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The Dentist’s Responsibility to the Cardiac Patient*
THE DENTIST’S RESPONSIBILITY TO THE CARDIAC PATIENT* By H. N. BOYNE, M.D., D.D.S., M.S., Omaha, Nebr. E A R T disease h as becom e th e le a d in g cause of d e a th in th e U n ite d S tates.1 S ta tistic s show th a t a n in creasin g n u m b e r of p erso n s a re develop in g som e fo rm o f c a rd ia c e m b a rra ssm e n t each y e a r. L ik ew ise th e d e n tis t h as a g re a te r n u m b e r of th ese p a tie n ts co m in g to h im fo r d e n ta l w o rk . I n these cases, th e cap acity o f th e h e a rt, w h ic h c a rrie s on one o f th e v ita l fu n c tio n s of life, is im paired , a n d w e m a y e n c o u n te r difficulties o r even d e a th w h ile c a rin g fo r th em . S u d d en d e a th is n o t u n co m m o n in p a tie n ts su fferin g fro m th e g ra v e r fo rm s o f h e a rt disease, because th e y a re re la tiv e ly in to l e ra n t o f sep tic p o iso n in g a n d e x h au stio n . I sh a ll e n d eav o r to p o rtra y th e o u tw a rd m an ife sta tio n s w h e re b y th e d e n tist m ay reco g n ize these d istu rb a n c e s, an d p re se n t a few suggestions fo r th e m a n a g e m e n t of these cases. T h e te r m “ c a rd ia c fa ilu re ” signifies th e in a b ility of th e h e a r t to disch arg e its c o n te n ts ad eq u ately , th e c irc u la tio n o f th e blood th r o u g h th e b o d y b ein g im p aired as a re su lt. C a rd ia c fa ilu re m ay be th e re s u lt o f one of tw o d efin ite c o n d itio n s : th e w eakness of th e h e a rt b e a t o r an increased resistance to its d is c h a rg e ; o r it m a y be a co m b in atio n o f th e tw o . I f som e p a r t of th e h e a rt is diseased, such as th e valves,
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m u scle o r p e ric a rd iu m , its p o w e r w ill be dim in ish ed a n d th e b e a t w e a k e r th a n n o r m a l. N a tu r a lly , it w ill n o t be able to fo rce th e n o rm a l su p p ly o f b lo o d in to c ir c u la tio n . A g a in , if th e h e a rt h as to fo rce th e b lo o d o n w a rd in th e presence o f an in creased p ressu re, as in h y p erten sio n , o r b lo ck in g o r stenosis o f an o u tg o in g vessel, su ch as th e a o rta , it w ill be im possible fo r it to sen d th e n o rm a l a m o u n t o f blood in to th e a rte rie s to su pp ly th e tissues w ith fo o d a n d oxygen. H o w can a d e n tist reco g n ize card iac fa ilu re in a p a tie n t ? A b rie f m edical his to ry ta k e n in e x a m in in g th e m o u th m ay rev eal c ard ia c fa ilu re w h e n th e d e n tist le ast expects it. T h is ex am in atio n also te n d s to have a good psychologic effect. T h e p a tie n t feels th a t th e d e n tist n o t o n ly u n d e rs ta n d s his w o rk b u t is also ta k in g a p erso n a l in te re st in th e case. A sk th e p a tie n t w h e n h e h a d his la st physical ex am in a tio n , a n d w h e th e r th e physician said a n y th in g a b o u t his h e a rt o r lu n g s a t th a t tim e. A sk h im w h e th e r he becom es sh o rt o f b re a th o n w a lk in g u p sta irs. T h e m o st v a lu a b le in d icatio n o f th e h e a r t’s essen tial so u n d n ess is its p o w e r to en g ag e fu lly in its w o rk w ith o u t c o m p la in t.2 B reath lessn ess on ex ertio n is one of th e first signs of a co m p lain in g h e a rt. T h e tissues receive oxygen an d give off carb o n d io x id e by m ean s of th e c irc u la tio n . D u r in g exercise o r on exer-
*Read before the Section on Oral Surgery, Exodontia and Anesthesia at the SeventySeventh Annual Session of the American Den tal Association, New Orleans, La., Nov. 5, 1935. 2. Lewis, Thom as: Diseases of the Heart, 1. Stone, C. T . : M ortality of H eart Dis New York City: T he Macmillan Company, 1933. ease, J.A.M.A., 103:151-154 (July 21) 1934. Jour. A .D .A ., Vol. 23, A ugust, 1936
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tio n , th e m etab o lic r a te is increased , a n d th e tissues give o u t m o re e n erg y a n d th e re fo re m o re oxygen is re q u ire d by th em . I f th e h e a rt reserv e is lessened, it w ill n o t be ab le to send th e e x tr a su p p ly o f o x y g en ate d b lo o d o u t th r o u g h th e a r te rie s to th ese tissues. T h e in d iv id u a l, in an e ffo rt to g e t th e n eed ed su p p ly o f oxy gen, w ill b re a th e fa s te r. A s th e h e a rt g ra d u a lly loses its reserv e, i t w ill n o t be able to force th e blood o n w a rd w h e n th e body is a t rest, a n d th e in d iv id u a l m ay becom e b reath less w h ile re s tin g in bed.
of ex tre m e nervousness. A tta c k s o f d iz z i ness, v e rtig o an d nose bleed a re o fte n as so ciated w ith h ig h b lo o d p re ssu re . C a r diac fa ilu re sh o u ld a lw a y s be suspected w h e n th e re is a h isto ry o f a c u te rh e u m a tic fev er, syphilis, s c a rle t fev er, a c u te s tre p to coccic in fe ctio n o r a n y o th e r severe in fec tio n , because th ese c o n d itio n s te n d to w eak en th e h e a r t m uscle. T h e b lo o d p re ssu re is a re lia b le g uide to th e co n d itio n o f th e c irc u la tio n . I t is w e ll to ask a ll a d u lt p a tie n ts w h e n th e ir blood p ressu re w a s la s t ta k e n a n d w h e th e r it w a s h ig h a t th a t tim e . I f th e
Fig. 1.—Roentgenogram showing blood sup ply of average heart with arteriosclerotic changes in vessels.
Fig. 2.—Clubbing of fingers due to long standing cardiac failure.
T h is co n d itio n in d icates t h a t th e h e a rt is u sin g its la s t reserve. W h ile ta lk in g to th e p a tie n t, ask w h e th e r he fre q u e n tly has sh a rp p a in s in his chest w h ic h a re re fe rre d d o w n his le ft arm , o r a t tim es has a fe e lin g o f w e ig h t o v er th e h e a rt. D u r in g th e c o n v e rsatio n , o th e r sym ptom s m a y be m e n tio n e d th a t sh o u ld n o t be d isre g a rd e d . P a tie n ts h a v in g card ia c fa ilu re a re o fte n tro u b le d w ith in so m n ja a n d a re o fte n restless, a n d th ey m ay give a h isto ry of h a v in g a tta c k s
d e n tist uses an y ty p e o f g e n e ra l an esth esia in his office, he sh o u ld th o ro u g h ly stu d y th e u se o f th e sp h y g m o m a n o m e ter a n d th e significance o f its re a d in g . T h e r e a re tw o blo o d p re ssu re s to be re a d , th e sys to lic a n d th e d iasto lic .3 T h e a v e ra g e a d u lt has a blo o d p re ssu re o f 1 2 0 -1 3 0 m m ., systolic, a n d 8 0 -9 0 m m ., d iasto lic . A s age increases, th e b lo o d p re ssu re h as a te n d ency to rise. T h e y o u th o f 2 0 p ro b a b ly 3. W hite, P. D .: H e art Disease, N ew Y ork C ity: T h e M acm illan Com pany, 1931.
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has a blood p ressu re of 120 m m ., systolic, an d w e m a y ex p ect th e p re ssu re to rise as he g ro w s o ld e r a t th e ra te o f a b o u t 1 m m . every tw o years. P re s su re rea d in g s of 135 m m ., systolic, a n d 9 5 m m ., d ias to lic, o r o v e r sh o u ld be co n sid ered p a th o logic a t any age. T h e e x tre m e ly lo w blood p re ssu re o f 90 m m ., systolic, an d 5 0 m m ., diastolic, o r lo w e r a re also p a th o logic. A n ab n o rm a lly lo w d ia sto lic p re s su re is alw ay s serious because it in d icates th a t th e h e a rt m uscle is p o o rly n o u rish ed . T h e systolic p ressu re is affected by such em o tio n s as fear, w o rry a n d a p p re h e n -
in th e m d u rin g th e re s t p erio d o f th e h e a rt. T h e ra tio b e tw e e n th is p re ssu re a n d th e d ia sto lic re a d in g is im p o rta n t as it offers th e ea rlie st d a n g e r sign al. I t m ay be fo u n d by d iv id in g th e pulse p re s s u re by th e d ia sto lic p re ssu re . N o rm a lly , th is ra tio sh o u ld be a b o u t 1 :2. W e m a y say th a t if th e ra tio b e tw e e n th e p ulse p ressu re a n d th e d iasto lic p ressu re is be tw e e n 2 :5 a n d 3 :5 , th e h e a r t is in fa irly good co n d itio n . T h e d e n tis t m ay g e t a fa ir idea o f th e c o n d itio n o f th e p a tie n t’s h e a rt b y th e le n g th o f tim e h e can h o ld h is b re a th . I f
Fig. 3.—Appearance of patient with exoph thalmic goiter; showing protrusion of eyeballs and enlargement of neck. T his is an advanced case of goitrous heart.
Fig. 4.— E ngorgem ent of ju g u la r vein in congestive h e art failure.
sion. T h e d iasto lic p ressu re is n o t so v a ri able a n d is th e re fo re th e m o re relia b le read in g . T h e d ifference in m illim e te rs b e tw een th e systolic a n d th e d ia sto lic p ressu re, called th e p u lse pressu re, re p re se n ts th e a m o u n t o f fo rce th e h e a rt m u s t e x e rt in o rd e r to m ove th e blood o n w a rd th ro u g h th e a rte rie s, a fte r it has o v erco m e th e d iasto lic p ressu re, o r th e p re ssu re th a t is
he c a n n o t h o ld it lo n g e r th a n th irty sec o nds, th e h e a rt m u scle m ay be w eaken ed . A fa irly a c c u ra te m e a n s o f d e te rm in in g th e co n d itio n of a h e a rt is an exercise test. F ir s t, th e pu lse ra te is ta k e n , th e n th e p a tie n t is asked to hop o n one fo o t sev eral tim es. A f te r a re s t of o n e m in u te , th e p ulse ra te sh o u ld r e tu r n to n o rm a l if th e h e a rt is in good c o n d itio n . A n o th e r index to th e h e a rt is th e h em o g lo b in , th e solid p a r t o f th e blood t h a t c a rrie s th e oxygen. N o rm a lly , a b o u t 9 0 p e r c e n t o f th e solids
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w ith in th e blood is h em o g lo b in . I f it is c o n sid erab ly b elo w n o rm a l, say 6 0 p e r ce n t, th e h e a rt is fo rced to w o rk h a rd e r to g et th e re q u ire d a m o u n t o f oxygen to th e tissues. T h is o v e rw o rk soon im p a irs th e h e a rt. W h e n th e h em oglobin is b elo w 70 p e r c e n t, th e case sh o u ld be tr e a te d as a h e a r t disease. T h e d e n tist w h o p ractices su rg e ry w ill p ro fit by p u rc h a sin g a h em o g lo b in o m eter. W i t h th is in s tr u m e n t, he can acc u ra te ly tak e th e h e m o g lo bin fo r an y p a tie n t w h o is a b o u t to h a v e an ex ten siv e o ra l o p e ra tio n . P a tie n ts
th a t th e blood is n o t b eing p ro p e rly a e ra te d o w in g to p o o r c irc u la tio n . T h e su p erficial vein s o f th e b o d y m ay be d iste n d e d . T h e w e a k e n e d h e a rt is u n a b le to tr a n s f e r th e n o rm a l a m o u n t of blo o d to th e a rte ria l side, a n d th e in creased a m o u n t o f b lo o d le f t o n th e v e n o u s side causes a d iste n tio n of th e veins. W h e n th e v en o u s p re ssu re becom es v e ry m a rk e d , th e excess fluid o f th e blood passes th r o u g h th e vessel w a lls in to th e tissue of th e body c a u sin g edem a, o r d ro p sy . A s th is u su a lly o ccu rs a t th e end
Fig. 5.—Enlarged tortuous vessels in arm, in case of arteriosclerosis.
Fig. 6 .-—Bulging of chest wall due to aneurism in severe case of cardiac syphilis.
w ith a lo w hem oglobin in d ex have a m u ch g re a te r te n d en c y to h e m o rrh a g e. T h e r e a re also m a n y p hysical sig n s o f c a rd ia c fa ilu re th a t th e d e n tist m ay n o te. I n cases o f ex trem e ly lo w blood p re ssu re o r p e rip h e ra l anem ia, th e p a tie n t m ay be pale. F lu s h in g of th e face m ay be seen in fever, e x citem en t a n d a o rtic insuffi ciency a n d a rte ria l h y p e rte n sio n . A n y d e gree o f cyanosis sh o u ld be n o te d , b ein g in d ic a te d by a bluish tin g e u s u a lly a b o u t th e lips, ears a n d fin g er n ails, in d ic a tin g
of th e day, th e p a tie n t sh o u ld be asked w h e th e r he h a s n o ticed th a t his an k les be com e sw o llen a t th e en d o f th e d ay . A s c a rd ia c fa ilu re ad v an ces, th e fluid o fte n co llects in th e ab d o m en , a d iste n tio n , k n o w n as ascites, re s u ltin g . R e n a l edem a o r ed em a caused b y d y sfu n c tio n in g o f th e kidneys, w h ic h a re u n a b le to c a rry off th e p ro p e r a m o u n t o f fluids, u su a lly ap p e a rs in th e m o rn in g a n d is n o tice a b le in th e face a n d th e so ft tissues a b o u t th e eyes, a n d o n th e d o rsu m o f th e h an d s. T h is
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co n d itio n is u su a lly asso ciate d w ith a p o o r circ u la tio n . W h e n th e re is a lo n g -sta n d in g stasis o f th e p u lm o n a ry c irc u la tio n o r lo n g s ta n d in g c a rd ia c disease, th e en d s o f th e fingers becom e clu b b e d . T h e p u p ils o f th e eyes sh o u ld be n o te d .4 A n in e q u a lity o f th e p u p ils m ay be d u e to a th o ra c ic a n eu ry sm p ressin g o n a sy m p a th etic n erv e. A b u lg in g o f th e c h e st w a ll m ay be caused by a n an e u ry sm o r in fla m m a tio n o f th e p e ric a rd iu m w ith effusion. I n cases o f h ig h blood p re ssu re , th e a rte rie s of th e neck m a y be seen to p u lsa te . T h is
e n la rg e d th y ro id m ay cause som e m e c h a n ic a l in te rfe re n c e w ith th e c irc u la tio n o r re sp ira tio n , th u s p la c in g a d d itio n a l w o rk o n th e h e a r t ; o r, m o re o fte n , an in crease in th e a m o u n t o f th y ro id secretio n th a t has been th r o w n in to th e c irc u la tio n by th e e n la rg e d th y ro id , m ay cause th e m etab o lic ra te to be g re a tly increased. I t is u su a lly n o t d ifficu lt to reco g n ize these cases. T h e p a tie n t is v ery n erv o u s, re s t less a n d h y p ersen sitiv e, a n d m ay h a v e a t tack s o f ra g e o r c ry in g , b ro u g h t on by som e in sig n ifica n t m a tte r . T h e eyeballs p ro tru d e a n d th e re is u su a lly a s ta rin g
Fig. 7.—Necropsy specimen from case of coronary thrombosis. T he ventricular wall is thin and there is scar tissue present in this serious form of heart disease.
Fig. 8.—Appearance of patient in case of m itral insufficiency complicated with peri cardial effusion. The facies is of the mitral type and there is bulging of the chest wall.
is also seen in p a tie n ts h a v in g ex o p h th a lm ic g o ite r. T h e r e is alw a y s a c ard ia c in v o lv m en t in these cases, th e h e a rt b eing e ith e r h y p e rtro p h ie d o r d ila te d fro m th e excessive w o rk th a t is th r o w n o n it. T h e a d d itio n a l w o rk m ay be d u e to one o f tw o c o n d itio n s : T h e p re ssu re o f th e
expression. T h e p u lse is rap id , v a ry in g fro m 120 to 160 b eats p e r m in u te . L ik e w ise, ra p id p u lsa tio n of th e a rte rie s o f th e n eck m ay be seen .5 T h e s e sym ptom s m ay n o t alw ay s be so p ro n o u n c e d , a n d a t tim es th e o n ly sy m p to m p re s e n t m ay be an in creased p u lse ra te associated w ith a
4. Morris, L. M .: C ardiac Aneurysm, Am.5. Bram, Israel: Role of Dentist in Goiter Heart J., 2:548-559 (June) 1927. Cases, J.A.D.A., 18:1544 (Aug.) 1931.
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tre m o r of th e fingers w h e n th e a rm is ex ten d ed . T h e pulse sh o u ld also be n o te d , as it is a good in d ex to th e c o n d itio n o f th e h e a rt. T h e d e n tist sh o u ld be ab le to de te c t re a d ily th e m o s t co m m o n p u lse ir re g u la ritie s. T h e p u lse sh o u ld n o t be p a lp a te d w ith th e th u m b as th e re is n o r m a lly a p u lsatio n in th e th u m b w h ich m ay b e fe lt, an e r r o r in th e in te rp re ta tio n re s u ltin g . T h e n o rm a l r a te is be tw e e n 70 a n d 80 b ea ts a m in u te . E x c ite m e n t o r em o tio n al s tra in w ill cause a rise in th is ra te . A n y g re a t v a ria tio n fro m n o rm a l, th e ra te b e in g e ith e r to o fa s t o r too slo w , in d icates c a rd ia c im p a irm e n t. A n in te rm itte n t o r ir r e g u la r p ulse, w h e n th e re is an om ission o f o n e o r m o re b eats, sh o u ld lead th e d e n tis t to tr e a t th e case as c a rd ia c ; a lth o u g h th is co n d itio n is o fte n fo u n d to b e in d e p e n d e n t o f a n y d ete c ta b le h e a rt disease. T h e v o lu m e o f th e p u lse sh o u ld be n o ted . A fu ll, b o u n d in g pu lse m a y in d i ca te h y p erten sio n . A feeble b e a t m a y be n o ted in w eak d e b ilita te d p a tie n ts w ith a p o o r c irc u la tio n a n d in a n em ic p a tie n ts. Since th e q u a lity o f th e h e a r t b e a t can be fa irly w e ll ju d g e d by ta k in g th e p ulse, I do n o t th in k it necessary f o r th e d e n tis t to use th e stethoscope. C o n tin u a l p ra c tic e w ith th is in s tru m e n t is re q u ire d to in te r p re t th e h e a rt so u n d s w ith an y d e g re e of accuracy, a n d th e re fo re th e a v e ra g e d e n tis t w ill n o t, I believe, d eriv e m u ch bene fit fro m its use. C a rd ia c fa ilu re is o fte n associated w ith tu b ercu lo sis, n e p h ritis, d iab etes a n d pernicious anem ia, a n d o th e r in fectio n s a n d d iso rd ers of lo n g s ta n d in g . T h e sam e precau tio n s sh o u ld be ta k e n in th ese cases as in an y o th e r c ard iac d istu rb an c e . W h a t a re th e p re c a u tio n s th a t a d en tis t sh o u ld ta k e w h e n c a rin g fo r a p a tie n t w ith card ia c fa ilu re ? F ir s t o f all, he sh o u ld g et in to u c h w ith th e p a tie n t’s physician, a n d re p o rt th e w o rk h e expects
to do fo r th e p a tie n t. A f te r th e physician has g iv en perm issio n to pro ceed w ith th e w o rk , th e resp o n sib ility is sh a re d by him . T h e d e n tis t sh o u ld also re m e m b e r t h a t persons su ffe rin g fro m a n y d eg ree o f c a rd ia c fa ilu re sh o u ld lea d a q u ie t life free fro m u n d u e fe ar, ex c ite m e n t, w o rry o r g re a t p h y sical a c tiv ity . T h e s e p a tie n ts a re v e ry o fte n n erv o u s, h y p ersen sitiv e an d irrita b le , a n d th e v isit to th e d e n ta l office m ay cause th e m to becom e q u ite ex cited. T h e y u s u a lly re a c t q u ic k ly to th e a t m o sp h ere s u rro u n d in g th e m ; a n d th e calm , c h e e rfu l d e n tist, by u sin g a little ta c t a n d patien ce, w ill g a in th e ir confi d ence. T h e y th e n a re u su a lly coo p erativ e w h ile th e d e n ta l w o rk is b e in g done. P re m e d ic a tio n b efo re o p eratio n s is fo r th ese p a tie n ts v e ry d esirab le . S om e de riv a tiv e o f b a rb itu ric acid h as p ro v ed m o st beneficial. W e u su a lly g iv e sodium a m y ta l, 3 g ra in s, o r n e m b u ta l, 1£ g rain s, fro m th ir ty to fo r ty m in u te s b efo re th e o p eratio n . W i t h p rem e d ic atio n , th e p a tie n t w ill be in a c a lm e r a n d m o re recep tiv e m ood, a n d th e possib ility o f any psychic shock is lessened. T h e in je ctio n s sh o u ld be m a d e as painless as possible by th e use of a w e a k so lu tio n o f cocaine o r a 2 p e r c e n t p an to c a in e on th e m ucous m em b ra n e . W e p re fe r p a n to c a in e as it is n o t so to x ic as cocaine. I t m u s t be re m em b ered th a t th ese p a tie n ts do n o t to l e ra te ep in e p h rin e w e ll as i t raises th e blo o d p re ssu re a n d places an e x tr a a m o u n t o f w o rk o n th e h e a rt. T h e so lu tio n fo r lo c al an esth esia sh o u ld c o n ta in th e least a m o u n t o f ep in e p h rin e possible. P re m e d i c atio n w ith one o f th e b a rb itu ra te s ten d s to c o m b a t th is rise in b lo o d p ressu re an d th e re b y increases th e to le ra n c e fo r local anesthesia. I t sh o u ld be g iven as a p ro p h y lactic, if th e re is any u n c e rta in ty in re g a rd to th e p a tie n t’s h e a rt. W h e n d o in g w o rk fo r persons h a v in g a c a rd ia c d istu rb a n c e , it m u s t be rem em
Boyne —D entist's Responsibility to the Cardiac Patient b e re d t h a t th ey do n o t to le ra te a la rg e a m o u n t o f w o rk a t o n e tim e. T h is is to be especially rem em b e red w h e n su rg ic a l p ro c e d u re s a re in d ic ate d . T h e ju d g m e n t o f b o th physician a n d d e n tist is necessary in d e c id in g such m a tte rs as th e a m o u n t of w o rk th a t m ay be d o n e a t o n e tim e, th e ty p e o f an esth esia th a t sh o u ld b e used a n d w h e th e r h o sp ita liz a tio n is necessary. R e m o v in g to o m a n y in fec ted te e th a t one tim e m ay p re c ip ita te h e a rt fa ilu re a n d even cause d e a th . I t is n o t ad v isab le to keep these p a tie n ts in th e d e n ta l c h a ir fo r m o re th a n th ir ty to fo rty -fiv e m in u te s a t o n e tim e. I n m o st e x tra c tio n s, th e p a tie n t is o f m id d le age o r o ld e r. A s it is d u r in g th is age th a t m o st o f th e c ard ia c c o m p la in ts occur, it is necessary th a t w e b e s u re o f th e co n d itio n o f th e h e a rt be fo re w e a tte m p t extensive o p e ra tio n s fo r these p a tien ts. L o c a l an esth esia6 is p re fe rre d to g e n eral an esth esia fo r e x tra c tio n s in cases o f c a r d iac fa ilu re . W h e n th ese p a tie n ts receive p ro p e r p re m e d ic a tio n a n d a re ta c tfu lly h a n d le d , th ey experience little o r n o shock if o n ly a fe w te e th a re rem o v ed a t a tim e. M o s t of th e m w ill s ta n d a g e n e ra l anes th e tic w e ll if it is g iven c o rre c tly . I t is a b so lu tely necessary th a t these p a tie n ts do n o t s tru g g le w h ile u n d e r an esth esia, as th is th ro w s e x tr a w o rk on th e h e a rt. I t is also necessary th a t no asp h y x iai s tra in be th r o w n o n th e h e a rt. T h e re sp ira tio n sh o u ld be k e p t free fro m e m b a rrassm en t, a n d as w id e a m a rg in o f oxygen as pos sible sh o u ld be given w ith th e an e sth e tic gas. I f th e c irc u la tio n is a lre a d y im p a ire d , a n y degree o f asp h y x ia places a g re a te r s tra in on th e h e a rt. A n e sth e tic ten sio n sh o u ld n o t be estab lish ed in these p a tie n ts by c u ttin g off th e o xygen. D e a th m a y ta k e place a fte r th e b rie fe st perio d of cyanosis.
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N itr o u s oxide-oxygen, th e le a st to x ic a n e sth e tic th a t w e h a v e a t p resen t, is th e one m o st g e n e ra lly u sed by d en tists. I t m u s t be rem e m b e red th a t th is is n o t so p o w e rfu l as som e o f th e o th e r anesthetics, a n d it m ay be d ifficu lt to m a in ta in th e p ro p e r d e g ree o f anesthesia, u n less th e p a tie n t is so m e w h a t cy an o tic.7 M a n y o f o u r b e tte r k n o w n a n e sth e tists te ll us th a t it is m o re d esirab le to a d d a sm a ll a m o u n t of e th e r to th e gas-oxygen m ix tu re th a n to lim it th e o xygen to th is e x te n t. A d m in is tra tio n o f e th e r te n d s to h av e a to x ic effect on th e kidneys, a n d w e do n o t lik e to em plo y it in h e a rt cases, y et a v e ry sm a ll a m o u n t o f it w ill do less h a rm th a n a p erio d o f cyanosis. E th y le n e is th e p re fe rre d a n e sth e tic in these cases. I t is m o re p o w e rfu l th a n n itro u s o xide a n d m o re oxygen m a y be given w ith it a n d th e p ro p e r d eg ree o f an esth esia still be m a in ta in e d . O w in g to its explosive p ro p e r ties, it has n o t been u sed w id e ly in th e d e n ta l office. W e m ay say th a t a m o re im p o rta n t co n sid eratio n th a n th e ty p e of an esth esia u sed is p ro b a b ly th e com pe ten ce o f th e a n e sth e tist. S ince it is im p e ra tiv e th a t th e an es th e tic be g iv en p ro p e rly , it is alw ay s a d visab le to in sist th a t th ese p a tie n ts e n te r th e h o sp ita l to h av e an y o ra l su rg ic al o p e ra tio n w h e n a g e n e ra l an esth etic is in d i c ate d . H e re , a tra in e d a n e sth e tist w ill a d m in is te r th e an e sth e tic a n d resu scitativ e m easu res can be im m ed iately em ployed in cases of syncope, re sp ira to ry fa ilu re a n d shock. S alin e a n d glucose so lu tio n s h av e been p re p a re d a n d m a y be g iven im m e d ia te ly w h e n needed. T h e s e so lu tio n s, w h e n placed in th e b lo o d stre a m , ra ise th e blood p ressu re a n d h elp c o m b a t shock. W h e n e v e r a d e n tist is o b lig ed to d o extensive w o rk fo r a pa-
7. Hewitt, F. D.: Anesthetics and T heir Lundy, J. S.: Anesthesia in Presence of Administration, a Textbook for Medical and G rave Surgical Risk, Report at Staff Meeting, Dental Practitioners and Students, Ed. 4, New T he Mayo Clinic, 1935. York City: T he Macmillan Company. 6.
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tie n t w ith ad v an ced c a rd ia c disease, it sh o u ld alw ay s be d o n e in th e h o sp ital. I f an y difficulties arise in th e office, th e d e n tist sh o u ld be ab le to re n d e r first aid. F e a r, w h en a b o u t to h av e an e x tra c tio n , m ay cause c e rta in p a tie n ts to fa in t. T h is is th e m o st com m on d ifficu lty th a t th e d e n tist en co u n te rs. I n th is c o n d itio n , th e bloo d has le f t th e b ra in a n d th e p a tie n t is in a m ild d eg ree o f shock. T h e p a tie n t’s head is lo w e re d so t h a t th e b lo o d w ill flow back to th e b ra in . A fe w b re a th s of sp irits of am m o n ia w ill in crease th e res p ira tio n ra te a n d fa c ilita te o x y g en atio n of th e blood. A lp h a lo b e lin is a g o o d re s p ira to ry stim u la n t. I t com es in am p u les a n d is given in tra m u sc u la rly . I f th e p u lse is w eak an d th e p a tie n t does n o t respond read ily , a h e a rt s tim u la n t sh o u ld be given. C affein e so lu tio n b en zo a te 7-J g rain s, epin ep h rin e, 0.5 to 1 c.c. o r c o ra m in e 1 am p u le m ay be g iv en in tra m u sc u la rly . T h e d e n tist sh o u ld keep a ste rile hypo d erm ic syringe re a d y a t a ll tim es. C o r am in e m ay be o b ta in e d in a p re p a ra tio n to be given o ra lly . W e find t h a t 2 0 d rops of th is so lu tio n in a little w a te r w ill aid g re a tly in re v iv in g a p a tie n t. A ll d e n tists sh o u ld be ab le to a d m in iste r a rtific ia l res p ira tio n c o rrectly . I f th e y h av e a gas m a chine, it is w e ll to h a v e it eq u ipp ed fo r carb o n dioxide a d m in is tra tio n , as th is is a v e ry effective re s p ira to ry s tim u la n t. C e rta in types o f c a rd ia c fa ilu re d e m a n d th e m o st c a re fu l a tte n tio n a n d con sid e ra tio n . P a tie n ts su ffe rin g w ith a n g in a pectoris, sy p h ilitic a o ritis, co r o n a ry throm bosis, a n eu ry sm , ad v an ced
g o ite r a ffec tin g th e h e a r t a n d severe h y p erten sio n a re in th is class. T h e s e p a tie n ts o fte n d ie su d d e n ly . I t is alw a y s im p o r ta n t th a t th e y be ex am in e d by th e ir physician a n d his aid b e o b ta in e d in de c id in g su ch m a tte r s as p rem ed ic a tio n , and th e tim e an d p la ce to o p erate . P e a rls o f a m y ta l n itr a te o r n itr o g ly cerin e ta b le ts sh o u ld be k e p t a t h a n d fo r p a tie n ts su ffe rin g w ith a n g in a pec to ris. T h e s e d ru g s d ila te th e co ro n a ry a rte rie s, w h ic h su p p ly th e h e a rt m uscle w ith b lo o d , a n d th e p a tie n t o b ta in s re lief fro m th e p ain th a t is c h a ra c te ristic of th is ty p e o f h e a r t disease. T h e necessity f o r th e p ro p e r m a n a g e m e n t o f p a tie n ts w ith c a rd ia c d is tu rb ances, as w e ll as p a tie n ts su ffe rin g w ith o th e r system ic d iso rd ers, is so im p o rta n t th a t I w o u ld su g g e st t h a t o u r stu d y clubs ta k e u p these su b je c ts. A re v ie w o f these d iso rd e rs th e m a n ife sta tio n s o f w hich m ay be p re s e n t in th e o ra l c a v ity a n d th e co m p lication s t h a t m ay arise fro m su rg i cal in te rfe re n c e a re su b je c ts stu d y of w h ich w o u ld g re a tly b en efit th e d en tist. T h e s e a re p o in ts t h a t o u r d e n ta l ed u c a tio n to o o fte n n eg lec ts. A stu d y o f these su b jects w ill g iv e th e d e n tis t a b ro a d e r in sig h t in to th e field o f m ed icin e, a n d en able h im to c o o p e ra te m o re closely w ith th e physician. T h e pro g ressiv e d e n tist of to d a y ap p rec ia te s th e b o n d th a t n o w exists b e tw een th e m e d ic a l a n d th e d e n ta l p ro fession. T h is b o n d o f in te rd e p e n d e n c e seem s to m e to be a n ecessity if w e a re to keep th e p a tie n t’s in te re st a t h e a rt. 1002 N ational B ank B uilding.
H
m u scle o r p e ric a rd iu m , its p o w e r w ill be dim in ish ed a n d th e b e a t w e a k e r th a n n o r m a l. N a tu r a lly , it w ill n o t be able to fo rce th e n o rm a l su p p ly o f b lo o d in to c ir c u la tio n . A g a in , if th e h e a rt h as to fo rce th e b lo o d o n w a rd in th e presence o f an in creased p ressu re, as in h y p erten sio n , o r b lo ck in g o r stenosis o f an o u tg o in g vessel, su ch as th e a o rta , it w ill be im possible fo r it to sen d th e n o rm a l a m o u n t o f blood in to th e a rte rie s to su pp ly th e tissues w ith fo o d a n d oxygen. H o w can a d e n tist reco g n ize card iac fa ilu re in a p a tie n t ? A b rie f m edical his to ry ta k e n in e x a m in in g th e m o u th m ay rev eal c ard ia c fa ilu re w h e n th e d e n tist le ast expects it. T h is ex am in atio n also te n d s to have a good psychologic effect. T h e p a tie n t feels th a t th e d e n tist n o t o n ly u n d e rs ta n d s his w o rk b u t is also ta k in g a p erso n a l in te re st in th e case. A sk th e p a tie n t w h e n h e h a d his la st physical ex am in a tio n , a n d w h e th e r th e physician said a n y th in g a b o u t his h e a rt o r lu n g s a t th a t tim e. A sk h im w h e th e r he becom es sh o rt o f b re a th o n w a lk in g u p sta irs. T h e m o st v a lu a b le in d icatio n o f th e h e a r t’s essen tial so u n d n ess is its p o w e r to en g ag e fu lly in its w o rk w ith o u t c o m p la in t.2 B reath lessn ess on ex ertio n is one of th e first signs of a co m p lain in g h e a rt. T h e tissues receive oxygen an d give off carb o n d io x id e by m ean s of th e c irc u la tio n . D u r in g exercise o r on exer-
*Read before the Section on Oral Surgery, Exodontia and Anesthesia at the SeventySeventh Annual Session of the American Den tal Association, New Orleans, La., Nov. 5, 1935. 2. Lewis, Thom as: Diseases of the Heart, 1. Stone, C. T . : M ortality of H eart Dis New York City: T he Macmillan Company, 1933. ease, J.A.M.A., 103:151-154 (July 21) 1934. Jour. A .D .A ., Vol. 23, A ugust, 1936
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tio n , th e m etab o lic r a te is increased , a n d th e tissues give o u t m o re e n erg y a n d th e re fo re m o re oxygen is re q u ire d by th em . I f th e h e a rt reserv e is lessened, it w ill n o t be ab le to send th e e x tr a su p p ly o f o x y g en ate d b lo o d o u t th r o u g h th e a r te rie s to th ese tissues. T h e in d iv id u a l, in an e ffo rt to g e t th e n eed ed su p p ly o f oxy gen, w ill b re a th e fa s te r. A s th e h e a rt g ra d u a lly loses its reserv e, i t w ill n o t be able to force th e blood o n w a rd w h e n th e body is a t rest, a n d th e in d iv id u a l m ay becom e b reath less w h ile re s tin g in bed.
of ex tre m e nervousness. A tta c k s o f d iz z i ness, v e rtig o an d nose bleed a re o fte n as so ciated w ith h ig h b lo o d p re ssu re . C a r diac fa ilu re sh o u ld a lw a y s be suspected w h e n th e re is a h isto ry o f a c u te rh e u m a tic fev er, syphilis, s c a rle t fev er, a c u te s tre p to coccic in fe ctio n o r a n y o th e r severe in fec tio n , because th ese c o n d itio n s te n d to w eak en th e h e a r t m uscle. T h e b lo o d p re ssu re is a re lia b le g uide to th e co n d itio n o f th e c irc u la tio n . I t is w e ll to ask a ll a d u lt p a tie n ts w h e n th e ir blood p ressu re w a s la s t ta k e n a n d w h e th e r it w a s h ig h a t th a t tim e . I f th e
Fig. 1.—Roentgenogram showing blood sup ply of average heart with arteriosclerotic changes in vessels.
Fig. 2.—Clubbing of fingers due to long standing cardiac failure.
T h is co n d itio n in d icates t h a t th e h e a rt is u sin g its la s t reserve. W h ile ta lk in g to th e p a tie n t, ask w h e th e r he fre q u e n tly has sh a rp p a in s in his chest w h ic h a re re fe rre d d o w n his le ft arm , o r a t tim es has a fe e lin g o f w e ig h t o v er th e h e a rt. D u r in g th e c o n v e rsatio n , o th e r sym ptom s m a y be m e n tio n e d th a t sh o u ld n o t be d isre g a rd e d . P a tie n ts h a v in g card ia c fa ilu re a re o fte n tro u b le d w ith in so m n ja a n d a re o fte n restless, a n d th ey m ay give a h isto ry of h a v in g a tta c k s
d e n tist uses an y ty p e o f g e n e ra l an esth esia in his office, he sh o u ld th o ro u g h ly stu d y th e u se o f th e sp h y g m o m a n o m e ter a n d th e significance o f its re a d in g . T h e r e a re tw o blo o d p re ssu re s to be re a d , th e sys to lic a n d th e d iasto lic .3 T h e a v e ra g e a d u lt has a blo o d p re ssu re o f 1 2 0 -1 3 0 m m ., systolic, a n d 8 0 -9 0 m m ., d iasto lic . A s age increases, th e b lo o d p re ssu re h as a te n d ency to rise. T h e y o u th o f 2 0 p ro b a b ly 3. W hite, P. D .: H e art Disease, N ew Y ork C ity: T h e M acm illan Com pany, 1931.
B o yn e — D e n tis t’s R esp o n sib ility to the C a rd ia c P a tie n t
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has a blood p ressu re of 120 m m ., systolic, an d w e m a y ex p ect th e p re ssu re to rise as he g ro w s o ld e r a t th e ra te o f a b o u t 1 m m . every tw o years. P re s su re rea d in g s of 135 m m ., systolic, a n d 9 5 m m ., d ias to lic, o r o v e r sh o u ld be co n sid ered p a th o logic a t any age. T h e e x tre m e ly lo w blood p re ssu re o f 90 m m ., systolic, an d 5 0 m m ., diastolic, o r lo w e r a re also p a th o logic. A n ab n o rm a lly lo w d ia sto lic p re s su re is alw ay s serious because it in d icates th a t th e h e a rt m uscle is p o o rly n o u rish ed . T h e systolic p ressu re is affected by such em o tio n s as fear, w o rry a n d a p p re h e n -
in th e m d u rin g th e re s t p erio d o f th e h e a rt. T h e ra tio b e tw e e n th is p re ssu re a n d th e d ia sto lic re a d in g is im p o rta n t as it offers th e ea rlie st d a n g e r sign al. I t m ay be fo u n d by d iv id in g th e pulse p re s s u re by th e d ia sto lic p re ssu re . N o rm a lly , th is ra tio sh o u ld be a b o u t 1 :2. W e m a y say th a t if th e ra tio b e tw e e n th e p ulse p ressu re a n d th e d iasto lic p ressu re is be tw e e n 2 :5 a n d 3 :5 , th e h e a r t is in fa irly good co n d itio n . T h e d e n tis t m ay g e t a fa ir idea o f th e c o n d itio n o f th e p a tie n t’s h e a rt b y th e le n g th o f tim e h e can h o ld h is b re a th . I f
Fig. 3.—Appearance of patient with exoph thalmic goiter; showing protrusion of eyeballs and enlargement of neck. T his is an advanced case of goitrous heart.
Fig. 4.— E ngorgem ent of ju g u la r vein in congestive h e art failure.
sion. T h e d iasto lic p ressu re is n o t so v a ri able a n d is th e re fo re th e m o re relia b le read in g . T h e d ifference in m illim e te rs b e tw een th e systolic a n d th e d ia sto lic p ressu re, called th e p u lse pressu re, re p re se n ts th e a m o u n t o f fo rce th e h e a rt m u s t e x e rt in o rd e r to m ove th e blood o n w a rd th ro u g h th e a rte rie s, a fte r it has o v erco m e th e d iasto lic p ressu re, o r th e p re ssu re th a t is
he c a n n o t h o ld it lo n g e r th a n th irty sec o nds, th e h e a rt m u scle m ay be w eaken ed . A fa irly a c c u ra te m e a n s o f d e te rm in in g th e co n d itio n of a h e a rt is an exercise test. F ir s t, th e pu lse ra te is ta k e n , th e n th e p a tie n t is asked to hop o n one fo o t sev eral tim es. A f te r a re s t of o n e m in u te , th e p ulse ra te sh o u ld r e tu r n to n o rm a l if th e h e a rt is in good c o n d itio n . A n o th e r index to th e h e a rt is th e h em o g lo b in , th e solid p a r t o f th e blood t h a t c a rrie s th e oxygen. N o rm a lly , a b o u t 9 0 p e r c e n t o f th e solids
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w ith in th e blood is h em o g lo b in . I f it is c o n sid erab ly b elo w n o rm a l, say 6 0 p e r ce n t, th e h e a rt is fo rced to w o rk h a rd e r to g et th e re q u ire d a m o u n t o f oxygen to th e tissues. T h is o v e rw o rk soon im p a irs th e h e a rt. W h e n th e h em oglobin is b elo w 70 p e r c e n t, th e case sh o u ld be tr e a te d as a h e a r t disease. T h e d e n tist w h o p ractices su rg e ry w ill p ro fit by p u rc h a sin g a h em o g lo b in o m eter. W i t h th is in s tr u m e n t, he can acc u ra te ly tak e th e h e m o g lo bin fo r an y p a tie n t w h o is a b o u t to h a v e an ex ten siv e o ra l o p e ra tio n . P a tie n ts
th a t th e blood is n o t b eing p ro p e rly a e ra te d o w in g to p o o r c irc u la tio n . T h e su p erficial vein s o f th e b o d y m ay be d iste n d e d . T h e w e a k e n e d h e a rt is u n a b le to tr a n s f e r th e n o rm a l a m o u n t of blo o d to th e a rte ria l side, a n d th e in creased a m o u n t o f b lo o d le f t o n th e v e n o u s side causes a d iste n tio n of th e veins. W h e n th e v en o u s p re ssu re becom es v e ry m a rk e d , th e excess fluid o f th e blood passes th r o u g h th e vessel w a lls in to th e tissue of th e body c a u sin g edem a, o r d ro p sy . A s th is u su a lly o ccu rs a t th e end
Fig. 5.—Enlarged tortuous vessels in arm, in case of arteriosclerosis.
Fig. 6 .-—Bulging of chest wall due to aneurism in severe case of cardiac syphilis.
w ith a lo w hem oglobin in d ex have a m u ch g re a te r te n d en c y to h e m o rrh a g e. T h e r e a re also m a n y p hysical sig n s o f c a rd ia c fa ilu re th a t th e d e n tist m ay n o te. I n cases o f ex trem e ly lo w blood p re ssu re o r p e rip h e ra l anem ia, th e p a tie n t m ay be pale. F lu s h in g of th e face m ay be seen in fever, e x citem en t a n d a o rtic insuffi ciency a n d a rte ria l h y p e rte n sio n . A n y d e gree o f cyanosis sh o u ld be n o te d , b ein g in d ic a te d by a bluish tin g e u s u a lly a b o u t th e lips, ears a n d fin g er n ails, in d ic a tin g
of th e day, th e p a tie n t sh o u ld be asked w h e th e r he h a s n o ticed th a t his an k les be com e sw o llen a t th e en d o f th e d ay . A s c a rd ia c fa ilu re ad v an ces, th e fluid o fte n co llects in th e ab d o m en , a d iste n tio n , k n o w n as ascites, re s u ltin g . R e n a l edem a o r ed em a caused b y d y sfu n c tio n in g o f th e kidneys, w h ic h a re u n a b le to c a rry off th e p ro p e r a m o u n t o f fluids, u su a lly ap p e a rs in th e m o rn in g a n d is n o tice a b le in th e face a n d th e so ft tissues a b o u t th e eyes, a n d o n th e d o rsu m o f th e h an d s. T h is
B oyn e — D e n tis t’s R esp o n sib ility to the C a rd ia c P a tie n t
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co n d itio n is u su a lly asso ciate d w ith a p o o r circ u la tio n . W h e n th e re is a lo n g -sta n d in g stasis o f th e p u lm o n a ry c irc u la tio n o r lo n g s ta n d in g c a rd ia c disease, th e en d s o f th e fingers becom e clu b b e d . T h e p u p ils o f th e eyes sh o u ld be n o te d .4 A n in e q u a lity o f th e p u p ils m ay be d u e to a th o ra c ic a n eu ry sm p ressin g o n a sy m p a th etic n erv e. A b u lg in g o f th e c h e st w a ll m ay be caused by a n an e u ry sm o r in fla m m a tio n o f th e p e ric a rd iu m w ith effusion. I n cases o f h ig h blood p re ssu re , th e a rte rie s of th e neck m a y be seen to p u lsa te . T h is
e n la rg e d th y ro id m ay cause som e m e c h a n ic a l in te rfe re n c e w ith th e c irc u la tio n o r re sp ira tio n , th u s p la c in g a d d itio n a l w o rk o n th e h e a r t ; o r, m o re o fte n , an in crease in th e a m o u n t o f th y ro id secretio n th a t has been th r o w n in to th e c irc u la tio n by th e e n la rg e d th y ro id , m ay cause th e m etab o lic ra te to be g re a tly increased. I t is u su a lly n o t d ifficu lt to reco g n ize these cases. T h e p a tie n t is v ery n erv o u s, re s t less a n d h y p ersen sitiv e, a n d m ay h a v e a t tack s o f ra g e o r c ry in g , b ro u g h t on by som e in sig n ifica n t m a tte r . T h e eyeballs p ro tru d e a n d th e re is u su a lly a s ta rin g
Fig. 7.—Necropsy specimen from case of coronary thrombosis. T he ventricular wall is thin and there is scar tissue present in this serious form of heart disease.
Fig. 8.—Appearance of patient in case of m itral insufficiency complicated with peri cardial effusion. The facies is of the mitral type and there is bulging of the chest wall.
is also seen in p a tie n ts h a v in g ex o p h th a lm ic g o ite r. T h e r e is alw a y s a c ard ia c in v o lv m en t in these cases, th e h e a rt b eing e ith e r h y p e rtro p h ie d o r d ila te d fro m th e excessive w o rk th a t is th r o w n o n it. T h e a d d itio n a l w o rk m ay be d u e to one o f tw o c o n d itio n s : T h e p re ssu re o f th e
expression. T h e p u lse is rap id , v a ry in g fro m 120 to 160 b eats p e r m in u te . L ik e w ise, ra p id p u lsa tio n of th e a rte rie s o f th e n eck m ay be seen .5 T h e s e sym ptom s m ay n o t alw ay s be so p ro n o u n c e d , a n d a t tim es th e o n ly sy m p to m p re s e n t m ay be an in creased p u lse ra te associated w ith a
4. Morris, L. M .: C ardiac Aneurysm, Am.5. Bram, Israel: Role of Dentist in Goiter Heart J., 2:548-559 (June) 1927. Cases, J.A.D.A., 18:1544 (Aug.) 1931.
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tre m o r of th e fingers w h e n th e a rm is ex ten d ed . T h e pulse sh o u ld also be n o te d , as it is a good in d ex to th e c o n d itio n o f th e h e a rt. T h e d e n tist sh o u ld be ab le to de te c t re a d ily th e m o s t co m m o n p u lse ir re g u la ritie s. T h e p u lse sh o u ld n o t be p a lp a te d w ith th e th u m b as th e re is n o r m a lly a p u lsatio n in th e th u m b w h ich m ay b e fe lt, an e r r o r in th e in te rp re ta tio n re s u ltin g . T h e n o rm a l r a te is be tw e e n 70 a n d 80 b ea ts a m in u te . E x c ite m e n t o r em o tio n al s tra in w ill cause a rise in th is ra te . A n y g re a t v a ria tio n fro m n o rm a l, th e ra te b e in g e ith e r to o fa s t o r too slo w , in d icates c a rd ia c im p a irm e n t. A n in te rm itte n t o r ir r e g u la r p ulse, w h e n th e re is an om ission o f o n e o r m o re b eats, sh o u ld lead th e d e n tis t to tr e a t th e case as c a rd ia c ; a lth o u g h th is co n d itio n is o fte n fo u n d to b e in d e p e n d e n t o f a n y d ete c ta b le h e a rt disease. T h e v o lu m e o f th e p u lse sh o u ld be n o ted . A fu ll, b o u n d in g pu lse m a y in d i ca te h y p erten sio n . A feeble b e a t m a y be n o ted in w eak d e b ilita te d p a tie n ts w ith a p o o r c irc u la tio n a n d in a n em ic p a tie n ts. Since th e q u a lity o f th e h e a r t b e a t can be fa irly w e ll ju d g e d by ta k in g th e p ulse, I do n o t th in k it necessary f o r th e d e n tis t to use th e stethoscope. C o n tin u a l p ra c tic e w ith th is in s tru m e n t is re q u ire d to in te r p re t th e h e a rt so u n d s w ith an y d e g re e of accuracy, a n d th e re fo re th e a v e ra g e d e n tis t w ill n o t, I believe, d eriv e m u ch bene fit fro m its use. C a rd ia c fa ilu re is o fte n associated w ith tu b ercu lo sis, n e p h ritis, d iab etes a n d pernicious anem ia, a n d o th e r in fectio n s a n d d iso rd ers of lo n g s ta n d in g . T h e sam e precau tio n s sh o u ld be ta k e n in th ese cases as in an y o th e r c ard iac d istu rb an c e . W h a t a re th e p re c a u tio n s th a t a d en tis t sh o u ld ta k e w h e n c a rin g fo r a p a tie n t w ith card ia c fa ilu re ? F ir s t o f all, he sh o u ld g et in to u c h w ith th e p a tie n t’s physician, a n d re p o rt th e w o rk h e expects
to do fo r th e p a tie n t. A f te r th e physician has g iv en perm issio n to pro ceed w ith th e w o rk , th e resp o n sib ility is sh a re d by him . T h e d e n tis t sh o u ld also re m e m b e r t h a t persons su ffe rin g fro m a n y d eg ree o f c a rd ia c fa ilu re sh o u ld lea d a q u ie t life free fro m u n d u e fe ar, ex c ite m e n t, w o rry o r g re a t p h y sical a c tiv ity . T h e s e p a tie n ts a re v e ry o fte n n erv o u s, h y p ersen sitiv e an d irrita b le , a n d th e v isit to th e d e n ta l office m ay cause th e m to becom e q u ite ex cited. T h e y u s u a lly re a c t q u ic k ly to th e a t m o sp h ere s u rro u n d in g th e m ; a n d th e calm , c h e e rfu l d e n tist, by u sin g a little ta c t a n d patien ce, w ill g a in th e ir confi d ence. T h e y th e n a re u su a lly coo p erativ e w h ile th e d e n ta l w o rk is b e in g done. P re m e d ic a tio n b efo re o p eratio n s is fo r th ese p a tie n ts v e ry d esirab le . S om e de riv a tiv e o f b a rb itu ric acid h as p ro v ed m o st beneficial. W e u su a lly g iv e sodium a m y ta l, 3 g ra in s, o r n e m b u ta l, 1£ g rain s, fro m th ir ty to fo r ty m in u te s b efo re th e o p eratio n . W i t h p rem e d ic atio n , th e p a tie n t w ill be in a c a lm e r a n d m o re recep tiv e m ood, a n d th e possib ility o f any psychic shock is lessened. T h e in je ctio n s sh o u ld be m a d e as painless as possible by th e use of a w e a k so lu tio n o f cocaine o r a 2 p e r c e n t p an to c a in e on th e m ucous m em b ra n e . W e p re fe r p a n to c a in e as it is n o t so to x ic as cocaine. I t m u s t be re m em b ered th a t th ese p a tie n ts do n o t to l e ra te ep in e p h rin e w e ll as i t raises th e blo o d p re ssu re a n d places an e x tr a a m o u n t o f w o rk o n th e h e a rt. T h e so lu tio n fo r lo c al an esth esia sh o u ld c o n ta in th e least a m o u n t o f ep in e p h rin e possible. P re m e d i c atio n w ith one o f th e b a rb itu ra te s ten d s to c o m b a t th is rise in b lo o d p ressu re an d th e re b y increases th e to le ra n c e fo r local anesthesia. I t sh o u ld be g iven as a p ro p h y lactic, if th e re is any u n c e rta in ty in re g a rd to th e p a tie n t’s h e a rt. W h e n d o in g w o rk fo r persons h a v in g a c a rd ia c d istu rb a n c e , it m u s t be rem em
Boyne —D entist's Responsibility to the Cardiac Patient b e re d t h a t th ey do n o t to le ra te a la rg e a m o u n t o f w o rk a t o n e tim e. T h is is to be especially rem em b e red w h e n su rg ic a l p ro c e d u re s a re in d ic ate d . T h e ju d g m e n t o f b o th physician a n d d e n tist is necessary in d e c id in g such m a tte rs as th e a m o u n t of w o rk th a t m ay be d o n e a t o n e tim e, th e ty p e o f an esth esia th a t sh o u ld b e used a n d w h e th e r h o sp ita liz a tio n is necessary. R e m o v in g to o m a n y in fec ted te e th a t one tim e m ay p re c ip ita te h e a rt fa ilu re a n d even cause d e a th . I t is n o t ad v isab le to keep these p a tie n ts in th e d e n ta l c h a ir fo r m o re th a n th ir ty to fo rty -fiv e m in u te s a t o n e tim e. I n m o st e x tra c tio n s, th e p a tie n t is o f m id d le age o r o ld e r. A s it is d u r in g th is age th a t m o st o f th e c ard ia c c o m p la in ts occur, it is necessary th a t w e b e s u re o f th e co n d itio n o f th e h e a rt be fo re w e a tte m p t extensive o p e ra tio n s fo r these p a tien ts. L o c a l an esth esia6 is p re fe rre d to g e n eral an esth esia fo r e x tra c tio n s in cases o f c a r d iac fa ilu re . W h e n th ese p a tie n ts receive p ro p e r p re m e d ic a tio n a n d a re ta c tfu lly h a n d le d , th ey experience little o r n o shock if o n ly a fe w te e th a re rem o v ed a t a tim e. M o s t of th e m w ill s ta n d a g e n e ra l anes th e tic w e ll if it is g iven c o rre c tly . I t is a b so lu tely necessary th a t these p a tie n ts do n o t s tru g g le w h ile u n d e r an esth esia, as th is th ro w s e x tr a w o rk on th e h e a rt. I t is also necessary th a t no asp h y x iai s tra in be th r o w n o n th e h e a rt. T h e re sp ira tio n sh o u ld be k e p t free fro m e m b a rrassm en t, a n d as w id e a m a rg in o f oxygen as pos sible sh o u ld be given w ith th e an e sth e tic gas. I f th e c irc u la tio n is a lre a d y im p a ire d , a n y degree o f asp h y x ia places a g re a te r s tra in on th e h e a rt. A n e sth e tic ten sio n sh o u ld n o t be estab lish ed in these p a tie n ts by c u ttin g off th e o xygen. D e a th m a y ta k e place a fte r th e b rie fe st perio d of cyanosis.
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N itr o u s oxide-oxygen, th e le a st to x ic a n e sth e tic th a t w e h a v e a t p resen t, is th e one m o st g e n e ra lly u sed by d en tists. I t m u s t be rem e m b e red th a t th is is n o t so p o w e rfu l as som e o f th e o th e r anesthetics, a n d it m ay be d ifficu lt to m a in ta in th e p ro p e r d e g ree o f anesthesia, u n less th e p a tie n t is so m e w h a t cy an o tic.7 M a n y o f o u r b e tte r k n o w n a n e sth e tists te ll us th a t it is m o re d esirab le to a d d a sm a ll a m o u n t of e th e r to th e gas-oxygen m ix tu re th a n to lim it th e o xygen to th is e x te n t. A d m in is tra tio n o f e th e r te n d s to h av e a to x ic effect on th e kidneys, a n d w e do n o t lik e to em plo y it in h e a rt cases, y et a v e ry sm a ll a m o u n t o f it w ill do less h a rm th a n a p erio d o f cyanosis. E th y le n e is th e p re fe rre d a n e sth e tic in these cases. I t is m o re p o w e rfu l th a n n itro u s o xide a n d m o re oxygen m a y be given w ith it a n d th e p ro p e r d eg ree o f an esth esia still be m a in ta in e d . O w in g to its explosive p ro p e r ties, it has n o t been u sed w id e ly in th e d e n ta l office. W e m ay say th a t a m o re im p o rta n t co n sid eratio n th a n th e ty p e of an esth esia u sed is p ro b a b ly th e com pe ten ce o f th e a n e sth e tist. S ince it is im p e ra tiv e th a t th e an es th e tic be g iv en p ro p e rly , it is alw ay s a d visab le to in sist th a t th ese p a tie n ts e n te r th e h o sp ita l to h av e an y o ra l su rg ic al o p e ra tio n w h e n a g e n e ra l an esth etic is in d i c ate d . H e re , a tra in e d a n e sth e tist w ill a d m in is te r th e an e sth e tic a n d resu scitativ e m easu res can be im m ed iately em ployed in cases of syncope, re sp ira to ry fa ilu re a n d shock. S alin e a n d glucose so lu tio n s h av e been p re p a re d a n d m a y be g iven im m e d ia te ly w h e n needed. T h e s e so lu tio n s, w h e n placed in th e b lo o d stre a m , ra ise th e blood p ressu re a n d h elp c o m b a t shock. W h e n e v e r a d e n tist is o b lig ed to d o extensive w o rk fo r a pa-
7. Hewitt, F. D.: Anesthetics and T heir Lundy, J. S.: Anesthesia in Presence of Administration, a Textbook for Medical and G rave Surgical Risk, Report at Staff Meeting, Dental Practitioners and Students, Ed. 4, New T he Mayo Clinic, 1935. York City: T he Macmillan Company. 6.
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T he Journal of the American D ental Association
tie n t w ith ad v an ced c a rd ia c disease, it sh o u ld alw ay s be d o n e in th e h o sp ital. I f an y difficulties arise in th e office, th e d e n tist sh o u ld be ab le to re n d e r first aid. F e a r, w h en a b o u t to h av e an e x tra c tio n , m ay cause c e rta in p a tie n ts to fa in t. T h is is th e m o st com m on d ifficu lty th a t th e d e n tist en co u n te rs. I n th is c o n d itio n , th e bloo d has le f t th e b ra in a n d th e p a tie n t is in a m ild d eg ree o f shock. T h e p a tie n t’s head is lo w e re d so t h a t th e b lo o d w ill flow back to th e b ra in . A fe w b re a th s of sp irits of am m o n ia w ill in crease th e res p ira tio n ra te a n d fa c ilita te o x y g en atio n of th e blood. A lp h a lo b e lin is a g o o d re s p ira to ry stim u la n t. I t com es in am p u les a n d is given in tra m u sc u la rly . I f th e p u lse is w eak an d th e p a tie n t does n o t respond read ily , a h e a rt s tim u la n t sh o u ld be given. C affein e so lu tio n b en zo a te 7-J g rain s, epin ep h rin e, 0.5 to 1 c.c. o r c o ra m in e 1 am p u le m ay be g iv en in tra m u sc u la rly . T h e d e n tist sh o u ld keep a ste rile hypo d erm ic syringe re a d y a t a ll tim es. C o r am in e m ay be o b ta in e d in a p re p a ra tio n to be given o ra lly . W e find t h a t 2 0 d rops of th is so lu tio n in a little w a te r w ill aid g re a tly in re v iv in g a p a tie n t. A ll d e n tists sh o u ld be ab le to a d m in iste r a rtific ia l res p ira tio n c o rrectly . I f th e y h av e a gas m a chine, it is w e ll to h a v e it eq u ipp ed fo r carb o n dioxide a d m in is tra tio n , as th is is a v e ry effective re s p ira to ry s tim u la n t. C e rta in types o f c a rd ia c fa ilu re d e m a n d th e m o st c a re fu l a tte n tio n a n d con sid e ra tio n . P a tie n ts su ffe rin g w ith a n g in a pectoris, sy p h ilitic a o ritis, co r o n a ry throm bosis, a n eu ry sm , ad v an ced
g o ite r a ffec tin g th e h e a r t a n d severe h y p erten sio n a re in th is class. T h e s e p a tie n ts o fte n d ie su d d e n ly . I t is alw a y s im p o r ta n t th a t th e y be ex am in e d by th e ir physician a n d his aid b e o b ta in e d in de c id in g su ch m a tte r s as p rem ed ic a tio n , and th e tim e an d p la ce to o p erate . P e a rls o f a m y ta l n itr a te o r n itr o g ly cerin e ta b le ts sh o u ld be k e p t a t h a n d fo r p a tie n ts su ffe rin g w ith a n g in a pec to ris. T h e s e d ru g s d ila te th e co ro n a ry a rte rie s, w h ic h su p p ly th e h e a rt m uscle w ith b lo o d , a n d th e p a tie n t o b ta in s re lief fro m th e p ain th a t is c h a ra c te ristic of th is ty p e o f h e a r t disease. T h e necessity f o r th e p ro p e r m a n a g e m e n t o f p a tie n ts w ith c a rd ia c d is tu rb ances, as w e ll as p a tie n ts su ffe rin g w ith o th e r system ic d iso rd ers, is so im p o rta n t th a t I w o u ld su g g e st t h a t o u r stu d y clubs ta k e u p these su b je c ts. A re v ie w o f these d iso rd e rs th e m a n ife sta tio n s o f w hich m ay be p re s e n t in th e o ra l c a v ity a n d th e co m p lication s t h a t m ay arise fro m su rg i cal in te rfe re n c e a re su b je c ts stu d y of w h ich w o u ld g re a tly b en efit th e d en tist. T h e s e a re p o in ts t h a t o u r d e n ta l ed u c a tio n to o o fte n n eg lec ts. A stu d y o f these su b jects w ill g iv e th e d e n tis t a b ro a d e r in sig h t in to th e field o f m ed icin e, a n d en able h im to c o o p e ra te m o re closely w ith th e physician. T h e pro g ressiv e d e n tist of to d a y ap p rec ia te s th e b o n d th a t n o w exists b e tw een th e m e d ic a l a n d th e d e n ta l p ro fession. T h is b o n d o f in te rd e p e n d e n c e seem s to m e to be a n ecessity if w e a re to keep th e p a tie n t’s in te re st a t h e a rt. 1002 N ational B ank B uilding.