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Dental Management of a Complex Patient > Cardiovascular 1 > Flashcards

Cardiovascular 1 Flashcards

1
Q

Most common cause of premature death in the world

A

CVD

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2
Q

Patients frequently have more than one

A

CVD

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3
Q

Many different types of CVD disease
(6)

A
  • Hypertension (HTN)
  • Atherosclerosis
  • Angina Pectoris
  • Congestive Heart Failure
  • Arrhythmias
  • Bacterial Endocarditis
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4
Q

Types of CVDs
(8)

A
  • Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
  • Hypertension (HTN)
  • Coronary Artery Disease (CAD)
  • Angina Pectoris
  • Bacterial Endocarditis
  • Congestive Heart Failure (CHF)
  • Arrhythmia
  • Valvular disease
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5
Q
  • Atheroslerosis aka Atherosclerotic Heart Disease (ASHD)
A
  • coronary artery disease leads to infarction
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6
Q
  • Bacterial Endocarditis
A
  • infection, inflammation and scarring
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7
Q
  • Congestive Heart Failure (CHF)
    (2)
A
  • dilated ventricles with weak muscles
  • thickened myocardium
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8
Q
  • Arrhythmia
A

–uncoordinated electrical signals
Bradycardia v. Tachycardia

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9
Q
  • Valvular disease
    (2)
A
    • stenotic and not capable of full closure for blood circulation
    • leads to CHF
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10
Q

CVD Risk factors
conditions (5)

A

high BP
high cholesterol
diabetes
rheumatic fever
>1 CVD

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11
Q

CVD Risk factors
behavioral
(6)

A

unhealthy diet
physical inactivity
obesity
too much alcohol
tobacco use
stress

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12
Q

CVD Risk factors
family history
(3)

A

genetics
becoming older
ethnicity

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13
Q

high BP (2)

A
  • Stiffens vessels which reduces blood flow
  • also a risk for stroke, kidney disease and dementia
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14
Q

high cholesterol (1)

A

LDLs

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15
Q

diabetes

A
  • Unstable glucose levels affect healthy myocardium function; angiopathy
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16
Q

Rheumatic fever

A

–valvular disease

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17
Q

unhealthy diet

A
  • Carbs, fats, caffeine, Na+
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18
Q

physical inactivity

A

poor circulation

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19
Q

obesity

A
  • Excess weight stresses heart function, HTN, CAD
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20
Q

too much alcohol

A
  • increases BP, arrythmias
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21
Q

tobacco use

A
  • increases HR, BP, CAD, etc.
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22
Q

Predisposing etiologies
(4)

A
  • Congenital
  • Hypertension (positive CVD feedback
    cycle)
  • Ischemia (positive CVD feedback cycle)
  • Inflammation
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23
Q

Contributary anatomic abnormalities
(5)

A
  • Hypertrophy
  • Dilation
  • Valves
  • Regurgitation
  • Stenosis
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24
Q

Physiologic changes
(3)

A
  • Arrhythmias
  • Heart failure
  • Ischemia
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25
Q

Staging of Cardiovascular Disease (CVD)
class 1
Physical Activity:
Symptoms:

A

physical activity: no limitation
no dyspnea, fatigue or palpitations with physical activity

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26
Q

Staging of Cardiovascular Disease (CVD)
class 2
Physical Activity:
Symptoms:

A

physical activity: slight limitation
fatigue, dyspnea, palpitations present with physical activity

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27
Q

Staging of Cardiovascular Disease (CVD)
class 3
Physical Activity:
Symptoms:

A

physical activity: marked limitation
less than normal physical activity results in symptoms. comfortable at rest

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28
Q

Staging of Cardiovascular Disease (CVD)
class 4
Physical Activity:
Symptoms:

A

physical activity: severely limited. exacerbates symptoms
symptoms present at rest

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29
Q

Signs and Symptoms of Cardiovascular Disease
Signs
(6)

A
  • Elevated BP
  • Irregular or abnormal heart rate
  • Abnormal respiratory rate
  • Shortness of breath upon exertion
  • Prolonged bleeding/easy bruising
  • Surgical scars
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30
Q

Signs and Symptoms of Cardiovascular Disease
Symptoms

A
  • Patient is uncomfortable in supine position
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31
Q
  • The less the symptoms and the better the control of risk factors
    THEN
  • the — a patient manages the stress
    AND
  • the — likely the patient will have a life threatening incident during a dental procedure
A

better
less

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32
Q
  • The greater the symptoms and the poorer the control of risk factors
    THEN
  • the — a patient manages the stress
    AND
    the — likely the patient will have a life threateningincident during a dental procedure
A

worse
more

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33
Q

Low Level Intervention
(6)

A
  • Health/medical evaluation
  • Exams
  • Prophy
  • Radiographs
  • Optical oral scans
  • Alginate impressions
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34
Q

Moderate Intervention
(4)

A
  • SRP (scaling and root planning)
  • Simple restorative procedures; 1-2 teeth
  • Simple extractions; 1-2 teeth
  • Restorative impressions needing retractions
    and longer setting times
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35
Q

High Risk Intervention
(6)

A
  • Complex restorative procedures on >2 teeth
  • Multiple extractions
  • Surgical extractions
  • Implant placement
  • Full arch impressions
  • Dental care under general anesthesia
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36
Q

Primary Hypertension
(2)

A
  • Multifactorial, gene-environment
  • 90-95% of cases
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37
Q

Secondary hypertension
(4)

A
  • Renal disease and renin-producing
    tumors
  • Endocrine
  • Cardiovascular
  • Neurologic
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38
Q
  • Endocrine
    (5)
A

➢Adrenal
➢Exogenous hormones
➢Pregnancy
➢Pheochromocytoma
➢Thyroid

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39
Q
  • Neurologic
    (4)
A

➢Psychogenic
➢Sleep apnea
➢Intracranial vascular pressure
➢Exogenous

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40
Q

Complications
(7)

A
  • Myocardial infarction
  • Stroke
  • Coronary artery disease
  • Peripheral artery disease
  • Heart failure
  • Retinopathy
  • End-stage renal disease
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41
Q

Blood Pressure
 Determined by

A

indirect measurement in the upper extremities with a BP
cuff and stethoscope

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42
Q

Determined by indirect measurement in the upper extremities with a BP
cuff and stethoscope
➢ Cuff should encompass —% of the circumference of the arm.
➢ Center of cuff over
➢ Cuff too small →
➢ Cuff too large →

A

80
brachial artery
falsely elevated values*
falsely low values*

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43
Q

‘White Coat HTN’ elevate BP by

A

30 mm Hg*

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44
Q

Pregnant pts w/ ≥ 10 mm Hg increase in systolic BP from baseline
➢ Risk of

A

eclampsia →immediate referral

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45
Q

Blood Pressure
 Arm position matters

A

➢ Horizontal at heart level (mid-sternum)

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46
Q

 Arm below heart level

A

Over-Estimates systolic and diastolic pressures
Similar to Cuff too small →falsely elevated values

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47
Q

 Arm above heart level

A

under-estimates systolic and diastolic pressures
Similar to Cuff too large →falsely low values

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48
Q

Hypertension
Goals depend on patient

A

age and comorbidities
Generally, goals are between <130 - 149/80-90 mm Hg

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49
Q

Blood Pressure
 NO dental care at UMKSC SOD if BP

A

≥ 180/110 mmHg
➢ 180/120 is classified as a Hypertensive Urgency by the AHA based on
2017 guidelines
➢ Urgent referral →see doctor ASAP
➢ If patient is symptomatic →Emergency Room

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50
Q

Medical Management
* Lifestyle modifications
(3)

A

➢ Diet (increase fruit intake, decrease sodium, increased potassium)
➢ Physical exercise/weight loss
➢ Tobacco cessation and alcohol intake reduction

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51
Q

Oral Manifestations
None due to hypertension itself
* Side-effects of pharmacotherapy:
(7)

A

➢ Dry mouth (anti-adrenergics and diuretics)
➢ Burning mouth (ACEi)
➢ Taste changes (antiadrenergics, ACEi)
➢ Angioedema (ACEi, ARB)
➢ Gingival hyperplasia (calcium-channel blockers, what are the other 2?)
➢ Lichenoid reactions (thiazides, methyldopa, propranolol, and labetalol)
➢ Lupus-like lesions (hydralazine)

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52
Q

Questions to Ask Your Patient with Hypertension
Physical Activity

A
  • Do you feel shortness of breath at rest?
  • Are you physically active?
    ➢ What kind of physical activities do you engage in?
    ➢ Do you feel shortness of breath after exercise?
    ➢ Does it limit the intensity of your physical activity
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53
Q

questions
Hypertension History

A
  • How long have you had high blood pressure?
  • Who manages your blood pressure, primary care or a cardiologist?
  • How long have you been on this current antihypertensive regimen?
  • Have there been any recent changes to your blood pressure medication? Why?
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54
Q

questions
Hypertension Monitoring
(3)

A
  • What is your usual BP level at the doctor’s office?
  • Do you check your BP at home?
  • What are your usual readings, how high does it get?
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55
Q

Dental Considerations for the Hypertensive Patient
Serious potential complications of severe uncontrolled HTN:
(4)

A
  • Stroke
  • Angina
  • Arrhythmia
  • Myocardial infarction
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56
Q

(3) may increase the patient’s BP and lead to complications

A

Stress, anxiety, fear

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57
Q

Patients taking nonselective beta-blockers

A

➢Use of vasoconstrictor can cause an acute rise in BP

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58
Q

Patients may be sensitive to sudden position changes causing

A

orthostatic hypotension

59
Q

Dental Considerations for the Hypertensive Patient
Pre-operative considerations

A
  • Reduce Stress and Anxiety
    ➢ May need oral and/or inhalation sedation
60
Q

Intra-operative considerations
(3)

A
  • Profound anesthesia!!!! (MOST IMPORTANT)
  • Limit epi to 2 carpules if taking a selective beta-blocker, (2 carp rule)*
  • Don’t use epinephrine-gingival retraction cord
61
Q

Post-operative considerations
(4)

A
  • Avoid macrolide antibiotics with calcium channel blocker (↑ CCB levels)
  • Avoid long-term use of NSAIDs (>2 weeks)
  • Stage 2, monitor BP during treatment, if 180/110 stop tx!
  • Raise patient slowly after treatment b/c of hypotension
62
Q

MEDICAL CONSULT LETTER –GENERAL GUIDELINES
(2)

A

Make explicit to physician when writing a medical consult (categorize procedure risks not dental details)
Ask very specific questions to the physician in relation to the current disease status of the patient

63
Q

time of procedure -

A

risk category

64
Q

Hypertension Medical Consult Questions*
(4)

A
  • What is the patient’sBP goal (range)
  • What have been patient’sin-office BP readings?
  • Does the patient have any end-organ damage?
  • Current medications prescribed to manage
    Hypertension
65
Q

Cardiac measures**
(4)

A
  • Stress reduction protocol
  • Nitrous oxide
  • Profound anesthesia
  • Cardiac epi dose = max 0.04mg
66
Q
  • Cardiac epi dose = max 0.04mg
    ✓Articaine for
    ✓2% lidocaine 1:100,00 epi for
    ✓3% mepivacaine without epi for
A

maxillary blocks and maxillary or mandibular infiltrations
IANB
anesthesia

67
Q

Atherosclerosis

A
  • Inflammatory disorder with accumulation of
    lipid plaque within the arterial walls
    ➢ Thickened intima (decreased arterial lumen)
    ➢ Decreased oxygen
    ➢ Decreased blood flow to the myocardium
68
Q

Atherosclerosis
* Leads to
(5)

A

➢ Stenosis
➢ Angina (stable ischemic disease)
➢ MI
➢ Ischemic stroke (acute ischemic disease)
➢ Peripheral arterial disease

69
Q

Atherosclerosis –Risk Factors

A

➢Depression
➢Family history of CVD
➢Insulin resistance
➢Diabetes mellitus

➢Male sex
➢Age
➢Smoking
➢Lack of exercise
➢Obesity
➢Stress
➢Depression
➢Family history of CVD
➢Hyperlipidemia
(↑LDL)
➢Hypertension
➢Insulin resistance
➢Diabetes mellitus

70
Q

Atherosclerotic plaques can lead to:
(2)

A
  • ischemia
  • thrombosis, (vascular blockage) if they
    rupture
71
Q

Atherosclerosis of the Circulatory System (Heart)
* Associated symptoms
(2)

A

➢ Chest pain
➢ Angina

72
Q

Atherosclerosis of the Circulatory System (Heart)
* Complications
(5)

A

➢ Unstable angina
➢ Myocardial infarction (necrosis)
➢ Thrombosis
➢ Embolism
➢ Aneurysm

73
Q

Angina Pectoris
* Chest pain resultant from

A

ischemic changes
➢Mid-chest pain described as
o“aching, heavy squeezing pressure or tightness”

74
Q

Angina Pectoris
* Pain may radiate (3)
* Pain lasts
* — used to resolve angina

A

➢Shoulder, arms, jaw
5-15 minutes
➢ If unstable angina, may be longer
Vasodilation

75
Q

Angina Pectoris
May be stable or unstable
* Stable
(4)

A

➢Imbalanced cardiac perfusion
➢Stable symptoms, reproducible, predictable, consistent
➢Chest pain precipitated by physical activity/exertion
➢Resolves with cessation of activity

76
Q
  • Unstable
    (4)
A

➢Disruption of atherosclerotic plaque
➢Possible partial thrombosis, embolism or vasospasm
➢Symptoms increasing
➢Chest pain at rest or with less intense physical activity/exertion

77
Q

Myocardial Infarction
* Definition
➢Lose normal (2)
➢— ventricle MI more common

A

Irreversible coagulative necrosis of the myocardium
conduction and contraction
Left

78
Q

Myocardial Infarction
* Symptoms similar to angina, plus
➢— features
➢Severe — pain with (3)

A

Radiating
substernal
shortness of breath, profuse sweating, and loss of consciousness

79
Q

Myocardial Infarction
Pain does not resolve with — and is more prolonged

A

vasodilators

80
Q

Medical Management
Treatment/reduction of modifiable risk factors and associated disease
Hypertension
(2)

A

➢Beta-blockers
➢Calcium channel blockers

81
Q

Angina
(1)

A

➢Nitrates (nitroglycerin) –stable angina

82
Q

Stroke
(1)

A

➢Antiplatelet agents (aspirin, clopidogrel) –stroke prevention

83
Q

Revascularization (interventional)
(2)

A

➢ Percutaneous transluminal coronary angioplasty with stenting (PCI;
stent)
➢ Coronary artery bypass grafting (CABG)

84
Q

Hyperlipidemia
(5)

A

➢Fibrates
oGemfibrozil
➢Niacin
oNiaspan
➢Omega-3 fatty acids
oLovaza
➢HMG-CoA reductase inhibitor
oStatins
➢Cholesterol absorption
inhibitor
oEzetimibe
➢Bile acid sequestrants
oCholestyramine
oColestipol

85
Q

FOR ALL ISCHEMIC DISEASE
(3)

A
  1. Severity of the disease
  2. Stability and cardiopulmonary reserve of the patient
    (i.e., the ability to tolerate dental care)
  3. Type and magnitude of the dental procedure
86
Q

Ischemic Heart Disease
Same questions as HTN + :
(6)

A
  • Do you have chest pain?
  • Do you get chest pain after exercise or at rest?
  • How often? When was the last time?
  • Has there been any change in frequency or intensity of your chest
    pain?
  • Do you take anything to make it stop?
  • Have you ever had cardiac surgery?
  • Which procedure(s)
  • How long ago was it?
  • Have you ever had a MI?
  • How long ago?
87
Q
  • Make sure you and/or patient have — on day of visit to use
    where applicable.
  • Be aware of signs and symptoms of MI and be prepared for an
    emergency
  • No elective treatment in patient with unstable angina or recent
    history of MI (major risk)
A

nitroglycerin

88
Q

Do you bruise easily?
(3)

A
  • Are you taking aspirin or clopidogrel (antiplatelet meds)?
  • When you cut yourself how long does it take to stop bleeding?
  • Have you ever been hospitalized for bleeding?
89
Q
  • Increased bleeding expected, have local measures ready
  • In general, no need to stop
  • If extensive surgery, may consider
A

antiplatelet therapy
drug holiday with physician
consultation

90
Q

Recent Myocardial Infarction <1
month
(3)

A
  • Urgent dental care only
    ➢ACUTE dental pain or infection
  • Consultation with physician
  • Consider referral to specialized center
91
Q

Past Myocardial Infarction
>1 month
* Consider severity of cardiac status and
comorbidities
* — can measure the
degree of heart failure
➢Measures amount (%) of
* Consider appropriate management
protocols

A

Ejection Fraction
blood that
leaves the left ventricle after
contraction.

92
Q

Past Myocardial Infarction
>1 month
* Consider severity of
* Consider appropriate management
protocols

A

cardiac status and
comorbidities
* Ejection Fraction can measure the
degree of heart failure
➢Measures amount (%) of blood that
leaves the left ventricle after
contraction.

93
Q
  • Ejection Fraction (EF) %: 55% to 70%
  • Pumping Ability of the Heart:
  • Level of Heart Failure/Effect on Pumping:
A

Normal
Heart function may be normal or you may have heart failure with preserved EF (HF-pEF).

94
Q
  • Ejection Fraction (EF) %: 40% to 54%
  • Pumping Ability of the Heart:
  • Level of Heart Failure/Effect on Pumping:
A

Slightly below normal
Less blood is available so less blood is ejected from the ventricles. There is a lower-than-normal amount of oxygen-rich blood available to the rest of the body. You may not have symptoms.

95
Q
  • Ejection Fraction (EF) %: 35% to 39%
  • Pumping Ability of the Heart:
  • Level of Heart Failure/Effect on Pumping:
A
  • Pumping Ability of the Heart: Moderately below normal
  • Level of Heart Failure/Effect on Pumping: Mild heart failure with reduced EF (HF-rEF).
96
Q
  • Ejection Fraction (EF) %: Less than 35%
  • Pumping Ability of the Heart:
  • Level of Heart Failure/Effect on Pumping:
A
  • Pumping Ability of the Heart: Severely below normal
  • Level of Heart Failure/Effect on Pumping: Moderate-to-severe HF-rEF. Severe HF-rEF increases the risk of life-threatening heartbeats and cardiac dyssynchrony/desynchronization (right and left ventricles do not pump in unison).
97
Q

Stress Reduction in Stable Angina or Past Myocardial Infarction
* Ideal
(3)

A

➢No ischemic symptoms
➢Intermediate risk
➢No other risk factors

98
Q

Stress Reduction in Stable Angina or Past Myocardial Infarction
Procedural Precautions
➢Short appointments in the –
➢Pre-treatment –
➢Availability of –
➢– sedation
➢– –oxygen sedation
➢Profound –
➢Limit amount of –
➢Avoid –
➢Effective post-operative – control

A

morning
vital signs
nitroglycerin
Oral
Nitrous oxide
local anesthesia
vasoconstrictor
epinephrine-impregnated retraction cord
pain

99
Q

Pre op sedation: (2)

A

short acting benzodiazepine (triazolam 0.125-0.25 mg)
1 hr before appointment and possibly the night before the day of the appointment

100
Q

Ischemic Heart Disease
Drug interactions and oral manifestations
Same as HTN + :
(3)

A
  • HLD
  • Limit epinephrine as discussed earlier
  • Bleeding as discussed earlier –limit NSAIDs.
101
Q
  • HLD
A
  • Statins –avoid CYP inhibitors (fluconazole, clarithromycin
  • ↑ statin levels
102
Q

SA node
(3)

A
  • Primary pacemaker
  • Regulates atrial function
  • Produces P wave (atrial
    depolarization)
103
Q

AV node
(2)

A
  • Regulates atrial impulses entering
    ventricles
  • Slows conduction rate of SA
    generated impulses
104
Q

QRS complex

A
  • Simultaneous depolarization of the
    ventricles
105
Q

T wave

A
  • Repolarization of the ventricles
106
Q

Arrhythmia

A

Disruption of the electrical impulse generation or conduction in the heart that
leads to abnormal cardiac function

107
Q

Arrhythmia
* Formation of
* Increased
*(2) impulse formation
* Delayed —
* — of the heart after refractory period

A

abnormal impulse
impulse formation
Enhanced or abnormal
depolarization
Re-excitation

108
Q

Arrhythmia
The disruption may be due to an area of:
(4)

A
  • Infarction
  • Ischemia
  • Electrolyte imbalance
  • Medication
109
Q

The most common cause of sudden cardiac death is

A

ventricular fibrillation*

110
Q

Causes of arrhythmias
(6)

A
  • Cardiovascular disorders
  • Pulmonary disorder
  • Autonomic disorder
    Arrhythmia
  • Hyperthyroidism
  • Drugs
  • Electrolyte imbalance
  • Anxiety and anger
111
Q
  • Cardiovascular disorders
    (5)
A
  • Myocardial infarction
  • Mitral stenosis
  • Valvular disease
  • Ischemic heart disease
  • Congestive heart failure
112
Q
  • Pulmonary disorder
    (2)
A

➢Pneumonia
➢Obstructive lung disease

113
Q
  • Drugs
    (6)
A

➢ Epinephrine
➢ Alcohol
➢ Digitalis
➢ Morphine
➢ Beta-blockers
➢ Tricyclic antidepressants, and
others

114
Q

Bradycardia
Tachycardia

A
  • <60 beats/min
  • > 100 beats/min
115
Q

Arrhythmia
Symptoms
(6)

A
  • Palpitations, fatigue
  • Dizziness, syncope, angina
  • Congestive heart failure
  • Shortness of breath
  • Orthopnea
  • Peripheral edema
116
Q

Atrial Fibrillation
(4)

A
  • Most common arrhythmia
  • Rapid uncontrolled atrial activity
  • Irregularly irregular rhythm
  • Risk of arterial clot formation
    ➢ Embolism and stroke
117
Q

Heart Block

A
  • Impulse is partially or completely blocked
    ➢Prolonged or no conduction
118
Q
  • First-degree
A

➢ Longer conduction time

119
Q
  • Second-degree
    ➢ Mobitz I
    ➢ Mobitz II*
A

oMore prolonged and no P wave
oRepetitive or occasional sudden blocks w/o previous prolonged
conduction time

120
Q
  • Third-degree
    (2)
A

➢ No impulses –COMPLETE BLOCK *
➢ Indication for pacemaker

121
Q

Ventricular Arrhythmias
(4)

A
  • Premature ventricular complexes (PVCs)
  • Common
  • Abnormal QRS complex + pause
  • Increased risk of death if patients have underlying CVD (heart failure,
    MI, valvular heart disease
122
Q

Ventricular tachycardia
(3)

A
  • If more than 3 consecutive PVC at 100 beats/min
  • If lasts for more that 30 seconds, requires termination
  • Torsades de pointes –potentially life-threatening
123
Q

Ventricular flutter and fibrillation
(3)

A
  • Lethal
  • Consequence of ischemic heart disease
  • Cardiac contraction is not sequential, chaotic
124
Q

Pharmacotherapy

A
  • Antiarrhythmics
125
Q

Pharmacotherapy
* Oral anticoagulants
➢ Clopidogrel (Plavix)
(2)

A

oInhibits platelet agglutination
oplatelet count not affected

126
Q

Pharmacotherapy
* Oral anticoagulants
➢ ASA (Aspirin 81mg - low dose)
(2)

A

oInhibits platelet agglutination
oplatelet count not affected

127
Q

Drugs that cause gingival hyperplasia (3)

A

Ca channel blockers (20% of pt affected)
-nifedipine
-verapamil

Immunosuppressants (30% of pt affected)
-cyclosporin
-tacrolimus

Anticonvusants (50% of pt affected)
-phenytoin

128
Q

Pharmacotherapy
* Oral anticoagulants
➢ Warfarin (Coumadin)
(3)

A

oVitamin K antagonist
oINR monitoring
oHighly variable

129
Q

Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct thrombin inhibitor
(2)

A

oDabigatran (Pradaxa)
oReversal agent available

130
Q

Pharmacotherapy
Direct Oral Anticoagulants (DOACs)
➢ Direct Factor Xa inhibitors
(4)

A

oRivaroxaban (Xarelto)
oApixaban (Eliquis)
oEdoxaban (Savaysa)
oReversal agents not available

131
Q

NEVER STOP ANTICOAGULATION FOR DENTAL TREATMENT UNLESS
RISK OF THROMBOSIS — RISK OF MASSIVE BLEED
CONSULT PHYSICIAN IF EXTENSIVE SURGERY NECESSARY
CONSIDER REFERRAL TO SPECIALIZED CENTER

A

EXTENSIVE SURGERY
>

132
Q

Non-pharmacologic
(4)

A
  • Pacemakers
  • Implanted Cardioverter-Defibrillator (ICD)
  • Surgery
  • Electrocardioversion and defibrillation
133
Q
  • Implanted Cardioverter-Defibrillator (ICD)
    (1)
A

➢ Sets pace and shocks

134
Q
  • Surgery
    (3)
A

➢ Tissue resection
➢ Cardiac ablation
➢ Surgery to address underlying cause such as stenosis

135
Q

Dental Treatment Considerations
* What type of arrhythmia?
questions
(5)

A

➢ When diagnosed? How frequent?
➢ How treated?
➢ Do you have a pacemaker or
defibrillator?
➢ Have you ever required emergency
intervention for arrhythmia?
➢ Is your arrhythmia stable now?

136
Q

Dental Treatment Considerations
(3)

A
  • What type of arrhythmia?
    Assess comorbidities (CVD, pulmonary)
  • ROS: palpitations, chest pain, dizziness,
    shortness of breath, syncope
137
Q

If severity, nature, treatment of C.A. is unclear obtain

A

Med Consult

138
Q

High Risk Arrhythmia
* – elective dental care
* Dental treatment should be limited to – care only
- Treatment of (3)
* If necessary treatment, obtain a –
* Management may include an (4)
* Cautious use of — (contraindicated if taking –)
* Prophylactic –

A

Defer
urgent
ACUTE pain, bleeding, or infection, only
medical consult
IV line, pulse oximeter, BP and oxygen, electrocardiogram monitoring
epinephrine, digoxin
nitroglycerin

139
Q

**Limit Local Anesthetics.

A

2 Carp or < Rule (Lido 1:100 epinephrine)

140
Q

Intermediate and Low Risk Arrhythmia
Elective care can be provided with following management protocols:
(4)

A

*Stress/Anxiety reduction:
*Assess pretreatment vital signs, have nitroglycerin available, limit
epinephrine (LA and gingival cord)
*Profound local anesthesia and pain control
*Devices

141
Q

*Stress/Anxiety reduction:

A

➢Oral sedative &/or inhalation sedative

142
Q

Devices
(3)

A

➢Electrosurgery units contraindicated in patient with pacemakers and ICDs
➢Ultrasonic scalers –low risk interference
➢Battery operated curing lights –low risk interference

143
Q

Dental Treatment Considerations
* Do you take a blood thinner?
(5)

A

➢ How often do you have your INR measured?
➢ What was your last reading? What has been your range? (Ideal: < 3)
➢ When is your next reading?
➢ Does it take a long for you to stop bleeding after a cut?
➢ Have you ever been hospitalized due to bleeding?

144
Q

Local measures for hemostasis/

A

*Gelatin sponges (Gelfoam)
*Oxidized cellulose
*Chitosan hemostatic products
*Sutures
*Gauze with applied pressure
*Topical tranexamic acid
*Topical aminocaproic acid (Amicar)
*Topical thrombin
Electrocautery - not with pacemakers

Dental Management of a Complex Patient (13 decks)

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