Clinical Decision Making for Treatment of Patients with Periodontal Disease and CVD in a Dental Setting

Caring for patients with both CVD and periodontitis requires careful evaluation, quantification and ongoing monitoring of existing periodontal inflammation. Consultation with a physician, in regards to the management of their CVD and the overall functional capacity of the patient is also recommended. A thorough medical history and physician consultation, if necessary, should be performed to assess the patient’s cardiovascular risk in association with dental procedures (Table 3).106 Patients should be triaged and care altered to account for their cardiovascular status (Table 4).106

Table 3. Cardiovascular risk assessment for dental patients.
American College of Cardiology Cardiac Risk Classification
Major Predictors
Unstable coronary syndromes
  • Acute or recent MI with evidence of important ischemic risk by clinical symptoms or noninvastive study
  • Unstable or severe angina (Canadian Class III or IV)
  • Decompensated hear failure
    Significant arrhythmias
  • High-grade atrioventricular block
  • Symptomatic ventricular arrhythmias in the presence of underlying heart disease
  • Supraventricular arrhythmias with uncontrolled ventricular rate
  • Severe Valvular disease
    Intermediate Predictors
    Mild angina pectoris (Canadian class I oe II)
    Previous MI by history or pathologic Qwaves
    Compensated or prior heart failure
    Diabetes mellitus (especially insulin-dependant type)
    Renal insufficiency
    Minor Predictors
    Advanced age
    Abnormal ECG (e.g. left ventricular hypertrophy, left bundle branch block, ST-T adnormalities)
    Rhythm other than sinus (e.g. atrial fibrillation)
    Low functional capacity (e.g. inability to climb one flight of stairs with a bag of groceries)
    History of stroke
    Uncontrolled systemic hypertension
    ECG, electrocardiogram; MI, myocardial infarction.
    Table 4. Patient care recommendations based upon cardiovascular status.

    Specific Management Protocols

    1. Patient with minor or intermediate risk predictor(s) for cardiovascular risk:
          BP < 180/< 110 mm Hg and normal pulse
          > 4 MET functional capacity
      • Comprehensive dental care
      • Routine medical referral as warranted for medical management
    2. Patient with minor or intermediate risk predictor(s) for cardiovascular risk:
          BP < 180/< 110 mm Hg and normal pulse
          < 4 MET functional capacity
      • Necessary limited dental care
      • Do not exceed 0.054 mg of epinephrine (=3 Carpules)
    3. Patient with minor or intermediate risk predictor(s) for cardiovascular risk:
          BP > 180/> 110 mm Hg and/or normal pulse
      • Emergency dental treatment
      • If patient is symptomatic with cardiovascular signs and symptoms: immediate referral for medical evaluation and treatment
      • If patient is asymptomatic: routine referral for medical management
    4. Patient with major risk predictor(s) of cardiovascular risk and clinical signs and symptoms:
      • Emergency dental care
      • Avoid epinephrine use
      • Immediate referral for medical evaluation and treatment
    BP = blood pressure; MET = metabolic equivalent