A Review on the Dental Management of specially abled patients with a systematic approach towards the Dental management of patients with Cardiovascular Disorders – An Evidence Based Decision Tree Analysis
K. V. Swathi1, Dr. G. Maragathavalli2
1Post Graduate Student, Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai-77.
2Professor and Head, Department of Oral Medicine and Radiology, Saveetha Dental College, Chennai-77.
The American Academy of Pediatric Dentistry (AAPD) defines special care needs as “any physical, developmental, mental, sensory, behavioral, cognitive or emotional impairment that requires medical management, health care intervention and/or use of specialized services or programs. The condition may be congenital, developmental or acquired through disease, trauma or environmental cause and may impose limitations in performing daily self-maintenance activities or substantial limitations in a major life activity”. Special care dentistry works on meeting the dental needs of a wide spectrum of specially abled patients who may be medically compromised, those with learning and physical disabilities, mentally challenged, pregnant, geriatric, anxious and petrified patients and referrals from head and neck oncology who are under radiotherapy, chemotherapeutic drugs for management of head and neck carcinomas. Hence it is very important for the dentists to have a thorough knowledge and undergo additional training for managing these patients during dental treatment. Cardio vascular disorders comprise of a group of diseases of the heart and vascular system. It has been reported in literatures that sometimes dental professionals play a key role in diagnosing various cardiovascular pathologies during routine dental examination. In this article, a review on the dental management of special care patients and an emphasis on the dental treatment protocol for patients with cardiovascular diseases through a decision tree analysis has been done.
Special care dentistry is a specialization that is concerned with the improvement and management of oral health of individuals and groups in society who have a physical, sensory, intellectual, mental, medical, emotional or social impairment or disability or, more often, a combination of a number of these factors that indicates a more cautious and special care approach while attending to their dental needs.
This branch of dentistry seeks to address the oral health needs of people with a range of primary conditions which may result in the compromisation of their oral health directly through the condition itself or indirectly through medication or poor access to care. Furthermore, there may only be access to limited dental care with practitioners unwilling or unable to provide routine dental care because of the skills, experience, facilities or remuneration available to them. Additionally, for those with certain impairments like learning disabilities or mentally challenged individuals, the issues of informed consent present an extra challenge. In such cases collateral informants like family members or nursing staff can be involved in the decision making process for further treatment procedures. Hence a holistic approach is needed to meet the complex requirements of these specially abled individuals.
A person is considered to be disabled if a long term physical or mental disorder or condition affects the performance of daily life activities which includes mobility, manual ability, physical coordination, continence, ability to heave, transport or move daily life objects, language, hearing or sight, memory or concentration skills, acknowledge and comprehension and awareness of the risk to have physical damage with a real difficulty, as well as consideration is paid to possible recurrences, progressive impairing conditions, cancer, HIV infection, multiple sclerosis, blindness and former suffering from disabilities. The disability is considered as the outcome of the interaction between the individual with impaired condition or disability and the environmental barriers like behavioral, social, physical, intellectual, etc. Disabilities occurring in adults can either be of developmental origin or acquired in later stages of life.
Access to oral care services:
The prevention of a disease and promotion of health would be more effective if individual risk factors assessments are done. A risk factor is “a biological, environmental and behavior factor that, throughout time, increases the possibility of pathology; if removed or absent, it reduces the probability. It is part of a casual chain or leads the host to the casual chain. When the pathology has been set off, the removal of it does not necessarily reduce it”. The access of dental care services to specially abled patients are limited due to the availability of the dentists to treat patients with special health care needs, awareness of the oral health issue in the patient’s environment known as halo effect.
Dental management of systemically compromised patients:
The dental management of medically compromised patients include patients with various organ systemic disorders such as cardiovascular, endocrine, gastrointestinal and pancreatic, hematology, hepatology, mental health, mucosal, oral and cutaneous disorders, nephrology, neurology, otorhinolaryngology, respiratory medicine, rheumatology and orthopedics. The common causes of these disorders, clinical features, general management and dental aspects should be considered.
Cardiovascular disorders comprise of organic disease of the heart and functional disorders. Organic disorders of the heart includes myocardial disorders due to overload secondary to hypertension or valve disease, coronary (ischaemic) heart disease, cardiomyopathies, endocardial disorders due to rheumatic heart disease, congenital anomalies and infective endocarditis, pericardial disorders due to pericarditis and pericardial effusion. The other group of cardiovascular disorders include functional disorders which may be due to hypertension, abnormalities in heart rate like tachycardias, bradycardias and other arrhythmias or changes in circulatory volume due to hypervolaemia.
A thorough medical history, drug history and premedical evaluation i.e. pulse, blood pressure, rate and depth of respiration, temperature should be recorded at the first dental appointment. Drug history or the information regarding the list of medications taken by the patient is very important to be noted to understand the potential complications and drug interactions that can occur during pre treatment or post treatment medication and during dental procedures or emergency care.
Congenital heart diseases:
Congenital heart defect is a gross structural abnormality of the heart or intrathoracic great vessels that is actually or potentially of functional significance.
The dental staff should be trained adequately in basic cardiopulmonary resuscitation (CPR) and the entire dental team should rehearse emergency dental procedures regularly. Consideration on how well the patient’s heart condition is compensated should be done. An aspirating syringe should be used while giving local anaesthetics. Gingival retraction cords containing adrenaline/epinephrine has to be avoided. All oral foci of infection has to be ruled out and appropriate emphasis on oral hygiene measures has to be advocated. An understanding of various syndromes associated with congenital heart diseases such as Marfan’s syndrome, Trisomy 21, DiGeorge’s syndrome, Noonan. s syndrome etc., should also be noted for. The common oral manifestations include periodontal manifestations, gingival hyperplasia, missing teeth, supernumerary teeth, abnormally shaped teeth, microdontia, high arched palate etc.,
Usually patients with CHD, are often under antiplatelet or anticoagulation therapy to prevent thrombosis or embolism. Patients on long term anticoagulant therapy may require a dose adjustment before dental treatment particularly during invasive dental procedures. Monitoring the patients’ level of International Normalised Ratio (INR) within 24 hrs prior to surgical procedures is also mandatory. Availability of local hemostatic measures and emergency drugs is essential.
Acquired heart diseases:
Ischaemic heart disease, coronary heart disease and functional disorders due to hypertension, abnormalities in heart rate such as bradycardias, tachycardias and arrhythmias, changes in circulatory volume due to hypervolaemia are some of the common forms of acquired heart diseases and special care is necessary during the dental management of these patients.
Coronary heart disease:
Atheroma or atherosclerosis is characterized by the increased accumulation of cholesterol and lipids in the intima of the arterial walls which may cause thromboembolism. It can arise as a combination of genetic and environmental factors.
Stress reduction, pain management is very essential. Usage of aspirating syringes, adrenaline/epinephrine containing LA should not be administered in excessive doses. An association between periodontititis and atherosclerosis has been established. Bacteria like Prevotella Intermedia, Porphyromonas Gingivalis, Aggregatibacter Actenomycetemcomitans involved in the pathogenesis of periodontal pocket formation have been found to be in increased amounts in atherosclerosis.
Angina Pectoris relates to the episodes of chest pain caused by myocardial ischaemia secondary to coronary artery disease. Angina can occur due to physical exertion (stable angina), Acute coronary syndrome (unstable angina), functional abnormality of coronary microcirculation (cardiac syndrome X), pain on lying down (decubitus angina), coronary artery spasm (vasospastic/prinzmetal angina).
Pre operative glyceryl trinitrate, oral sedation should be considered. Blood pressure and other vital signs should be monitored before dental procedures. Angina pectoris begins with acute mandibular pain and earlier warning signs should be noted before the commencement of the dental procedures. Conscious or general sedation should be avoided in patients for at least 3 months with a recent onset of angina.
Myocardial infarction (MI):
Also known as coronary thrombosis or in simple terms as heart attack results from the complete occlusion (blockage) of one or more coronary arteries. It arises due to the rupture of atherosclerotic plaques which may cause platelet activation, adhesion and aggregation with subsequent thromboembolism.
Recent MI (within 6 months of onset) are considered as a greater risk category for arrhythmias, cardiac ischaemias following any invasive dental interventions. Only simple emergency treatment under LA may be given during the first 6 months after MI, but clearance for dental treatment from the patient’s cardiologist/general physician has to be obtained. Symptomatic patients with previous older MI (more than 6 months and under 12 months) can normally have simple elective dental care. Asymptomatic patients but older MI (more than 12 months) can have elective dental treatment carried out safely. Adrenaline/epinephrine should be used in low doses and under careful monitoring.
Cardiomyopathy in simple terms refers to the cardiac abnormalities that is caused as a result of disease of the heart muscle. Can occur due to drug, alcohol toxicity, infections, genetics and ceratin idiopathic causes. Cardiomyopathies include arrythmogenic right ventricular cardiomyopathy, dilated cardiomyopathy, hypertrophic cardiomyopathy and restrictive cardiomyopathy etc.
Adrenaline/epinephrine should be used in low doses and under careful monitoring. Nitroglycerin is contraindicated in these patients. CPR, emergency drugs, oxygen delivery system should be readily available during any crisis situation.
It is a term to denote any of a large and heterogenous group of conditions where there is an abnormal electrical activity of the heart. It includes ectopics (extrasystoles), premature atrial contractions (atrial extrasystoles), ventricular systoles etc., Based on heart rate they can be tachycardia, bradycardia and by mechanism they include automaticity, re-entry, fibrillation.
Before the commencement of dental procedures, analysis of risk factors, stress reduction, caution with vasoconstrictive agents, electrical equipment, avoidance of general anaesthesia, recognition of anticoagulant therapy, consideration of digitalis intoxicity and infective endocarditis should be evaluated.
Valvular heart diseases and cardiac failure:
Valvular heart diseases includes rheumatic fever, mucocutaneous lymph node syndrome, drug induced cardiac valvular lesions, cardiac valve surgery and infective endocardititis.
Appropriate use of antibiotic prophylaxis regime, using a sterilized working environment is very important for infection control in patients with valvular heart diseases and those with prosthetic heart devices to minimize the risk of infective endocarditis. When patients are under ACE inhibitors, digitalis and other cardiac glycosides for cardiac failure, certain NSAIDs like aspirin, antibiotics like erythromycin, tetracycline should be used with caution.
Special care dentistry is of growing importance due to the increased prevalence of various systemic disorders and genetic abnormalities. The prevalence of cardiovascular disorders also has been increasing in the recent times due to multifactorial reasons, lifestyle modifications etc., and also been increasing in women especially after menopause. Hence the dental management of these patients should be done with utmost care and caution and a holistic approach is required by the dental team members for a more efficient, quality treatment and also to prevent potential complications.
Fig 1: Decision tree analysis for the dental considerations of patients with cardiovascular disorders
1. Guideline on Management of Dental Patients with Special Health Care Needs. American academy of pediatric dentistry. Clinical practice guidelines. Reference manual V 37 / NO 6 15 / 16.
3. Ramya Balasubramanian et al. Education And Training In Special Care Dentistry- A Review. Med. Res. Chron., 2014, 1 (2), 183-189.
4. Borreani E, Wright D, Scambler S, Gallagher JE. Minimising barriers to dental care in older people. BMC Oral Health. 2008;8:7.
5. Amer AB. Informed Consent in Adult Psychiatry. Oman Medical Journal. 2013, 28(4):228-231.
6. Doris J. Stiefel. Dental Considerations for Disabled Adults. Spec Care Dentist. 2002, 22(3): 26S-39S.
7. Vozza I, Cavallè E, Corridore D, et al. Preventive strategies in oral health for special needs patients. Annali di Stomatologia. 2015, 6(3-4): 96-99.
8. Poul Erik Petersen and Stella Kwan. Evaluation of community-based oral health promotion andoral disease prevention – WHO recommendations for improved evidence in public health practice. Community Dental Health . 2004;21:319–329.
9. John Wyckoff, Claire Lingg. Etiology in organic heart disease. American Heart Journal. 1926, 1(4):446-470.
10. Madhav Kamath M, Kundabala Mala, Manuel S. Thomas. Modification of Dental Care for Patients with Cardiac Disease. 2016, 15(5):286-90.
11. Ko JM. Genetic Syndromes associated with Congenital Heart Disease. Korean Circ J. 2015 Sep;45(5):357-61.
12. Mariamma Kuruvilla, PharmD and Cheryle Gurk-Turner. A review of warfarin dosing and monitoring. Proc (Bayl Univ Med Cent). 2001, 14(3): 305–306.
13. Bartova J, Sommerova P, Lyuya-Mi Y, Mysak J, Prochazkova J, Duskova J, et al. Periodontitis as a Risk Factor of Atherosclerosis. Journal of Immunology Research. 2014.
14. Juhani Kahri and Janne Rapola. Cardiovascular disorders in dental practice. Nor Tannlegeforen Tid 2005, 115: 84-90.
15. Avinash Murthyetal. Epinephrine use results in ‘stress’ cardiomyopathy. Journal of Cardiology Cases. 2015, 11(3): 85-87.
16. William E Boden et al. Role of short-acting nitroglycerin in the management of ischemic heart disease. Drug Des Devel Ther. 2015; 9: 4793–4805.
17. Nelson L Rhodus, James W Little. Dental management of the patient with cardiac arrhythmias: an update. Oral surg Oral med Oral Pathol Oral Radiol Endod, 2003;96(6): 659-68.
18. Matthew Pincus. Management of digoxin toxicity. Aust Prescr. 2016; 39(1): 18–20.
19. Gary Warburton and John Caccamese. Valvular Heart Disease and Heart Failure: Dental Management Considerations. Dent Clin N Am. 2006;50:495-512.
20. L. Reethega, R. Gayatri Devi, A. Jothi Priya. A survey on prevalence of heart diseases in women after menopause. Drug Intervention Today.2018, 10(1):2597-9.
Received on 23.02.2019 Modified on 20.03.2019
Accepted on 22.04.2019 © RJPT All right reserved