Acute Coronary Syndrome

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Acute Coronary Syndrome

Cardiovascular disease are one of the many disease which has a high mortality rate in today’s world. Moreover, such disorders are of great importance due to the increased number affected individuals and the need for treatment. Coronary artery disease trends, complications, oral manifestations, dental management and associated therapies impact the dental health and treatment. Such patients require a different approach and special consideration with regard to when and which dental treatment is suitable and what precautions clinicians should take note of.

Valvular Heart Disease

Valvular heart disease is characterized by damage to or defective in one of the four heart valves: the mitral, aortic, tricuspid or pulmonary. Some types of valvular heart disease include valvular stenosis, vascular prolapse and regurgitation.

Oral Manifestations

Oral infections may pose risk during postoperative period of heart valve surgery. Oral health in patients scheduled for heart valve surgery is poorer than in individuals without valve disease. Most of them suffer periodontitis due to high dental plaque scores, reflecting poorer dental hygiene. This situation could favour the appearance of bacteremia following tooth brushing in these individuals. Bacteremia secondary to periodontal infection is known to be one of the primary causes of infectious endocarditis, particularly in patient with heart valve disorders. Therefore, buccodental disease prior to performing heart surgery. Periodontal treatment is advised in patients with advanced periodontitis, followed by root planing and ultrasound treatment. Those teeth not amenable to treatment and with poor prognosis should be removed as pre surgical preventive measures.

Dental Management

The two main concerns during dental treatment for people of patient with valvular heart disease are the risk of infective endocarditis and bleeding in anti coagulated patients. Endocarditis is more likely to occur in patients who have previously had endocarditis and those with certain cardiac lesions. Risk of a normally functioning prosthesis being infected after a dental procedure is probably no higher than risk in patient with damaged native valves. However, mortality and morbidity is much higher should prosthesis become infected. Patient with native valve disease can often stop or reduce their anticoagulants, but those with prosthetic valves should not discontinue anticoagulants without cardiological advice. Mechanical mitral valves are prone to thrombosis, which cause emboli if adequate anti-coagulation is not maintained, although short term modification may be possible. 

Heart Failure

Heart failure (HF) is defined as the incapacity of the heart to function properly, pumping insufficient blood towards the tissues and leading to fluid accumulation within the lungs, liver and peripheral tissues.

Oral Manifestations

    Most if not all patients with heart failure will be undergoing drug treatments for their condition and these drugs can produce a series of oral manifestation. In this context, angiotensin-converting enzyme (ACE) inhibitors such as captopril and enalapril can produce burning mouth sensation lichenoid reactions and a loss of taste sensation, while diuretics like furosemide can produce xerostomia.

Dental Management

    Consultation with the supervising physician is highly advised in order to understand the patient’s current condition and the medication prescribed. The patient should be receiving medical care, and heart failure should be compensated. Dental treatment is to be limited to patients who are in stable condition, since these people are at a high risk of developing questionable arrhythmias and even sudden death secondary to cardiopulmonary arrest. Stress and anxiety are to be avoided during the visits, which in turn should be brief (< 30 minutes) and are to be scheduled for the morning sessions. The patient should be seated on the chair in a semi-supine position, with control of body movements (which should be slow), to avoid orthostatic hypotension. In patients who has been administered with digitalis agents (digoxin, methyl-digoxin), the vasoconstrictor dose should be limited to two anaesthetic carpules, since this drug combination can cause arrhythmias. Aspirin (acetylsalicylic acid) can lead to fluid and sodium retention, and therefore should not be prescribed in patients with heart failure.

In emergency (i.e., lung edema), after contacting the emergency service, the patient should be seated with the legs lowered, and receiving nasal oxygen at a rate of 4-6 liters/minute. Sublingual nitroglycerin tablets are indicated (0.4-0.8 mg), and the dose may be repeated every 5 or 10 minutes if blood pressure is maintained.

Arrhythmia

Arrhythmias are variations in normal heart rate due to cardiac rhythm, frequency or contraction disorders. The most common type of cardiac arrhythmia is atrial fibrillation.

Oral Manifestations

    Many anti-arrhythmic drugs have side effects such as gingival hyperplasia or xerostomia.

Dental Management

    Consultation with the supervising physician is also advised in order to understand the patient’s current condition and the type of arrhythmia involved, as well as the medication prescribed. It must be checked that the patient uses the medication correctly. Stress and anxiety can be reduced with anxiolytics. Short visits in the morning are to be preferred. Patient monitoring, with recording of the pulse, is indicated before treatment. It is very important to limit the use of vasoconstrictor in local anesthesia, with no more than two carpules. The treatment planned should not be too long or complicated. Although modern pacemakers are more resistant to electromagnetic interferences, caution is required when using electrical devices like ultrasound and electric scalpels that might interfere with pacemakers – especially the older models, since such devices developed in the last 30 years are bipolar and are generally not affected by the small electromagnetic fields generated by dental equipment. It is therefore important to know the type of pacemaker, the degree of electromagnetic protection of the generator, and the nature of the arrhythmia. If arrhythmia develops during dental treatment, the procedure should be suspended, oxygen is to be given, and the patient vital signs are to be assessed: body temperature (normal values: 35.5-37oC), pulse (normal values: 60-100 bpm), respiratory frequency (normal values in adults: 14-20 cycles or respirations per minute), blood pressure (normal values: systolic blood pressure under 140 mmHg and diastolic blood pressure under 90 mmHg). Sublingual nitrites are to be administered if there is chest pain. The patient should be placed in the Trendelenburg position, with vagal maneuvering where necessary (valsalva maneuver, massage in the carotid pulse region). The dental team should be prepared for basic cardiopulmonary resuscitation and initiation of the emergency procedure for evacuation to a hospital centre, if necessary.

References

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