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Coronary heart disease
64/348 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
phasized. Attention is given the contact relations of the upper lingual cusps and the lower buccal cusps in their respective occlusal fossae. This is meant to include that portion of the buccal and lingual sur faces immediately beyond the buccoocclusal and linguo-occlusal angles which assumes contact during functional move ment. COMM ENT
T h e dental profession has progressed far in developing methods of establishing sat isfactory functional occlusion for fixed partial denture services. There is, how ever, need for further research at the basic, clinical and technical levels. A proved investigative approach which is
reasonably reliable should not be dis carded in favor of one which produces as its ultimate result chaos generated by con fusion. T h e present background of infor mation and clinical experience should be utilized in seeking a better understanding of diagnosis, treatment planning and re storative procedures for rendering a satis factory fixed partial denture service for the patient. Regardless of persisting doc trines it is a sobering experience to observe the occlusal idiosyncrasies of the patients who are being treated. 618 W . Lombard Street
*Professor and head o f departm ent o f fixed partial prosthodontics, Dental School, University of Maryland. I. Glossary o f prosthodontic terms. Academy o f Den ture Prosthetics, ed. J.Pros.Den. Vol. 10 Nov.-Dec. I960.
Coronary heart disease
Joseph B. Vander V e e r * M .D ., Philadelphia
Atherosclerosis of the coronary arteries is the greatest cause of death and disability among adult Americans. Aspects of coro nary heart disease of special importance to dentists include
the following:
(1 )
manifestations which mimic disease of the oral cavity, face or mandible; (2 ) problems related to anesthesia and medi cations; ( 3 ) dental care in the patient with cardiac failure; (4 ) bleeding, result ing from or aggravated by anticoagulant therapy, and (5 ) prognosis and manage ment of the patient with coronary heart disease. A case history describes success ful dental treatment in a 60 year old woman with coronary heart disease.
Coronary heart disease, that group of cardiac affections resulting from athero sclerosis of the coronary arteries, is the most important of all conditions affecting the heart and the greatest single cause of death and disability in this country. Its interest to doctors of dentistry is similar to that of doctors of medicine— it is a frequent primary or complicating factor in their patients and the condition most apt to cause disability or death in them selves or their family, during the most prodùctive years of life. Arteriosclerosis, or more accurately atherosclerosis, was once regarded as a natural and inevitable consequence of aging but since this condi tion is found to be the cause of one fourth of all the cardiac deaths in the age group
VANDER VEER . . . V O LU M E 66, M A R C H 1963 • 65/349
of 25 to 44 years, it must be looked on as a disease. This one type of heart disease far out ranks every other cause of death in the United States, accounting for nearly half a million deaths each year. Undoubtedly, the incidence of coronary heart disease is increasing. T h e life expectancy of a child born in 1900 was 48 years and there were only 8.5 million people in the United States in the age group of 50 to 75 years. In 1960 life expectancy had risen to nearly 70 years and there were nearly 30 million people in the 50 to 75 group. This rapid aging of the population accounts for much of the increase of coronary heart disease since it is primarily a disease of the middle and older age groups. Probably 15 per cent only of the higher heart disease mortality rate, however, is actually due to an increase in the disease. Greater awareness, improved diagnostic facilities and more frequent postmortem examina tions account for the rest of the increase in the mortality rate classified under this heading. C A U S E S O F A T H E R O S C L E R O S IS
Atherosclerosis of the coronary arteries is a multifaceted disease with no single etiologic or epidemiologic cause. It results from or is accelerated by a combination of factors which may not always be the same in different persons. The importance of age has been stressed. Heredity plays an important though variable part and it is one that we, as individuals, can do little about. T h e male sex is much more frequently affected below the age of 50, the ratio being at least 3 to 1. After 50, the ratio becomes more balanced, reach ing nearly an equal incidence in the two sexes by 60 years of age. Certain other conditions and diseases are known to be predisposing factors. Am ong these, hy pertension, obesity and diabetes are im portant. Presently stressed are hyper cholesterolemia and disturbances of lipid metabolism. Overwork, frequently asso ciated with tension, fatigue and faulty
eating habits, may be a significant factor in some. Hard work is not involved, how ever, since this and regular exercise may well have a beneficial or even preventive effect. There is an increasing evidence pointing to excessive smoking of cigarettes as an etiologic factor. There is no evi dence that alcohol per se has any causal relation to coronary disease. This is reas suring; however, alcohol is high in cal ories and, when taken in excess, may contribute to obesity and sedentary living, which, in turn, may be detrimental. There is no scientific proof that alcohol is a “ coronary dilator” or that it helps delay the onset of arteriosclerosis. These views may have originated to some extent in wishful thinking. In the relief of pain of coronary origin, alcohol is less safe and less effective than nitroglycerine and may give a false sense of security which could be harmful. A n interesting, impor tant and complicated facet of this prob lem is the relation of diet, especially fats, to this disease. Dietary fat is a mixture of fatty acids, steroids and other substances, and fats from animal and vegetable sources differ in their composition. In ad dition, the body is capable of synthesizing fat from other foodstuffs. T h e type of fat ingested, as well as its relation to the carbohydrate and protein in the diet and to the total caloric intake, is probably im portant. Important discoveries in this field are imminent but at present the ho rizon is still clouded.
E F F E C T S O F A T H E R O S C L E R O S IS
Arteriosclerosis, means, literally, harden ing of the arteries. The term atheroscle rosis is a more accurate one for the condi tion as it involves smaller arteries, like those of the heart. This is a process of fibrosis and lipidosis of the intimal lining of the vessel which reduces the size of the lumen. T h e earliest lesion is an ac cumulation of fat droplets within the in timal cells. These lipids probably come from the blood plasma. Neutral fats, cholesterol and cholesterol esters are
66/350 • TH E JO U R N A L O F THE AMERICAN DENTAL ASSOCIATION
found in these lesions. Damage to the intima occurs and proliferation of con nective tissue results in the formation of hyaline fibrous tissue. Calcification is apt to follow in the older lesions. Complete closure of the lumen may result from the atherosclerotic lesion alone. Frequently, however, a narrowed, diseased vessel is rapidly occluded by a blood clot or throm bus developing at the site of the damage. Roughening of the intimai lining may pre dispose to this, and various factors which affect intravascular clotting (trauma, postprandial lipemia, infections and many others still unknown) are probably im portant in this sudden occlusion. T h e symptoms, or clinical syndrome, which follow in a given patient depend on many factors, but the rapidity of closure of the vessel and the ability to develop a col lateral circulation to supply the heart muscle with vital oxygen and nutrition are two important ones. The presence of disease and whether it is localized or dif fuse are also significant in relation to whether a given acute episode results in illness or death. R E S U L T IN G S Y N D R O M E S
The clinical picture which results from coronary artery narrowing or occlusion may be dramatic or insidious, with the end result varying from sudden, unex pected death, to slight shortness of breath on physical effort or substernal “ distress” with excitement or exertion. Less dra matic but important manifestations of coronary disease include various cardiac arrhythmias, especially atrial fibrillation, failure of the left ventricle with pul monary edema and congestive heart fail ure. Hypertension, so frequently seen in this age group, is commonly associated
recent therapeutic advances in the man agement of hypertension have alleviated or eliminated this problem. The clinical syndromes resulting from occlusive cor onary disease may be classified under five headings: ( 1 ) the anginal syndrome, ( 2 ) acute myocardial infarction, (3 ) coronary insufficiency, an “ in between” stage, (4) arrhythmias of the auricles and ventricles, and (5 ) failures of the ventricular myo cardium as the result of anoxia and fibrosis— cardiac failure. The latter usu ally affects first the left ventricle and occurs in conjunction with pulmonary congestion, cough and shortness of breath. Weakness of the right ventricle, which often follows, brings on a congestion of the visceral organs and edema of the lower extremities with the clinical picture of congestive heart failure. Obviously, combinations of these manifestations are frequent in patients with coronary dis ease.
D E N T IS T R Y A N D H E A R T D IS E A S E
The following aspects of coronary heart disease or problems related to it, seem to be of special importance to the dental profession: 1. Coronary disease manifestations which mimic disease of the oral cavity, face or mandible. 2. Problems related to anesthesia and medications. 3. Dental care in the patient with car diac failure. 4.
Bleeding, resulting from or aggra
vated by anticoagulant therapy. 5. Prognosis and management of the patient with coronary heart disease. T h e pain of acute coronary insuffi
with coronary disease and can be re garded as a detrimental factor. By in creasing the work of the left ventricle
ciency, whether it is the transient distress of angina pectoris or the more prolonged pain of myocardial infarction, may be
and hastening the atherosclerotic process, it is responsible for complications which
situated in some patients primarily above the level of the clavicles. This location of
increase illness and death. Fortunately,
pain is consistent in these individuals,
VANDER VEER . . . V O LU M E 66, M A R C H 1963 • 67/35J
with one or both angles of the jaw being the most frequent site. Other areas which are sometimes involved are the chin,
should be taken and the oral rather than parenteral administration of antibiotics and other medications is preferred, when
nasion, cheeks and back of the neck. W hen the pain is located only in these areas and not associated with chest or arm distress, the dentist may be the first one consulted. This pain, or it may even be termed a “ distress” by some patients, has certain characteristics. It is often difficult for the patient to describe it accurately. There is a tendency for the pain to come and go rather than be absolutely con stant, if it is prolonged. I f it is transient (a few minutes duration), it is usually related to effort or emotional upset and will cease quickly on removal of the in citing factor or with nitroglycerin.
ever possible. General dental care is frequently needed in patients with chronic coronary heart disease. In the patient with angina pectoris, excitement and pain should be avoided or minimized. Presedation may be helpful, using such drugs as phéno barbital, orally. A tablet of nitroglycerine (0.3 m g.) under the tongue prior to a short procedure or the longer acting erythrityl tetranitrate (15 m g.) by the same route are good prophylactic meas ures. The patient with cardiac failure should be brought to the best possible state of compensation by rest, adminis tration of digitalis, low salt regimen and diuretic therapy. The increasing experi ence with major surgery in geriatric pa
A N E S T H E S I A FO R CARDIAC P A T IE N T S
The patient with coronary disease is more susceptible to all types of arrhythmias and is much less tolerant to anoxia than a normal individual. T h e risk of sudden death, most often the result of ventricular fibrillation, is far greater with both intra venous and inhalation anesthesia in the patient with coronary disease. Premedica tion (sedation), adequate oxygen and an open airway are of the utmost impor tance. W ith proper basal anesthesia, (as thiopental sodium) a higher per cent of oxygen can be utilized with inhalation anesthesia and still adequate relaxation of the patient can be obtained. Increased safety is thus assured. A n experienced an esthetist is of even greater importance than the anesthetic which is used. In the patient who has sustained a recent myo cardial infarction, all operative proce dures should be assiduously avoided for several weeks. Any imperative dental work should be done under local anes thesia, with little or no vasoconstrictor, with adequate sedation and with oxygen available. It should be emphasized that these patients tolerate allergic reactions and drug idiosyncrasies poorly. A careful history for known sensitivities of this type
tients has demonstrated that those suffer ing from coronary disease may tolerate such procedures well, provided they re ceive a proper anesthetic and careful pre operative and postoperative care. I f this is true, the less strenuous procedures of dental practice in these chronic but se verely ill patients need not be feared. U S E O F A N T IC O A G U L A N T S
Anticoagulant therapy is being utilized increasingly in patients with coronary dis ease as a therapeutic and prophylactic measure. It can be expected that prob lems of bleeding secondary to this will be encountered frequently by the dental sur geon. W ith severe bleeding as the result of trauma, vitamin K i is indicated and should be given intravenously in a dose of 20 mg. to 40 mg. I f bleeding continues, a transfusion should be given. W ith planned dental procedures where bleed ing may occur, it is desirable to discon tinue the oral anticoagulant for one or more days prior to the procedure to allow the prothrombin time to return to a more normal level. Unusual bleeding is seldom seen following extractions or other oper
68/352 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
ative measures when the prothrombin time is in the neighborhood of 40 per cent of normal time or slightly above it. The
of 1960. In M ay, 1961, she split a molar and another tooth became abscessed. Her dentist recommended that several teeth
anticoagulant therapy usually can be re sumed within a few hours after the sur gery. T h e use o f vitamin K i or blood to raise the prothrombin per cent rapidly is to be avoided whenever possible as throm boembolic complications have been ob served on numerous occasions when this has been done. W ith slight or moderate bleeding associated with a prothrombin time which is below a safe therapeutic level (15 per cent of normal time or be low) vitamin K i given orally in one or two doses of 5 mg. each is often adequate (omitting the anticoagulant for at least one d a y ). Doses of this magnitude are usually effective and do not tend to make the patient highly refractory in case the anticoagulant therapy is to be resumed.
be removed but a hospital room could not be obtained before her summer vacation. In the meantime, temporary therapy was given. Her summer was uneventful and she continued with her numerous medica tions, including Dicumarol which was regulated according to a weekly pro thrombin time. She entered the hospital for dental extractions on October 5, 1961. Prior to this, her dentist had prepared an upper partial denture. T h e prothrom bin time was 43 per cent of normal time on the day before admission and the Dicumarol dosage was reduced from a previous daily dose of 37.5 mg. to 25 mg. on this day. T h e day of admission the prothrombin time was 29 per cent of nor mal time and as surgery was planned for the next morning, Dicumarol was omitted and 2.5 mg. of vitamin K i was given. Premedication included sedation with phenobarbital on the day prior to the operation and secobarbital 0.1 mg. before retiring. T h e following morning, one half hour prior to being sent to the operating room, she was given 50 mg. of meperidine
Report of Case • A 60 year old school teacher was first seen in 1956 because of hypertension and mild angina pectoris. Examination disclosed she was overweight and her blood pressure was found to be 1 90/110. The heart was slightly enlarged and the electrocardiogram revealed a left bundle branch block. Over the next four years, she continued to teach and the hypertension was quite well controlled by sedation and weight loss. Digitalis was started in 1957 because of a low cardiac reserve. In 1959, a mild diabetes was dis covered on the routine check of the blood sugar two hours after a regular breakfast. In March of 1960, the patient suffered a coronary thrombosis with an acute myo cardial infarction. She was treated in the hospital for a period of seven weeks and was quite ill during the first three weeks. Considerable cardiac enlargement devel oped with some failure of the left ven
and 0.4 mg. of atropine sulfate by hypo dermic. Intravenous glucose in water was started and thiopental sodium 250 mg. and succinylcholine chloride 40 mg. were given intravenously. The patient was in tubated and halothane with nitrous oxideoxygen was administered. T h e extractions included an upper left impacted third molar, upper left molar with adjacent root, an upper right bicuspid and a lower right bicuspid. During the operation, which took 30 minutes, there was a period of about five minutes when the heart rhythm changed to atrial fibrillation. The pulse rate rose to about 100 at this time
tricle. Heparin was utilized at the onset
but the arrhythmia subsided spontane
of her treatment, followed by Dicumarol. She was discharged from the hospital and
ously. T h e blood pressure was well main tained during the procedure (average
digitalis, sedation, Dicumarol and tolbu tamide were prescribed. T h e patient was
bleeding and mandibular and maxillary
able to return to her teaching in the fall
partial dentures were inserted after the
about
1 4 0 /8 0 ) .
There was very little
VANDER VEER . . . VOLUME 66, MARCH 1963 • 69/3 53
operation. A total of 400 cc. of 5 per cent glucose in water was given intravenously and the patient was kept in a recovery room for two hours after the surgery. There was moderate swelling and pain but no significant bleeding occurred dur ing the next 24 hours. Dicumarol was again prescribed on the evening of the day of the operation and her diabetes and blood pressure remained under good con trol. T h e prothrombin time was 46 per cent of normal time on the day after sur gery. T h e patient was discharged 48 hours after operation and her recovery has been uneventful. C O N C L U S IO N S
Atherosclerosis of the coronary arteries is the greatest cause of death and disability in the adult population. It must be re garded as a disease process and not as an inevitable consequence of aging. Its inci dence is much greater in the male sex until' the older age groups are reached. Heredity and habits of living play an important part in this disease. O n the more hopeful side of the ledger it can be said that about 85 per cent of patients recover from their first “ heart attack” (acute myocardial infarction) and that at least three fourths of these can return to their previous occupation. Am ong pro fessional men, where some modification of the work load is usually possible, a greater per cent than this may be re habilitated. Despite the lack of knowl edge regarding the actual cause of athero sclerosis, a great deal is known about the disease it produces in the heart and more is being learned about the means of pre
venting and alleviating these troubles. Certain things cannot be changed, for example, heredity, age and sex. However, there are many important etiologic fac tors which can be controlled. Habits of eating, smoking and drinking usually can be improved if the person has the desire and is convinced of the value of change. Reduction in work hours usually is pos sible. Stress may be cut down but prob ably never eliminated. T h e control of obesity is of great consequence and now adequate means of controlling most ar terial hypertension are available. The proper management of patients with dia betes, gout and other metabolic conditions is of importance in the prevention and treatment of this type of heart disease. A reduction in the total fat and especially the “ saturated” fats (those found in ani mal and milk products) of the diet is indicated, in the light of present knowl edge, in patients with coronary disease. There is not enough evidence, at present, however, to indicate a radical change in the dietary habits of the normal, nonobese members of the population. Regular physical exercise has a place in the health picture of normal adults. It is also a beneficial therapeutic aid in those cardiac patients with adequate myocardial re serve. A t the present time there is more scientific research being done on the mys teries of atherosclerosis than on any other medical problem. It seems likely that ad vances in this field will continue to benefit mankind in the years ahead.
*Head of the cardiovascular departm ent o f the Penn sylvania H ospital; associate professor of clinical m edi cine, University of Pennsylvania.
phasized. Attention is given the contact relations of the upper lingual cusps and the lower buccal cusps in their respective occlusal fossae. This is meant to include that portion of the buccal and lingual sur faces immediately beyond the buccoocclusal and linguo-occlusal angles which assumes contact during functional move ment. COMM ENT
T h e dental profession has progressed far in developing methods of establishing sat isfactory functional occlusion for fixed partial denture services. There is, how ever, need for further research at the basic, clinical and technical levels. A proved investigative approach which is
reasonably reliable should not be dis carded in favor of one which produces as its ultimate result chaos generated by con fusion. T h e present background of infor mation and clinical experience should be utilized in seeking a better understanding of diagnosis, treatment planning and re storative procedures for rendering a satis factory fixed partial denture service for the patient. Regardless of persisting doc trines it is a sobering experience to observe the occlusal idiosyncrasies of the patients who are being treated. 618 W . Lombard Street
*Professor and head o f departm ent o f fixed partial prosthodontics, Dental School, University of Maryland. I. Glossary o f prosthodontic terms. Academy o f Den ture Prosthetics, ed. J.Pros.Den. Vol. 10 Nov.-Dec. I960.
Coronary heart disease
Joseph B. Vander V e e r * M .D ., Philadelphia
Atherosclerosis of the coronary arteries is the greatest cause of death and disability among adult Americans. Aspects of coro nary heart disease of special importance to dentists include
the following:
(1 )
manifestations which mimic disease of the oral cavity, face or mandible; (2 ) problems related to anesthesia and medi cations; ( 3 ) dental care in the patient with cardiac failure; (4 ) bleeding, result ing from or aggravated by anticoagulant therapy, and (5 ) prognosis and manage ment of the patient with coronary heart disease. A case history describes success ful dental treatment in a 60 year old woman with coronary heart disease.
Coronary heart disease, that group of cardiac affections resulting from athero sclerosis of the coronary arteries, is the most important of all conditions affecting the heart and the greatest single cause of death and disability in this country. Its interest to doctors of dentistry is similar to that of doctors of medicine— it is a frequent primary or complicating factor in their patients and the condition most apt to cause disability or death in them selves or their family, during the most prodùctive years of life. Arteriosclerosis, or more accurately atherosclerosis, was once regarded as a natural and inevitable consequence of aging but since this condi tion is found to be the cause of one fourth of all the cardiac deaths in the age group
VANDER VEER . . . V O LU M E 66, M A R C H 1963 • 65/349
of 25 to 44 years, it must be looked on as a disease. This one type of heart disease far out ranks every other cause of death in the United States, accounting for nearly half a million deaths each year. Undoubtedly, the incidence of coronary heart disease is increasing. T h e life expectancy of a child born in 1900 was 48 years and there were only 8.5 million people in the United States in the age group of 50 to 75 years. In 1960 life expectancy had risen to nearly 70 years and there were nearly 30 million people in the 50 to 75 group. This rapid aging of the population accounts for much of the increase of coronary heart disease since it is primarily a disease of the middle and older age groups. Probably 15 per cent only of the higher heart disease mortality rate, however, is actually due to an increase in the disease. Greater awareness, improved diagnostic facilities and more frequent postmortem examina tions account for the rest of the increase in the mortality rate classified under this heading. C A U S E S O F A T H E R O S C L E R O S IS
Atherosclerosis of the coronary arteries is a multifaceted disease with no single etiologic or epidemiologic cause. It results from or is accelerated by a combination of factors which may not always be the same in different persons. The importance of age has been stressed. Heredity plays an important though variable part and it is one that we, as individuals, can do little about. T h e male sex is much more frequently affected below the age of 50, the ratio being at least 3 to 1. After 50, the ratio becomes more balanced, reach ing nearly an equal incidence in the two sexes by 60 years of age. Certain other conditions and diseases are known to be predisposing factors. Am ong these, hy pertension, obesity and diabetes are im portant. Presently stressed are hyper cholesterolemia and disturbances of lipid metabolism. Overwork, frequently asso ciated with tension, fatigue and faulty
eating habits, may be a significant factor in some. Hard work is not involved, how ever, since this and regular exercise may well have a beneficial or even preventive effect. There is an increasing evidence pointing to excessive smoking of cigarettes as an etiologic factor. There is no evi dence that alcohol per se has any causal relation to coronary disease. This is reas suring; however, alcohol is high in cal ories and, when taken in excess, may contribute to obesity and sedentary living, which, in turn, may be detrimental. There is no scientific proof that alcohol is a “ coronary dilator” or that it helps delay the onset of arteriosclerosis. These views may have originated to some extent in wishful thinking. In the relief of pain of coronary origin, alcohol is less safe and less effective than nitroglycerine and may give a false sense of security which could be harmful. A n interesting, impor tant and complicated facet of this prob lem is the relation of diet, especially fats, to this disease. Dietary fat is a mixture of fatty acids, steroids and other substances, and fats from animal and vegetable sources differ in their composition. In ad dition, the body is capable of synthesizing fat from other foodstuffs. T h e type of fat ingested, as well as its relation to the carbohydrate and protein in the diet and to the total caloric intake, is probably im portant. Important discoveries in this field are imminent but at present the ho rizon is still clouded.
E F F E C T S O F A T H E R O S C L E R O S IS
Arteriosclerosis, means, literally, harden ing of the arteries. The term atheroscle rosis is a more accurate one for the condi tion as it involves smaller arteries, like those of the heart. This is a process of fibrosis and lipidosis of the intimal lining of the vessel which reduces the size of the lumen. T h e earliest lesion is an ac cumulation of fat droplets within the in timal cells. These lipids probably come from the blood plasma. Neutral fats, cholesterol and cholesterol esters are
66/350 • TH E JO U R N A L O F THE AMERICAN DENTAL ASSOCIATION
found in these lesions. Damage to the intima occurs and proliferation of con nective tissue results in the formation of hyaline fibrous tissue. Calcification is apt to follow in the older lesions. Complete closure of the lumen may result from the atherosclerotic lesion alone. Frequently, however, a narrowed, diseased vessel is rapidly occluded by a blood clot or throm bus developing at the site of the damage. Roughening of the intimai lining may pre dispose to this, and various factors which affect intravascular clotting (trauma, postprandial lipemia, infections and many others still unknown) are probably im portant in this sudden occlusion. T h e symptoms, or clinical syndrome, which follow in a given patient depend on many factors, but the rapidity of closure of the vessel and the ability to develop a col lateral circulation to supply the heart muscle with vital oxygen and nutrition are two important ones. The presence of disease and whether it is localized or dif fuse are also significant in relation to whether a given acute episode results in illness or death. R E S U L T IN G S Y N D R O M E S
The clinical picture which results from coronary artery narrowing or occlusion may be dramatic or insidious, with the end result varying from sudden, unex pected death, to slight shortness of breath on physical effort or substernal “ distress” with excitement or exertion. Less dra matic but important manifestations of coronary disease include various cardiac arrhythmias, especially atrial fibrillation, failure of the left ventricle with pul monary edema and congestive heart fail ure. Hypertension, so frequently seen in this age group, is commonly associated
recent therapeutic advances in the man agement of hypertension have alleviated or eliminated this problem. The clinical syndromes resulting from occlusive cor onary disease may be classified under five headings: ( 1 ) the anginal syndrome, ( 2 ) acute myocardial infarction, (3 ) coronary insufficiency, an “ in between” stage, (4) arrhythmias of the auricles and ventricles, and (5 ) failures of the ventricular myo cardium as the result of anoxia and fibrosis— cardiac failure. The latter usu ally affects first the left ventricle and occurs in conjunction with pulmonary congestion, cough and shortness of breath. Weakness of the right ventricle, which often follows, brings on a congestion of the visceral organs and edema of the lower extremities with the clinical picture of congestive heart failure. Obviously, combinations of these manifestations are frequent in patients with coronary dis ease.
D E N T IS T R Y A N D H E A R T D IS E A S E
The following aspects of coronary heart disease or problems related to it, seem to be of special importance to the dental profession: 1. Coronary disease manifestations which mimic disease of the oral cavity, face or mandible. 2. Problems related to anesthesia and medications. 3. Dental care in the patient with car diac failure. 4.
Bleeding, resulting from or aggra
vated by anticoagulant therapy. 5. Prognosis and management of the patient with coronary heart disease. T h e pain of acute coronary insuffi
with coronary disease and can be re garded as a detrimental factor. By in creasing the work of the left ventricle
ciency, whether it is the transient distress of angina pectoris or the more prolonged pain of myocardial infarction, may be
and hastening the atherosclerotic process, it is responsible for complications which
situated in some patients primarily above the level of the clavicles. This location of
increase illness and death. Fortunately,
pain is consistent in these individuals,
VANDER VEER . . . V O LU M E 66, M A R C H 1963 • 67/35J
with one or both angles of the jaw being the most frequent site. Other areas which are sometimes involved are the chin,
should be taken and the oral rather than parenteral administration of antibiotics and other medications is preferred, when
nasion, cheeks and back of the neck. W hen the pain is located only in these areas and not associated with chest or arm distress, the dentist may be the first one consulted. This pain, or it may even be termed a “ distress” by some patients, has certain characteristics. It is often difficult for the patient to describe it accurately. There is a tendency for the pain to come and go rather than be absolutely con stant, if it is prolonged. I f it is transient (a few minutes duration), it is usually related to effort or emotional upset and will cease quickly on removal of the in citing factor or with nitroglycerin.
ever possible. General dental care is frequently needed in patients with chronic coronary heart disease. In the patient with angina pectoris, excitement and pain should be avoided or minimized. Presedation may be helpful, using such drugs as phéno barbital, orally. A tablet of nitroglycerine (0.3 m g.) under the tongue prior to a short procedure or the longer acting erythrityl tetranitrate (15 m g.) by the same route are good prophylactic meas ures. The patient with cardiac failure should be brought to the best possible state of compensation by rest, adminis tration of digitalis, low salt regimen and diuretic therapy. The increasing experi ence with major surgery in geriatric pa
A N E S T H E S I A FO R CARDIAC P A T IE N T S
The patient with coronary disease is more susceptible to all types of arrhythmias and is much less tolerant to anoxia than a normal individual. T h e risk of sudden death, most often the result of ventricular fibrillation, is far greater with both intra venous and inhalation anesthesia in the patient with coronary disease. Premedica tion (sedation), adequate oxygen and an open airway are of the utmost impor tance. W ith proper basal anesthesia, (as thiopental sodium) a higher per cent of oxygen can be utilized with inhalation anesthesia and still adequate relaxation of the patient can be obtained. Increased safety is thus assured. A n experienced an esthetist is of even greater importance than the anesthetic which is used. In the patient who has sustained a recent myo cardial infarction, all operative proce dures should be assiduously avoided for several weeks. Any imperative dental work should be done under local anes thesia, with little or no vasoconstrictor, with adequate sedation and with oxygen available. It should be emphasized that these patients tolerate allergic reactions and drug idiosyncrasies poorly. A careful history for known sensitivities of this type
tients has demonstrated that those suffer ing from coronary disease may tolerate such procedures well, provided they re ceive a proper anesthetic and careful pre operative and postoperative care. I f this is true, the less strenuous procedures of dental practice in these chronic but se verely ill patients need not be feared. U S E O F A N T IC O A G U L A N T S
Anticoagulant therapy is being utilized increasingly in patients with coronary dis ease as a therapeutic and prophylactic measure. It can be expected that prob lems of bleeding secondary to this will be encountered frequently by the dental sur geon. W ith severe bleeding as the result of trauma, vitamin K i is indicated and should be given intravenously in a dose of 20 mg. to 40 mg. I f bleeding continues, a transfusion should be given. W ith planned dental procedures where bleed ing may occur, it is desirable to discon tinue the oral anticoagulant for one or more days prior to the procedure to allow the prothrombin time to return to a more normal level. Unusual bleeding is seldom seen following extractions or other oper
68/352 • THE JOURNAL OF THE AMERICAN DENTAL ASSOCIATION
ative measures when the prothrombin time is in the neighborhood of 40 per cent of normal time or slightly above it. The
of 1960. In M ay, 1961, she split a molar and another tooth became abscessed. Her dentist recommended that several teeth
anticoagulant therapy usually can be re sumed within a few hours after the sur gery. T h e use o f vitamin K i or blood to raise the prothrombin per cent rapidly is to be avoided whenever possible as throm boembolic complications have been ob served on numerous occasions when this has been done. W ith slight or moderate bleeding associated with a prothrombin time which is below a safe therapeutic level (15 per cent of normal time or be low) vitamin K i given orally in one or two doses of 5 mg. each is often adequate (omitting the anticoagulant for at least one d a y ). Doses of this magnitude are usually effective and do not tend to make the patient highly refractory in case the anticoagulant therapy is to be resumed.
be removed but a hospital room could not be obtained before her summer vacation. In the meantime, temporary therapy was given. Her summer was uneventful and she continued with her numerous medica tions, including Dicumarol which was regulated according to a weekly pro thrombin time. She entered the hospital for dental extractions on October 5, 1961. Prior to this, her dentist had prepared an upper partial denture. T h e prothrom bin time was 43 per cent of normal time on the day before admission and the Dicumarol dosage was reduced from a previous daily dose of 37.5 mg. to 25 mg. on this day. T h e day of admission the prothrombin time was 29 per cent of nor mal time and as surgery was planned for the next morning, Dicumarol was omitted and 2.5 mg. of vitamin K i was given. Premedication included sedation with phenobarbital on the day prior to the operation and secobarbital 0.1 mg. before retiring. T h e following morning, one half hour prior to being sent to the operating room, she was given 50 mg. of meperidine
Report of Case • A 60 year old school teacher was first seen in 1956 because of hypertension and mild angina pectoris. Examination disclosed she was overweight and her blood pressure was found to be 1 90/110. The heart was slightly enlarged and the electrocardiogram revealed a left bundle branch block. Over the next four years, she continued to teach and the hypertension was quite well controlled by sedation and weight loss. Digitalis was started in 1957 because of a low cardiac reserve. In 1959, a mild diabetes was dis covered on the routine check of the blood sugar two hours after a regular breakfast. In March of 1960, the patient suffered a coronary thrombosis with an acute myo cardial infarction. She was treated in the hospital for a period of seven weeks and was quite ill during the first three weeks. Considerable cardiac enlargement devel oped with some failure of the left ven
and 0.4 mg. of atropine sulfate by hypo dermic. Intravenous glucose in water was started and thiopental sodium 250 mg. and succinylcholine chloride 40 mg. were given intravenously. The patient was in tubated and halothane with nitrous oxideoxygen was administered. T h e extractions included an upper left impacted third molar, upper left molar with adjacent root, an upper right bicuspid and a lower right bicuspid. During the operation, which took 30 minutes, there was a period of about five minutes when the heart rhythm changed to atrial fibrillation. The pulse rate rose to about 100 at this time
tricle. Heparin was utilized at the onset
but the arrhythmia subsided spontane
of her treatment, followed by Dicumarol. She was discharged from the hospital and
ously. T h e blood pressure was well main tained during the procedure (average
digitalis, sedation, Dicumarol and tolbu tamide were prescribed. T h e patient was
bleeding and mandibular and maxillary
able to return to her teaching in the fall
partial dentures were inserted after the
about
1 4 0 /8 0 ) .
There was very little
VANDER VEER . . . VOLUME 66, MARCH 1963 • 69/3 53
operation. A total of 400 cc. of 5 per cent glucose in water was given intravenously and the patient was kept in a recovery room for two hours after the surgery. There was moderate swelling and pain but no significant bleeding occurred dur ing the next 24 hours. Dicumarol was again prescribed on the evening of the day of the operation and her diabetes and blood pressure remained under good con trol. T h e prothrombin time was 46 per cent of normal time on the day after sur gery. T h e patient was discharged 48 hours after operation and her recovery has been uneventful. C O N C L U S IO N S
Atherosclerosis of the coronary arteries is the greatest cause of death and disability in the adult population. It must be re garded as a disease process and not as an inevitable consequence of aging. Its inci dence is much greater in the male sex until' the older age groups are reached. Heredity and habits of living play an important part in this disease. O n the more hopeful side of the ledger it can be said that about 85 per cent of patients recover from their first “ heart attack” (acute myocardial infarction) and that at least three fourths of these can return to their previous occupation. Am ong pro fessional men, where some modification of the work load is usually possible, a greater per cent than this may be re habilitated. Despite the lack of knowl edge regarding the actual cause of athero sclerosis, a great deal is known about the disease it produces in the heart and more is being learned about the means of pre
venting and alleviating these troubles. Certain things cannot be changed, for example, heredity, age and sex. However, there are many important etiologic fac tors which can be controlled. Habits of eating, smoking and drinking usually can be improved if the person has the desire and is convinced of the value of change. Reduction in work hours usually is pos sible. Stress may be cut down but prob ably never eliminated. T h e control of obesity is of great consequence and now adequate means of controlling most ar terial hypertension are available. The proper management of patients with dia betes, gout and other metabolic conditions is of importance in the prevention and treatment of this type of heart disease. A reduction in the total fat and especially the “ saturated” fats (those found in ani mal and milk products) of the diet is indicated, in the light of present knowl edge, in patients with coronary disease. There is not enough evidence, at present, however, to indicate a radical change in the dietary habits of the normal, nonobese members of the population. Regular physical exercise has a place in the health picture of normal adults. It is also a beneficial therapeutic aid in those cardiac patients with adequate myocardial re serve. A t the present time there is more scientific research being done on the mys teries of atherosclerosis than on any other medical problem. It seems likely that ad vances in this field will continue to benefit mankind in the years ahead.
*Head of the cardiovascular departm ent o f the Penn sylvania H ospital; associate professor of clinical m edi cine, University of Pennsylvania.