Cardiovascular Diseases / Dental management

Cardiovascular
Diseases (I)
Prepared & designed by:
Mohammed M. Nasser

Cardiovascular diseases (CVD)
A group of diseases of heart and the
vascular system.
▪ 1- Hypertension
▪ 2- Ischemic Heart diseases (AP and MI)
▪ 3- Congenital Heart diseases
▪ 4- Rheumatic Heart Diseases
▪ 5- Cardiac Arrythmia
▪ 6- Infective Endocarditis
▪ 7- Surgically Corrected Cardiovascular
Lesions
Mohammed
M.
Nasser

Cardiovascular diseases (CVD)
Hypertension Angina pectoris Myocardial
infarction (MI)
Previous CVA
Congestive heart
failure
Cardiac pacemakers Infective
endocarditis
Mohammed
M.
Nasser

Hypertension
▪ Hypertension is an abnormal elevation in arterial
pressure that can be fatal if sustained and untreated.
▪ The blood pressure is the product of cardiac output
and peripheral resistance and is dependent on the
heart and vasculature, autonomic nervous system,
endocrine system and kidneys.
▪ In adults, a sustained systolic blood pressure of 140
mmHg or greater and/or a sustained diastolic blood
pressure of 90 mmHg or greater is defined as
hypertension.
Mohammed
M.
Nasser

Hypertension
▪ The systolic pressure is the force that the blood exerts on the artery walls as
the heart contracts to pump the blood to the peripheral organs, while the
diastolic pressure is residual pressure exerted on the arteries as the heart
relaxes.
▪ The difference between diastolic and systolic pressures is called pulse
pressure.
▪ Mean arterial pressure is roughly defined as the sum of the diastolic pressure
plus one-third the pulse pressure.
Mohammed
M.
Nasser

Etiology
Primary/
Essential/
Idiopathic
Hypertension
Secondary
Hypertension
Mohammed
M.
Nasser

Etiology
Primary/ Essential/ Idiopathic
Hypertension
▪ Primary/essential hypertension is the
most common type of hypertension
and accounts for about 90% of all
cases presenting with high blood
pressure with no readily identifiable
cause for their disease.
▪ This type of hypertension has and a
genetic link and is often associated
with cardiovascular risk factors,
smoking, obesity, lipid problems, and
diabetes.
Secondary Hypertension
▪ Secondary hypertension is always due to an underlying
cause such as intrinsic renal diseases, renovascular disease,
Pheochromocytoma, Cushing’s syndrome, thyroid or
parathyroid disease, heavy alcohol consumption, chronic
corticosteroid therapy, chronic NSAIDS therapy, or long-
term oral contraceptive use can lead to secondary
hypertension.
▪ The secondary hypertension patient experiences symptoms
quite early on compared to the primary/essential
hypertension patient and the symptoms are more severe.
▪ Many patients with secondary hypertension may be cured
after treatment of the underlying cause.
Mohammed
M.
Nasser

Classification of Hypertension Adults
and Recommendations for Follow-Up
▪ A recent classification redefines “normal” blood pressure as <120/80 mmHg and introduces a new
category of “prehypertension” (120-139/80-89 mmHg).
▪ Adapted from the National Heart, Lung, and Blood Institute.
BP Classification Systolic BP
(mm Hg)
Diastolic BP
(mm Hg)
Recommended Follow-up
Normal <120 and <80 Recheck in 2 years.
Prehypertension 120–139 or 80–89 Recheck in 1 year.
Stage 1
hypertension
140–159 or 90–99 Confirm within 2 months.
Stage 2
hypertension
≥160 or ≥100 Evaluate or refer to source of care within 1 month.
For patients with higher pressures (e.g., >180/110
mm Hg), evaluation and treatment referral are needed
immediately or within 1 week, depending on the
clinical situation and complications.
Mohammed
M.
Nasser

Classification of Hypertension Adults
and Recommendations for Follow-Up
Some authors define hypertension as:
• Mild when the systolic blood pressure is140-159 mmHg and the diastolic is
90-99 mmHg.
• Moderate when the systolic is 160-179 mmHg and diastolic is 100-109
mmHg.
• Severe when the systolic pressure is ≥180 mmHg and the diastolic is ≥110
mmHg.
Mohammed
M.
Nasser

Lifestyle risk factors modifying
hypertension
▪ Lifestyle can play an important
role in the severity and
progression of hypertension,
significant contributing factors
include:
▪ Obesity
▪ Excessive alcohol intake
▪ Excessive dietary sodium
▪ Physical inactivity
Mohammed
M.
Nasser

Clinical features
▪ One third of the hypertensive patients are asymptomatic or only have trivial
complications like epistaxis.
▪ Symptoms include; headaches, visual disturbances, tinnitus, dizziness.
▪ Signs include; hypertension on testing, retinal changes, left ventricular
hypertrophy, proteinuria and hematuria.
▪ Blood pressure is measured with the use of a sphygmomanometer. The
diagnosis is based on an average of two or more properly measured, seated
blood pressure readings on each of two or more office visits.
Mohammed
M.
Nasser

▪ (A) Standard blood pressure cuff (sphygmomanometer) and stethoscope
▪ (B) and (C) automated blood pressure devices.
Mohammed
M.
Nasser

The manual technique for recording blood
pressure includes the following steps:
▪ 1. Alcohol and smoking should be avoided for 30 min before measurement.
▪ 2. Allow the patient to sit comfortably seated without the legs crossed for as long as possible
(at least 5 minute).
▪ 3. Palpate right brachial pulse Before placement of the cuff.
▪ 4. Place sphygmomanometer cuff on right upper arm with about 3 cm of skin visible at the
antecubital fossa: The standard cuff typically has a mark or arrow that designates the
midpoint of the bladder, which is centered above the previously palpated brachial artery.
▪ 5. The stethoscope is placed over the previously palpated brachial artery at the bend of the
elbow in the antecubital fossa (not touching the cuff)
Mohammed
M.
Nasser

The manual technique for recording blood
pressure includes the following steps:
▪ 6. Inflate the cuff slowly to about 200–250 mmHg, or until the pulse is no longer palpable.
▪ 7. Deflate cuff slowly while listening with stethoscope over the brachial artery over skin on
inside of arm below cuff.
▪ 8. Record the systolic pressure as the pressure when the first tapping sounds appear
(Korotkoff sounds).
▪ 9. Deflate cuff further until the tapping sounds become muffled (diastolic pressure) and then
disappear.
▪ 10. Record blood pressure as systolic/diastolic pressures.
Mohammed
M.
Nasser

Blood pressure cuff and stethoscope in place.
Mohammed
M.
Nasser

Management
❖ Hypertension is diagnosed by standardized serial blood pressure
measurements. Investigations to identify a ‘secondary’ cause and
assess end-organ damage (also called target organ damage)
include:
▪ chest radiography (cardiomegaly is suggestive of hypertensive
heart disease)
▪ ECG (may indicate ischemic heart diseases)
▪ serum urea and electrolytes (deranged in hypertensive renal
disease and endocrine causes of secondary hypertension)
▪ urine testing (blood and protein suggests renal disease).
Mohammed
M.
Nasser

Management
❖ Relaxation, weight loss, high-fiber
diet, reduction in salt intake,
restricting alcohol consumption,
restricting caffeine intake, stopping
smoking and taking more exercise and
avoidance of acute emotions.
❖ Antihypertensive therapy; the
minimum dose should be used with
minimum side effects.
Mohammed
M.
Nasser

Management
❖ Note: About 20% of patients with untreated stage
1 hypertension have what is called white coat
hypertension, which is defined as consistently
elevated BP only in the presence of a health care
worker but not elsewhere.
In these patients, accurate BP readings may require
self-measurement at home or 24-hour ambulatory
monitoring.
Persons with BP elevation in this setting are at lower
risk for hypertensive complications than are those
with sustained hypertension.

Antihypertensive
agents
Diuretics
•Thiazide diuretics like Chlorothiazide
•Loop diuretics like Furosemide
•Potassium-sparing diuretics like Amiloride
•Aldosterone receptor blocker like Spironolactone
•combination like Aldactazide.
Angiotensin-converting enzyme
(ACE) inhibitors
•Captopril, Enalapril and Ramipril.
Angiotensin receptor blockers
(ARBs)
•Candesartan
•Losartan.
Beta-adrenergic blockers
•Cardioselective like Atenolol
•Nonselective like propranolol.
Calcium-channel blockers (CCBs) •Amlodipine, Nifedipine and Verapamil.
Alpha1-adrenergic blockers •Doxazosin & Prazosin.
Combined alpha and beta blockers •Carvedilol.
Central alpha2-agonists and
centrally acting drugs
(Sympatholytics)
•Clonidine & Methyldopa.
Vasodilators •Hydralazine & Minoxidil.

Management/ Malignant
(accelerated) hypertension
▪ Accelerated hypertension (systolic >200 mmHg, diastolic >130 mmHg) typically affects young
adults, especially those of African or Afro-Caribbean heritage and, like essential
hypertension, often causes no symptoms until complications develop. It may present with
headaches, visual impairment, nausea, vomiting, fits (seizures) or acute cardiac failure. The
chief complication is severe ischemic damage to the kidneys and renal failure, which can be
fatal within 1 year of diagnosis. Other causes of death are cardiac failure or cerebrovascular
accidents.
▪ Life-threatening accelerated hypertension requires urgent hospital admission with the aim to
reduce the blood pressure slowly with oral antihypertensives. Rarely, intravenous
antihypertensives (sodium nitroprusside) are used but a sudden drop in blood pressure may
result in a stroke (cerebral infarction), thus it should be avoided. Vigorous treatment, if
started before renal damage is too far advanced, can greatly improve the life expectancy.
About 50% of such patients can now expect to live for at least 5 years.
Mohammed
M.
Nasser

Dental management
The first task is to identify patients with hypertension, both
diagnosed and undiagnosed. A medical history, including:
▪ The diagnosis of hypertension
▪ Treatment
▪ Identification of antihypertensive drugs
▪ Compliance of the patient
▪ The presence of symptoms and signs associated with
hypertension
▪ The level of stability of the disease, should be obtained.
Mohammed
M.
Nasser

Dental management
Blood pressure
measurements should be
routinely performed for all
new patients and at recall
appointments, also for
patients who are not
compliant with treatment,
who are poorly controlled, or
who have comorbid conditions
such as heart failure, previous
MI, or stroke.
Mohammed
M.
Nasser

Dental management
The main concerns when one is providing dental treatment for a patient with hypertension:
1. During the course of treatment, the patient might experience an acute elevation in blood
pressure that could lead to a serious outcome such as stroke or MI. This acute elevation in
blood pressure could result from the release of endogenous catecholamines in response to
stress and anxiety, from injection of exogenous catecholamines in the form of vasoconstrictors
in the local anesthetic, or from absorption of a vasoconstrictor from the gingival retraction
cord.
2. Potential drug interactions between the patient's antihypertensive medications and the
drugs prescribed and oral adverse effects that might be caused by antihypertensive
medications.
Hypertension is regarded as a minor clinical predictor of increased perioperative cardiovascular
risk.
Mohammed
M.
Nasser

Dental management
Based on blood pressure measurements, the dental management is as follows:
Blood pressure Dental management
≤120/80 Any treatment can be provided.
≥ 120/80 but ˂ 140/90 Any treatment can be provided but encourage the patient to seek medical consultation.
≥ 140/90 but ˂ 160/100 Any treatment can be provided but encourage the patient to seek medical consultation.
≥ 160/100 but ˂ 180/110 Any treatment; consider intraoperative monitoring of blood pressure for upper level stage
2, treatment should be terminated if blood pressure rises above 179/109.
The patient should be referred to physician promptly.
≥ 180/110 Any elective treatment is deferred and the patient is referred to physician.
Only emergency treatment is provided; the patient should be managed in consultation
with the physician, and measures such as intraoperative blood pressure monitoring,
electrocardiogram monitoring, establishment of an intravenous line, and sedation may be
used. The decision must always be made as to whether the benefit of proposed treatment
outweighs the potential risks.
Mohammed
M.
Nasser

Dental management
Once it has been determined that the hypertensive patient can be safely treated, the
following should be considered:
✓ Stress/anxiety reduction.
✓ Establishment of good rapport.
✓ Short, morning appointments.
✓ Consider premedication with sedative/anxiolytic like Diazepam 2-5 mg the night before
surgery and/or 1 hour before surgery
Mohammed
M.
Nasser

Dental management
✓ Consider the use of nitrous oxide/oxygen
(conscious sedation), ensure adequate oxygenation
at all times, especially at the termination of
administration. Hypoxia is to be avoided because of
the resultant elevation in blood pressure that may
occur.
✓ Slow position changes to prevent orthostatic
hypotension.
✓ Consider periodic intraoperative blood pressure
monitoring for patients with upper level stage 2
hypertension; terminate appointment if blood
pressure rises above 179/109.
Mohammed
M.
Nasser

Dental management
✓ Obtain excellent local anesthesia; adrenalin in modest amounts is acceptable. One or two
cartridges of 2% lidocaine with 1:100.000 adrenalin are of little clinical significance in most
patients with hypertension. Use of more than this amount may well be tolerated but with
increasing risk for adverse hemodynamic changes. Intravascular injections should be avoided
through the use of aspirating syringes.
✓ Avoid the use of adrenalin-impregnated gingival retraction cord because these cords contain
highly concentrated adrenalin, which can be quickly absorbed through the gingival sulcular
tissues, resulting in tachycardia and elevated blood pressure.
✓ Noradrenalin and levonordefrin should be avoided in patients with hypertension because of
their comparative excessive alpha1 stimulation.
Mohammed
M.
Nasser

Dental management
✓ The use of adrenalin is generally not advised in patients with uncontrolled or severe
hypertension, and indeed. However, if urgent treatment becomes necessary, a decision must be
made about the use of adrenalin, which will be dictated by the situation.
✓ The other concern is for the adverse interactions between vasoconstrictors and the
nonselective beta-blocking agents (such as propranolol) or peripheral adrenergic antagonists
(such as Reserpine and Guanethidine). Available reports and clinical experience suggest that
adrenalin in small doses of one to two cartridges containing 1:100.000 adrenalin can be used
safely in most patients.
Mohammed
M.
Nasser

Adrenalin-impregnated gingival
retraction cord
Mohammed
M.
Nasser

Oral Manifestations
No oral complications have been associated with hypertension itself.
➢ Patients with malignant hypertension have been reported to occasionally develop facial palsy.
➢ Patients with severe hypertension have been reported to bleed excessively after surgical procedures or
trauma.
➢ Patients who take antihypertensive drugs, especially diuretics, may report dry mouth.
➢ Lichenoid reactions have been reported with thiazides, methyldopa, propranolol, and labetalol.
➢ ACE inhibitors may cause neutropenia, resulting in delayed healing or gingival bleeding, non-allergic
angioedema and burning mouth.
➢ All calcium channel blockers may cause gingival hyperplasia.
Mohammed
M.
Nasser

Gingival hyperplasia in a patient
taking a CCB.
Mohammed
M.
Nasser

Cardiovascular Diseases / Dental management

Ischemic Heart diseases
▪ Ischemic Heart Disease (IHD) also called Coronary Artery Disease
(CAD) is the most common and important cardiac disease and it is the
most common cause of death.
▪ IHD is cause by Atheroma (Atherosclerosis, also called
Arteriosclerosis), it is characterized by the accumulation of
cholesterol and lipids in the intima of arterial walls, and can lead to
thromboses, which sometimes break off and move within the vessels
to lodge in and occlude small vessels (embolism). Atheroma can thus
lead to IHD with angina, myocardial infarction (MI), cerebrovascular
disease and stroke. It also affects other arteries and can cause, for
example, ischemic pain in the calves whilst walking – intermittent
claudication – seen especially in young smokers.
Mohammed
M.
Nasser

Ischemic Heart diseases
Atheroma results from a combination of genetic and lifestyle factors.
❖ Irreversible (fixed) risk factors include increasing age, male gender and family history of atheroma.
❖ Potentially reversible risk factors for atheroma include:
• Cigarette smoking. Persons who smoke 20 or more cigarettes daily have a two or threefold increase in
coronary artery diseases.
• Blood lipids.
• Hypertension.
• Diabetes mellitus. There is a two-eightfold higher rate of cardiovascular events.
• Obesity and lack of exercise.
Mohammed
M.
Nasser

Progression
of myocardial
necrosis after
coronary
artery
occlusion

Angina pectoris
▪ Episodes of chest pain caused by myocardial
ischemia, it affects 1% of the adult
population and its prevalence increases with
age.
▪ The usual underlying causes are
atherosclerotic plaques that rupture. Arterial
spasm alone may, rarely, be responsible.
▪ The mortality rate in angina is about 4% per
year, the prognosis depending on the degree
of coronary artery narrowing.
Mohammed
M.
Nasser

Angina pectoris
The most common precipitating causes of angina pain are:
▪ Physical exertion (particularly in cold weather)
▪ Emotion (especially anger or anxiety)
▪ Stress caused by fear or pain, leading to adrenal release of
catecholamines (epinephrine and norepinephrine) and consequent
tachycardia, vasoconstriction and raised blood pressure.
▪ Consequently, an increased cardiac workload is accompanied by a
paradoxical drop in blood flow and myocardial ischemia occurs
resulting in angina.
Mohammed
M.
Nasser

Angina pectoris/ Clinical features of
angina
• Chest pain described as a pressure sensation,
fullness or squeezing in the mid-portion of the
thorax, the pain lasts for less than 10-15 minutes
about 2-5 minutes in most cases, relieved by rest or
glyceryl trinitrate.
• Radiation of chest pain into the jaw/teeth,
shoulder, arm, and/or back.
• Occasionally associated dyspnea or shortness of
breath, epigastric discomfort or sweating.
Mohammed
M.
Nasser

Angina pectoris/ Types of angina
➢ Stable angina: induced by effort, stress or sometimes eating, it is relieved by rest or
Nitroglycerin.
➢ Unstable angina: (crescendo) angina of increasing frequency or severity, occurs on minimal
exertion or at rest, the pain is not readily relieved by Nitroglycerin, there is increased risk of MI.
➢ Decubitus angina: precipitated by lying down.
➢ Variant or Prinzmetal's angina: caused by coronary artery spasm.
* The term acute coronary syndromes (ACS) are a term used in unstable angina and evolving
MI which share a common underlying pathology; plaque rupture, thrombosis and
inflammation.
Mohammed
M.
Nasser

Angina pectoris/ Tests
✓ Resting ECG; ST depression, flat or
inverted T wave.
✓ Exercise ECG.
✓ Thallium-201 scan; highlights ischemic
myocardium.
✓ ambulatory (Holter) electrocardiography
and exercise echocardiography.
✓ Coronary angiography.
Mohammed
M.
Nasser

Angina pectoris/ Management
❖ Identify and correct risk factors;
▪ Stop smoking
▪ Encourage exercise and weight loss
▪ Control hypertension and diabetes.
Mohammed
M.
Nasser

❖ Antiplatelet drugs like aspirin 75-325 mg/24 h andor clopidogrel.
❖ β blockers; atenolol 50-100 mg/24h, unless contraindicated (asthma, COPD,
bradycardia, coronary artery spasm).
❖ Nitrates; for symptoms give glyceryl trinitrate (GTN) spray or sublingual tablets 0.3
mg to reduce the peripheral vascular resistance and reduce oxygen demands. Also long
acting nitrates isosorbide mononitrate 20-40 mg twice daily or slow-release nitrate.
❖ Calcium antagonists; amlodipine, diltiazem, especially when β-blockers are
contraindicated.
❖ Potassium channel activator; nicorandil.
Mohammed
M.
Nasser

❖ Percutaneous transluminal
coronary angioplasty (PTCA); aims
to open up the coronary blood flow
by inserting a balloon- tipped
catheter through the groin up into
the area of arterial blockage.
❖ Coronary artery bypass grafts
(CABG) are vascular grafts made to
bridge the obstructions in the
coronary blood vessels.
Mohammed
M.
Nasser

Myocardial Infarction (MI)
▪ Myocardial infarction results from the
complete occlusion (blockage) of one or
more coronary arteries.
▪ It arises when atherosclerotic plaques
rupture causing platelet activation,
adhesion and aggregation with
subsequent thrombus formation within
the coronary circulation.
▪ Angina may progress to MI but fewer
than 50% of patients with MI have any
preceding symptoms.
Mohammed
M.
Nasser

Myocardial Infarction (MI)
▪ Complications of MI include weakened heart muscle, resulting in acute
congestive heart failure, post-infarction angina, infarct extension, cardiogenic
shock, pericarditis, and arrhythmias.
▪ Causes of death in patients who have had an acute MI include ventricular
fibrillation, cardiac standstill, congestive heart failure, embolism, and rupture
of the heart wall or septum.
Mohammed
M.
Nasser

Myocardial Infarction (MI)/ Clinical
features
➢ Chest pain described as a pressure
sensation, fullness or squeezing in the mid-
portion of the thorax. 10-20% of individuals
have silent (painless) MI.
➢ Radiation of chest pain into the jaw/teeth,
shoulder, arm, and/or back.
➢ Associated dyspnea or shortness of
breath.
➢ Associated epigastric discomfort with or
without nausea and vomiting.
➢ Associated diaphoresis or sweating.
➢ Syncope or near-syncope without other
cause.
➢ Impairment of cognitive function without
other cause.
* 50% of the patients die within the first hour
of MI and a further 10-20% within the next
few days.
Mohammed
M.
Nasser

Myocardial Infarction (MI)/ Diagnosis
Diagnosis of MI is by:
▪ Clinical features
▪ ECG (large Q wave, ST elevation and T
inversion)
▪ Change in the serum levels of cardiac
enzymes which include; Troponin T (TT),
Creatine Kinase MB (CK-MB), Aspartate
transaminase (AST) and Lactic
dehydrogenase (LDH).
Mohammed
M.
Nasser

Myocardial Infarction (MI)/
Management
• Alert emergency services (if in community) or cardiac arrest team (if in
hospital).
• Aspirin (300 mg); to be chewed. Clopidogrel.
• Rest and reassure.
• Pain relief: opioid analgesia (diamorphine) is usually necessary.
• Oxygen administration.
Mohammed
M.
Nasser

Management
• Early thrombolytic therapy (Streptokinase, Urokinase, Alteplase or Reteplase), the greatest
benefit is realized when patients receive thrombolytic drugs within the first 3 hours after
infarction; however, modest benefit is possible even up to 12 hours after the event. The early
use of thrombolytic drugs may decrease the extent of necrosis and myocardial damage and
dramatically improve outcome and prognosis.
• Primary percutaneous intervention to dissolve the coronary thrombus provided the patient is
not at risk of a life-threatening hemorrhage.
• Insulin infusion to prevent stress hyperglycemia.
Mohammed
M.
Nasser

Management
• General pharmacologic measures for patients with acute MI include the use
of nitrates, beta blockers, calcium channel blockers, ACE inhibitors, and lipid-
lowering agents. Antiplatelet drugs are significant in decreasing morbidity and
mortality.
• Sedatives and anxiolytic medications also may be used.
• Prompt treatment of complications, particularly cardiac arrhythmias. During
the first several weeks after an infarction, the conduction system of the heart
may be unstable, and patients are prone to serious arrhythmias and re-
infarction.
Mohammed
M.
Nasser

Dental management
➢ Identification of patients with a history of ischemic heart diseases, and if the patient
is not under medical control we have to refer him to physician for an evaluation and
control.
➢ The potential problem related to the dental procedure is that, the stress and anxiety
during the dental procedure, and excessive amount of vasoconstrictor in local
anesthesia may precipitate the attack of angina pectoris, MI, arrhythmia, or sudden
death.
➢ In general, recent MI and unstable angina are classified as clinical predictors of
major risk for perioperative complications like serious arrhythmias and re-infarction.
Stable (mild) angina and past history of MI are identified as clinical predictors of
intermediate risk for perioperative complications.
Mohammed
M.
Nasser

Dental management/ Patients with
stable angina or past history of MI (more
than 6 months) [Intermediate risk]
➢ Short Morning appointment with comfortable chair position is
recommended.
➢ Pretreatment vital signs should be recorded including pulse rate and blood
pressure as a base line record.
➢ Nitroglycerin sublingual tablets should be readily available and in some cases
prophylactic preoperative nitroglycerin is advisable especially when the patient
has angina more than once a week.
Mohammed
M.
Nasser

➢ Stress-reduction measures which include:
✓ Good communication
✓ Oral sedation (e.g., Diazepam 2-5 mg on the night before and 1 hour before
the appointment)
✓ Intraoperative Nitrous oxide and oxygen but hypoxia should be avoided.
✓ Excellent local anesthesia
Mohammed
M.
Nasser

➢ Limited use of vasoconstrictor (maximum 0.036 mg adrenalin, 0.20 mg levonordefrine), not
more than two cartridges containing 1: 100.000 adrenalin or 1:20.000 levonordefrine, this is
also applicable if patient is taking a nonselective beta-blocker. Avoid intravascular injections
through the use of aspirating syringe.
➢ Avoidance of adrenalin-impregnated retraction cord.
➢ Antibiotic prophylaxis not recommended for history of coronary artery bypass graft (CABG).
➢ Avoidance of anticholinergics (e.g., scopolamine, and atropine).
➢ Adequate postoperative pain control.
Mohammed
M.
Nasser

➢ For patients with coronary artery stents, elective dental care should be deferred for 6 months;
emergency dental care should be in a hospital setting. It may be prudent to provide antibiotic coverage if
emergency dental treatment is required during the first six weeks postoperatively. Patients may require
long-term anticoagulant medication, but most patients are on aspirin or clopidogrel rather than warfarin.
➢ If a patient experiences chest pain in the dental surgery, dental treatment must be stopped, the
patient should be given nitroglycerine sublingually and oxygen, and be kept sitting upright. Vital signs
should be monitored. The pain should be relieved in 2–3 min; the patient should then rest and be
accompanied home.
If chest pain persists after three doses of nitroglycerin given every 5 min, that lasts more than 15–20 min,
or that is associated with nausea, vomiting, syncope or hypertension is highly suggestive of MI, oxygen
should be continued, and 300 mg of aspirin should be chewed.
Mohammed
M.
Nasser

unstable angina or recent MI (less than 6
months) [Major risk]
➢ Avoid elective care, only emergency treatment should be provided, consult with
physician and limit treatment to pain relief, treatment of acute infection, or control of
bleeding.
➢ Prophylactic nitroglycerin sublingually is advisable.
➢ Placement of intravenous line.
➢ Sedation and oxygen.
➢ Frequent monitoring of blood pressure and vital signs, using a pulse oximeter and
continuous electrocardiographic monitoring.
Mohammed
M.
Nasser

unstable angina or recent MI (less than 6
months) [Major risk]
➢ Cautious use of adrenalin in local anesthetic, local anesthesia without adrenalin can
be used or not more than two cartridges containing 1: 100.000 adrenalin or 1:20.000
levonordefrine using aspirating syringes.
➢ In general, conscious sedation and general anesthesia should be deferred for at
least 3 months in patients with recent-onset angina, unstable angina or recent
development of bundle branch block and, in any case, it should be given in hospital.
➢ Adrenalin-impregnated retraction cords are avoided.
➢ If the patient experiences pain during treatment, the management is the same as
above.
Mohammed
M.
Nasser

Dental management/ The use of
antiplatelet and anticoagulation drugs
▪ Patients who take aspirin or another platelet aggregation antagonist
such as clopidogrel can expect some increase in bleeding. This effect
generally is not clinically significant, and bleeding may be controlled
through local measures. Discontinuation of these agents before dental
treatment generally is unnecessary.
▪ Patients who take warfarin for anticoagulation must have a current
international normalized ratio (INR) determined before any invasive
procedure and they are managed after consultation with physician.
▪ The Local hemostatic measures that are used to control bleeding include
the use of hemostatic agents in the sockets (gelfoam, surgicel), suturing
and gauze pressure packs.
Mohammed
M.
Nasser

Cardiovascular
Diseases (II)
Mohammed M. Nasser

Heart failure
Causes
Classification
Signs and Symptoms
Diagnosis
Management
Dental management
Oral manifestations
Mohammed
M.
Nasser

Heart failure
Heart failure (HF), also known
as congestive heart failure
(CHF), defined by (ACCAHA)
as a complex clinical syndrome
that can result from any
structural or functional cardiac
disorder that impairs the
ability of the ventricle to fill
with or eject blood which
leads to blood output
insufficient to meet the body
requirement.
Mohammed
M.
Nasser

Heart failure
Prevalence is 1-3% of
the general
population and 10%
among the elderly
population.
The prognosis is poor,
25-50% of the
patients die within 5
years.
Mohammed
M.
Nasser

Effects of right- and left-sided heart
failure
Mohammed
M.
Nasser

Causes
▪ Ischemic heart diseases
(the most common cause)
▪ Congenital heart diseases
▪ Hypertension
▪ Pulmonary hypertension
▪ Pulmonary embolism
▪ Myocarditis
▪ Infective endocarditis
▪ Cardiomyopathies
▪ Valvular heart diseases
▪ Endocrine diseases
▪ Chronic anemia
▪ Arrhythmias
Heart failure is a symptom complex that is caused by many diseases such as;
Mohammed
M.
Nasser

Classification
The American Heart Association and the American College of Cardiology (AHA/ACC) classify
heart failure into 4 stages:( reflecting the fact that HF is a progressive disease and whose
outcome can be modified by early identification and treatment).
• Stage A: patients with risk factors that predispose to HF but with no left ventricular
hypertrophy or dysfunction (structural heart disease).
• Stage B: patients with risk factors that predispose to HF with left ventricular hypertrophy or
dysfunction but with no symptoms.
• Stage C: patients with past or present symptoms of HF with structural heart disease.
• Stage D: patients with refractory HF who require specialized care.
Mohammed
M.
Nasser

Classification
Based on severity of symptoms and the amount of effort needed to elicit symptoms, another
classification was developed by the New York Heart Association (NYHA); it is complementary to
the previous system.
✓ Class I: No limitation of physical activity, no signs or symptoms with ordinary activity.
✓ Class II: Slight limitation of the physical activity but the patients remains comfortable at
rest.
✓ Class III: Marked limitation of activity but the patients are comfortable at rest.
✓ Class IV: Symptoms are present at rest and physical activity exacerbates the symptoms.
* The term compensated HF is used when neurohumoral responses eliminate the symptoms
while the symptomatic HF is termed as decompensated HF.
Mohammed
M.
Nasser

Signs and Symptoms
Mohammed
M.
Nasser

Signs and Symptoms
❖ Dyspnea (perceived shortness of breath).
❖ Fatigue and weakness (especially muscular).
❖ Orthopnea (dyspnea in recumbent position)
❖ Paroxysmal nocturnal dyspnea (dyspnea
that awakens patient from sleep)
❖ Acute pulmonary edema (cough or
progressive dyspnea)
Mohammed
M.
Nasser

Signs and Symptoms
❖ Exercise intolerance (inability to climb a
flight of stairs)
❖ Dependent peripheral edema (swelling
of feet and ankles after standing or walking)
❖ Report of weight gain or increased
abdominal girth (fluid accumulation; ascites)
❖ Right upper quadrant pain (liver
congestion)
Mohammed
M.
Nasser

Signs and Symptoms
❖ Anorexia, nausea, vomiting, constipation
(bowel edema)
❖ Cheyne-Stokes respiration (hyperventilation
alternating with apnea during sleep)
❖ Heart murmur.
❖ Increased venous pressure.
❖ Enlargement of cardiac silhouette on chest
radiograph
Mohammed
M.
Nasser

Signs and Symptoms
❖ Pulsus alternans; a
regular rhythm with
alternating strong and
weak ventricular
contractions.
❖ Distended neck
veins.
❖ Cyanosis
❖ Clubbing of fingers
Mohammed
M.
Nasser

▪ Serial chest radiographs demonstrating the resolution of pulmonary
edema (left to right). Note the enlargement of the cardiac silhouette.
Mohammed
M.
Nasser

Pulmonary
congestion
and edema
Mohammed
M.
Nasser

Distended jugular
vein in patient
with heart failure.
Mohammed
M.
Nasser

Pitting edema in
a patient with
heart failure. A
depression (“pit”)
remains in the
edematous tissue
for some minutes
after firm
fingertip pressure
is applied.
Mohammed
M.
Nasser

Clubbing of the
fingers in a
patient with
congestive heart
failure.
Mohammed
M.
Nasser

Diagnosis
Heart failure is diagnosed clinically
and by chest radiography
(cardiomegaly), echocardiography,
ECG and biochemistry.
Echocardiography determines the stroke
volume (SV; the amount of blood that
exits the ventricles with each heartbeat).
The end-diastolic volume (EDV; the
amount of blood at the end of diastole).
The SV in proportion to the EDV (the
ejection fraction; EF). Normally, the EF
should lie between 50 and 70% but, in
cardiac failure, it is < 40%.
Mohammed
M.
Nasser

Management
The management depends on the stage
(NYHA) of the disease but the general lines
of treatment are:
• General measures; rest, control of stress,
salt restriction and controlling hypertension,
anemia or any underlying causes.
• Angiotensin-converting enzyme inhibitors
(ACE-I); like enalapril and lisinopril.
• Angiotensin II receptor blockers; like
losartan and valsartan.
• Vasodilators like isosorbide dinitrate plus
hydralazine.
• Diuretics like furosemide and
spironolactone.
• Digoxin may be helpful when failure is
associated with atrial fibrillation.
• Supplemental oxygen may be required.
• Heart transplantation.
Mohammed
M.
Nasser

Dental management
The risk of treating a patient with symptomatic heart failure is that symptoms
could abruptly worsen and result in acute failure, a fatal arrhythmia, stroke, or
myocardial infarction.
➢ Identification of patients with a history of heart failure, those with
undiagnosed heart failure, or those prone to developing heart failure is the first
step in risk assessment, this is accomplished by obtaining a thorough medical
history, including a pertinent review of systems, and measuring and evaluating
vital signs (i.e., pulse rate and rhythm, blood pressure, respiratory rate).
➢ For patients with symptoms of untreated or uncontrolled heart failure, defer
elective dental care and refer to physician.
Mohammed
M.
Nasser

Dental management
➢ For patients diagnosed and treated for heart failure:
✓ Confirm status with patient or physician
✓ Identify underlying cardiovascular disease (i.e., coronary artery disease, hypertension,
cardiomyopathy, valvular disease), and manage appropriately.
✓ New York Heart Association (NYHA) class I patients (asymptomatic), routine care can be
provided.
✓ NYHA class II (and some class III patients), obtain consultation with physician for medical
clearance and provide routine care.
✓ NYHA (some class III and class IV) patients obtain consultation with physician; consider
treatment in a special care or hospital setting.
Mohammed
M.
Nasser

Dental management
➢ Drug considerations:
✓ For patients taking digitalis, avoid adrenalin; if considered essential,
use cautiously (maximum 0.036 mg adrenalin or 0.20 mg levonordefrin),
which is no more than 2 cartridges containing 1:100.000 adrenalin or 1:
20.000 levonordefrine with care to avoid intravascular injection; avoid
gag reflex; avoid erythromycin and clarithromycin, which may increase
the absorption of digitalis and lead to toxicity.
✓ For patients with NYHA class III and IV congestive heart failure, avoid
use of vasoconstrictors; if use is considered essential, discuss with
physician.
✓ Avoid adrenalin-impregnated retraction cord.
Mohammed
M.
Nasser

Dental management
➢ Schedule short, stress-free appointments.
➢ Use semisupine or upright chair position.
➢ Watch for orthostatic hypotension, make
position or chair changes slowly, and assist
patient into and out of chair.
➢ Avoid the use of nonsteroidal
antiinflammatory drugs (NSAIDs) because
they can exacerbate symptoms of heart
failure.
Mohammed
M.
Nasser

Dental management
➢ Watch for signs of digitalis toxicity
(tachycardia, hypersalivation, visual
disturbances) which if it occurs the patient
must be referred to physician promptly.
➢ Nitrous oxide/oxygen sedation may be used
with a minimum of 30% oxygen.
➢ The dentist should be aware that even these
HF patients with NYHA class I should not be
considered “mild” because they indeed could
be decompensated during dental treatment.
Mohammed
M.
Nasser

Oral manifestations
No oral manifestations are related to heart failure but some drugs can cause:
❖ Dry mouth in patients taking diuretics or vasodilators.
❖ Angioedema of lip, face, or tongue, taste changes, burning mouth in patients
taking ACE inhibitors.
❖ Lichenoid reactions in patients taking ACE inhibitors and Beta blockers.
❖ Increased gag reflex and hypersalivation in patients taking Digitalis.
❖ Lupus like lesions and lymphadenopathy in patients taking vasodilators.
Mohammed
M.
Nasser

Cardiac Arrhythmias
Causes
Classification
Clinical features
Medical management
Dental management
Mohammed
M.
Nasser

Cardiac Arrhythmias
Arrhythmia is simply defined as disturbance of heartbeat including disturbance
rhythm, rate or conduction pattern of the heart, in which there is abnormal
electrical activity in the heart.
15-17% of the population may have arrhythmias and the prevalence increases
with age.
It has been shown that potentially fatal arrhythmias can be precipitated by
strong emotion such as anxiety or anger, as well as by various drugs, both of
which can be precipitated by dental treatment.
Mohammed
M.
Nasser

Causes
Causes; are broadly classified as:
❖ Cardiac; as in MI, mitral valve diseases,
cardiomyopathy, pericarditis, or aberrant
conduction pathways.
❖ Non-cardiac; caffeine, smoking, alcohol, fever,
respiratory, autonomic, endocrine diseases,
hypoxia or electrolyte disturbances.
Surgery is sometimes implicated.
Mohammed
M.
Nasser

Classification
They are classified according to:
✓ Rate into: tachycardia and
bradycardia.
✓ Mechanism into: automaticity,
re-entry and fibrillation.
✓ Site of origin into:
supraventricular and ventricular
arrhythmias.
Mohammed
M.
Nasser

Clinical features
Signs include; slow (less than 60 beat/min)
or fast (more than 100 beat/min) heart
rate, irregular rhythm.
Symptoms include; palpitation, fatigue,
dizziness, syncope, angina pectoris,
dyspnea and those related to congestive
heart failure (e.g., Shortness of breath,
Orthopnea, Peripheral edema).
The primary tool for diagnosis of
arrhythmia is electrocardiogram (ECG).
Mohammed
M.
Nasser

Medical management
• Physical maneuvers. In supraventricular arrhythmias, pressure on the neck
may increase parasympathetic stimulation to the heart inhibiting electrical
conduction through the AV nodes.
• Antiarrhythmic drugs; these are divided into 4 classes: class I are sodium
channel blockers, class II drugs are beta blockers, class III drugs act on
potassium channels and prolong the duration of action potential, while class IV
drugs are calcium channel blockers.
• Oral Anticoagulant (OAC) Therapy: Patients who have AF are at increased risk
for stroke and thromboembolism. To reduce this risk, the American Heart
Association (AHA) recommends OAC therapy.
Mohammed
M.
Nasser

Medical management
• Defibrillation or cardioversion:
• Pacemakers. Which is a
subcutaneously implanted
generator in the left
infraclavicular area, it produces
an electrical impulse that is
transmitted by a lead inserted
into the heart via subclavian
vein to an electrode in contact
with endocardial or myocardial
tissue.
Mohammed
M.
Nasser

Medical management
• Implanted cardioverter-defibrillator (ICD) which is similar to pacemaker. Both
are subject to electromagnetic interferences (EMI).
ICDs are capable not only of delivering a shock but also of providing
antitachycardia pacing (ATP) and ventricular bradycardia pacing.
• Radiofrequency catheter ablation. In which a catheter is introduced through
the vein to the area which is the source of arrhythmia, radiofrequency energy is
then delivered that cause irreversible tissue destruction.
• Surgery.
• Anticoagulants.
Mohammed
M.
Nasser

A, The site of implantation of a
permanent pacemaker (note:
can be inserted in the left or
right intraclavicular chest wall).
B, A chest x-ray showing a
pacemaker in a patient.
Mohammed
M.
Nasser

Cardioversion/
defibrillation
paddles in
place on a
patient.
Mohammed
M.
Nasser

Dental management
Stress associated with dental
treatment or excessive amounts of
injected adrenalin may lead to life
threatening cardiac arrhythmias in
susceptible dental patients.
The keys to successful dental
management of patients prone to
developing a cardiac arrhythmia and
those with an existing arrhythmia are
identification and prevention.
Mohammed
M.
Nasser

Dental management
➢ Patients with cardiac
arrhythmias may be identified by
the following:
✓ Medical history to identify: type of
arrhythmia, treatment, presence of
pacemaker or defibrillator and stability.
The dentist may need to consult with
physician to obtain or verify this
information
✓ Risk for arrhythmia is increased in the
presence of other cardiovascular or
pulmonary disease
✓ Patient does not report an arrhythmia,
but may be taking one or more of the
antiarrhythmic drugs
✓ The presence of symptoms that could
be caused by arrhythmias.
✓ Vital signs are suggestive of arrhythmia
(rapid pulse rate, slow pulse rate, irregular
pulse)
Refer patient to physician if signs or
symptoms are present that are
suggestive of a cardiac arrhythmia or
other cardiovascular disease.
Mohammed
M.
Nasser

Dental management
➢ Cardiac arrhythmias that may be associated
with major perioperative risk during dental
treatment include:
❖ High-grade atrioventricular (AV) block.
❖ Symptomatic ventricular arrhythmias in the
presence of underlying heart disease.
❖ Supraventricular arrhythmias with uncontrolled
ventricular rate.
Elective dental treatment is avoided in such cases,
only urgent care is provided and preferably in
hospital
the following should be considered:
✓ Consult with physician.
✓ Provide limited care only for pain control,
treatment of acute infection, or control of
bleeding.
✓ Intravenous line.
✓ Sedation
✓ Electrocardiogram (ECG) monitoring
✓ Pulse oximeter
✓ Blood pressure monitoring
✓ Avoid or limit adrenalin.
Mohammed
M.
Nasser

Dental management
Other types of cardiac arrhythmias are associated with intermediate or minor
perioperative risk during dental treatment in such cases elective dental
treatment is allowed.
Mohammed
M.
Nasser

Dental management
➢ Stress and anxiety reduction
✓ Establish good rapport.
✓ Schedule short, morning
appointments.
✓ Ensure comfortable chair position.
✓ Provide preoperative sedation
(short-acting benzodiazepine night
before and/or 1 hour before
appointment).
✓ Administer intraoperative sedation
(nitrous oxide/oxygen).
✓ Obtain pretreatment vital signs.
✓ Ensure profound local anesthesia.
✓ Provide adequate postoperative
analgesia.
Mohammed
M.
Nasser

Dental management
➢ The use vasoconstrictors
✓ The use of vasoconstrictors in local anesthetics poses potential problems for
patients with arrhythmias because of the possibility of precipitating cardiac
tachycardia or another arrhythmia. A local anesthetic without vasoconstrictor
may be used as needed.
✓ If a vasoconstrictor is deemed necessary, patients in the low- to
intermediate-risk category and those taking nonselective betablockers can
safely be given up to 0.036 mg of epinephrine (two cartridges containing 1:
100,000 epinephrine); intravascular injections should be avoided. Greater
quantities of vasoconstrictor may well be tolerated, but increasing quantities
are associated with increased risk for adverse cardiovascular effects.
Mohammed
M.
Nasser

Dental management
➢ The use vasoconstrictors
✓ Vasoconstrictors should be avoided in patients taking
digoxin because of the potential for inducing arrhythmias.
✓ For patients at major risk for arrhythmias, the use of
vasoconstrictors should be avoided, but if their use is
considered essential, it should be discussed with the
physician.
✓ Avoid the use of adrenalin in retraction cord.
Mohammed
M.
Nasser

Dental management
➢ Patients who are taking Warfarin
✓ Should have current international normalized ratio
(INR) (within 24 hours of surgical procedure).
✓ If INR is within the therapeutic range (INR, 2.0-3.5),
dental treatment, including minor oral surgery, can be
performed without stopping or altering the drug.
✓ Local measures include gelatin sponge or oxidized
cellulose in sockets, suturing, gauze pressure packs,
preoperative stents, and tranexamic acid or
aminocaproic acid mouth rinse and/or to soak gauze.
Mohammed
M.
Nasser

Dental management
➢ Patients with pacemakers
✓ Antibiotic prophylaxis to prevent bacterial endocarditis is not recommended
✓ Avoid the use of electrosurgery and ultrasonic scalers.
Mohammed
M.
Nasser

Dental management
➢ Patients taking Digoxin
✓ Watch for signs or symptoms of toxicity (e.g., hypersalivation)
✓ Avoid adrenalin or levonordefrine
Mohammed
M.
Nasser

Cardiovascular
Diseases (III)
Mohammed M. Nasser

Infective Endocarditis
Classification
Etiology & Predisposing conditions
Pathophysiology
Signs and symptoms
Diagnosis
Complications
Medical Management
Dental management
Mohammed
M.
Nasser

▪ Infective endocarditis (IE) is defined as a microbial infection of the
endothelial surface of the heart or heart valves that most often occurs
in proximity to congenital or acquired cardiac defects.
▪ Its intracardiac effects include severe valvular insufficiency, which may
lead to intractable congestive heart failure and myocardial abscesses,
therefore, emphasis has long been directed toward its prevention.
▪ Although bacteria most often cause these diseases, fungi and other
microorganisms may also cause infection; thus, the term infective
endocarditis (IE) is used to reflect this multimicrobial origin.
Mohammed
M.
Nasser

Mohammed
M.
Nasser

Classification
IE is classified based on:
❖ The causative microorganism (e.g., streptococcal endocarditis,
staphylococcal endocarditis, candidal endocarditis)
❖ The type of valve that is infected (e.g., native valve endocarditis
[NVE], prosthetic valve endocarditis [PVE]).
❖ The source of infection; whether community acquired or hospital
acquired, or whether the patient is an intravenous (IV) drug user or
not.
Mohammed
M.
Nasser

Prosthetic cardiac valves.
▪ A, Starr-Edwards caged
ball mechanical valve.
▪ B, Hancock porcine
bioprosthetic valve.
▪ C, Prosthetic valve
endocarditis.
C
B
A
Mohammed
M.
Nasser

Etiology
✓ Streptococci are the most common cause of IE 30%-65%, of which streptococci
viridans (alpha-hemolytic streptococci), which are normal constituents of the oral flora
and gastrointestinal tract, remain the most common cause of community acquired NVE.
✓ Staphylococci are the cause of at least 30%-40% of cases of IE; mostly coagulase-
positive Staphylococcus aureus which is the most common pathogen in IE associated
with IV drug abuse, it is also the most common pathogen in nonvalvular cardiovascular
device infections.
✓ In some recent studies, S. aureus has emerged as the most common cause of IE and
rates of viridans streptococci have decreased.
✓ Other microbial agents that less commonly cause IE such as the HACEK group
(Haemophilus, Actinobacillus, Cardiobacterium, Eikenella, Kingella), Pseudomonas
aeruginosa, Corynebacterium, Bacteroides fragilis, and fungi.
Mohammed
M.
Nasser

Predisposing conditions attributed
to IE include:
➢ Mitral valve prolapse 25%-30%.
➢ Aortic valve disease 12%-30%.
➢ Congenital heart disease 10%-20%.
➢ Prosthetic valve 10%-30%.
➢ Intravenous drug abuse 5%-20%.
➢ No identifiable condition 25%-47%.
Mohammed
M.
Nasser

Prolapse of the
posterior mitral valve
leaflet into the left
atrium.

Prolapse
of the
posterior
mitral
valve
leaflet into
the left
atrium.

Calcific aortic
stenosis of a
previously
normal valve.

Calcific
aortic
stenosis of
a previously
normal
valve.

Pathophysiology
IE is thought to be
the result of a
series of complex
interactions of
several factors
involving
endothelium,
bacteria, and the
host immune
response.
Mohammed
M.
Nasser

Pathophysiology
The sequences of events include:
1. Injury or damage to an endothelial surface, most often of a cardiac valve leaflet.
2. Fibrin and platelets then adhere to the roughened endothelial surface and form small
clusters or masses called nonbacterial thrombotic endocarditis (NBTE), these masses are sterile
and do not contain microorganisms.
3. With the occurrence of a transient bacteremia, bacteria can be seeded into and adhere to
the mass.
4. Additional platelets and fibrin are then deposited onto the surface of the mass, which serves
to protect the bacteria that undergo rapid multiplication within the protection of the vegetative
mass.
Mohammed
M.
Nasser

Pathophysiology
The sequences of events include:
5. The clinical outcome results from:
• Local destructive effects of intracardiac (valvular) lesions.
• Embolization of vegetative fragments to distant sites, resulting in infarction or infection.
• Hematogenous seeding of remote sites during continuous bacteremia.
• Antibody response to the infecting organism with subsequent tissue injury caused by
deposition of preformed immune complexes or antibody/complement interaction with
antigens deposited in tissues.
Mohammed
M.
Nasser

Signs and symptoms
The clinical presentation may be varied; the
interval between the presumed initiating
bacteremia and the onset of symptoms of IE is
estimated to be less than 2 weeks in more than
80% of patients.
✓ Fever (most common).
✓ Heart murmur.
✓ Petechiae of the palpebral conjunctiva, the
buccal and palatal mucosa, and extremities.
Mohammed
M.
Nasser

Signs and symptoms
✓ Osler's nodes (small, tender, subcutaneous nodules that develop in the pulp
of the digits). Named after Sir William Osler (1849-1919). They are caused by
immune-complex deposition.
✓ Janeway lesions (small, erythematous or hemorrhagic, macular nontender
lesions on the palms and soles). Named after Edward Janeway (1841-1911).
They are caused by septic emboli which deposit bacteria, forming micro-
abscesses of the dermis with marked necrosis and inflammatory infiltrate not
involving the epidermis.
✓ Splinter hemorrhages in the nail beds
Mohammed
M.
Nasser

Osler’s node
in infective
endocarditis.

Splinter
hemorrhages
of the nail
beds in
infective
endocarditis.

Signs and symptoms
✓ Roth spots (oval retinal hemorrhages with pale centers). Caused by immune
complex mediated vasculitis. Named after Moritz Roth, a Swiss Pathologist
(1839-1914).
✓ Splenomegaly
✓ Clubbing of the digits.
✓ Positive blood cultures in most cases. Although up to 30% of cases of IE are
initially found to be “culture negative,” especially in patients who have taken
antibiotics prior to the diagnosis of IE.
Mohammed
M.
Nasser

Roth spot in the retina
in infective
endocarditis.

Nail clubbing may appear within a few weeks
of development of IE.

Diagnosis
Duke criteria were
developed to facilitate
diagnosis of IE.
These criteria are
categorized as major
and minor.
Definitive diagnosis of
IE requires the
presence of:
▪ Two major criteria.
▪ One major and
three minor criteria.
▪ Five minor criteria.
Mohammed
M.
Nasser

Diagnosis
❖ Major criteria:
➢ Positive blood
cultures.
➢ Evidence of
endocardial
involvement e.g.,
positive
echocardiography,
presence of new
valvular regurgitation.
Mohammed
M.
Nasser

Diagnosis
❖ Minor criteria:
➢ Predisposing heart condition or IV drug use.
➢ Fever.
➢ Vascular phenomena, including embolic events.
➢ Immunologic phenomena.
➢ Microbiologic evidence other than positive
blood culture.
Mohammed
M.
Nasser

Complications
• Heart failure as a result of severe valvular
dysfunction.
• Embolization of vegetation fragments
leads to stroke, MI, pulmonary embolism.
Emboli also may involve other systemic
organs, including the liver, spleen, kidney,
and abdominal mesenteric vessels.
• Renal dysfunction is also common and
may be due to immune complex
glomerulonephritis or infarction.
Mohammed
M.
Nasser

Medical Management
▪ Generally, it consists of antibiotics and surgery.
▪ The most widely used antibiotics include penicillin,
ceftriaxone, gentamicin and vancomycin while most
staphylococcus aureus organisms that produce
betalactamase respond to nafcillin and oxacillin and
for strains resistant to oxacillin, vancomycin is
combined with rifampin and gentamicin.
▪ Surgical intervention may be necessary to facilitate
a cure for IE or to repair damage caused by the
infection.
Mohammed
M.
Nasser

Dental Management
➢ The dentist should identify from history taking
those patients with cardiac conditions that
increase risk for IE and should remain alert and
refer the patient with signs or symptoms of IE to
physician. This would apply whether or not the
patient has received prophylactic antibiotics for
dental procedures.
Mohammed
M.
Nasser

Dental Management
➢ The basic assumption is that IE is most often due
to a bacteremia that results from an invasive dental
procedure, and that through the administration of
antibiotics prior to those procedures, IE could be
prevented. But studies have shown that bacteremia
can also result from many normal daily activities
such as tooth brushing, flossing, using toothpicks,
using oral water irrigation devices, and chewing
emphasizing the need to maintain good oral
hygiene and eradicating dental/oral disease for
decreasing the frequency of bacteremia produced
by normal daily activities.
Mohammed
M.
Nasser

Dental Management
➢ Cardiac Conditions Associated with the
Highest Risk of Adverse Outcome from
Endocarditis for which Prophylaxis with Dental
procedures is recommended:
1. Prosthetic cardiac valve
2. Previous infective endocarditis
3. Congenital heart disease (CHD)
✓ Unrepaired cyanotic CHD, including
those with palliative shunts and
conduits.
✓ Completely repaired CHD with
prosthetic material or device by surgery
or catheter intervention during the first 6
months after the procedure. Prophylaxis
is reasonable because endothelialization
of prosthetic material occurs within 6
months after the procedure.
✓ Repaired CHD with residual defects at
the site or adjacent to the site of a
prosthetic patch or prosthetic device,
which inhibits endothelialization
4. Cardiac transplantation recipients who
develop cardiac valvulopathy.
Mohammed
M.
Nasser

Dental Management
➢ IE antibiotic prophylaxis is recommended only for patients listed above who
undergo any dental procedure that involves the manipulation of gingival tissues
or the periapical region of a tooth and for those procedures that perforate the
oral mucosa.
➢ The following procedures and events do not need prophylaxis: routine
anesthetic injections through noninfected tissue, restorative dentistry, taking
dental radiographs, placement of removable prosthodontic or orthodontic
appliances, adjustment of orthodontic appliances, placement of orthodontic
brackets, shedding of deciduous teeth, suture removal, fluoride treatment and
bleeding from trauma to the lips or oral mucosa.
Mohammed
M.
Nasser

Dental Management
➢ Antibiotic
prophylaxis regimens
* Cephalosporins
should not be used in
an individual with a
history of anaphylaxis,
angioedema, or
urticaria with
penicillins or ampicillin.
Situation Agent
Regimen: Single dose 30 - 60
Minutes before Procedure
Adult Child
Oral Amoxicillin 2 g 50 mg/kg
Unable to take oral
medication
Ampicillin 2g IM or IV 50 mg/kg
IM or IV
Cefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM
or IV
Allergic to Penicillins or
Ampicillin Oral
Cephalexin 2 g 50 mg/kg
Clindamycin 600 mg 20 mg/kg
Azithromycin or
Clarithromycin
500 mg 15 mg/kg
Allergic to Penicillins or
Ampicillin and cannot
take oral medications
Cefazolin or Ceftriaxone 1 g IM or IV 50 mg/kg IM
or IV
Clindamycin 600 mg IM or
IV
20 mg/kg IM
or IV
Mohammed
M.
Nasser

Dental Management
➢ Preoperative use of 0.2% Chlohexidine mouth washes is advisable.
➢ In patients who are already taking penicillin or amoxicillin for eradication of an infection
or for long-term secondary prevention of rheumatic fever are likely to have streptococcus
viridans that are relatively resistant to penicillin or amoxicillin. Therefore:
✓ Clindamycin, azithromycin, or clarithromycin should be selected for prophylaxis if
treatment is immediately necessary. Cephalosporins should be avoided because of cross
resistance.
✓ An alternative approach is to wait for at least 10 days after completion of antibiotic
therapy before administering prophylactic antibiotics. In this case, the usual regimen can
be used.
Mohammed
M.
Nasser

Dental Management
➢ In case of prolonged dental procedures (longer than 6 hours) it is advisable to
administer an additional prophylactic dose (same dose).
➢ Prior to cardiac valve surgery or replacement or repair of congenital heart disease, it
is recommended that preoperative dental evaluation be performed and necessary
dental treatment provided whenever possible in an effort to decrease the incidence of
late PVE caused by viridans group streptococci.
Mohammed
M.
Nasser

Rheumatic fever
and rheumatic
heart disease

Rheumatic fever and rheumatic
heart disease
Clinical manifestations
Medical management
Dental management
Mohammed
M.
Nasser

Rheumatic fever and rheumatic
heart disease
Rheumatic fever is an autoimmune inflammatory
process that develops after pharyngeal infection with
group A beta-hemolytic streptococci (streptococcus
pyogenes).
It predominantly affects children between 5- 15
years. Rheumatic fever may occasionally be followed
by chronic rheumatic carditis with permanent cardiac
valvular damage that appears to be immunologically
mediated tissue damage, which may lead to fibrosis
and distortion of the cardiac valves (chronic
rheumatic heart disease).
Mohammed
M.
Nasser

The clinical manifestations of acute rheumatic fever are so variable that the
diagnosis is made only if at least two of the major criteria are fulfilled
Diagnostic criteria
Major Minor
Carditis Pyrexia
Polyarthritis Arthralgia
Chorea Previous rheumatic fever
Erythema marginatum Raised ESR and C-reactive protein
Subcutaneous nodules Characteristic ECG changes
?
Mohammed
M.
Nasser

Chorea
Chorea is a movement disorder that causes involuntary,
irregular, unpredictable muscle movements.
The disorder can make you look like you're dancing (the
word chorea comes from the Greek word for “dance”) or
look restless or fidgety.
Chorea is a movement problem that occurs in many
different diseases and conditions.
Mohammed
M.
Nasser

Chorea
Mohammed
M.
Nasser

➢ A sore throat may be followed after about 3 weeks by
an acute febrile illness with multiple joints pain
(migratory arthralgia) which heals without permanent
damage in about 3 weeks.
➢ Cerebral involvement causing spasmodic involuntary
movements (Sydenham chorea, St. Vitus dance).
➢ A characteristic rash (erythema marginatum).
➢ Lung involvement
Mohammed
M.
Nasser

➢ Subcutaneous nodules (usually around the elbows).
➢ The most serious cardiac complication is
subendocardial inflammation, particularly along the lines
of closure of the mitral and aortic valve cusps, resulting in
the formation of fibrinous vegetations and later scarring,
fibrotic stiffening and distortion of the heart valves, often
causing mitral valve and/or aortic valve stenosis. This is
essentially a mechanical, hemodynamic disorder, in which
the defective valves may become infected at any time,
leading to infective endocarditis. Cardiac failure can
develop, often after many years.
Mohammed
M.
Nasser

Mohammed
M.
Nasser

Medical management
✓ Prompt antimicrobial treatment of streptococcal sore throat (within 24 hours
of onset) prevents the development of rheumatic fever in most cases.
✓ After an attack of rheumatic carditis, there is a risk of recurrence and
continuous antibiotic prophylaxis becomes necessary to lessen the risk of
permanent cardiac damage. The drug of choice is usually oral phenoxymethyl
penicillin until the age of 20. For those allergic to penicillin, sulfadimidine
should be given.
Mohammed
M.
Nasser

Dental management
➢ Acute rheumatic fever patients are exceedingly unlikely to be seen during an attack but
emergency dental treatment may be necessary.
➢ Patients with history of rheumatic fever but without cardiac involvement are treated as a
normal person.
➢ Most patients with chronic rheumatic heart diseases are anticoagulated and they should be
managed after determining their prothrombin time and INR and the treatment can be done
under local anesthesia with vasoconstrictor in consultation with the physician. Conscious
sedation with nitrous oxide may be given if cardiac function is good and with the approval of
the physician.
➢ Indications for prophylactic antibiotics are only for the high risk patients mentioned in the
dental management of IE.
Mohammed
M.
Nasser

Congenital heart diseases
Cyanotic CHDs
Acyanotic CHDs
Dental management
Oral manifestations
Mohammed
M.
Nasser

Congenital heart diseases
▪ Congenital heart
diseases (CHD) are the
most common type of
cardiac diseases present
in children.
▪ They can broadly be
classified as Cyanotic
and Acyanotic (non-
cyanotic).
Mohammed
M.
Nasser

Cyanotic CHDs
The cyanosis results from shunting of
deoxygenated blood from the right ventricle into
the left side of the heart and the systemic
circulation (right to left shunt) leading to chronic
hypoxemia, they include:
✓ Eisenmenger syndrome (Named after Victor
Eisenmenger who described this condition in
1897).
✓ Fallot's tetralogy (Named after the French
physician EtienneLouis-Arthur Fallot 1850-
1911).
✓ Pulmonary atresia.
✓ Pulmonary valve stenosis.
✓ Total anomalous venous drainage.
✓ Transposition of great vessels.
✓ Tricuspid atrasia.
Patients may crouch to improve venous return,
but eventually polycythemia with hemorrhagic
and thrombotic tendencies develop, finger and
toe clubbing develops but after 3 months of age.
If untreated, 40% of patients with cyanotic CHD
die within 5 years.
Mohammed
M.
Nasser

Acyanotic CHDs
▪ They are further divided into those with no shunt like; Aortic
stenosis, bicuspid aortic valve, coarctation of the aorta,
dextrocardia and mitral valve prolapse. The other division of the
Acyanotic CHD is those diseases with left to right shunt and these
include; Atrial septal defects (ASD), Ventricular septal defects
(VSD) and patent ductus arteriosus (PDA).
▪ Some CHD start as Acyanotic diseases and become cyanotic with
time. Most of these cardiac defects are well tolerated in utero, and
it is only after birth that their anatomic and hemodynamic
abnormalities become evident.
Mohammed
M.
Nasser

Diagnosis and Medical management
▪ CHD is most commonly diagnosed through echocardiography, and confirmed by
cardiac magnetic resonance imaging (MRI). Early correction of the congenital defect,
often by transvenous catheter techniques, is the treatment of choice. More complex
defects may require an operation. Medical treatment may be needed for the
management of pulmonary edema, heart failure, polycythemia, infection or
emotional disturbances.
▪ Modern surgical and medical care helps children survive into adult life and patients
are then often called adult or ‘grown-up’ CHD. Nevertheless, complications observed
in adults who were previously thought to have had successful repair of CHD include
arrhythmias, valve disorders and cardiac failure, and residual defects can still
predispose to complications such as infective endocarditis.
Mohammed
M.
Nasser

Dental management
➢ The most important aspect for dentists to consider is how well the patient’s
heart condition is compensated. Consultation with the physician is
recommended.
➢ Patients with heart disease should take their medications as usual on the day
of the dental procedure, and should bring all their medications to the dental
office for review at the time of the first appointment.
➢ Patients with stable heart disease receiving atraumatic treatment under local
anesthesia can receive treatment.
➢ Late morning or early afternoon appointments are advisable.
Mohammed
M.
Nasser

Dental management
➢ Stress-reduction and good analgesia should be provided.
➢ Limited use of vasoconstrictor with aspirating syringes.
➢ Retraction cords containing adrenalin should be avoided.
➢ Conscious sedation preferably with nitrous oxide can be given with the
approval of the physician. General anesthesia should only be provided by
expert anesthetists in hospital.
➢ Bleeding tendencies due to platelet dysfunction or coagulation defects
should be evaluated and managed accordingly.
Mohammed
M.
Nasser

Dental management
➢ There may be susceptibility to infective endocarditis, so prophylactic antibiotics
should be used in the following cases:
✓ Unrepaired cyanotic CHD, including those with palliative shunts and conduits
✓ Completely repaired CHD with prosthetic material or device by surgery or
catheter intervention during the first 6 months after the procedure. Prophylaxis
is reasonable because endothelialization of prosthetic material occurs within 6
months after the procedure.
✓ Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device, which inhibits endothelialization.
Mohammed
M.
Nasser

Dental management
➢ Prior to cardiac valve surgery or replacement or repair of congenital heart
disease, it is recommended that preoperative dental evaluation be performed
and necessary dental treatment provided whenever possible in an effort to
decrease the incidence of late PVE caused by viridans group streptococci.
Mohammed
M.
Nasser

Oral manifestations
• Delayed eruption of both dentitions
• Enamel hypoplasia; the teeth often have a bluish-white ‘skimmed milk’
appearance and there is gross vasodilatation in the pulps
• Greater caries and periodontal disease activity, probably because of poor oral
hygiene and lack of dental attention
• After cardiac surgery, transient small white non-ulcerated mucosal lesions of
unknown etiology may appear.
Mohammed
M.
Nasser

Cardiovascular Diseases / Dental management

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