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8001_IPC_AAP_553142 8/5/02 1:56 PM Page 954 Periodontal Management of Patients With Cardiovascular
Diseases*
Periodontists are often called upon to provide periodontal therapy for patients with a variety of cardiovascu-lar diseases. Safe and effective periodontal treatment requires a general understanding of the underlying car-diovascular diseases, their medical management, and necessary modifications to dental/periodontal therapythat may be required. In this informational paper more common cardiovascular disorders will be discussedand dental management considerations briefly described. This paper is intended for the use of periodontistsand members of the dental profession. J Periodontol 2002;73:954-968. In recent years tremendous progress has been made tissues. Coronary artery disease is the most com- regarding the prevention, diagnosis, and treatment mon cause of CHF although hypertension, valvar (or of cardiovascular diseases. The importance of valvular) heart disease, cardiomyopathy, or diabetes proper diet, weight control, exercise, reduced alco- mellitus may also be causal or contributing factors.21 hol and tobacco consumption, and life-style changes Ventricular arrythmia and sudden death are common has been emphasized both in prevention and treat- in patients with CHF and intractable CHF may be ment of these diseases.1-12 A wide variety of new best treated by heart transplantation.1 Heart failure drugs have been developed and multidrug therapy is is associated with pulmonary congestion and venous commonly used.1 Use of newer diagnostic devices hypertension. Patients with CHF manifest variable such as transesophageal or transthoracic echocardi- levels of functional compensation that must be ology are increasing and additional devices are cur- assessed before considering dental treatment.21,22 rently being tested.6,7 Because of these medical The presence of increasing dyspnea with minimal advances survival of individuals with cardiovascular exertion, dyspnea at rest, or nocturnal angina indi- diseases (CVD) has markedly increased, yet CVD cates poor functional compensation.23,24 Elective continues to be the most serious and common health dental treatment for patients with poor compensa- problem in the United States.1,8 Recent evidence sug- tion should be delayed until the condition has been gests that the presence of severe generalized peri- stabilized with medical treatment. Emergency dental odontitis may predispose individuals to coronary care for the unstable patient should be conservative, artery disease.9,13-17 The above factors coupled with principally consisting of the use of analgesics and the increased numbers of dentate elderly who develop antibiotics. Medical consultation is indicated prior to periodontal disease indicates that periodontists must treatment. In contrast, well-compensated patients be prepared and will be expected to provide peri- may sometimes be considered for dental care with- odontal therapeutic support for increasing numbers out mandatory medical consultation. Appointments of individuals with CVD. Successful and safe patient should be short, and the dental chair kept in a par- management is predicated on obtaining a thorough tially reclining or erect position. Appropriate seda- medical history and physical examination. The exam- tives should be considered for the anxious patient, ination should include identification of any physical and supplemental oxygen should be readily avail- signs and symptoms of cardiac dysfunction and eval- able. Patients should not be placed in a supine posi- uation of vital signs when appropriate, including blood tion, since this may allow peripheral blood to return pressure, pulse rate and respiratory function. Medical to the central circulation and overwhelm the decom- consultation should be sought when indicated.18-20 pensated myocar-dium, resulting in orthopnea.22,23 Medical treatment for CHF has become more effec- CONGESTIVE HEART FAILURE
tive and often results in increased survival and qual- Congestive heart failure (CHF) is characterized by ity of life. Monodrug therapy or combined drug reg- the inability of the heart to supply sufficient oxy- imens are used24,25 (Tables 1 through 3). Each drug genated blood to meet the metabolic needs of body has potential side effects which must be monitoredin dental practice. For example, digitalis toxicity is * This paper was developed under the direction of the Research, Science and Therapy Committee and approved by the Board of Trustees of the relatively common and the dental clinician should be American Academy of Periodontology in May 2002.
alert for evidence of toxicity in any patient receiving 8001_IPC_AAP_553142 8/5/02 1:56 PM Page 955 evidence suggests thatSCA is poorly respon- Medications Commonly Used in Congestive Heart Failure
sive to drugs or cardio-pulmonary resuscitation Inotrophic agents
Vasodilators
Angiotensin-converting enzyme
inhibitors See Table 3.
Angiotensin-converting enzyme
receptor blockers See Table 3.
Calcium channel blockers
Diuretics
See Table 3. These drugs are in increasing use hydrochlorothiazide (Exidrix, Mictrin, Oretic) pated atrial or ventricu-lar arrythmias to includefibrillation or even asys- this drug. Symptoms may include anorexia, diarrhea, tole.12 In addition, vasoconstrictors may adversely fatigue, headache, dizziness, or delirium, but the most interact with digoxin, non-selective B adrenergic dangerous manifestation is altered cardiac rhythm.26 blocking drugs, antidepressants or cocaine.33 Most Angiotensin enzyme inhibitors may induce a cough studies indicate, however, that the judicious use of reflex which could interfere with periodontal therapy1 local anesthetics containing vasoconstrictors is desir- while the use of calcium channel blocking agents able in obtaining profound anesthesia for arrhthymic may result in unwanted gingival overgrowth.27,28 individuals but the quantity of vasoconstrictor shouldbe controlled.33-39 There appears to be no advantage CARDIAC ARRHYTHMIAS
or disadvantage to using levonordefrin as a substitute Cardiac arrhythmias may be caused by a variety of for epinephrine.37,38 Intraosseous or intraligamental reversible abnormal physiologic events such as injections with anesthetic agents containing these hypoxia and electrolyte or acid-base abnormalities.
drugs should usually be avoided to prevent exces- Cardiovascular causes include myocardial ischemia, sive systemic absorption of the vasoconstrictor.12,37 bradycardia, hypertensive heart disease, valvar heart With careful adherance to established safety princi- disease, increased sympathetic activity, and CHF.
ples, local anesthetics with vasoconstrictors can be Sudden cardiac arrest (SCA) is a constant threat administered to patients with arrythmia, partially con- among refractory dysrhythmic individuals.12,29 Recent trolled hypertension, or other forms of cardiovascu- Academy Report
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 956 report, however, a patient experienced markedly ele-vated blood pressure despite the administration of Common Cardiac Antiarrythmics
Some arrhythmias and even refractory vasovagal syncope49 are best managed by implantation of car- diac pacemakers, most of which are placed in theupper chest wall and inserted into the heart by the transvenous route.50 This creates a low risk for infec- tive endocarditis, but the American Heart Associa-tion (AHA) does not recommend prophylactic antibi- otic coverage for dental procedures in these patients.51 Pacemakers may be disrupted by exter-nal electrical fields such as those generated by air- port security devices, powerful magnets (including magnetic resonance imaging), and even cellular tele-phones.23,52-54 Pacemaker dysfunction was a greater problem, however, with older models which were unipolar and poorly insulated. In the past, concernswere expressed over the potential for electrical den- tal devices to disrupt pacemaker function.55,56 These concerns were largely resolved with the advent ofbipolar titanium insulated cardio-pacer devices54 and dual chamber pacemakers significantly reduce the incidence of life threatening arrhythmias in individu-als at risk.1,50 Some dental electrical devices capa-ble of generating electromagnetic radiation may con- lar disease although limiting the total epinephrine to tinue, however, to pose a low-grade threat to dental 0.04 to 0.054 mg per appointment is often recom- patients. In an evaluation of the effect of 14 electri- mended.2,38-40 This translates into two-three carpules cal dental devices on cardio-pacemakers it was deter- of lidocaine with 1:100,00 epinephrine (0.02 mg per mined that three of these devices (electrosurgical carpule), as compared to a maximum of 0.2mg in a units, ultrasonic instrument baths, and magnetore- healthy adult male (11 carpules). Others have dis- strictive ultrasonic scalers) were capable of disrupt- puted this dosage restriction although most dental ing pacemaker function if the devices were placed in local anesthetic studies conducted in the past 15 close approximation to the pacemaker. Neither sonic years have used a quantity of local anesthetic near scalers nor electric toothbrushes adversely affected or below the recommended levels.35,39,41-45 There is little doubt that most patients can safely tolerate epi- Recurrent supraventricular and ventricular tachy- nephrine but patient response can be widely variable arrhythmias are increasingly being managed by and careful monitoring is indicated.35,39 Several con- implantation of automatic cardioverter defibrillators trolled studies have confirmed significant changes in often in combination with single or dual chamber heart function when local anesthetics with vasocon- pacemakers. Defibrillation devices were originally strictors are used for patients with cardiovascular dis- placed in the subcutaneous paraumbilical area of the ease35,36,42,43,45 while others have not.39,44,46 This abdomen. Patch electrodes were attached to the epi- appears to relate to variations in individual response cardium but electrodes of newer automatic implanted to the agents although higher dosages are more likely cardioversion devices or combined pacemaker/car- to induce cardiac dysfunction.36,44,47,48 Elevation in dioversion devices are most often implanted in the blood pressure has been described in older patients chest wall and inserted into the heart transvenously.50 prior to initiation of treatment or in the midst of treat- According to the AHA, patients with implanted defi- ment rather than during administration of local anes- brillators are not at increased risk for infective endo- thetics.39 This suggests that endogenous epinephrine carditis and prophylactic antibiotic coverage is not precipitates this rise in blood pressure and that stress necessary unless other risk factors are present.51 Cer- reduction procedures are indicated. In one case tain precautions are recommended, however, for den- Periodontal Management of Patients With Cardiovascular Diseases
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 957 tal procedures. The defibrillator may activate with- Patients with stable angina may receive dental care out significant warning, potentially causing the patient in short, minimally stressful appointments. Tradi- to flinch, bite down, or perform other sudden move- tionally, morning appointments have been recom- ments that may result in injury to the patient or the mended. However, recent evidence indicates that clinician. Some patients with implanted defibrillators endogenous epinephrine levels peak during morning experience loss of consciousness when the device is hours and the majority of sudden cardiac arrests activated. This is less likely to occur with newer occur between the hours of 8 a.m. to 11 a.m. Con- devices that initially emit low level electrical bursts fol- sequently, late morning or early afternoon appoint- lowed by stronger shocks if cardioversion does not ments have been recommended although schedul- occur immediately. Epinephrine or other vasocon- ing is properly at the discretion of the practitioner.12,61 strictors are contraindicated in all intractable arrhyth- Profound local anesthesia is necessary to prevent mias50,57 and should be used with caution (reduced large amounts of endogenous epinephrine from being dose with careful monitoring) in patients with pace- released in response to pain as described above.39,53 makers and implanted defibrillators.
If angina occurs during dental treatment, the proce-dure should be terminated and the patient placed in CORONARY ARTERY DISEASE
a semi-supine position; 100% oxygen should be Atherosclerotic changes in the coronary arteries pro- administered; and 0.32 or 0.4 mg nitroglycerin duce ischemic heart disease which is the leading (preferably the patient’s own drug if it does not exceed cause of sudden death in the United States.9,21 The its expiration date) placed sublingually. Nitroglycerin patient with ischemic heart disease may also expe- should be repeated if necessary but the minimal dose rience atrial fibrillation,12 angina pectoris, myocar- required for patient comfort should be used. Vital dial infarction, or other changes. Coronary artery dis- signs should be monitored and further emergency ease (CAD) is more prevalent in the elderly, but can measures taken if necessary.23 Pain that persists after occur at any age.58-60 Atherosclerotic CAD may rep- 3 doses of nitroglycerin given every 5 minutes; that resent a response to injury to the vascular wall by lasts more than 15 to 20 minutes; or that is associ- mechanical, biochemical, immunochemical, viral or ated with diaphoresis, nausea, vomiting, syncope, or bacterial insult including chlamydial infection or pos- hypertension may be suggestive of a myocardial sibly, severe generalized periodontitis.9,13,15,16 infarction. While arrangements are made for imme- Angina Pectoris
diate transportation to a hospital, vital signs must be Anginal pain is always caused by a discrepancy closely monitored. The patient should continue oxy- between myocardial oxygen demands and the abil- gen, and chew 160 to 325 mg of aspirin. In addition, ity of the coronary arteries to deliver this substrate.
5 to 10 mg of morphine sulfate may be given intra- In most instances this occurs due to narrowing of a venously for pain and anxiety. Should cardiopul- major coronary artery. Spasm of the coronary arter- monary arrest occur while aid is still forthcoming, resuscitative measures must be undertaken to include Angina is characterized by pain, pressure, or heav- application of automatic external cardio-defibrillation iness in the retrosternal area that may radiate across the chest, into the left shoulder, down either arm, “Unstable angina” represents a clinical syndrome possibly between the shoulder blades, and occa- that is intermediate between stable angina and sionally to the side of the neck, mandible, and face.
myocardial infarction. It features a significant change Pain duration is measured in minutes and is con- in the patient’s previous anginal pattern. The patient stricting, crushing or burning in nature. Any situa- may experience a progressive increase in frequency tion, physical or psychological, that may increase the or severity of pain. The angina may occur at rest, or demands on the myocardium beyond the capacity after minimal exertion, It may become more resis- of the coronary circulation may initiate such pain.
tant to relief by nitrates. Patients with unstable angina “Stable angina” refers to chest pain which results should receive only emergency or minimal dental from a predictable amount of exertion and which care after consultation with a physician. Administra- responds to rest or nitroglycerin.59,60 Patients with tion of vasoconstrictors is contraindicated and the stable angina are usually under medical care, which hospital may be the most appropriate environment for commonly includes combinations of beta-adrenergic blocking agents, nitrates, and calcium channel block- “Variant angina” (Prinzmetal’s angina) may be pre- cipitated by coronary artery spasm with or without Academy Report
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 958 coronary artery compromise.60 Arrhythmias are enlargement may restrict movement of the septal common during painful episodes although the pain leaflets of the mitral valve leading to valvar insuffi- is usually quickly relieved by administration of ciency and regurgitation. Patients with this disorder nitrates.20,29,60 Coronary artery spasm has been are therefore susceptible to infective endocarditis and reported in association with cocaine abuse. The pres- antibiotic prophylaxis should be considered.70-72 Such ence of variant angina, especially in the absence of patients are also at risk for myocardial ischemia and vascular lesions, should be reported to the patient’s arrhythmias, including ventricular fibrillation. Exer- physician to rule out the possibility of drug abuse.
cise-induced sudden death is a constant risk. Epi- Vasoconstrictors should be used with extreme caution nephrine should be used with caution in these patients and nitroglycerin or similar drugs are contraindi-cated.70 If angina pectoris, myocardial infarction, or Myocardial Infarction
fibrillation occurs in the dental office the clinician Myocardial infarction occurs when the narrowed ath- should administer oxygen and be prepared to per- erosclerotic coronary arteries become acutely form cardiopulmonary resuscitation and to activate occluded by thrombus formation leading ultimately to the medical emergency response system.
necrosis of the portion of the heart muscle suppliedby that artery. Affected patients generally report VALVAR HEART DISEASE
crushing substernal pain frequently with radiation to Valvar heart disease is relatively common in individ- the neck, jaw, or left arm.64 The pain may be accom- uals of all ages. It results from diverse pathological panied by shortness of breath, anxiety, nausea, and processes such as rheumatic fever, congenital heart diaphoresis. The highest risk of death following acute defects, ischemic heart disease, mitral valve prolapse, myocardial infarction occurs during the first 12 hours Kawasaki’s disease (mucocutaneous lymph node syn- when the risk of ventricular fibrillation is greatest.59,65 drome), and systemic lupus erythematosus.51,72-74 Patients who have sustained a myocardial infarc- These conditions are associated with valvar stenosis tion are at increased risk of an additional infarction and regurgitation. In recent years a significant decline for 6 months thereafter. Consequently, current guide- in the incidence of rheumatic fever has occurred in lines indicate that only minimal treatment for acute developed countries although the incidence of infec- dental problems is advised within 6 months of an tive endocarditis (IE) remains unchanged.75 infarction after consultation with the patient’s physi- Rheumatic fever is most often initiated by Strepto- cian.65 Elective dental care can usually be provided coccal sepsis. It can induce fibrotic scarring of val- 6 months after a myocardial infarction. Consultation var tissue that may be gradually progressive in adult with the physician is recommended, and if no prob- life. Kawasaki’s disease is an acute febrile disease lems are noted, the dentist may proceed with treat- complex of unknown etiology.76,77 It features con- ment employing those principles used when caring for junctival congestion; dryness of lips; skin and the the patient with stable angina pectoris.66 These prin- oral cavity; cervical lymphadenopathy; and cardio- ciples include late morning appointments, profound vascular changes, including coronary thromboarteri- local anesthesia, oral or inhalation sedation if needed, tis, aneurysms, mitral valve insufficiency, and myocar- and close monitoring of the patient’s vital signs.53,67 dial ischemia.77 Congenital heart anomalies may Most individuals with a history of CAD are taking induce cardiac blood turbulence and permanent valve maintenance medication or those medications are damage even after surgical repair. Therefore, patients available for use as indicated. The dental practitioner with congenital defects should be considered at risk should ascertain what medications the patient is tak- ing and should seek to avoid use of any drug known Heart transplantation or ischemic heart disease to produce an adverse interaction with such med- may lead to valvar calcification, rupture, or scarring ication. Additionally, the practitioner should remain and predispose elderly patients to IE.78 A previous alert for signs or symptoms of adverse drug reac- incident of IE at any age may result in valvar dam- tions or multi-drug interactions in this patient age and predispose to recurrence of IE.75,78,79 Mitral valve prolapse (floppy valve syndrome) occurs in response to idiopathic loss of the fibrous and HYPERTROPHIC CARDIOMYOPATHY
elastic tissue of mitral valve leaflets or the chordae Hypertrophic cardiomyopathy is an autosomal dom- tendineae. It is highly prevalent in Down syndrome inant, genetically derived condition.70 Heart muscle or in heritable connective tissue disorders, particularly Periodontal Management of Patients With Cardiovascular Diseases
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 959 Ehlers-Danlos syndrome and Marfan syndrome.80 It is also quite common in the general population, espe- Drugs for Hypertension
cially in young women and in individuals sufferingfrom psychiatric disorders (e.g. panic disorder), Angiotensin-converting enzyme (ACE) inhibitors
severe depression or anorexia nervosa.80-82 Accord- ing to the AHA the degree of risk for IE in associa- tion with mitral valve prolapse may have been over- stated83 and prophylactic antibiotic coverage for dental procedures is required only if regurgitation is The use of fenfluramine-phenteramine, a combi- nation of weight control drugs, has been associated with an increased incidence of valvar thickening with regurgitation, which may place individuals at risk of Angiotensin receptor antagonist
IE. The degree of risk associated with this drug is unknown, but a 1998 study suggests that the inci- dence is low (4.3%) and remission of valvar lesions may occur after discontinuing the drugs.84 Systemic lupus erythematosus (SLE) is sometimes associated with vegetative valvar or perivalvar lesions Beta-adrenergic blocking agents (See Table 1)
which increase the potential for subsequent IE,although occurrence is relatively rare. Some authors, Diuretics (See Table 1)
however, recommend prophylactic antibiotic cover- Calcium-channel blocking agents
age for SLE patients when dental procedures are per- A patient history suggesting the presence of a heart murmur requires medical consultation and a thor- ough understanding of the patient’s condition and its possible ramifications.85 Echocardiographic exami- nation is extremely accurate in identifying valvar dam- age and some evidence suggests that magnetic res- verapamil (Calan, Isoptin,Verelan, Covera-HS) onance may be of benefit in establishing the degree diltiazem (Cardizem, Dilacor, Diltia,Timate,Tiazac) The individual with valvar heart disease faces 3 basic risks: heart failure, hemodynamically signifi- Alpha-adrenergic blocking drugs
cant arrhythmia, and IE. Of these, the dentist is most frequently required to manage patients at risk of IE.
Patients who have received valvar prostheses are at special risk for occurrence of IE.78,86,87 Dental pro- Central alpha-adrenergic agonists
cedures that involve manipulation of soft tissue and bleeding can produce transient bacteremias.51 These procedures include periodontal probing, administra- tion of intraligamental analgesia, and use of oral irri- gators or air abrasive polishing devices.75,88-95 How- Direct vasodilators
ever, transient odontogenic bacteremias also occur in association with chewing and toothbrushing, bringing into question the additional benefit gained when pro-phylactic antibiotic coverage is administered for den- Peripheral adrenergic neuron antagonists
Bloodborne microorganisms may lodge on dam- aged and abnormal heart valves, in the endocardiumor in the endothelium near congenital anatomic Academy Report
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 960 defects, resulting in IE or endarteritis. It is not possi- ble to predict which patient will develop this infection Cardiac Conditions Not Requiring
or which particular procedure will be responsible.51,96 Prophylaxis for Dental Treatment
This has caused many experts to consider dentaltreatment involving manipulation of soft tissues a riskfactor for IE. In 1997, the AHA revised its recom- Isolated secundum atrial septal defect.
mendations regarding dental management of patients Surgical repair of secundum atrial septal defects, ventricular septal at risk for infectious endocarditis. Although not all defects, or patent ductus arteriosis after 6 months and without authorities agree, the AHA continues to recommend prophylactic antibiotic coverage in the presence of Previous coronary artery bypass graft surgery.
certain cardiac anomalies and during specific dentaltreatment procedures.51 These recommendations are Mitral valve prolapse without valvular regurgitation.
principally directed toward prevention of endocardi- Physiologic, functional, or innocent heart murmurs.
tis induced by oral Streptococcus viridans. The degreeof risk generated by the presence of specific valvar Previous rheumatic fever without valvular dysfunction.
disease is identified in Tables 4 and 5 while specific Previous Kawasaki disease without valvular dysfunction.
dental procedures likely to induce significant bac-teremias are listed in Tables 6 and 7.
Cardiac pacemakers and implanted defibrillators.
Risk for IE increases in individuals with poor peri- odontal health or other oral infections.51,97-99 Rinsingwith antimicrobial agents containing chlorhexidine Modified from: Dajani AS, Taubert KA, Wilson W, et al. Prevention ofbacterial endocarditis. Recommendations by the American Heart gluconate or povidone-iodine is recommended prior Association. Circulation 1997;96:358-366.
to manipulation of dental tissues. To date there is noconclusive evidence, however, confirming that reduc- tion of the oral bioload reduces the risk of bacteremiasor IE.95-103 Frequent home use of antiseptic rinses is Dental Procedures Creating Risk of
not recommended due to the potential for develop- Significant Bacteremia
In patients at risk, antibiotic prophylaxis is rec- ommended for dental procedures likely to induce sig- Implant placement and tooth reimplantation.
Periodontal treatment procedures likely to cause bleeding.
Endodontic surgery or instrumentation beyond the root apex.
Cardiac Conditions Requiring Prophylaxis
for Dental Treatment
Subgingival placement of antibiotic fibers or strips.
High risk
Modified from: Dajani AS, Taubert KA, Wilson W, et al. Prevention ofbacterial endocarditis. Recommendations by the American Heart Prosthetic cardiac valves, including bioprosthetic and Association. Circulation 1997;96:358-366.
Previous infective endocarditis, even in the absence of heart nificant bleeding of hard or soft oral tissues. This Complex congenital cardiac malformations.
includes most surgical or non-surgical periodontal Surgically constructed systemic/pulmonary shunts.
therapy with the possible exception of judicious den- Moderate risk
tal polishing that does not induce bleeding (prophy- Rheumatic and other acquired valvular dysfunction even after laxis). If a series of dental procedures is required, an interval of 9 to14 days between procedures may min- imize the risk of the emergence of resistant strains of Mitral valve prolapse with valvular regurgitation.
organisms.51,75 If unanticipated bleeding occurs dur- Non-complex congenital cardiac malformations.
ing low risk dental procedures, antibiotics adminis- Modified from: Dajani AS, Taubert KA, Wilson W, et al. Prevention of tered within 2 hours of the event may have some bacterial endocarditis. Recommendations by the American HeartAssociation. Circulation 1997;96:358-366.
benefit although there is no evidence of prophylac- Periodontal Management of Patients With Cardiovascular Diseases
8001_IPC_AAP_553142 8/5/02 1:56 PM Page 961 otic or antimicrobial agents have recently been sug-gested for local delivery in treatment of periodonti- Dental Procedures Creating Low Risk of
tis.110 The AHA recommends systemic prophylaxis Bacteremias
when these agents are inserted in high risk patients,due to the potential for traumatic injury and bleed- Restorative procedures with or without placement of retraction ing during these procedures.51 Antibiotic prophylaxis only minimizes the risk of IE and the clinician must remain alert for symptoms associated with the con-dition. These may include: persistent fever, night sweats, myalgia, arthralgia, malaise, anorexia, and Individuals with prosthetic heart valves experience Placement or adjustment of orthodontic or removable high morbidity and mortality if IE occurs.75,78 Under ideal circumstances a dental/periodontal examina- tion should be performed on all patients scheduledfor valve replacement open heart surgery. When pos- sible all potential oral foci of infection should be elim- inated or minimized prior to any heart surgery, includ-ing transplantation.51,75 Routine periodontal therapy is not appropriate within 6 months of valve place- Modified from: Dajani AS, Taubert KA, Wilson W, et al. Prevention of ment and periodontal health is an extremely impor- bacterial endocarditis. Recommendations by the American HeartAssociation. Circulation 1997;96:358-366.
tant goal for the lifetime of the patient. Prophylacticantibiotic coverage should be provided during per- tic benefit if administered four or more hours after formance of most periodontal treatment proce- The AHA recommendations for specific prophy- lactic antibiotic regimens for dental procedures are ANTICOAGULATED PATIENTS
widely published and will only be briefly described Anticoagulant therapy is frequently administered for (Table 8). These measures are considered adequate patients with prosthetic valves, thromboembolic phe- for patients who are at high risk from IE including nomena, or other flow disturbances.75,111 This therapy may be used for a few months following placement of Individuals who take penicillin frequently may porcine artificial heart valves but recipients of mechan- harbor oral microorganisms that are relatively resis- ical heart prostheses may use anticoagulants for life.
tant to penicillin, amoxicillin, or ampicillin. In this Warfarin sodium preparations are the agents used event, clindamycin or another of the alternative reg- most often for outpatient anticoagulation. Warfarin imens is recommended for endocarditis prophylaxis.
inhibits vitamin K utilization and depletes coagulation Cephalosporins should be used with caution in these factors II, VII, IX, and X.112 The drug has a delayed individuals due to the potential for microbial cross- onset and a prolonged effect. Serum level is moni- resistance between cephalosporin and penicillin de- tored via the corrected prothrombin time, called the International Normalized Ratio (INR). Normal pro- Professional judgment is required in managing thromin time has an INR value of approximately 1.0 patients who do not fit the established AHA guidelines.
while therapeutic doses of anticoagulant usually sus- Tetracyclines are not recommended for prophylactic tain the INR between 2.0 to 3.5.97 Home PT/INR mon- antibiotic coverage.51 However, patients with peri- itoring devices have proven to be accurate in sus- odontal infections induced by tetracycline-sensitive taining target INR levels.113 On occasion, INR levels organisms may be best managed by pretreatment of 4.0 to 4.5 may be required to prevent intravascu- with tetracyclines for 2 to 3 weeks, followed by a lar clotting.12 Most evidence indicates that dental sur- week delay and periodontal therapy performed using gical procedures such as extractions or limited peri- AHA recommended prophylactic regimens.109 Med- odontal surgery can be performed without modifying ical consultation should be obtained for patients who INR levels except in extreme circumstances. Prolonged require multiple, prolonged, or unusual regimens of postoperative bleeding rarely occurs within an INR prophylactic antibiotic coverage. A variety of antibi- range of 1.0 to 3.0 although higher INR levels may be Academy Report
8001_IPC_AAP_553142 8/5/02 1:57 PM Page 962 the antibiotics may increaseprothrombin time.119 Synopsis of AHA Recommendations for Adults at Risk of IE
adjustments are necessary. Onrare occasions it may be nec- cedure. Checking the INR levelon the day of the procedure may nary artery stent thrombois.
Hemorrhagic complications are * Modified from: Dajani AD, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JADA 1997;128:1142-1151.
alter bleeding time. Patientsusing higher aspirin dosages or associated with mild to moderate localized hemor- those routinely taking non-steroidal anti-inflamma- rhage.97,99,114 Patients receiving systemic anticoag- tory drugs are at some risk for prolonged postoper- ulants can usually be managed using local hemostat- ative hemorrhage following periodontal therapy. For ic measures. These include atraumatic surgical these individuals, the medication may be discontin- technique; adequate wound closure; application of ued for 1 to 2 weeks prior to the scheduled proce- postsurgical pressure; and use of topical clotting dure to allow normal or near-normal platelet aggre- agents such as foamed gelatin, oxidized regenerative cellulose, thrombin, or synthetic collagen.115-117 Thereis little evidence to indicate that one agent is prefer- HYPERTENSION
able to another, although one recent paper indicated High blood pressure is the primary risk factor for car- more rapid wound healing when oxidized regenera- diovascular disease and stroke as well as a major tive cellulose was used.118 Oral rinsing with tranexamic cause of end stage renal disease.2 It affects 15% to acid has been reported to further promote post-sur- 20% of adults in the United States.123 In 1997 the gical hemostasis although this drug is costly and its Sixth Report of the Joint National Committee on Pre- use is rarely necessary.115-117 Tetracyclines, ery- vention, Detection, Evaluation and Treatment of thromycin, clarithromycin, and metronidazole are con- Hypertension released new guidelines defining the traindicated in patients on anticoagulant drugs since condition.123 According to this report, isolated ele- Periodontal Management of Patients With Cardiovascular Diseases
8001_IPC_AAP_553142 8/5/02 1:57 PM Page 963 should be as conservative as possible for the uncon-trolled or untreated hypertensive individual. There Classification of Adult Blood Pressure
are no contraindications, however, to providing den- (modified from reference 2)
tal care for the well-controlled patient.128 In some instances, illicit drugs (cocaine, amphet- amines) or prescribed drugs (immunosuppressives,erythropoietin, mineralocorticoids, anabolic steroids) may elevate blood pressure readings. Patients using these drugs should be identified when possible andmanaged with care in the dental office.2 These sub- stances are usually contraindicated in patients with 180 or > systolic/110 or > diastolic A variety of drugs are used in treatment of hyper- tension and multidrug therapy is common129 (Table3). Complications and side effects of these drugs vations of either systolic or diastolic blood pressure include hypokalemia with associated arrhythmias, are of concern in patient management and in pre- postural hypertension, mental confusion, depression, vention of unwanted sequelae. An individual is con- drowsiness, paroxysimal coughing, and xerosto- sidered to have hypertension if blood pressure mia.2,68,128,129 Some non-steroidal anti-inflammatory reaches 140 mm/Hg systolic or 90 mm/Hg diastolic.
drugs (indomethacin, ibuprofen and naproxen) can Diagnosis is based on average values obtained from reduce the efficacy of antihypertensive agents.97,129 at least 2 readings obtained on separate visits after Under most circumstances the use of epinephrine in an initial baseline measurement. Hypertension was combination with local anesthetics is not contraindi- stratified into stages (Table 9). Individuals with blood cated in the hypertensive patient unless the systolic pressure readings within normal range but who are pressure is over 200 mm/Hg and/or the diastolic is using anti-hypertension drugs should also be con- over 115 mm/Hg.2,128 As previously described, use sidered to have hypertension and be carefully mon- of vasoconstrictors in local anesthetics should be itored. Therapeutic decisions are based on the pres- carefully monitored to assure patient safety. However, ence or absence of risk factors and the level of profound anesthesia is indicated to minimize release hypertension. Lifestyle changes and/or drug therapy of endogenous epinephrine in response to pain.129,130 are recommended for individuals with high normal Adequate aspiration is critical to prevent intravascu- blood pressure if they are afflicted with target organ lar injection.53,130 Vasopressors are contraindicated for disease, other cardiovascular disorders, or diabetes use in achieving gingival retraction or to control local mellitus.2,123,124 Individuals with Stage 3 hypertension bleeding.99 Psychosedation techniques and oral and should only receive elective dental procedures until inhalation sedation; e.g., tranquilizers and nitrous oxide the blood pressure is controlled. Stress reduction pro- may be useful in treating this group of patients. Gen- tocols should be used with any individual with high eral anesthesia is not recommended on an outpatient normal blood pressure or hypertension.2 Therapeu- basis in individuals with significant hypertensive dis- tic goals may vary according to the patient’s age, ease and care in a hospital setting may be indicated.130 An alarming number of individuals with known VASCULAR STENTS
hypertension are not compliant with recommended Vascular stents are increasingly being used to main- medical therapy while many hypertensives remain tain patent vessels in many parts of the cardiovas- undiagnosed.2 For these reasons, dental health care cular system. Although the risk of postoperative stent workers can have an important role in detection and infection is rare, it has been reported. Nevertheless, management of hypertensive patients. With routine antibiotic prophylaxis for dental treatment is gener- blood pressure monitoring, undiagnosed hyperten- ally not considered necessary for successfully sive patients may be identified, informed of their ele- engrafted cardiovascular stents. However it may be vated blood pressure readings, and advised to seek prudent to provide antibiotic coverage for emergent medical consultation. Previously identified hyperten- dental treatment during the first 4 to 6 weeks post- sive patients should have their blood pressure taken operatively.131,132 Stent recipients may require long- at each visit.127,128 Emergency dental treatment term anticoagulant medication and appropriate action Academy Report
8001_IPC_AAP_553142 8/5/02 1:57 PM Page 964 should be taken to manage these individuals during Immunosuppressive drugs may mask early man- ifestations of oral infection, leading to locally severeor disseminated disease.97 These drugs include HEART TRANSPLANTATION
cyclosporin, corticosteriods, antilymphocyte globu- Heart transplantation has become a major component lin, azathioprine or others. Cyclosporin-induced gin- in management of cardiovascular diseases. It may gival overgrowth and increased susceptibility to skin be indicated for patients with congestive heart failure, and oral squamous cell carcinoma have been ischemic heart disease, hypertrophic cardiomyopa- reported.27,140-142 Impaired bone marrow function thy, severe valvar defects, or intractable ventricular may lead to thrombocytopenia, anemia or neutrope- tachyarrhythmias.134,135 Patients scheduled for organ nia all of which could affect the oral cavity and patient transplants are carefully selected and the dentist should be an important participant in treatment plan- No firm dental management protocols have been ning both before and after elective transplantation.
described for recipients of solid organ transplants.
Most organ transplant centers are limited in acquisi- However, prophylactic antibiotic therapy is probably tion of donor organs. Consequently, elective proce- indicated if periodontal therapy is required within the dures are generally projected only for those individ- first 6 months following heart transplantation. Pro- uals not expected to survive more than 2 years phylactic antibiotics may continue to be required for without transplantation. As a result, periodontal inter- individuals who do not achieve maximal restoration vention is a realistic possibility for these patients of cardiac function or who experience acute or chronic although the underlying cardiovascular condition may organ rejection and ongoing immunosuppressant ther- limit choices of periodontal therapy. Pre-transplant apy. Prophylactic antibiotic therapy may be consis- dental therapy should be directed toward elimination tent with the guidelines established by the AHA.51 of active or potential oral sources of infection with However, more stringent antibiotic usage may be awareness that the patient may receive immunosup- pressant therapy for the remainder of his/her life toprevent organ rejection. Patients who require emer- gency heart transplantation, yet have concomitant Patients with a wide variety of cardiovascular diseases oral infections, may require antibiotics during and are frequently encountered in periodontal practice. Peri- after transplantation until the necessary dental treat- odontal health and absence of other oral foci of infec- tion are essential and on some occasions prophylac- Complications are common following heart trans- tic antibiotic coverage is required. Safe and effective plantation.135,136 These may include acute or chronic periodontal management of such patients requires close graft rejection, heart failure, infection or sudden death.
medical and dental coordination, an understanding of Bacterial, viral, and protozoal infections are common the potential hazards during dental treatment, knowl- due to long-term administration of anti-inflammatory edge of drugs used in treatment of cardiovascular dis- and immunosuppressive drugs. Some evidence indi- eases, and the potential adverse effects of drugs com- cates a correlation between the presence of severe, generalized periodontitis and risk of myocardial infarc- ACKNOWLEDGMENTS
tion.137-140 Therefore periodontal health may beextremely important for heart transplant recipients.
This paper was revised by Dr. Terry D. Rees and In successful organ transplantation, maximal heart replaces the 1996 version authored by Dr. Rees and function may approach 70% of normal.135 The trans- Dr. Louis F. Rose. Members of the 2001-2002 planted heart usually remains denervated although Research, Science and Therapy Committee include: an active vaso-vagal reflex has been reported sug- Drs. Terry D. Rees, Chair; Timothy Blieden; Petros gesting occasional reestablishment of neural function Damoulis; Joseph P. Fiorellini; William V. Giannobile; or an alternative non-neural mechanism for this Gary Greenstein; Henry Greenwell; Vincent J. Iacono; reflex.6,141 Due to the absence of innervation, angina Angelo Mariotti; Richard Nagy; Robert J. Genco, Con- is rare and patients may experience “silent” myocar- sultant; Barry Wagenberg, Board Liaison.
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