Clinical Scenario

A 63‐year‐old man presents to the dental clinic concerned about a lump on the gum in the upper right quadrant which appeared 3 days ago and is causing increasing discomfort. The patient is afraid as he has heard that infections in the mouth can make his heart condition worse.

Structured Learning

1. Is the patient correct that his dental infection can make his heart condition worse?
   • There is a potential link
   • Dental infection (particularly periodontal disease) is a source of chronic inflammation and is postulated to contribute to the development and progression of atherosclerosis
   • Angina is caused by coronary artery atherosclerosis and can manifest as acute coronary syndrome
   • Acute coronary syndrome is ~3 times more common among people with apical dental infections
     

     

   • Furthermore, the psychological and physical stress associated with dental pain can trigger an acute angina‐related event
   • However, it is important to note that dental infection in a patient with angina does not predispose to infective endocarditis, as the latter condition is related to the lining of the heart, not the blood supply to it

2. The patient does not want #14 extracted as it is part of the fixed bridge. He consents to an apicoectomy. What factors are considered important in assessing the risk of managing this patient?
   • Social
     • Limited availability for dental clinic visits (due to his work)
     • Low commitment to following health promotion instructions (e.g. nutrition counselling) as evidenced by his high BMI
   • Medical
     • Risk of an acute presentation of angina‐related chest pain in the dental setting
     • Chronic obstructive pulmonary disease may compound hypoxia risk; airflow limitation (e.g. rubber dam use) and drug selection/interactions need to be considered (see Chapter 9.1)
     • Depressive syndrome can result in irregular attendance and lack of commitment to the treatment plan
     • Obesity‐related risks (see Chapter 16.4)
     • Tendency to bleed due to the acetylsalicylic acid (minimal risk) (see Chapter 10.5)
     • Drug allergy includes some non‐steroidal anti‐inflammatory drugs and antibiotics (see Chapter 16.1)
     • Drug interactions
   • Dental
     • Irregular dental attender with suboptimal oral hygiene (this is likely to be related to his job and recent MI)
     • The radiolucent area associated with #14 may require a more extensive surgical approach due to its size (i.e. cystectomy)
     • Orofacial complaints (e.g. dry mouth, chronic facial pain or burning mouth syndrome) are common in depression syndrome (see Chapter 15.2)
3. Avoiding stress during dental treatment is particularly important for this patient. What factors would you consider in relation to the use of pharmacological methods to reduce his anxiety?
   • The patient’s chronic obstructive pulmonary disease is mild
   • Nitrous oxide may be used (in addition to relaxing the patient, this also delivers an additional oxygen supply)
   • Benzodiazepines are not contraindicated, although they can present a tolerance problem for this patient (the patient takes lorazepam regularly), and the respiratory disease needs to be considered. It has been suggested that benzodiazepines can worsen the cardiovascular condition
   • Occasionally antihistamines may also be prescribed; however, it is advisable to avoid using hydroxyzine in patients with heart disease
4. What type of local anaesthetic is recommended?
   • Any local anaesthetic may be employed
   • If the decision is made to use an anaesthetic with a vasoconstrictor, ensure a self‐aspirating technique is used to avoid intravascular injections
   • Avoid exceeding 2 anaesthetic cartridges with epinephrine
5. What antibiotics should be avoided with this patient?
   • The patient is allergic to cefuroxime, a cephalosporin antibiotic
   • Cross‐reaction within the cephalosporin group is rare
   • Cross‐reactive allergy between penicillins and cephalosporins is also rare
   • However, as a precaution, do not prescribe cephalosporins or penicillins, if it can be avoided
   • Avoid macrolides because they interact with simvastatin, increasing the risk of rhabdomyolysis
   • Ampicillin reduces the bioavailability of some beta‐blockers such as atenolol, but this interaction has not been confirmed with carvedilol

6. Which should you consider when prescribing postoperative analgesics for this patient?
   • The patient is allergic to 2 non‐selective anti‐inflammatory cyclooxygenase inhibitors (previously known as selective COX‐1 inhibitors) – diclofenac and metamizole
     • Cross‐reactivity with other anti‐inflammatory agents of this type is therefore possible
     • The probability of cross‐reactivity with paracetamol is low
   • Selective anti‐inflammatory COX‐2 inhibitors are contraindicated for patients with heart problems
   • Additionally, non‐steroidal anti‐inflammatory drugs can hinder the antihypertensive effect of beta‐adrenergic blockers (carvedilol) and can decrease the therapeutic response to nitroglycerin
   • Paracetamol may be administered if no cross‐reactivity with this drug has been confirmed; if this information is not available, however, the most advisable course of action is to administer acetylsalicylic acid (which the patient is already taking routinely), despite its disadvantages
7. The patient also reports that he is aware of a bad smell from his mouth but feels that this was present before he developed the gingival swelling. What should you consider if oral/dental factors are ruled out?
   • Undertake an organoleptic assessment (the patient breathes deeply by inspiring the air by nostrils and holds their breath for 5 seconds and then expires by the mouth directly, while the examiner sniffs the odour at a distance of 20 cm – scales of severity 0–5 commonly used)
   • Approximately 10% of people with halitosis have an extraoral cause of their symptoms, including diet (e.g. garlic, onions, spicy foods), medications (e.g. nitrates and nitrates, disulfiram, amphetamines), respiratory disorders (e.g. tonsillitis, sinusitis), gastrointestinal disease (e.g. gastro‐oesophageal reflux disease), hepatic disease, renal failure, haematological or endocrine system disorders and metabolic conditions
   • In this patient, potential contributing factors include:
     • Chronic obstructive pulmonary disease increases mucus production/chronic cough
     • Depression can lead to xerostomia due to related anxiety or as a side‐effect of medication (lorazepam); subsequent development of halitosis can worsen the symptoms of depression due to the psychological impact
     • Medication‐related halitosis could be due to the nitroglycerin sublingual spray; if dysgeusia is also present, however, the main candidate is the beta‐adrenergic blocker with the associated side‐effect of a dry mouth (carvedilol)

General Dental Considerations