OVERVIEW OF CARDIOVASCULAR SYSTEM Clinical Examination

The cardiovascular system refers to
● Heart
● Blood vessels (arteries, capillaries and veins)
● blood
Main functions:
● Transport nutrients, gases and waste products around
the body
● Protect the body from infection and blood loss
● Help body maintain constant body temperature 1. Superior and
● Help maintain fluid balance within the body
Medical history and physical exam are always a part of
evaluating a person who has symptoms of chest pain or
pressure or risk factors for coronary artery disease
focus on areas such as:
● Chest pain or pressure, or other symptoms of heart
disease. Ask your patient to describe the symptoms,
does the pain spread to other parts of your body..
● Ask about their health and lifestyle. Ask about
cholesterol levels, blood pressure, exercise habits,
stress level, and other areas of their life. Do they
2. Inferior Vena cava
3. Right atrium (unoxygenated)
smoke or have diabetes or any other health problems?
4. tricuspid valve (unoxygenated) ●
5. right ventricle (unoxygenated)
Family medical history . Ask if one or more of their
6. pulmonary valve (unoxygenated)
7. pulmonary artery (unoxygenated) close relatives have or had early coronary artery
8. pulmonary vein (oxygenated) disease, if they have a family history of heart attack,
9. left atrium (oxygenated)
10. mitral valve(oxygenated)
11. left ventricle (oxygenated)
heart failure, abnormal heart rhythms, sudden death,
12. aortic valve (oxygenated)
13. aorta (oxygenated)
diabetes, high cholesterol, and high blood pressure.
A complete physical exam will also be done. This may include:

• A blood pressure check.

All blood enters the right side of the heart through two
veins: The superior vena cava (SVC) and the inferior vena cava
(IVC)
The SVC collects blood from the upper half of the body. The
IVC collects blood from the lower half of the body. Blood leaves
the SVC and the IVC and enters the right atrium (RA)
When the RA contracts, the blood goes through the tricuspid
valve (4) and into the right ventricle (RV) (5). When the RV
contracts, blood is pumped through the pulmonary valve (6),
into the pulmonary artery (PA) (7) and into the lungs where it
picks up oxygen
Blood now returns to the heart from the lungs by way
of the pulmonary veins (8) and goes into the left atrium (LA) (9).
When the LA contracts, blood travels through the mitral valve
(10) and into the left ventricle (LV) (11). The LV is a very
important chamber that pumps blood through the aortic valve
(12) and into the aorta (13). The aorta is the main artery of the
body. It receives all the blood that the heart has pumped out
and distributes it to the rest of the body. The LV has a thicker
muscle than any other heart chamber because it must pump
blood to the rest of the body against much higher pressure in
the general circulation (blood pressure).
CORONARY ARTERY DISEASE
Coronary arteries are the blood vessels carrying blood
to the heart. Coronary artery disease is the narrowing or
blockage of the coronary arteries, usually caused by
atherosclerosis.
Atherosclerosis is the build-up of cholesterol and fatty
deposits (called plaques) inside the arteries. These plaques can
clog the arteries or damage the arteries, which limits or stops
blood flow to the heart muscle. If coronary arteries are blocked
the heart does not get enough blood, it cannot get the oxygen
and nutrients it needs to work properly. This can cause chest
pain (angina) or a heart attack
• An examination for fatty deposits (xanthomas) under the
skin.
• A general assessment of blood circulation. Circulation
can be evaluated by checking skin color, fingernails and
toenails, and pulses in several locations, including the
neck, wrist, and feet.
• A funduscopic exam of the back of the eye (retina).
Changes in the blood vessels in the retina give clues to
the presence and severity of high blood pressure or
diabetes .
• An examination of the blood vessels of the neck by
looking at them and by listening to blood flow using a
stethoscope.
Bulging or swollen neck veins may be a sign of heart
failure .
Changes in how the blood sounds as it flows
through a narrowed artery can be heard when
listening to the arteries in the neck (carotid arteries).
• Listening to the heart with a stethoscope for heart
murmurs and extra heart sounds.
• Listening to the lungs for abnormal breath sounds. Soft
crackling sounds (crepitations or rales) may be a sign that
heart failure has caused fluid to build up in the lungs.
• An examination of the abdomen. Using a stethoscope,
the doctor will listen to blood flow in the abdomen.
Changes in the sounds of blood flow (bruits) may indicate
a narrowed blood vessel in the abdomen. This is a sign
of hardening of the arteries ( atherosclerosis ) in the large
blood vessels that run through the abdomen.
• A check for swelling in the feet and legs (a sign of heart
failure). Fluid buildup in the legs causes swelling (edema)
and may be a sign of heart failure. To assess swelling in
the legs, the doctor will press down on the skin over the
lower leg bone. Edema is present if the pressure leaves a
dent in the skin.
Diagnosis
The combination of medical history, physical exam,
and electrocardiography (ECG or EKG) is used to evaluate most
people who have chest pain or pressure that does not have a
clear cause. This combination of tests also is used to evaluate
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people who have chest pain or pressure that appears to be
stable angina or those who are at risk for heart disease.
The most common symptom of CAD is angina. Angina
is chest pain and can also be described as chest discomfort,
heaviness, tightness, pressure, aching, burning, numbness,
fullness, or squeezing. It can be mistaken for indigestion or
heartburn. Angina is usually felt in the chest, but you may also
feel it in your left shoulder, arms, neck, back or jaw. Other
symptoms of coronary artery disease include:
• Shortness of breath
• Heart palpitations: irregular heartbeats, skipped
beats or a “flip-flop” feeling in your chest
• A faster-than-normal heartbeat
• Dizziness
• Nausea
• Fatigue
• Sweating
• Shock
• Syncope
• Leg edema
• Pulmonary congestion
• Difficulty breathing when lying down.
Echocardiography
Stress echocardiography can be used to evaluate
hemodynamically significant stenoses in stable patients who are
thought to have CAD. Treadmill echocardiography stress
testing and dobutamine echocardiography stress testing
provide equivalent predictive values.
Nuclear Imaging Studies
Useful in assessing patients with coronary artery
stenoses.
Types of nuclear imaging stress tests include a
treadmill nuclear stress test, a dipyridamole (Persantine) or
adenosine nuclear stress test, and a dobutamine nuclear stress
test.
Computed Tomography
Plaque characteristics on CT angiography appear to
help identify high-risk coronary lesions. Detect and
characterizes coronary plaques prone to rupture,
Electron Beam Computed Tomography
Electron beam CT (EBCT) is a new, noninvasive
method of evaluating calcium content in the coronary arteries.
Healthy coronary arteries lack calcium. As atherosclerotic
plaques grow, calcium accumulates. EBCT is currently used as
a screening test in asymptomatic patients and as a diagnostic
test for obstructive CAD in symptomatic patients,
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) may be used to
gain information noninvasively about blood vessel wall structure
and to characterize plaque composition
Coronary Angiography
An iodinated contrast agent is injected through a
catheter placed at the ostium of the coronaries. The contrast
agent is then visualized through radiographic fluoroscopic
examination of the heart.
Dental Management of Patients
Preventive Measures: careful hx taking, ask about events
causing angina, response to medications or diminished activity,
consult physician.
deal with all the identified risk factors involved.
Early and short morning appointments are advised for all such
patients.
attain a comfortable position in a dental chair.
Pre-medication should be considered to alleviate anxiety and
effective analgesia is important to reduce stress
keep procedure time down to a minimum, and treatment
should be terminated early if the patient becomes overly
anxious.
During Surgery: monitor vital signs, regular verbal contact,
nitrous oxide/ conscious sedation, nitroglycerin nearby
Current medications which the patients are taking and allergies
to any drugs and also any potential drug interactions and side
effects are noted
HYPERTENSION
Hypertension, also known as high or raised blood pressure, is a
condition in which the blood vessels have persistently raised
pressure. Blood is carried from the heart to all parts of the body
in the vessels. Each time the heart beats, it pumps blood into
the vessels.
CLINICAL EXAMINATION
An examination for high blood pressure also includes a medical
history. The extent of the physical exam and the level of detail
in your doctor's questions depend on how high your blood
pressure is and whether you have other risk factors for heart
disease. People who have many risk factors may have a more
detailed evaluation.
The physical exam and medical history includes:
- Your medical history, to evaluate risk factors such as
smoking or family history of high blood pressure.
- Two or more blood pressure measurements.
Measurements may be taken from both the left and
right arms and legs and may be taken in more than
one position, such as lying down, standing, or sitting.
Multiple measurements may be taken and averaged.
- Measurement of your weight, height, and waist.
- An exam of the retina, the light-sensitive lining at the
back of the eye.
- A heart exam.
- An exam of your legs for fluid buildup (edema), and
the pulse in several areas, including the neck.
- An exam of your abdomen using a stethoscope. A
doctor will listen to the blood vessels in the abdomen
for abnormal sounds. These sounds may be caused by
blood flow through a narrowed artery in the abdomen
(abdominal bruits).
- An exam of your neck for an enlarged thyroid ,
distended neck veins, and bruits in the carotid arteries.
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The physical exam and medical history are done to:
1. Check to see if you might have high blood pressure .
2. Check for effects of high blood pressure on organs
such as the kidneys and heart.
3. Determine whether you have risk factors for heart
disease or stroke .
4. Rule out other causes of high blood pressure
(secondary high blood pressure), such as medicines or
other medical conditions.
Your doctor might check for signs that high blood pressure has
already caused damage to your blood vessels, heart, or eyes.
Your doctor might check for:
1. Extra heart sounds caused by enlargement of the
heart.
2. Swollen (distended) neck veins, which may point to
possible heart failure.
3. Abnormal sounds when the doctor listens to the blood
vessels in the abdomen using a stethoscope. These
sounds may be caused by blood flow through a
narrowed artery in the abdomen (abdominal bruits) or
a narrowed artery leading to the kidney (renal artery
stenosis) or by abnormal movement of blood through
the aorta, the main artery that carries blood from the
heart to the rest of the body.
4. Abnormal sound of blood flow (bruit) or diminished or
absent blood flow (pulses) in the blood vessels of the
arms and legs.
5. Abnormal buildup of fluid in the abdomen or legs
(edema).
6. Abnormalities of the blood vessels in the back of the
eye.
CLINICAL MANIFESTATION
Primary hypertension is asymptomatic until complications
develop in target organs, particularly the kidney, cardiovascular
system, cerebrovascular system, peripheral vascular system,
and eyes. Common to the pathogenesis in all of these organ
systems is vascular damage described histologically as either
arteriolosclerosis or arteriosclerosis. Additionally, hypertension
leads to increased atherosclerosis. The kidney is a major target
for the ill effects of hypertension, although this damage may be
occult until late in the progression of the disease.
DIAGNOSIS:
The diagnosis of primary hypertension depends on elevated
systolic and/or diastolic blood pressure in the absence of
secondary causes. Repeated determinations of the blood
pressure are obtained on each of 3 days before a patient is
diagnosed as hypertensive according to the classification
system adopted by the fifth Joint National Committee on
Detection, Evaluation, and Treatment of High Blood Pressure.
When systolic and diastolic pressures fall into different
categories, the higher category is used to determine treatment
strategies. The basic evaluation recommended for patients
diagnosed with hypertension includes a review of the medical
history, physical examination, and laboratory studies.
Fewer than 5% of hypertensive patients have secondary
hypertension caused by pheochromocytoma, renovascular
hypertension, primary aldosteronism, Cusbing's syndrome, or
coarctation of the aorta. Indications for specialized diagnostic
procedures to rule out secondary hypertension are onset of
hypertension before age 30 or after age 60, diastolic blood
pressure greater than 120 mm Hg (millimiters of mercury),
abrupt onset of hypertension, hypertensive retinopathy, or
refractory hypertension. Renovascular disease is the most likely
etiologic factor in younger and older patients suffering from
severe hypertension.
DENTAL MANAGEMENT
Initial evaluation of each patient with hypertension should
include detailed family history of cardiovascular disease and
other related diseases, history of hypertension, medications,
duration and antihypertensive treatment history, severity of
disease, and its complications. Before starting dental treatment,
a dentist has to assess the presence of hypertension, to
determine the presence of associated organ disease and
determine dental treatment changes needed.
Particular attention should be given to accurate measurement
of BP in pregnant women, since pregnancy may alter the patient
BP values, more than 10% of pregnant women having clinically
relevant hypertension. BP monitoring is also necessary in
diabetic patients, patients with autonomous dysfunction, and
elderly patients for which orthostatic hypotension is a big
problem. The dentist must be familiar with other diseases
treated with antihypertensive drugs (such as atenolol,
amlodipine, and carteolol) as headaches, regional pain, renal
failure, glaucoma, and congestive heart failure.
HEART FAILURE
chronic, progressive condition in which the heart muscle is
unable to pump enough blood to meet the body's needs for
blood and oxygen. Basically, the heart can't keep up with its
workload
CLINICAL EXAMINATION
Heart failure is a clinical syndrome and is best defined as a
condition in which patients have - symptoms of heart failure:
typically shortness of breath at rest or during exertion, and/or
fatigue; signs of fluid retention, such as pulmonary congestion
or ankle swelling; and objective evidence of abnormality of the
structure or function of the heart at rest.
Symptoms due to excess fluid accumulation:
- Cough
- Wheezing
- Dyspnea
- Lower extremity edema
Symptoms due to a reduction in cardiac output:
- Fatigue
- Weakness
- Palpitations
- Fainting
Physical findings in heart failure
DIAGNOSIS
Tests you may have to diagnose heart failure include:
- blood tests – to check whether there's anything in your
blood that might indicate heart failure or another illness
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 - an electrocardiogram (ECG) – this records the electrical
activity of your heart to check for problems
- an echocardiogram – a type of ultrasound scan where
sound waves are used to examine your heart
- breathing tests – you may be asked to blow into a tube
to check whether a lung problem is contributing to your
breathlessness; common tests include spirometry and a
peak flow test
- a chest X-ray – to check whether your heart's bigger than
it should be, whether there's fluid in your lungs (a sign of
heart failure), or whether a lung condition could be
causing your symptoms
DENTAL MANAGEMENT
- For undiagnosed patient with symptoms of heart failure:
avoid elective care; refer to physician
- For patients with diagnosed heart failure:
Class I (asymptomatic): routine care
Class II (mild symptoms with exertion): elective care is
good and recommend consultation with physician
Class III or IV (symptoms with minimal activity or at rest):
avoid elective care; if treatment necessary, manage in
consultation with physician; consider referral to a
special patient care setting; avoid use of
vasoconstrictors
- Stress management protocol
- Semisupine or upright chair position
- Take BP, monitor with pulse oximeter
Drug considerations:
- If taking digitalis, avoid vasoconstrictors if possible
- Watch for digitalis toxicity
ARRHYTHMIAS (Dysrhythmias)
The normal heart beats in a regular, coordinated way
because electrical impulses generated and spread by myocytes
with unique electrical properties trigger a sequence of
organized myocardial contractions. Arrhythmias and
conduction disorders are caused by abnormalities in the
generation or conduction of these electrical impulses or both.
Any heart disorder, including congenital abnormalities
of structure (eg, accessory atrioventricular connection) or
function (eg, hereditary ion channelopathies), can disturb
rhythm. Systemic factors that can cause or contribute to a
rhythm disturbance include electrolyte abnormalities
(particularly low potassium or magnesium), hypoxia, hormonal
imbalances (eg, hypothyroidism, hyperthyroidism), and drugs
and toxins (eg, alcohol, caffeine).
Clinical Examination
Signs & Symptoms
Arrhythmia and conduction disturbances may be
asymptomatic or cause palpitations (sensation of skipped beats
or rapid or forceful beats), symptoms of hemodynamic
compromise (eg, dyspnea, chest discomfort, presyncope,
syncope), or cardiac arrest. Occasionally, polyuria results from
release of atrial natriuretic peptide during prolonged
supraventricular tachycardias (SVTs).
Palpation of pulse and cardiac auscultation can
determine ventricular rate and its regularity or irregularity.
Examination of the jugular venous pulse waves may help in the
diagnosis of AV blocks and tachyarrhythmias. For example, in
complete AV block, the atria intermittently contract when the
AV valves are closed, producing large a (cannon) waves in the
jugular venous pulse. There are few other physical findings of
arrhythmias.
Diagnosis
ECG
History and physical examination may detect an arrhythmia and
suggest possible causes, but diagnosis requires a 12-lead ECG
or, less reliably, a rhythm strip, preferably obtained during
symptoms to establish the relationship between symptoms and
rhythm.
The ECG is approached systematically; calipers measure
intervals and identify subtle irregularities. The key diagnostic
features are
● Rate and regularity of atrial activation
● Rate and regularity of ventricular activation
● The relationship between the two
Irregular activation signals are classified as regularly irregular or
irregularly irregular (no detectable pattern). Regular irregularity
is intermittent irregularity in an otherwise regular rhythm (eg,
premature beats) or a predictable pattern of irregularity (eg,
recurrent relationships between groups of beats).
A narrow QRS complex (< 0.12 seconds) indicates a
supraventricular origin (above the His bundle bifurcation).
A wide QRS complex (≥ 0.12 seconds) indicates a ventricular
origin (below the His bundle bifurcation) or a supraventricular
rhythm conducted with an intraventricular conduction defect or
with ventricular preexcitation in the Wolff-Parkinson-White
syndrome.
Bradyarrhythmias
ECG diagnosis of bradyarrhythmias depends on the presence
or absence of P waves, morphology of the P waves, and the
relationship between P waves and QRS complexes.
AV block is indicated by a bradyarrhythmia with no relationship
between P waves and QRS complexes and more P waves than
QRS complexes; the escape rhythm can be
● Junctional with normal AV conduction (narrow QRS
complex)
● Junctional with aberrant AV conduction (wide QRS
complex)
● Ventricular (wide QRS complex)
Absence of AV block is indicated by a regular QRS
bradyarrhythmia with a 1:1 relationship between P waves and
QRS complexes. P waves preceding QRS complexes indicate
sinus bradycardia (if P waves are normal) or sinus arrest with an
escape atrial bradycardia (if P waves are abnormal). P waves
after QRS complexes indicate sinus arrest with a junctional or
ventricular escape rhythm and retrograde atrial activation. A
ventricular escape rhythm results in a wide QRS complex; a
junctional escape rhythm usually has a narrow QRS (or a wide
QRS with bundle branch block or preexcitation).
When the QRS rhythm is irregular, P waves usually outnumber
QRS complexes; some P waves produce QRS complexes, but
some do not (indicating 2nd-degree AV block). An irregular
QRS rhythm with a 1:1 relationship between P waves and the
following QRS complexes usually indicates sinus arrhythmia
with gradual acceleration and deceleration of the sinus rate (if
P waves are normal).
Pauses in an otherwise regular QRS rhythm may be caused by
blocked P waves (an abnormal P wave can usually be discerned
just after the preceding T wave or distorting the morphology of
HOSPIDENT | 4
the preceding T wave), sinus arrest, or sinus exit block, as well
as by 2nd-degree AV block.
Tachyarrhythmias
Tachyarrhythmias may be divided into 4 groups, defined by the
QRS complexes:
● Visibly regular vs irregular
● Narrow vs wide QRS complexes
Irregular, narrow QRS complex tachyarrhythmias include the
following 4 rhythms. Differentiation is based on atrial ECG
signals, which are best seen in the longer pauses between QRS
complexes.
● Atrial fibrillation (AF): Atrial ECG signals (usually best
seen in lead V1) that are continuous, irregular in timing
and morphology, and very rapid (> 300 beats/minute)
without discrete P waves
● Atrial flutter with variable AV conduction: Regular,
discrete, uniform atrial signals (usually best seen in
leads II, III, and aVF) without intervening isoelectric
periods, usually at rates > 250 beats/minute
● True atrial tachycardia with variable AV conduction:
Regular, discrete, uniform, abnormal atrial signals with
intervening isoelectric periods (usually at rates < 250
beats/minute)
● Multifocal atrial tachycardia: Discrete P waves that vary
from beat to beat with at least 3 different
morphologies
Irregular, wide QRS complex tachyarrhythmias include
● The above 4 irregular, narrow atrial tachyarrhythmias
conducted with either bundle branch block or
ventricular preexcitation
● Polymorphic ventricular tachycardia (VT)
Differentiation is based on atrial ECG signals and the presence
in polymorphic VT of a very rapid ventricular rate (> 250
beats/minute).
Regular, narrow QRS complex tachyarrhythmias include
● Sinus tachycardia
● Atrial flutter with a consistent AV conduction ratio
● True atrial tachycardia with a consistent AV conduction
ratio
● Paroxysmal supraventricular tachycardias ([SVT] such
as AV nodal reentrant SVT, orthodromic reciprocating
AV tachycardia in the presence of an accessory AV
connection, and SA nodal reentrant SVT)
Vagal maneuvers or pharmacologic AV nodal blockade can help
distinguish among these tachycardias. With these maneuvers,
sinus tachycardia is not terminated, but it slows or AV block
develops, disclosing normal P waves. Similarly, atrial flutter and
true atrial tachycardia are usually not terminated, but AV block
discloses flutter waves or abnormal P waves. The most common
forms of paroxysmal SVT (AV nodal reentry and orthodromic
reciprocating tachycardia) must terminate if AV block occurs.
Regular, wide QRS complex tachyarrhythmias include
● The above 4 regular, narrow QRS complex
tachyarrhythmias conducted with bundle branch block
or ventricular preexcitation
● Monomorphic VT
Vagal maneuvers can help distinguish among them. ECG
criteria to distinguish between VT and SVT with an
intraventricular conduction defect are often used (see figure
Modified Brugada criteria for ventricular tachycardia). When in
doubt, the rhythm is assumed to be VT because some drugs for
SVTs can worsen the clinical state if the rhythm is VT; however,
the reverse is not true.
Dental Management
Dysrhythmias. Patients who are prone to or who have
cardiac dysrhythmias usually have a history of ischemic heart
disease requiring dental management modifications. Many
advocate limiting the total amount of epinephrine
administration to 0.04 mg. However, in addition, these patients
may have been prescribed anticoagulants or have a permanent
cardiac pacemaker. Pacemakers pose no contraindications to
oral surgery, and no evidence exists that shows the need for
antibiotic prophylaxis in patients with pacemakers. Electrical
equipment such as electrocautery and microwaves should not
be used near the patient. As with other medically compromised
patients, vital signs should be carefully monitored.
INFECTIVE ENDOCARDITIS
Endocarditis usually refers to infection of the
endocardium (ie, infective endocarditis). The term can also
include noninfective endocarditis, in which sterile platelet and
fibrin thrombi form on cardiac valves and adjacent
endocardium. Noninfective endocarditis sometimes leads to
infective endocarditis. Both can result in embolization and
impaired cardiac function.
The diagnosis of infective endocarditis is usually based
on a constellation of clinical findings rather than a single
definitive test result.
Clinical Examination
Infective endocarditis can occur at any age. Men are
affected about twice as often as women. Intravenous drug
abusers, immunocompromised patients, and patients with
prosthetic heart valves and other intracardiac devices are at
highest risk.
Symptoms and Signs
Symptoms and signs vary based on the classification but are
nonspecific.
● Subacute bacterial endocarditis
Initially, symptoms of subacute bacterial endocarditis
are vague: low-grade fever (< 39° C), night sweats,
fatigability, malaise, and weight loss. Chills and
arthralgias may occur. Symptoms and signs of valvular
insufficiency may be a first clue. Initially, ≤ 15% of
patients have fever or a murmur, but eventually almost
all develop both. Physical examination may be normal
or include pallor, fever, change in a preexisting murmur
or development of a new regurgitant murmur, and
tachycardia.
Retinal emboli can cause round or oval hemorrhagic
retinal lesions with small white centers (Roth spots).
Cutaneous manifestations include petechiae (on the
upper trunk, conjunctivae, mucous membranes, and
distal extremities), painful erythematous subcutaneous
nodules on the tips of digits (Osler nodes), nontender
hemorrhagic macules on the palms or soles (Janeway
lesions), and splinter hemorrhages under the nails.
About 35% of patients have central nervous system
(CNS) effects, including transient ischemic attacks,
HOSPIDENT | 5
 stroke, toxic encephalopathy, and, if a mycotic CNS
aneurysm ruptures, brain abscess and subarachnoid
hemorrhage. Renal emboli may cause flank pain and,
rarely, gross hematuria. Splenic emboli may cause left
upper quadrant pain. Prolonged infection may cause
splenomegaly or clubbing of fingers and toes.
● Acute bacterial endocarditis and prosthetic valvular
endocarditis
Symptoms and signs of acute bacterial endocarditis and
prosthetic valvular endocarditis are similar to those of
subacute bacterial endocarditis, but the course is more
rapid. Fever is almost always present initially, and
patients appear toxic; sometimes septic shock develops.
Heart murmur is present initially in about 50 to 80% and
eventually in > 90%. Rarely, purulent meningitis occurs.
● Right-sided endocarditis
Septic pulmonary emboli may cause cough, pleuritic
chest pain, and sometimes hemoptysis. A murmur of
tricuspid regurgitation is typical.
Diagnosis
● Blood cultures
● Echocardiography and sometimes other imaging
modalities
● Clinical criteria
Because symptoms and signs are nonspecific, vary
greatly, and may develop insidiously, diagnosis requires a high
index of suspicion. Endocarditis should be suspected in
patients with fever and no obvious source of infection,
particularly if a heart murmur is present. Suspicion of
endocarditis should be very high if blood cultures are positive
in patients who have a history of a heart valve disorder, who
have had certain recent invasive procedures, or who abuse IV
drugs. Patients with documented bacteremia should be
examined thoroughly and repeatedly for new valvular murmurs
and signs of emboli.
Other than positive blood cultures, there are no
specific laboratory findings. Established infections often cause
a normocytic-normochromic anemia, elevated white blood cell
count, increased erythrocyte sedimentation rate, increased
immunoglobulin levels, and the presence of circulating immune
complexes and rheumatoid factor, but these findings are not
diagnostically helpful. Urinalysis often shows microscopic
hematuria and, occasionally, red blood cell casts, pyuria, or
bacteriuria.
Dental Management
Heart abnormalities that predispose to infective endocarditis.
The internal cardiac surface, or endocardium, can be
predisposed to infection when abnormalities of its surface allow
pathologic bacteria to attach and multiply.
Prophylaxis Against Infectious Endocarditis
● Historically, the rationale for antibiotic prophylaxis of
infectious endocarditis (IE) after dental procedures has
been based on the following facts: Bacteremias have been
shown to cause IE; viridans group streptococci are part of
the normal oral flora and have been commonly found in IE;
dental procedures can cause bacteremias because of
Streptococcus viridans; a large number of case reports
associate dental procedures with subsequent IE; S. viridans
is generally susceptible to the antibiotics recommended for
prophylaxis of IE; antibiotic prophylaxis has been shown to
prevent experimental endocarditis caused by S. viridans in
animals; the risk of significant adverse reaction to the
antibiotic is low in an individual patient, and the morbidity
and mortality of IE are high. When this occurs, the patient
must be treated in the hospital with high doses of
intravenous antibiotics for prolonged periods. Often, the
damaged native heart valve must be surgically replaced
with a prosthetic valve. Although initial recovery from
bacterial endocarditis approaches 100%, recurrent
episodes reduce the 5-year survival rate of patients with
this disease to approximately 60%.
● Recent evidence puts into question the likelihood,
however, that prophylactic antibiotics prevent IE in human
beings. Antibiotics do not consistently prevent
bacteremias after dental procedures. Bacteremias after
chewing, toothbrushing, and other daily activities occur far
more frequently than after dental procedures. Endocarditis
has been shown to occur despite appropriate antibiotic
prophylaxis for dental procedures. Only a small proportion
of IE cases are from dental procedures, and very few cases
of IE would be prevented by antibiotic prophylaxis for
dental procedures, even it if were 100% effective.
ANGINA PECTORIS
Angina pectoris, or just angina, is temporary chest pain or
discomfort caused by decreased blood flow to the heart
muscle.A narrowing of the coronary arteries reduces blood flow
to the myocardium (heart muscle). During times of high demand
such as exercise there is insufficient supply of blood to meet
demand. This causes symptoms the symptoms of angina,
typically constricting chest pain with or without radiation to jaw
or arms. Angina is “stable” when symptoms are always relieved
by rest or glyceryl trinitrate (GTN). It is “unstable” when the
symptoms come on randomly whilst at rest, and this is
considered as an Acute Coronary Syndrome.
DIAGNOSIS
In order to diagnose the cause of angina, the following tests
may be performed:
● Electrocardiogram (ECG): This test records the electrical
activity of the heart, which is used to diagnose heart
abnormalities such as arrhythmias or to show ischemia (lack
of oxygen and blood) to the heart.
● Stress test without imaging: This heart-monitoring test is
used to help evaluate how well the heart performs with
activity. During a stress test, you will usually be asked to
perform physical exercise, like walking on a treadmill. An
ECG is recorded during the period of exercise. The ECG is
assessed by your doctor to see if your heart reached an
appropriate heart rate and if there were any changes to
suggest decreased blood flow to your heart. If you are
unable to perform exercise, pharmaceuticals that mimic the
heart's response to exercise may be used.
● Blood tests: The tests can identify certain enzymes such as
troponin that leak into the blood after your heart has
suffered severe angina or a heart attack. Blood tests can
also identify elevated cholesterol, LDL and triglycerides
that place you at higher risk for coronary artery disease and
therefore angina.
Additionally, the following imaging tests may be performed:
● Chest x-ray: This noninvasive imaging test helps your
doctor rule out other sources of chest pain such as
pneumonia. Imaging with x-rays involves exposing the
chest to a small dose of radiation to produce pictures of
the chest and heart. See the Safety page for more
information about x-rays.
HOSPIDENT | 6
● CT of the chest: Chest CT is a more sensitive test than
chest x-ray that can identify other causes of chest pain
such as aortic disease or blood clots in the blood
vessels of the lungs. This imaging test combines
special x-ray equipment with sophisticated computers
to produce multiple images of the chest and heart. See
the Safety page for more information about x-rays.
● Coronary computed tomography (CT) angiography:
This exam evaluates the coronary arteries (blood
vessels that supply blood and oxygen to the heart) to
determine the extent of narrowing of the arteries due
to plaque without the need for an invasive catheter
feed through the arteries into the heart. Contrast
material is injected through a small line in the arm vein,
similar to the ones used to draw blood.
● Magnetic resonance (MR) imaging: The primary
purpose of this exam is to determine whether there is
good blood flow to the heart muscle. If there are areas
with decreased blood flow, this could indicate plaque
with blood vessel narrowing. This blood flow
evaluation may be done twice during the exam with
the use of a contrast material. The first time may be
performed after the administration of a formation of a blood clot (thrombus). The blood clot typically
pharmaceutical, which stresses the heart like exercise.
The second time will be at rest. Performing the
evaluation both with stress and rest helps determine if
the decreased blood flow only occurs with exercise.
This exam can also assess function of the heart and
determine if there is any scar in the heart muscle. MRI
machines use a powerful magnetic field, radio waves
and a computer to produce detailed images. See the
MRI Safety page for more information about MRI.
● Catheter angiography: In this invasive imaging test, a
thin, long plastic tube, called a catheter, is inserted
into an artery in your groin or hand using a needle. The
catheter is guided with a wire into the coronary arteries
and is used to inject contrast material directly into the
coronary arteries to determine whether there is any
narrowing of the blood vessels. Images of the contrast
material in the blood vessels are captured using x-rays.
Narrowed portions of the vessels can be reopened
using either a balloon or stents.
● Echocardiogram: During this test, a transducer that
produces high-frequency sound waves is used to
create moving images of the heart. The motion of the
walls of the heart is evaluated. If there is decreased
motion within a portion of the wall of the heart, this
could indicate decreased blood flow from narrowing
of the coronary artery. Imaging can also be performed
with a pharmaceutical agent stressing the heart to
detect decreased motion in a portion of the heart
muscle with stress.
● Myocardial Single Photon Emission Computed
Tomography (SPECT): This stress test with imaging is
performed with a nuclear medicine tracer. During an
imaging stress test, the patient is usually asked to
perform some kind of physical exercise like walking on
a treadmill. If the patient is unable to perform exercise
for any reason, drugs that mimic the heart's response
to exercise may be used. A radioactive tracer will be
injected into the blood during the peak of exercise and
images of the heart will be taken. The radioactive
tracer flows with the blood and will show whether
there is an area of the heart with decreased blood flow.
Dental Management
1. People with stable angina can be treated like any other
patients, with a few differences, dentist should have
oxygen and nitroglycerin available during your visit
and should consult with physician before the
appointment to evaluate condition.
2. People with unstable angina should not receive
elective dental care. Emergency dental care should be
performed under continuous heart monitoring
3. Use pulse oximeter to assure good breathing and
oxygenation
4. Excellent local anesthesia- use epinephrine, if needed
in limited amount (max 0.04mg) or levonordefrin (max.
0.20mg)
PREVIOUS MYOCARDIAL INFARCTION
A heart attack occurs when one of the heart's coronary arteries
is blocked suddenly or has extremely slow blood flow. A heart
attack also is called a myocardial infarction.
The usual cause of sudden blockage in a coronary artery is the
forms inside a coronary artery that already has been narrowed
by atherosclerosis, a condition in which fatty deposits (plaques)
build up along the inside walls of blood vessels.
Clinical Examination
An electrocardiogram (EKG)
A physical examination, with special attention to your heart and
blood pressure
Blood tests for serum cardiac markers — chemicals that are
released into the blood when the heart muscle is damaged. The
blood test that doctors order most frequently to diagnose a
heart attack is called troponin.
Additional tests may be needed, including:
An echocardiogram — A painless test that uses sound waves to
look at the heart muscle and heart valves.
Radionuclide imaging — Scans that use special radioactive
isotopes to detect areas of poor blood flow in the heart
Dental Management
1. Consult’s patient’s primary care physician
2. Check with the physician if invasive dental care is
needed before 6 months since the MI.
3. Check wether the patient is using anticoagulants
(including aspirin)
4. Reduction of stress and anxiety
5. Treatment procedure should be minimal invasive
3. Present a case from a credible journal on one of the diseases
mentioned. Make sure it includes the examination up to the
medical management and if possible any DENTAL
CORRELATION or SIGNIFICANCE in terms of DENTAL
MANAGEMENT. Make sure your sources are credible.
HOSPIDENT | 7
 Introduction to Respiratory System
Definition
- The Respiratory System consists of the organs that
exchange these gases between the atmosphere and the
blood.
- Those organs are the nose, pharynx, larynx, trachea,
bronchi, and lungs.
- The overall exchange of gases between the atmosphere,
the blood, and the cells is called respiration.
- The two systems of the body that share the responsibility
of supplying oxygen and eliminating carbon dioxide gas
are the Cardiovascular System and Respiratory System.
- The respiratory and cardiovascular systems participate
equally in respiration. If either system malfunctions, the
body cells will die from oxygen deprivation and
accumulation of carbon dioxide gas death will be
inevitable.
Structure of the Respiratory System
Nose
- Formed by a framework of cartilage and bone covered
with skin and lined internally with mucous membrane.
- The nasal cavity is the uppermost part of the respiratory
system, divided into two by the nasal septum. It is the
best entrance for outside air, as hairs and mucus line the
inside wall and operate as air cleansers
- Function
o Present for creating speech sound - First line of
defense to prevent foreign objects from
entering the respiratory system.
o Detected for the sense of smell
Pharynx
- It is a 5 inches long tube that begins at the internal nares
and extends part way down the neck.
- It also connects the nasal and oral cavities with the
larynx and esophagus.
- It is divided into 3 portions:
o Nasopharynx - uppermost portion, This keeps
the passage to the esophagus covered,
preventing air from entering the digestive
system.
o Oropharynx- Second portion
o Laryngopharynx - lowermost portion
- Function
o Passageway for both air and food
o It forms a resonating chamber for speech
sounds
Larynx
- It is a short passageway that connects the pharynx with
the trachea.
- t has a dual function in the respiratory system: as an air
canal to the lungs (while stopping food and drink from
blocking the airway) –
- It has 2 pair of folds:
o False vocal cords (Vestibular fold) - Prevent air
from exiting the lungs and prevent food or
liquids from getting into larynx
o True vocal cords (Vocal cord) - Produces sounds
- Function
o Produce sound
o It connects the pharynx with the trachea and is
held together by ligaments, membranes, and
fibrous tissue
Trachea
- It is a 4.5 inches long tubular passage connecting throat
and lungs
- Also referred as a windpipe
- It is a pseudostratified, ciliated columnar cells with
goblet cells and basal cells
- Function
o Its most vital function is to enable airflow to
and from the lungs.
Bronchi
- Divided into right primary bronchus and a left primary
bronchus
- The right primary bronchus is more vertical, shorter, and
wider than the left.
- If a foreign object gets past the throat into the trachea, it
will frequently get caught and lodge in the right primary
bronchus.
- The Primary bronchi divide to form smaller bronchi called
secondary or lobar bronchi
- The Secondary bronchi continue to branch forming even
smaller bronchi called tertiary or segmental bronchi
- The Tertiary bronchi divide into smaller branches called
bronchioles
- Bronchioles finally branch into even smaller tubes called
terminal bronchioles
- Function
o Connects trachea into each lung
Lungs
- Are paired, cone-shaped organs located in and filling
the pleural divisions of the thoracic cavity
- There is a grape-like sac in both lungs that allows the
exchange of oxygen and carbon dioxide to take place
called alveoli
- It has been estimated that the lungs contain over 300
million alveoli
- Function
o Give enough supply of oxygen to the body
How does the Respiratory system work?
There are three basic processes of respiration. The first
process is ventilation or breathing, which is the movement of air
between the atmosphere and the lungs. Ventilation has two phases:
inhalation or inspiration to move air into the lungs and exhalation or
expiration to move air out of the lungs. So when you inhale the air
containing the oxygen will enter our nose, pharynx, larynx, trachea
and will divide into the primary bronchi and it will pass through the
bronchioles up to the grape-like sac called alveoli. The alveoli are
connected to the blood vessels called the capillaries which are the
carrier of our blood that contains carbon dioxide. So, when the air
reaches the alveoli which contains the oxygen there is a process
called diffusion that the oxygen in the alveoli will be transfer to the
blood and the carbon dioxide in the blood will be transfer to the
alveoli and then when we exhale the air that comes out is now a
carbon dioxide. During inhalation the diaphragm contracts and pulls
downward, causing the thoracic cavity to expand. During
exhalation the diaphragm relaxes and moves upward, causing the
thoracic cavity to become narrower.

CHRONIC OBSTRUCTIVE PULMONARY DISEASE (COPD)
DEFINITION
- Chronic obstructive pulmonary disease (COPD) is a
chronic inflammatory lung disease that causes obstructed
airflow from the lungs.
- It is a progressive disease that makes it hard to breathe
which means the disease gets worse over time.
- Other terms for COPD include:
o Chronic obstructive airway disease (COAD)
o Chronic airway limitation (CAL)
o Chronic obstructive respiratory disease (CORD).
ETIOLOGY
- Smoking – leading cause of COPD; shows up in a later
part of the patient's life where the lungs are already in
a worse state.
- Occupational smoking - exposure to workplace dusts
found in coal mining, gold mining, and the cotton textile
industry and chemicals such as cadmium, isocyanates,
and fumes from welding have been implicated in the
development of airflow obstruction.
- Air pollution/second hand smoking - it has been
mentioned plenty of times that the effects of secondhand
smoking may be far worse than those who actually
smoke.
- One of the causes is a genetic disorder - Alpha 1-
antitrypsin deficiency is a genetic condition that is
responsible for about 2% of cases of COPD. In this
condition, the body does not make enough of a protein
made in the liver, alpha 1-antitrypsin. Alpha 1-
antitrypsin protects the lungs from damage caused by
protease enzymes, such as elastase and trypsin, that can
be released as a result of an inflammatory response to
tobacco smoke.
- People with present conditions such as asthma may
develop into COPD. Since asthma has bronchial
hyperresponsiveness, this disease inflames and narrows
the airways of the lungs which is one characteristic of
COPD.
CLINICAL EXAMINATION ○
Signs and Symptoms
- Chronic cough - since it is a disease that worsen overtime.
- Wheezing cough is coughing accompanied by
mucus/sputum.
- Chest tightness due to inflamed air sacs so when the
patient breathes in causes an overall feeling of tightness
because the oxygen has difficulty traveling.
- Dyspnea on exertion which means shortness of breath
that is also accompanied by the inflamed air acs.
- Weight loss is a common trait of any patient with a
respiratory disease.
- Respiratory insufficiency - some patients are not able to
breath on their own and require oxygen, or in worse
cases an intubation.
- Respiratory infections - they are more prone to catch
colds, the flu or pneumonia since they are
immunocompromised.
- Barrel chest - a chronic hyperinflation that leads to loss
of lung elasticity caused by blockage of airway due to
air sacs being less elastic.
Clinical Manifestation
- Bronchitis
o It is a condition in which the bronchial tubes are
inflamed. When the lining of the bronchial
tubes are constantly irritated and inflamed, it
causes a long term cough with mucus.
- Emphysema
o It is defined as enlargement of the air spaces
distal to the terminal bronchioles, with
destruction of their walls of the alveoli.
DIAGNOSIS
- The patient should provide current and past medical
history.
- Determine if the patient recently had a cold or the flu, if
the patient or spend time around others who smoke, and
if the patient has been exposed to dust, fumes, vapors,
or air pollution.
- Sputum Mucus Test - to see whether you have a bacterial
infection
- Chest X-ray
- Lung function tests
- Complete Blood Count (CBC)
- Arterial Blood Gas analysis (ABG)
TREATMENT AND MANAGEMENT
Bronchitis and Emphysema
- Medication
o Bronchodilators - Beta Agonist (Albuterol),
Anticholinergics (Ipratropium Bromide-Atrovent)
o Methylxanthines (Theophylline, Aminophylline)
o Corticosteroids
o Oxygen Administration
o Remove Bronchial Secretion
o Promote Exercise
o Control Complications
o Improve General Health
- Surgical
o Bullectomy - Bullae are enlarged air spaces
that do not contribute to ventilation but occupy
space in the thorax, these may be surgically
exercised.
o Lung Volume Reduction Surgery - It involves the
removal of a portion of diseased lung
parenchyma. This allows functional tissue to
expand.
o Lung Transplantation
DENTAL MANAGEMENT
Assessment of medical history (Medical clearance).
- Before doing any procedure, always consider the past
medical history to know if there are any medical
symptoms that may cause complications.
- This may help to provide the type of dental procedure to
be done to the patient. It may help us determine if the
patient is able to undergo a dental procedure or if he is
contraindicated to do so.
- The most important part of the procedure is for the
patient to provide a medical clearance from an
attending physician, preferably a Pulmonologist in order
for the dentist to be able to do the procedure. The
physician will have the authority to decide whether the
patient is allowed to undergo a dental procedure that
won’t cause any complications to the patients current
medical status.

Considerations with sedations.
- In other countries, they provide nitrous oxide as a
sedation in every dental procedure that they do.
- Nitrous oxide is contraindicated in patients with COPD
since it will cause respiratory depression.
Require antibiotic prophylaxis but only with certain drugs.
- It is important for an immunocompromised patient to
undergo prophylactic antibiotics since it prevents the
patients from having bacterial infection afterwards.
- COPD patients who are taking theophylline should not
be given macrolides (e.g. erythromycin, azithromycin and
clarithromycin) ciprofloxacin, clindamycin, which can lead
IV methylxanthine toxicity.
- In any case, the dentist should be prepared to provide a
care for a patient with a complex medical disease such
as COPD because any neglect from either the dentist or
physician can endanger the patient.
BRONCHIAL ASTHMA
DEFINITION
- Asthma is a chronic inflammatory disease that Causes
hyperreactivity of the airways of lungs leading to
wheezing, shortness of breath, chest tightness, and
coughing.
- Asthma is common and prevalent worldwide. There is no
age bar for it, but nearly 50% of cases develop before
the age of 10 years and mostly before age 30.
CLINICAL EXAMINATION
- Wheezing, dyspnea and cough
- Tenacious mucus production
- Symptoms worse at night
- Nonproductive cough
- Limitation of activity
SIGNS
- High respiratory rate, with use of accessory muscles
- Hyper-resonant percussion note
- Expiratory rhonchi, expiration > inspiration
- During very severe attacks, airflow may be insufficient to
produce rhonchi -> SILENT CHEST
- No findings when asthma is under control or with attacks
DIAGNOSIS
- History and patterns of symptoms
- Measurements of lung function
- Spirometry
- Peak expiratory flow
- Measurement of airway responsiveness
- Measurements of allergic status to identify risk factors
- Extra measures may be required to diagnose asthma in
children 5 years and younger and the elderly
DENTAL MANAGEMENT
- Avoid anxiety which may precipitate an asthmatic attack
- Patients are advised to bring their regular medication
with them
- Elective dental care should be deferred in severe
asthmatics until they are in a better phase
- Patient should not be treated during sicknesses (ex. Flu-
like symptoms)
- Allergy to penicillin may be more frequent
PULMONARY TUBERCULOSIS
DEFINITION
- The bacterium Mycobacterium tuberculosis causes
tuberculosis (TB), a contagious, airborne infection that
destroys body tissue. Pulmonary TB occurs when M.
tuberculosis primarily attacks the lungs. However, it can
spread from there to other organs. Pulmonary TB is
curable with an early diagnosis and antibiotic treatment.
- Pulmonary TB, also known as consumption, spread widely
as an epidemic during the 18th and 19th centuries in
North America and Europe. After the discovery of
antibiotics like streptomycin and especially isoniazid,
along with improved living standards, doctors were
better able to treat and control the spread of TB.
- Since that time, TB has been in decline in most
industrialized nations. However, TB remains in the top 10
causes of death worldwide, according to the World
Health Organization (WHO)Trusted Source, with an
estimated 95 percent of TB diagnoses as well as TB-
related deaths occur in developing countries.
- That said, it’s important to protect yourself against TB.
Over 9.6 million people have an active form of the
disease, according to the American Lung Association
(ALA). If left untreated, the disease can cause life-
threatening complications like permanent lung damage.
CLINICAL EXAMINATION
Examination of bronchial asthma is facilitated by using the
following diagnostic criteria:
- attacks of suffocation with difficulty exhaling,
accompanied by dry rales over the entire surface of the
lungs, which can be heard even from a distance (distant
dry rales);
- equivalents of a typical attack of bronchial asthma:
paroxysmal cough at night, disturbing sleep; resurgent
wheezing; difficulty breathing or feeling tight in the
chest; the appearance of cough, wheezing, or wheezing
at a certain time of the year, in contact with certain
agents (animals, tobacco smoke, perfume products,
exhaust gases, etc.) or after physical exertion;
- the detection of an obstructive type of respiratory
failure in the study of parameters of the function of
external respiration
- daily variability of peak expiratory flow rate (20% or
more in patients receiving bronchodilators, 10% or more
without bronchodilators);- disappearance or significant
relief of breathing and an increase in FEV1 by 20% or
more after the application of bronchodilators;
- the presence of a biological marker of bronchial asthma
- a high level of nitrogen oxide (NO) in the exhaled air.
DIAGNOSIS
- To diagnose pulmonary TB specifically, a doctor will ask
a person to perform a strong cough and produce sputum
up to three separate times. The doctor will send the
samples to a laboratory. At the lab, a technician will
examine the sputum under a microscope to identify TB
bacteria.
DENTAL MANAGEMENT
- ACTIVE SPUTUM - Positive tuberculosis should not pre
treated on an outpatient basis.
- PATIENT WITH PAST HISTORY OF PULMONARY TB -
Dentist should obtain medical history of treatment
 duration if less than 18 months or 9 months with physician
consultation.
- PATIENT WITH POSITIVE TUBERCULIN TEST AND A
HISTORY OF ACTIVE
- TB - Prophylactic ionized may be started for 6 months to
a year to prevent clinical disease. Normal treatment can
be done without special precautions
OBSTRUCTIVE SLEEP APNEA
DEFINITION
- Obstructive sleep apnea (OSA) is a condition in which
breathing stops involuntarily for brief periods of time
during sleep. It is a potentially serious sleep disorder.
- This type of apnea occurs when your throat muscles
intermittently relax and block your airway during sleep.
It is when something blocks part or all of your upper
airway while you sleep.
- Periods when breathing stops are called apnea or
apneic episodes
- Snoring is caused by airflow squeezing through the
narrowed airway space.
CLINICAL EXAMINATION
- Normally, air flows smoothly from the mouth and nose
into the lungs at all times. In OSA, the normal flow of air
is repeatedly stopped throughout the night. The flow of
air stops because the airway space in the area of the
throat is too narrow. Snoring is characteristic of
obstructive sleep apnea.
- Your diaphragm and chest muscles have to work harder
to open your airway and pull air into your lungs. Your
breath can become very shallow, or you may even stop
breathing briefly. You usually start to breathe again with
a loud gasp, snort, or body jerk. You may not sleep well,
but you probably won't know that it’s happening.
- The condition can also lower the flow of oxygen to your
organs and cause uneven heart rhythms.
Signs and symptoms of obstructive sleep apnea include:
- Excessive daytime sleepiness
- Loud snoring
- Observed episodes of stopped breathing during sleep
- Abrupt awakenings accompanied by gasping or choking
- Awakening with a dry mouth or sore throat
- Morning headache
- Drowsiness
- Daytime drowsiness puts people with sleep apnea at risk
for motor vehicle crashes and industrial accidents.
Treatment can help to completely relieve daytime
drowsiness caused by sleep apnea.
- Difficulty concentrating during the day
- Experiencing mood changes, such as depression or
irritability
- High blood pressure
- Nighttime sweating
DIAGNOSIS
- It begins with a complete history and physical
examination. A history of daytime drowsiness and
snoring are important clues. Your doctor will examine
your head and neck to identify any physical factors that
are associated with sleep apnea. Your doctor may ask
you to fill out a questionnaire about daytime drowsiness,
sleep habits, and quality of sleep
Tests that may be performed include:
- Polysomnogram - usually requires that you stay overnight
in a hospital or a sleep study center. The test lasts for an
entire night. While you sleep, the polysomnogram will
measure the activity of different organ systems
associated with sleep. It may include:
o Electroencephalogram (EEG), which measures
brain waves
o Electro-oculogram (EOM), which measures eye
movement
o Electromyogram (EMG), which measures muscle
activity
o Electrocardiogram (EKG or ECG), which
measures heart rate and rhythm
o Pulse oximetry test, which measures changes in
your oxygen levels in your blood
o Arterial blood gas analysis (ABG)
MANAGEMENT
- Continuous positive airway pressure (CPAP) therapy is
the first line of treatment for obstructive sleep apnea.
CPAP is administered through a facemask that’s worn at
night. The facemask gently delivers positive airflow to
keep the airways open at night. The positive airflow
props the airways open. CPAP is a highly effective
treatment for sleep apnea.
- Weight Loss
- Nasal decongestants
- Bilevel Positive Airway Pressure (BiPAP or BPAP) - Bilevel
positive airway pressure machines are sometimes used
for the treatment of OSA if CPAP therapy is not
effective. BiPAP machines have settings, high and low,
that respond to your breathing. This means the pressure
changes during inhaling versus exhaling.
- Positional Therapy - Since sleeping on the back (supine
position) can make sleep apnea worse for some people,
positional therapy is used to help those with sleep apnea
learn to sleep in other positions.
- Surgery
o Uvulopalatopharyngoplasty (UPPP) involves
removal of extra tissues from the back of the
throat. UPPP is the most common type of
surgery for OSA, and it helps relieve snoring.
o Tracheostomy may be done as a procedure of
last resort. Tracheostomy punctures an opening
in the windpipe that bypasses the obstruction in
the throat.
DENTAL MANAGEMENT
- Oral appliance therapy is also a commonly
recommended modality for patients with mild to
moderate OSA (or people with severe apnea who
cannot tolerate the use of PAP).
- For people with mild to moderate sleep apnea,
particularly those who sleep on their backs or stomachs,
dental devices may improve sleep and reduce the
frequency and loudness of snoring. Also, people are
more likely to use their dental appliances regularly than
CPAP.
- Mandibular advancement device (MAD). The most widely
used mouth device for sleep apnea, MADs look much like
a mouth guard used in sports. The devices snap over the
upper and lower dental arches and have metal hinges
that make it possible for the lower jaw to be eased
forward. Some, such as the Thornton Adjustable
Positioner (TAP), allow you to control the degree of
advancement.
 - Tongue retaining device. Used less commonly than MAD,
this device is a splint that holds the tongue in place to
keep the airway open.
PULMONARY EMBOLISM
DEFINITION
- A pulmonary embolism (PE) occurs when there is a
blockage in the lung (pulmonary) arteries.
- A blood clot breaks off from another part of the
bloodstream and travels to the arteries in the lungs.
- It can damage part of the lung due to restricted blood
flow, decrease oxygen levels in the blood, and affect
other organs as well. Large or multiple blood clots can
be fatal.
- Deep vein thrombosis (DVT): When a clot is in a deep
vein usually in the thigh or lower leg
CLINICAL EXAMINATION
- Blood clots in the deep veins of the body can have
several different causes, including:
- Injury or damage: Injuries like bone fractures or muscle
tears can cause damage to blood vessels, leading to
clots.
- Inactivity: During long periods of inactivity, gravity
causes blood to stagnate in the lowest areas of your
body, which may lead to a blood clot. This could occur if
you’re sitting for a lengthy trip or if you’re lying in bed
recovering from an illness.
- Medical conditions: Some health conditions cause blood
to clot too easily, which can lead to pulmonary embolism.
Treatments for medical conditions, such as surgery or
chemotherapy for cancer, can also cause blood clots.
SIGNS AND SYMPTOMS
- Shortness of breath - most common symptom
- bluish skin (Cyanosis)
- Chest pain that may extend into your arm, jaw, neck,
and shoulder
- Fainting and lightheadedness
- Swelling of the leg or vein in the leg
- Irregular heartbeat
- Rapid breathing
- Rapid heartbeat
- Restlessness
Spitting up blood
- Weak pulse
DIAGNOSIS
- Chest X-ray: This standard, noninvasive test allows
doctors to see your heart and lungs in detail, as well as
any problems with the bones around your lungs.
- Electrocardiography (ECG)
- MRI
- CT scan
- Pulmonary angiography: This test involves making a
small incision so your doctor can guide specialized tools
through your veins. Your doctor will inject a special dye
so that the blood vessels of the lung can be seen.
- Duplex venous ultrasound: This test uses radio waves to
visualize the flow of blood and to check for blood clots
in your legs.
- Venography: This is a specialized X-ray of the veins of
your legs.
- D-dimer test: A type of blood test.
MANAGEMENT
- Anticoagulants also called blood thinners, prevent new
clots from forming in your blood.
- Clot dissolvers (thrombolytics): These drugs speed up the
breakdown of a clot. They’re typically reserved for
emergency situations because side effects may include
dangerous bleeding problems.
- Compression stocking: These are long socks that squeeze
your legs. The extra pressure helps blood move through
your veins and leg muscles.
- Exercise: It’ll keep the blood in your legs flowing so it
doesn’t have a chance to pool.
- Surgery
o Vein Filter
o Clot Removal
o Open Surgery
DENTAL MANAGEMENT
- They may do the dental procedure in one of 3 ways:
1. continue taking the medications as normal
2. change the dose or type of medications
3. stop the medication before the procedure.
- Furthermore, precautions may be made before, during
and after the dental procedure to reduce the risk of
significant oral bleeding.
- Do not discontinue or alter your medications without the
advice of your physician and dentist.
CASE REPORT
Mark is a 49-year-old Caucasian male who presents to
his PCP for a routine cholesterol check.
Mark has a BMI of 35.4 and was recently diagnosed with high
cholesterol. His doctor had previously advised him to eat better
and exercise to lose weight to improve his cholesterol levels.
Although Mark has been making better nutritional choices in
avoiding foods high in cholesterol, he still hasn’t lost any
meaningful weight. His wife, Sherry, accompanies him to his
appointment. She has been increasingly concerned with Mark’s
actions while resting. She decides to discuss her concerns with the
physician during the routine exam.
Sherry tells the doctor that Mark wakes up throughout
the night, sometimes very abruptly, with choking sounds. She says
that sometimes it also appears as if he is holding his breath for
short amounts of time or even not breathing. When she wakes him,
he is usually startled. The doctor asks if Mark snores, to which
Sherry laughs that Mark has snored very loudly for as long as she
can remember. The doctor questions Mark as to how he feels in the
morning when he wakes up. Mark responds that he usually still
feels tired and catches up on sleep by taking naps. The doctor
refers Mark to a sleep specialist to
determine the cause of his symptoms.
Mark arrives with his wife at the specialist’s office the
following week. Before he sees the physician,
the nurse has Mark and Sherry complete an Epworth questionnaire
to subjectively assess Mark’s degree of sleepiness. The doctor then
performs a physical examination and takes Mark’s medical history,
including sleep and daily functioning habits for him and his family.
The doctor also checks Mark’s tonsils, uvula, and soft palate for
enlarged tissues. Following the examination, the doctor suspects
sleep apnea and orders a polysomnogram (PSG) at the sleep
center in a nearby hospital.
The next evening, Mark appears at the hospital for his
PSG. His doctor has scheduled him to stay overnight for the test.
While he sleeps, the PSG is recording his brain activity, eye
movement, muscle activity, breathing and heart rate, airflow
through his lungs, and oxygen percentage in his blood. He is
monitored by staff at the sleep center while he sleeps. The next
morning, Mark leaves the hospital and is told by staff that his
sleep specialist will call him with the results of the PSG.

Mark’s PSG report shows 24 awakenings in a recording

period of 6.63 hours, resulting in 1.1 hours awake and 5.5 hours
asleep. He has a sleep onset latency of 5.5 minutes. His overall
sleep efficiency is 84%. Throughout the recording period, he is in
Stage 1 sleep for 116.5 minutes, Stage 2 for 203 minutes, and
REM for 10.5 minutes. His EKG summary shows a mean HR of 90
bpm, with his highest

HR at 197 bpm and lowest 41 bpm. The majority of his

sleep (82.11%) was spent in the EKG range of
80-110 bpm. Mark showed obstructive apneas 226 times with the
longest event reaching 41.7 seconds. He had 446 hypopneas with
the longest being 37.9 seconds. His overall RDI was 122.2.
Throughout the study, Mark’s sleeping position was on his back.
The oxygen saturation score showed a total number of drops >4%
of baseline at 629. Mark had 148 respiratory arousals, or
26.9/hour and an index of 8.36 for limb movements.

In a follow-p visit, Mark learns from his physician that he

has a positive diagnosis for obstructive sleep
apnea (OSA), the most common type of sleep apnea. The doctor
explains that the disorder has been
causing Mark to stop breathing for many seconds at a time while
he sleeps. He says that this happens multiple times per hour
because a sufficient quantity of air is not able to flow into Mark’s
lungs as he sleeps. The throat briefly collapses, causing the pause
in breathing. In Mark’s case, because he is overweight, the
enlarged tissue in his throat restricts the throat area from being
open enough to allow
adequate air to flow to his lungs. This causes the amount of
oxygen in his blood to drop. Patients move out of deep and into
light sleep several times throughout the night, resulting in poor
sleep quality. The doctor explains that this is why Mark usually still
feels tired in the morning when he gets out of bed and fatigued
during the day.

The doctor tells Mark that there are currently no

medications to treat the disorder, but there are other
therapeutic methods that can be utilized to help him. The goal for
Mark is to restore his regular nighttime breathing and decrease his
snoring and daytime fatigue. Mark’s doctor warns that if left
untreated, his sleep apnea can increase the chance of having high
blood pressure and even a heart attack or stroke. Since diabetes
also runs in his family, it is also important to know that his sleep
apnea could increase the risk for developing it. Other problems
that could arise are work-related or driving accidents
due to his daytime sleepiness.

His physician recommends that he try to lose some

weight, and prescribes the most common treatment for sleep
apnea, a continuous positive airway pressure (CPAP) machine.
Mark has an insurance plan that covers his PSG, and treatment for
OSA. After the doctor’s medical claim for services goes through to
the insurance company, Mark is assigned a case manager to help
him appropriately handle his disorder.