Faculty of Dental medicine, Medical University – Sofia Department of Oral and Imaging Diagnostic

ORAL PATHOLOGY

Lecture 4

Diseases of the CardiovascularSystem

Assoc. prof. dr A. Krasteva, Ph.D.

Disease of the cardiovascular system – Hypertension

§Hypertension is a persistently raised blood pressure.

Hypertension is defined as having §systolic blood pressure (SBP) 140 mm

Hg or diastolic blood pressure (DBP) 90 mm Hg

Classification of Blood Pressure for Adults

Blood Pressure Classification

SBP (mm Hg) DBP (mm Hg)

Normal < 120 and < 90

Prehypertension 120–139 80–89

Stage 1 hypertension

140–159 90–99

Stage 2 hypertension

160 100

Secondary hypertension Idiopathic (essential)hypertension•Genetic predisposition•High alcohol intake•High salt intake; •High body metabolicndex (BMI)•Insulin resistance

• Idiopathic (essential) hypertension• Renal disease –

• Endocrine conditions – pregnancy, Cushing syndrome and corticosteroid

Thyroid or parathyroid disease

• Cerebral disease – (mainly strokes, head injuries or tumours)

• Coarctation of aorta

• Drugs – oral contraceptive pill; corticosteroids, non-

steroidal anti-inflammatory drugs• Sleep apnoea

Causes of hypertension

Features of advanced hypertension

Symptoms SignsHeadaches hypertension on

testing

Visual disorders Retinal changes

Tinnitus Left ventricular hypertrophy

Dizziness ProteinuriaAngina Haematuria

Hypertension complications § stroke and myocardial

infarction

§ Coronary Artery Disease (CAD)

§ Treatment focuses on prevention and reduce complications

§ Complications - cerebral hemorrhage, left ventricular hypertrophy, CHF, renal insufficiency, aortic dissection, and atherosclerotic.

Oral Health – antihypertensive medications

oral dryness, gingival overgrowth, or ulcerations.

§The use of epinephrine is controversial.

§Concentrations of epinephrine greater than 1:100,000 are unnecessary and carry a higher risk.

Dental aspects of hypertension

§epinephrine (adrenaline) -intravenously may increase hypertension and precipitate arrhythmias.

Dental aspects of hypertension

§ Epinephrine (adrenaline)-containing LA - taking beta-blockers,

§ Lidocaine - caution in patients taking beta-blockers.

§ Adrenaline/epinephrine effects may be reversed in patients taking alpha-blockers causing vasodilation.

§ Gingival retraction cordscontaining adrenaline/epinephrine should be avoided.

Dental aspects of hypertension§Raising the patient suddenly

from the supine position may cause postural hypotension

§All antihypertensive drugs are potentiated by GA agents

§ Intravenous barbiturates in particular can be dangerous

Dental aspects of hypertension

§ facial palsy - malignant hypertension.

Antihypertensive drugs § xerostomia, § salivary gland swelling or pain,§ lichenoid reactions, § erythema multiforme, § angioedema, § gingival swelling, sore mouth or

paraesthesiae.

Coronary Artery Disease

Atherosclerosis

§Atherosclerosis-plaque formation, with compromise of effective arterial luminal area.

Atherosclerosis

§myocardial ischemia or it may cause acute plaque rupture, with intracoronary thrombus formation and subsequent myocardial infarction.

§Atherosclerosis may affect any vascular bed.

Atherosclerosis – Clinical features

§Atheromatous plaques may rupture

§ thromboembolism

§embolism

Coronary artery disease – general aspect

§ ANGINA PECTORIS § greatest risk from

myocardial infarction.

§ MYOCARDIAL INFARCTION differs from angina in that it causes more severe and persistent chest pain

General PrecautionsRegarding Dental Procedures

§Anxiety – can provoke angina or ischemia

§antianxiety medications and inhalation nitrous oxide

Coronary artery disease – General Precautions Regarding Dental Procedures

§Most such events occur between 6:00 am and noon.

§Medications designed to prevent these events, such as beta-blockers, aspirin, and antihypertensives, should be continued.

§ In the late morning or the early afternoon.

Coronary artery disease – General PrecautionsRegarding Dental Procedures

§Elective procedures –avoided for at least 4 weeks following an myocardial infarction

§acute risk of administering local anesthesia for dental procedures 3 weeks after an uncomplicated acute myocardial infarction is very low;

Anticoagulation Therapy and Dental Care

§aspirin or clopidogrel

§minimum of 4 weeks after stent placement and for a minimum of 3 to 6 months following the use of the newer drug-eluting stents

Anticoagulation Therapy and Dental Care

§These agents may increase the risk of bleeding when used alone or in combination.

§A bleeding time test is recommended to evaluate the qualitative defect in platelets.

Anticoagulation Therapy and Dental Care

Medical conditions for which prophylactic anticoagulation therapy is instituted include:

§ atrial fibrillation, § valvular heart disease, § ischemic heart disease, § cerebrovascular accidents, § pulmonary embolism§ deep venous thrombosis.

Anticoagulation Therapy and Dental Care

§Actually the prothrombin time is expressed by INR.

§ LEVELS UNDER 1,2 ALLOW ANY ORAL SURGICAL PROCEDURE!

§The anticoagulation therapy should be discontinued before minor oral surgical procedures.

Dental procedures performed following coronary stenting

§ It is prudent to wait approximately 1 month after this procedure, to allow endothelialization of the stent to decrease the risk of subacute thrombosis.

§ Re-endothelialization is considered to be complete approximately 4 weeks after bare metal stentplacement and at 3 to 6 monthsfollowing the use of a drug-eluting (“coated”) stent.

§ The patient’s cardiologist should be contacted prior to carrying out invasive dental procedures.

Dental procedures performed following coronary stenting

§ It is recommended antibiotic prophylaxis in patients after coronary stent placement before some dental invasive procedures.

§Elective dental care should therefore be postponed until the patient can sit comfortably for the required time period.

Heart Failure

§inability of the cardiovascular system to meet the demands of the end-organs

Heart Failure§ Dyspnea, orthopnea, and paroxysmal nocturnal dyspnea

§ chest discomfort, fatigue, palpitations, dizziness, and syncope

Heart FailureOral Health Considerations§For well-compensated patients

with heart failure, no special dental modifications are necessary unless the underlying causes for the heart failure require modifications.

§When the patient is to be placed in a supine position this may cause severe dyspnea.

PATIENTS WITH CARDIAC DISEASE – DENTAL ASPECTS

§stress-reduction protocol §limiting the dosage of epinephrine

§cords containing adrenaline/epinephrine should be avoided.

PATIENTS WITH CARDIAC DISEASE– DENTAL ASPECTS

Oral abnormalities can be associated with cyanotic CHD andmay include: §delayed eruption §enamel hypoplasia §greater caries and periodontal

disease activity

ANGINA PECTORIS

§ episodes of chest pain caused by myocardial ischemia

§ 1%

§ underlying causes are atherosclerotic plaques

§The mortality rate in angina is about 4% per year.

ANGINA PECTORIS§This is often an unmistakable pain described as a sense of strangling or choking, heaviness, compression or constriction of the chest, sometimes radiating to the left arm or jaw.

ANGINA PECTORIS – Dental aspects§ If chest pain is not relieved within about 3 min, Myocardial

infarction is a possible

§ nausea, vomiting, syncope or hypertension is highly suggestive of Myocardial infarction.

§ If pain persists, the patient should continue oxygen, and chew 300 mg of aspirin.

ANGINA PECTORIS – Dental aspects§ Angina is a rare cause of pain in

the mandible, teeth or other oral tissues, or pharynx.

§ Drugs - lichenoid lesions (calcium-channel blockers), gingival swelling (calcium-channel blockers) or ulcers (nicorandil).

§ Conscious sedation should be deferred for at least 3 months in patients with recent-onset angina,

§ General anaesthesia should be deferred for at least 3 months Intravenous barbiturates are particularly dangerous.

MYOCARDIAL INFARCTIONGeneral aspects

§ Myocardial infarction results from the complete occlusion (blockage) of one or more coronary arteries.

§ central chest pain similar to that of angina but is not relieved by rest or with sublingual nitrates.

§ radiates to the left arm or jaw.

MYOCARDIAL INFARCTION – Dental aspects§ re-infarction of 50%

§ Simple emergency dental treatment under local anesthesia may be given during the first 6 months

§ to minimize pain and anxiety§ Elective surgery under GA should

therefore be postponed for at least 3 months and preferably a year.

MYOCARDIAL INFARCTION – Dental aspects§ re-infarction of 50%

§ Simple emergency dental treatment under local anesthesia may be given during the first 6 months

§ to minimize pain and anxiety§ Elective surgery under GA should

therefore be postponed for at least 3 months and preferably a year.

MYOCARDIAL INFARCTION – Dental aspects

§ monitoring of blood pressure, ECG, pulse and oxygen saturation are indicated. There must be ready access to oxygen and medical help.

§Dental procedures should be stopped if there is chest pain, dyspnoea, a rise in heart rate of 40 beats/ min or more or a rise in systolic BP > 20 mmHg.

§Vasoconstrictors such as adrenaline/epinephrine or levonordefrin may raise blood pressure or lead to unanticipated atrial or ventricular

§ Interaction between adrenaline/epinephrine and the beta-blocking agent may induce hypertension and cardiovascular complications.

§Mepivacaine 3% is thought to be preferable to lidocaine.

Endocarditis lenta – general aspect§ Infective endocarditis is a microbial

infection ofthe endothelial surface of the heart or heart valves

§ Most often the condition is caused by bacteria,

§ As damage to heart valves can lead to heart failure,

§ A total of 80% to 90% of cases of identifi ed IE are due to streptococci and staphylococci

Endocarditis lenta – general aspect

§Bacterial endocarditis arises when bacteria enter the blood, traveling from a site of infection (dental infection).

There are two ways that the symptoms of endocarditis can develop:

Common symptoms of endocarditis include:§ a high temperature (fever) of

38°C or above chills§ loss of appetite, unexplained

weight loss§ Headache, muscle and joint

pain§ night sweats§ shortness of breath,

persistent cough§ heart murmurs

A stroke is one of the most serious complications that can develop from endocarditis.

FAST§ Face: the face may have fallen on one side, the

person may be unable to smile, or their mouth, or eye, may have drooped.

§ Arms: the person may be unable to raise both arms and keep them there as a result of weakness or numbness.

§ Speech: the person’s speech may be slurred.§ Time: it is time to dial 112 immediately if there are

any of these signs or symptoms.

Endocarditis lenta – Antibiotic prophylaxis

§Enterococci, streptococci and staphylococci are the most prominent organisms. All patients at risk (high and medium) were recommended to have prophylaxis.§Dental procedures for which prophylaxis is reasonable are – all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

Endocarditis lenta – antibiotic prophylactic regiment for dental procedures

Situation Agent Regimen single dose30-60 min before procedureAdults children

Oral amoxicillin 2g 50 mg/kg

Unable to take oral medication

Ampicillin or

Cefazoline or ceftriaxone

2 g im or iv

1g im ot iv

50 mg/kg im ot iv

50 mg/kg im or iv

Allergic to penicillins or ampicillinOral regimen

CephalexinorClindamycin

2 g

600 mg

50 mg/kg

20 mg/kg

Azithromycin 500 mg 15 mg/kg

Allergic to penicillins or ampicillin and unable to take oral medication

Cefazoline or ceftriaxone or clindamycin

1g im or iv

600 mg im or iv

50 mg/kg im or iv

20 mg/kg im or iv

Arrhythmia

Definition and Incidence

Cardiac arrhythmia, which refers to any variationin the normal heartbeat, includes disturbances ofrhythm, rate, or the conduction pattern of theheart. § Abnormalities of cardiac rhythm can be broadly defined as any

deviation from the normal cardiac pacemaker and conduction mechanism.

§ Tachyarrhythmia, when the heart rate is >100 bpm. § Bradyarrhythmias are associated with heart rates of <60 bpm. § Both tachyarrhythmia and bradyarrhythmias may be

hemodynamically well tolerated in patients with normal cardiac function, or they may result in cardiovascular collapse if cardiac output is significantly compromised.

Major Causes of Cardiac Arrhythmias§ Primary cardiovascular disease§ Pulmonary disorders§ Autonomic disorders§ Systemic diseases§ Drug-related adverse effects§ Electrolyte imbalances

Signs and Symptoms of Cardiac ArrhythmiasSIGNS

§ Slow heart rate (<60 beats/min)

§ • Fast heart rate (>100 beats/min)

§ • Irregular rhythm§ SYMPTOMS§ • Palpitations§ • Fatigue§ • Dizziness

§ • Syncope§ • Angina§ • Congestive heart failure§ • Shortness of breath§ • Orthopnea§ • Peripheral edema

Arrhythmia – Patient management

Manage underlying condition such as rheumatic heart disease (antibiotic prophylaxis to prevent bacterial endocarditis)4. Avoid use of general anesthesia in most dental practices5. In general, avoid the use of the following devices:

§ Electrosurgery units § Ultrasonic bath cleaners§ Ultrasonic scalers

Arrhythmia – Patient management1. Reduce anxiety as much as possible2. Avoid excessive amounts of epinephrine

Arrhythmia – Patient managementRecognize anticoagulant therapy: § anticoagulant therapy, and therefore the INR level

must be determined before performing surgical procedures.

§ If the INR is 1.5 or less, most dental treatments (including minor oral surgery) can be safely performed.

Arrhythmia – Patient management§ If the INR is greater than 2, the physician should

consider reducing the warfarin dosage.§ If the warfarin dosage is reduced, it will take 3 to 4

days for the INR reduction to occur. §On the day of surgery, the level of anticoagulation

must be determined. If it is within the desired range, then the surgery can be performed.

§ If excessive bleeding should occur, it can usually be controlled by using local measures such as pressure packs, Gelfoam/thrombin, Oxycel,Surgicel, micro- fibrillar collagen, or tranexamic acid.

Heart Failureinability of the cardiovascular system to meet the demands of the end-organs.

§ Common causes of diastolic dysfunction include hypertension, Coronary Artery Disease, long-standing diabetes, and advanced age.

Heart FailureDiagnosis§ Dyspnea, nocturnal dyspnea§ are classic symptoms, but

nonspecific complaints, such as chest discomfort, fatigue, palpitations, dizziness, and syncope, are not uncommon

Heart FailureOral Health Considerations§When the patient is to be placed

in a supine position this may cause severe dyspnea.

Signs of Heart Failure§ • Rapid, shallow breathing§ • Cheyne-Stokes respiration (hyperventilation alternating with apnea

during sleep)§ • Inspiratory rales • Heart murmur§ • Gallop rhythm§ • Increased venous pressure§ • Enlargement of cardiac silhouette on chest radiograph§ • Pulsus alternans§ • Distended neck veins§ • Large, tender liver, • Jaundice • Ascites§ • Peripheral edema§ • Cyanosis§ • Weight gain§ • Clubbing of fingers

Symptoms of Heart Failure§ Dyspnea • Fatigue and weakness§ Orthopnea (dyspnea in recumbent position)§ Paroxysmal nocturnal dyspnea (dyspnea thatawakens patient from sleep)§ Acute pulmonary edema (cough or progressive dyspnea)§ Exercise intolerance • Fatigue (especially muscular)§ Dependent 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)§ Anorexia, nausea, vomiting, constipation (bowel edema)§ Hyperventilation followed by apnea during sleep(Cheyne-Stokes respiration)

HEART DISEASES

§Heart disease is a major killer: in the USA possibly one person dies from heart disease every 30 s.

§ It also causes significant morbidity and disability in many aspects of life.

Distended jugular vein in patient with heartfailure.

Pitting edema in a patient with heart failure. Adepression (“pit”) remains in the edematous tissue for someminutes after fi rm fi ngertip pressure is applied

§ Ascites.

Clubbing of the fi ngers in a patient with congestiveheart failure.