This document provides guidelines for managing patients with cardiovascular disease undergoing periodontal treatment. It discusses identifying various cardiovascular conditions like hypertension, ischemic heart disease, congestive heart failure, infective endocarditis, and cerebrovascular accidents. For each condition, it outlines steps to take such as consulting the patient's physician, using local anesthetics with low epinephrine concentration, scheduling short and stress-free appointments, and being prepared to treat anginal episodes or arrhythmias that may occur during treatment. The goal is to perform periodontal therapy safely for patients with cardiovascular complications through proper medical evaluation and stress reduction strategies.

1. MANAGEMENT OF PATIENTS
WITH CARDIOVASCULAR
DISEASE
SUBMITTED BY:SHUBHRA BARDHAR
ROLL NO : 1165
B.D.S IV YEAR

2.  Cardiovascular disease is a common medical condition
found in elderly and medically compromised patients. The
periodontist should identify new cases of these diseases
and must be able to provide adequate periodontal care to
patients. These disorders generally include Hypertension,
Ischemic heart disease, Congestive heart failure, Infective
endocarditis, Cerebrovascular accidents etc.
 CVD can be identified by:
 Taking detailed medical history & limited physical
examination
 Identifying vital signs, including BP & pulse rate
 Consultation with physician if needed
INTRODUCTION

3.  It is defined as a systolic blood pressure of 90 mm Hg or
greater
HYPERTENSION

4.  Stress free, calm & relaxing environment
 Short & afternoon appointments
 LA containing epinephrine conc. not greater than
1:100,000 should be used
 Postural hypotension can be minimized by slow positional
changes in dental chair
 Gingival retraction cord containing epinephrine should be
avoided
 Aspirin may cause sodium & fluid retention & may be
contraindicated in severe hypertension
Guidelines To Do Periodontal
Treatment In Hypertensive Patient

5.  Commonly manifested as angina pectoris & myocardial
infarction
 Guidelines To Do Periodontal Treatment :
1. Physician should be consulted to obtain the formers
fitness to undergo periodontal therapy
2. Instruct the patient to bring their medications,
particularly if they are on nitroglycerin
3. Keep the visit short. Include smaller areas in the mouth
for each visit
4. Dental treatment is generally deferred for atleast 6
months following myocardial infarction because peak
mortality rate is during this time
5. Stress reduction protocol: it induces acute angina attacks
ISCHEMIC HEART DISEASE

6.  Discontinue periodontal procedure
 Administer one tablet (0.3-0.6 mg) of nitroglycerine
sublingually
 Reassure the patient & loosen restrictive garments
 Administer oxygen to the patient in reclined position
 If the signs & symptoms cease within 3 min. complete
the periodontal procedure if possible, making sure that
the patient is comfortable. Terminate the procedure at
the earliest convenient time
 If the anginal signs & symptoms do not resolve with this
treatment within 2-3 min, administer another dose of
nitroglycerin, monitor the patients vital signs , call the
patient’s physician, & be ready to accompany the patient
A Patient Who Has An Anginal Episode In dental
Chair Should Receive Following Emergency Medical
Treatment

7.  A third nitroglycerin tablet may be given 3 min. after
the second. Chest pain that is not relieved by three
tablets of nitroglycerin indicates possible MI. The
patient should be transported to the nearest
emergency medical facility immediately
 Pain that persists after 3 doses & last more than 15-20
min. or associated with diaphoresis, nausea vomiting
syncope or hypotension usually indicate MI. Immediate
transportation to a hospital & vital signs should be
monitered closely . Patient should continue to receive
oxygen along with administration of 5-10 mg of
morphine sulfate IV for pain & anxiety , if
cardiopulmonary arrest occurs while aid is arriving , the
dentist & staff should perform resuscitative measures

8. Cardiac arrhythmias need special attention during
periodontal therapy. Cardiac usually managed with
medications. However some are treated with implantable
pacemaker or automobile defibrillators.
 Guidelines For Periodontal Treatment
 Prior opinion from the patients physician allows
determination of cardiac status the type of pacemaker &
automatic defibrillator
 Treatment should be done in controlled medical setting
with careful cardiac monitoring
 In refractory arrhythmia patient’s use of LA with
vasoconstrictors may be contraindicated
 Stabilizing the operating field with bite blocks or other
devices can prevent unexpected trauma
CARDIAC PACEMAKER & AUTOMATIC
DEFIBRILLATORS

9.  It is a condition in which the pump function of heart is
unable to supply sufficient amount of oxygenated blood
to meet the body’s needs
 Guidelines For Periodontal Treatment
 Semi-recumbent or Upright position : The dental chair
should be adjusted to a comfortable level for the patient
instead of being placed in a supine position. However, it
should be adjusted at a comfortable position for the
patient, especially semi- recumbent or upright
 Schedule stress free, short appointments. Profound local
anesthesia, possibly conscious sedation & use of
supplemental oxygen should be considered
CONGESTIVEHEART FAILURE

10.  It is a disease in which microorganisms colonize the damaged
endocardium or heart valves. Organisms most commonly
encountered in IE are α-hemolytic streptococci along with it
nonstreptococcal organisms present in periodontal pocket including
Eikenella corrodens, Actinobacillus actinomycetemcomitans
Lactobacillus species increase risk of IE
 Preventive Measures To Reduce Risk Of IE :
 A careful medical history will disclose the susceptible patient
 Consult patients physician
 Oral hygeine should be practiced with methods that improve gingival
health yet minimizes bacteremia , In patients with gingival
inflamation , oral hygeine should be limite to procedures ( oral rinse
& gentle toothbrushing) to minimize bleeding , as gingival health
improves more oral hygiene may be initiated
INFECTIVE ENDOCARDITIS

11.  Consult patients physician
 Recommended prophylactic regimens should be practiced
with all susceptible patients
 Pretreatment with chlorhexidine mouthrinses are
recommended before all procedures, including periodontal
probing, to reduce the presence of bacteria on mucosal
surfaces
 When possible , allow 7 days between appointments . If
this is not possible, select an alternate antibiotic regimen
for appointments within 7 day time period
 Teeth with severe periodontitis & poor prognosis may
require extraction
 Sutures reabsorbing in short period of time like chromic
catgut are indicated
Guidelines For Periodontal Treatment

13.  It occurs as a result of ischemic changes or hemorrhagic phenomena
 A sudden interruption of blood flow to the brain, deprives the
neuronal cells from oxygen & result in stroke . Hypertension &
atherosclerosis are predisposing factors to CVA and clinician should
be alert to evaluate them
 Guidelines For Periodontal Treatment
 Stroke patients usually needs oral anti coagulant therapy
 No periodontal therapy should be performed for 6 months due to
risk of recurrence
 Short appointments with minimizing stress
 LA containing epinephrine conc. not greater than 1:100,000 should
be used
 Light concious sedation may be used for anxious patients
 Monitor blood pressure carefully
CEREBROVASCULAR ACCIDENTS

14.  Textbook of periodontics- Shalu Bathla
 Carranza’s clinical periodontology
REFERENCE

15. THANK YOU