Dental Management

of
Patients with Cardiovascular Diseases

BY
Dr . Mohamed Seif
Senior Consultant Cardiologist , UHS

1
 Lecture Outlines
n Overview of management of medical
emergencies in the dental clinic.
n Dental management of patients with
common cardiovascular diseases.
n Principals of Cardio-Pulmonary
Resuscitation (CPR).

4/16/22 2
 Lecture Outlines
n Overview of management of medical
emergencies in the dental clinic.
n Dental management of patients with
common cardiovascular diseases.
n Principals of Cardio-Pulmonary
Resuscitation (CPR).

4/16/22 3
Management of Medical Emergencies

Incidence
n A survey done in the 90’s showed that, over
a 10 year period, 90% of dentists have
encountered at least one medical
emergencies.

4
Types
TYPE OF EMERGENCY NUMBER PERCENT

Altered Consciousness 17,782 59

Cardiovascular 4,280 14
Allergy 2,887 9.5
Respiratory 2,718 9
Seizures 1,595 5
Diabetes-Related 999 3
5
Management of Medical Emergencies

n Basic Life Support

n Advanced Life Support

6
 Management of Medical Emergencies
Emergency situations
n Managed properly most emergencies are resolved satisfactorily
n Mismanaged even benign emergencies can turn disastrous
n Recognize
n Position
n Stabilize
n Diagnose
n Treat
n Refer

7
Management of Medical Emergencies

1. Recognition
2. Prevention
3. Preparation
4. Basic life support (BLS)
5. Cardiopulmonary resuscitation (CPR)
6. Specific medical emergencies

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Prevention
n IS THE BEST
TREATMENT

Know your patient

Never treat a STANGER

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Prevention
n 90% of life-threatening situations can be
prevented
n 10% will occur in spite of all preventive
efforts (sudden unexpected death)

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Prevention
n Medical History
n Physical Evaluation
n Vital Signs
n Dialogue History
n Determination of Medical Risk
n Stress Reduction

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Prevention

MEDICAL HISTORY
n Review
n Update
n Medication
n Medical consultation

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Prevention
PHYSICAL EVALUATION
n Length of time since last evaluation
n Vital signs
n Visual inspection of patients
n Referral to physician

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 Prevention

VITAL SIGNS

n Blood pressure n Temperature

n Pulse rate n Height
n Respiratory rate n Weight

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Prevention
DETERMINATION OF MEDICAL RISK.
n Ability of patient to safely tolerate dental
treatment.
n Does patient represent increased medical
risk?
n Can patient be managed in the dental
office?

15
Determination Of Medical Risk

American Society of
Anesthesiology
Physical Status Classification
System

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 ASA I
n A patient without n Can tolerate stress involved
systemic disease In dental treatment
n A normal healthy n No added risk of serious
patient Complications
n Treatment modification
Usually not necessary

17
 ASA II
A patient with mild systemic n Represent minimal risk
disease during dental treatment
Example: n Routine dental treatment
-Well-controlled diabetic With minor modifications
-Well-controlled asthma -Short early appointments
-ASA I with anxiety -Antibiotic prophylaxis
-Sedation

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 ASA III
A patient with severe systemic n Elective Dental Treatment
disease that limits activity but is is not Contraindicated
not incapacitating n Treatment Modification is
Example: Required
- a stable angina - Reduce Stress
- 6 mos. Post - MI - Sedation
- 6 mos. Post - CVA - Short Appointments
- COPD

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 ASA IV
A patient with incapacitating
systemic disease that is a
constant threat to life
Example:
- Unstable angina
- M I within 6 months
- CVA within 6 months
- BP greater than 200/115
- Uncontrolled diabetic
n Elective dental care
should be postponed
n Emergency dental care
only
u Rx only to control
pain and infection
u Other treatment in
hospital
t (I&D, extraction)
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 ASA V
A morbid patient not Elective treatment
expected to survive definitely
Example: contraindicated
- End stage renal disease
- End stage hepatic disease Emergency care only
- Terminal cancer to relieve pain
- End stage infectious disease

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Prevention
STRESS REDUCTION
n Premedication
n Sedation
n Pain control (intra and post-op)
n Early appointments
n Short appointments

22
 Lecture Outlines
n Overview of management of medical
emergencies in the dental clinic.
n Dental management of patients with
common cardiovascular diseases.
n Principals of Cardio-Pulmonary
Resuscitation (CPR).

4/16/22 23
 Common Cardiovascular problems
• Ischemic heart disease :
- Stable Angina Pectoris.
- Acute Myocardial Infarction
• Hypertensive Heart Disease
• Dysrhythmias
• Infective endocarditis
• Dental management of patients using Warfarin
ANGINA PECTORIS
 ANGINA PECTORIS
n Angina is a symptom of ischemic
heart disease produced by myocardial
demand-supply mismatch
n Dental aspects:
q Preoperative glyceryl trinitrate and
oral sedation must be e.g.
Tremazepam are advised .
q Effective local anesthesia is essential.
q Ready access to medical help, oxygen
and nitroglycerine are essential.
4/16/22 27
MYOCARDIAL INFARCTION
( HEART ATTACK )
 MYOCARDIAL INFARCTION
n MI is a condition caused by necrosis of a region of
myocardium due to decrease in myocardial supply.
n It is characterized clinically by substernal pain which
stimulates angina pectoris but is of more intense and is of
longer duration.
n Signs and symptoms:
q Dyspnea
q Orthopnea
q Giddiness
q Nausea
q Vomiting
q Light headedness
4/16/22 30
 MANAGEMENT OF MYOCARDIAL INFARACTION
n PATIENT WITH RECENT ATTACK OF MI
(WITHIN 6 MONTHS):
Ø These patients are on antiplatelets and are on
increased risk of another episode.
Ø Delay of dental treatment for 6 months is advisable.
n PATIENTS WITH EPISODE OF MI(LESS
THAN 6 MONTHS):
Ø Anxiety reduction protocol must be followed.
Ø Dental treatment must be carried out with effective
Local anesthesia, less anxiety and oxygen saturation.
Ø Gingival retraction cords having Adrenaline must be
avoided.
4/16/22 31
AN EPISODE OF MI ON DENTAL CHAIR :
q Terminate all dental treatment if he complaints of chest
pain.
q Remove all foreign objects including cotton gauge
q Change the patient’s position to patient’s comfort. (mostly
upright) .
q Administer 0.5 mg Glyceryl tri-nitrate (GTN) sublingually.
q Monitor vials.
q Postpone dental treatment if can be done.
q Position the patient in a semi reclined procedure if he is
unconscious.
q If conscious, change position to sitting procedure.
q Repeat this after 5 minutes.
4/16/22 32
HYPERTENSION
 HYPERTENSION
n Hypertension refers to blood
pressure that is consistently above
140 /90 mm Hg.
n The blood pressure must be
controlled before any dental
treatment or opinion of a physician
must be sought first.
n It is essential to avoid stress and
anxiety since endogenous
epinephrine released in response to
pain and fear may induce
dysrhythmias.

4/16/22 34
Hypertension
n ASA Risk Status I n ASA Risk Status II
u <140 and < 90 u 140-160 and 90 to 95

u Routine dental u Recheck BP for next

management 3 appointments, if
u Recheck in 6 elevated get medical
months consultation
u Routine dental care

u Stress reducyion

4/16/22 35
Hypertension
n ASA Risk Status III n ASA Risk Status IV

u 160-200 and 95 to 115 u >200/115

u Recheck BP in minutes
u If elevated, medical
consult before dental
treatment
u Stress reduction
4/16/22 36
u Recheck BP in 5
minutes
u Immediate medical
consultation
u No routine treatment
u Emergency treatment
in hospital
u Rx for pain and
infection
 HYPERTENSION
n Systemic corticosteroids may raise BP , must be adjusted
accordingly.
n Some NSAIDS like indomethacin, ibuprofen, naproxen
can reduce efficiency of antihypertensive drugs.
n While giving local anesthetic solution, epinephrine must be
avoided or an aspirating syringe is used (can elevate the
BP causing shock and arrhythmias.)
n Adrenaline is contraindicated in patient with systolic BP
more than 150 mm Hg and diastolic BP more than 110 mm
Hg.
n Conscious sedation is advisable to control anxiety.
n Halothane, enflurane and isoflurane may cause
hypotension in these patients
4/16/22 37
 Vasovagal Syncope

Cause:
Loss of vasomotor tone due to a massive
parasympathetic discharge leading to
decreased pulse rate, and decreased blood
pressure which leads to cerebral hypoxia
and pooling of blood.
 Fainting: Vasovagal Syncope

In Dentistry
n The most common cause is psychogenic due to
fear and anxiety; especially from local anesthetic
n Most common between the ages of 16 and 35
n Males more prone than females
n Fainting is considered SERIOUS in PEDIATRIC
patients and patients OVER 40 years of age
 Vasovagal Syncope
Signs/Symptoms: Treatment:
1. Frightened anxious 1. Place patient in
patient. Trendelenberg’s position.
2. Decreased pulse rate. 2. Monitor vital signs.
3. Decreased blood 3. Administer aromatic
pressure. spirits of ammonia.
4. Cool, moist, clammy 4. Apply cold towel to
skin. forehead.
5. Pale appearance. 5. Administer 100%
oxygen.
6. Reassurance.
Postural Hypotension
Cause:
n disorder of the autonomic nervous system in
which syncope occurs when the patient
assumes the upright position.
 Fainting: Postural Hypotension
n The second most common cause of transient loss
of consciousness.
n Not associated with fear an anxiety
n Predisposing factors
u Administration of Drugs

• Antihypertensive
• Psychotropics, Sedatives, and
Tranquilizers.
u Age: increases with increasing age

u Prolonged recumbency
 Postural Hypotension
Signs/Symptoms: Treatment:
n Decrease in BP and loss of n Stop treatment
consciousness without n Assess consciousness
prodromal signs and n Place patient in the supine
symptoms position with legs elevated
n Heart rate is normal,
n Oxygen
unlike Bradycardia in
Vasovagal Syncope. n Monitor vital signs
n All manifestations of n Slowly reposition patient
unconsciousness
n When patient is placed in
the supine position,
consciousness rapidly
returns.
DYSRHYTHMIA
4/16/22 45
 Heart Dysrhythmias

n Dysrhythmia refers to abnormality in rate , sequence of

cardiac activation due to disturbance in cardiac impulse
generation or conduction.
n It is commonly seen in patients with ischemic heart disease
or myocardial infraction.
n Management :
n Limit the epinephrine level to 0.04 mg.
n Stop dental treatment.
n If angina pectoris occurs, administer oxygen ,minimize
stress and wait till pain resolves.
4/16/22 46
INFECTIVE ENDOCARDITIS
 INFECTIVE ENDOCARDITIS
n Infective endocarditis is infection of heart chambers and
heart valves caused by bacteria, viruses or fungi.
n Infective endocarditis is usually caused by
STREPTOCOCCUS VIRIDANS.
n Other causative organisms include Staphylococcus and
Enterococcus.
n AGGREVATING FACTORS:
n Congenital heart disease
n Rheumatic heart disease
n Prosthetic heart valve
n Scar tissue in cardiovascular system
4/16/22 48
 INFECTIVE ENDOCARDITIS
n DENTAL ASPECTS:
q For dental point of view , it is obligatory to
prevent onset of infective endocarditis.
q This can be done by planned dental care.
q Proper sterilization of dental instruments and
surroundings.
q Giving appropriate antibiotics at appropriate time.
q Proper case history and examination is must in
managing patient with infective endocarditis.

4/16/22 49
 SBE Prophylaxis (Guidelines Update)
n The conditions for which premedication is necessary
includes:
u artificial heart valves

u a history of infective endocarditis

u a cardiac transplant that develops a heart valve problem

u the following congenital (present from birth) heart

conditions:
*unrepaired or incompletely repaired cyanotic congenital
heart disease, including those with palliative shunts and
conduits
*a 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
*any repaired congenital heart defect with residual defect
at the site or adjacent to the site of a prosthetic patch or a
prosthetic device 50
 SBE Prophylaxis

n Patients who previously needed antibiotic

prophylactic but no longer need them include:
u mitral valve prolapse
u rheumatic heart disease
u bicuspid valve disease
u calcified aortic stenosis
u congenital (present from birth) heart
conditions such as ventricular septal defect,
atrial septal defect and hypertrophic
cardiomyopathy
51
SBE Prophylaxis
n Procedures needing prophylaxis:
u All dental procedures that involve manipulation
of gingival tissue or the periapical region of
teeth or perforation of the oral mucosa.
u procedures that do not require prophylaxis are
radiographs, placement of removable
prosthesis, and placement orthodontic bracket.

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53
Prior use of Oral Anticoagulants
LM is scheduled for a root canal. What should be
recommended regarding LM’s warfarin therapy?

A. Continue warfarin therapy

B. Stop warfarin 5 days prior to procedure
C. Stop warfarin 5 days prior and bridge with
low molecular weight heparin therapy
D. Stop warfarin one day prior
E. Check INR and confirm result is < 1.5

4/16/22 55
 Dental Procedures
§ Continue Warfarin
§ Single/multiple tooth
extractions (up to 3)
• Endodontics (root canal)
• Dental hygiene
• Restorative surgery;
supra-gingival
• Dental scaling
• Prosthetics
• Crowns and bridges
4/16/22
Consider other options
Full-mouth extractions
Multiple implant
placements
Extractions of multiple
bony impactions
Gingivectomy
Orthoganthic surgery
56
LM is scheduled for a root canal. What should be
recommended regarding LM’s warfarin therapy?

A. Continue warfarin therapy

B. Stop warfarin 5 days prior to procedure
C. Stop warfarin 5 days prior and bridge with
low molecular weight heparin therapy
D. Stop warfarin one day prior
E. Check INR and confirm result is < 1.5

4/16/22 57
 Lecture Outlines
n Overview of management of medical
emergencies in the dental clinic.
n Dental management of patients with
common cardiovascular diseases.
n Principals of Cardio-Pulmonary
Resuscitation (CPR).

4/16/22 58
Basic Life Support (CPR)
 Survey The Scene, then: RAP

nR -
Responsiveness
u Tap shoulder and
shout “Are you
ok?”
 RAP Activate EMS
n Glance for
spontaneous
breathing and signs
of survival
n A -Then Activate
EMS
 CPR Sequence C-A-B
The 2010 AHA Guidelines for CPR and ECC
recommend CAB sequence.
(chest compressions- airway- breathing)
! Important Points
Five key Rate
aspects Depth
to Great Release
CPR Ventilation
Uninterrupted
Thank you