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The problems of patients with cardiovascular disease undergoing dental treatment
There are many reasons why the dentist needs to be concerned with heart disease. Currently, average human life expectancy is over 70 years, and more than 28 million persons have cardiovascular disease. These patients have a decreased ability to recover from stress, and dental treatment often needs to be altered.
The problems of patients with cardiovascular disease undergoing dental treatment
S te p h e n P. G la s s e r,
MD, Tampa, Fla ■ ■ ■ ■ ■ ■ ■
There has long been a close association between the cardiologist and the dentist, probably be cause of the many problems that overlap these fields of study. The physician’s concern about the dentist was emphasized as early as 1892 when one observer said that dentists “ suffer to an un usual degree from neurasthenia, nervous debil ity, migraine, sciatica, herpes zoster, insomnia, etc.,” and attributed this to “ confinement, over work, and bad air.” Most may still agree that things are no different. There are many reasons why the dentist needs to be concerned with heart disease. Currently, the average human life expectancy is over 70 years, and there are over 28 million persons in the United States with cardiovascular disease. Cardiovascular disease is responsible for 50% of all deaths, and there are more than 600,000 cases of acute coronary occlusion each year—which averages more than one every minute. The prob lems of dental treatment in these patients are, therefore, an important part of dental practice, since it is more difficult for patients with cardio vascular disease to recover from stress. Thus, the dentist is often required to alter treatment. Perhaps the most important part of the cardiologist-dentist relationship is the concept of pre ventive dentistry. The evaluation and dental therapy at the time of the original diagnosis of heart disease, and periodic réévaluation and in 1158 ■ JA D A , V ol. 94, J u n e 1977
terval treatment may help eliminate emergency dental surgery during the subsequent course of cardiovascular disease. The main intent of this article is to discuss some of the more common cardiologic problems facing the dentist and answer frequent questions we as cardiologists are asked by the dental pro fession. What are the contraindications to perform ing dental procedures in patients with cardiac disease? Generally, there are five absolute contraindica tions: an acute or recent (within the preceding three to six months) myocardial infarction; un stable or recent onset of angina pectoris; conges tive heart failure; uncontrolled arrhythmia; and significant, uncontrolled hypertension. An elective procedure should be performed on a patient as long after a myocardial infarction as possible. Topkins and Artusio1 studied the rec ords of 12,712 male surgical patients over age 50 and found the incidence of postoperative myo cardial infarction in patients without preopera tive infarction was 0.66%. This compared to an incidence of 6.5% in patients with known preop erative infarction. The mortality after postoper ative infarction for the respective groups was
26.5% and 70%, and the rate of recurrent infarc tion was greater when the interval between in farction and surgery was less than two years and was greatest when the interval was less than six months. Although most of these patients had general anesthesia, the anesthetic agent, dura tion of the surgery, or the nature of the surgery did not play a significant role. Tarhan and assoc iates2 have recently reported a similar experi ence. In patients with uncontrollable hypertension, arrhythmia, or congestive heart failure, there are obvious risks in response to surgery because of their decreased tolerance. In addition, these pa tients are usually taking medication that also may affect their response to anesthesia and surgery. An essential safeguard to prevent such prob lems is a thorough history-taking. The dentist should determine who is the patient’s primary physician and establish a working relationship with him so that if an emergency should arise, immediate contact can be made. Dental history should include a history of bleeding tendencies, allergies, or idiosyncratic drug reactions, as well as information about illnesses such as the pres ence of congenital heart disease, valvular heart disease, coronary artery disease, and so on. Spe cific questions should be asked about shortness of breath (dyspnea), palpitations, or angina pec toris, and how these are provoked, and most im portantly, if there has been a recent change in symptoms. Most patients with cardiac disease will have included in their diagnosis the physician’s assess ment of symptom limitation expressed as a func tional and therapeutic classification. This has been developed and published by the New York Heart Association.3 Functional classifications I-IV refer to greater degrees of limitation with class I being no symptoms; class V refers to pa tients who have symptoms despite bed rest. Therapeutic classifications A E indicate the physician’s recommendation on how much ac tivity the patient may engage in. Class A means no limitation, while E indicates that the patient should be at complete bed rest.
How do you treat a patient who is taking anticoagulant drugs? Anticoagulants are now an accepted form of therapy for many patients with various forms of
cardiovascular diseases, such as those that fol low myocardial infarction, embolization in rheu matic and arteriosclerotic heart disease, certain types of strokes, venous disease, and pulmonary embolization. They are administered both as specific treatment for thromboembolic manifes tations and as a prophylactic measure to prevent recurrence. In the latter instance, they are often continued for long periods of time, sometimes for the rest of the patient’s life.4 A common oral anticoagulant administered in this country is sodium warfarin. The aim of anticoagulant treatment is to retard or prevent intravascular coagulation. In the United States, the prothrombin time is used as an indicator of the effect of the drugs. One compares the normal prothrombin time to the therapeutic range, which is usually considered to be 2 to 2Vi times the control level. Some of the earlier reports of oral surgical pro cedures performed purposely or inadvertently on patients receiving anticoagulant drugs re vealed the occurrence of prolonged postopera tive hemorrhage. Recommendations were made that no surgery be performed on patients during anticoagulant therapy so that if surgery was necessary, anticoagulant therapy was discon tinued until the prothrombin time returned to an acceptable level. At the same time, however, there were reports in the literature on the danger of discontinuance of anticoagulant therapy be cause of an increased incidence of blood clots with embolization.5 This prompted a number of studies, and although there is still some contro versy surrounding the question, I have found that many minor and major surgical procedures have been safely performed on patients taking anticoagulant drugs. Although some reports6-7 have suggested that oral bleeding in anticoagu lated patients after dental extractions is a signifi cant problem, recent studies have not substan tiated this.8 It is now generally agreed that sin gle or multiple extractions can be performed in these patients if proper attention is given to care ful hemostasis procedures.8,9 In fact, Chamberlain9 stated that the danger of clotting when anti coagulant drugs are discontinued is greater than the danger of bleeding when the drugs are con tinued, providing that the proper safeguards are used. The blood prothrombin time should be held in low optimal range (1Vi times the control level.) Additional safeguards include advising hos pitalization, applying constant pressure to the Glasser: DENTAL PATIENTS WITH CARDIOVASCULAR DISEASE ■ 1159
involved tissues during surgery, placing a foamed gelatin in each socket, placing multiple sutures under tension, having the patient apply heavy biting pressure for 30 minutes maintained by bit ing on gauze pressure packs, applying ice packs externally 30 minutes on and 30 minutes off for 48 hours, withholding mouthrinses and hot li quids for 48 hours, and maintaining a soft diet for 48 to 72 hours.
Which anesthetic agents are recommended? When complete and total, anesthesia effectively minimizes apprehension and reduces the amount of endogenous epinephrine excretion. Adequate premedication is equally important and must be individualized. This also reduces apprehension and minimizes blood pressure elevation during the waiting room period.10 Pentobarbital (30-60 mg) or secobarbital (50-100 mg) are satisfactory for most patients. The importance of the aspira tion technique when administering anesthetics cannot be overemphasized. Harris11 demon strated that up to 3.2% of taps are “ bloody” and cannot be detected unless the plunger of the sy ringe is slightly but definitely withdrawn. By this maneuver, he was able to reduce the frequency of undesirable side effects from 8.8% to 3.8%. Intra-arterial injections cause distant anesthesia and blanching of the immediate region. The most common cause of reactions to local anesthesia in dentistry is intravenous injection. This may cause central nervous system stimulation or de pression, hypertensive crisis, or dangerous de grees of myocardial ischemia.12
What about vasoconstrictors, and which local anesthetics should be used? Recent evidence claims it is safe and beneficial to use vasoconstrictors with local anesthesia. In 1955, the New York Heart Association9 rec ommended a dose of no more than 10 cc of a 1: 50,000 dilution of epinephrine be administered in one session. It has been found that since pro caine itself has a slight vasodilating effect, this dose of epinephrine is necessary. When lidocaine is used, even smaller amounts of epineph rine (1:100,000 for instance) can be used. As long 1160 ■ JADA, Vol. 94, June 1977
as the aspiration technique is carefully admin istered, the benefit engendered by the use of vas oconstriction with local anesthesia far outweighs the minimal risk.13 What is the relationship between subacute bacterial endocarditis and dental treatment? The causal relationship between dental extrac tion and bacterial endocarditis is probably re lated to a dental infection or previous extrac tions.14 It has therefore become generally ac ceptable to give patients with congenital or rheu matic valvular heart disease antibiotics (prefer ably penicillin) prophylactically before dental extraction.14'17 In general, patients with a structural lesion of the heart that can serve as a nidus for bacterial endocarditis should receive subacute bacterial endocarditis prophylaxis. This includes almost all patients with cardiac murmurs (except those that are clearly functional) and those with con genital heart disease. In my experience I have found that patients with repaired congenital heart disease do not need prophylaxis unless there is a residual defect. Even if the repair included the use of artificial material, subacute bacterial en docarditis prophylaxis is still not warranted. One major exception is after the repair of coarctation of the aorta. Since 25% to 75% of these patients have associated bicuspid aortic valves that may not be clinically manifest, subacute bacterial endocarditis prophylaxis is justified. Subacute bacterial endocarditis is relatively common even with mild valvular lesions.11 Conversely, patients who have had rheumatic fever without cardiac involvement do not require prophylaxis. Important here is the knowledge that the dentist must specifically seek out infor mation on the need for prophylaxis. He cannot depend on patient knowledge. Harvey and Ca pone14 demonstrated that in patients with rheu matic heart disease, only 24.3% (of 181 patients) knew that they should have antibiotic coverage for dental extractions, and only 8.3% knew that they should be protected during prophylaxis and amalgam restorations. Patients with congenital heart disease had even less knowledge of their needs.14 The amount of trauma induced by a proce dure has a great bearing on the amount of bac teremia that develops. Bender and others18,19
demonstrated an 85% incidence of bacteremia immediately after multiple extractions and gingivectomy. With deep scaling, the incidence was 53% and with light scaling, 30%. They conclud ed that procedures such as fabrication of crowns, orthodontic manipulation, impression-taking, and amalgam restorations should cause no con cern since they are not associated with hemor rhage or bacteremia. Harvey and Capone14 how ever, reported two patients with subacute bac terial endocarditis preceded by only an amalgam restoration two and three months prior. In recent years, the illicit use of intravenous drugs (primarily heroin) has become an impor tant associated factor. Mostaghim and Millard’s20 study revealed that 10% of their patients with bacterial endocarditis were “ mainliners.” Although there is some controversy as to who should receive subacute bacterial endocarditis prophylaxis, there is almost no question on what constitutes prophylaxis. Penicillin is the drug of choice, and there is no disagreement on the ad visability of using penicillin immediately before and after dental treatment.19-21 There is some argument on how long antibiotics should be giv en before the procedure, but I believe it is gen erally one to two days. A longer period is not likely to cause sterilized root abscesses or in fected tonsils, but may cause sensitive bacteria to be replaced by penicillin-resistant strains.21 The American Heart Association suggests 500 mg of penicillin V or phenethicillin one hour be fore the procedure and then 250 mg every six hours for at least two days after the procedure; 600.000 units of procaine penicillin G mixed with 200.000 units of crystalline penicillin G given by intramuscular injection one hour before the pro cedure and then once daily for at least two days.21 For patients allergic to penicillin, erythromy cin can be used with an initial dose of 500 mg one to 1Vi hours before the procedure and then 250 mg four times daily. For small children, 10 mg/ kg should be given every six hours.21 In the past, this drug has not been given intramuscularly be cause of its proclivity to sterile abscess, but rec ently erythromycin preparations for parenteral use have become available. The antibiotic coverage should be broadened for patients who require emergency dental pro cedures during active subacute bacterial endo carditis. In some patients with prosthetic heart valves, staphylococcic infection can become a problem. Cohn and others22 described three pa tients with bacterial endocarditis involving an
aortic valve prosthesis. This occurred after den tal extractions, despite the use of penicillin pro phylaxis. Because of this, they suggested a more comprehensive antibiotic regimen consisting of broad spectrum antibiotic troches for two days before the procedure, 600,000 units of procaine penicillin every six hours, 500 mg of streptomy cin every 12 hours on the day before, on the day of the procedure, and three to five days after it. Methicillin sodium (5g) should be given intra venously on the day of surgery, and sodium ox acillin (4g) should be given orally for three to five days after the procedure.
What cardiac drugs are important to the dentist? ■ Sodium warfarin: The problem of anticoagu lation has been partly discussed. It was conclud ed that with careful hemostasis most dental pro cedures can be carried out with the prothrom bin time in full therapeutic range. If postoper ative bleeding should become a problem, hemo stasis is still the first consideration. However, if you decide to withdraw anticoagulation, there are several considerations. Discontinuation of the drug is the first consid eration if the situation is not emergent, since there will be a lag of 24 to 48 hours before the pro thrombin time begins returning to normal. If the problem requires more immediate therapy, how ever, the administration of Aquamephyion In jection parenterally or orally, depending on the rapidity of correction necessary, is of value. ■ Antihypertensives: These drugs are probably the most important group of agents with which the dentist should be familiar. In many instances their most prominent side effect is orthostatic hypotension, resulting at times in syncope when the patient suddenly assumes the upright posi tion. Guanethedine sulfate (Ismelin) and the ganglionic blocking drugs are the most important agents. Somewhat less commonly methyldopa (Aldomet) may be the cause. The indiscriminate use of diuretic agents may result in hypovolemia and/or hypopotassemia, which can produce sim ilar symptoms; and the latter may also exacer bate digitalis toxicity.23"24 These agents, in addition to Rauwolfia prep arations, also increase responsiveness to vaso constrictors, so extra care should be used to pre vent intravascular injection. Glasser: DENTAL PATIENTS WITH CARDIOVASCULAR DISEASE ■ 1161
■ Nitroglycerin: If a patient develops angina pectoris during a dental procedure, nitroglycerin can be given for relief. A fresh supply should be available (the drug deteriorates and should not be more than six months to 1 year old for full ef fectiveness). Its side effects are primarily secon dary to vasodilatation with resultant flushing and headache. Blood pressure generally falls after nitroglycerin is administered. ■ Saliva-inhibiting drugs: Atropine and its pro totypes are used in dentistry for obvious reasons. However, it is important to realize that because of their vagolytic effect, a tachycardia may re sult. In the cardiac-prone patient this may result in breathlessness and angina pectoris. ■ Digitalis: This is a drug that many cardiac patients will be taking, but unless digitalis toxic ity is present, it will usually cause little problem. Discussion of this important drug is otherwise beyond the scope of this paper, but several mon ographs have been published recently.23,24 ■ Propranolol: Many patients with angina pectoris will be receiving this medication, which acts primarily by slowing the resting pulse and blunting the pulse rate response to exercise, anxiety, and so forth. Also important is the dan ger of sudden discontinuation of this medication. If dental treatment will result in the patient’s in ability to swallow oral medications, this must be considered.25 What should the dentist do in case of a car diac emergency? Emergency treatment proce dures have been described.12 A cardiac emer gency is suspected when a patient has fainted or is having chest pain, persistent breathlessness, or prolonged unconsciousness. This can occur in a patient with known disease, or it can be the first manifestation of cardiac disease. Dr. Glasser is associate professor of medicine and director of the Cardiac Non-lnvasive Laboratory, University of South Florida College of Medicine, department of internal medicine, section of cardiology, 13000 N 30th St, Tampa, Fla 33612. 1. Topkins, M.J., and Artusio, J.F., Jr. Myocardial infarction and surgery: a five year study. Anesthesia and Analgesia 43:716 Nov-Dee 1964. 2. Tarhan, S., and others. Myocardial infarction after general anesthesia. JAMA 220:1451 June 12, 1972.
1162 ■ JADA, Vol. 94, June 1977
3. The functional and therapeutic classifications of patients with diseases of the heart. Copyright 1964 by the New York Heart Association, Inc. In Diseases of the heart and blood vessels— nomenclature and criteria for diagnosis, ed 6. Boston, Little, Brown, and Co., 1964. 4. Behrman, S.J., and Wright, I.S. Dental surgery during con tinuous anticoagulant therapy. JAMA 175:483 Feb 11, 1961. 5. Shira, R.B.; Hall, R.J.; and Guernsey, L.H. Minor oral sur gery during prolonged anticoagulant therapy. J Oral Surg 20:93 March 1962. 6. Ziffer, A.M., and others. Profound bleeding after dental extractions during dicumarol therapy. New Engl J Med 256:351, 1957. 7. Scopp, I.W., and Fredrics, H. Dental extractions in patients undergoing anticoagulant therapy. Oral Surg 11:470 May 1958. 8. Frank, B.W.; Dickhaus, D.W.; and Claus, E.C. Dental extrac tions in the presence of continual anticoagulant therapy. Ann of Intern Med 59:911 Dec 1963. 9. Report of the special committee of the New York Heart As sociation, Inc. on the use of epinephrine in connection with pro caine in dental procedures. 50:108 Jan 1955. 10. Chamberlain, F.L. Management of medical-dental prob lems in patients with cardiovascular diseases. Mod Concepts Cardiovasc Dis 30:697 Dec 1961. 11. Harris, S.C. Action of local anesthetic agents. Dent Clin North Am July 1961 p 231. 12. Management of dental problems in patients with cardio vascular disease. Report of a working conference jointly spon sored by the ADA and American Heart Association. JADA 68:333 March 1964. 13. Anderson, T.O., and others. Management of dental prob lems in patients with cardiovascular disease. JAMA 187:848 March 14, 1964. 14. Harvey, W.P., and Capone, M.A. Bacterial endocarditis related to cleaning and filling of teeth (with particular reference to the inadequacy of present day knowledge and practice of antibiotic prophylaxis for all dental procedures). Am J of Cardiol 7:793 June 1961. 15. Gould, L., and Sperber, R.J. Prevention of subacute bac terial endocarditis associated with dental procedures. Am Heart J 187:134, 1966. 16. Garrod, L.P., and Waterworth, P.M. The risks of dental extraction during penicillin treatment. Br Heart J 24:39 Jan 1962. 17. Schirger, A., and others. Bacterial invasion of blood after oral surgical procedures. J Lab Clin Med, p 376, March 1960. 18. Bender, I.B., and others. Dental procedures in patients with rheumatic heart disease. Oral Surg 16:466 April 1963. 19. Bender, I.B., and Seltzer, S. Dental procedures of interest to the physician in the management of patients with cardiovas cular disease. Am Heart J 66:697 Nov 1963. 20. Mostaghim, D., and Millard, H.D. Bacterial endocarditis: a retrospective study. Oral Surg 40:219 Aug 1975. 21. Prevention of bacterial endocarditis. Am Heart Assoc Bulletin 7-72-200M, 1972. 22. Cohn, L.H., and others. Bacterial endocarditis following aortic valve replacement. Clinical and pathological correlations. Circulation 33:209 Feb 1966. 23. Doherty, J.E. Digitalis glycosides. Pharmacokinetics and their clinical implications. Ann Intern Med 79:229 Aug 1973. 24. Smith, T.W., and Haber, E. Digitalis. New Engl J Med 289: 945 Nov 1973. 25. Bennett, K.R. Cessation of propranolol therapy and re bound angina pectoris. Chest 70:314 Aug 1976.
The problems of patients with cardiovascular disease undergoing dental treatment
S te p h e n P. G la s s e r,
MD, Tampa, Fla ■ ■ ■ ■ ■ ■ ■
There has long been a close association between the cardiologist and the dentist, probably be cause of the many problems that overlap these fields of study. The physician’s concern about the dentist was emphasized as early as 1892 when one observer said that dentists “ suffer to an un usual degree from neurasthenia, nervous debil ity, migraine, sciatica, herpes zoster, insomnia, etc.,” and attributed this to “ confinement, over work, and bad air.” Most may still agree that things are no different. There are many reasons why the dentist needs to be concerned with heart disease. Currently, the average human life expectancy is over 70 years, and there are over 28 million persons in the United States with cardiovascular disease. Cardiovascular disease is responsible for 50% of all deaths, and there are more than 600,000 cases of acute coronary occlusion each year—which averages more than one every minute. The prob lems of dental treatment in these patients are, therefore, an important part of dental practice, since it is more difficult for patients with cardio vascular disease to recover from stress. Thus, the dentist is often required to alter treatment. Perhaps the most important part of the cardiologist-dentist relationship is the concept of pre ventive dentistry. The evaluation and dental therapy at the time of the original diagnosis of heart disease, and periodic réévaluation and in 1158 ■ JA D A , V ol. 94, J u n e 1977
terval treatment may help eliminate emergency dental surgery during the subsequent course of cardiovascular disease. The main intent of this article is to discuss some of the more common cardiologic problems facing the dentist and answer frequent questions we as cardiologists are asked by the dental pro fession. What are the contraindications to perform ing dental procedures in patients with cardiac disease? Generally, there are five absolute contraindica tions: an acute or recent (within the preceding three to six months) myocardial infarction; un stable or recent onset of angina pectoris; conges tive heart failure; uncontrolled arrhythmia; and significant, uncontrolled hypertension. An elective procedure should be performed on a patient as long after a myocardial infarction as possible. Topkins and Artusio1 studied the rec ords of 12,712 male surgical patients over age 50 and found the incidence of postoperative myo cardial infarction in patients without preopera tive infarction was 0.66%. This compared to an incidence of 6.5% in patients with known preop erative infarction. The mortality after postoper ative infarction for the respective groups was
26.5% and 70%, and the rate of recurrent infarc tion was greater when the interval between in farction and surgery was less than two years and was greatest when the interval was less than six months. Although most of these patients had general anesthesia, the anesthetic agent, dura tion of the surgery, or the nature of the surgery did not play a significant role. Tarhan and assoc iates2 have recently reported a similar experi ence. In patients with uncontrollable hypertension, arrhythmia, or congestive heart failure, there are obvious risks in response to surgery because of their decreased tolerance. In addition, these pa tients are usually taking medication that also may affect their response to anesthesia and surgery. An essential safeguard to prevent such prob lems is a thorough history-taking. The dentist should determine who is the patient’s primary physician and establish a working relationship with him so that if an emergency should arise, immediate contact can be made. Dental history should include a history of bleeding tendencies, allergies, or idiosyncratic drug reactions, as well as information about illnesses such as the pres ence of congenital heart disease, valvular heart disease, coronary artery disease, and so on. Spe cific questions should be asked about shortness of breath (dyspnea), palpitations, or angina pec toris, and how these are provoked, and most im portantly, if there has been a recent change in symptoms. Most patients with cardiac disease will have included in their diagnosis the physician’s assess ment of symptom limitation expressed as a func tional and therapeutic classification. This has been developed and published by the New York Heart Association.3 Functional classifications I-IV refer to greater degrees of limitation with class I being no symptoms; class V refers to pa tients who have symptoms despite bed rest. Therapeutic classifications A E indicate the physician’s recommendation on how much ac tivity the patient may engage in. Class A means no limitation, while E indicates that the patient should be at complete bed rest.
How do you treat a patient who is taking anticoagulant drugs? Anticoagulants are now an accepted form of therapy for many patients with various forms of
cardiovascular diseases, such as those that fol low myocardial infarction, embolization in rheu matic and arteriosclerotic heart disease, certain types of strokes, venous disease, and pulmonary embolization. They are administered both as specific treatment for thromboembolic manifes tations and as a prophylactic measure to prevent recurrence. In the latter instance, they are often continued for long periods of time, sometimes for the rest of the patient’s life.4 A common oral anticoagulant administered in this country is sodium warfarin. The aim of anticoagulant treatment is to retard or prevent intravascular coagulation. In the United States, the prothrombin time is used as an indicator of the effect of the drugs. One compares the normal prothrombin time to the therapeutic range, which is usually considered to be 2 to 2Vi times the control level. Some of the earlier reports of oral surgical pro cedures performed purposely or inadvertently on patients receiving anticoagulant drugs re vealed the occurrence of prolonged postopera tive hemorrhage. Recommendations were made that no surgery be performed on patients during anticoagulant therapy so that if surgery was necessary, anticoagulant therapy was discon tinued until the prothrombin time returned to an acceptable level. At the same time, however, there were reports in the literature on the danger of discontinuance of anticoagulant therapy be cause of an increased incidence of blood clots with embolization.5 This prompted a number of studies, and although there is still some contro versy surrounding the question, I have found that many minor and major surgical procedures have been safely performed on patients taking anticoagulant drugs. Although some reports6-7 have suggested that oral bleeding in anticoagu lated patients after dental extractions is a signifi cant problem, recent studies have not substan tiated this.8 It is now generally agreed that sin gle or multiple extractions can be performed in these patients if proper attention is given to care ful hemostasis procedures.8,9 In fact, Chamberlain9 stated that the danger of clotting when anti coagulant drugs are discontinued is greater than the danger of bleeding when the drugs are con tinued, providing that the proper safeguards are used. The blood prothrombin time should be held in low optimal range (1Vi times the control level.) Additional safeguards include advising hos pitalization, applying constant pressure to the Glasser: DENTAL PATIENTS WITH CARDIOVASCULAR DISEASE ■ 1159
involved tissues during surgery, placing a foamed gelatin in each socket, placing multiple sutures under tension, having the patient apply heavy biting pressure for 30 minutes maintained by bit ing on gauze pressure packs, applying ice packs externally 30 minutes on and 30 minutes off for 48 hours, withholding mouthrinses and hot li quids for 48 hours, and maintaining a soft diet for 48 to 72 hours.
Which anesthetic agents are recommended? When complete and total, anesthesia effectively minimizes apprehension and reduces the amount of endogenous epinephrine excretion. Adequate premedication is equally important and must be individualized. This also reduces apprehension and minimizes blood pressure elevation during the waiting room period.10 Pentobarbital (30-60 mg) or secobarbital (50-100 mg) are satisfactory for most patients. The importance of the aspira tion technique when administering anesthetics cannot be overemphasized. Harris11 demon strated that up to 3.2% of taps are “ bloody” and cannot be detected unless the plunger of the sy ringe is slightly but definitely withdrawn. By this maneuver, he was able to reduce the frequency of undesirable side effects from 8.8% to 3.8%. Intra-arterial injections cause distant anesthesia and blanching of the immediate region. The most common cause of reactions to local anesthesia in dentistry is intravenous injection. This may cause central nervous system stimulation or de pression, hypertensive crisis, or dangerous de grees of myocardial ischemia.12
What about vasoconstrictors, and which local anesthetics should be used? Recent evidence claims it is safe and beneficial to use vasoconstrictors with local anesthesia. In 1955, the New York Heart Association9 rec ommended a dose of no more than 10 cc of a 1: 50,000 dilution of epinephrine be administered in one session. It has been found that since pro caine itself has a slight vasodilating effect, this dose of epinephrine is necessary. When lidocaine is used, even smaller amounts of epineph rine (1:100,000 for instance) can be used. As long 1160 ■ JADA, Vol. 94, June 1977
as the aspiration technique is carefully admin istered, the benefit engendered by the use of vas oconstriction with local anesthesia far outweighs the minimal risk.13 What is the relationship between subacute bacterial endocarditis and dental treatment? The causal relationship between dental extrac tion and bacterial endocarditis is probably re lated to a dental infection or previous extrac tions.14 It has therefore become generally ac ceptable to give patients with congenital or rheu matic valvular heart disease antibiotics (prefer ably penicillin) prophylactically before dental extraction.14'17 In general, patients with a structural lesion of the heart that can serve as a nidus for bacterial endocarditis should receive subacute bacterial endocarditis prophylaxis. This includes almost all patients with cardiac murmurs (except those that are clearly functional) and those with con genital heart disease. In my experience I have found that patients with repaired congenital heart disease do not need prophylaxis unless there is a residual defect. Even if the repair included the use of artificial material, subacute bacterial en docarditis prophylaxis is still not warranted. One major exception is after the repair of coarctation of the aorta. Since 25% to 75% of these patients have associated bicuspid aortic valves that may not be clinically manifest, subacute bacterial endocarditis prophylaxis is justified. Subacute bacterial endocarditis is relatively common even with mild valvular lesions.11 Conversely, patients who have had rheumatic fever without cardiac involvement do not require prophylaxis. Important here is the knowledge that the dentist must specifically seek out infor mation on the need for prophylaxis. He cannot depend on patient knowledge. Harvey and Ca pone14 demonstrated that in patients with rheu matic heart disease, only 24.3% (of 181 patients) knew that they should have antibiotic coverage for dental extractions, and only 8.3% knew that they should be protected during prophylaxis and amalgam restorations. Patients with congenital heart disease had even less knowledge of their needs.14 The amount of trauma induced by a proce dure has a great bearing on the amount of bac teremia that develops. Bender and others18,19
demonstrated an 85% incidence of bacteremia immediately after multiple extractions and gingivectomy. With deep scaling, the incidence was 53% and with light scaling, 30%. They conclud ed that procedures such as fabrication of crowns, orthodontic manipulation, impression-taking, and amalgam restorations should cause no con cern since they are not associated with hemor rhage or bacteremia. Harvey and Capone14 how ever, reported two patients with subacute bac terial endocarditis preceded by only an amalgam restoration two and three months prior. In recent years, the illicit use of intravenous drugs (primarily heroin) has become an impor tant associated factor. Mostaghim and Millard’s20 study revealed that 10% of their patients with bacterial endocarditis were “ mainliners.” Although there is some controversy as to who should receive subacute bacterial endocarditis prophylaxis, there is almost no question on what constitutes prophylaxis. Penicillin is the drug of choice, and there is no disagreement on the ad visability of using penicillin immediately before and after dental treatment.19-21 There is some argument on how long antibiotics should be giv en before the procedure, but I believe it is gen erally one to two days. A longer period is not likely to cause sterilized root abscesses or in fected tonsils, but may cause sensitive bacteria to be replaced by penicillin-resistant strains.21 The American Heart Association suggests 500 mg of penicillin V or phenethicillin one hour be fore the procedure and then 250 mg every six hours for at least two days after the procedure; 600.000 units of procaine penicillin G mixed with 200.000 units of crystalline penicillin G given by intramuscular injection one hour before the pro cedure and then once daily for at least two days.21 For patients allergic to penicillin, erythromy cin can be used with an initial dose of 500 mg one to 1Vi hours before the procedure and then 250 mg four times daily. For small children, 10 mg/ kg should be given every six hours.21 In the past, this drug has not been given intramuscularly be cause of its proclivity to sterile abscess, but rec ently erythromycin preparations for parenteral use have become available. The antibiotic coverage should be broadened for patients who require emergency dental pro cedures during active subacute bacterial endo carditis. In some patients with prosthetic heart valves, staphylococcic infection can become a problem. Cohn and others22 described three pa tients with bacterial endocarditis involving an
aortic valve prosthesis. This occurred after den tal extractions, despite the use of penicillin pro phylaxis. Because of this, they suggested a more comprehensive antibiotic regimen consisting of broad spectrum antibiotic troches for two days before the procedure, 600,000 units of procaine penicillin every six hours, 500 mg of streptomy cin every 12 hours on the day before, on the day of the procedure, and three to five days after it. Methicillin sodium (5g) should be given intra venously on the day of surgery, and sodium ox acillin (4g) should be given orally for three to five days after the procedure.
What cardiac drugs are important to the dentist? ■ Sodium warfarin: The problem of anticoagu lation has been partly discussed. It was conclud ed that with careful hemostasis most dental pro cedures can be carried out with the prothrom bin time in full therapeutic range. If postoper ative bleeding should become a problem, hemo stasis is still the first consideration. However, if you decide to withdraw anticoagulation, there are several considerations. Discontinuation of the drug is the first consid eration if the situation is not emergent, since there will be a lag of 24 to 48 hours before the pro thrombin time begins returning to normal. If the problem requires more immediate therapy, how ever, the administration of Aquamephyion In jection parenterally or orally, depending on the rapidity of correction necessary, is of value. ■ Antihypertensives: These drugs are probably the most important group of agents with which the dentist should be familiar. In many instances their most prominent side effect is orthostatic hypotension, resulting at times in syncope when the patient suddenly assumes the upright posi tion. Guanethedine sulfate (Ismelin) and the ganglionic blocking drugs are the most important agents. Somewhat less commonly methyldopa (Aldomet) may be the cause. The indiscriminate use of diuretic agents may result in hypovolemia and/or hypopotassemia, which can produce sim ilar symptoms; and the latter may also exacer bate digitalis toxicity.23"24 These agents, in addition to Rauwolfia prep arations, also increase responsiveness to vaso constrictors, so extra care should be used to pre vent intravascular injection. Glasser: DENTAL PATIENTS WITH CARDIOVASCULAR DISEASE ■ 1161
■ Nitroglycerin: If a patient develops angina pectoris during a dental procedure, nitroglycerin can be given for relief. A fresh supply should be available (the drug deteriorates and should not be more than six months to 1 year old for full ef fectiveness). Its side effects are primarily secon dary to vasodilatation with resultant flushing and headache. Blood pressure generally falls after nitroglycerin is administered. ■ Saliva-inhibiting drugs: Atropine and its pro totypes are used in dentistry for obvious reasons. However, it is important to realize that because of their vagolytic effect, a tachycardia may re sult. In the cardiac-prone patient this may result in breathlessness and angina pectoris. ■ Digitalis: This is a drug that many cardiac patients will be taking, but unless digitalis toxic ity is present, it will usually cause little problem. Discussion of this important drug is otherwise beyond the scope of this paper, but several mon ographs have been published recently.23,24 ■ Propranolol: Many patients with angina pectoris will be receiving this medication, which acts primarily by slowing the resting pulse and blunting the pulse rate response to exercise, anxiety, and so forth. Also important is the dan ger of sudden discontinuation of this medication. If dental treatment will result in the patient’s in ability to swallow oral medications, this must be considered.25 What should the dentist do in case of a car diac emergency? Emergency treatment proce dures have been described.12 A cardiac emer gency is suspected when a patient has fainted or is having chest pain, persistent breathlessness, or prolonged unconsciousness. This can occur in a patient with known disease, or it can be the first manifestation of cardiac disease. Dr. Glasser is associate professor of medicine and director of the Cardiac Non-lnvasive Laboratory, University of South Florida College of Medicine, department of internal medicine, section of cardiology, 13000 N 30th St, Tampa, Fla 33612. 1. Topkins, M.J., and Artusio, J.F., Jr. Myocardial infarction and surgery: a five year study. Anesthesia and Analgesia 43:716 Nov-Dee 1964. 2. Tarhan, S., and others. Myocardial infarction after general anesthesia. JAMA 220:1451 June 12, 1972.
1162 ■ JADA, Vol. 94, June 1977
3. The functional and therapeutic classifications of patients with diseases of the heart. Copyright 1964 by the New York Heart Association, Inc. In Diseases of the heart and blood vessels— nomenclature and criteria for diagnosis, ed 6. Boston, Little, Brown, and Co., 1964. 4. Behrman, S.J., and Wright, I.S. Dental surgery during con tinuous anticoagulant therapy. JAMA 175:483 Feb 11, 1961. 5. Shira, R.B.; Hall, R.J.; and Guernsey, L.H. Minor oral sur gery during prolonged anticoagulant therapy. J Oral Surg 20:93 March 1962. 6. Ziffer, A.M., and others. Profound bleeding after dental extractions during dicumarol therapy. New Engl J Med 256:351, 1957. 7. Scopp, I.W., and Fredrics, H. Dental extractions in patients undergoing anticoagulant therapy. Oral Surg 11:470 May 1958. 8. Frank, B.W.; Dickhaus, D.W.; and Claus, E.C. Dental extrac tions in the presence of continual anticoagulant therapy. Ann of Intern Med 59:911 Dec 1963. 9. Report of the special committee of the New York Heart As sociation, Inc. on the use of epinephrine in connection with pro caine in dental procedures. 50:108 Jan 1955. 10. Chamberlain, F.L. Management of medical-dental prob lems in patients with cardiovascular diseases. Mod Concepts Cardiovasc Dis 30:697 Dec 1961. 11. Harris, S.C. Action of local anesthetic agents. Dent Clin North Am July 1961 p 231. 12. Management of dental problems in patients with cardio vascular disease. Report of a working conference jointly spon sored by the ADA and American Heart Association. JADA 68:333 March 1964. 13. Anderson, T.O., and others. Management of dental prob lems in patients with cardiovascular disease. JAMA 187:848 March 14, 1964. 14. Harvey, W.P., and Capone, M.A. Bacterial endocarditis related to cleaning and filling of teeth (with particular reference to the inadequacy of present day knowledge and practice of antibiotic prophylaxis for all dental procedures). Am J of Cardiol 7:793 June 1961. 15. Gould, L., and Sperber, R.J. Prevention of subacute bac terial endocarditis associated with dental procedures. Am Heart J 187:134, 1966. 16. Garrod, L.P., and Waterworth, P.M. The risks of dental extraction during penicillin treatment. Br Heart J 24:39 Jan 1962. 17. Schirger, A., and others. Bacterial invasion of blood after oral surgical procedures. J Lab Clin Med, p 376, March 1960. 18. Bender, I.B., and others. Dental procedures in patients with rheumatic heart disease. Oral Surg 16:466 April 1963. 19. Bender, I.B., and Seltzer, S. Dental procedures of interest to the physician in the management of patients with cardiovas cular disease. Am Heart J 66:697 Nov 1963. 20. Mostaghim, D., and Millard, H.D. Bacterial endocarditis: a retrospective study. Oral Surg 40:219 Aug 1975. 21. Prevention of bacterial endocarditis. Am Heart Assoc Bulletin 7-72-200M, 1972. 22. Cohn, L.H., and others. Bacterial endocarditis following aortic valve replacement. Clinical and pathological correlations. Circulation 33:209 Feb 1966. 23. Doherty, J.E. Digitalis glycosides. Pharmacokinetics and their clinical implications. Ann Intern Med 79:229 Aug 1973. 24. Smith, T.W., and Haber, E. Digitalis. New Engl J Med 289: 945 Nov 1973. 25. Bennett, K.R. Cessation of propranolol therapy and re bound angina pectoris. Chest 70:314 Aug 1976.