CV med in dentistry

1. CARDIOVASCULAR
MEDICINE IN DENTISTRY
Ammar Ghanem Salem
KBMS 4th year Restorative

2. COMMON CV DISEASE
Those that commonly causes heart failure:
Overload 2nd to HTN or valve disease.
IHD
Congenital anomalies.
HTN

3. CONGENITAL HEART DISEASE
Common in children.
Maybe cyanotic (more severe) or
acyanotic.
20% with CHD have other congenital
anomalies.
Develops chronic hypoxemia,
polycythemia, bleeding tendencies,
cardiac failure, pulmonary oedema, and

4. CHD IN DENTISTRY
Should know cardiopulmonary resuscitation CPR.
Take usual medicine on day of dental procedure.
Stability of heart condition with atraumatic dental
treatment under LA is ok.
Visits avoid early morning, favor late morning or early
afternoon.
Adrenaline theoretically raise the BP/precipitate
arrhythmias.
Avoid retraction cords with adrenaline.
Risk of cerebral abscess from oral bacteria.

5. ORAL ABNORMALITIES WITH
CYANOTIC CHD
Delayed eruption of both dentitions.
Positional anomalies.
Enamel hypoplasia.
Higher caries and periodontal disease
activity.

6. ACQUIRED HEART DISEASE
IHD is the major killer in the world.
Serious heart disease can kill without any previous
symptoms.
Common clinical features are:
breathlessness.
Chest pain.
Palpitations.
Cyanosis.
Finger clubbing.

7. IHD IN DENTISTRY
Management depend on the degree of CV risk.
Anxiety and pain can enhance sympathetic activity and adrenaline release 
this increases the load on the heart, risk of angina/arrhythmias.
Hospital admission for dental care in those who have unstable angina and
those who have MI in last 3 months.
Patients with stable angina and 3 months post MI can be treated but with:
 Appointment late morning.
 GTN available and used preoperatively.
 Use of pulse oximetry.
 Avoid adrenaline LA.
 If patient take non-selective beta-blocker max 2 carpules of LA with adrenaline 1:80 000.
 In case of emergency, use GTN aspirin and oxygen.
 Avoid gingival retraction cords with adrenaline.

8. CARDIAC DRUGS SIDE EFFECTS
AND INTERACTIONS (DENTAL
ASPECT)
Indometacin  may interfere with antiHTN
agents
Macrolides and azoles  may cause statins to
produce increased muscle damage.
Diuretics, ACEIs, ARBs, beta blockers (non-
cardioselective), alpha blockers  dry mouth.
ACEIs, ARBs  taste disturbance.
ACEIs, CCBs  angioedema.

9. HYPERTENSION
It is major risk for IS, CVA, MI, HF, CKD…
ASA grading HTN and dental management:
Grade I: <140/90  routine dental care.
Grade II: 140/90-159/99  stage 1 HTN (check BP
before routine dental care).
Grade III: 160/95-179/109 stage 2 HTN (check BP +
seek medical advice + restrict adrenaline use) before
routine dental care.
Grade IV: >180/110  stage 3 HTN ( recheck BP after
5min quiet rest + seek medical advice + only emergency
care until BP is controlled + avoid adrenaline).

10. HTN
It can be primary essential or secondary.
Causes of HTN:
Primary: high (alcohol, salt, BMI), insulin resistance,
sympathetic overactivity).
Secondary: renal, endocrine, cerebral, drugs.
Lifestyle factors:
Increasing BP: obesity, high (salt, alcohol), smoking, stress,
no physical activity).
Decreasing BP: low (salt, alcohol), stop smoking, physical
activity, relaxation, omega-3 fatty acids, fruits and
vegetables, potassium).

11. HTN AND DENTISTRY
Orofacial manifestations:
Facial palsy.
hyposalivation.
Salivary gland swelling and pain.
Lichenoid reactions.
Erythema multiforme.
Angioedema.
Sore mouth.
Paresthesia.

12. HTN AND DENTISTRY
Preoperative reassurance and sedative temazepam given to reduce anxiety.
Treat in late morning.
Aspiration before LA injection.
Caution of lidocaine use in patients on beta blockers (induce HTN and CV
complications).
Avoid retraction cords with adrenaline.
Conscious sedation is advisable.
Avoid sudden change in patient position due to risk of postural hypotension
due to use of antiHTN drugs.
GA agents potentiate antiHTN drugs.
Systemic corticosteroids may raise BP and antiHTN treatment might need
adjustments.

13. IHD AND ATHEROMA
Atheroma: is accumulation of cholesterol and lipids in the
intima of arterial walls.
Can lead to thromboses that break off and move within the
vessels and occlude small vessels (embolism).
Atheroma can lead to  CAD/IHD with angina, MI, CVD
and stroke.
Risk factors are irreversible and reversible:
Irreversible: age, gender, and family history.
Reversible: smoking, blood lipids, HTN, DM, obesity (lack
exercise), and metabolic syndrome.

14. IHD AND DENTISTRY
Short, minimal stressful appointments.
Late morning.
Effective LA with aspiration.
Avoid excessive use of adrenaline, especially those on beta
blockers.
Avoid retraction cord with adrenaline.
Defer conscious sedation for 3 months after MI, recent
angina.
Avoid GA as possible.
Coronary artery stenosis and dental pulp calcification are
significantly associated.

15. ANGINA PECTORIS
Episodes of chest pain caused by myocardial
ischemia 2nd to IHD/CAD.
Usual underlying cause is atherosclerotic plaques
that rupture with resulting platelet activation,
adhesion, and aggregation. Which impeding
coronary artery blood flow.
Features: chest pain (pressure, squeezing in
midportion of the thorax), radiating pain to jaw,
shoulder, arm), dyspnea, epigastric discomfort,
sweating.
Relieved by GTN.

16. ANGINA PECTORIS AND DENTISTRY
Preoperative GTN, oral sedative (temazepam).
Minimal pain, anxiety tx.
Monitoring BP and pulse.
If during treatment patient experience chest pain give GTN
sublingually and oxygen, sit the patient upright and monitor vital
signs, if relieved within 3 mins dismiss home with companion.
If not relieved, MI is possible, summon help, especially if after 3
doses of GTN every 5 mins (continue o2 and let him chew 300mg
aspirin).
Defer CS for at least 3 months with recent AP, unstable angina.
Defer GA for at least 3 months with recent AP, unstable angina.

17. MI AND DENTISTRY
Result from complete blockage of one or more coronary
arteries.
Present similar to AP but is not relieved with rest or
sublingual GTN.
Patient within 6 months of MI are classed as ASA IV, defer
elective procedures and simple emergency under LA by
opinion of a physician first.
Symptomatic patients with old MI 6-12 months, carry out
elective procedures safely with minimal anxiety and pain,
while high risk procedures elective ones defer.
Asymptomatic patients with older MI >12 months, normal
elective procedure carried out with minimal pain and

18. MI AND DENTISTRY
Preoperative GTN.
Monitoring BP, pulse and oxygen saturation.
Stop procedure if chest pain, dyspnea, rise in PR
40beats/min, arrhythmias, or rise in systolic BP
>20.
Elective surgery under GA should be postponed for
at least 3 months.
Use adrenaline with caution.
Do not need antibiotic cover to prevent
endocarditis.

19. CARDIOMYOPATHY AND DENTISTRY
Heart muscle disease.
Factors: IHD/CAD, nutritional diseases, HTN…all are extrinsic.
Intrinsic: drug and alcohol toxicity, hepatitis C.
Most individuals have normal quality and duration of life.
Limited amount of adrenaline.
GTN contraindicated.
CS with approval of physician.
GA poor risk.
In case of AP, MI or fibrillation occurs give o2, perform CPR and call
emergency.

20. ARRHYTHMIAS
Any disorder of heart rate or rhythm.
If beats too quickly (tachycardia), too slowly (bradycardia) or
irregularly.
Most arise from problems in cardiac electrical system.
Significance:
-Atrial fibrillation  dangerous (due to thromboses)
-Bradycardia  occasional dangerous.
-Premature contraction  maybe insignificant.
-Tachycardia  can be dangerous.
-Ventricular fibrillation  emergency (cardiac arrest).

21. ARRHYTHMIAS
Extrasystoles are most common true arrhythmia.
It is extra beats or contractions, and a feature of cardiac
disease or injury.
Atrial extrasystoles (PACs): common in healthy people with
normal heart, but can occur when there’s increased pressure on
atria (Cardiac failure, mitral valve disease).
Ventricular extrasystoles: more common in heart disease. It is
commonest type of arrhythmia arising after MI, may lead to
CHF.
Tachycardias: resting HR >100 beats/min.
Sinus tachycardia: increase HR in normal response to exercise
or emotional stress by effect sympathetic NS.

22. ARRHYTHMIAS
Supraventricular tachycardia (SVT/atrial tachycardia): is fast HR that
starts in the cardiac upper chambers.
The rapid HR doesn’t allow enough time for the heart to fill before it
contracts, so blood to body is compromised.
SVT is common in: children, females, anxious young ppl, large
amounts of coffee, drink alcohol heavily, smoke heavily.
Atrial fibrillation AF is most common arrhythmia. It is end point for
many cardiac diseases that caused atrial myocyte damage and
fibrosis.
AF is associated with thrombus formation.
Ventricular tachycardia: usually result of heart disease most
commonly previous MI.

23. ARRHYTHMIAS
VF is dangerous and rapid heart rate doesn’t allow the
heart to be filled before it contracts, compromising body.
VF is effective type of cardiac arrest and an imminently
life-threatening.
Bradycardias: slow cardiac rhythm <60 beats/min, caused
by pause in normal activity of SA node or blocking of
impulse between the atria and ventricles.
Long QT syndrome: liable to sudden death, they have
delayed ventricular repolarization, second most common
cause of sudden cardiac arrest in children and young
adults.

24. LONG QT SYNDROME AND
DENTISTRY
Cardiologist consultation.
Avoid stress and GA.
Avoid adrenaline and other drugs that prolong QT interval.
Bupivacaine, erythromycin, azole antifungals and GA
agents (ketamine, succinylcholine, atropine) are
contraindicated.
Lidocaine and mepivacaine are preferred due to less
cardiac arrest.
Midazolam or propofol maybe used.
Isoflurane is GA of choice.
If sudden cardiac arrest occur only treatment is AED.

25. ARRHYTHMIAS AND DENTISTRY
Appointments late morning or early afternoon.
Arrhythmias can be induced in old patients and
those of IHD /aortic stenosis by:
 Neck manipulation (vagal reflex)
 LA rarely
 Supraventricular or ventricular ectopics develop during
dental extractions or surgery (rare).
 Drugs (GA agents esp. halothane, digitalis, erythromycin,
azole antifungals)

26. CARDIOVASCULAR IMPLANTABLE
ELECTRONIC DEVICES (CIED) AND
DENTISTRY
Avoid elective dental care for first few weeks.
Aspiration before LA.
Avoid stress and pain (danger of endogenous
adrenaline).
Avoid vasoconstrictors (may rise BP 
atrial/ventricular arrhythmias).
Avoid intraligamental or intraosseous injections.
Avoid gingival retraction cords.
Mepivacaine is preferable to lidocaine

27. PACEMAKERS AND DENTISTRY
Avoid some dental electrical devices, especially if it
is placed very close to the pacemaker.
Electrosurgery is contraindicated.
Avoid use of piezoelectric ultrasonic scalers,
ultrasonic baths, pulp testers, electronic apex
locators. Belt-driven motors in dental chairs, old
radiography machines.
Should be supine, electrical equipment should be
30 cm away.
No need antibiotic cover to prevent endocarditis.

28. AUTOMATIC IMPLANTABLE
CARDIOVERTER DEFIBRILLATORS
(AICD) AND DENTISTRY
Caution with use of adrenaline.
Device can function suddenly which
lead to possible injury to patient or
clinician.
Do not need antibiotic cover.

29. THYROID RELATED HEART DISEASE
AND DENTISTRY
Hyperthyroidism can raise metabolic rate and activity of the heart.
It can lead to tachycardia and arrhythmias  cardiac failure or MI.
Hypothyroidism can slow heart rate and develops atheroma in patients with
hypercholesterolemia which lead to IHD.
If uncontrolled hyperthyroidism, high anxiety, hyperexcitability, excessive
sympathetic activity.
Effective anesthesia with aspiration, avoiding LA with epinephrine in large
doses.
Avoid gingival retraction cords.
CS maybe beneficial preferring NO and O2.
Avoid GA.
Hypothyroid patients are at risk in dental surgery if have CAD.

30. PULMONARY HEART DISEASE (COR
PULMONALE)
Heart disease result from excessive overload on the right
ventricle by diseases of the lungs or pulmonary
circulation esp. COPD.
Drug can cause dry mouth.
LA to control pain.
CS with diazepam or midazolam is contraindicated
(respiratory depressant).
NO and O2 maybe acceptable.
IV barbiturates contraindicated due to same effect of
diazepam.

31. KAWASAKI DISEASE
Acute febrile illness with
lymphadenopathy and desquamation of
lips, fingers, and toes.
Most common cause of severe childhood
heart disease.
LA maybe given, CS inappropriate, and GA
is contraindicated.

32. KAWASAKI AND DENTISTRY
Oral changes:
Strawberry tongue.
Labial oedema.
Crusting/cracking of lips.
Pharyngitis.
Oropharyngeal erythema.
Cervical lymphadenopathy.
Facial palsy (sometimes).

33. VALVULAR HEART DISEASE
RHEUMATIC FEVER
Affect children 5-15 yrs old.
Usually followed by chronic rheumatic carditis with
permanent cardiac valvular damage.
It follow a sore throat after 3 weeks by acute
febrile illness.
Emergency dental treatment maybe necessary.
They are mostly anticoagulated.
Effective LA is given.
CS is given if cardiac function is good.

34. INFECTIVE ENDOCARDITIS
A result of bacterial or fungal infection of the
endocardium.
Rare but potentially life-threatening.
Predominantly affecting damaged heart valves.
Risk factors:
Prosthetic heart valve.
Structural/ congenital heart disease.
IV drug use.
Invasive procedures.

35. WHO NEED PRE-MEDICATION
Prosthetic cardiac valve.
History of previous IE.
History of CHD

36. IE AND DENTISTRY
Low risk category doesn’t need antibiotic prophylaxis.
Procedures associated with bleeding no longer exclusively indicated
for antibiotic prophylaxis.
Only procedures with statistically significant difference in
bacteremia between a pre- and post-procedure blood
sample.
Use of azithromycin syrup for children who refuse tab or
cap and those who have dysphagia. (this might affect QT
interval).
Antibiotic prophylaxis is no longer mandatory for IE susceptible
patients who are to undergo dental care.
Why?? Next slide

37. WHY NO LONGER RECOMMENDED?
The antibiotic regimens fail in some instances.
Adverse reactions to antimicrobials are possible
(anaphylaxis).
Cost effectiveness is questionable.
Increased risk of resistant bacteria.
Dental treatment is a proven cause of few cases of IE.
NICE issued in 2008 “antibiotic prophylaxis is now not
recommended for patients at risk of endocarditis

38. CARDIAC FAILURE
When any structural or functional
impairment of the pumping action of the
heart leads to blood output insufficient to
meet the body’s demands.
HF or congestive HF is common.
Most common cause is IHD.

39. HF AND DENTISTRY
Control medical condition for uncontrolled CF before any dental tx.
Elective to be deferred, while emergent are treated conservatively by
analgesics and antibiotics.
Those who mild controlled CF, should be short appointments, in late
morning.
Keep dental chair in partial reclining or erect position (supine worsen
dyspnea in left sided HF).
Effective analgesia due to danger of arrhythmia from pain and anxiety.
Avoid bupivacaine, use lidocaine or prilocaine.
Use LA with aspiration and avoid large doses of adrenaline.
Avoid gingival retraction cords containing adrenaline.
Supplement with O2, CS usually safe, GA is contraindicated until it’s under
control.

40. CF TX DRUGS
ACEIs: causes coughing, angioedema, burning
mouth, erythema multiforme.
Digitalis: vomiting, caution with erythromycin
and tetracyline.
Diuretics: orthostatic hypotension, caution with
carbamazepine.

41. SURGERY
Vascular surgery: bypass grafts to the aorta and lower limb
vasculature, no evidence of odontogenic infection of such
grafts , nor any good evidence that antimicrobial
prophylaxis should be given for dental care.
Post-angioplasty: elective dental care is deferred for 6
months, emergency should be given in hospital.
Coronary artery bypass graft: should not receive
adrenaline, first weeks after surgery patient feel severe
pain when reclining in dental chair.
Vascular stents successfully engrafted: prudent to provide
antibiotic coverage if emergent dental tx required during
the first 6 weeks. Elective tx deferred. Long term use of

42. SURGERY
Cardiac valve surgery: should have excellent oral
health before operation.
Teeth with poor pulpal and periodontal prognosis
should be removed before valve replacement,
major surgery for congenital anomaly of a heart
transplant.
Teeth with shallow caries and PDL pocket should
conserved.
Avoid elective dental care for 6 months after
surgery.
st

43. HEART TRANSPLANTATION AND
DENTISTRY
Immunosuppressive therapy can lead to
liability to infections and to a bleeding
tendency.
Establish optimal oral health before surgery.
6 months after surgery, defer elective tx, and
for dental surgical tx during the 6 months that
follow the transplantation, until ECG is
normal, give antibiotic prophylaxis against EI.
LA without adrenaline is indicated.

44. REFERENCE
Scully’s medical problems in
dentistry, chapter 5,
cardiovascular medicine p.125-
170