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Questions and Answers
What is the most prominent oral sign of tissue hypoxia in patients with valvular heart disease?
Which of the following conditions necessitates antibiotic prophylaxis during dental procedures?
In which of the following dental procedures is antibiotic prophylaxis recommended to minimize the risk of bacterial endocarditis?
Which of these patients is least likely to require antibiotic prophylaxis for dental procedures?
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What should be administered to patients who have undergone mitral valve repair?
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Which of the following is NOT a non-pharmacological treatment for hypertension?
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What is one potential oral manifestation of hypertension caused by anti-hypertensive drugs?
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Which of the following is considered a risk factor for coronary artery disease (CAD)?
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Which symptom is NOT commonly associated with the clinical presentation of coronary artery disease?
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What is a recommended dietary modification for hypertension management?
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Which condition is associated with elfin facies?
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What oral abnormality is characterized by an enlarged and bright red tongue?
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Which of the following conditions is associated with high arched palate?
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What characteristic finding may indicate the presence of coronary artery disease?
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Which of the following is true regarding Roth's spots?
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Gingival hyperplasia can occur as a side effect of which medication?
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What is the likely cardiovascular abnormality in a patient with blue sclera?
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What finding is a potential result of acute swelling in the mouth due to medication use?
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Which symptom is characterized by severe shortness of breath and is commonly associated with left-sided cardiac failure?
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What grading of dyspnoea indicates no limitation of any physical activity but dyspnoea occurs on more than ordinary exertion?
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Which type of dyspnoea occurs while lying down, usually within minutes of assuming that position?
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Which symptom involves a bluish-purple hue to the skin, often indicating a lack of oxygen?
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Which type of dyspnoea occurs in the upright position rather than while lying down, potentially indicating left atrial myxoma?
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Which of the following is NOT a typical gastrointestinal symptom associated with cardiovascular issues?
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Which condition is characterized by fainting or ‘passing out’?
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Which of these medical histories is least likely to be significant in a patient with cardiovascular disorders?
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What is the recommended position for the dental chair when treating patients with certain cardiac conditions?
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Which of the following is a common oral manifestation due to certain cardiac medications?
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In what circumstance is antibiotic prophylaxis particularly important for dental care?
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Which condition is classified as tachycardia?
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What should be avoided when administering local anesthetics to patients on beta blockers?
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Which of the following is a symptom of congestive heart failure that may be encountered clinically?
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What is the primary risk associated with the delay of elective dental care in patients with a history of recent myocardial infarction?
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What is a notable electrical activity abnormality in the heart that may lead to syncope?
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Study Notes
Oral Health Considerations and Oral Manifestations
- Valvular heart disease that compromises cardiac output can lead to signs of hypoxemia and cyanosis of lips and oral mucosa.
- Antibiotic prophylaxis should be administered to patients with a history of mitral or aortic valve repair or replacement, infective endocarditis, mitral or aortic regurgitation or stenosis, mitral valvular prolapse with valvular regurgitation, prosthetic heart valves, previous bacterial endocarditis, acquired valvular dysfunction, complex cyanotic congenital heart disease, and surgically constructed systemic pulmonary shunts.
Oral Procedures & Need for Antibiotic Prophylaxis to Minimize Risk of Bacterial Endocarditis
- Extractions, periodontal procedures including surgery, subgingival placement of antibiotic fibers or strips, scaling and root planning, implant placement, tooth reimplantation, placement of orthodontic bands (not brackets), endodontic instrumentation, intra-ligamentary injection, prophylactic cleaning of teeth where bleeding is anticipated, and other procedures in which significant bleeding is anticipated require antibiotic prophylaxis.
Cardiovascular Disorders
- Dyspnea, chest pain, palpitation, syncope, cough with expectoration and hemoptysis, cyanosis, right hypochondrial pain, swelling of feet, decrease in urine output, gastrointestinal symptoms like anorexia, fullness of abdomen, vomiting, fatigability, fever, diabetes mellitus, and hypertension are common symptoms and history of present illness.
Past History
- Rheumatic fever, cyanotic spells, recurrent respiratory infections since childhood, detection of murmur/cardiac lesion at school, recent dental extraction, genitourinary instrumentations, hypertension, diabetes mellitus, ischemic heart disease, or any other significant medical illness are important to consider in past history.
Family History
- Hypertension, ischemic heart disease, congenital heart disease, rheumatic heart disease, and sudden death are common family history features.
Personal History
- Appetite, weight loss, disturbed sleep, bowel and bladder disturbances, habits such as smoking and alcoholism, and exposure to syphilis are important personal history points.
Treatment History
- Nifedipine can cause gingival hyperplasia.
Approach to a Patient of Cardiac Disease - Analysis of Presenting Symptoms
- Dyspnea is a significant manifestation of cardiac failure, more common in left-sided heart failure than right heart failure.
- Functional grading of dyspnea includes Grade I: no limitation of physical activity but dyspnea occurs on more than ordinary exertion, Grade II: dyspnea on ordinary daily activity, Grade III: dyspnea on less than ordinary daily activities, and Grade IV: limitations of all activities (dyspnea at rest).
Orthopnea
- Dyspnea that occurs usually on lying down is orthopnea.
- It occurs within minutes of assuming recumbency and may indicate severe left heart failure (pulmonary edema).
Platypnea
- Dyspnea that occurs on sitting (upright) rather than lying down position is platypnea.
- It may be associated with left atrial myxoma or left atrial ball valve thrombus.
Trepopnea
- Breathlessness that occurs only when lying down in a lateral position is trepopnea.
- It could be due to ventilation-perfusion relationship alteration in certain body positions.
Abnormal Facial Features and Associated Conditions
- Elfin facies (receding jaws, flared nostrils, pointed ears) is associated with supraventricular aortic stenosis.
- High arched palate is associated with Marfan Syndrome.
- Mitral facies (malar flush and pinkish purple patches over the cheek) is associated with mitral stenosis with decreased cardiac output and systemic vasoconstriction.
Oral Manifestations of Cardiovascular Diseases
- Acute macroglossia: the tongue is diffusely enlarged and bright red along its lateral portion.
- Acute macroglossia due to Enalapril: swelling of tongue and lips.
- Gingival hyperplasia due to Dilantin: similar findings may be seen in patients on nifedipine.
- Tangier Disease of the Tonsils: enlarged tonsils with bright orange-yellow streaks ("Tiger Stripes").
Examination of Ear
- Presence of a crease in the pinna of the ear is associated with increased incidence of coronary artery disease.
Examination of Eyes
- Exophthalmus (bulging eyes): associated with Thyroid artery disease.
- Blue Sclera: Osteogenesis Imperfecta with aortic regurgitation.
- Roth's Spots (of infective endocarditis): small, white spots surrounded by a hemorrhagic halo in the retina.
Examination of Fingers
- Clubbing: thickening and widening of the fingertips, associated with various conditions including heart disease.
Causes of Cardiovascular Disease
-
Organic Disease of the Heart:
- Myocardial Overload: secondary to hypertension or valve disease.
- Coronary (Ischaemic) Heart Disease.
- Cardiomyopathies.
-
Endocardial Disease:
- Infective Endocarditis.
Dental Management
- Measure and record blood pressure at the initial visit.
- Assess the presence of hypertension.
- Determine the presence of target organ disease.
- Determine dental treatment modifications.
Treatment of Hypertension
-
Non-Pharmacological Treatment and Lifestyle Modifications:
- Salt restriction.
- Weight reduction.
- Stop smoking.
- Diet modifications: reduce intake of cholesterol and saturated fat, adequate intake of calcium and magnesium.
- Limit alcohol intake.
- Relaxation techniques like yoga and psychotherapy.
- Regular exercise.
Oral Manifestations of Hypertension
- There are no recognized oral manifestations of hypertension, but anti-hypertensive drugs can cause side effects such as:
- Xerostomia.
- Gingival overgrowth.
- Salivary gland swelling or pain.
- Lichenoid drug reactions.
- Erythema multiforme.
- Taste sense alteration.
- Paresthesia (tingling sensation).
Coronary (Ischemic) Artery Disease
- Atherosclerosis is the most common cause of coronary artery disease (CAD).
Etiopathogenesis of Coronary Artery Disease
- Risk factors include:
- Lipids (especially HDL).
- Hypertension.
- Diabetes mellitus and glucose intolerance.
- Cigarette smoking.
- Lifestyle and dietary factors.
- Exercise.
- Obesity.
- Vitamins.
- Plasma fibrinogen.
- Endothelial dysfunction.
- Antioxidants.
- Estrogen deficiency.
Diagnosis of Coronary Artery Disease
- Clinical Presentation: chest tightness, jaw discomfort, left arm pain, dyspnea, epigastric distress.
- Electrocardiogram (ECG/EKG).
- Imaging: echocardiography, electrophysiology.
- Blood Tests.
- Monitoring.
Oral Manifestations of Coronary Artery Disease
- Distention of the external jugular veins.
- Compensatory polycythemia: ruddy complexion and bleeding tendencies.
- Abnormal production of clotting factors.
Dental Aspects of Coronary Artery Disease
- Keep the dental chair in a partially reclining or erect position and raise the patient slowly to an upright position.
- Emergency dental care should be conservative, primarily with analgesics and antibiotics.
- Appointments should be short and non-stressful.
- Treat patients in the late morning because epinephrine levels peak in the early morning.
- Avoid bupivacaine as it is cardiotoxic.
- Use an aspirating syringe to give local anesthetic.
- Avoid large doses of epinephrine-containing local anesthetics in patients taking beta-blockers.
- Avoid gingival retraction cords containing epinephrine.
- Antibiotic prophylaxis is required for dental care.
- Delay elective dental care for 6 months after a recent myocardial infarction (MI).
Cardiac Arrhythmia
- Cardiac arrhythmia (also dysrhythmia) is any condition with abnormal electrical activity in the heart.
- The heartbeat may be too fast or too slow.
- Two types: Atrial arrhythmia and Ventricular arrhythmia.
Tachycardia
- Any heart rate faster than 100 beats/minute is considered tachycardia.
Bradycardia
- A slow rhythm (less than 60 beats/minute) can lead to syncope (fainting).
Heart Block
- Blockage of cardiac impulses anywhere in the conduction system.
Oral Manifestations Due to Medications
- Oral ulcerations.
- Xerostomia.
- Gingival hyperplasia.
Dental Considerations for Cardiac Arrhythmia
- A proper history should be taken.
- Stress and anxiety should be minimized.
- Appointments should be short.
- Use of epinephrine should be minimized.
- Proper chair position is important, preferably supine.
- At the end of the appointment, the chair should be raised slowly to minimize orthostatic hypotension.
- Use of vasoconstrictors should be minimized.
- Prophylactic antibiotics before and after treatment may be needed in recently placed pacemaker patients.
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Description
This quiz covers essential oral health considerations related to patients with valvular heart disease and the necessary antibiotic prophylaxis to prevent bacterial endocarditis. It addresses the oral manifestations of such conditions and the various oral procedures requiring special attention. Understand the critical link between oral health and cardiovascular risks.
