OF HYPERTENSION
Non Pharmacological Treatment
Lifestyle Modifications
1. Salt restriction
2. Weight reduction
3. Stop smoking
4. Diet modifications such as:
• Reduce intake of Cholesterol &
Saturated fat.
• Adequate intake of Calcium &
Magnesium.
76

77
5.Avoid / Limit of alcohol intake
6. Relaxation such as yoga, psychotherapy etc.
7. Regular exercise.

ORAL MEDICATIONS USED FOR
TREATMENT OF HYPERTENSION
•Diuretics
•Beta-Adrenergic Blockers
•Central Acting Inhibitors
•Peripheral Acting Inhibitors
•Non-Selective alpha & beta Adrenergic
Inhibitors
•Vasodilators
•Angiotensin Converting Enzyme ACE
Inhibitors
78

ORAL MANIFESTATION OF
HYPERTENSION
There are no recognized manifestations of
hypertension but anti-hypertensive drugs can often
cause side affects ,such as:
•Xerostomia,
•Gingival overgrowth,
•Salivary gland swelling or pain,
•Lichenoid drug reactions,
•Erythema multiforme,
•Taste sense alteration,
•Paresthesia.
79

CONCLUSION
• HYPERTENSION has no cure, but it can be
controlled with proper diet, lifestyle changes,
and if necessary medications.
• Get regular health check ups. Think about the
consequences of untreated high blood pressure.
• Do not take chances with the disease that can be
controlled.
• Lastly, Hypertension is a silent disease, but its
silence is not golden.
80

CORONARY
(ISHAEMIC) ARTERY
DISEASE
81

Coronary artery diseases
1) Etiopathogenesis
2) Risk factors
3) Diagnosis
4) Management
5) Dental aspects
82

• Atherosclerosis is the most common cause of
CAD
ETIOPATHOGENESIS
Various risk factors include:
1. lipids (especially HDL)
2. hypertension
3. diabetes mellitus & glucose intolerance
4. cigarette smoking
5. lifestyle & dietary factors
6. exercise
7. obesity 83

8. plasma fibrinogen
9. endothelial dysfunction
10. antioxidants
11. estrogen deficiency
84

RISK FACTORS
Induce variety of pathological processes
Interaction & disruption of vascular endothelium
Plaque formation
Effective arterial luminal area compromised
Myocardial ischaemia acute plaque rupture
thrombus formation
angina
M I
85

DIAGNOSIS
1) Based on clinical presentation :
 chest tightness
 Jaw discomfort
 Left arm pain
 Dyspnea
 Epigastric distress
2) E.C.G.
3) Exercise E.C.G.
4) Coronary Angiography
5) P.C.I.(Percutaneous Coronary Intervention)
6) In case of complications like stroke/ shock – EEG
7) Recent development : One minute angiogram 88

MANAGEMENT
Management of CAD depends on:
• Extent and severity of ischemia
• Exercise capacity
• Prognosis based on exercise testing
• Overall LV function
• Associated features such as diabetes mellitus
 Patients with a small ischemic burden, normal exercise
tolerance, and normal LV function may be safely treated
with pharmacologic therapy.
 Selected use of aspirin, β-blockers, ACEIs, and
HMG CoA reductase inhibitors.
 Nitrates and calcium channel blockers may be added
to primary agents to relieve symptoms of ischemia in
selected patients.
89

• SURGICAL
MANAGEMENT:
 Percutaneous coronary
intervention (PCI) with
percutaneous transluminal
coronary angioplasty
(PTCA) and intra coronary
stenting relieves symptoms in
chronic ishchemia.
90

• Patient with complex
multivessel CAD require
PCI with medical therapy
of surgical
revascularization.
• Patients with reduced LV
function and severe
ischemia, often associated
with left main or
multivessel CAD, are best
served by coronary artery
bypass graft (CABG)
surgery.
91

DENTAL ASPECTS
• STRESS, ANXIETY, EXERTION or PAIN
can provoke angina.
• Short, minimally stressful dental appointments.
• Late morning appointments.
• Excessive dose of LA containing adrenaline to
be avoided in patients taking beta blockers.
• More Common - severe dental caries and
periodontal disease in pts of IHD.
92

• Name given to paroxysms of severe chest pain
CLINICAL FEATURES
1) 40 TO 60 years , M > F
2) Pain often described as sense of Strangling, choking ,
Tightness, Heaviness ,Compression, or Constriction of
chest.
3) PAIN MAY RADIATE TO JAW or left arm.
4) Rarely pain in mandible, teeth or other tissues.
PRECIPITATING FACTORS
• Physical exertion(main) particularly in cold weather
• Emotion(anger or anxiety) & stress caused by fear or
pain
 TYPICALLY RELEIVED BY REST
94

Dental aspects
 Preoprerative glyceryl trinitrate & oral sedation advised
sometimes.
 Dental care carried with minimal anxiety & oxygen
saturation
 Monitor pulse & B.P.
 POST ANGIOPLASTY elective dental care deffered for 6
months , emergency dental care in a hospital setting.
 Patients with BYPASS GRAFTS – anti biotic cover
against infective endocarditis .
- LA containing adrenaline is
contraindicated (may ppt dysrhythmia)
95

Patients with vascular stents – no antibiotic
cover except during 1st 6 week postop for
emergency dental care.
 DRUGS used in t/t of angina may cause
oral adverse effects like :
-lichenoid reaction Ca channel
- gingival swelling blockers
- ulcers (nicorandil)
96

Gingival
hyperplasia in
patient consuming
Ca channel blockers
97

• Synonyms – coronary thrombosis or heart attack
CLINICAL FEATURES
1. Clinical picture is variable
2. More than 50% patients are symptomless
3. MI may be preceded by angina often felt as indigestion
like pain
4. any anginal attack lasting longer than 30 minutes is
considered MI
5. Tachycardia &irregular pulse
6. Nausea, vomitting, sweating ,restlessness, facial pallor
7. Breathlessness, cough
8. Loss of conciousness, shock & even death
9. Many pts die within 1st hour to few days after attack.
Thus, MI is a MEDICAL EMERGENCY.
99

DIAGNOSIS
I. Based on clinical features
II. Elevated TLC & ESR during 1st wk
III.ECG changes
IV.Rise in serum “cardiac” enzymes ( CPK)
V. Rise in troponin T within 4-8 hours
VI.Echocardiography
101

General Precautions during Dental Procedures
• Dental clinic should have advanced cardiac life support or at
least basic cardiac life support.
• Use of pulse oximeter to determine the level oxygenation.
• Automatic external defibrillator.
• Determination of vital signs prior to dental care.
• BP & pulse rate & rhythm should be recorded & any
abnormal findings should be addressed.
• Premedication with antianxiety drugs and inhalation nitrous
oxide in anxious patients.
• Elective procedures esp those requiring GA should be
avoided for atleast 4 wks aftr MI. consult pt’s physician prior
to dental therapy
102

Management on dental chair
1. Terminate all dental treatment
2. Position pt in semirecline position
3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray
4. Administer oxygen
5. Check pulse & B.P.
Discomfort relieved Discomfort continues 3 mins after 2nd TNG
6. Assume angina pectoris is 6. give 2nd TNG dose
present 7. monitor vital signs.
7. Slowly taper oxygen over
5 mins
8. Modify t/t to prevent recurrence discomfort discomfort
continues
relieved 3 mins after TNG
103

8. give 3rd TNG dose
9. Monitor vitals
10. Call for medical assistance
Discomfort relieved discomfort continues 3 mins after 3rd TNG dose
11. Refer pt for medical 12.assume MI is in progress
evaluation before 13. start i.v. line with drip of a crystalloid
solution
further dental care at 30 mL/ hr
14. If discomfort severe titrate morfine sulphate 2mg s/c or i/v every 3 mins
until relief is obtained
15. Transport to emergency care. Administer Basic Life Support ,if
necessary.
104

Anticoagulation Therapy & Dental Care
• Anticoagulant therapy is used both to treat & to
prevent throboembolism.
• 2 major types : 1. antiplatelet medications
2. antithrombin medications
• Acetylsalicylic acid (ASA) + clopidogrel (
anticoagulant) given for 4 weeks after stent
implantation.
• daily aspirin typically continued lifelong.
• May increase risk of oral bleeding following surgical
procedures.
• Associated conditions which predispose patient to
uncontrolled hemostasis : uraemia or liver diseases or
use of NSAIDS.
• If emergency surgery needs to be done,DDAVP(1-
desamino-8-D-arginine vasopressin) is
administered{0.3 micro kg/body wt parenterally}
within 1 hr of surgery.
105

• Antithrombin medications are dicumarols ( eg.
Warfarin), it inhibits biosynthesis of vit. – K
dependent coagulations protein.
- Efficacy monitored by prothrombin time or the
international normalized ratio (INR), which is
calculated on the basis of international sensitivity
index (ISI).
- INR ranges from 2.0 – 3.5 & it should be performed
within 24 hrs of surgery.
- If INR is < 3.5, anticoagulation therapy should be
discontinued before minor surgical procedures.
106

 3 different protocols used to treat patients with
elevated INR :
• Ist protocol – warfarin not discontinued
(minimizes thromboembolic events & increases
risk of bleeding after surgery).
• IInd protocol – warfarin discontinued (drug should
be discontinued 2-3 days prior to surgery, during
this period patient is at risk of developing
thromboembolic event but not bleeding).
• IIIrd protocol – warfarin discontinued & patient
placed on alternative anticoagulant therapy
(thromboembolic event minimized).
107

• Rheumatic fever is an inflammatory disease
that may develop two to three weeks after a
Group A streptococcal infection (such as strep
throat or scarlet fever). It is believed to be
caused by antibody cross-reactivity and can
involve the heart, joints, skin, and
Brain .
• Acute rheumatic fever commonly appears in
children ages 5 through 15, with only 20% of first
time attacks occurring in adults.
109

• What are the symptoms of strep
throat?
• Sudden onset of sore throat
(streptococcal oropharyngitis)
• Pain on swallowing
• Fever, usually 101–104°F
• Headache
• Red and edematous soft palate and
oropharynx.
• Areas of tonsillar ulceration and
exudation.
• Abdominal pain, nausea and
vomiting may also occur,
especially in children.
111

 What are the symptoms/clinical features of
rheumatic fever?
Symptoms may include:
• fever
• painful, tender, red swollen joints
• pain in one joint that migrates to another one
• heart palpitations
• chest pain
• shortness of breath
• skin rashes
• fatigue
• small, painless nodules under the skin
112

• Minor criteria
• Fever
• Arthralgia
• Laboratory abnormalities: increased
Erythrocyte sedimentation rate
• Electrocardiogram abnormalities
• Evidence of Group A Strep infection:
elevated or rising Antistreptolysin O titre.
114

LAB INVESTIGATIONS
• Raised ESR
• Culture studies of throat
swabs is always negative in
RF.
• High anti sterptolysin
o(ASO)titre-300 micro
units
• Chest radiograph-
enlargement of heart
• ECG-prolonged PR
interval
• Echocardiogram-confirms
ventricular dilatation n
pericardial effusion
115

• TREATMENT :
• Oral phenoxymthyl penicillin 500 mg until
age of 20 yrs.
• Allergic to penicillin,sulfadimidine by
mouth.
• Aspirin for fever and pain 50mg/kg in 4 hrly
doses
• Corticosteroids 60-80mg prednisolone
• Digoxin and diuretics for heart failure
• Ballon valvuloplasty,using inoue balloon,if
mitral valves damage.
116

DENTAL CONSIDERATION
• Dental extractions and local
anesthesia in consent with
physician.
• The prophylactic use of
antibiotics prior to a dental
procedure is now
recommended ONLY for
those patients with the
highest risk of adverse
outcome resulting from
endocarditis.
• GA should be avoided if
essential must be given in
hospital.
117

Rheumatic heart disease :
• History of rheumatic fever during childhood
or adolescence can act as a predisposing
factor for RHD after several years.
• Common signs-murmur due to valvular
damage n later enlargement of heart.
119

ORAL MANIFESTATIONS
• Most prominent during acute
phase
• Pharyngitis
• Inc oral temperature
• Distended neck veins and a
bluish color of the skin.
121

DENTAL CONSIDERATIONS
• To prevent complication of infective
endocarditis ,all dental procedures should be
carried under antibiotic cover.
• Amoxicillin prophylaxis-1 hour before and 6
hours after the initial dose.
• Good oral hygiene measures ,fluoride
treatment, chlorhexidine rinses and routine
cleanings to reduce harmful bacteremias.
122

• Proper history should be taken to identify
history of rheumatic fever during childhood.
• Suspicious cases should be referred to
cardiologist for cardiac evaluation prior to
dental procedures.
• Clindamycin or erythromycin prophylaxis
during dental treatment.
• Elective dental treatment under physician
consultation.
123

HEART FAILURE
• Heart failure (HF) is a
condition in which a
problem with the structure
or function of the heart
impairs its ability to supply
sufficient blood flow to
meet the body's needs .
• Common causes of heart
failure –
• ischemic heart diseases
• Hypertension
• Valvular diseases
125

Left-sided failure(MORE COMMON)
• Failure of the left ventricle causes congestion of the
pulmonary vasculature, and so the symptoms are
predominantly respiratory in nature. The patient
will have dyspnea (shortness of breath) on
exertion and in severe cases, dyspnea at rest.
Increasing breathlessness on lying flat, called
orthopnea.
• Another symptom of heart failure is paroxysma
nocturnal dyspnea also known as "cardiac asthma",
a sudden nighttime attack of severe breathlessness,
usually several hours after going to sleep.
• Inadequate cerebral oxygenation leads to loss of
concentration,restlessness and irritability. 126

Right-sided failure
• Failure of the right ventricle leads to
congestion of systemic capillaries. This helps
to generate excess fluid accumulation in the
body. This causes swelling under the skin
(termed peripheral edema or anasarca)
• If occurs with Mitral stenosis is called
congestive heart failure.
127

• Biventricular failure ,faiure
of one side of heart leads to
failure of other.
CLINICAL FEATURES
• Pedal edema
• Dyspnea
• Congestion of neck veins
• Cynosis
• Fatigue
128

DIAGNOSIS
• Imaging
Echocardiography
• Electrophysiology
electrocardiogram
(ECG/EKG)
• Blood tests
• Angiography
• Monitoring
129

TREATMENT MODALITIES
• Diet and lifestyle measures
• Weight reduction
• Monitor weight
• Sodium restriction -excessive sodium intake may
precipitate or exacerbate heart failure
• Fluid restriction – patients with CHF have a
diminished ability to excrete free water load.
• stress reduction,rest
• Stop smoking
130

Pharmacological management
• Diuretic
• Loop diuretics (e.g. furosemide, bumetanide)
• ACE inhibitor/ Angiotensin II receptor antagonist
Positive inotropes
• Digoxin
• Beta blockers
• Alternative vasodilators
• The combination of isosorbid dinitrate/hydralazine
131

ORAL MANIFESTATIONS
• Distention of the external
jugular viens.
• Compensatory polycythemia
–ruddy complexion and
bleeding tendencies.
• Abnormal production of
clotting factors
• Bleeding can be spontaneous
or extravasational.
132

DENTAL ASPECTS
• The dental chair should be kept in partially
reclining or erect position and patient should be
raised slowly in upright position.
• Emergency dental care should be conservative,
principally with analgesics and antibiotics.
• Appointments should be short
• Non stressful appointments
• Patients are best treated in late morning because of
epinephrine levels peak in early morning.
133

• Bupivacaine should be avoided as it is
cardiotoxic.
• An aspirating syringe should be used to give
local anesthetic
• Epinephrine containing LA should be not
given in large doses to patients taking beta
blockers.
• Gingival retraction cords containing
epinephrine should be avoided
134

• Supplemental O2 should be available
• Rubber dam is contraindicated when it
contributes to breathing difficulty.
• NSAIDS other than aspirin should be
avoided in pts taking ACE inhibitors (renal
damage).
• Erythromycin and tetracycline to be avoided
as they may induce digitalis toxicity
135

• GA is contraindicated in cardiac failure.until under
control (venous thrombosis and pulmonary
embolism)
• ACE inhibitors can sometimes cause erythema
multiforme, angioedema or burning mouth.
• Antibiotic prophylaxis required for dental care.
• History of recent MI ,required delay of elective
dental care for 6 months.
136

CARDIAC ARRHYTHMIA :
• Cardiac arrhythmia (also
dysrhythmia) is a term for
any of a large and
heterogeneous group of
conditions in which there is
abnormal electrical activity
in the heart.
• The heart beat may be too
fast or too slow, and may be
regular or irregular .
• Accordingly there are 2 types
:
1) Atrial arrhythmia
2) Ventricular arrhythmia
138

• TACHYCARDIA : Any heart rate faster
than 100 beats/minute is labelled tachycardia.
• BRADYCARDIAS :A slow rhythm, (less
than 60 beats/min), can lead to syncope.
• HEART BLOCK :Blockage of cardiac
impulse anywhere in the conduction system.
139

TREATMENT
AA :
• Digoxin
• Propanolol
• Quinidine sulphate
• Anticoagulant such as
warfarin
VA :
• Procainamide
• Phenytoin
• Dispyramide
• Propanolol
141

• Physical maneuvers
• Antiarrhythmic drugs
• Electricity
• Electrical cautery
142

ORAL MANIFESTATIONS
• Procainamide can cause
agranulocytosis,oral
ulcerations.
• Quinidine-infrequent oral
ulcerations.
• Disopyramide is
anticholinergic agent capable
of producing xerostomia.
• verapamil,enalapril can cause
gingival hyperplasia.
143

DENTAL
CONSIDERATIONS
• A proper history to be
taken.
• Stress and anxiety
be minimized.
• Short appointments
• Use of epinephrine to be
minimized.
• Proper chair position is
important, SUPINE.
• At end of appointment
chair should be raised
slowly to minimize
orthostatic hypotension.
144

• Use of vasoconstrictors should be minimized
in pts taking digitalis glycosides.
• The equipments like pulp testers ,ultrasonic
scalers ,electrosurgical units ,should not be in
close proximity.
• Prophylactic antibiotics before and after
treatment in recently placed pacemaker
patients.
• Pts who report palpitations or skipped beats
must be evaluated by physician. 145

• Sustained sinus tachycardia above 100
beats/min in resting position is indicative of
sinus tachycardia.
• Dental treatment shd not be carried out in
patients with irregular pulse.
• Long use of procainamide can cause a lupus
like syndrome.
• Drug like quinidine can cause erythema
multiforme.
• CA may be induced by general anesthesia
and vagal reflex.
146

ORAL HEALTH
CONSIDERATION & ORAL
MANIFESTATION
147

• Valvular heart disease that compromises cardiac output
produces signs of hypoxemia.
• Cyanosis of lips and oral mucosa is the most prominent oral
sign of tissue hypoxia.
According to American heart association guidelines:
• Antibiotic prophylaxis should be administered to patients
who have undergone mitral or aortic valve repair or
replacement.
• Patients with a prior history of infective endocarditis.
• Patients with mitral or aortic regurgigation or stenosis.
• Patients with mitral valvular prolapse with valvular
regurgigation.
148

• Prosthetic heart valves.
• Previous bacterial endocarditis.
• Acquired valvular dysfunction.
• Complex cyanotic congenital heart disease.
• Surgically constructed systemic pulmonary
shunts.
149

ORAL PROCEDURES & NEED FOR
ANTIBIOTIC PROPHYLAXIS TO MINIMISE
RISK OF BACTERIAL ENDOCARDITIS
• Extractions.
• Periodontal procedures including surgery,subgingival,placement
of antibiotic fibers or Strips,scaling &root planning.
• Implant placement.
• Tooth reimplantation.
• Placement of orthodontic bands(not brackets).
• Endodontic instrumentation.
• Intra ligamentary injection.
• Prophylatic cleaning of teeth where bleeding is anticipated.
• Other procedure in which significant bleeding is anticipated.
150

STANDARD REGIMENS FOR PROPHYLAXIS
TO MINIMISE RISK OF BACTERIAL
ENDOCARDITIS
• Oral medication.
• Adults & children not allergic to penicillin-amoxicillin.
• Adults & children allergic to penicillin-clindamycin.
• Non oral medication.
• Adults & Childrens not allergic to penicillin-iv or im
ampicillin.
• Adults & children alergic to penicillin-iv clindamycin.
151

PREGNANCY
&
CARDIOVASCULAR
DISEASES
154

• Diagnosis of congenital cardiac malformations
can be made as early as 13 weeks, and, in
families with heart disease.
• Early examination in pregnancy allows parents
to consider all options, including termination of
pregnancy, if there are major malformations.
• Hypertensive disorders during pregnancy occur
in women with pre-existing primary or
secondary chronic hypertension, and in women
who develop new-onset hypertension in the
second half of pregnancy.
155

• Congenital heart disease usually manifests in
childhood but may pass unrecognised and not
present until adult life.
• The fetus has only a small flow of blood
through the lungs, as it does not breathe in
utero. The fetal circulation allows oxygenated
blood from the placenta to pass directly to the
left side of the heart through the foramen ovale
without having to flow through the lungs.
159

Persistent Ductus Arteriosus
• During fetal life, before the lungs begin to
function, most of the blood from the
pulmonary artery passes through the ductus
arteriosus into the aorta.
• Normally, the ductus closes soon after birth
but sometimes fails to do so.
• Since the pressure in the aorta is higher than
that in the pulmonary artery, there will be a
continuous arteriovenous shunt.
160

Management :
• A patent ductus is closed at cardiac
catheterisation with an implantable occlusive
device.
• When the ductus is structurally intact, a
prostaglandin synthetase inhibitor (indometacin
or ibuprofen) may be used in the first week of
life and also improving oxygenation to induce
closure.
162

Coarctation of the aorta
• Narrowing of the aorta occurs in the region
where the ductus arteriosus joins the aorta, i.e.
at the isthmus just below the origin of the left
subclavian artery.
• Management : In untreated cases, death may
occur from left ventricular failure, dissection of
the aorta or cerebral haemorrhage.
163

Atrial septal defect
• ‘Ostium primum’ defects result from a defect in
the atrioventricular septum and are associated
with a ‘cleft mitral valve’ (split anterior leaflet).
• As a result there is gradual enlargement of the
right side of the heart and of the pulmonary
arteries.
164

• Management : Closure can also be
accomplished at cardiac catheterisation using
implantable closure devices.
• Severe pulmonary hypertension and shunt
reversal are both contraindications to surgery
166

Ventricular septal defect
• Congenital ventricular septal defect occurs as a result
of incomplete septation of the ventricles.
• Management : Small ventricular septal defects
require no specific treatment. Cardiac failure in
infancy is initially treated medically with digoxin
and diuretics. Persisting failure is an indication for
surgical repair of the defect. Percutaneous closure
devices are under development.
167

STUDIES SHOWING
ASSOCIATION OF
PERIODONTITIS AND
CARDIOVASCULAR DISEASES
172

Periodontal infections and cardiovascular
disease.The heart of the matter
• Journal :The Journal of the American Dental Association (October
2006) 137, 14S-20S.
• Author :Ryan T. Demmer
• Conclusions. Evidence continues to support an association among
periodontal infections, atherosclerosis and vascular disease. Ongoing
observational and focused pilot intervention studies may inform the
design of large-scale clinical intervention studies. Recommending
periodontal treatment for the prevention of atherosclerotic CVD is not
warranted based on scientific evidence. Periodontal treatment must be
recommended on the basis of the value of its benefits for the oral health
of patients, recognizing that patients are not healthy without good oral
health. However, the emergence of periodontal infections as a potential
risk factor for CVD is leading to a convergence in oral and medical care
that can only benefit the patients and public health.
173

Association between dental health and
acute myocardial infarction.
• Journal : BMJ 2009;298:779.
• Authors: K. J. Mattila et al.
• Abstract
Known risk factors for coronary heart disease do not explain all of the clinical
and epidemiological features of the disease. To examine the role of chronic
bacterial infections as risk factors for the disease the association between poor
dental health and acute myocardial infarction was investigated in two separate
case-control studies of a total of 100 patients with acute myocardial infarction
and 102 controls selected from the community at random. Dental health was
graded by using two indexes, one of which was assessed blind. Based on these
indexes dental health was significantly worse in patients with acute myocardial
infarction than in controls. The association remained valid after adjustment for
age, social class, smoking, serum lipid concentrations, and the presence of
diabetes. Further prospective studies are required in different populations to
confirm the association and to elucidate its nature.
174

CONCLUSION
• Cardiovascular problems are non-communicable
diseases which are growing in India and other parts
of the world very fast.
• The dental considerations for such cases are required
with proper investigations and medications.
LETS JOIN HANDS FOR SAVING THE HEARTS
OF THE NATION!
177

REFERENCES
• Davidson’s Principle and Practice of Medicine – 21st
Edition
• Burket’s Book of Oral Medicine – 11th Edition
• Emerging risk factors for cardiovascular
diseases:Indian context. Sushil et al. Indian Journal
of Endocrinology and Metabolism / Sep-Oct 2013 /
Vol 17 | Issue 5
• Heart Disease and Stroke Statistics--2010 Update: A
Report From the American Heart Association
178

• Oral Health, Atherosclerosis, And
Cardiovascular Disease. Jukka H. Meurman
Et Al. Crit Rev Oral Biol Med; 15(6):403-413
(2004).
• 2007 Guidelines For The Management Of
Arterial Hypertension. European Heart
Journal (2007) 28, 1462–1536.
• Dental Disease And Risk Ofcoronary Heart
Disease And Mortality. Frank Destefano Et
Al. Bmj Volume 306 13 March 1993.
179

• Coronary Artery Disease. Munther K.
Homoud. Seminar By Md Of Tufts-new
England Medical Center Spring 2008.
• Hypertension In Pregnancy:the Management
Of Hypertensive Disorders During Pregnancy.
Royal College Of Obstetricians And
Gynaecologists. National Collaborating Centre
For Women’s And Children’s Health.Aug 2010.
• Relationship Between Oral Health Lars Frithiof
Et Al. J Clin Periodontol 2001; 28: 762–768.
180

• Definition And Classification Of
Hypertension: An Update. Emerging Concept.
Thomas D. Giles Et Al. The Journal Of
Clinical Hypertension. Vol. 11 No. 11 November
2009.
• Prevention Of Infective Endocarditis:
Guidelines From The American Heart
Association. A Guideline From The American
Heart Association.
• Dental Considerations In Patients With Heart
Disease. Marta Cruz-pamplona Et Al. J Clin
Exp Dent. 2011;3(2):e97-105.
181

• Hypertension Guidelines: Revisiting The JNC
7 Recommendations. The Journal Of Lancaster
General Hospital • Fall 2008 • Vol. 3 – No. 3.
• ESC Guidelines On The Management Of
Cardiovascular Diseases During Pregnancy.
European Heart Journal (2011) 32, 3147–3197.
• Peripheral Signs Of Endocarditis. Frank L.
Urbano. Hospital Physician May 2000.
182

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