basic guidlines for and emergency management of dental patients with cadio-vascular complications

1. • Research seminar reference book : LITTLE and
FALACE’s Dental Management of medically
Compromised patients

2. Dental
Managements Of
Medically
Compromised
Patients

3.  THE KEY TO A SUCCESSFUL DENTAL MANAGEMENT OF A MEDICALLY
COMPROMISED PATIENT IS A GOOD EVALUATION OF THE PATIENT
FOLLOWED BY A RISK ASSESSMENT TO DETERMINE WHETHER THE
DENTAL PROCEDURE IS CONSIDERED SAFE OR NOT
 THE FUNDAMENTAL MOTIVE OF DENTAL TREATMENT FOR
MEDICALLY COMPROMISED PATIENTS IS WHETHER THE
TREATMENT BENEFITS WOULD OUTWEIGHS ANY MEDICAL
COMPLICATION DURING OR AFTER DENTAL TREATMENT .

4. Patient evaluation and risk
assessment
Awareness of
the possible
complications
Reviewing
medical
history
Identifying all
past or present
medications and
drugs or
therapies taken
by the patient
Examination
of all signs
and
symptoms of
any diseases
Examination
of vital signs
Obtain recent
laboratory tests or
images or ordering
new ones when
something is
suspected
Obtain a medical
consultation if the
patient is poorly
controlled or when
an undiagnosed
problem is
suspected

5.  Types of potential risks diseases :
1. Cardiovascular diseases
2. Pulmonary diseases
3. Gastrointestinal diseases
4. Genitourinary diseases
5. Endocrine and metabolic diseases
6. Immunological diseases
7. Hematological and oncologic diseases
8. Neurologic and psychiatric diseases

6. 1. Cardio-vascular diseases

7. A.Infective Endocarditis
 Infective Endocarditis is a microbial infection manifesting on the
endothelial tissues of the heart or the heart valves that is related to
congenital or acquired cardiac defects.
 This infection is not only caused by Bacteria, but it could also be caused
by Fungi and other microorganisms.
 IE can be caused by oral flora during any dental procedures

8.  Pathophysiology :
- When a damage occurs to the endothelium of the heart that can be caused
by a variety of events (ex: Flow from a narrowed orifice at a high
velocity), Fibrin and Platelets then adhere to the roughened surface of
Endothelium, where they form small masses causing a non-bacterial
thrombotic Endocarditis
- Bacteria from oral flora can adhere to the mass , then undergoing rapid
multiplication , transforming into a vegetative mass, then bacteria is
slowly shed into the bloodstream resulting in bacteremia, heart failure,
stroke, embolization, abscesses, Aneurysm, septic shock

9. Signs and Symptoms :
- The onset of symptoms is within 2 weeks or more
- It may include [ fever, heart murmur, positive culture (most common
are the streptococcus).
 Dental management :
1)Current guidelines recommend antibiotic prophylaxis only for patients
with potential risks outcome from dental procedures [ex: prosthetic valve,
previous IE, congenital heart disease, cardiac transplant]
2)maintaining good oral hygiene on a daily basis
N.B: All dental procedures that involve manipulation of the gingival
tissues or the periapical lesions or perforation of the oral mucosa are
indicative for a prophylactic antibiotics for patients with cardiac risks.
Also for the non-valvular devices(ex;stents,grafts)in some
procedues(ex:incision and drainage).
N.B: If the pt. is already taking penicillin or amoxicillin, it is advised to
wait for at least 10 days after completion of antibiotic therapy before
administering of a prophylactic antibiotic.

10. B- Hypertension

11. - Hypertension is the abnormal elevation in arterial pressure, patients may be
asymptomatic but eventually may experience symptoms due to damage of
kidneys, heart, brain eyes.
• Pts can be classified to : 1- normal (<120/80)
2- pre-hypertensive (120-139 sp) or (80-90 dp)
3- stage 1 hypertension (140-150 sp) or (90-100dp)
4- stage 2 hypertension (>160 sp) or (>100– dp)
 Etiology:
• Hypertension occurs with any defect or abnormalities in the elasticity of
arteries or the vascular resistance
• Also, hypertension can be primary or secondary to diseases that causes
turbulence in BP such as : -chronic kidney disease – steroid therapy –
coarctation of the aorta –hyper-aldosteronism …..etc

12.  Signs and Symptoms:
 Early signs can be presented as : [ sustained elevated BP- Headaches-
dizziness- Tinnitus- Palpitations]
 Advanced symptoms such as [Hemorrhage of retinal arterioles- renal
failure- angina pectoris- encephalopathy]
 Dental Considerations:
 The primary concern for dentists is a sudden acute elevation of BP during
the treatment that may lead to a stroke, MI, Angina pectoris
 Antibiotics are nor indicated fo hypertensive pts.
 Bleeding is of no concern to the dentist, If the pt in taking aspirin or an
antiplatelet agent, dental procedures can be preformed normally. When
the pt. is taking Anticoagulants , then some precautions are taken.
 Blood pressure in pts of less than (180/110) can undergo any necessary
treatment , pts with BP of ( 180/110) or greater, then elective dental care
is performed and referral to a physician.

13. • Chair position should not be changed quickly due to
antihypertensive drug associated orthostatic hypotension to avoid
dizziness and light-headed side effects
• Stress reduction protocol should be used with all pts to reduce
stress and anxiety
• NSAIDs should be reduced to minimum as they reduce anti-
hypertensive effect, not more than 2 weeks

14. • Anti-hypertensive drugs may have some oral manifestations as
(diuretics causing dry mouth ) – (beta blockers, ex: Inderal, may cause
taste changes) – (gingival hyperplasia caused by CCBs)
• Vasoconstrictors have little or no effect and advisable for more
profound and prolonged anesthesia only within normal doses of
epinephrine for pts BP less than 180/110
• Gingival retractors added with epinephrine are avoided

15. C- Ischemic heart diseases
- Coronary atherosclerosis (or ischemic heart diseases ) is the
thickening of the internal layer of the arterial wall caused by
accumulation of plaques
- It results in a narrowed lumen with decreased oxygen supply and
blood flow
- Atherosclerosis is the most common cause for Angina Pectoris, MI,
Stroke
- Symptoms are mainly caused by oxygen deprivation to a part of thr
myocardium
Etiology :
- It is related to several factors such as (old age- family history –
hypertension- obesity- physical inactivity- diabetes mellitus)

16.  Pathophysiology :
1- First step begins with an inflammatory response secondary to any
physiologic or pathologic injury (ex: lipids accumulation)
2- Monocytes and macrophages engulf lipid cells to create foam cells
3-Additional adherence of T-lymphocytes and collagen cells to form create
a cap above the foam cells forming plaques
4- Plaques can grow inside or outside the lumen of the artery, if inside the
lumen, that may cause a decrease in blood flow
5- If plaques rupture, this leads to adherence of blood and platelets causing
plaque formation causing the acute coronary symptoms (ex: MI, Angina)
 Signs and Symptoms :
-Chest Pain is the most common and important symptom, it is brief in stable
Angina, prolonged in MI and unstable Angina
- Aching, heavy, squeezing Pressure in the Mid-chest region , May radiate in
the left shoulder, Arm, Neck, Lower jaw.

17.  Dental Management :
- stress reduction protocol is indicated for all pts.
- Nitroglycerin should be present in case of emergency
- Limited amount of Vasoconstrictors , or even avoided, ONLY when
necessary to insure profound anesthesia , pts with intermediate clinical risks and
those taking non-selective Beta-Blockers can safely be given up to 2 cartridges
- Pts with previous symptomatic MI and unstable Angina within a month , Only
necessary and conservative ttt. to eliminate pain.
- Antibiotic prophylaxis is Not recommended
- Daily Aspirin /Anti-platelet intake may cause some extra bleeding but no
dangerous, no need for drug cessation before dental ttt.
- Warfarin intake is safe with normal and surgical dental procedures.
- Sudden chair position changes are avoided
- Epinephrine retraction cords are Avoided
- NSAIDs are avoided with coronary artery disease, especially with a history of
MI as they may precipitate acute symptoms of MI, only Naproxen (ex:
Apranox, Myoprox 250mg, noprofen 500mg) can be used for less than 7
days
- Clarithromycin , Erythromycin antibiotics should be avoided due to some
drug interactions

18.  Oral Manifestations :
- Carotid artery calcification may be noticed in panoramic xrays in
some pts.
- There is a strong association between coronary artery diseases
and periodontal disease
- Drugs used in ttt. for ischemia (ex: nitrates, CCBs, BBs, PAIs)
may have some oral manifestations (ex: Dry mouth, Gingival
Hyperplasia, Taste changes, Stomatitis) so good oral hygiene
and periodic plaque control are indicated

19. D- Heart Failure
 Heart Failure or Congestive heart failure is a complex of syndromes that
can result form any cardiac disorder , that impairs the ability of the ventricles to
fill or eject blood to the tissues
 Most common causes of Heart failure are : 1-Hypertension
2-Infective endocarditis
3- cardio-myopathy
4- coronary heart disease
 HF may occur as a result of Impaired Myocardial contractility / or /
Impaired Myocardial relaxation / or / Any cardiac abnormalities (
ex: regurgitation of valves )
 Left-side HF is the most common and It usually preceds Right-side HF

22.  Clinical Presentation :
 Signs :
- Rapid, shallow breathing
- Increased heart rate
- Distended neck veins
- Cyanosis
- Clubbing of fingers
- Abdominal ascites
- Peripheral edema
 Symptoms :
- Dyspnea (shortness of breath)
- Orthopnea
- Fatigue
- Weight gain
- Paroxysmal nocturnal dyspnea
- Cough
- Constipation, vomiting , anorexia
- Dependent edema

24. Dental Considerations :
 Antibiotics are NOT recommended UNLESS there is a prosthetic
heart valve
 Stress reduction protocol in mandatory
 Bleeding may occur due to the intake of the anticoagulant drugs ,
should consult physician before stopping the dose
 Measuring Blood pressure at the same appointment before the dental
procedure
 Pts. May not tolerate Supine chair position because of pulmonary
edema, so they may require a semi-supine or upright position
 Profound anesthesia and pain control is important, however,
anesthesia with vasoconstrictors should be avoided, if necessary,
Not more than 2 carpules with Epinephrine of 2% lidocain
 Retraction cord with epinephrine are avoided
 General anesthesia should be avoided in dentistry
 NSAIDs should be avoided As much as possible as they can induce HF
 Digitalis intake is with epinepherine

25.  Oral Manifestations :
 Many of the drugs in HF can have oral manifestations ( ex: Dry Mouth,
oral lesions )
 Digitails intake can cause Gag Reflex and hypersalivation