Periodontal management of Cardiac patients

1. Periodontal pathology in cardiovascular diseases
Prepared by
SACHIN SUNNY OTTA
DEPARTMENT OF PERIODONTOLOGY
St.Gregorios Dental College
“Wake Up Every Morning With The Thought That Something
Wonderful Is About To Happen”
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2. INTRODUCTION
• It has long been theorized that there is a relationship
between
Periodontal disease and Cardiovascular disease.
Only in the last decade, however, has science made
progress in identifying what dentists have long
observed; that there are cardiac implications in
periodontal disease patients.
• As science discovers new ways to identify the
specific disease process, and pathogens, the dental
profession discovers new ways to manage the
disease from a medical approach.The dental
practitioner will be challenged with a new paradigm
in the next decade and well into the new millennium.
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3. 8/26/2016 3

4. why gingiva succeptible?
BECK’S CASCADE
Perio
Pathogen
LPS
Endotoxin
MØ+PGE & IL
Vasodilation
Vasopermeability
Connective Tissue Degradation
Vasculature
Platelets
Endothelial
Deposition
Smooth
Muscle
Deposition
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5. ETIOPATHOGENESIS
Atheromatous plaque
Periodontal disease
Blood vessel
Blood vessel Atheromatous plaque formation Atheromatous plaque maturation
Vascular subendothelium
Periodontal bacteria (P. gingivalis, F.nucleatum…)
Proinflammatory signals (Cytokines IL6, IL8, etc.)
Medium
layer
InnerlayerBloodvessellumen
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6. Most prevalent category of systemic disease:
• Hypertension
• Angina pectoris
• Myocardial infarction
• Previous cardiac bypass surgery
• Previous cerebrovascular accident
• Congestive heart failure
• Presence of cardiac pacemaker or automatic
cardioverter-defibrillators
• Infective endocarditis
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7. CARDIOVASCULAR DISEASE
CVD caused by
atherosclerosis:
•Coronary heart disease
(myocardial infarction)
•Cerebrovascular disease (stroke)
•Peripheral vascular disease
•Hypertension (high blood
pressure)
Other CVD:
•Congenital heart disease
•Rheumatic heart disease
•Cardiomyopathy
•Cardiac arrhythmias
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8. CARDIOVASCULAR DISEASE vs
PERIODONTAL DISEASE
Cardiovascular disease (CVD) caused by atheroesclerosis have been proven to be
associated with periodontal disease.
Periodontitis is a risk factor for the
development of cardiovascular disease
The Guidelines of the European Society of Cardiology
(ESC) include periodontitis as a risk factor
Individuals with periodontitis are 25% more likely to develop coronary heart disease
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9. Individuals with periodontitis are at increased risk:
2.1 times for acute myocardial infarction
4.3 times for stroke
2.3 times for peripheral vascular disease
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10. FIRST VISIT
Patients physician should be
consulted especially if stressful
or prolonged treatment is
anticipated.
Short appointments and a calm ,
relaxing environment help
minimize stress and maintain
hemodynamic stability.
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11. • AIM :Short appointments in calm , relaxing environment
• MINIMIZE STRESS
• Careful history and consultation from physician
• Proper BP monitoring
-average value of two or more BP readings at 10 min interval,
taken at two or more appointments
• Follow STRESS REDUCTION PROTOCOL
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HYPERTENSION

12. Recognize patient level of anxiety
Premedicate the evening before dental appointment &
after dental t/t (nitrous oxide, diazepam 5mg night before
and 1hr before procedure)
Schedule appointment during afternoon. Avoid during
early morning
Minimize patient`s waiting time.
Short appointments.
Periodic follow up
STRESS REDUCTION PROTOCOL
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13. • Afternoon dental appointments should be given due to
low BP level in the afternoon.
• For systolic BP>180 mm hg & diastolic >110mm hg,
only emergency care should be given.
• Analgesics for pain & antibiotics for infection is given.
• Acute infection require surgical incision & drainage
and surgical field should be limited due to excessive
bleeding.
• Clinician should not use a local anaesthetic containing
epinephrine > 1: 100000 nor a vasopressor to control
bleeding.
• Local anaesthetic without epinephrine can be used for
short procedures.
• Intraligamentary injections are contraindicated.
• If patient exhibits anxiety ,use of conscious sedation in
conjunction with periodontal procedure is warranted.
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14. The initial aim of treatment is to control the infection to stop disease
progression:
 Mechanical biofilm control:
• Oral hygiene at home: brushing, interproximal
hygiene, oral irrigation
• Supragingival tartar removal
• Subgingival scaling and root planing
• Periodontal surgery
 Chemical biofilm control:
• Use of daily-use antiseptics as adjunctive therapy
PERIODONTAL TREATMENT
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15.  Locally:
 Restores health of gums and teeth
 Systemically:
 Reduces systemic inflammation: by lowering levels of C-reactive
protein
 Improves clinical levels of endothelial function
Both parameters are related to an increased risk for future
cardiovascular episodes.
BENEFITS FROM PERIODONTAL
TREATMENT
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16. ISCHEMIC HEART DISEASES
Consist of angina pectoris and myocardial infarction.
Angina pectoris
•Occurs when myocardial oxygen demand exceeds
supply resulting in temporary myocardial ischemia.
•Patients taking nitro-glycerine should be instructed to
bring medication to dental appointments.
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17. For stressful procedures, patient may take nitroglycerin
tablet preoperatively to prevent angina.
A patient who has an angina episode in dental chair should
receive the following emergency medical treatment:
• Discontinue periodontal treatment
• Administer one tablet (0.3-0.6 mg) of nitroglycerin
sublingually.
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18. Administer oxygen with patient in reclined position.
• If signs and symptoms cease within 3 minutes, complete the
periodontal procedure as early as possible.
• If signs and symptoms donot resolve within 2-3 minutes,
administer another dose of nitroglcerin monitor patients vital
sign, call patients physician and be ready to accompany the
patient to emergency department.
Recently,nitroglycerin lingual spray formulation are available,
which provide greater and more rapid vasodilatation with longer
duration of action.
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19. MYOCARDIAL INFARCTION
Dental procedures are deferred for atleast 6 months due
to peak mortality during this time.
• If any of the procedures like cardiac bypass,femoral
artery bypass, angioplasty and endarterectomy are
performed recently , physician should be consulted to
determine degree of heart damage, stability of
patients condition and potential for infective
endocarditis or graft rejection.
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20. CONGESTIVE HEART FAILURE
Congestive heart failure is a condition in which the
pump function of heart is unable to supply sufficient
amounts of oxygenated blood to meet body’s needs.
•
Orthopnea can occur in CHF patients so dental chair
should be adjusted to comfortable level for patient.
• Short appointments, stress reduction with profound
local anesthesia and conscious sedation and use of
supplemental oxygen should be considered.
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21. CARDIAC PACEMAKER AND IMPLANTABLE
CARDIOVERTER- DEFIBRILLATORS
•
Consult with patients physician to determine
underlying cardiac status, type of pacemaker or
automatic cardioverter defibrillator or any precautions
to be taken.
• Older pacemakers are unipolar & generate EM field
newer ones are bipolar and not affected by dental
equipment.
• Automatic cardioverter-defibrillators activate without
warning and cause sudden patient movement
• Stabilize the operating field with bite blocks to
prevent unexpected trauma .
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22. INFECTIVE ENDOCARDITIS
Disease in which microorganisms colonise damaged
endocardium or heart valves
Infective endocarditis prophylaxis recommended:
1.Previous history of infective endocarditis
2.Prosthetic heart valves or prosthetic materials used for
cardiac valve repair
3.CHD with following conditions:
•Unrepaired cyanotic CHD
•Completely repaired congenital heart defect with
prosthetic material or device ,whether placed by surgery
or by catheter intervention during the first six months
after the procedure
•Repair CHD with residual defects at the site or adjacent
to the site of a prosthetic device8/26/2016 22

23. Preventive measures to reduce risk of IE includes:
• Define susceptible patient
• Provide oral hygiene :oral rinses and gentle tooth
brushing with soft brush. As gingival health
improves, more aggressive oral hygiene should be
initiated .Oral irrigators are not used as they may
induce bacteraemia
• During periodontal treatment,currently recommended
Antibiotic Prophylactic Regimen should be practised
with all high risk patients
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24. Regimen Antibiotic Dosage
Standard oral regimen Amoxicillin 2g
30-60min before procedure
Patients Allergic to
penicillin
Clindamycin
Or
Azithromycin
Or
Cephalexin
600mg,30-60min before
procedure
500mg,30-60min before
procedure
2g,30-60min before
procedure
Patient unable to take oral
medication
Ampicillin 2g im or iv within 30 min
before procedure
Patient unable to take oral
medicine & allergic to
penicillin
Clindamycin
Or
Cefazolin
600mg iv within 30min
before procedure
1g iv or im within 30min
before procedure
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25. If periodontal patient is taking systemic antibiotic as
part of periodontal therapy,change in IE prophylaxis
regimen is indicated eg.patient taking penicillin agent
after regenerative therapy may be placed in
azithromycin before next periodontal procedure
• Patients with early onset form of periodontitis have
high level of AA in subgingival plaque which is
resistant to penicillin so tetracycline 250mg 4 times
daily for 14 days is used
• Periodontal treatment should be designed for
susceptible patients to accommodate their particular
degree of periodontal involvement
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26. Guidelines that aid in development of periodontal
treatment plan are:
1. Teeth with severe periodontitis and poor prognosis
require extraction
2. All periodontal treatment procedures require
antibiotic prophylaxis:gentle oral hygiene measures
are excluded
3. Pretreatment chlorhexidine rinses are recommended
before all procedures to reduce bacteria on mucosal
surfaces
4. To reduce the number of visits required numerous
procedure may be accomplished at each appointment
based on patients need
5. When possible ,allow at least 7days between
appointment8/26/2016 26

27. 6. Evidence does not support a need to place
patients at risk for IE on extended antibiotic
regimen after treatment.Therefore patients who
had periodontal surgery are not placed on
antibiotics for first week of healing
7. Regular recall appointments ,oral hygiene
reinforcement, maintenance of periodontal health
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28. CEREBROVASCULAR ACCIDENTS
Results from ischaemic changes or haemorrhagic
phenomenon
• Before any periodontal procedure,there should be
physicians consent
• Active infection should be treated aggressively as
they trigger thrombus formation and ensue cerebral
infraction. So patients should be counselled about
thorough oral hygiene.
• Long term chlorhexidine rinses can be used
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29. Guidelines to treat post cerebrovascular
accident patients:
• No periodontal therapy should be performed for
six months
• After six months,periodontal therapy can be
performed with short appointment and minimal
stress .Concentration of epinephrine in LA greater
than 1:1,00000 is contraindicated
• Light conscious sedation can be used for anxious
patients
• Stroke patients are frequently on oral
anticoagulants. Change in regimen should be done
in consultation with patients physician
• BP should be monitored carefully
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30. TREATMENT
In patients with periodontal disease, the use of antiseptics such as
Chlorhexidine (CHX) combined with Cetylpyridinium chloride (CPC)
are recommended for controlling the level of periodontal
pathogens.
• Maintenance (up to 6 months):
CHX 0.05% + CPC 0.05%
• Treatment (2-4 weeks):
CHX 0.12% + CPC 0.05%
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31. PERIOSTAT
• Suppresses collagenase
• Inhibits host response
• 20 mg capsule
• bid for 3 months
(doxycycline hyclate)
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32. ATRIDOX
(10% doxycycline hyclate)
• Sustained release gel
• suppresses
collagenase
• 1 application X 7 days
• Stand alone therapy
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33. PERIOCHIP
(chlorhexidine digluconate)
• Biodegradable chip
• destroys the bacterial
cell membrane and lyses
the cell
• > 5 mm pockets
• Maintenance
supplement
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34. PREVENTION
In patients with healthy gums, the occurrence of gingivitis must be
prevented.
If gingivitis already exists, its evolution to periodontitis (related with an
increased risk for CVD) must be prevented.
A daily-use antiseptic with Cetylpyridinium
chloride (CPC) is recommended:
Prevents and helps treat gingival inflammation and
bleeding from gingivitis
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35. - Teaching oral hygiene (brushing technique, interproximal
hygiene, etc.)
- Motivation: long-term treatment success depends on
patient compliance
- Dentists form part of a multidisciplinary team, in which
primary care doctors and/or cardiologists are also
participating, to ensure safe and effective treatment of
patients.
RECOMMENDATIONS
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36. DOCTOR DENTIST
Periodontics, as well as the dental profession as a whole, has seen a
shift from surgical to non-surgical approaches based on medicine.
The mechanical/surgical paradigm of practice will be converted to a
pharmacological/regenerative paradigm. It is important to control the
oral microflora for systemic reasons, based on the increasingly strong
association now established between focal infection of oral origin,
specifically periodontal, and a range of systemic diseases, including
coronary heart disease. In a 1998 editorial by Dr. Meskin in the
JADA, he warns the dental practitioner to get ready, because the
word is out that research has identified periodontal disease as a major
risk factor for cardiovascular disease. In short, the dentist is about to
become a doctor and our ability to diagnose must improve. G. V.
Black, in 1908, feared that dentists would become mechanics only
and divorce themselves from the study of pathology. We can
confidently expect future diagnostic tools to be organic, instead of
metallic.
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37. CONCLUSION
It has been proven that a link exists between periodontal disease
and cardiovascular disease.
Periodontal disease is a risk factor for the future development of
cardiovascular disease.
The prevention and treatment of periodontal disease reduces the
risk of cardiovascular disease.
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38. 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.
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39. REFERENCES
• Carranza’s Clinical Periodontology- 11th Edition
(Newman Takei Klokkevold Carranza)
• Textbook of medicine – Churchill Livingstone (3rd edtn)
• Medical problems in dentistry – Prof.Crispian
Scully(7th )
• Emerging risk factors for cardiovascular
diseases:Indian context. Sushil et al. Indian Journal of
Endocrinology and Metabolism / Sep-Oct 2013 / Vol 17
| Issue 5
• www.dentalaid.com
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40. THANK YOU
“…smart people speak from
experience. Smarter people, from
experience do not speak.”
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