Transcript Heart

Heart
Congestive heart failure
• or heart failure :
condition : heart is unable to
adequately pump blood throughout
the body
• Characterized :
–shortness of breath (dyspnea)
–abnormal fluid retention, which
usually results in swelling
(edema) in the feet and legs.
Heart failure
• Left-sided heart failure
• Right-sided heart failure
Left-sided heart failure.
When LV cannot adequately
pump blood out of the left atrium,
or when one or more of the heart
valves becomes leaky or narrowed
(stenotic), blood can "back up"
into the lungs
left-sided heart failure:
• lungs become congested with fluid
(called pulmonary edema),
– causing difficulty breathing and
– interfering with the movement of
oxygen from the lungs into the
bloodstream, causing fatigue.
Right-sided heart failure
• abnormality or condition affects
the flow of blood through the right
ventricle, pressure in the blood
vessels increases and fluid is
forced from the blood vessels into
body tissues.
• causes swelling (edema), usually
in the feet and legs, and
sometimes, in the abdomen.
The NYHA functional class
(the New York Heart Association)
• determine how much CHF limits their
lifestyle
• Useful in following the course of disease
and assessing the effects of therapy
• Aid in the dental management
Class I: No symptoms at any level of exertion,
no limitation of physical activity
Class II: Slight limitation of physical activity.
Fatigue, palpitations and dyspnea with
ordinary physical activity but
comfortable at rest
Class III: marked limitation of activity. Less than
ordinary physical activity results in symptoms,
but patients are comfortable at rest
Class IV: Symptoms are present at rest, and any
physical exertion exacerbates the symptoms
Congestive heart failure
Potential problem related to dental care
1. sudden death from cardiac arrest or
arrhythmia
2. Myocardial infarction
3. CVA
4. Infective endocarditis if CHF is caused
by rheumatic heart dis., congenital
heart dis.
CHF
Potential problem related to dental care
5. Shortness of breath
6. Drug side effects :
orthostatic hypotension (diuretics,vasodilators)
arrhythmia (digoxin overdose)
nausea, vomiting (digoxin, vasodilators)
palpitations (vasodilators)
7. Infection
Prevention of complication
1. Detection and referral to physician
2. No routine dental care until under good
medical management (class I or II and
possibly III)
3. Good medical management – cause of heart
failure
- hypertension
- valvular dis. (rheumatic heart dis.)
- congenital heart dis., MI
- Renal failure
- Thyrotoxicosis
- chronic obstructive lung disease
4. Class I or II, use max. 0.036 mg epinephrine
avoid vasoconstrictors in class III or IV
5. Semisupine or upright position
(decrease collection of fluid in lung)
6. Terminate appointment if patient becomes fatigue
7. Drug considerations
digitalis – N/V
anticoagulants - PT = 2times or less,
- INR = 3.0 or less
antidysrhythmic agents, antihypertensive
avoidance of outpatient general anesthesia
CHF
Emergency care
1. Conservative in acute congestive failure:
drug for pain control and
antibiotics for infection
2. Under good medical management:
deal with underlying cause and presence of
any complications in dental management
Endocarditis
• Inflammation of endocardium
• most common structures involved are the
heart valves.
• Endocarditis can be classified by etiology as
either infective or non-infective
Infective endocarditis
• valves of the heart do not actually
receive any blood supply of their own,
defense mechanisms (such as white
blood cells) cannot enter.
• If an organism (such as bacteria) hold
on the valves, the body cannot get rid of
them.
• If valve damaged (for instance in
rheumatic fever) bacteria have a chance
to hold.
• clinically divided into
– acute and subacute endocarditis.
This classifies both the tempo of
progression and severity of disease.
• Subacute bacterial endocarditis (SBE) :
often due to streptococci of low
virulence and mild to moderate illness
which progresses slowly over weeks
and months
• Acute bacterial endocarditis (ABE) :
fulminant illness over days to weeks,
more likely due to Staphylococcus
aureus (greater virulence, or diseaseproducing capacity)
Aetiology and pathogenesis
• altered blood flow around the valves is a
risk factor in obtaining endocarditis.
• The valves may be damaged congenitally,
from surgery, by auto-immune mechanisms,
or simply as a consequence of old age.
• The damaged part of a heart valve becomes
covered with a blood clot, a condition
known as non-bacterial thrombotic
endocarditis (NBTE).
• In healthy individual, a bacteraemia
would normally be cleared quickly with
no adverse consequences.
• If a heart valve is damaged and covered
with a piece of a blood clot, the valve
provides a place for the bacteria to
attach themselves and an infection can
be established.
• The bacteraemia is often caused by minor
dental procedures, such as a tooth removal.
• Another causes result from a high number
of bacteria getting into the bloodstream.
(Colorectal cancer, serious urinary tract
infections and IV drug use)
• With a large number of bacteria, even a
normal heart valve may be infected.
• A more virulent organism (Staphylococcus
aureus) is usually responsible for infecting a
normal valve.
• Intravenous drug users : right heart
valves infected (veins that are injected
enter the right side of the heart)
• The injured valve is most commonly
affected when there is a pre-existing
disease. (rheumatic heart disease this is
the aortic and the mitral valves) : left
heart valves
Clinical and pathological features
• Fever (often spiking)
• Continuous presence of micro-organisms in
the bloodstream determined by serial
collection of blood cultures
• Vegetations on valves on echocardiography
• Septic emboli, causing circulatory problems
(stroke, gangrene of fingers)
• Chronic renal failure
Clinical and pathological features
• Osler's nodes (painful subcutaneous lesions
in the distal fingers)
• Janeway lesions (painless hemorrhagic
cutaneous lesions on the palms and soles)
• Roth spots on the retina
• Conjunctival petechiae
• A new or changing heart murmur,
particularly murmurs suggestive of valvular
incompetence
• Splinter haemorrhages
Micro-organisms responsible
• Many types of organism
• isolated by blood culture
• Alpha-haemolytic streptococci, that are
present in the mouth will often be the
organism isolated if a dental procedure
caused the bacteraemia.
• If bacteraemia was introduced through
the skin, such as contamination in
surgery, during catheterisation, or in an
IV drug user
Staphylococcus aureus
• A third important cause of endocarditis
is Enterococci (abnormalities in the
gastrointestinal or urinary tracts)
• Enterococci : causes of nosocomial or
hospital-acquired endocarditis.
• alpha-haemolytic streptococci and
Staphylococcus aureus : causes of
community-acquired endocarditis.
Treatment
• High dose antibiotics ( by intravenous
route)
• Antibiotics are continued for a long time,
typically two to six weeks.
• Surgical removal of the valve is necessary
in patients who fail to clear microorganisms from their blood in response to
antibiotic therapy, or in patients who
develop cardiac failure resulting from
destruction of a valve
• A removed valve is usually replaced with an
artificial valve which may either be
mechanical (metallic) or obtained from an
animal such as a pig (bioprosthetic valves)
• Infective endocarditis is associated with a
25% mortality.
ENDOCARDITIS RISK STRATIFICATION
Endocarditis prophylaxis recommended
High risk
• Prosthetic heart valves
• Prior bacterial endocarditis
• Complex cyanotic congenital heart disease
• Surgically constructed systemic
pulmonary shunts or conduct
ENDOCARDITIS RISK STRATIFICATION
Endocarditis prophylaxis recommended
Moderate risk
• Most other congenital cardiac
malformations
• Acquired valvular dysfunction
• Hypertrophic cardiomyopathy
• Mitral valve prolapse with regurgitations
and/or thickened leaflets
ENDOCARDITIS RISK STRATIFICATION
Endocarditis prophylaxis not recommended
Negligible risk
• Isolated secundum atrial septal defect
• Surgical repair of ASD, VSD, or PDA (without
residua beyond 6 mo.)
• Prior coronary artery bypass graft
• Mitral valve prolapse without regurgitation
• Physiologic, functional, or innocent heart
murmurs
ENDOCARDITIS RISK STRATIFICATION
Endocarditis prophylaxis not recommended
Negligible risk
• Previous Kawasaki dis. without valvular
dysfunction
• Previous rheumatic fever without valvular
dysfunction
• Cardiac pacemakers and implanted
defibrillators
DENTAL AND ORAL SURGERY PROCEDURES
AND ENDOCARDITIS PROPHYLAXIS
Endocarditis prophylaxis recommended in
high- and moderate-risk cardiac conditions
• Exodontia
• Periodontal procedures
• Incision and drainage of abscesses
• Dental implant placement and uncovering
• Reimplantation of avulsed teeth
• Endodontic therapy or apical surgery
• Placement of intermaxillary fixation
DENTAL AND ORAL SURGERY PROCEDURES
AND ENDOCARDITIS PROPHYLAXIS
Endocarditis prophylaxis recommended in
high- and moderate-risk cardiac conditions
• Reduction of contaminated maxillofacial
fractures
• Osteotomies
• Subgingival placement of antibiotic fibers or
strips
• Intraligamentary LA injections
• Prophylactic dental or implant cleaning
• Intraoral biopsies
DENTAL AND ORAL SURGERY PROCEDURES
AND ENDOCARDITIS PROPHYLAXIS
Endocarditis prophylaxis not recommended
• Restorative dentistry
• Nonintraligamentary LA injections
• Postoperative suture removal
• Placement of removable orthodontic or
prosthodontic appliances
• Taking oral impressions
• Shedding (naturally) of primary teeth
ANTIBIOTIC PROPHYLACTIC REGIMENS FOR
DENTAL
AND ORAL SURGICAL PROCEDURES
circumstance
drug
regimen
Standard
prophylaxis
amoxicillin Adults : 2 g po
Children : 50 mg/kg po
1 hr before procedure
Unable to take
oral medications
ampicillin
Adults : 2g IM or IV
Children : 50 mg/kg IM
or IV
Within 30 min of
procedure
circumstance
drug
regimen
Penicillin allergy
Clindamycin
or
Cephalexin or
cefadroxil
or
Azithromycin or
clarithromycin
Adults : 600 mg po 1hr before
Children : 20 mg/kg po
Adults : 2g po 1hr before
Children : 50 mg/kg po
Penicillin allergy and Clindamycin
unable to take oral
medications
or
cefazolin
Adults : 500 mg po
Children : 15 mg/kg po
1 hr before procedure
Adults : 600 mg IM or IV
Children : 20 mg/kg IM or IV
within 30 min of procedure
Adults : 1 g IM or IV
Children : 25 mg/kg IM or IV
within 30 min of procedure
Congenital heart disease
• defect of heart that exists primarily at birth
• environmental, such as chemicals, drugs, or
infection (i.e. rubella)
• genetic
• mother's excessive intake of alcohol and
drugs while pregnant
Classifications
• Acyanotic
• Cyanotic
• Cyanotic :
Disorders that cause profusion or an
insufficient amount of oxygen in the blood
pumped throughout the body (bluish-grey
discoloration of the skin)
• truncus arteriosus, total anomalous
pulmonary venous return, tetralogy of
Fallot, transpositon of the great arteries, and
tricuspid atresia.
Types of congenital heart disease
• Patent ductus arteriosus
• Obstruction defects :
pulmonary valve stenosis
aortic valve stenosis
coarctation of the aorta
• Septal defects
Signs and Symptoms
related to the type and severity of defects.
• no signs
• exhibit shortness of breath,
• cyanosis, chest pain, syncope, sweating,
heart murmur, respiratory infections,
underdeveloping of limbs and muscles, poor
feeding, or poor growth
Patent ductus arteriosus
• In developing fetus, ductus arteriosus (DA)
is a shunt connecting the pulmonary artery
to the aortic arch
• allows blood from the right ventricle to
bypass the fetus' fluid-filled lungs.
• During fetal development, shunt protects
the lungs from being overworked and
allows the right ventricle to strengthen.
• first breath, the lungs open and pulmonary
pressure decreases below that of the left heart.
• At the same time, the lungs release bradykinin to
constrict the smooth muscle wall of the DA and
reduce blood flow.
• reduced pulmonary resistance, more blood flows
from the pulmonary arteries to the lungs and lungs
deliver more oxygenated blood to the left heart.
This further increases aortic pressure so that blood
no longer flows from the pulmonary artery to the
aorta via the DA.
PDA
• normal newborns, DA is closed within 15 hours
after birth, and is completely sealed after three
weeks.
• A nonfunctional vestige of the DA, called
ligamentum arteriosum, remains in the adult heart.
• not close in the newborn, the blood that is suppose
to flow through the aorta goes to the lungs : PDA
• common in premature infants
Signs and symptoms
• oxygenated blood flow from aorta to pulmonary
arteries
• some of infant's oxygenated blood does not reach
the body, and the infant becomes short of breath
and cyanotic.
• Tachycardia : increasing the speed with which
blood is oxygenated and delivered to the body
• Untreated : suffer from congestive heart failure
Atrial septal defects (ASD)
• communication between atria of the heart
and may involve the interatrial septum.
• possible for blood from left side of heart to
right side,
• or resulting in mixing of arterial and venous
blood
• foramen ovale remains open during fetal
development (allow blood from the venous
system to bypass the lungs and go to the
systemic circulation)
• prior to birth, the oxygenation of the blood
is via the placenta and not the lungs.
• A layer of tissue begins to cover the
foramen ovale during fetal development,
and will close completely soon after birth
• After birth, pressure in the pulmonary
circulation drops, and foramen ovale closes
• approximately 30% of adults the foramen
ovale does not seal over.
• In this case, elevation of pressure in the
pulmonary circulation (ie: pulmonary
hypertension) can cause opening of the
foramen ovale. This is known as a patent
foramen ovale (PFO).
• right ventricle have to push out more blood
than the left ventricle due to the left-to-right
shunt.
• Eventually the pulmonary vasculature will
develop pulmonary hypertension to try to
divert the extra blood volume away from
the lungs.
• lead to right ventricular failure (dilatation
and decreased systolic function of the right
ventricle) or elevations of the right sided
pressures to levels greater than the left sided
pressures.
• uncorrected, pressure in right side > left
side
• cause pressure in right atrium > left atrium
This will reverse the pressure gradient
across the ASD, and the shunt will reverse;
a right-to-left shunt will exist.
• Once right-to-left shunting occurs, a portion
of oxygen-poor blood will get shunted to
the left side of the heart and ejected to the
peripheral vascular system. This will cause
signs of cyanosis
types of atrial septal defects.
• They are differentiated
– involve other structures of the heart and
– how they are formed during the developmental
process during early fetal development
1. Ostium secundum atrial septal defect
• most common type of ASD
• 6-10% of all congenital heart diseases
• usually from :
– enlarged foramen ovale,
– inadequate growth of the septum secundum,
– or excessive absorption of the septum primum.
• 10 to 20 percent of individuals with ostium
secundum ASDs also have mitral valve prolapse
Complications of an uncorrected secundum
ASD
• pulmonary hypertension,
• right-sided heart failure,
• atrial fibrillation or flutter,
• stroke
• Eisenmenger's syndrome.
2. Ostium primum atrial septal defect
• endocardial cushion defect
• defect in the atrial septum at the level of the
tricuspid and mitral valves
• often involves the endocardial cushion
most common congenital heart defect that is
associated with Down's syndrome
3. Sinus venosus atrial septal defect
• defect in the septum involves the venous
inflow (superior vena cava or the inferior
vena cava)
4. Common or single atrium
• failure of development of the embyologic
components that contribute to the atrial
septal complex
Treatment
• Closure of an ASD in individuals under age
25 has been shown to have a low risk of
complications
• have a normal lifespan
Ventricular septal defect
• defect in the ventricular septum
• Congenital VSDs : the most common congenital
heart defect
• associated with other congenital conditions, such
as Down syndrome
• ventricular septum
– muscular (inferior)
– membranous portion (superior) - is close to the
AV node is most commonly affected
Pathophysiology
• Large VSDs result in a significant left-toright shunt and increase load on the
right ventricle. If untreated, they result in
hypertrophy of the right ventricle, which
ultimately leads to right heart failure and
death.
Treatment
• Treatment
– surgical
– conservative
• Smaller congenital VSDs often close on
their own (as the heart grows) and are
treated conservatively
Tetralogy of Fallot
• significant and complex congenital heart
defect.
involves four different heart malformations:
1.ventricular septal defect (VSD)
2.Pulmonic stenosis: Right ventricular
outflow tract obstruction, a narrowing at or
just below the pulmonary valve.
3.Overriding aorta: The aorta is positioned
over the VSD instead of in the left ventricle.
4.Right ventricular hypertrophy (RVH): The
right ventricle is more muscular than
normal.
• Sometimes pulmonary valve is
completely obstructed (pulmonary
atresia).
• Infants and young children with
unrepaired TOF are often cyanotic
(some oxygen-poor blood is pumped to
the body)
• The development of right ventricular
hypertrophy is a result of a longstanding,
untreated disease.
• right-to-left shunt
• Squatting
simple procedures such as knee-chest
position which reduces systemic venous
return (to reduce the right-to-left shunting),
increases systemic vascular resistance
Surgical Treatment
A temporary operation may be done at
first if the baby is small
Complete repair later
Pulmonary valve stenosis
•
•
•
•
reduction of flow of blood to the lungs
The most common cause is congenital
cyanosis
secondary to other conditions such as
endocarditis
• valve may become narrowed (stenotic) or
leaky (insufficient). The stenosis,
insufficiency or both can be mild to severe.
Surgical Treatment
If stenosis is severe, the pulmonary
valve must be opened to increase blood
flow to the lungs. A balloon-tipped
catheter is used
• If the insufficiency is severe, an
operation is required to repair or replace
the pulmonary valve.
Coarctation of the aorta
การตีบคอดของ aorta
Symptoms : decreased exercise performance,
cold feet or legs, and shortness of breath.
Other symptoms include:
• dizziness or fainting
• headache
• nosebleed
• leg cramps with exercise
• hypertension with exercise
• Note: There may be no symptoms.
Signs and tests:
• examination : high BP in the arms and
low BP in the legs,
significant BP difference between the arms
and legs.
The femoral pulse is weaker than the
carotid pulse, or the femoral pulse may be
totally absent.
Congenital heart disease
• Potential problem
1. Infective endocarditis, infective endarteritis
2. Prolonged bleeding
– Thrombocytopenia
– Lack of coagulation factor (thrombosis in small
vessels)
– Anticoagulation medication
3. Infection : leukopenia
4. Congestive heart failure
–
–
–
–
Infection
Cardiac arrest
Cardiac dysrhythmia
Breathing difficulties (pulmonary edema)
Prevention of complications
1. Detection
2. Referral for medical Dx. and treatment
3. Consult before dental Treatment
4. Prophylactic antibiotic before dental
procedure
5. Avoidance of dehydration in oral infection
6. Bleeding time and prothrombin time before
surgery, consult if prolonged
7. White blood cell count
Low : antibiotic
8. Effective local anesthetic – maximum
epinephrine 0.036 mg, aspirate, injection
slowly
Valvular heart disease
Mitral stenosis
• the valve does not open completely,
• so the left atrium has to have a higher
pressure than normal to have the blood
overcome the increased gradient caused by
the mitral valve stenosis
Symptoms and signs
• Pulmonary hypertension
• Exertional dyspnea
• Orthopnea
• congestive heart failure
Treatment requires replacement of the
diseased valve with a porcine valve, or an
prosthetic valve.
Aortic insufficiency
• aortic regurgitation (AR),
• leaking of the aortic valve that causes blood
to flow in the reverse direction during
ventricular diastole, from the aorta into the
left ventricle.
• some of the blood that was already ejected
from the heart is regurgitating back into the
heart
Etiology
• Most cases : secondary to rheumatic fever
and the consequent rheumatic heart disease
• Less common causes : calcification of the
mitral valve leaflets, and as a form of
congenital heart disease
Aortic valve stenosis
• The more constricted the valve, the higher
the gradient between the LV and the aorta.
• LV has to generate an increased pressure in
order to overcome the increased afterload
caused by the stenotic aortic valve and eject
blood out of the LV
• Due to the increased pressures generated by
the left ventricle, the myocardium of the LV
undergoes hypertrophy
• thickening of the walls of the LV. The type
of hypertrophy most commonly seen in AS
is concentric hypertrophy, meaning that all
the walls of the LV are (approximately)
equally thickened
Etiology
• include acute rheumatic fever, bicuspid
aortic valve and congenital anomalies.
• As individuals age, calcification of the
aortic valves may occur and result in
stenosis.
Symptoms and signs of aortic
stenosis
• Symptomatic
– syncope, angina and congestive heart
failure
• Treatment requires replacement of the
diseased valve with a porcine aortic valve or
a cadaveric aortic valve, or an prosthetic
aortic valve.
Aortic insufficiency
• aortic regurgitation (AR),
• leaking of the aortic valve that causes blood
to flow in the reverse direction during
ventricular diastole, from the aorta into the
left ventricle.
• some of the blood that was already ejected
from the heart is regurgitating back into the
heart
Etiology
• half of the cases of aortic insufficiency are
due to the aortic root dilatation : idiopathic
in over 80% of cases
• aging and hypertension, Marfan syndrome,
aortic dissection, and syphilis
• 15% the cause is bicuspidal aortic valve
• 15% due to retraction of the cusps
(postinflammatory processes of endocarditis
in rheumatic fever and collagen vascular
diseases)
• regurgitant flow causes :
– decrease in the diastolic blood pressure,
– increase in the pulse pressure and
hypertension
• pressure overload causes left ventricular
hypertrophy (LVH).
Acute aortic insufficiency
• acute perforation of aortic valve due to
endocarditis
• sudden increase in the volume of blood in
the left ventricle
• pressure of the left ventricle will increase
• causes pressure in the left atrium to rise, and
the individual will develop congestive heart
failure
Severe acute aortic insufficiency
is considered a medical emergency
• immediate surgery for aortic valve
replacement
Chronic aortic insufficiency
• left ventricle adapts by hypertrophy and
dilatation of the left ventricle, and the
volume overload is compensated
• Eventually the left ventricle will become
decompensated, and filling pressures will
increase : symptoms of congestive heart
failure
Valvular heart disease
Potential problem
1. Infective endocarditis
2. Prolonged bleeding
- Anticoagulation medication
3. Congestive heart failure
Prevention of complications
1. Detection
2. Referral for medical Dx. and treatment or
consult before dental Tx.
3. Prophylactic antibiotic before dental
procedure
4. Bleeding time and prothrombin time
before surgery, consult if prolonged
5. Effective local anesthetic – maximum
epinephrine 0.036 mg, aspirate, injection
slowly
Ischemic heart disease
Definition
• weakened heart pumps (due to previous
heart attacks or due to current blockages of
the coronary arteries)
• Cardiomyopathy - ischemic
Causes, incidence, and risk factors
• coronary arteries are blocked.
• Ischemic cardiomyopathy is a common
cause of congestive heart failure.
• heart attack, angina or unstable angina.
• A few patients may not have noticed
any previous symptoms.
Risks include :
• personal or family history of heart
attack, angina, unstable angina,
atherosclerosis,or other coronary artery
diseases.
• High blood pressure, smoking, diabetes,
high fat diet, high blood cholesterol,
obesity
• (rarely) stress can precipitate
Symptoms
• chest pain
o under the sternum may radiate to the neck, jaw,
back, shoulder, arm
o may feel tight, pressure, crushing, squeezing
o may or may not be relieved by rest or
nitroglycerin
• sensation of feeling the heart beat
(palpitations)
• irregular or rapid pulse
• shortness of breath, especially with activity
• shortness of breath that occurs after
lying down
• cough
• fatigue, weakness, faintness
• decreased alertness or concentration
• decreased urine output
• excessive urination at night
• overall swelling
• breathing difficulty when lying down
Physical examination
• may be normal
• may reveal signs of fluid buildup
(leg swelling, enlarged liver, "crackles"
in the lungs, extra heart sounds, or an
elevated pressure in the neck vein)
• may be other signs of heart failure.
MI
Potential problem related to dental care
1. Cardiac arrest
2. MI
3. Angina pectoris
4. Congestive heart failure
5. Bleeding tendency secondary to
anticoagulant
6. Electrical interference with pacemaker
Prevention of complication
1. No routine dental care until at least 6 mo after MI
(increase risk of new infarction and arrhythmia)
2. Consultation before starting routine dental care
3. Morning appointments
4. Short appointments
5. Terminate appointment if fatigue , short of
breath, change in pulse rate or rhythm
Inform physician
Chest pain – manage as unstable angina
6. LA with max. epinephrine 0.036 mg,
aspiration, inject slowly
avoid use of vasopressor to control loss of blood, in
gingival packing material
do not use epinephrine In LA in severe arrhythmia
7. Premedication with diazepam 5-10 mg before
appointment and/or the night before
8. Anticoagulant medication
surgery or scaling for patient taking coumadin:
consult physician, PT = 2 times normal or less,
INR< 3.0, ASA or other antiplatelet aggregation
may have increased bleeding
9. Digitalis – prone to N/V, avoid stimulating
gag reflex
10. Antisialagogues – atropine and scopolamine
may cause tachycardia; check physician
before use
11. Antiarrhythmic agents (quinidine,
procainamide) –nausea,vomit, hypotension
oral ulceration may indicate agranulocytosis
12. Avoid use of electrocautery in patients with
pacemaker
Treatment plan modifications
1. 6 mo. or more after infarction with no
complications, any routine dental care can
be performed
2. complications such as CHF are present,
dental Tx. should be limited to immediate
needs only
Emergency care
1. During first 6 mo. After infarction, emergency
dental care only after consultation
- Conservative as possible
- Drug for pain control
- Antibiotics for infection
- Pulpotomy rather than extraction
2. More than 6 mo. after infarction
a. no complications – can receive any treatment
indicated
b. complications – medical consultation