Dental Significance of Cardiovascular Disease

• Hypertension is:

  • Elevated blood pressure
  • Blood pressure checked by listening to Korotkow sounds
  • Systolic pressure when sounds appear
  • Diastolic pressure when they disappear
  • Blood pressure shows variation throughout the day
• Normal blood pressure is 120/80 mmHg - 120 (systolic pressure), 80 (diastolic pressure).
• What level of blood pressure constitutes hypertension:

  • Above 140/90 mmHg - previous standard
  • Now tend to treat according to level of BP and overall cardiovascular risk
• Measuring blood pressure:

  • Use device which is recommended by BHS (British Hypertension Society)
  • Sitting: at least 2 measurements
  • Average 2 readings
  • Ambulatory blood pressure monitoring
  • Variable between home and clinic
  • "White coat effect" - blood pressure raises when setting foot in doctor/dental surgery
• Aetiology of cardiovascular disease - essential hypertension in 90% of cases:

  • Poly-causal
  • Essentially a diagnosis of exclusion (checked all other potetial causes first)
  • Multiple genetic loci influence
  • Environmental
  • Obesity
  • Salt intake
  • Lack of exercise
• Secondary hypertension:

  • Commonest causes renal - renal artery stenosis (older pt with vascular disease)
  • Endocrine causes
  • Conn's syndrome
  • Cushing's syndrome
  • Intrinsic renal disease eg glomerulonephritis
• Effect of elevated blood pressure:

  • Heart: increases risk of coronary heart disease (CHD), left ventricular hypertrophy (LVH), arrhythmias
  • Aortic aneurysm
  • Peripheral vascular disease
  • Arteriosclerosis
  • Cerebral circulation
  • Increased risk of cerebral infarction and cerebral haemorrhage
• Elevated blood pressure is known as a silent killer; hypertension can cause lots of problems, but show very little symptoms.
• Non-therapeutic treatment measures of hypertension:

  • Weight reduction
  • Exercise
  • Decrease salt intake
  • Alcohol reduction
• Treatment of hypertension - measures that reduce cardiovascular risk but not blood pressure:

  • Stop smoking
  • Reduce saturated fat intake
  • Increase intake of oily fish
• Periodontitis has systematic consequences and that it is a risk factor for peripheral macrovascular disease and diabetes. Epidemiological studies largely support an association between periodontitis and atherosclerotic vascular disease (AVD), independently of smoking status. It has been shown that there is a bi-directional relationship between periodontal inflammation and diabetic control.
• Sources of blood-bourne infections - infective endocarditis:

  • Mouth
  • Toothbrushing
  • Chewing
  • Gingival bleeding
  • Skin lesions
  • GI (gastro-intestinal)/GU (genito-urinary) tract
  • Pregnancy, delivery
• Healthcare professionals should offer people clear and consistent advice about prevention including:

  • Benefits and risks of antibiotic prophylaxis
  • The importance of maintaining good oral health
  • Symptoms that may indicate infective endocarditis and when to seek expert advice
  • Risks of undergoing invasive procedures such as body piercing or tattooing
• Complications of anti-hypertensive treatment:

  • Orthostatic hypotension - may feel light-headed if lying down/getting up too quickly
  • Xerostomia
  • Gingival overgrowth
  • Lichenoid reactions - like lichen planus but secondary to medications being taken
  • Other potential adverse reactions
  • Potential drug interactions
• Considerations relevant to the dental management of patients with significant cardiovascular compromise:

  • Shorter appointments (morning)
  • Effective LA
  • Conscious sedation
  • Post-operative analgesia
  • LA: to use or not to use vasoconstrictor
• LA use in pts with cardiovascular disease:

  • Normal adrenaline release can increase x20 during stress
  • Recommendations: pts with mild to moderate cardiovascular disease can have LA containing adrenaline
  • Severe cardiovascular disease (unstable angina, recent myocardial infarction, dysrhythmias, severe high blood pressure or chronic heart failure) may be considered relative contraindications to vasoconstrictor use
• Patients with ischaemic heart disease: specific considerations regarding dental treatment

  • Acute myocardial infarction: postpone elective treatment until 3-6 months later
  • Unstable angina: dental care in suitable facilities/postpone
  • Cardiac failure: dyspnoea (do not lie flat)
• Pacemakers and implanted defibrillators - ensure these are compatible with those devices:

  • Diathermy
  • Electrosurgical units
  • Ultrasonic scalers

  Sudden defibrillation = risk of injury

  Newer devices are markedly less susceptible
• Dental treatment and cardiac surgery:

  • CABG (coronary artery bypass graft)/stent/angioplasty
  • Valve surgery/replacement

  Procedures themselves do not pose any contraindication

  Avoid immediate post-op period
• Monitoring high risk patients involves:

  • Clinical signs & symptoms
  • Blood pressure
  • Pulse oximetry
  • ECG
• Angina:

  • GTN spray - 2 actuations every 3 minutes
  • 100% oxygen at 15 litres/minute (size CD oxygen cylinder)
• Myocardial infarction:

  • 100% oxygen at 15 litres/minute
  • GTN spray sublingually
  • Aspirin 300mg (chewed)
• Managing pts who are taking antiplatelet drugs eg aspirin: no alteration of drug regimen. Attention to local haemostasis.
• Managing pts who are taking warfarin:

  • INR upper limit 4.0
  • INR check
  • Invasive procedures
• Oral manifestations related to cardiovascular disease:

  • Dry mouth
  • Lichenoid drug eruptions
  • Gingival hyperplasia
  • Angioedema
  • Nicorandil
• Xerostomia can be caused by:

  • Beta-blockers
  • Diuretics
  • ACE inhibitors
  • Calcium channel blockers

  If a pt complains of dry mouth may be worth checking with GP if they could try other medications.
• Lichenoid drug reaction can be caused by:

  • NSAIDs
  • Beta-blockers
  • Diuretics
  • Oral hypoglycaemics
  • Statins
  • Antimalarials
  • Sulphonamides

  
• Calcium channel blockers examples:

  • Nifedipine
  • Amlodipine
  • Nicardipine
  • Nimodipine
  • Verapamil
  • Diltiazem
• Calcium channel blockers can produce florid gingival hyperplasia. Managed by optimising oral hygiene, do high quality scaling and possibly try to change medication too - may even need gingivectomy.

  
• Nicorandil:

  • Potassium channel activator
  • Vasodilator
  • Angina treatment

  Somtimes severe, persistent oral ulceration as an unwanted side effect - so severe it could be thought to be cancerous. Even though it's likely to be due to the Nicorandil, it would still be advised to get an incisional biopsy to check.

  
• Angioedema:

  • ACE inhibitors notorious for causing angioedema
  • Beware of neck/submandibular involvement (may not be able to breathe)
  • Management - try to change medication, may need to be admitted to hospital if airway blocked/tongue involved