ORAL DIAGNOSIS

• Cardiovascular diseases


  Broad term used to describe a range of diseases affecting the heart and the blood vessels
• Blood vessels


  • Through the years, the lumen thickens (yellow part)
  • Too much oil, even if you're still young -> CVD
• Types of cardiovascular diseases


  • Hypertension
  • Bacterial Endocarditis
  • Congestive Heart Failure
  • Angina Pectoris
  • Myocardial Infarction

  
• Hypertension


  Defined as a sustained elevation of the diastolic pressure that results from increased peripheral arteriolar resistance
• Blood pressure measurement


  • Sphygmomanometer (most accurate)
  • Dentists do not diagnose, only measure blood pressure
• Hypertension


  • An abnormal elevation of arterial pressure that can be fatal if sustained and untreated
  • Symptomatic manifestation of an abnormal state of circulation

  
• Korotkoff sounds

  • Sounds when you auscultate the antecubital fossa with bp apparatus
  • First loudest sound - Systolic
  • Almost no sound at all - Diastolic
• Blood pressure categories


  • Normal
  • High Normal
  • Hypertension Stage 1 (mild)
  • Hypertension Stage 2 (moderate)
  • Hypertension Stage 3 (severe)
  • Hypertension Stage 4 (Very severe)

  
• Hypertension types


  • Primary (Essential or Idiopathic) - 90-95% of cases
  • Secondary - 5-10% of cases
• Primary hypertension


  Genetic link, no clearly established genetic pattern
• Secondary hypertension


  Underlying systemic disease that produces hypertension as a secondary complication
• Isolated systolic hypertension


  • Systolic BP >140 mmHg, Diastolic BP <90 mmHg
  • Etiology: decreased aortic distensibility (elasticity) secondary to aortic arteriosclerosis
  • Patient may not display symptoms for a long time but could experience organ damage
• Dentist must evaluate BP findings in terms of normal for that particular individual, not just general norms
• Signs and symptoms of hypertension


  • Occipital headache
  • Dizziness
  • Tingling of the hands and feet
  • Weakness
  • Angina pectoris
  • Ringing of the ears
• Only the physician diagnoses hypertension and makes decision on its treatment
• Systolic pressure


  Pressure at the peak of ventricular contraction
• Diastolic pressure


  Represents the total resting resistance in the arterial system after passage of the pulsating force produced by contraction of the L ventricle

  
• Potential problems to dental care for hypertensive patients


  • Stress and anxiety may cause increase in BP, angina, MI, Cerebro-vascular disease
  • Patients being treated may become nauseated or develop orthostatic hypotension
  • Excessive use of vasopressors may cause significant elevation of BP
  • Sedative medications may bring about hypotensive episodes
• Management considerations for hypertensive patients


  • Identification
  • Monitoring
  • Stress and anxiety reduction
  • Prevention of drug interactions
  • Awareness and management of drug effects
  • Management of drug effects on the tissues
• Identification of hypertensive patients

  • Dentist should not make the diagnosis but inform patient of abnormal BP reading and recommend physician evaluation
  • Medical history - family history, risk factors, associated disorders, history of known hypertension and treatment
• Stress and anxiety reduction


  Establish rapport, encourage patient expression, premedicate with benzodiazepine, avoid long/stressful appointments, use limited local anesthesia
• Prevention of problems in hypertensive patients


  • Reduce stress and anxiety
  • Avoid orthostatic hypotension
  • Avoid stimulating gag reflex
• Prevention of drug interactions


  • Anti-hypertensives and barbiturates/sedatives - reduce dosage
  • Anti-hypertensives and NSAIDs - decrease activity of anti-hypertensives
  • Diuretics - reduce plasma volume and extracellular fluid
  • Beta-blockers - altered taste and lichenoid reactions
  • Calcium channel blockers - gingival hyperplasia, dry mouth
• Drug considerations


  Use local anesthesia judiciously with minimal vasopressor, reduce dosage of barbiturates and sedatives
• Treatment planning modification


  • For patients under good medical management, any indicated treatment may be provided
  • For patients with complications, refer to physician
• Congestive heart failure


  A severe cardiovascular disease where the heart's function as a pump is inadequate to meet the body's needs

  
• Congestive heart failure is a "walking time bomb" where the patient can pass out anytime
• Causes of congestive heart failure


  • Coronary artery disease
  • Hypertension
  • Cardiomyopathy
  • Valvular heart disease

  
• In congestive heart failure, the heart is a failing pump and the end-diastolic volume (preload) increases, leading to overstretching and less forceful contraction

  
• If the left ventricle fails first, blood backs up in the lungs resulting in pulmonary edema. If the right ventricle fails first, blood backs up in the systemic vessels resulting in peripheral edema.

  
• Severe congestive heart failure worsens, with 50-60% of patients with severe symptoms dying within a year and 50% of those with less severe symptoms dying in 3-5 years

  
• Signs and symptoms of congestive heart failure

  • Cheyne-Stokes respiration
  • Pulsus alternans
  • Distended neck veins
  • Peripheral edema
  • Clubbing of the fingers
  • Dyspnea
  • Orthopnea
  • Paroxysmal nocturnal dyspnea
  • Fatigue and weakness
  • Low grade fever

  
• Laboratory tests for congestive heart failure

  • Chest x-ray - heart size, shape, and pulmonary congestion
  • ECG - myocardial ischemia, infarction
  • Serum albumin levels - edema

  
• Ventricular failure


  Dilation and hypertrophy of the ventricle to compensate for its inability to keep up with the workload
• Severe Congestive Heart Failure worsens
• 50-60% with severe symptoms die within a year
• 50% will die in 3-5 years for those with less severe symptoms
• Signs and Symptoms of Congestive Heart Failure


  • Cheyne-Stokes respiration
  • Pulsus alternans
  • Distended neck veins
  • Peripheral edema
  • Clubbing of the fingers
  • Dyspnea
  • Orthopnea
  • PND
  • Fatigue and weakness
  • Low grade fever

  
• Laboratory Tests for Congestive Heart Failure


  • Chest x-ray
  • ECG
  • Serum albumin levels
  • Exercise stress test

  
• Medical Management of Congestive Heart Failure


  1. Identification of all the causative factors, their correction and stabilization

  2. Lifestyle modification

  3. Drug therapy