cardiovascular disease nd edntal considerations

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cardiovascular disease nd edntal considerations

  1. 1. DEPARTMENT OF ORAL MEDICINE AND RADIOLOGY Guided By: DR. NEELKAMAL DR. VERMA Submitted By: Nishtha Singhal (45) Nidhi Nagar (46) Neha Sachdeva (47) Pallavi Singh (48) BDS Final Year Batch 2005-06
  2. 2. CARDIOVASCULAR DISEASES
  3. 3. A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS B)PAST HISTORY C)FAMILY HISTORY D)PERSONAL HISTORY E)TREATMENT HISTORY SCHEME OF HISTORY TAKING
  4. 4. <ul><li>A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS </li></ul><ul><li>DYSPNOEA </li></ul><ul><li>CHEST PAIN </li></ul><ul><li>PALPITATION </li></ul><ul><li>SYNCOPE </li></ul><ul><li>COUGH WITH EXPECTORATION AND HAEMOPTYSIS </li></ul><ul><li>CYANOSIS </li></ul><ul><li>RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINE OUTPUT </li></ul><ul><li>GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN AND VOMITING </li></ul><ul><li>FATIGABILITY </li></ul><ul><li>FEVER </li></ul><ul><li>DIABETES MELLITUS AND HYPERTENSION </li></ul><ul><li>B)PAST HISTORY </li></ul><ul><li>RHEUMATIC FEVER </li></ul><ul><li>CYANOTIC SPELLS </li></ul><ul><li>RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD </li></ul><ul><li>DETECTION OF MURMUR/CARDIAC LESION AT SCHOOL </li></ul><ul><li>RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS </li></ul><ul><li>HYPERTENSION, DIABETES MELLITUS, ISCHAEMIC HEART DISEASE OR ANY OTHER SIGNIFICANT MEDICAL ILLNESS </li></ul>
  5. 5. <ul><li>C)FAMILY HISTORY </li></ul><ul><li>HYPERTENSION </li></ul><ul><li>ISCHAEMIC HEART DISEASE </li></ul><ul><li>CONGENTAL HEART DISEASE </li></ul><ul><li>RHEUMATIC HEART DISEASE </li></ul><ul><li>SUDDEN DEATH </li></ul><ul><li>D)PERSONAL HISTORY </li></ul><ul><li>APPETITE </li></ul><ul><li>WEIGHT LOSS </li></ul><ul><li>DISTURBED SLEEP </li></ul><ul><li>BOWEL AND BLADDER DISTURBANCES </li></ul><ul><li>HABITS- SMOKING AND ALCOHOLISM </li></ul><ul><li>EXPOSURE TO SYPHILIS </li></ul><ul><li>E)TREATMENT HISTORY </li></ul><ul><li>NIFEDIPINE- GINGIVAL HYPERPLASIA </li></ul>
  6. 6. <ul><li>APPROACH TO A PATIENT OF CARDIAC DISEAASE </li></ul><ul><li>ANALYSIS OF PRESENTING SYMPTOMS </li></ul><ul><li>1)DYSPNOEA </li></ul><ul><li>DEFINITION:- ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT. </li></ul><ul><li>DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE. </li></ul><ul><li>DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURE THAN DUE TO RIGHT HEART FAILURE. </li></ul><ul><li>SEVERITY (GRADING) </li></ul><ul><li>FUNCTIONAL GRADING OF DYSPNOEA </li></ul><ul><li>GRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA OCCURS ON MORE THAN ORDINARY (UNOCCUSTOMED) EXERTION. </li></ul><ul><li>GRADE II: DYSPNOEA ON ORDINARY DAILY ACTIVITY </li></ul><ul><li>GRADE III : DYSPNOEA ON LESS THAN ORDINARY DAILY ACTIVITIES. </li></ul><ul><li>GRADE IV : LIMITATIONS OF ALL ACTIVITIES( DYSPNOEA AT REST) </li></ul><ul><li>2)ORTHOPNOEA </li></ul><ul><li>DEFINITION: DYSPNOEA THAT OCCURS USUALLY ON LYING DOWN. </li></ul><ul><li>CHARACTERISTIC FEATURES: USALLY OCCURS WITHIN MINUTES OF ASSUMPTION OF RECUMBENCY. </li></ul><ul><li>OCCURS WHEN A PATIENT IS AWAKE. </li></ul><ul><li>INDICATES THE PRESENCE OF SEVERE LEFT HEART FAILRE (PULMONARY OEDEMA). </li></ul><ul><li>MANIFESTS LATER THAN PND. (IN SLOWLY PROGRESSIVE LEFT HEART DISEASE). </li></ul>
  7. 7. <ul><li>3)PLATYPNEA: DYSPNOEA OCCURS ON SITTING (UPRIGHT) RATHER THAN ON </li></ul><ul><li>LYING DOWN POSITION. </li></ul><ul><li>EXAMPLE: LEFT ATRIAL MYXOMA,LEFT ATRIAL BALL VALVE THROMBUS </li></ul><ul><li>4)TREPOPNEA : OCCURS ON BREATHLESSNESS ONLY WHEN LYING DOWN IN LATERAL POSITION. </li></ul><ul><li>MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP </li></ul><ul><li>ALTERATION IN CERTAIN BODY POSITION. </li></ul><ul><li>5)PROXIMAL NOCTURNAL DYSPNOEA </li></ul><ul><li>ATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE </li></ul><ul><li>DEGREE OF LEFT HEART FAILURE. </li></ul><ul><li>6)CHEYNES-STROKE BREATHING </li></ul><ul><li>THERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OF APNOEA.SIGN OF SEVERE HEART FAILURE. </li></ul><ul><li>7)CYANOSIS </li></ul><ul><li>A)CYANOSIS APPEARING IN INFANCY INDICATES THE PRESENCE OF CONGENITAL CARDIAC ANOMALIES WITH RIGHT TO LEFT SHUNT(TERATOLOGY OF FALLOT) </li></ul><ul><li>B)CYANOSIS BEGINNING TO APPEAR AFTER 6 WEEKS OF AGE MAY BE AN INDICATION OF VSD WITH SLOWLY PROGRESSIVE RIGHT VENTRICUAR OUTFLOW OBSTRUCTION. </li></ul><ul><li>C)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) </li></ul>
  8. 8. <ul><li>8)SWELLING OF FEET (PEDAL ODEMA) </li></ul><ul><li>RIGHT HEART FAILURE CAUSES SYSTEMIC VENOUS CONGESTION </li></ul><ul><li>WITH INCREASED HYDROSTATIC PRESURE IN THE LOWER </li></ul><ul><li>LIMB VEINS. THIS RESULT IN THE TRANSUDATION OF FLUID </li></ul><ul><li>CAUSING EDEMA. </li></ul><ul><li>ANKLE EDEMA IS MORE COMMON IN AMBULATORY PATIENTS. BED-RIDDEN PATIENT DEVELOP SACRAL EDEMA. </li></ul><ul><li>9) RIGHT HYPOCHODRAL PAIN </li></ul><ul><li>THIS IS DUE TO ENLARGED AND CONGESTED LIVER AND STREACHING OF ITS CAPSULE. </li></ul><ul><li>10) DECREASED URINE OUTPUT </li></ul><ul><li>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 URNE OUTPUT IN PATIENTS WITH CARDIAC FAILURE . </li></ul><ul><li>11)SYNCOPE </li></ul><ul><li>TRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE. </li></ul><ul><li>12)COUGH AND EXPECTORATION </li></ul><ul><li>13)PALPITATION </li></ul><ul><li>SUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT. </li></ul>
  9. 9. EXAMINATION OF CARDIOVASCUAR SYSTEM <ul><li>SCHEME OF EXAMINATION </li></ul><ul><li>GENERAL EXAMINATION </li></ul><ul><li>1. BUILD </li></ul><ul><li>2. NOURISHMENT </li></ul><ul><li>3.PALLOR </li></ul><ul><li>4.CYANOSIS </li></ul><ul><li>5. CLUBBING </li></ul><ul><li>6. JAUNDICE </li></ul><ul><li>7. PEDAL ODEMA </li></ul><ul><li>8. LYMPHADENOPATHY </li></ul>
  10. 10. <ul><li>EXTERNAL MARKERS OF CARDIAC DISEASE </li></ul><ul><li>EXAMINATION OF :- </li></ul><ul><li>FACE </li></ul><ul><li>EYES </li></ul><ul><li>EARS </li></ul><ul><li>SKIN AND MUCOSA </li></ul><ul><li>EXTREMITIES </li></ul><ul><li>VITAL SIGNS:- </li></ul><ul><li>PULSE </li></ul><ul><li>BLOOD PRESSURE </li></ul><ul><li>RESPIRATORY RATE </li></ul><ul><li>TEMPERATURE </li></ul>EXAMINATION OF PERIPHERAL CARDIOVASCUAR SYSTEM RADIAL PULSE:- RATE RTHYM VOLUME CHARACTER CONDITION OF VESSEL WALL EXAMINATION OF:- THE CAROTIDS THEIR PERIPHERAL PULSES JUGULAR VENOUS PULSE AND PRESSURE PERIPHERAL SIGNS OF WIDE PULSE PRESSURE(IN RELEVANT SITUATION) PERIPHERAL SIGNS OF INFECTIVE ENDOCARDITIS PERIPHERAL SIGNS OF RHEUMATIC FEVER
  11. 11. <ul><li>EXAMINATION OF THE PRECORDIUM </li></ul><ul><li>INSPECTION </li></ul><ul><li>1. PRECORDIAL BULGE </li></ul><ul><li>POSITION OF APICAL IMPULSE </li></ul><ul><li>PULSATIONS IN THE:- </li></ul><ul><li>A. LEFT PARASTERNAL REGION </li></ul><ul><li>B. 2 ND LEFT INTERCOSTAL SPACE </li></ul><ul><li>C. 2 ND RIGHT INTERCOSTAL SPACE </li></ul><ul><li>D. EPIGASTRIC PULSATION </li></ul><ul><li>E. SUPRASTERNAL PULSATION </li></ul><ul><li>F. ENGORGED VEINS OVER THE CHEST </li></ul><ul><li>G. SPINE(KYPHOSCOLIOSIS) </li></ul><ul><li>PALPATION </li></ul><ul><li>1)APICAL IMPULSE- POSITION AND CHARACTER </li></ul><ul><li>2)LEFT PARASTERNAL HEAVE </li></ul><ul><li>3) OF EPIGASTRIC PULSATION </li></ul><ul><li>THRILLS </li></ul><ul><li>4)PALPABLE SOUNDS </li></ul>PERCUSSION 1)RIGHT CARDIAC BORDER 2)LEFT CARDIAC BORDER 3)LEFT AND RIGHT 2ND INTERCOSTAL SPACE.
  12. 12. <ul><li>AUSCULTATION </li></ul><ul><li>MITRAL, TRICUSPID, AORTIC, PULMONARY AND OTHER ADDITIONAL AREAS FOR:- </li></ul><ul><li>A. 1 ST AND 2 ND HEART SOUNDS </li></ul><ul><li>B. ADDITOINAL SOUNDS </li></ul><ul><li>C. MURMURS </li></ul>
  13. 13. <ul><li>EXAMINATION ALSO INCLUDES THE FOLOWING SIGNS </li></ul><ul><li>A)PALLOR </li></ul><ul><li>SEVERE ANEMIA MAY BE ASSOCIATED WITH: </li></ul><ul><li>1. CHRONIC CCF </li></ul><ul><li>2. INFECTIVE ENDOCARDITIS </li></ul><ul><li>SEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE OR AGGRAVATE THE UNDERLYING HEART DISEASE. </li></ul><ul><li>PATIENTS WITH CYANOTIC CONGENITAL HEART DISEASE MAY HAVE POLYCYTHEMIA WITH SUFFUSED CONJUNCTIVA. </li></ul>
  14. 14. <ul><li>B)CYANOSIS: </li></ul><ul><li>CENTRAL CYANOSIS OCCURS IN: </li></ul><ul><li>1. CYANOTIC CONGENITAL HEART DISEASE </li></ul><ul><li>2. REVERSAL OF LEFT TO RIGHT SHUNT </li></ul><ul><li>3. INTRAPULMONARY RIGHT TO LEFT SHUNT </li></ul><ul><li>4. PULMONARY EDEMA (LEFT HEART FAILURE) </li></ul><ul><li>PERIPHERAL CYANOSIS OCCURS IN: </li></ul><ul><li>1. CONGENITAL CARDIAC FAILURE </li></ul><ul><li>2. PERIPHERAL VASCULAR DISEASE </li></ul><ul><li>DIFFERENTIAL CYANOSIS: </li></ul><ul><li>1. FEET AND TOES ARE BLUE BUT HANDS AND FINGERS ARE NOT CYNOSED. </li></ul><ul><li>E.G. PDA WITH PULMONARY HYPERTENSION WITH REVERSAL OF SHUNT. </li></ul><ul><li>REVERSE DIFFERENTAL CYANOSIS: </li></ul><ul><li>1. FINGERS ARE MORE CYANOSED THAN TOES. </li></ul><ul><li>E.G. TRANSPSITION OF GREAT VESSELS WITH PULMONARY HYPERTENSION WITH PREDUCTAL COARCTATION WITH REVERSED FLOW THROUGH PDA. </li></ul>
  15. 15. <ul><li>C))CLUBBING </li></ul><ul><li>CARDIAC CAUSES: </li></ul><ul><li>1. CYANOTIC CONGENTAL HEART DISEASE </li></ul><ul><li>2. REVERSAL OF LEFT TO RIGHT SHUNT </li></ul><ul><li>3. INFECTIVE ENDOCARDITIS </li></ul><ul><li>CYANOTIC CONGENITAL HEART DISEASE MAY BE ASSOCIATED WITH HYPERTROPHIC PULMONARY OSTEOARTHROPATHY. </li></ul><ul><li>D)JAUNDICE </li></ul><ul><li>FOLLOWING CARDIAC CONDITIONS MAY BE ASSOCIATED WITH JAUNDICE: </li></ul><ul><li>1. CONGESTIVE CARDIAC FAILURE WITH CONGESTIVE HEPATOMEGALY </li></ul><ul><li>2. CARDIAC CIRRHOSIS </li></ul><ul><li>3. PULMONARY INFARCTION </li></ul>
  16. 16. <ul><li>E)PEDAL EDEMA </li></ul><ul><li>PITTING EDEMA OF FEET CAN OCCUR IN: </li></ul><ul><li>1. CONGESTIVE CARDIAC FAILURE </li></ul><ul><li>2. CONSTRICTIVE PERICARDITIS </li></ul><ul><li>3. TRICUSPID VALVE DISEASE </li></ul><ul><li>F)LYMPHADENPATHY: </li></ul><ul><li>CONDITION ASSOCIATED WITH GENERALIZED LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULAR SYSTEM. E.G. LYMPHOMA, SLE ETC. </li></ul>
  17. 17. EXAMINATION OF FACE <ul><li>FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYING CAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE. </li></ul>ABNORMALITIES CONDITION 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 VASOCNSTRICTION
  18. 18. MALAR FLUSH MARFAN SYNDROME TERATOLGY OF FALLOT
  19. 19. 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
  20. 20. 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).
  21. 21. EXAMINATION OF EAR: PRESENCE OF CREASE IN THE PINNA OF THE EAR- ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY DISEASE.
  22. 22. <ul><li>EXAMINATION OF EYES: </li></ul><ul><li>EXOPTHALMUS: ASSOCIATED WITH THYROID ARTERY </li></ul><ul><li>DISEASE. </li></ul><ul><li>BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTIC REGULTATION. </li></ul><ul><li>OPTHALMIC FUNDUS: LOOK FOR </li></ul><ul><li>A. ARTERIOSCLEROTIC CHANGES </li></ul><ul><li>B. HYPERTENSIVE RETINOPATHY </li></ul><ul><li>C. ROTH’S SPOTS( OF INFECTIVE ENDOCARDITIS) </li></ul><ul><li>D. ARTERIAL PULSATION IN AR </li></ul><ul><li>E. CORK SCREW ARTERIES- COARCTATION OF AORTA. </li></ul>BLUE SCLERA ROTHS SPOT
  23. 23. EXAMINATION OF FINGER <ul><li>CLUBBING </li></ul>CLUBING NEGATIVE
  24. 24. OSLERS NODE IN ENDOCARDITIS SUBUNGAL HAEMORRHAGES JANEWAY LESIONS
  25. 25. <ul><li>CAUSES OF CARDIOVASCLAR DISEASE </li></ul><ul><li>ORGANIC DISEASE OF HEART </li></ul><ul><li>1. MYOCARDIAL </li></ul><ul><li>A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASE </li></ul><ul><li>B. CORONARY( ISCHAEMIC) HEART DISEASE </li></ul><ul><li>C. CARDIOMYOPATHIES </li></ul><ul><li>2. ENDOCARDIAL </li></ul><ul><li>A. RHEUMATIC HEART DISEASE </li></ul><ul><li>B. CONGENITAL ANOMALIES </li></ul><ul><li>C. INFECTIVE ENDOCARDITIS </li></ul><ul><li>3. PERICARDIAL </li></ul><ul><li>A. PERICARDITIS </li></ul><ul><li>B. PERICARDIAL EFFUSION </li></ul><ul><li>C. FUNCTIONAL DISORDERS </li></ul><ul><li>DUE TO HYPERTENSION </li></ul><ul><li>DUE TO ABNORMALITIES IN HEART RATE </li></ul><ul><li>A. TACHYCARDIA </li></ul><ul><li>B. BRADICARDIA </li></ul><ul><li>C. OTHER DYSRTHYMIAS </li></ul><ul><li>CHANGES IN CIRCULATORY VOLUME </li></ul><ul><li>A. HYPOVOLOEMIA (SHOCH SYNDROME) </li></ul><ul><li>B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD) </li></ul><ul><li>C. OTHERS </li></ul>
  26. 26. 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.
  27. 27. HYPERTENSION <ul><li>Hypertension is known as Silent Killer of mankind. </li></ul><ul><li>Most of the sufferers (85 %) are asymptomatic and hence early diagnosis is a problem. </li></ul><ul><li>More than 65 lakh Americans and over 1 billion worlwide suffer with hypertension. </li></ul>
  28. 28. Definition <ul><li>Hypertension is defined as having systolic blood pressure (SBP) >/= 140mm of Hg or </li></ul><ul><li>diastolic blood pressure (DBP) >/= 90mm of Hg or </li></ul><ul><li>as having to use antihypertensive medications. </li></ul>
  29. 29. Classification <ul><li>The Seventh Joint National Committee Criteria (JNC VII) classifies hypertension for adults aged 18 years and older into following stages: </li></ul><ul><li>Blood Pressure Classification SBP(mm Hg) DBP(mmHg) </li></ul><ul><li>Normal <120 & <90 </li></ul><ul><li>Pre hypertension 120-139 & 80-89 </li></ul><ul><li>Stage I hypertension 140-159 & 90-99 </li></ul><ul><li>Stage II hypertension >/=160 & >/=100 </li></ul>
  30. 30. Types
  31. 31. Other Risk Factor of Hypertension <ul><li>Lack of exercise </li></ul><ul><li>Increased salt intake </li></ul><ul><li>Family history </li></ul><ul><li>Too little potassium </li></ul><ul><li>Alcohol </li></ul><ul><li>Smoking </li></ul><ul><li>Stress & </li></ul><ul><li>Age </li></ul>
  32. 32. Effect of hypertension <ul><li>The common target organs damaged by long standing hypertension are: </li></ul><ul><li>Brain </li></ul><ul><li>Heart </li></ul><ul><li>Kidneys </li></ul><ul><li>Eyes & </li></ul><ul><li>Peripheral arteries. </li></ul>
  33. 33. Complications of hypertension <ul><li>Left ventricular hypertrophy </li></ul><ul><li>Heart failure </li></ul><ul><li>Cerebral hemorrhage </li></ul><ul><li>Renal insufficiency </li></ul><ul><li>Aortic dissection </li></ul><ul><li>Atherosclerotic disease </li></ul>
  34. 34. Symptoms <ul><li>Symptoms due to hypertension : </li></ul><ul><li>Headache - usually in morning hours. </li></ul><ul><li>Dizziness </li></ul><ul><li>Epistaxis </li></ul><ul><li>Symptoms due to affection of target organs : </li></ul><ul><li>CVS: </li></ul><ul><li>Dyspnea on exertion </li></ul><ul><li>Anginal chest pain </li></ul><ul><li>Palpitations </li></ul>
  35. 35. <ul><li>2. Kidneys : Hematuria , nocturia , polyuria . </li></ul><ul><li>3. CNS : </li></ul><ul><li>Transient ischemic attacks ( TIA or Stroke) </li></ul><ul><li>Hypertensive encephalopathy(headache , vomiting etc.) </li></ul><ul><li>Dizziness, Tinnitus & syncope. </li></ul><ul><li>4 . Retina : </li></ul><ul><li>Blurred vision or </li></ul><ul><li>sudden blindness. </li></ul>
  36. 36. Diagnosis <ul><li>Physical Examination </li></ul><ul><li>Laboratory and Additional Testing – it includes </li></ul><ul><li>Routine laboratory procedures like hemoglobin, urinalysis, routine blood chemistries and fasting lipid profile. </li></ul><ul><li>Electrocardiography </li></ul><ul><li>Ambulatory BP Monitoring </li></ul><ul><li>Plasma renin activity testing </li></ul><ul><li>Radiologic testing </li></ul>
  37. 37. WHITE COAT HYPERTENSION <ul><li>‘’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. </li></ul><ul><li>20% of mild hypertensive individuals may present with white coat hypertension. </li></ul>
  38. 38. Dental Management <ul><li>Measure and record BP at initial visit </li></ul>
  39. 39. <ul><li>Recheck :- </li></ul><ul><li>Every 2 yrs for patient with BP <120/80 mm Hg. </li></ul><ul><li>Every 1 yr for patient with BP 120-139/80-89 mm Hg. </li></ul><ul><li>Every visit for patient with BP >140-90 mm Hg. </li></ul><ul><li>Every visit for patient with established coronary artery disease, diabetes mellitus or chronic renal disease with BP >135-85 mm Hg. </li></ul><ul><li>Every visit for patient with established hypertension. </li></ul><ul><li>Before initiating dental care: </li></ul><ul><li>Assess presence of hypertension </li></ul><ul><li>Determine presence of target organ disease </li></ul><ul><li>Determine dental treatment modifications </li></ul>
  40. 40. <ul><li>1. Asymptomatic BP <159/99 mm Hg, no history of target organ disease </li></ul><ul><li>No modifications needed </li></ul><ul><li>Can safely be treated in dental setting </li></ul><ul><li>2 . Asymptomatic BP 160-179/100-109 mm Hg, no history of target organ disease </li></ul><ul><li>Assessment on an individual basis with regard to type of dental procedure BP>180/110 mm Hg, no history of target organ disease </li></ul><ul><li>No elective dental care </li></ul><ul><li>3. Presence of target organ disease or poorly controlled diabetes mellitus </li></ul><ul><li>No elective dental care until BP is controlled , preferable below 140-90 mm Hg. </li></ul>
  41. 41. TREATMENT OF HYPERTENSION <ul><li>NON PHARMACOLOGICAL TREATMENT LIFESTYLE MODIFICATIONS </li></ul><ul><li>Salt restriction </li></ul><ul><li>Weight reduction </li></ul><ul><li>3. Stop smoking </li></ul><ul><li>4. Diet modifications such as: </li></ul><ul><li>Reduce intake of Cholesterol & Saturated fat. </li></ul><ul><li>Adequate intake of Calcium & Magnesium. </li></ul>
  42. 42. 5. Limit of alcohol intake 6. Relaxation such as yoga, psychotherapy etc. 7. Regular exercise.
  43. 43. ORAL MEDICATIONS USED FOR TREATMENT OF HYPERTENSION <ul><li>Diuretics </li></ul><ul><li>Beta-Adrenergic Blockers </li></ul><ul><li>Central Acting Inhibitors </li></ul><ul><li>Peripheral Acting Inhibitors </li></ul><ul><li>Non-Selective alpha & beta Adrenergic Inhibitors </li></ul><ul><li>Vasodilators </li></ul><ul><li>Angiotensin Converting Enzyme ACE Inhibitors </li></ul>
  44. 44. ORAL MANIFESTATION OF HYPERTENSION <ul><li>There are no recognized manifestations of hypertension but anti-hypertensive drugs can often cause side affects , such as: </li></ul><ul><li>Xerostomia, </li></ul><ul><li>Gingival overgrowth, </li></ul><ul><li>Salivary gland swelling or pain, </li></ul><ul><li>Lichenoid drug reactions, </li></ul><ul><li>Erythema multiforme, </li></ul><ul><li>Taste sense alteration, </li></ul><ul><li>Paresthesia. </li></ul>
  45. 45. CONCLUSION <ul><li>HYPERTENSION has no cure, but it can be controlled with proper diet, lifestyle changes, and if necessary medications. </li></ul><ul><li>Get regular health check ups. Think about the consequences of untreated high blood pressure. </li></ul><ul><li>Do not take chances with the disease that can be controlled. </li></ul><ul><li>Lastly, Hypertension is a silent disease, but its silence is not golden. </li></ul>
  46. 46. CORONARY (ISHAEMIC) ARTERY DISEASE
  47. 47. <ul><li>Atherosclerosis is the most common cause of CAD </li></ul><ul><li>ETIOPATHOGENESIS </li></ul><ul><li>Various risk factors include: </li></ul><ul><li>1. lipids (especially HDL) </li></ul><ul><li>2. hypertension </li></ul><ul><li>3. diabetes mellitus & glucose intolerance </li></ul><ul><li>4. cigarette smoking </li></ul><ul><li>5. lifestyle & dietary factors </li></ul><ul><li>6. exercise </li></ul><ul><li>7. obesity </li></ul>
  48. 48. <ul><li>8. vitamins & homocystiene </li></ul><ul><li>9. plasma fibrinogen </li></ul><ul><li>10. endothelial dysfunction </li></ul><ul><li>11. antioxidants </li></ul><ul><li>12. estrogen deficiency </li></ul>
  49. 49. <ul><li>RISK FACTORS </li></ul><ul><li>Induce variety of pathological processes </li></ul><ul><li>Interaction & disruption of vascular endothelium </li></ul><ul><li>Plaque formation </li></ul><ul><li>Effective arterial luminal area compromised </li></ul><ul><li>Myocardial ischaemia acute plaque rupture </li></ul><ul><li> thrombus formation </li></ul><ul><li>angina </li></ul><ul><li> M I </li></ul>
  50. 51. DIAGNOSIS <ul><li>1) Based on clinical presentation : </li></ul><ul><li>chest tightness </li></ul><ul><li>Jaw discomfort </li></ul><ul><li>Left arm pain </li></ul><ul><li>Dyspnea </li></ul><ul><li>Epigastric distress </li></ul><ul><li>2) E.C.G. </li></ul><ul><li>3) Exercise E.C.G. </li></ul><ul><li>4) Coronary Angiography </li></ul><ul><li>5) P.C.I. (Percutaneous Coronary Intervention) </li></ul>
  51. 52. MANAGEMENT <ul><li>Management of CAD depends on: </li></ul><ul><li>Extent and severity of ischemia </li></ul><ul><li>Exercise capacity </li></ul><ul><li>Prognosis based on exercise testing </li></ul><ul><li>Overall LV function </li></ul><ul><li>Associated features such as diabetes mellitus </li></ul><ul><li>Patients with a small ischemic burden, normal exercise tolerance, and normal LV function may be safely treated with pharmacologic therapy. </li></ul><ul><li>Selected use of aspirin, β -blockers, ACEIs, and HMG CoA reductase inhibitors. </li></ul><ul><li>Nitrates and calcium channel blockers may be added to primary agents to relieve symptoms of ischemia in selected patients. </li></ul>
  52. 53. <ul><li>Percutaneous coronary intervention (PCI) with percutaneous transluminal coronary angioplasty (PTCA) and intra coronary stenting relieves symptoms chronic ishchemia. </li></ul>
  53. 54. <ul><li>Patient with complex multivessel CAD require PCI with medical therapy of surgical revascularization. </li></ul><ul><li>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 . </li></ul>
  54. 55. DENTAL ASPECTS <ul><li>STRESS, ANXIETY, EXERTION or PAIN can provoke angina </li></ul><ul><li>Short, minimally stressful dental appointments </li></ul><ul><li>Late morning appointments </li></ul><ul><li>Excessive dose of LA containing adrenaline to be avoided in patients taking beta blockers </li></ul><ul><li>More severe dental caries and periodontal disease in pts of IHD </li></ul>
  55. 56. Acute Coronary Syndromes <ul><li>Represent a continuous spectrum of disease ranging from unstable angina to MI </li></ul>
  56. 57. Angina pectoris <ul><li>Name given to paroxysms of severe chest pain </li></ul><ul><li>CLINICAL FEATURES </li></ul><ul><li>1) 40 TO 60 years , M > F </li></ul><ul><li>2) pain often described as sense of Strangling, choking , Tightness, Heaviness ,Compression, or Constriction of chest </li></ul><ul><li>3) PAIN MAY RADIATE TO JAW or left arm </li></ul><ul><li>4) rarely pain in mandible, teeth or other tissues </li></ul><ul><li>PRECIPITATING FACTORS </li></ul><ul><li>Physical exertion(main) particularly in cold weather </li></ul><ul><li>Emotion(anger or anxiety) & stress caused by fear or pain </li></ul><ul><li>TYPICALLY RELEIVED BY REST </li></ul>
  57. 58. Dental aspects <ul><li>Preoprerative glyceryl trinitrate & oral sedation advised sometimes </li></ul><ul><li>dental care carried with minimal anxiety & oxygen saturation </li></ul><ul><li>Monitor pulse & B.P. </li></ul><ul><li>POST ANGIOPLASTY elective dental care deffered for 6 months , emergency dental care in a hospital setting </li></ul><ul><li>PTS with BYPASS GRAFTS – no anti biotic cover against infective endocarditis </li></ul><ul><li> - LA containing adrenaline is contraindicated (may ppt dysrhythmia) </li></ul>
  58. 59. <ul><li>PTS with vascular stents – no antibiotic cover </li></ul><ul><li>except during 1 st 6 week postop for emergency dental care </li></ul><ul><li>DRUGS used in t/t of angina may cause oral adverse effects like : </li></ul><ul><li>-lichenoid reaction Ca channel </li></ul><ul><li>- gingival swelling blockers </li></ul><ul><li>- ulcers (nicorandil) </li></ul>
  59. 60. Gingival hyperplasia in patient consuming Ca channel blockers
  60. 61. Myocardial infarction <ul><li>Synonyms – coronary thrombosis or heart attack </li></ul><ul><li>CLINICAL FEATURES </li></ul><ul><li>Clinical picture is variable </li></ul><ul><li>More than 50% patients are symptomless </li></ul><ul><li>MI may be preceded by angina often felt as indigestion like pain </li></ul><ul><li>any anginal attack lasting longer than 30 minutes is considered MI </li></ul><ul><li>Tachycardia &irregular pulse </li></ul><ul><li>nausea, vomitting, sweating ,restlessness, facial pallor </li></ul><ul><li>breathlessness, cough </li></ul><ul><li>Loss of conciousness, shock & even death </li></ul><ul><li>Many pts die within 1 st hour to few days after attack </li></ul><ul><li>THUS, MI is a MEDICAL EMERGENCY </li></ul>
  61. 63. DIAGNOSIS <ul><li>Based on clinical features </li></ul><ul><li>Elevated TLC & ESR during 1 st wk </li></ul><ul><li>ECG changes </li></ul><ul><li>Rise in serum “cardiac” enzymes ( CPK) </li></ul><ul><li>Rise in troponin T within 4-8 hours </li></ul><ul><li>echocardiography </li></ul>
  62. 64. General Precautions during Dental Procedures <ul><li>Dental clinic should have advanced cardiac life support or at least basic cardiac life support. </li></ul><ul><li>Use of pulse oximeter to determine the level oxygenation. </li></ul><ul><li>Automatic external defibrillator . </li></ul><ul><li>Determination of vital signs prior to dental care. </li></ul><ul><li>BP & pulse rate & rhythm should be recorded & any abnormal findings should be addressed. </li></ul><ul><li>Premedication with antianxiety drugs and inhalation nitrous oxide in anxious patients. </li></ul><ul><li>Elective procedures esp those requiring GA should be avoided for atleast 4 wks aftr MI . consult pt’s physician prior to dental therapy </li></ul>
  63. 65. Management on dental chair <ul><li>Terminate all dental treatment </li></ul><ul><li>Position pt in semirecline position </li></ul><ul><li>Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray </li></ul><ul><li>Administer oxygen </li></ul><ul><li>Check pulse & B.P . </li></ul><ul><li>Discomfort relieved Discomfort continues 3 mins after 2 nd TNG </li></ul><ul><li>6. Assume angina pectoris is 6. give 2 nd TNG dose </li></ul><ul><li>present 7. monitor vital signs. </li></ul><ul><li>7. Slowly taper oxygen over </li></ul><ul><li>5 mins </li></ul><ul><li>8. Modify t/t to prevent recurrence discomfort discomfort continues </li></ul><ul><li>relieved 3 mins after TNG </li></ul>
  64. 66. <ul><li>8. give 3 rd TNG dose </li></ul><ul><li>9. Monitor vitals </li></ul><ul><li>10. Call for medical assistance </li></ul><ul><li>Discomfort relieved discomfort continues 3 mins after 3 rd TNG dose </li></ul><ul><li>11. Refer pt for medical 12.assume MI is in progress </li></ul><ul><li>evaluation before 13. start i.v. line with drip of a crystalloid solution </li></ul><ul><li>further dental care at 30 mL/ hr </li></ul><ul><li>14. If discomfort severe titrate morfine sulphate 2mg s/c or i/v every 3 mins until relief is obtained </li></ul><ul><li>15. Transport to emergency care. Administer Basic Life Support ,if necessary. </li></ul>
  65. 67. Anticoagulation Therapy & Dental Care <ul><li>Anticoagulant therapy is used both to treat & to prevent throboembolism. </li></ul><ul><li>2 major types : 1. antiplatlet medications </li></ul><ul><li> 2. antithrombin medications </li></ul><ul><li>Acetylsalicylic acid (ASA) + clopidogrel ( anticoagulant) given for 4 weeks after stent implantation </li></ul><ul><li>daily aspirin typically continued lifelong. </li></ul><ul><li>May increase risk of oral bleeding following surgical procedures </li></ul><ul><li>Associated conditions which predispose patient to uncontrolled hemostasis : uraemia or liver diseases or use of NSAIDS </li></ul><ul><li>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 </li></ul>
  66. 68. <ul><li>Antithrombin medications are dicumarols ( eg. Warfarin), it inhibits biosynthesis of vit. – K dependent coagulations protein. </li></ul><ul><li>Efficacy monitored by prothrombin time or the international normalized ratio (INR), which is calculated on the basis of international sensitivity index (ISI). </li></ul><ul><li>INR ranges from 2.0 – 3.5 & it should be performed within 24 hrs of surgery. </li></ul><ul><li>If INR is < 3.5, anticoagulation therapy should be discontinued before minor surgical procedures . </li></ul>
  67. 69. <ul><li>3 different protocols used to treat patients with elevated INR : </li></ul><ul><li>Ist protocol – warfarin not discontinued (minimizes thromboembolic events & increases risk of bleeding after surgery). </li></ul><ul><li>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). </li></ul><ul><li>IIIrd protocol – warfarin discontinued & patient placed on alternative anticoagulant therapy (thromboembolic event minimized). </li></ul>
  68. 70. <ul><li>We always plan a t/t by comparing potential risk for excessive bleeding after procedures if anticoagulation therapy is not reduced or stopped v/s risk of pt experiencing a thromboembolic event if anticoagulation therapy is altered. </li></ul>
  69. 71. 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 B rain Acute rheumatic fever commonly appears in children ages 5 through 15, with only 20% of first time attacks occurring in adults
  70. 72. Rheumatic fever
  71. 73. <ul><li>What are the symptoms of strep throat? </li></ul><ul><li>sudden onset of sore throat (streptococcal oropharyngitis) </li></ul><ul><li>pain on swallowing </li></ul><ul><li>fever, usually 101–104°F </li></ul><ul><li>Headache </li></ul><ul><li>Red and edematous soft palate and oropharynx. </li></ul><ul><li>Areas of tonsillar ulceration and exudation. </li></ul><ul><li>abdominal pain, nausea and vomiting may also occur, especially in children </li></ul>
  72. 74. <ul><li>What are the symptoms/clinical features of rheumatic fever? </li></ul><ul><li>Symptoms may include: </li></ul><ul><li>fever </li></ul><ul><li>painful, tender, red swollen joints </li></ul><ul><li>pain in one joint that migrates to another one </li></ul><ul><li>heart palpitations </li></ul><ul><li>chest pain  </li></ul><ul><li>shortness of breath </li></ul><ul><li>skin rashes </li></ul><ul><li>fatigue </li></ul><ul><li>small, painless nodules under the skin  </li></ul>
  73. 75. <ul><li>Diagnosis </li></ul><ul><li>Two major criteria, or one major and two minor criteria , </li></ul><ul><li>Major criteria(jones) </li></ul><ul><li>J oints ( Migratory polyarthritis ): </li></ul><ul><li>O [imagine heart-shaped O] ( carditis ): </li></ul><ul><li>N odules (subcutaneous nodules - a form of Aschoff bodies ): </li></ul><ul><li>E rythema marginatum : </li></ul><ul><li>S ydenham's chorea </li></ul>
  74. 76. <ul><li>mnemonic: C.A.N.C.ER </li></ul><ul><li>C: Carditis </li></ul><ul><li>A: Arthritis </li></ul><ul><li>N: Nodules (sub cutaneous) </li></ul><ul><li>C: Chorea </li></ul><ul><li>ER: ERythema Marginatum </li></ul><ul><li>Another way of remembering it is CASES </li></ul>
  75. 77. <ul><li>Minor criteria </li></ul><ul><li>Fever : </li></ul><ul><li>Arthralgia </li></ul><ul><li>Laboratory abnormalities: increased Erythrocyte sedimentation rate </li></ul><ul><li>Electrocardiogram abnormalities </li></ul><ul><li>Evidence of Group A Strep infection: elevated or rising Antistreptolysin O titre , </li></ul>
  76. 78. <ul><li>LAB INVESTIGATIONS- </li></ul><ul><li>raised ESR </li></ul><ul><li>culture studies of throat swabs is always negative in RF </li></ul><ul><li>High anti sterptolysin o(ASO)titre-!300 todd units </li></ul><ul><li>Chest radiograph-enlargement of heart </li></ul><ul><li>ECG-prolonged PR interval </li></ul><ul><li>Echocardiogram-confirms ventricular dilatation n pericardial effusion </li></ul>
  77. 79. <ul><li>TREATMENT- </li></ul><ul><li>Oral phenoxymthylpenicillin 500 mguntil age of 20 yrs. </li></ul><ul><li>Allergic to penicillin,sulfadimidine by mouth. </li></ul><ul><li>Aspirin for fever and pain 50mg/kg bwt in 4 hrly doses </li></ul><ul><li>Corticosteroids 60-80mg prednisolone </li></ul><ul><li>Digoxin and diuretics for heart failure </li></ul><ul><li>Ballon valvuloplasty,using inoue balloon,if mitral valves damage. </li></ul>
  78. 80. <ul><li>DENTAL CONSIDERATION- </li></ul><ul><li>Dental extractions and local anesthesia in consent with physician. </li></ul><ul><li>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 </li></ul><ul><li>No2 used with approval of physician. </li></ul><ul><li>GA shd be avoided if essential must be given in hospital . </li></ul>
  79. 81. <ul><li>Rheumatic heart disease- </li></ul><ul><li>History of rheumatic fever during childhood or adollescence can act as a predisposing factor for RHD after several years. </li></ul><ul><li>Common signs-murmur due to valvular damage n later enlargement of heart. </li></ul>
  80. 83. <ul><li>ORAL MANIFESTATIONS </li></ul><ul><li>Most prominent during acute phase, </li></ul><ul><li>Pharyngitis </li></ul><ul><li>Inc oral temperature </li></ul><ul><li>Distended neck veins and a bluish color of the skin. </li></ul>
  81. 84. <ul><li>DENTAL CONSIDERATIONS- </li></ul><ul><li>To prevent complication of infective endocarditis ,all dental procedures should be carried under antibiotic cover. </li></ul><ul><li>Amoxicillin prophylaxis-1 hour before and 6 hours after the initial dose. </li></ul><ul><li>Good oral hygiene measures ,fluoride treatment, chlorhexidine rinses and routine cleanings to reduce harmful bacteremias. </li></ul>
  82. 85. <ul><li>Proper history should be taken to identify history of rheumatic fever during childhood. </li></ul><ul><li>Suspicious cases should be referred to cardiologist for cardiac evaluation prior to dental procedures. </li></ul><ul><li>Clindamycin or erythromycin prophylaxis during dental treatment. </li></ul><ul><li>Elective dental treatment under physician consultation. </li></ul>
  83. 86. <ul><li>HEART FAILURE- </li></ul><ul><li>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 . </li></ul><ul><li>Common causes of heart failure – </li></ul><ul><li>ischemic heart diseases </li></ul><ul><li>Hypertension </li></ul><ul><li>Valvular diseases </li></ul>
  84. 87. <ul><li>Left-sided failure(MORE COMMON) </li></ul><ul><li>Backward 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 . </li></ul><ul><li>Another symptom of heart failure is paroxysmal nocturnal dyspnea also known as &quot;cardiac asthma&quot;, a sudden nighttime attack of severe breathlessness, usually several hours after going to sleep </li></ul><ul><li>Inadequate cerebral oxygenation leads to loss of concentration,restlessness and irritability. </li></ul>
  85. 88. <ul><li>Right-sided failure </li></ul><ul><li>Backward 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 ) </li></ul><ul><li>IF occurs with MS is called congestive heart failure. </li></ul>
  86. 90. <ul><li>Biventricular failure ,faiure of one side of heart leads to failure of other. </li></ul><ul><li>CLINICAL FEATURES </li></ul><ul><li>pedal edema </li></ul><ul><li>Dyspnea </li></ul><ul><li>Congestion of neck veins </li></ul><ul><li>Cynosis </li></ul><ul><li>Fatigue </li></ul>
  87. 91. <ul><li>DIAGNOSIS </li></ul><ul><li>Imaging Echocardiography </li></ul><ul><li>Electrophysiology electrocardiogram (ECG/EKG) </li></ul><ul><li>Blood tests </li></ul><ul><li>Angiography </li></ul><ul><li>Monitoring </li></ul>
  88. 92. <ul><li>TREATMENT MODALITIES- </li></ul><ul><li>Diet and lifestyle measures </li></ul><ul><li>Weight reduction </li></ul><ul><li>Monitor weight </li></ul><ul><li>Sodium restriction -excessive sodium intake may precipitate or exacerbate heart failure </li></ul><ul><li>Fluid restriction – patients with CHF have a diminished ability to excrete free water load </li></ul><ul><li>stress reduction,rest </li></ul><ul><li>Stop smoking </li></ul>
  89. 93. <ul><li>Pharmacological management </li></ul><ul><li>diuretic </li></ul><ul><li>Loop diuretics (e.g. furosemide , bumetanide ) </li></ul><ul><li>ACE inhibitor/ Angiotensin II receptor antagonist Positive inotropes </li></ul><ul><li>Digoxin </li></ul><ul><li>Beta blockers </li></ul><ul><li>Alternative vasodilators </li></ul><ul><li>The combination of isosorbide dinitrate/hydralazine </li></ul>
  90. 94. ORAL MANIFESTATIONS <ul><li>Distention of the external jugular viens. </li></ul><ul><li>Compensatory polycythemia –ruddy complexion and bleeding tendencies. </li></ul><ul><li>Abnormal production of clotting factors </li></ul><ul><li>Bleeding can be spontaneous or extravasational. </li></ul>
  91. 95. <ul><li>DENTAL ASPECTS- </li></ul><ul><li>The dental chair should be kept in partially reclining or erect position and patient should be raised slowly in upright position. </li></ul><ul><li>Emergency dental care should be conservative ,principally with analgesics and antibiotics. </li></ul><ul><li>Appointments should be short </li></ul><ul><li>Non stressful appointments </li></ul><ul><li>Patients are best treated in late morning because of epinephrine levels peak in early morning. </li></ul>
  92. 96. <ul><li>Bupivacaine should be avoided as it is cardiotoxic. </li></ul><ul><li>An aspirating syringe should be used to give local anesthetic </li></ul><ul><li>Epinephrine containing LA should be not given in large doses to patients taking beta blockers. </li></ul><ul><li>Gingival retraction cords containing epinephrine should be avoided </li></ul>
  93. 97. <ul><li>Supplemental o2 shd be available </li></ul><ul><li>Rubber dam is contraindicated when it contributes to breathing difficulty. </li></ul><ul><li>NSAIDS other than aspirin shd be avoided in pts taking ACE inhibitors(renal damage). </li></ul><ul><li>Erythromycin and tetracycline to be avoided as they may induce digitalis toxicity </li></ul>
  94. 98. <ul><li>GA is contraindicated in cardiac failure.until under control(venous thrombosis and pulmonary embolism) </li></ul><ul><li>ACE inhibitors can sometimes cause erythema multiforme,angioedema or burning mouth. </li></ul><ul><li>Antibiotic prophylaxis req for dental care </li></ul><ul><li>History of recent MI ,req delay of elective dental care for 6 months </li></ul>
  95. 99. Ortho static hypotension
  96. 100. <ul><li>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 </li></ul><ul><li>Accordingly there r 2 types- </li></ul><ul><li>Atrial arrhythmia </li></ul><ul><li>Ventricular arrhythmia </li></ul><ul><li>More fatal than AA </li></ul>
  97. 101. <ul><li>TACHYCARDIA- </li></ul><ul><li>Any heart rate faster than 100 beats/minute is labelled tachycardia . BRADYCARDIAS </li></ul><ul><li>A slow rhythm, (less than 60 beats/min), can lead to syncope. </li></ul><ul><li>HEART BLOCK-blockage of cardiac impulse anywhere in the conduction system. </li></ul>
  98. 103. TREATMENT <ul><li>AA- </li></ul><ul><li>Digoxin </li></ul><ul><li>Propanolol </li></ul><ul><li>qUinidine sulphate </li></ul><ul><li>Anticoagulant such as warfarin </li></ul><ul><li>VA- </li></ul><ul><li>Procainamide </li></ul><ul><li>Phenytoin </li></ul><ul><li>Dispyramide </li></ul><ul><li>Propanolol </li></ul>
  99. 104. <ul><li>Physical maneuvers </li></ul><ul><li>Antiarrhythmic drugs </li></ul><ul><li>Electricity </li></ul><ul><li>Electrical cautery </li></ul>
  100. 105. ORAL MANIFESTATIONS <ul><li>Procainamide can cause agranulocytosis,oral ulcerations </li></ul><ul><li>Quinidine-infrequent oral ulcerations </li></ul><ul><li>Disopyramide is anticholinergic agent capable of producing xerostomia. </li></ul><ul><li>verapamil,enalapril can cause gingival hyperplasia. </li></ul>
  101. 106. <ul><li>DENTAL CONSIDERATIONS- </li></ul><ul><li>A proper history to be taken </li></ul><ul><li>Stress and anxiety </li></ul><ul><li>be minimized </li></ul><ul><li>Short appointments </li></ul><ul><li>Use of epinephrine to be minimized </li></ul><ul><li>Proper chair position is important, SUPINE </li></ul><ul><li>At end of appointment chair should be raised slowly to minimize orthostatic hypotension. </li></ul>
  102. 107. <ul><li>Use of vasoconstrictors should be minimized in pts taking digitalis glycosides. </li></ul><ul><li>The equipments like pulp testers ,ultrasonic scalers ,electrosurgical units ,should not be in close proximity. </li></ul><ul><li>Prophylactic antibiotics before and after treatment in recently placed pacemaker patients. </li></ul><ul><li>Pts who report palpitations or skipped beats must be evaluated by physician </li></ul>
  103. 108. <ul><li>Sustained sinus tachycardia above 100 beats/min in resting position is indicative of sinus tachycardia </li></ul><ul><li>Dental treatment shd not be carried out in patients with irregular pulse </li></ul><ul><li>Long use of procainamide can cause a lupus like syndrome </li></ul><ul><li>Drug like quinidine can cause erythema multiforme </li></ul><ul><li>CA may be induced by general anesthesia and vagal reflex </li></ul>
  104. 109. ORAL HEALTH CONSIDERATION & ORAL MANIFESTATION <ul><li>Valvular heart disease that compromises cardiac output produces signs of hypoxemia. </li></ul><ul><li>Cyanosis of lips and oral mucosa is the most prominent oral sign of tissue hypoxia. </li></ul><ul><li>According to American heart association guidelines: Antibiotic prophylaxis should be administered to patitents who have undergone mitral or aortic valve repair or replacement. </li></ul><ul><li>Patients with a prior history of infective endocarditis. </li></ul><ul><li>Patients with mitral or aortic regurgigation or stenosis. </li></ul><ul><li>Patients with mitral valvular prolapse with valvular regurgigation. </li></ul><ul><li>Prosthetic heart valves. </li></ul><ul><li>Previous bacterial endocarditis. </li></ul><ul><li>Acquired valvular dysfunction. </li></ul><ul><li>Complex cyanotic congenital heart disease. </li></ul><ul><li>Surgically constructed systemic pulmonary shunts. </li></ul>
  105. 110. ORAL PROCEDURES & NEED FOR ANTIBIOTIC PROPHYLAXIS TO MINIMISE RISK OF BACTERIAL ENDOCARDITIS <ul><li>Extractions. </li></ul><ul><li>Periodontal procedures including surgery,subgingival,placement of antibiotic fibers or Strips,scaling &root planning. </li></ul><ul><li>Implant placement. </li></ul><ul><li>Tooth reimplantation. </li></ul><ul><li>Placement of orthodontic bands(not brackets). </li></ul><ul><li>Endodontic instrumentation. </li></ul><ul><li>Intra ligamentary injection. </li></ul><ul><li>Prophylatic cleaning of teeth where bleeding is anticipated. </li></ul><ul><li>Other procedure in which significant bleeding is anticipated. </li></ul>
  106. 111. STANDARD REGIMENS FOR PROPHYLAXIS TO MINIMISE RISK OF BACTERIAL ENDOCARDITIS <ul><li>Oral medication. </li></ul><ul><li>Adults & children not allergic to penicillin-amoxicillin. </li></ul><ul><li>Adults & children allergic to penicillin-clindamycin. </li></ul><ul><li>Non oral medication. </li></ul><ul><li>Adults & Childrens not allergic to penicillin-iv or im ampicillin. </li></ul><ul><li>Adults & children alergic to penicillin-iv clindamycin. </li></ul>

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