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Prosthodontic Considerations in Cardiovascular Patients- A Comprehensive Prospective

Dr. Sumit Singh Phukela

Professor and Head, Department of Prosthodontics, Faculty Of Dental Science, SGT University, Gurgaon, India, E Mail [email protected]

Abstract

Prosthodontic treatment involves the replacement & restoration of teeth by artificial substitutes. Its focus is to restore function, esthetics & comfort. Cardiovascular diseases (CVD) comprise of a group of diseases of the heart and vascular system affecting majority of individuals worldwide .Ischemic heart disease, Hypertension, Dysrhythmias, and Infective Endocarditis are some of the cardiovascular conditions most commonly seen among the population .Prosthodontics can offer exceptional satisfaction for bothPatient & the Dentist . The present review throws some light on various cardiovascular conditions commonly seen in Prosthodontic practice and a systematic approach toward their management.

Key words ;HypertensionAngina Pectoris Myocardial Infarction Congestive Heart Failure

Introduction

Disease can be defined as a definite deviation from the normal state, characterized by a series of symptoms. Disease may be caused by developmental disturbances, genetic factors, metabolic factors, living agents, & physical & chemical or the radiant energy or the cause may be unknown.Itcan transform unhealthy,unattractive dentition withpoor function into acomfortable, healthyocclusionCo-existent cardiovascular disease is the most frequently cited medical condition for patient referral from general dental practitioners to hospital departments, which reflects widespread concern over potential problems during treatment 1.Cardiovascular diseases are one of the main causes of mortality in the developed world2,3The prevalence of CVD is reported to be 2–3 times higher in the urban population as compared to the rural population. 4Important goal of treatment to manage patients with cardiovascular diseases is to deal with all the identified risk factors involved. Current medications which the patients are taking and allergies to any drugs and also any potential drug interactions and side effects are noted 5.The present

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study offers a review of the heart diseases most often seen in prosthodontic practice, such as

;HypertensionAngina Pectoris Myocardial Infarction Congestive Heart Failure

FIGURE 1

HYPERTENSION

Hypertension is a key risk factor for cardiovascular disease6 .Hypertension has been identified by WHO as one of the most significant risk factors for morbidity and mortality worldwide and is responsible for the deaths of approximately nine million people annually 7.Hypertension is largely identified in this way by physicians routinely or opportunistically assessing blood pressure in a primary care clinic setting

8However, it has been estimated that between a third and a half of hypertensive patients remain undiagnosed, indicating the need for better screening 9 Once a person has been screened and found to have high blood pressure, ambulatory blood pressure monitoring (ABPM) is regarded as the most accurate way to diagnose hypertension and is recommended by guidelines to routinely to confirm elevated blood pressure readings . 10,11Advances in technology have allowed for the development of new ‗cuff-less‘ BP monitoring devices however, which continuously monitor BP without disruption to daily activities. Cuff-less BP monitoring devices utilizes smartphone or wearable sensor technologies that can estimate BP from ECG signals, Photoplethysmogram (PPG) signals (using infrared light on the finger to estimation of skin blood flow), or a combination of both. 12

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FIGURE 2 Management Of Hypertension

Self-monitoring of blood pressure can improve blood pressure control and is an increasingly common part of hypertension management. It is well tolerated by patients and has been shown to be a better predictor of end organ damage than clinic measurement. 13,14,15Hypertension is treated with medications which may have an impact on dental/prosthodontic therapy because of their numerous side effects.

These include orthostatic hypotension, dehydration, sedation, xerostomia & depression . These side effects may alter treatment

 Orthostatic hypotensionaffects a patient broughtfrom a supine to an upright position

FIGURE 3

The patient may fainttherefore for such patientsthe dental chair should beset upright gradually

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Among the 13 broad categories of oral side effects of 200 most frequent prescribed drugs reported side effects are mainly of Xerostomia.This may lead to increased periodontal diseases,caries&bacterial infection caused by loss of protection bysaliva.

FIGURE 4

Xerostomia also decreases the valve seal of soft tissue – borne removable prosthesis & increases the risk of abrasions &sorespots .Management of such patients includes saliva substitutes, salivary stimulants, frequent glasses of water throughoutthe day, strict control of diet to decrease cariogenicity& avoidance of alcohol & tobaccoproducts.Calcium channel blockers used to treat hypertension or congestive heart failure can cause gingival hyperplasia aroundthe teeth or implants (similar to dilatin) & have been linked to erythema multiforme & other types of oral ulcerations

FIGURE 5

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Anxiety greatly affects the blood pressure,therefore a stress reducing protocol is indicated for a hypertensivepatient .An early appointment is beneficial because the medication may still havean effect on the elderlypatient

ANGINA PECTORIS

FIGURE 6

Angina pectoris (AP) is the clinical manifestation of inadequate myocardial oxygen delivery and is common among patients with stable ischaemic heart disease16Heberden's classic description of the symptoms was a ‗painful and most disagreeable sensation in the breast, which seems as if it would extinguish life…but the moment they stand still, all this uneasiness vanishes‘17.The exact etiology of stable angina is not well defined; however, it is thought to be secondary to a mismatch between myocardial supply and demand 18,19 .Angina pectoris or chest pain or cramp of the cardiac muscle, is a form of coronary heartdiseaseOccasionally the myocardium needs more oxygen laden blood than it receives.Transient myocardialoxygen demand is inexcess of the supplyIt is a symptomaticexpression oftransient myocardialischemia .The prognosis for patients with stable angina varies, but there is an annual mortality rate of up to 3.2%. Long-term prognosis is influenced by left ventricular systolic function, extent of coronary artery disease (CAD), exercise duration or effort tolerance, and comorbid conditions20

Arthrosclerosis of the coronary vessel is the usual cause, although anemia or hypotension, emboli, acquired arthritis, & hereditary connective tissue disease may also beinvolved

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The classical symptom ofretrosternal pain oftendevelops during stress orphysical exertion, radiatesto the shoulders, left arm,or mandible, or right arm,or neck, palate & tongue.These symptoms arerelieved by rest.

Management

The dental emergency kit should include nitroglycerine tablets (0.3 to 0.4 mg) or translingual spray, which are replaced every 6 months because of their short shelflife. During an angina attack all dental treatment should be stoppedimmediatelyNitroglycerine isadministered sublingually &100% oxygen is given at 6L/min, with the patient in asemisupine or 45o

position. Vital signs should be monitored after nitroglycerine is administered because transient hypotension mayoccur.

There is a decrease pressure, which causes a decrease of the blood flow to brain Pulse rate mayincrease upto160beats/min. Blushing of the face& shoulders iscommon A headache may occur after administration, often analgesicsare indicated

MYOCARDIAL INFARCTION

FIGURE 7

Acute Myocardial infarction, usually referred to in lay terms as a heart attack, is most often caused by a decrease or stoppage of blood flow to a portion of the heart, leading to necrosis of heart muscle. 21 The role of thrombosis as a cause of AMI was debated for decades in the 20th century until the 1970s, when it

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was clearly established as the cause of nearly all AMIs seen at autopsy and most large AMIs presenting clinically 22,23.Myocardial infarction is prolong lack of oxygen that causes injury to theheart. The patient usually has severe chest pain in the substernal or left precordial area during a myocardial infarctionepisode

It may radiate to the left arm orthe mandible. This pain is similar to angina pectoris but is moresevere .Cyanosis, cold sweat, weakness, nausea or vomiting & irregular & increased pulse rate are all signs &

symptoms of myocardial infarction Management

The dental evaluation should include the dates of all episodes of myocardial infarction.

Medical consultation should preclude any extensive restorative of surgical procedure

Patients with a myocardialinfarction episode in thepreceding 6 months mayhave dental examinationswithout any special protocolAny treatment should be postponed if for 6 months

Patients who experienced anMyocardial Infarction 6– 12 months preceding consultation may have examinations, nonsurgical procedures & simple emergency surgical procedures performed after medicalconsultation

Longer proceduresshould be segmentedinto several shorterappointment CONGESTIVE HEART FAILURE

FIGURE 8

Heart failure constitutes an increasing health hazard with major demands on health care resources. Recent major advances in drug treatment have yet to be translated into increased survival of heart failure patients

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in the community at large .Knowledge of the basic pathophysiological processes and the mechanisms whereby they induce the clinical expressions of heart failure continues to increase, spurred on, not only by the development of new drugs, but also by increasing refinement of methods of evaluating their efficacy The targets for therapeutic intervention may be categorized (i) haemodynamic, neuroendocrine and metabolic disorders (ii) symptoms and quality of life, (iii) morbidity and mortality risks. Symptoms and quality of life are the prime concerns of the physician in the treatment in the individual patient24

Medications prescribed for Congestive Heart Failure are classified as threeD‘s:

1. Digitalis (digoxin,lanoxin) 2. Diuretics (furosemide,lasix) 3. Dialators(ACE)

Trigeminal neuralgia like symptoms may occur with the use ofdigitalis

Calcium channel blockers are given to treat Congestive Heart Failure &Hypertension

SABACUTE BACTERIAL ENDOCARDITIS

FIGURE 9

Despite advances in medical and surgical therapy, Infective endocarditis (IE) remains a highl y morbid and deadly infection. 25Bacterial endocarditis is an infection of the heart valves or the endothelial surfaces of theheart It is result of the bacterial growth on the damaged cardiac surfaces

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The microorganisms mostoften associated withendocarditis followingdental treatment are alpha- hemolytic streptococcusviridans& less frequentlystaphylococci & anaerobes. Diagnosis of Bacterial endocarditis is made in part by echocardiographic findings. The presence of an oscillating intracardiac mass, either on a valve, in the path of a regurgitant jet, or on implanted material, is the classic finding, though abscess or new partial dehiscence of a prosthetic valve also meets diagnostic criteria 26Dental procedures causing transient bacteremia are a major cause of bacterial endocarditis

Altered surfaces of the heart have many causes, the best known to the dental profession is the mitral valve defectfrom rheumaticfever

The risk of bacterialendocarditis increases with theamount of intraoral soft tissuetrauma

FIGURE 10

There is a correlation betweentheincidence of endocarditis & the number of teeth extracted or the degree of a preexisting inflammatory disease in the mouth

FIGURE 11

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A 6 times higher incidence of bacteremia isfound in patients with severe periodontal disease. If scaling &

root planning are performed before subsequent procedures, the riskof endocarditis is greatlyreduced .Chlorhexidine painted on the isolated gingiva or irrigation of the sulcus 3 – 5 minutes before any procedure reduces the postoperativebacteremia

CONCLUSION

Cardiovascular diseases result in changes of oral mucosa ,maxilla and mandible.Patients with a wide variety of cardiovascular diseases are frequently encountered in Prosthodontic practice and it is necessary to treat them. Safe and effective dental management of such patients requires close medical and dental coordination, an understanding of the potential hazards during Prosthodontic treatment, knowledge of drugs used in treatment of cardiovascular diseases, and the potential adverse effects of drugs commonly used in periodontal practice. Prosthodontic procedure should not be planned until the systemic condition of the patient isevaluated.

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2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults: executive summary: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2018;138(17):e426–ee83

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