6.5 - Dental Management of Heart Failure

dental management

heart failure is constellation of sign and symptoms as an endpoint of other disease processes

• major risk → asymptomatic heart failure patient may abruptly decompensate during dental treatment

  • possible consequences include acute heart failure, fatal arrhythmia, MI, CVA

• recognize heart failure patient before treatment

  • medical history

  • review pertinent body systems → orthopnea, weight gain, etc

  • measuring and evaluating vital signs

  • thorough list of patient medications

• if disease is identified → consultation with patient cardiologist

where HF patients can be treated

• stage A / B — treatable in typical office setting pending physician / cardiologist consult

• stage C — NYHA I, II, selected III in typical office setting with consult

  • critical to realize potential for decompensation during appointment

    • typically related to non-compliance with treatment regimen

  • remaining class III and IV → best managed in hospital dental clinic

• stage D — best managed in hospital dental clinic

dental appointment modifications for HF patients

short appointments, morning appointments

• nitrous oxide (minimum 30%) or supplemental oxygen may be used

• avoid positioning in fully supine position

  • increases venous return to failing heart, worsening pulmonary congestion and worsening dyspnea

  • sit upright or semi-supine position

• use of vasoconstrictors:

  • if not taking digoxin → limit to 2 cartridges of 1:100,000 epi

    • avoid vasoconstrictors in NYHA III and IV

  • if taking digoxin → avoid epinephrine because can precipitate arrhythmia

  • avoid epinephrine-impregnated retraction cord

• avoid NSAIDs

digoxin

used in heart failure and arrhythmias to increase force of contraction and decrease heart rate

• with epinephrine → precipitates dangerous arrhythmia

• narrow therapeutic range, so toxicity is important to recognize

  • headache, nausea, vomiting, hypersalivation, altered vision / color perception, fatigue, malaise, drowsiness, arrhythmia

  • if multiple findings are present → immediate physician referral