Cardiovascular Disorders DHS PDF

CARDIOVASCULAR DISORDERS The Cardiovascular system A)SYMPTOMS AND HISTORY OF PRESENT ILLNESS 1. DYSPNOEA - severe shortness of breath, or difficulty in breathing 2. CHEST PAIN 3. PALPITATION 4. SYNCOPE - fainting or “passing out” 5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS - coug...

CARDIOVASCULAR DISORDERS The Cardiovascular system A)SYMPTOMS AND HISTORY OF PRESENT ILLNESS 1. DYSPNOEA - severe shortness of breath, or difficulty in breathing 2. CHEST PAIN 3. PALPITATION 4. SYNCOPE - fainting or “passing out” 5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS - coughing up blood from the lungs 6. CYANOSIS - bluish-purple hue to the skin 7. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINE OUTPUT 8. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN AND VOMITING 9. FATIGABILITY 10. FEVER 11. DIABETES MELLITUS AND HYPERTENSION B)PAST HISTORY 1. RHEUMATIC FEVER 2. CYANOTIC SPELLS 3. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD 4. DETECTION OF MURMUR/CARDIAC LESION AT SCHOOL 5. RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS 6. HYPERTENSION, DIABETES MELLITUS, ISCHAEMIC HEART DISEASE OR ANY OTHER SIGNIFICANT MEDICAL ILLNESS C)FAMILY HISTORY 1. HYPERTENSION 2. ISCHAEMIC HEART DISEASE 3. CONGENTAL HEART DISEASE 4. RHEUMATIC HEART DISEASE 5. SUDDEN DEATH D)PERSONAL HISTORY 1. APPETITE 2. WEIGHT LOSS 3. DISTURBED SLEEP 4. BOWEL AND BLADDER DISTURBANCES 5. HABITS- SMOKING AND ALCOHOLISM 6. EXPOSURE TO SYPHILIS E)TREATMENT HISTORY NIFEDIPINE- GINGIVAL HYPERPLASIA APPROACH TO A PATIENT OF CARDIAC DISEAASE ANALYSIS OF PRESENTING SYMPTOMS 1)DYSPNOEA DEFINITION:- ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT. DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE. DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURE THAN DUE TO RIGHT HEART FAILURE. SEVERITY (GRADING) FUNCTIONAL GRADING OF DYSPNOEA GRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA OCCURS ON MORE THAN ORDINARY (UNOCCUSTOMED) EXERTION. GRADE II: DYSPNOEA ON ORDINARY DAILY ACTIVITY GRADE III : DYSPNOEA ON LESS THAN ORDINARY DAILY ACTIVITIES. GRADE IV : LIMITATIONS OF ALL ACTIVITIES( DYSPNOEA AT REST) 2)ORTHOPNOEA DEFINITION: DYSPNOEA THAT OCCURS USUALLY ON LYING DOWN. CHARACTERISTIC FEATURES: USALLY OCCURS WITHIN MINUTES OF ASSUMPTION OF RECUMBENCY. OCCURS WHEN A PATIENT IS AWAKE. INDICATES THE PRESENCE OF SEVERE LEFT HEART FAILRE (PULMONARY OEDEMA). 3)PLATYPNEA: DYSPNOEA OCCURS ON SITTING (UPRIGHT) RATHER THAN ON LYING DOWN POSITION. EXAMPLE: LEFT ATRIAL MYXOMA,LEFT ATRIAL BALL VALVE THROMBUS 4)TREPOPNEA: OCCURS ON BREATHLESSNESS ONLY WHEN LYING DOWN IN LATERAL POSITION. MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP ALTERATION IN CERTAIN BODY POSITION. 5)PROXIMAL NOCTURNAL DYSPNOEA ATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE DEGREE OF LEFT HEART FAILURE. 6)CHEYNES-STOKES BREATHING THERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OF APNOEA.SIGN OF SEVERE HEART FAILURE. 7)CYANOSIS A)CYANOSIS APPEARING IN INFANCY INDICATES THE PRESENCE OF CONGENITAL CARDIAC ANOMALIES WITH RIGHT TO LEFT SHUNT(TERATOLOGY OF FALLOT) B)CYANOSIS BEGINNING TO APPEAR AFTER 6 WEEKS OF AGE MAY BE AN INDICATION OF VSD WITH SLOWLY PROGRESSIVE RIGHT VENTRICUAR OUTFLOW OBSTRUCTION. C)HISTORY OF CYANOSIS IN A SUSPECTED PATIENT OF CONGENITAL HEART DISEASE BETWEEN THE AGE OF 5-20 YEARS INDICATES REVERSAL OF LEFT TO RIGHT SHUNT(EISENMEGER) 8)SWELLING OF FEET (PEDAL ODEMA) RIGHT HEART FAILURE CAUSES SYSTEMIC VENOUS CONGESTION WITH INCREASED HYDROSTATIC PRESURE IN THE LOWER LIMB VEINS. THIS RESULT IN THE TRANSUDATION OF FLUID CAUSING EDEMA. ANKLE EDEMA IS MORE COMMON IN AMBULATORY PATIENTS. BED-RIDDEN PATIENT DEVELOP SACRAL EDEMA. 9) DECREASED URINE OUTPUT IN THE PRESENCE OF CARDIAC FAILURE DUE TO DECREASED CARDIAC OUTPUT, RENAL BLOOD FLOW DECREASES WITH DECREASE IN THE GLOMERULAR FITRATION RATE, THIS CAUSES DECREASE OF URNE OUTPUT IN PATIENTS WITH CARDIAC FAILURE. 10)SYNCOPE TRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE. 11)COUGH AND EXPECTORATION 12)PALPITATION SUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT. EXAMINATION OF CARDIOVASCUAR SYSTEM SCHEME OF EXAMINATION GENERAL EXAMINATION 1. BUILD 2. NOURISHMENT 3.PALLOR 4.CYANOSIS 5. CLUBBING 6. JAUNDICE 7. PEDAL ODEMA 8. LYMPHADENOPATHY EXTERNAL MARKERS OF CARDIAC EXAMINATION OF PERIPHERAL DISEASE CARDIOVASCUAR SYSTEM RADIAL PULSE:- EXAMINATION OF :- RATE FACE RTHYM EYES VOLUME EARS CHARACTER SKIN AND MUCOSA CONDITION OF VESSEL WALL EXTREMITIES EXAMINATION OF:- VITAL SIGNS:- THE CAROTIDS PULSE THEIR PERIPHERAL PULSES BLOOD PRESSURE JUGULAR VENOUS PULSE AND PRESSURE RESPIRATORY RATE PERIPHERAL SIGNS OF WIDE PULSE TEMPERATURE PRESSURE(IN RELEVANT SITUATION) PERIPHERAL SIGNS OF INFECTIVE ENDOCARDITIS PERIPHERAL SIGNS OF RHEUMATIC FEVER EXAMINATION ALSO INCLUDES THE FOLOWING SIGNS A)PALLOR SEVERE ANEMIA MAY BE ASSOCIATED WITH: 1. CHRONIC Congestive Cardiac Failure CCF 2. INFECTIVE ENDOCARDITIS SEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE OR AGGRAVATE THE UNDERLYING HEART DISEASE. B)CYANOSIS: CENTRAL CYANOSIS OCCURS IN: 1. CYANOTIC CONGENITAL HEART DISEASE 2. REVERSAL OF LEFT TO RIGHT SHUNT 3. INTRAPULMONARY RIGHT TO LEFT SHUNT 4. PULMONARY EDEMA (LEFT HEART FAILURE) PERIPHERAL CYANOSIS OCCURS IN: 1. CONGENITAL CARDIAC FAILURE 2. PERIPHERAL VASCULAR DISEASE C))CLUBBING CARDIAC CAUSES: 1. CYANOTIC CONGENTAL HEART DISEASE 2. REVERSAL OF LEFT TO RIGHT SHUNT 3. INFECTIVE ENDOCARDITIS D)JAUNDICE FOLLOWING CARDIAC CONDITIONS MAY BE ASSOCIATED WITH JAUNDICE: 1. CONGESTIVE CARDIAC FAILURE WITH CONGESTIVE HEPATOMEGALY 2. CARDIAC CIRRHOSIS - hepatic disorders that occur secondary to hepatic congestion due to cardiac dysfunction 3. PULMONARY INFARCTION - occurs when a section of lung tissue dies because its blood supply has become blocked. E)PEDAL EDEMA PITTING EDEMA OF FEET CAN OCCUR IN: 1. CONGESTIVE CARDIAC FAILURE 2. CONSTRICTIVE PERICARDITIS 3. TRICUSPID VALVE DISEASE F)LYMPHADENPATHY: CONDITION ASSOCIATED WITH GENERALIZED LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULAR SYSTEM. E.G. LYMPHOMA EXAMINATION OF FACE FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYING CAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE. ABNORMALITIES CONDITION ASSOCIATED ELFIN FACIES RECEDING JAWS, SUPRAVENTRICULAR FLARED NOSTRILS, AORTIC STENOSIS POINTED EARS (narrowing of the portion of the aorta located just above the aortic valve) HIGH ARCHED PALATE MARFAN SYNDROME MITRAL FACIES MALAR FLUSH AND MITRAL STENOSIS PINKISH PURPLE WITH DECREASED PATCHES OVER THE CARDIAC OUTPUT CHEEK AND SYSTEMIC VASOCNSTRICTION MALAR FLUSH TETRATOLGY OF FALLOT MARFAN SYNDROME EXAMINATION OF MOUTH Acute macroglossia: the tongue is diffusely enlarged and bright red along its lateral portion. The patient had bleeding into the tongue while on anticoagulants. Acute macroglossia due to Enalapril: this 75-year-old Black female developed acute swelling of tongue and lips after being on enalapril for 2 days. She was unable to talk or swallow (upper photo). In lower photo, 2 days after stopping enalapril, the tongue and lips have returned to their normal size. GINGIVAL HYPERPLASIA DUE TO DILANTIN. SIMILAR FINDINGS MAY BE SEEN IN PATIENTS ON NIFEDIPINE TANGIER DISEASE OF THE TONSILS: THE TONSILS ARE ENLARGED WITH BRIGHT ORANGE YELLOW STREAKS (“TIGER STRIPES”) EXAMINATION OF EAR: PRESENCE OF CREASE IN THE PINNA OF THE EAR- ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY DISEASE.  EXAMINATION OF EYES: EXOPTHALMUS (bulging eyes): ASSOCIATED WITH THYROID ARTERY DISEASE. BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTIC REGULTATION. ROTH’S SPOTS( OF INFECTIVE ENDOCARDITIS) BLUE SCLERA ROTHS SPOT EXAMINATION OF FINGER CLUBBING CLUBING NEGATIVE CAUSES OF CARDIOVASCLAR DISEASE ORGANIC DISEASE OF HEART 1. MYOCARDIAL A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASE B. CORONARY( ISCHAEMIC) HEART DISEASE C. CARDIOMYOPATHIES 2. ENDOCARDIAL A. RHEUMATIC HEART DISEASE B. CONGENITAL ANOMALIES C. INFECTIVE ENDOCARDITIS 3. PERICARDIAL A. PERICARDITIS B. PERICARDIAL EFFUSION C. FUNCTIONAL DISORDERS DUE TO HYPERTENSION DUE TO ABNORMALITIES IN HEART RATE A. TACHYCARDIA B. BRADICARDIA C. OTHER DYSRTHYMIAS CHANGES IN CIRCULATORY VOLUME A. HYPOVOLOEMIA (SHOCK SYNDROME) B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD) C. OTHERS  HYPERTENSION Hypertension is known as Silent Killer of mankind. Most of the sufferers (85 %) are asymptomatic and hence early diagnosis is a problem. 22  Definition Hypertension is defined as having systolic blood pressure (SBP) >/= 130mm of Hg or diastolic blood pressure (DBP) >/= 90mm of Hg or as having to use antihypertensive medications. 23  Classification The Seventh Joint National Committee Criteria (JNC VII) classifies hypertension for adults aged 18 years and older into following stages: Blood Pressure Classification SBP(mm Hg) DBP(mmHg) Normal /=100 Types 25 Other Risk Factor of Hypertension Lack of exercise Increased salt intake Family history Too little potassium Alcohol Smoking Stress & Age 26  Effect of hypertension The common target organs damaged by long standing hypertension are: Brain Heart Kidneys Eyes & Peripheral arteries. 27  Symptoms Symptoms due to hypertension: 1.Headache - usually in morning hours. 2.Dizziness 3.Epistaxis Symptoms due to affection of target organs: 1.CVS: a.Dyspnea on exertion b.Anginal chest pain 28 c.Palpitations  2. Kidneys: Hematuria , nocturia , polyuria. 3.CNS: a.Transient ischemic attacks ( TIA or Stroke) b.Hypertensive encephalopathy(headache , vomiting etc.) c.Dizziness, Tinnitus & syncope. 4. Retina: a.Blurred vision or b.sudden blindness. 29  WHITE COAT HYPERTENSION ‘’White coat hypertension’’ is a phenomenon in which individuals present with persistent elevated BP in a clinical setting but present with non-elevated BP in an ambulatory setting. 20% of mild hypertensive individuals may present with white coat hypertension. 30  Dental Management Measure and record BP at initial visit 31 Before initiating dental care: Assess presence of hypertension Determine presence of target organ disease Determine dental treatment modifications 32  TREATMENT OF HYPERTENSION NON PHARMACOLOGICAL TREATMENT LIFESTYLE MODIFICATIONS 1. Salt restriction 2. Weight reduction 3. Stop smoking 4. Diet modifications such as: Reduce intake of Cholesterol & Saturated fat. Adequate intake of Calcium & Magnesium. 33 5. Limit of alcohol intake 6. Relaxation such as yoga, psychotherapy etc. 7. Regular exercise. 34  ORAL MANIFESTATION OF HYPERTENSION There are no recognized manifestations of hypertension but anti-hypertensive drugs can often cause side affects , such as: Xerostomia, Gingival overgrowth, Salivary gland swelling or pain, Lichenoid drug reactions, Erythema multiforme, Taste sense alteration, Paresthesia – tingling sensation 35  CORONARY (ISHAEMIC) ARTERY DISEASE  Atherosclerosis is the most common cause of CAD ETIOPATHOGENESIS Various risk factors include: 1. lipids (especially HDL) 2. hypertension 3. diabetes mellitus & glucose intolerance 4. cigarette smoking 5. lifestyle & dietary factors 6. exercise 7. obesity 8. vitamins 9. plasma fibrinogen 10. endothelial dysfunction 11. antioxidants 12. estrogen deficiency  DIAGNOSIS 1) Based on clinical presentation :  chest tightness  Jaw discomfort  Left arm pain  Dyspnea  Epigastric distress 2) E.C.G.  DENTAL ASPECTS STRESS, ANXIETY, EXERTION or PAIN can provoke angina Short, minimally stressful dental appointments Late morning appointments Excessive dose of LA containing adrenaline to be avoided in patients taking beta blockers Acute Coronary Syndromes Represent a continuous spectrum of disease ranging from unstable angina to MI  Angina pectoris Name given to paroxysms of severe chest pain CLINICAL FEATURES 1) 40 TO 60 years , M > F 2) pain often described as sense of Strangling, choking , Tightness, Heaviness ,Compression, or Constriction of chest 3) PAIN MAY RADIATE TO JAW or left arm 4) rarely pain in mandible, teeth or other tissues PRECIPITATING FACTORS Physical exertion(main) particularly in cold weather Emotion(anger or anxiety) & stress caused by fear or pain TYPICALLY RELIEVED BY REST  Dental aspects  Preoprerative glyceryl trinitrate & oral sedation advised sometimes  dental care carried with minimal anxiety & oxygen saturation  Monitor pulse & B.P.  POST ANGIOPLASTY elective dental care differed for 6 months , emergency dental care in a hospital setting  PTS with BYPASS GRAFTS – no anti biotic cover against infective endocarditis - LA containing adrenaline is contraindicated (may cause dysrhythmia)  PTS with vascular stents – no antibiotic cover except during 1st 6 week postop for emergency dental care  DRUGS used in treatment of angina may cause oral adverse effects like : -lichenoid reaction - gingival swelling - ulcers Gingival hyperplasia in patient consuming Ca channel blockers  Myocardial infarction Synonyms – coronary thrombosis or heart attack CLINICAL FEATURES 1. Clinical picture is variable 2. More than 50% patients are symptomless 3. MI may be preceded by angina often felt as indigestion like pain 4. any anginal attack lasting longer than 30 minutes is considered MI 5. Tachycardia &irregular pulse 6. nausea, vomitting, sweating ,restlessness, facial pallor 7. breathlessness, cough 8. Loss of conciousness, shock & even death 9. Many pts die within 1st hour to few days after attack THUS, MI is a MEDICAL EMERGENCY  General Precautions during Dental Procedures Dental clinic should have advanced cardiac life support or at least basic cardiac life support. Use of pulse oximeter to determine the level oxygenation. Automatic external defibrillator. Determination of vital signs prior to dental care. BP & pulse rate & rhythm should be recorded & any abnormal findings should be addressed. Premedication with antianxiety drugs and inhalation nitrous oxide in anxious patients. Elective procedures especially those requiring GA should be avoided for at least 4 wks after MI. consult pt’s physician prior to dental therapy  Management in dental chair 1. Terminate all dental treatment 2. Position pt in semirecline position 3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray 4. Administer oxygen 5. Check pulse & B.P. Discomfort relieved Discomfort continues 3 mins after 2 nd TNG 6. Assume angina pectoris is 6. give 2 nd TNG dose present 7. monitor vital signs. 7. Slowly taper oxygen over 5 mins 8. Modify t/t to prevent recurrence discomfort discomfort continues relieved 3 mins after TNG 8. give 3rd TNG dose 9. Monitor vitals 10. Call for medical assistance Discomfort relieved discomfort continues 3 mins after 3 rd TNG dose 11. Refer pt for medical 12.assume MI is in progress evaluation before 13. start i.v. line with drip of a crystalloid solution further dental care at 30 mL/ hr 14. If discomfort severe titrate morfine sulphate 2mg s/c or i/v every 3 mins until relief is obtained 15. Transport to emergency care. Administer Basic Life Support ,if necessary.  Anticoagulation Therapy & Dental Care Anticoagulant therapy is used both to treat & to prevent throboembolism. 2 major types : 1. antiplatlet medications 2. antithrombin medications Daily aspirin typically continued lifelong. May increase risk of oral bleeding following surgical procedures Rheumatic fever is an inflammatory disease that may develop two to three weeks after a Group A streptococcal infection (such as strep throat or scarlet fever). It is believed to be caused by antibody cross-reactivity and can involve the heart, joints, skin, and Brain Acute rheumatic fever commonly appears in children ages 5 through 15, with only 20% of first time attacks occurring in adults  What are the symptoms of strep throat? sudden onset of sore throat (streptococcal oropharyngitis) pain on swallowing fever, usually 101–104°F Headache Red and edematous soft palate and oropharynx. Areas of tonsillar ulceration and exudation. abdominal pain, nausea and vomiting may also occur, especially in children  What are the symptoms/clinical features of rheumatic fever? Symptoms may include: fever painful, tender, red swollen joints pain in one joint that migrates to another one heart palpitations chest pain shortness of breath skin rashes fatigue small, painless nodules under the skin  DENTAL CONSIDERATION- Dental extractions and local anesthesia in consent with physician. The prophylactic use of antibiotics prior to a dental procedure is now recommended ONLY for those patients with the highest risk of adverse outcome resulting from endocarditis Nitrous oxide used with approval of physician. General Anesthesia should be avoided, if essential must be given in hospital.  Rheumatic heart disease- History of rheumatic fever during childhood or adolescence can act as a predisposing factor for RHD after several years. Common signs- murmur due to valvular damage and later enlargement of heart.  ORAL MANIFESTATIONS Most prominent during acute phase, Pharyngitis Increase oral temperature Distended neck veins and a bluish color of the skin.  DENTAL CONSIDERATIONS- To prevent complication of infective endocarditis ,all dental procedures should be carried under antibiotic cover. Amoxicillin prophylaxis-1 hour before and 6 hours after the initial dose. Good oral hygiene measures ,fluoride treatment, chlorhexidine rinses and routine cleanings to reduce harmful bacteremias.  Proper history should be taken to identify history of rheumatic fever during childhood. Suspicious cases should be referred to cardiologist for cardiac evaluation prior to dental procedures. Clindamycin or erythromycin prophylaxis during dental treatment. Elective dental treatment under physician consultation.  HEART FAILURE- Heart failure (HF) is a condition in which a problem with the structure or function of the heart impairs its ability to supply sufficient blood flow to meet the body's needs. Common causes of heart failure – ischemic heart diseases Hypertension Valvular diseases  Biventricular failure - failure of one side of heart leads to failure of other. CLINICAL FEATURES pedal edema Dyspnea Congestion of neck veins Cyanosis Fatigue  DIAGNOSIS Imaging Echocardiography Electrophysiology electrocardiogram (ECG/EKG) Blood tests Monitoring  ORAL MANIFESTATIONS Distention of the external jugular viens. Compensatory polycythemia – ruddy complexion and bleeding tendencies. Abnormal production of clotting factors Bleeding can be spontaneous or extravasational (leaking).  DENTAL ASPECTS- The dental chair should be kept in partially reclining or erect position and patient should be raised slowly in upright position. Emergency dental care should be conservative principally with analgesics and antibiotics. Appointments should be short Non stressful appointments Patients are best treated in late morning because of epinephrine levels peak in early morning.  Bupivacaine should be avoided as it is cardiotoxic. An aspirating syringe should be used to give local anesthetic Epinephrine containing LA should be not given in large doses to patients taking beta blockers. Gingival retraction cords containing epinephrine should be avoided  Antibiotic prophylaxis req for dental care History of recent MI ,req delay of elective dental care for 6 months  CARDIAC ARRHYTHMIA -Cardiac arrhythmia (also dysrhythmia) is a term for any of a large and heterogeneous group of conditions in which there is abnormal electrical activity in the heart. The heart beat may be too fast or too slow, Two types- Atrial arrhythmia Ventricular arrhythmia  TACHYCARDIA- Any heart rate faster than 100 beats/minute is labelled tachycardia. BRADYCARDIA - A slow rhythm, (less than 60 beats/min), can lead to syncope. HEART BLOCK-blockage of cardiac impulse anywhere in the conduction system. ORAL MANIFESTATIONS DUE TO MEDICATION oral ulcerations xerostomia. gingival hyperplasia.  DENTAL CONSIDERATIONS- A proper history to be taken Stress and anxiety be minimized Short appointments Use of epinephrine to be minimized Proper chair position is important, SUPINE At end of appointment chair should be raised slowly to minimize orthostatic hypotension.  Use of vasoconstrictors should be minimized. Prophylactic antibiotics before and after treatment in recently placed pacemaker patients. Pts who report palpitations or skipped beats must be evaluated by physician  ORAL HEALTH CONSIDERATION & ORAL MANIFESTATION Valvular heart disease that compromises cardiac output produces signs of hypoxemia. Cyanosis of lips and oral mucosa is the most prominent oral sign of tissue hypoxia. According to American heart association guidelines: Antibiotic prophylaxis should be administered to patitents who have undergone mitral or aortic valve repair or replacement. Patients with a prior history of infective endocarditis. Patients with mitral or aortic regurgigation or stenosis. Patients with mitral valvular prolapse with valvular regurgigation. Prosthetic heart valves. Previous bacterial endocarditis. Acquired valvular dysfunction. Complex cyanotic congenital heart disease. Surgically constructed systemic pulmonary shunts. ORAL PROCEDURES & NEED FOR ANTIBIOTIC PROPHYLAXIS TO MINIMISE RISK OF BACTERIAL ENDOCARDITIS Extractions. Periodontal procedures including surgery,subgingival,placement of antibiotic fibers or Strips,scaling &root planning. Implant placement. Tooth reimplantation. Placement of orthodontic bands(not brackets). Endodontic instrumentation. Intra ligamentary injection. Prophylatic cleaning of teeth where bleeding is anticipated. Other procedure in which significant bleeding is anticipated.