Dental Considerations-CVS Diseases

Medical Diseases

Leading cause of death in the U.S.Includes diseases of the heart and blood vessels.

Disease ClassificationAnatomic System

Diseases of pericardium, myocardium, endocardium, heart valves and blood vessels

Etiologic System Diseases by causitive agent includes

infectious agents, atherosclerosis, hypertension, immunologic mehanisms and congenital anomalies

Congenital Heart DiseaseEmbryonic defects

that occur during 1st nine weeks

Accurate patient history to determine nature of lesion and degree of disability

Medical consultMay require premed

Rheumatic Heart DiseaseComplications following rheumatic fever

- affects connective tissue especially heart, its valves and the joints of body

Valves become chronically inflamedPatient may need premedAlways consult physician to verify

necessity of premedication if patient unsure

Infective EndocarditisBacterial invasion of heart valve or

endocardium that occurs in proximity to congenital or acquired defects

Bacteria usually Streptococcus viridans that enters during dental treatment and settles on valve previously damaged

Causes bacteremia-prognosis depends on degree of cardiac damage,valves involved

Prevention of Infective Endocarditis

Antibiotic premedication

Accurate medical history

Patient following approved prophylaxis regimen of antibiotic

HypertensionResults from increased load on the

heart because of high blood pressure

Can lead to enlarged heart, then heart failure

Elevation of blood pressure is symptom of hypertension

HYPERTENSIONPRIMARY

(ESSENTIAL) Hypertension: Etiologic factors unknown-could be diet, obesity, smoking,etc.

90% of people have this type

SECONDARY Hypertension: Specific causes can be identified- increased blood pressure is secondary to major disease - kidney disease,diabetes

10% of people have this type

Ischemic Heart DiseaseCoronary Heart DiseaseCaused by reduction or arrest of

blood supply- usually because of atherosclerosis of the vessel walls

Angina pectoris, myocardial infarction, congestive heart failure

Angina PectorisCoronary arteries unable to supply

sufficient blood to myocardiumResult is pain in chest, mild to severe

crushing pain which radiates from heart to left arm

Unstable angina -increased intensity of attacks,serious sign of impending myocardial infarction

Patients should carry own nitroglycerin

Myocardial InfarctionHeart attack, coronary occlusion, coronary

thrombosisResults from sudden reduction of coronary

blood flowArea affected by zero blood flow is said to

be infarctedNeed to know severity,residual damage,

and time elapsed since attackDental treatment cancelled 6 months

Congestive Heart FailureOccurs when ventricles fail to maintain an

adequate output of blood for the needs of the body

Assess degree of heart failure with help of medical consult and patient information

Patient may not be able to breath if lowered too far back

Administration of O2 may be necessary for dental treatment

Cardiovascular Conditions Contraindicate TreatmentACUTE conditions of

Angina pectoris

Congestive heart failure

Extreme hypertension

Prevention of Infective EndocarditisIdentify high risk patientsProphylactic antibiotic coverage for

appointmentsWorking with patient to improve and

maintain high level of oral health to diminish frequency or severity of bacteremia

Bacteremia lasts only 15 minutes after prophy

Oral Tissue Characteristics Patient health history may not reveal

blood disorders

Oral manifestations of blood disorders are usually exaggerated when there is plaque and local irritating factors

Oral Findings of Blood DisorderGingival bleeding or

history of difficulty in controlling bleeding

Bruises easilyNumerous petechiaeMarked pallor of

mucous membranesAtrophy of tongue

papillae

Acute or chronic infections in mouth that do not respond to treatment

Severe ulcerations gingival that do not respond to treatment

Exaggerated gingival response to local irritants with characteristics of NUG

Normal Blood Composition

55% plasma fluid

45% formed element

Three types of formed elements Erythrocytes - RBC

Leukocytes - WBC

Thrombocytes - Platelets

Functions of Blood CellsRBC’s: sensitive,flexible and change shape

readily; contain hemoglobin- carries O2 to cells

WBC’s: motile so pass into connective tissue; work in CT - phagocytic and immunologic - respond to invasion of microorganisms

Platelets: 1/4 size of RBC’s, active in blood clotting mechanisms, capillary repair

AnemiaReduction of hemoglobin concentration-

which carries O2, hematocrit (fraction of blood occupied by RBC’s)

Causes of anemia - Blood loss:iron deficiency anemia Increased hemolysis(destruction of RBC’s): sickle

cell anemia Diminished production of RBC’s:

nutritional iron deficiency aplastic anemia-bone marrow failure

Characteristics of AnemiaPale and thin skinWeakness,

malaise, easily fatigued

Dyspnea on slight exertion, faintness

Headache, vertigo, tinnitus

Dimness of vision, spots before eyes

Brittle nails with loss of convexity

Treatment ConsiderationsDecreased ability of blood to carry

oxygen throughout body

Fainting may occur more easily

IV sedation must have supplemental O2

Treatment Sickle Cell Hereditary hemolytic

form Occurs primarily in

blacks and mediterranean origin

Concerned with SC crisis-acute stage

Do not treat if in this stage

Treatment Sickle CellPremed if not completely controlledCrisis seen in periods of unusual stress

or when patient does not receive adequate oxygen supply

When SC not controlled patient susceptible to infection

Perio disease may be present even in children

PolycythemiaAn increase in number and

concentrations of RBC’s above normal level

Relative polycythemia- loss of plasma without loss of RBC’s so concentration of RBC’s increased caused by dehydration,diarrhea,repeated

vomiting,sweating or fluid loss from burns

PolycythemiaPrimary polycythemia - actual increase in

number of circulating RBC’s and platelets viscosity of blood increased,which

affects oxygen transport to tissues results from bone disorder

Secondary polycythemia - increase number of RBC’s

causes are hypoxia(high altitudes and diseases or tumors

LeukopeniaDecrease in number of WBC’sResults when cell production can’t keep

pace with the turnover rate or when accelerated rate of removal occurs ( in certain diseases)

Causes are typhoid fever, influenza,malaria, measles, German measles,chronic drug poisoning and radiation

LeukocytosisIncrease in number of circulating WBC’sMay be caused by inflammatory and

infectious states, trauma,exerciseMost extreme cause is Leukemia

Malignant proliferation of WBC’s in bone marrow -results numerous immature WBC’s

Oral complications, more severe tissue response Need shorter appts, good preventive care,

possibly premed

Hemorrhagic DisordersDiseases that have

tendency spontaneous bleeding and/or moderate to excessive bleeding after trauma or surgical procedure

Types due to: abnormalities of

blood capillaries

platelet dysfunction or deficiency

blood clotting defects

Blood Capillary Disorder

Vascular fragility increased which leads to petechial hemorrhages in skin or mucous membranes, includes gingiva

May be caused by severe infections such as typhoid, drug reaction, scurvy

Platelet Deficiency and DysfunctionThrombocytopenia

Lowered number of platelets due to decreased production in bone marrow

Leukemia or vitamin B12 deficiency

Platelet Dysfunction

Interferes with clotting mechanism and leads to prolonged bleeding time

aspirin contraindicated

Blood Clotting Defect

Possible irregularity or disorder is associated with each of the many clotting factors

Examples include Vitamin K deficiency, liver disease, hereditary disorders - Hemophilia A and B

Characteristics of HemophiliaCongenital disorders of the blood

clotting mechanismSeverity variesHemophilia A and B inherited by malesAcceptable minimal surgical level of

the clotting factor is 30% - includes subgingival scaling

Treatment of HemophiliaMust consult patient’s hematologist - they

may need clotting factor replacement therapy before and after appointment

Susceptible to infection-may need premed

Avoid nerve blocks since positive aspiration of blood is great - hematoma

Prosthetic Joint ReplacementReplacement of hips, knees, and

elbows with prosthetic devices is becoming common

Common practice to premedicate to prevent bacteremia

Consultation with orthopedic surgeon essential before proceeding with appt

Pulmonary DiseasesAbnormal condition of the

respiratory system, characterized by cough, chest pain, shortness of breath, sputum production, wheezing

Diseases are Obstructive or Restrictive

ObstructiveResult of an obstacle in airway that

impedes the flow of air, especially during expiration

May be caused by bronchospasms, edema, loss of lung elasticity or thick bronchial secretions

Asthma, bronchitis, emphysemaAsthmatics frequently allergic to aspirin

RestrictiveCaused by conditions that limit lung

expansion by an actual reduction of the volume of inspired air

Increased work to breath and an inefficient exchange of gases

Examples include pulmonary fibrosis or chest deformities

Treatment Considerations for Pulmonary DiseasesSupplemental

oxygen may be necessary

Chair position may be important - allow patient to feel comfortable about breathing

Not suitable for nitrous oxide usage

Asthmatics should have their own medications chairside

Diabetes Mellitus

Genetically heterogenous group of disorders that are characterized by glucose intolerance

Three types of diabetic syndromes:

Type I - Insulin Dependent

Type II - Noninsulin-dependent

Type III - Gestational

Diabetes Type IInsulin dependent

Patient has natural insulin deficiencyPatient depends on insulin for

survivalUsually begins in childhoodAbrupt onset of symptoms

Diabetes Type IINoninsulin dependent

May or may not use insulin for symptom control but do not need it for survival

Slow progression of diseaseTypically begins after 35 - 40 years of

ageObese type - weight control and diet

Diabetes Type IIIGestational

Begins or is noticed during pregnancyAbove average risk of perinatal

complicationsGlucose intolerance may not last past

pregnancy

Function of InsulinHormoneFacilitates conversion of glucose to fat in

adipose tissueSpeeds the conversion of glucose to

glycogen in the liver and musclesFacilitates the transmission of glucose into

cellsSpeeds the oxidation of glucose within the

cells for energy

Effects of Decreased Insulin In diabetes, insulin is decreased in amount

or functionLess glucose is transmitted through cell

walls into the cellsGlucose increases in the circulating blood

until a threshold is reached when glucose spills over into urine

Without glucose in the cells to use for energy, the cells utilize fats

When cells utilize fats….

End products of fat metabolism (ketones) accumulate in the blood

Acidosis results

Acidosis can result in diabetic coma

Insulin ComplicationsInsulin reaction -

hypoglycemia

lowered blood glucose with excess insulin proportion

sudden onset

Diabetic coma - ketoacidosis

Too little insulin with excess ketones in blood

gradual onset

Uncontrolled DiabetesPatient has symptoms known as

Classic TriadExcess urine - polyuria

Excessive thirst - polydipsia

Increased appetite - polyphagia

Uncontrolled Diabetes - Other SymptomsDehydration from fluid lossGeneral weakness,drowsiness,fatigueweight loss from inability to utilize foodselevated blood glucoseglucose in urineslow wound healing, persistent infectionspain and/or numbness in fingers or toeschanges in vision

Infection and DiabetesMore susceptible to infectionFailure to treat an infection increases

severity of diabetic state and intensifies the symptoms

With infection present, insulin requirements increase, infection heals,insulin lowered

Frequently seen infections-urinary tract infections, skin, lungs and oral cavity

DiabetesDiet therapy- eliminate concentrated

carbohydratesAppointment therapy: stress reduction critical- watch stress

level best appt is in morning 1 to 3 hours

after normal breakfast and medication

Diabetes - Appointment ConsiderationsAntibiotic protection may be indicated for

a patient who has history of slow healing from previous scaling or any surgical procedure

May need to recheck tissues one week post-scaling appt for healing response

May want to postpone fluoride application if scaling was difficulty until healing

Diabetes - Progress of Periodontal DiseasePatients with insulin dependent

diabetes have a tendency to develop perio disease - even at early age

Diabetes doesn’t cause disease just decreases resistance to bacteria

Reactive HypoglycemiaLow blood sugar, deficiency of sugar in

bloodTypes: most common following meal,

due to delayed insulin response in some mild maturity onset diabetes after carbo load

alcohol induced, functional ( unknown causes)

Reactive HypoglycemiaSymptoms: lightheadedness,

palpitations, sweating, hunger,nervousness

Symptoms trigger a ripple effect of fatigue, depression, consciousness, convulsions, and coma

Stress intensifies rippleSymptoms relieved by oral glucose

Hypothyroidism & Hyperthyroidism

Most patients will be sensitive to temperature changes.

Most people will have had the disease but be under control due to drugs or surgery.

Hypothyroidism & HyperthyroidismHYPO

atrophy of gland less secretions from

thyroid sluggish decreases basal

metabolism

HYPER enlarged gland more secretions

from thyroid increases basal

metabolism nervous

Corticosteroid TherapyHormonal steroidUsed in the management of a wide

variety of diseases including arthritis, allergic diseases, and pemphigus

Corticosteroids depress the natural defensive responses including inflammation and alter connective tissue response to injury

Corticosteroid TherapyIn dentistry, use

corticoids for oral ulcerations, arthritis of TMJ

Usually applied topically for suppression of local inflammation

Treatment considerations: arthritis patients may

be on long term treatment with CS

dental treatment causes stress-need to ascertain if patient has complications with handling stress

Corticosteroid Therapy Treatment Considerations Patient may have high BP, salt and water

retentionTopical applications should be avoided in

patients suffering from diabetes,hyper- tension,peptic ulcer,TB or viral infections

For those on long term therapy, early signs of inflammation will be masked and correct diagnosis may be missed

Oral candidiasis is frequent complication

Allergic ReactionsMild: Characterized by swelling,redness,

itching- delayedSevere: Characterized by respiratory

depression and circulatory system involvement-anaphylaxis-abrupt & immediate

ANY allergies must be fully evaluated before the start of treatment and any drug administration

Mental ConditionsConsiderations for patients on

antianxiety, antipsychotic, or antidepressants

Usually under care of a physicianMay be taking multiple drugs for

management of their disordersSide effects might include xerostomia

and/or lack of mental alertness

EpilepsyFind out type of seizure activity, its

frequency,drugs used to prevent seizures.

Minimize and/or reduce stress level for patient.

Gingiva may be enlarged from medications.

Pharmacological ConsiderationsCENTRAL NERVOUS SYSTEM

DEPRESSANTS: Barbituates:effective sedative and hypnotics -

long acting barbs used fro seizure disorders and mild anxiety

Narcotics: pain control in terminal disease Antianxiety:used in psychiatric treatment Treatment considerations: If patient has been

on medication for a long period of time they will have LESS pain tolerance

Pharmacological ConsiderationsCENTRAL NERVOUS SYSTEM

STIMULANTS: Include antihistamines, diet pills, caffeine,

cocaine Side effects include:

• xerstomia - dry mouth• increase in vital signs• nervousness, talkative

Severe overstimulation can cause heart failure

Cancer PatientsUsually on anti-neoplastic (chemotherapy)

drugs- in combination with surgery, and radiotherapy-may cause oral manifestations side effects

oral ulcerations, mucosal sloughing, necrotic lesionsincreased susceptibility to infections such as

candidiasis due to suppression of normal defense mechanisms

bleeding problems from suppression of blood clotting factors

Cancer PatientsPre-medication may be necessary; consult

oncologist; immune system compromised; will be susceptible to infections

Treatment problems When head and neck area radiated it may cause

necrosis of bone in jaws and rampant caries Oncological treatment

Before: prophy to decrease risk of infectionAfter: fluoride, saliva substitute for xerostomia

Liver DiseaseCaused by:

hepatitis-drug induced,alcoholic,viral

cirrhosis-alcoholic,biliary

infiltrations-glycogen,fat

biliary obstruction severe vascular

diseases

Problems with treatment: serious bleeding

problems may occur;may need replacement of clotting proteins

Reduced capability to metabolize drugs-prolonged blood levels of drugs

Childbearing Age FemalesOral contraceptives: usually mixture

of estrogen and progesteroneTissues may mimic effects of

pregnancy mild inflammation and edema loss of tissue tone spontaneous bleeding tenderness and ulcerations

Alcohol and Drug Addiction PatientsHigher than normal

incidence of liver disease

Increase of valvular damage

May need premedication

Low tolerance for pain

TuberculosisContracted by inhalation of fresh

droplets containing tubercle bacilliPredisposing factors - any

debilitating or immunosuppressive condition-eg. HIV,diabetes.chronic lung disease, alcoholism

Incubation period- up to 6 months

TuberculosisEarly symptoms: low grade fever, loss

of appetite, weight loss, tire easily,slight cough

Later symptoms: definite temperature elevations, night sweats, weakness and persistent cough

Re-infection TB: infection may remain inactive and later produce a recurrence

TuberculosisClinical management:

May have enlarged lymph nodes, ulcers on palate

Chemotherapy can control patients contagious condition

Consult physician to clarify if active- can usually treat patient if they have been on medication for 2-3 weeks

Hepatitis AOccurs most frequently in children

and young adultsMost common transmission is

through close contact in unsanitary conditions (fecal-oral route)

Prevention by universal precautions

Hepatitis BOccurs at any ageVery different disease process than HepAMajor source of HPB from patients with

acute infection and symptomless chronic carriers

Transmitted by blood, other bodily, perinatal transmission

Prevention through immunization

Hepatitis D - DeltaCan only cause infection in presence

of HBV Occurs primarily in persons who

have multiple exposures of HBVTransmission same as HBVMore severe than HBVPrevention is same as HBV

HIV Infected patients have variety of

symptoms since disease has 3 stages

Asymptomatic

AIDS related complex- ARC

AIDS

HIVDamages immune

and neurological system

Transmission via blood,semen,vaginal secretions,breast milk

Patient highly susceptible to infection

Consult physician- may need premed if abnormal white cell, fungslT-cell and/or platelet count

Patient may have opportunistic diseases fungal-candidiasis bacterial-

sinusitis,gingivitis viral- herpes,shingles

HIVNeoplasms-Kaposi’s

sarcoma,squamous cell carcinoma, Non-Hodgkin’s lymphoma

Neurological disturbances- facial palsyUnknown etiological diseases-

recurrent apthous ulcers, delayed wound healing, salivary gland enlargement, xerostomia

Herpes Virus DiseasesVaricella-zoster:

Chicken pox - highly contagious; lesions on trunk

Shingles- painful, burning and itching lesions that may be anywhere on the body

Herpes Virus DiseaseEpstein-Barr virus:Infectious

MononucleosisCharacterized by fever, swollen lymph

nodes and sore throat

Transmitted orally by direct contact and droplets

Herpes Virus DiseasesCytomegalovirus: CMV- Salivary gland

viruses-Occurs congenitally,postnatally, or at any age,

ranges in severity from a slight infection without complications through disease manifested by fever, hepatitis, pneumonitis, and in neonates- severe brain damage resulting in stillbirth or perinatal deaths

60-90% adults have experienced infectionTransmitted by blood transfusion, graft

transplant,sexual transmission,respiratory droplet

Herpes Simplex VirusPrimary herpetic gingivostomatitis-

primary infection may be asymptomatic or with symptoms-usually painful lesions and flu-like symptoms

Herpes labialis (HSV-1) or genital herpes (HSV-2)- cold sores,fever blister, both cause genital and oral-facial infections that can’t be distinguished clinically

Herpes Virus DiseaseHerpes labialis:

Usually triggered by stress, sunlight, illness or trauma

Healing may take 10 days Lesions are infectious and can be

spread to eye, nose and genitals Treat after lesion has burst and dried,

crusted appearance

Herpes Virus DiseaseHerpetic Whitlow: HSV infection of fingers

that results from the virus entering through minor skin abrasions

May be recurrent lesion of HSV-1 or HSV-2

Transmission results from direct contact with a vesicular lesion on patient’s lip or saliva- lesions are infectious and transmissible before appearing

Herpes Virus Diseases

Ocular herpes- HSV-1 or HSV-2 in the eye

Transmission by splashing saliva or fluid from lesion into eye, extension from facial lesion, or during birth

Herpes Virus DiseasesClinician with a

herpetic lesion -

Herpetic Whitlow - direct patient care should be avoided for duration

Herpes Labialis- careful isolation with mask,care that mask does not become moist