Systemic Disorders and their Clinical Implications
Cardiovascular disease is quite common, though more frequent and severe in later life, can also affect young individuals. It is one of the leading causes of death in the world. A thorough knowledge of cardiovascular diseases is necessary because of its implications in dentistry and also the initial measures taken by the dentists in case of certain emergency conditions can be lifesaving.
Clinicians must assess the status of cardiovascular system within the context of the patient’s overall health. These associated conditions can heighten cardiovascular risk during dental care. Consequently, an initial medical history should be obtained from all patients and it must be reviewed with the patient at each appointment to identify serious cardiac conditions. The clinicians should also note history of cerebrovascular disease, renal dysfunction, chronic pulmonary disease, diabetes mellitus, anemia, dyslipidemia, peripheral vascular disease, orthostatic intolerance and anemia. Further an accurate record of current medication taken by the patient, use of tobacco products, alcohol and over-the-counter and recreational drugs should be documented.
It is the common presentation of cardiac diseases, though can be a manifestation of disease of the lungs, musculoskeletal system or gastrointestinal system. Pain is usually felt behind the sternum, radiates across the chest and down the arms, it may also radiate to the back or to the mandible.
It is a major symptom of many cardiac disorders, particularly left heart failure. Dyspnea may vary in severity from an uncomfortable awareness of breathing to a frightening sensation of fighting for breath.
The general appearance of the patient can provide valuable information related to his/her physical and emotional state. Pallor, cyanosis, peripheral edema, dyspnea, tremors, Cheyne–Stokes respiration, obesity and anxiety are clues that suggest the presence of cardiovascular disease.
It is defined as the blue color of the skin and mucous membranes due to the presence of excessive amount of deoxygenated hemoglobin in these tissues. It is seen in heart failure, cyanotic congenital cardiac disease and chronic cardiac disorders.
It is the obliteration of the angle between nail base and adjacent skin of the finger. Clubbing is characterized by the thickening of the nail bed secondary to hypervascularity and opening of the anastomotic channels in the nail bed. It is seen in congenital cardiac disease and infective endocarditis.
Bilateral swelling of both the legs may be due to chronic heart failure. Edema is detectable by fingertip pressure over the tibial bone for about 30 seconds, a pit due to physical displacement of excessive tissue fluid is observed.
Determination of the blood pressure provides a useful clue that will confirm or rule out significant cardiovascular disease. It should be recorded on all new patients at the time of initial appointment and at all subsequent appointments on all patients with a history of hypertension, cardiovascular disease, diabetes mellitus, thyroid disorders, adrenal disease, renal dysfunction and significant use of tobacco, alcohol or coffee. The auscultatory method of measurement of BP is recommended. In patients older than 50 years, elevated systolic pressure may predict the potential for cardiovascular morbidity and mortality.
The pulse pressure closely correlates with systolic pressure and is a reliable cofactor that will provide us with information on cardiovascular disease. Rate below 60 or above 100 in adults and if associated with symptoms such as sweating, weakness, dyspnea and chest pain should be considered as a risk factor in association with non-cardiac procedures. Further abnormalities in the normal rhythm of the pulse should provoke a search for any underlying cardiac diseases.
Hypertension is a disorder characterized by an abnormal elevation of arterial pressure, which if sustained and untreated, is associated with a significant increase in morbidity and mortality. The systolic or diastolic pressure or both are elevated in hypertension.
Majority of the patients with hypertension have no cause for their disease. These patients are diagnosed to have primary, idiopathic or essential hypertension. Essential hypertension is seen in elderly, obese and individuals who are tensed and fearful. Genetic factors also play a role. However, a few patients have underlying systemic diseases that produce hypertension, which is known as a secondary hypertension.
A patient with hypertension is usually asymptomatic for quite a few years. The early symptoms include occipital headache, vision changes, ringing ears, dizziness, weakness and nose bleeding. Odontalgia due to hyperemia or congestion of dental pulp has also been reported.
Untreated hypertension reduces the life span by 10–20 years. Even mild hypertension that has not been treated for 7–10 years increases the risk of complications. Sustained hypertension results in arterial damage (atherosclerosis) and the onset of these vascular changes in the kidney, cardiovascular system, cerebrovascular system and eyes can cause complications such as renal failure, coronary insufficiency, myocardial infarction, congestive cardiac failure, cerebrovascular accident (stroke) and blindness in patients. Malignant hypertension develops in 1% of hypertensives. The chief complication is severe ischemic damage to kidney and renal failure. In the absence of treatment, it can be fatal within 1 year of diagnosis.
|Classification||Systolic BP (mmHg)||Diastolic BP (mmHg)|
|Stage 1 hypertension||140–159||90–99|
|Stage 2 hypertension||>160||>100|
It is a highly elevated blood pressure associated with organ damage (eyes, brain, lungs and kidneys are affected). The systolic and diastolic blood pressures are usually more than 240 mmHg and 120 mmHg respectively.
It is a phenomenon in which patients exhibit elevated blood pressure in a clinical setting but not when recorded by themselves at home or when ambulatory. White coat hypertension is believed to be secondary to anxiety, some individuals may experience during their visit to a hospital.
Beta blockers: Propranolol and sotolol reduce heart rate, and force of contraction. Selective beta blockers are preferred. Non-selective beta blockers are contra-indicated in patients with asthma, because their beta agonist action is blocked.
|Therapeutic goal||Pharmacologic strategies|
|Reduce volume overload||Diuretics|
|Block beta-1 adrenergic receptors||Beta-1 adrenergic receptor antagonists|
|Dilate blood vessels||Angiotensin II receptor antagonists|
|Reduce sympathetic outflow from the central nervous system||Calcium channel blocking agents|
|Alpha-1 adrenergic receptor antagonists|
|Alpha-2 adrenergic receptor antagonists|
|Diuretics||Dry mouth, lichenoid reactions|
|Beta blockers||Dry mouth, lichenoid reactions, taste change|
|ACE inhibitors||Loss of taste, dry mouth, ulcerations, angioedema|
|Calcium channel blockers||Gingival enlargement, dry mouth, altered taste|
|Alpha blockers||Dry mouth|
|Direct-acting vasodilators||Facial flushing possible, increased risk of gingival bleeding and infection|
|Central-acting agents||Dry mouth, taste changes, parotid pain|
|Angiotensin II antagonists||Dry mouth, angioedema, sinusitis, taste loss|
It is one of the most common medical problem in general population. Coronary heart disease is an inflammatory disease affecting the large and medium sized arteries of heart resulting in inadequate or decreased coronary blood flow. Atherosclerosis and hypertension are the major contributory factors.
Atherosclerosis basically refers to the formation of fibro-fatty lesions in the walls of arteries. These may increase in size to cause stenosis of the vessels reducing the blood flow to the heart on exercise. This is known as angina. In the later stages, the atherosclerotic plaque ruptures and exposes the arterial blood to the plaque contents and stimulates the formation of hemostatic plug. This occlusive thrombus may cause myocardial infarction.
It is the most common clinical presentation of ischemic heart disease and is infrequent before the age of 40 years. It may be defined as a temporary inability of the coronary arteries to supply the myocardium with the sufficient amount of circulated blood. Atherosclerotic narrowing of the coronary arteries is an important cause of this imbalance in oxygen supply. It is rarely caused by spasm of the blood vessels. Initially, the atherosclerosis does not lead to any symptoms. However, the obstruction becomes large over a period of decades to cause pain. The pain of angina is described as a sense of choking, tightness, heaviness, or compression of the chest, sometimes radiating to the left arm or jaws. The common precipitating causes include physical exertion and emotions.
Levine’s sign is characteristic of ischemic chest pain. It is seen in angina pectoris and myocardial infarction. This sign described by Dr Sam Levine who observed many of his patients suffering from chest pain hold their fist over the chest.
Angina at rest, angina appearing more frequently, appearing at lower level of exertion, requiring larger doses for relief or relief taking longer. It is caused by dynamic obstruction of coronary artery due to plaque rupture with superimposed thrombosis and spasms.
Beta adrenergic blockers prevent the effects of cardiac sympathetic stimulation and reduce myocardial oxygen demand by decreasing the heart rate, ventricular systolic pressure and peripheral arterial pressure.
If a person develops angina during dental treatment, the procedure should be terminated and the patient should be seated in semi-inclined position and the patient should be given nitroglycerin 0.3–0.6 mg sublingually. If pain persists even after 3 minutes, additional doses (up to 3 mg) every 5 minutes should be given and medical help should be sought. If pain persists, 300 mg of chewable aspirin is given. Moreover, morphine sulfate (IV) relieves pain and anxiety.
It is a severe form of coronary artery disease. An anginal pain lasting longer than 30 minutes is considered to be a myocardial infarction. The pain may be accompanied by nausea and vomiting, tachycardia, grossly irregular pulse, pallor and difficulty in breathing, sweating, and restlessness. About 10% have painless infarctions.
The diagnosis of acute myocardial infarction is based on the presence of two of the following three criteria: (1) signs and symptoms compatible with myocardial ischemia, (2) typical ECG changes—ST segment elevation at the end of the PR segment, (3) measurement of creatinine kinase (CK) and myocardial-bound CK (CK-MB).
|Therapeutic goals||Pharmacological strategies|
|Inhibit progression of atherosclerosis||Lipid-lowering agents
HMG-Co-A reductase inhibitors
|Improve circulation in coronary arteries||Nitrated calcium channel blockers|
|Reduce workload||Beta-1 adrenergic receptor antagonists|
|Prevent thrombus formation||Antithrombotic agents|
2. Patients within 6 months of an MI (recent MI) are at the risk of further complications, hence, elective dental care should be deferred. However, the first 6 weeks is more critical, and with the physician’s consent, simple emergency dental treatment under LA may be done during the first 6 months.
Local hemostasis should be promoted (procoagulant materials such as collagen or topical thrombin should be used). Local pressure should be applied for a longer duration. Injecting vasoconstrictor containing local anesthesia directly into surgical site and using sutures is not required.
It is a common heart disease among children, present in 1% of live births. Congenital defects involving heart or adjacent vessels may be associated with other congenital anomalies. These congenital anomalies can be cyanotic or acyanotic in nature.
Rheumatic fever is the most common cause of cardiac valve disorders. The mitral valve is affected more frequently. It results from an altered immunologic response to a group A beta hemolytic streptococcal pharyngitis, leading to formation of Aschoffs nodules in the myocardium which develops 1–3 weeks after the streptococcal infection. Though, only 3% of cases of beta hemolytic pharyngitis resulting in rheumatic disease, there is no way to forecast which individuals will have rheumatic heart disease (RHD).
Common manifestations include new onset murmur, carditis, polyarthritis, chorea, erythema marginatum, fever and subcutaneous nodules (modified Jones criteria). The beta streptococcal infection is confirmed by increased serum antistreptolysin O (ASO) antibody titer or positive throat culture. RHD resulting in valvular injury is confirmed by echocardiography for any patient with a history of rheumatic fever, it is imperative to determine whether the infection resulted in RHD.
Infective endocarditis (IE) is a rare, potentially lethal infection, predominantly affecting heart valves. The endocardium can also be affected. It results from bacteremia originating from any site and representing almost any species. It is caused mainly by bacteria as well as fungi.
It usually occurs in older individuals, peak prevalence is 6th or 7th decade. It is less frequent in the young, except in intravenous drug users. It occurs predominantly in males. Most patients have pre-existing cardiac disease. The mitral valve is more frequently affected followed by aortic valve and tricuspid valve. Sterile vegetations, i.e. comprising of platelets and fibrins accumulate over the damaged valves and these get readily infected during bacteremias resulting in infective endocarditis.
|Main groups affected by infective endocarditis||Approximate percentage of all cases of infective endocarditis|
|No obvious cardiac valve disease||40%|
|Chronic rheumatic heart disease||30%|
|Congenital heart disease||10%|
|Prosthetic cardiac valves||10%|
|Intravenous drug abuse||10%|
Oral microorganisms could play an important role in the pathogenesis of infective endocarditis. Some oral microorganisms pass into the blood stream and colonize areas of valvular endothelium on a previous sterile incipient vegetation. Staphylococcus aureus usually produces an acute infection, whereas Streptococcus viridans, enterococci, certain gram-positive and gram-negative bacteria and fungi may produce subacute infection. Dental treatment precedes infective endocarditis only in 5–10% of cases though a number of oral manipulations can cause bacteremia.
It has been reported that some cases of infective endocarditis have been associated with oral infections in the absence of dental manipulations and hence a synergistic effect between the presence of periodontal or periapical infections and dental manipulations could favor the development of infective endocarditis.
Moreover, a number of studies have reported that brushing teeth, chewing gum or eating may provoke bacteremia and that the prevalence of IE increases when these acts are performed by patients with intraoral infections.
Because of the high morbidity and mortality associated with IE, antibiotic prophylaxis has been advised. Though, antibiotic therapy has not proven to prevent endocarditis and it also carries with a risk of adverse reactions (anaphylaxis), it is still advised prophylactically for certain treatment procedures.
Shunts are placed in patients with hydrocephaly to help in the drainage of cerebrospinal fluid. The ventriculoatrial shunt allows drainage of the CSF from the lateral ventricles to the venous circulation. The ventriculo-peritoneal shunt helps drain the CSF into the abdominal cavity.
Antibiotic prophylaxis is indicated only in instances where the catheters are on the right side of the heart. Only the first 2 weeks are critical and indicated for antibiotic prophylaxis when stents are placed in cardiac patients. The risks of developing a superinfection are very minimal after the first few weeks as an epithelial layer develops over these stents.
Patients receiving peritoneal dialysis do not require antibiotic prophylaxis. However, patients who have an arteriovenous shunt (made up of autogenous tissue or a silastic tube) implanted for dialysis require antibiotic coverage during dental procedures, as these shunts are vulnerable to infection.
Patients undergoing chemotherapy are prone to develop infections as the chemotherapeutic agents suppress the inherent immune system. Invasive dental procedures such as extraction of teeth, subgingival scaling and periodontal surgeries that might cause significant bleeding warrant antibiotic prophylaxis in these patients.
Patients inflicted with HIV/AIDS generally do not require antibiotic cover; nevertheless it is always wise to perform dental procedures such as extraction of teeth and periodontal surgeries under antibiotic cover as it might minimize the risk of the patient acquiring a superinfection.
Patients with uncontrolled insulin-dependent diabetes mellitus (IDDM) are vulnerable to infections. Invasive dental procedures that involve significant amount of bleeding may require antibiotic cover.