Dental Treatments For Heart Patients
Heart disease is an important topic for dental applications. In particular, the control of blood thinners, which most heart patients take regularly, and the prophylaxis of people with valvular heart disease are also important with regard to dental treatments. In coronary heart disease, depending on the severity of the disease, there is a risk of another heart attack or ischaemia during dental operations. For this reason, it is necessary for a dentist to know the type and severity of disease in people with heart disease, as this knowledge can change the form and timing of treatment.
Let’s take a closer look at some of the most common heart diseases:
Hypertension
If the diastolic blood pressure is 90 mm and the systolic blood pressure at rest is above 140 mm, this indicates hypertension. Most hypertensive patients are not aware of this situation. Late detected high blood pressure can lead to kidney damage.
The cause of hypertension is usually primary, i.e. the cause is not exactly known or occurs under the influence of genetic factors. Hormones, vascular or kidney diseases are responsible for the rest. Hypertension also has causes such as excessive salt consumption, stress, alcohol and cigarette consumption, obesity and inactivity. Painkillers, medicines for flu and colds can also raise blood pressure.
Fear of the dentist can increase blood pressure more in hypertensive patients. For this reason, the patient should have taken the medicine before the treatment, wait a while and the blood pressure should be measured before the treatment. Appointments should be made in the morning hours and the duration of treatment should be kept as short as possible. In patients with uncontrolled high blood pressure, conditions such as angina and congestive heart disease may develop along with stress. Simple surgical procedures and other treatments can easily be performed with local anaesthetics in patients whose blood pressure is under control. For advanced surgical procedures, the procedure should be performed with diazepam, nitrous oxide inhalation anaesthesia or oral sedatives. In patients with a blood pressure of about 160-169/100-109 mm Hg, dental treatment should not be performed and the patient should be referred to a physician.
The use of antihypertensive drugs may cause ulceration of the mouth, enlargement of the gums, lichenoid reactions and dry mouth. The patient’s oral care should be regular and motivated. In case of medication changes, the patient’s doctor should be contacted if necessary.
Arrhythmia
A disturbance of the heart rhythm in its normal course is called an arrhythmia. Arrhythmias can occur in coronary artery disease, hypertension and ageing. There are two types of arrhythmias, ventricular and atrial. The most common atrial arrhythmia is sinus tachycardia. While the heart rate in patients with atrial tachycardia is 120 per minute, in ventricular tachycardia it is 150. Stress, anxiety and exercise increase the heart rate, so fear of the dentist can cause sinus tachycardia.
In arrhythmia patients, a cardiac history should be obtained before dental treatment and a consultation requested if necessary. In these patients, treatments should be given in shorter sessions and the amount of anaesthetic solution to be used should be minimised. It may be uncomfortable to use electrical equipment such as electrosurgical and ultrasound instruments in patients with pacemakers.
Coronary Heart Diseases
Myocardial infarction (heart attack) due to long-term ischaemic injury to the heart and angina pectoris (chest pain) due to myocardial oxygen deprivation are known as coronary artery disease. Atherosclerosis (plaque formation due to accumulation of large amounts of lipids on the artery wall) is the most important cause of this disease.
There is a risk of developing new ischaemia or a heart attack when dental work is done in people with this disease. To avoid this risk, details such as the frequency of recurrence of ischaemic events, whether the disease is stable and how much time has passed since the previous heart attack should be obtained from the patient. The dentist treating people with ischaemic heart disease should have basic knowledge of life support (cardiac massage and artificial respiration). Before treatment, the patient’s vital signs (blood pressure, fever, respiratory rate, pulse) should be checked and necessary precautions taken. Anxiety can lead to ischaemia and angina by increasing blood pressure and heart rate. For this reason, anxiety should first be taken under control in stressed patients.
In patients who have just suffered an acute myocardial infarction, treatments should be postponed for at least 4 weeks to avoid the risk of another attack.
Anticoagulant therapy is used prophylactically for prosthetic valves, valvular heart disease, cerebrovascular accidents, ischaemic heart disease, deep vein thrombosis and pulmonary embolism. There are 2 types of drugs used for anticoagulant therapy. These are antithrombin and antiplatelet agents. Aspirin is the most common antiplatelet drug. It is used continuously in small doses for cerebrovascular and cardiovascular control. Aspirin reduces platelet aggregation and prolongs bleeding time. Aspirin 40-325 mg once daily, used by most patients, carries no risk of bleeding after surgery. If the patient has reasons such as uraemia or liver disease that increase the risk of bleeding, and if they are using other anticoagulants in addition to aspirin, they should stop taking aspirin 3-7 days before the surgical procedure. There is no need to discontinue the use of other antiplatelet agents before minor surgery. Warfarin is mainly used as an antithrombin. The therapeutic effect of this drug occurs after 48-72 hours and persists for 36-72 hours after discontinuation of the drug. The effectiveness of the drug warfarin can be determined using the International Normalised Ratio (INR). The patient’s INR should be determined within 24 hours of the surgical procedure. In healthy people, the normal INR is around 1. In patients receiving anticoagulant therapy, this value is in the range of 2.5-3.5. Minor surgery can be performed if the patient’s INR is below 3.0. If the patient’s INR is too high, 3 different routes can be considered: first, warfarin is not discontinued and antifibrinolytic mouthwashes and vitamin K injections are given to control bleeding. In the second, warfarin use is stopped 2-3 days before surgery and no other anticoagulant treatment is used. Thirdly, the treatment with warfarin is replaced by another treatment with anticoagulants (e.g. heparin). The main advantage in this case is the reduction in the patient’s risk of thromboembolism. Heparin can be used up to 6 hours before surgery and is administered together with warfarin after surgery. The process is continued until the INR reaches the desired value. It is advantageous that heparin can be used just before surgery, but there is a risk of thrombocytopenia.
Heart Valve Diseases
Bacterial endocarditis is an infection of the endocardium or heart valves, the inner layer of the heart. People with a previous diagnosis of endocarditis, people with artificial heart valves, people with damaged heart valves for reasons such as rheumatic fever, people with hypertrophic cardiomyopathy (thickening and hardening of the muscles in the ventricular walls and circulatory problems in the heart and its pumps) and people with congenital heart valve problems are at risk. Microorganisms in the oral flora can also cause bacterial endocarditis, and dentists should be alert to this situation. Therefore, a dentist should administer antibiotic prophylaxis to all patients with valvular heart disease to avoid the risk of bacterial endocarditis. Processes such as, implant placement, invasive tooth cleaning, subgingival curettage, incision and drainage of infections, all types of tooth extractions, reimplantations, endodontic treatments and endodontic surgery to pass the tip of the tooth, placement of orthodontic bands, intraligamentary injections that cause bleeding during the procedure, carry the risk of endocarditis. Not only bleeding processes in the mouth, but also periodontal or periapical infections can cause bacterial endocarditis. For this reason, it is the dentist’s responsibility to eliminate the identified foci of infection. Antiseptic mouthwashes used before dental procedures can help control bacteraemia.
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