DentalCare Logo

Management of Patients with Chronic Diseases

Course Number: 567

Heart Disease

Conditions that affect the heart and how it functions including coronary artery disease, myocardial infarction (heart attack), congestive heart failure, and atrial fibrillation.55 Coronary artery disease (the buildup of plaque inside the coronary arteries56) is the most common form of heart disease.55 Clinical signs and symptoms of heart disease are summarized in Figure 12. One of the signs and symptoms of heart disease that oral health professionals need to be mindful of is orofacial (jaw) pain that mimics a toothache. This is an early cardiac warning sign that is especially prevalent in women. When a patient presents with unexplained orofacial pain oral health providers may want to see if the pain subsides when the patient takes the vasodilator called nitroglycerin. There are several signs that may suggest orofacial pain is due to heart issues. These include pain that is: burning or pulsing, oppressive, spontaneous in multiple teeth, does not stop after administering local anesthesia block, or does not respond to dental treatment.101

Figure 12. Signs and Symptoms of Heart Disease.55,56

  • Chest pain, particularly pain that worsens with activity
  • Pain in the jaw, neck, or back
  • Feeling weak, lightheaded, or faint
  • Pain in arms or shoulder
  • Shortness of breath
  • Unusual tiredness
  • Nausea/vomiting
  • Heart failure – shortness of breath, fatigue, and swelling of lower extremities, stomach, and veins in the neck

Epidemiology and Etiology

Heart disease is the leading cause of death for both men and women in the United States.55 In the United States it accounts for 25% of deaths.55 Figure 13 lists disease risk factors.

Figure 13. Risk Factors for Heart Disease.55,56

  • High blood pressure, high cholesterol, and diabetes
  • Physical inactivity, diet high in saturated fats/trans fats/cholesterol, obesity, excessive alcohol, tobacco use
  • Genetics and family history
  • Increasing age
  • Metabolic syndrome
  • Elevated C-reactive protein, sleep apnea, stress, preeclampsia

Patient Management and Oral Health Considerations for Heart Disease

When providing care to patients diagnosed with some form of heart disease, dental providers should assess the patient’s risk for complications before providing any dental care. Items to consider include severity of the disease, type and magnitude of dental procedure, and patient stability.49 Patients who have experienced a myocardial infarction within the last 30 days are at major risk for complications. Elective care should be postponed..49 A consultation with the patient’s physician is recommended. Short stress-free appointments scheduled in the morning reduce the risk for complications. It is important to make sure the chair position is comfortable. Dental providers may need to provide care with the patient seated semi supine or upright. Patients who are taking Warfarin should report their international normalized ratio (INR). A therapeutic range is 3.5 or less. It is not necessary to discontinue or alter the dosage for most dental procedures (including minor surgery)49 Avoid placing a retraction cord impregnated with epinephrine and prescribing anticholinergics.49 Prescribing NSAIDs should be avoided in patients who have a history of myocardial infarction because NSAIDs increase the risk for subsequent myocardial infarctions.49 If using NSAIDs is unavoidable, the drug of choice is naproxen administered for less than 7 days.49

Effective pain control during and following the procedure will reduce stress and the risk for complications. Local anesthesia should have a limited amount of vasoconstrictor (epinephrine). If a vasoconstrictor is necessary, patients can be safely given 2 cartridges of anesthesia with epinephrine 1:100,000 (0.036 mg) or 2 cartridges of levonordefrin 1:20,000 (0.20 mg). Intravascular injections should be avoided. It is very important to effectively aspirate before depositing any anesthesia. Dental providers should observe the patient for signs of digitalis toxicity, such as hypersalivation, if a patient is taking digitalis glycoside (digoxin).49

There are no oral manifestations that are the direct result of heart disease. Medications used to treat heart disease may produce taste changes, stomatitis, gingival bleeding, petechiae, xerostomia or lichenoid mucosal lesions.49Calcium channel blockers may produce gingival overgrowth.49