American Society of Anesthesiologists has incorporated a grading system corresponding to a patient’s physical health to assimilate the degree of fragility in the patient’s status. Cardiovascular system has been designated as of prime importance for evaluation to a dentist before carrying out any dental procedure since its pathological interference may give rise to disconcerting developments.
For the pre-dental treatment, evaluation of most patients suffering from cardiovascular impairment, physician’s consultation should be taken. The cardiovascular condition of concern to a dentist are likely to be divided into Congenital Heart Disease & Acquired Heart Disease.
Congenital Heart Disease
Patients suffering from congenital heart disease may have poor prognosis, hence a little carelessness can be fatal for these patients. They can be recognized by clubbed fingers, cyanosis of skin, lips, nailbed and general retardation in their maturation and growth. For such patients, Local Anesthesia with minimum amount of vasoconstriction is preferred for pain control. Pre-medication is advised and heavy sedation is avoided to prevent any complications. Administration of oxygen during the procedure often depends upon the degree of occurrence of cyanosis indicating hypoxia or polycythemia.
For patient’s with minimal congenital defects, treatment could be carried out normally. However, physician’s consultation is advisable.
Acquired Heart Disease
Generally, prevalent around and after 40yrs of age. The most easy way of detection for Acquired Heart Disease is a patient’s history/patient’s record. Diseases that can be identified under Acquired Heart Disease are Rheumatic Heart Disease, Atherosclerotic Heart Disease (Angina Pectoris and Coronary Artery Disease), Hypertension, Hypotension, Pending Congestive Heart Failure, Chronic Valvular Disease, Conductive System Defects (Arrhythmias),etc. Dentists should be abreast with these conditions as the possibility of the occurrence of these in prodromal patients is quite frequent.
Rheumatic Heart Disease
A dentist should suspect Rheumatic Heart Disease, even if there’s negative history in an individual, if he presents shortness of breath, dyspnea, intermittent fever and a consistently increased pulse. Physician’s advise is needed. It is important to administer an antibiotic before all dental procedures, to prevent development of bacterial endocarditis. Patients should be well sedated with narcotics if needed and profound analgesia with minimal vasoconstrictor, to prevent a resulting tachycardia.
Angina Pectoris
It is common in men over 50yrs of age, especially if associated with diabetes mellitus, anemia, hyperthyroidism amongst other diseases. Since patient may seek dental treatment for the paroxysmal attack of pain, usually noticeable in lower teeth or jaw, hence, it can be usually recognized during patient's history as the pain is of short duration and not excruciating. Patients have to be premedicated and care should be taken to prevent any painful stimuli. Preceding a dental procedure, patients are advised a light meal to prevent any anginal attack (which are prone when large meals are coupled with stressful situation).
Coronary Artery Disease
Coronary Artery Disease is commonly known as “Heart Attack”. Determination of the time lapse of the attack is important as a patient with 2yr gap with no symptoms can be treated as normal patients. It is advisable to make certain that these patients carry their medications at all times, so that they are readily available in case of an emergency. However, dentists are also advised to keep Nitroglycerin or any other vasodilator drug on hand while dealing with such patients.
Hypertension & Hypotension
Hypertension is often called “silent killer”. Determining administration of any anti-hypertensive drug is important in these patients. If the patient is taking the medicine, physician’s advice is needed. Patients who have moderate hypertension and exhibit no extra symptoms can be treated normally. Whereas malignant hypertensive patients have to be sedated and premedicated. Hypertension can be first recognized by a dentist. Failure to do so may lead to elevated blood pressure causing syncope.
Hypertension is an extremely common disease we see in an outpatient dental office. Many of our patients, adult patients, have this condition and we need to be mindful of it prior to any type of invasive procedure. Often a dentist will be called to take a patient's blood pressure prior to the procedure and then can inform the patient as to the results of that blood pressure recording. If the recording is elevated to a large degree, dental treatment should and could be postponed. But, that's often rare because most folks that do have hypertension are pretty well controlled with their medication. The dentist's office though, can serve for those unknown patients, patients with unknown hypertension. Mindful that it has little to no symptoms, the dental office could provide a screening for that particular patient and refer their patient to their primary care physician for management.
Dr. Thomas P. Sollecito, D.M.D,F.D.S, R.C.S.Ed, Professor and Chairman of Oral Medicine, School Of Dental Medicine, University Of Pennsylvania[Coursera]
Hypotension causes no concern to dentist if there’s no apparent deviation.
Pending Congestive Heart Failure
They are the most hazardous patients for a dentist to deal. Such patients are treated with caution to avoid tachycardia that may exacerbate the existing condition. Preoperative medications and good pain control is an absolute must while dealing with them. A close check on the pulse rate of these patients is to be kept. In case of sudden increase of pulse rate, rest period should be initiated. If the pulse still remains abnormal, all the procedures are to be stopped and the patient is given another appointment for other day.
Chronic Valvular Disease
This condition can be extremely debilitating when combined with other conditions. The type of valve defect and the origin of murmur is of importance to dentist as they indicate the physical wellness of the patient. If the patient can carry out his daily activities regardless of the disease, dental treatment with ordinary care is no problem. Physician’s consultation may be needed. If indicated, then patients may need to be premedicated with proper antibiotics.
Cardiac Arrhythmias
Dentists are not expected to make diagnosis but they should check the pulse of the patients to determine whether they are suffering from tachycardia or bradycardia. If a patient is also subjected to dyspnea, proper precautions should be taken to prevent any mishappening. If the patient is able to carry on his unimpeded life, he can undergo dental procedure.
Majority of cardiovascular emergencies occur from a combination of stress and exacerbated symptoms in a dental clinic. Pre-treatment evaluation forewarns the dentist of the risk these patients most likely can present. Hence, a dentist should treat these patients with care and utmost attentiveness so that proper steps can be taken to prevent any emergency.
