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ACQUIRED HEART DISEASE CONGENITAL HEART DISEASES VALVULAR HEART DISEASE INFECTIVE ENDOCARDITIS RHEUMATIC FEVER
AQUIRED HEART DISEASE
ISCHAEMIC HEART DISEASE (CORONARY ARTERY DISEASE) ANGINA PECTORIS MYOCARDIAL INFARCTION HYPERTENSION
CORONARY (ISCHAEMIC) HEART DISEASE
CAUSE Atherosclerosis: it is the accumulation of lipids in the arterial walls due to variety of factors. It can lead to vascular thrombosis (clots) and result in embolism
. Its presence is manifested only by its dramatic complications namely: ANGINA PECTORIS MYOCARDIAL INFARCTION IHD often comes without warning or history of heart disease.CORONARY (ISCHAEMIC) HEART DISEASE Clinical features: Cardiac ischaemia in itself is symptomless.
exertion or pain can provoke angina. minimally stressful appointments. Patient should receive dental care in short. Effective painless local anesthesia is essential. anxiety.CORONARY (ISCHAEMIC) HEART DISEASE Dental considerations: Stress. . Patients are best treated in the late mornings.
Vasoconstrictor-containing local anesthetics should not be given to patients taking B-blockers..: Confirm negative aspiration before injection. .CORONARY (ISCHAEMIC) HEART DISEASE Dental considerations«.
.ANGINA PECTORIS It is a severe paroxysmal chest pain caused due to higher myocardial oxygen demand. Cause: ruptured coronary atherosclerotic plaques.
(unlike AMI) .ANGINA PECTORIS Clinical features: Strangling. Precipitated by physical exertion especially in cold weather and emotional stress. compression of the chest sometimes radiating to the left arm or jaw. heaviness. or tightness. Pain is relieved by rest.
ANGINA PECTORIS .
SIGNS & SYMPTOMS .
Dental care should carried out with minimal anxiety & monitor oxygen saturation. Ready access to medical help.ANGINA PECTORIS Dental considerations: Pre-operative glyceryl trinitrate & oral sedation with timazepam are adviced. Effective local anesthesia is essential. oxygen & nitroglycerin is essential . BP & pulse.
Pain should be relieved in 2-3 minutes.ANGINA PECTORIS Management of acute attack during Dental treatment : Stop the treatment immediately. Give 0. Monitor vital signs. Patient should then rest & be accompanied home .6mg sublingual glyceryl trinitrate. Give oxygen & seat the patient upright.3-0.
syncope or hypertension is highly suggestive of MI Continue oxygen & chew 300 mg aspirin & insert IV cannula.ANGINA PECTORIS Management of acute attack during Dental treatment : Pain that persists after 3 doses of nitroglycerin given every 5 minutes & that lasts for more than 15-20 minutes or that is associated with nausea. vomiting. Nitrous oxide/oxygen or 5-10mg of morphine sulphate IV to relieve pain & anxiety .
Pain is NOT relieved by rest. Precipitated by physical exertion and emotional stress. compression of the chest sometimes radiating to the left arm or jaw. MYOCARDIAL INFARCTION (CORONARY THROMBOSIS OR HEART ATTACK) . Strangling. or tightness. Persist for a few hours if death does not supervene. heaviness.Clinical features: Sometimes it is preceded by angina.
cough . sweating. facial pallor. loss of consciousness may also occur. MYOCARDIAL INFARCTION (CORONARY THROMBOSIS OR HEART ATTACK) .Clinical features«: The pain of MI may sometimes start at rest and is not relieved by nitrates. restlessness. Restlessness. Vomiting. apprehension are common.
pain & anxiety should be minimized. MYOCARDIAL INFARCTION (CORONARY THROMBOSIS OR HEART ATTACK) . elective dental care can be carried out safely. Simple emergency dental treatment under LA can be given but opinion of the physician should be sought first. In asymptomatic patients with previous older MI ( >6months & <12 months).Dental considerations: Dental intervention can precipitate dysrhythmias or aggravate cardiac ischaemia especially patients within 6 months of an MI attack (ASA IV). but pain & anxiety should be minimized. In symptomatic patients but older MI (>12 months).
dyspnoea . Dental care should be stopped if there is /are: .rise in HR>40beats/minute ..: Monitor BP.rise in systolic BP >20mmHg There should be ready access to oxygen & medical help MYOCARDIAL INFARCTION (CORONARY THROMBOSIS OR HEART ATTACK) .dysrhythmias .rise in ST segment displacement > 0.2mv on ECG .chest pain . ECG. pulse & oxygen saturation.Dental considerations«.
MANAGEMENT OF MI AS AN EMERGENCY IN DENTAL SURGERY Assess the situation : shake the person & ask in a loud voice ³Are you OK?´ If there is no response Call for medical help Begin basic life support & CPR & continue until help arrives. .
CARDIO PULMONARY RESUSCITATION .
EXTERNAL CARDIAC MASSAGE .
it is generally regarded as hypertension.HYPERTENSION When either or both systolic or diastolic pressure are persistently raised. . with systolic pressure >140 & diastolic >90 mm Hg. & on remeasurement .
Features of advanced hypertension SYMPTOMS Headaches Visual disorders Tinnitus Dizziness Angina SIGNS Hypertension on testing Retinal changes Left ventricular hypertrophy Proteinuria hematuria .
Medical advice before routine dental care.>110 IV 3 .90-99 160-179. Avoid vasoconstrictor.95-109 I II III 1 2 Recheck BP before starting.diastolic ASA grade Hypertension stage Key considerations Routine dental care <140.<90 140-159. Restrict use of epinephrine Recheck BP after 5 mins. Only emergency care until BP controlled. >180.ASA grading & dental management considerations for hypertension BP (mmHg) systolic. quiet rest. Routine dental care Recheck BP before starting .Medical advice before routine dental care.
Avoid anxiety & pain. Pre-operative assurance is important. Some NSAIDS can reduce the efficacy of anti hypertensive agents. Patients are best treated in the late morning.HYPERTENSION Dental considerations: BP should be controlled before elective dental treatment. Do not raise the patient suddenly from the supine position as it may cause postural hypotension & loss of consciousness. Appointments should be short & minimally stressful. . sedation with 10mg temazipam may be helpful. Continuous BP monitoring is indicated.
HYPERTENSION Dental considerations«.: Adequate analgesia must be provided. . Epinephrine effect may be reversed in patients taking beta blockers causing vasodilatation. confirm negative aspiration Vasoconstrictor containing LA should not be given in large doses to patients taking beta blockers.
CONGENITAL HEART DISEASE Clinical features Most striking feature: CYANOSIS Shunting of deoxygenated blood from the right ventricle directly into the left side of the heart & systemic circulation leads to chronic hypoxemia. Chronic hypoxemia causes severely impaired development & often gross clubbing of fingers & toes. . Hemorrhagic or thrombotic tendencies may develop.
greater caries & periodontal disease activity.CONGENITAL HEART DISEASE Dental considerations: Confirm negative aspiration before injection of LA. enamel hypoplasia. Patient with congenital cardiac defects are often liable to infective endocarditis & other complications. greater frequency of positional anomalies. . Oral abnormalities associated are: Delayed eruption of both dentitions. Adequate analgesia must be provided.
a characteristic rash (erythema marginatum).pyogenes) Clinical features A sore throat maybe followed after 3 weeks by an acute febrile illness with pain flitting from one joint to another. Essential features of c/c rheumatic heart disease are fibrotic stiffening & distortion of heart valves often causing mitral stenosis. Usually resolves within 6-12 weeks Other effects: cerebral involvement causing spasmodic involuntary movements (sydenham¶s chorea). lung involvement. . subcutaneous nodules usually around the elbows.RHEUMATIC FEVER It is a disease which sometimes follows a sore throat caused by certain strains of beta-haemolytic streptoccoci (strep.
ERYTHEMA MARGINATUM .
. No special precautions should be necessary as there appears to be little risk of infective endocarditis at this stage.RHEUMATIC FEVER Dental considerations: Acute rheumatic fever patients are exceedingly unlikely to be seen during an attack. Treatment can be done under LA in consultation with the physician. but emergency dental treatment maybe necessary.
INFECTIVE ENDOCARDITIS It is a rare but dangerous. .sanguis It results from two main predisposing factors-bacteraemia and a cardiac lesion where there is turbulent blood flow. potentially lethal infection predominantly affecting the heart valves. Causative organisms: viridans streptococci such as strep.mutans & S.
joint pains. Main effects include progressive heart damage. hepatosplenomegaly are typical. palor.3-4 weeks after dental operation there is insidious onset of low fever & malaise. infection or embolic damage of many organs especially kidneys. . café-au-lait pigmentation of the skin.INFECTIVE ENDOCARDITIS Clinical features: In a previously healthy patient who acquires endocarditis.
PROPHYLAXIS OF INFECTIVE ENDOCARDITIS Situation Standard prophylaxis Medication Amoxicillin Dosage Adult-2 gm Children-50 mg/kg orally 1 hr before procedure Adult-2gm IM/IV Children-30 mg/kg IM/V 30min before procedure Adult-600mg. children-20 mg/kg orally 1 hour before procedure Adult-2 gm children-50mg/kg orally 1 hr before procedure Adult -500mg. children-20mg/kg IV with 30min before procedure Adult-1gm. children-25mg/kg IM/IV with 30min before procedure . children-15mg/kg Orally 1 hr before procedure Unable to take oral medication Ampicillin Clindamycin OR Cephalexin or cefadroxil OR Azithromycin or clarithromycin Clindamycin OR cefazolin Allergic to pencillin Allergic to pencilin &unable to take oral medication Adult-600mg.
Most common cause :IHD .HEART FAILURE Heart failure is when the pumping action of the heart is insufficient to meet the body¶s demand. Lack of tissue & organ perfusion results.
cyanosis. dyspnoea. pink frothy sputum Right sided heart failure: congestion of systemic & portal venous system causing peripheral oedema . coughing. makes respiration less effective .oedema. hepatomegaly&ascites.HEART FAILURE Clinical features Left sided heart failure: lying down worsens pulmonary congestion.fatigue. .
angina & heart failure. dental chair should be kept in a partially reclining or erect position. Dental treatment may precipitate dysrhythmias. Mild controlled cardiac failure: routine dental care can usually be provided Anxiety & pain must be minimised Poorly controlled or uncontrolled cardiac failure: attain medical attention before dental treatment. Emergency dental care with analgesics & antibiotics. Elective dental treatment should be delayed until the condition has been stabilized medically. .HEART FAILURE Dental considerations: It is dangerous to lay any person with left sided heart failure supine.
Confirm negative aspiration before injection.(cardiac failure) . Effective analgesia must be provided.(coughing) itraconazole .HEART FAILURE Dental considerations: Late morning appointments are recommended. Diuretic drugs may cause orthostatic hypotension.thus patient should be raised slowly to upright position. Drugs that can complicate dental treatment: Digitalis .(vomiting) ACE inhibitors . Vasoconstrictor-containing local anesthetics should not be given to patients taking B-blockers. NSAIDs other than aspirin should be avoided in those patients taking ACE inhibitors as they increase risk of renal damage. Monitor BP & ECG especially in patients taking digoxin.
pulmonary hypertension. dysrhythmias. palpitations. . Alcoholic effects on the heart: precordial pain. right ventricular failure.CARDIMYOPATHIES It is a disease of the heart muscle commonly caused by alcoholism Clinical features Frequently there are no symptoms until complications develop.
MI or fibrillation occurs.Antibiotic prophylaxis must be given.CARDIMYOPATHIES Dental considerations Heart muscle enlargement may restrict the movement of the mitral valve leaflets leading to valvular insufficiency & regurgitation. Hence patient is susceptible to Infective endocarditis. Use epinephrine only in limited amounts Nitroglycerines or similar drugs are contraindicated If angina pectoris. oxygen should be administered & CPR must be given. Activate the medical emergency response system .
hypoxia or electrolyte disturbances. fever. Dysrhythmias may arise from cardiac. palpitations & syncope . May be symptomless. Causes dyspnoea. Reduce cardiac efficiency & cardiac output.DYSRHYTHMIAS Clinical features They are disturbances of the heart rhythm or gross disturbances of heart rate resulting from disturbed cardiac impulse generation or conduction. respiratory autonomic or endocrine disease.
defibrillators.DYSRHYTHMIAS Dental considerations Appointments must be made for late mornings or early afternoon. Vasoconstrictor-containing local anesthetics should not be given to patients taking B-blockers. Effective analgesia must be provided. Epinephrine & other vasoconstrictors should be used with caution (lower dose & careful monitoring) in patients with pacemakers & implanted cardioverter. . Confirm negative aspiration before injection.
. Hypothyroidism: slows heart rate Myxoedema: hypercholestremia associated with atherosclerosis.THYROID-RELATED HEART DISEASE Clinical features Untreated thyrotoxicosis: tachycardia. dysrhythmias leading to cardiac failure & MI especially in elderly.
. Vasoconstrictor-containing local anesthetics should not be given to patients taking B-blockers. Effective analgesia must be provided. Hypothyroidism patients with IHD are at increased risk in the dental surgery In severe myxoedema diazepam & other CNS depressants can precipitate coma. Confirm negative aspiration before injection. hyperexcitabilty & excessive sympathetic activity.THYROID-RELATED HEART DISEASE Dental considerations Sedation is desirable as they have heightened anxiety.
chronic cough.PULMONARY HEART DISEASE Clinical features Right ventricular hypertrophy leads to right sided failure with systemic venous congestion & persistent hypoxia. wheezing. often cyanosis . In early stages: dyspnoea.
PULMONARY HEART DISEASE Dental considerations Ipratropium bromide can cause dry mouth Contraindicated drugs: Diazepam or midazolam IV barbituarates -due to their respiratory depressant effects .