Cardiovascular Diseases.pdf

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Cardiovascular Diseases Assoc. Prof. Büşra Yılmaz School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] OUTLINE Atherosclerosis Hypertension Angina Pectoris Heart Failure Arrhythmia Bacterial Endocarditis Heart t...

ORAL DIAGNOSIS AND DENTAL RADIOLOGY-II Cardiovascular Diseases Assoc. Prof. Büşra Yılmaz School of Dental Medicine Department of Oral and Maxillofacial Radiology [email protected] OUTLINE Atherosclerosis Hypertension Angina Pectoris Heart Failure Arrhythmia Bacterial Endocarditis Heart transplantation Congenıtal Heart Dıseases Atherosclerosis Characterized by lipid deposition on arterial walls Formed ATHEROM PLATES narrows the vessel diameter ischemia Ischemia: An inadequate blood supply to an organ or part of the body, especially the heart muscles. Atherosclerosis CLINICALLY; Arteriosclerotic Heart Disease (Angina etc.) Cerebrovascular Disease (Paralysis) Peripheral Vascular Diseases (Muscle Spasm) Atherosclerosis Narrowing of Coronary Arteries; Anginal Complaints Myocardial Infarction Arrhythmia Congestive Heart Failure Sudden death Atherosclerosis RISK FACTORS • • • • • • • • • • Hypertension Smoking High Blood Cholesterol Diabetes Mellitus Familial Predisposition Stress Birth Control Medicines (Oral contraceptives) Being in the Postmenopausal Period Obesity Inactivity Definition, Classification  European Society of Cardiology (ESC) guidelines that have a higher threshold for hypertension definition, with a systolic BP >140 mm Hg or a diastolic BP >90 mm Hg Hypertension is classified as primary and secondary…  Primary or essential hypertension accounts for ~90%. Etiology  Genetic factors  Age  Dietary intake (particularly sodium and potassium)  Physical inactivity  Obesity  Alcohol use Hypertension is classified as primary and secondary… Secondary hypertension accounts for ~10%.  A specific treatable cause of hypertension can be identified Etiology  Drug-related causes (in particular nsaids, oral contraceptives, and corticosteroids etc)  Primary renal disease: Glomerulonephritis, pyelonephritis, diabetic nephropathy  Endocrinologic causes such as a primary hyperparathyroidism  Central Nervous System Diseases: Increased intracranial pressure, Encephalitis CLINICAL FINDINGS • Frequent recurrent headaches • Weight loss • Anorexia • Dizziness • Nausea • Redness on face • Tiredness • Epistaxis • Visual ımpairments • Irritability Management Pharmacologic management of hypertension  Thiazide diuretic (e.g., 12.5–25 mg of hydrochlorothiazide or 25–50 mg of chlorthalidone)  ACEi, angiotensin receptor blocker (ARB), or a calcium-channel blocker can also be considered as first-line agents.  Aldosterone antagonist (such as spironolactone or eplerenone) or a beta-blocker, particularly one with some degree of alpha blockade (such as a carvedilol), can be added as second-line options. GINGIVAL HYPERPASTIC CHANGES MAY OCCUR DUE TO MEDICAMENTS nifedipine, nitrendipine, felodipine, amlodipine, nisoldipine, verapamil, and diltiazem Dental Management Considerations for Patients with Hypertension • Patients with elevated BP are potentially at increased risk for adverse events in a dental office setting, particularly if their BP is poorly controlled or if there is target organ disease involvement (heart, brain, kidney, peripheral arteries). • However, the absence of target organ disease does not mitigate a careful evaluation and treatment of patients within safe and appropriate parameters of care. • The primary concern for these patients is precipitating a hypertensive crisis, stroke, or MI. • Poor compliance with antihypertensive medications and diet is a common problem, and dentists can help by reinforcing the importance of following medical advice and guidelines. • Dental management guidelines have been proposed based on the medical model for assessment, risk stratification, and treatment of patients with hypertension.22–24Side effects of antihypertensive medications vary and can include orthostatic hypotension, synergistic activity with narcotics, and potassium depletion. Dental Management Considerations for Patients with Hypertension • Although safe limits for invasive dental procedures cannot be strictly defined, and they are largely based on an individual patient's overall medical condition, there arc general guidelines depending on whether patients have prehypertension, stage one or stage two hypertension, and target organ disease. • Elective treatment should be avoided if the BP is significantly above the patient's baseline or if it is >180 mm Hg systolic or >100 mm Hg diastolic. • If patients have any symptoms potentially related to hypertension, such as chest pain, headache, or focal neurologic symptoms, elective procedures should be canceled. • For patients who have an urgent dental problem, it may be desirable to remove the source (e.g., abscessed tooth) if the patient has mildly elevated BP, but if significantly elevated, oral pain and infection can usually be well managed pharmacologically until the BP is brought under control. • Patients may have somewhat elevated BP from pain and/or anxiety and they may have some lowering of their BP after local anesthesia, but this is unpredictable. ANGINA PECTORIS SHORT TERM TREATMENT Sublingual nitroglycerin tablet (0.3-0.6 mg.) Inhaled amylnitrate Sublingual trinitrate spray LONG-TERM TREATMENT Nitrates Beta blockers Calcium channel blockers Aspirin and heparin ANGINA PECTORIS Stable Angina: • Symptoms occur with exertion or exercise. • It disappears with rest or by taking a sublingual nitroglycerin tablet. Unstable Angina (Unstable Angina): • Pain with minimal exertion or at rest, especially at night • Lasts for a long time • The intensity and frequency of pain gradually increases, • Not good response to nitroglycerin ANGINA PECTORIS A symptom of pain in the chest as a result of myocardial ischemia PAIN; • Compression feeling in the retrosternal or precardial region, Pressure sensation • Shoulders, left arm, 4th and 5th fingers, may spread to the lower jaw, teeth • It usually takes 5-30 minutes • Relieve with nitroglycerin ANGINA PECTORIS TREATMENT NITRATES (Nitroglycerin, Isosorbide dinitrate) Facilitates the spread of blood from the coronary vessels to the subendocardium, reduces the workload of the heart Orthostatic hypotension, syncope, headache, nausea, vomiting BETA BLOCKERS (Propranolol, Pindolol) They prevent the effects of sympathetic stimuli and reduce the heart rate. Bradycardia, orthostatic hypotension, heart failure aggravating effect, fatigue, depression (Contraindicated in heart failure, conduction disorders, bronchial asthma) CALCIUM CHANNEL BLOCKERS (Nifedipine) They reduce Ca influx into myocardial cells, thereby reducing cardiac muscle contraction. Peripheral edema, GINGIVAL HYPERPLASIA ANGINA PECTORIS Dental Management Considerations; • Sessions should be kept short • Avoid creating stress and pain • Stressful patients should be sedated • Be cautious against side effects such as orthostatic hypotension and bradycardia. • Local anesthesia should be preferred • Deep anesthesia should be provided in a way that does not cause pain Myocardial Infarction (MI) heart attack, TR: kalp krizi Irreversible myocardial damage due to prolonged ischemia Clinical findings; Pain in the substernal or left precardial region Palpitation (TR: çarpıntı) Breathing difficulties Nausea, vomiting Abnormal heart rate Shock symptoms Myocardial Infarction (MI) DENTAL TREATMENT CONSIDERATIONS • • • • • • • • • Dental treatment should not be applied in the first 6 months Consultation with doctor needed Sedation before treatment Precautions to excessive bleeding Prothrombin time should be measured before surgery Appointments should be made in the morning Sessions should be kept short If pain occurs during treatment, treatment should be discontinued. Deep anesthesia should be applied in a way that does not cause pain HEART FAILURE (CONGESTIVE HEART FAILURE) Heart failure occurs when the heart muscle doesn't pump blood as well as it should. SYMPTOMS shortness of breath, excessive tiredness, leg swelling. HEART FAILURE Pulmonary edema, also known as pulmonary congestion, is excessive liquid accumulation in the tissue and air spaces (usually alveoli) of the lungs. • • • • • In cases with pulmonary edema; Chronic cough Edema A bluish tint to the skin and mucous membranes Swelling of the neck vein Cyanosis MANAGEMENT • Physical activities are limited • Bed rest is recommended • Emotional stress should be minimized • Dietary salt and water intake is restricted • Diuretics • Digitalis preparations are used DENTAL TREATMENT CONSIDERATIONS Patients in the low risk group; No dyspnea in normal activity Routine tests are done Under medication Using diuretics Conservative and prosthetic treatments Single tooth extraction Complicated interventions  Consultation + sedation Moderate risk patients Heart failure symptoms despite medication (+) Dyspnea at rest (-) Dyspnea during exercises (+) DENTAL TREATMENT 1- Consultation 2- After the clinical symptoms improve Conservative and prosthetic treatment Simple surgical interventions Complicated surgery in a hospital setting Patients in the high risk group Severe heart failure symptoms despite medication Dyspnea, orthopnea, paroxysmal nocturnal dyspnea peripheral edema, tachycardia and cyanosis DENTAL TREATMENT 1- Consultation 2- After the clinical symptoms improve Conservative and prosthetic treatment with sedation Simple surgical interventions Complicated surgery in a hospital setting ARRHYTHMIA Disturbances in the normal rhythm of the heart Heart rhythm problems (heart arrhythmias) occur when the electrical signals that coordinate the heart's beats don't work properly. The faulty signaling causes the heart to beat too fast (tachycardia), too slow (bradycardia) or irregularly ARRHYTHMIA • • • • DENTAL TREATMENT CONSIDERATIONS Detailed anamnesis Sedation Local anesthetics containing minimal adrenaline Treatment sessions are short If the heart rate is 60-100 If there are no symptoms If using medication Conservative treatment Simple surgical interventions Consultation + Treatment Advanced surgery  Hospital environment Electrical devices that prevent pacemakers from working Pacemaker (TR: kalp pili) An electronic device that is implanted in the body to monitor heart rate and rhythm. It gives the heart electrical stimulation when it does not beat normally. • • • • • • • Ultrasonic dental cleaning devices Vitalometers Electrical surgical instruments Radar currents Physical therapy tools Metal detectors Electrical devices with insufficient grounding ACUTE RHEUMATIC FEVER Rheumatic fever (RF) is an inflammatory disease that can involve the heart, joints, skin, and brain. The disease typically develops two to four weeks after a streptococcal throat infection. Group A, ß hemolytic streptococci Age; 5-15 years old Complication; Aort- Mythral Valves ACUTE RHEUMATIC FEVER TREATMENT: Anti-inflammatory drugs Aspirin Cortisone Antibiotic (Benzathine Penicillin G) BACTERIAL ENDOCARDITIS Endothelial valves of the heart or heart Infectious disease of the surfaces Bacteremia is the presence of bacteria in the bloodstream • Tooth extraction 10-100% • Periodontal surgery applications 36-88% • Tooth surface cleaning with ultrasonic devices 40% • Tooth brushing, use of dental floss 20-68% • Suture removal 6-16% • Chewing food 7-51% Without dental application; POOR ORAL HYGIENE PERIODONTITIS EVERYTHING THAT CAUSES BLEEDING IN GINGIVA AND MUCOSA CAN CAUSE PERIAPICAL INFECTIONS BACTEREMIA!!! Dental treatment Possibility of bacteremia??? Affecting the patient??? Gingival - mucosal bleeding Risky patient ANTIBIOTIC PROPHYLAXY HIGH RISK GROUP • • • • • • Patients with heart valve prosthesis Those with a history of endocarditis Those with complex cyanotic heart disease Single ventricle condition Transposition of the great arteries Tetralogy of Fallot (VSD, Right ventricular obstruction, hypertrophy, aortic dextro) • Patients who underwent surgical systemic pulmonary shunt MEDIUM RISK GROUP • Congenital heart malformations • Patent ductus arteriosus (The ductus arteriosus, which is located between the aorta and the left pulmonary artery in the fetal circulation, remains open after birth.) • Ventricular septal defect • Primum atrial septal defect • Aortic coartation • Bicuspid aortic valve • Acquired valve dysfunctions (ACUTE RHEUMATIC FEVER) • Hypertrophic cardiomyopathy • Mitral valve prolapse with valvar regurgitation (During the systole, cambering of the mitral valve leaflets into the left atrium) LOW RISK GROUP • Isolated secundum atrial septal defect • Surgically treated atrial - ventricular septal defect, patent ductus arteriosus • Past bypass operation • Mitral valve prolapse without valvar regurgitation • Physiological, functional and harmless heart sounds • Previous Kawasaki disease without valve dysfunction • Past rheumatic fever • Cardiac pace maker and implanted defibrillators APPLICATIONS THAT ENDOCARDITS PROPHYLAXY IS SUGGESTED         Tooth extraction Periodontal surgical applications Dental implant placement Root canal treatment / apical resection Subgingival placement of antibiotic fiber bands Placement of orthodontic bands Intraligamentary local anesthetic injections Prophylaxis in areas where bleeding is expected around the implant or teeth APPLICATIONS THAT DO NOT REQUIRE PROFILAXY      Restorative treatments Local anesthetic injections (non-intraligamentary) Endodontic treatments confined to the root canal Rubber dam placement Postoperative suture removal  Taking impression of tooth  Placement of removable dentures and orthodontic appliances  Fluor application  Taking oral radiographs  Adjusting orthodontic appliances  Decidious tooth extractions DENTAL APPROACH IN PATIENTS TO HAVE A HEART OPERATION  Short appointments and sedation practice  Epinephrine use should be restricted  Hospital environment in advanced dental practice  All acute infections should be treated in patients at low risk of postoperative bacterial endocarditis.  In patients with high risk of postoperative bacterial endocarditis, teeth with acute infection and teeth with poor prognosis due to pulpal / periodontal reasons should be extracted. DENTAL APPROACH IN PATIENTS WITH HEART OPERATION PROPHYLAXY Anticoagulant dose adjustment should be made Short appointments and sedation practice Epinephrine use should be restricted HEART TRANSPLANTATION Immunosuppression Steroid therapy Risk of infective endocarditis in the first 6 months Gingival Hyperplasia in patients using cyclosporine ORAL HYGIENE PROPHYLAXY CONGENITAL HEART DISEASES Ventricular Septal Defect (VSD) 30.5% Atrial Septal Defect (ASD) 9.8% Patent Ductus Arteriosus (PDA) 9.7% Pulmonary Stenosis (PS) 6.9% Coarctation of the Aorta 6.8% Congenital Aortic Stenosis 6.1% Tetralogy of Fallot 5.8% Transposition of the Great Vessels 4.2% Truncus Arteriosus 2.2% Tricuspid Atresia 1.3% Others 16.7% PATENT DUCTUS ARTERIOSUS Ductus arteriosus, a vascular structure connecting the pulmonary artery (pulmonary artery) and the main artery (aorta) At birth, all babies have it normally. It needs to be closed a few hours after birth. OPEN PATENT DUCTUS ARTERIOSUS Some of the oxygen-rich blood from the aorta returns to the lungs through this connection. Pressure rises in the pulmonary artery The left side of the heart is overloaded VENTRICULAR SEPTAL DEFECT (VSD) There is an opening between the two ventricles of the heart Too much blood passes from the left ventricle to the right ventricle due to the pressure difference From the lungs to the left of the heart oxygen-rich blood passes to the right, pumped back into the lungs PULMONARY ARTERY PRESSURE INCREASES Atrial Septal Defect (ASD) Excess oxygen-rich blood passes from the left side of the heart to the right side, and the blood is pumped back to the lungs. The blood flow to the lungs increases and the pulmonary vascular pressure rises. In the advanced stages, heart failure irregularities in heart rhythm develop. and Atrioventricular Septal Defect (ASD)  There is a large hole in the middle of the heart.  This opening involves both atria and ventricles.  In addition, the valves that separate the atria and ventricles from each other (mitral and tricuspid valves) are not fully formed and both are in the form of a single large valve.  It may be associated with Down syndrome. Aortic Stenosis • The aortic valve area is normally 2.5 cm2. • In a 1/3 narrowing, it becomes difficult to pump blood. • The second most common (4-7%) is cyanotic heart disease. • There are three leaflets in the aortic valve. • In congenital stenosis of the aorta, there may be a single thick and hard leaflet (unicuspid) or two leaflets (bicuspid) on the valve. Aortic Coarctation • Aorta (main artery) narrowed • Blood pressure increases from the heart to the site of the stenosis • The stenosis is usually seen after the veins leading to the head and arms have separated from the aorta. • According to the degree of stenosis, signs of heart failure occur. • Mild stenosis can be detected by heart murmur or hypertension without causing any complaints. References • Michael Glick (ed.); Martin S. Greenberg (ed.); Peter B. Lockhart (ed.); Stephen J. Challacombe (ed.). Burket's Oral Medicine. 13th edition. Wiley-Blackwell. June 2021. ISBN: 9781119597780