CH61: The Patient with a Cardiovascular Disease (LECTURE)

Learning objectives

• Identify the cardiovascular conditions that may be encountered in patients seeking oral health care

• Discuss the etiology, symptoms, and risk factors associated with cardiovascular conditions

• Discuss the impact of cardiovascular diseases on the oral cavity and their relationship to oral health

• Plan dental hygiene treatment modifications for the patient with cardiovascular disease

Why this matters

Cardiovascular disease = #1 cause of death in the U.S.

Oral inflammation ↔systemic inflammation

Dental hygienists often first to identify risk factors

Our goal: keep hearts safe during care + support prevention

Cardiovascular system review

Heart + vessels work with lungs to deliver oxygen

Pump deoxygenated blood →lungs; oxygenated →body

Both systems interdependent —disease in one affects the other

Modifiable risk factors  

90 % of MI & stroke risk is preventable

Change be changed: tobacco use, hypertension, hyperlipidemia, diabetes, obesity, stress, inactivity, poor diet

Non-modifiable: age, sex, family history

Dental team role = identify and reinforce healthy behaviors

Prevention and lifestyle counseling

Encourage tobacco cessation, exercise, diet changes

Link oral and cardiovascular health

Refer to physician if risk signs appear

Infective endocarditis

Bacterial infection of endocardium or heart valves →vegetations

Caused by: Streptococcus viridans, Staphylococcus aureus

Risk ↑ with bacteremia during subgingival instrumentation

Prevention = excellent oral hygiene + appropriate antibiotic prophylaxis

Who Needs Premedication?

Only for patients at highest risk of adverse outcomes from this

◦ Prosthetic valves or material used for valve repair

◦ Previous infective endocarditis

◦ Certain congenital heart defects

◦ Unrepaired cyanotic CHD (shunts/conduits)

◦ Repaired CHD with residual defect near prosthetic patch/device

◦ Cardiac transplant recipients with abnormal valves

Clinical Management for at risk pts

• Review medical history each visit –confirm cardiac status

• Ask: “Has your cardiologist recommended antibiotic premed?”

• Delay elective care if unclear or unstable

• Reinforce biofilm control & document antibiotic use

Fetal circulation and development 

Fetal heart is completely developed by week 9 of gestation

Ductus arteriosus connects pulmonary artery →aorta (bypasses fetal lungs)

Normally closes shortly after birth

If it stays open →patent ductus arteriosus (PDA)

Congenital heart defects and dental implications

Ventricular septal defect (VSD) = most common congenital heart defect

Other examples: atrial septal defect (ASD) and PDA

May occur with Trisomy 21 and other genetic syndromes

Surgically repaired early in life (may involve prosthetic device or patch)

Premedication indicated for 6 months post-repair or if residual defect remains

• If unsure whether premed is still needed, always consult with the cardiologist!

Rheumatic heart disease

From Group A strep →rheumatic fever →valve damage

Preventable by early antibiotic therapy for strep throat

Usually no premed unless other AHA indications exist

Mitral valve prolapse

Valve between left atrium and left ventricle doesn’t close properly →slight backflow of blood

May produce a click or murmur, often benign

Most cases asymptomatic

No premedication needed unless other qualifying cardiac condition exists

If patient uncertain, verify with physician before treatment

Heart murmurs and valve disorders

Murmur = sound from turbulent valve flow (not disease itself)

May indicate MVP or rheumatic scarring

Requires medical evaluation if new or symptomatic

Hypertension

“Silent killer” → major MI/stroke risk

Risk factors: age, obesity, diet, stress

Proceed if controlled; stress reduction, epi ≤ 0.04 mg, monitor BP every visit

≥180/110 + symptoms (severe dyspnea, headache)→ activate EMS

Ischemic heart disease

Reduced blood flow → reduced oxygen to tissue → pain or tissue death

Includes angina, MI, and heart failure

Risk factors: atherosclerosis (*main cause), smoking, hypertension

Angina pectoris

Chest pain due to temporary ischemia

Stable →predictable triggers (stress, exercise); relieved by rest/nitro

Unstable →unpredictable; may precede MI →urgent referral

Limit stress and chair time; always have nitro & oxygen accessible

Myocardial infarction

Complete coronary blockage → tissue death

Symptoms: chest pressure, nausea, sweating, shortness of breath, fatigue

Not relieved by rest or nitroglycerin

Emergency response: terminate treatment, sit upright, oxygen, call 911

Do not perform chest compressions unless unconscious & no pulse

Post Care:

Delay elective dental care 4-6 weeks, only after cardiology clearance

◦ Older “6 months” rule no longer currrent

Use stress-reduction techniques and monitor vitals

Keep oxygen and nitroglycerin available during appointments

Heart failure (CHF) 

Heart can’t pump adequately

Left sided: pulmonary congestion →shortness of breath, fatigue

Right sided: systemic congestion →swelling in feet/ankles, distended neck veins

Both sides: fluid in lungs and legs

Semi-supine or upright; short appointments; limit aerosols

Ischemic and circulatory conditions at a glance

Cardiac arrhythmias and devices

Abnormal rhythm or rate →may have pacemaker or ICD

Can be symptomatic or asymptomatic

Most do not require treatment

If they do:

◦ Drug therapy

◦ Lifestyle modification

◦ Medical procedures

Cardiac surgery and devices

CABG: bypass surgery; no premed after healing (~6 weeks)

Coronary stent: on antiplatelets →mild bleeding; don’t stop without MD approval

Pacemaker/ICD: avoid electromagnetic interference (ultrasonic cords, magnets)

Document device type + placement date

Antithrombotic therapy

Warfarin, DOACs, Aspirin, Clopidogrel ↑bleeding risk

Do not discontinue without physician clearance

Use local hemostatic measures (pressure, sutures, hemostatic agents)

Appointment planning and instrumentation

Review history & BP each visit

Stress-reduction protocol (quiet room, short appointments)

Semi-supine if dyspneic

Use HVE; avoid ultrasonic if pacemaker unshielded or respiratory distress present

Patient education and collaboration

Emphasize daily biofilm control →↓bacteremia risk

Reinforce modifiable risk factors (quit smoking, diet, activity)

Encourage compliance with meds & follow-ups

Coordinate with medical providers as needed

Key takeaways

Identify cardiac risk →modify care appropriately

4–6 weeks post-MI before elective care (when cleared)

AHA premed = high-risk only

90 % of CVD risk modifiable —DH impact matters