the cardio vascular disease power point .docx
drsanjaybedi
86 views
195 slides
Jul 06, 2024
Slide 1 of 195
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87
88
89
90
91
92
93
94
95
96
97
98
99
100
101
102
103
104
105
106
107
108
109
110
111
112
113
114
115
116
117
118
119
120
121
122
123
124
125
126
127
128
129
130
131
132
133
134
135
136
137
138
139
140
141
142
143
144
145
146
147
148
149
150
151
152
153
154
155
156
157
158
159
160
161
162
163
164
165
166
167
168
169
170
171
172
173
174
175
176
177
178
179
180
181
182
183
184
185
186
187
188
189
190
191
192
193
194
195
About This Presentation
this topic will illustrates and help the people to understand the knowledge regarding cardio vascular system disease condition.
Slide Content
CARDIOVASCULAR
DISEASES
Dr Sharad Chand Gupta
1
DISEASES
Dr Sharad Chand Gupta
1
1) Introduction
2) Diagnosis of Cardiovascular
diseases
3) Causesofcardiovasculardiseases
4) Hypertension
5) CoronaryArteryDiseases(ischemic)
2
CONTENTS
2) Diagnosis of Cardiovascular
diseases
3) Causesofcardiovasculardiseases
4) Hypertension
5) CoronaryArteryDiseases(ischemic)
2
CONTENTS
6) Anginapectoris
7) MyocardialInfarction
8) Rheumaticfever
9) Rheumaticheartdiseases
10) HeartFailure
11) CardiacArrhythmia
12) OralHealthConsideration&OralManifestation
13) Oral Procedures & Need For Antibiotic
Prophylaxis To Minimise Risk Of Bacterial
7) MyocardialInfarction
8) Rheumaticfever
9) Rheumaticheartdiseases
10) HeartFailure
11) CardiacArrhythmia
12) OralHealthConsideration&OralManifestation
13) Oral Procedures & Need For Antibiotic
Prophylaxis To Minimise Risk Of Bacterial
Endocarditis
3
3
14) Pregnancyandcardiovasculardiseases
15) CongenitalCardiovasculardiseases
16) Studies involving cardiovascular diseases
and dentistry
15)Summary&Conclusion
15)References
4
15) CongenitalCardiovasculardiseases
16) Studies involving cardiovascular diseases
and dentistry
15)Summary&Conclusion
15)References
4
Cardiovasculardiseases(CVD)compriseofagroupofdiseas
es of heart and the vascular system.
30.5% of all deaths takes places globally according to the
global and regional estimates for 2008.
Compared with all other countries, India suffers thehighest
loss, due to dealths from CVDin people aged 35-64 years.
TheprevalenceofCVDis2-3timesmoreinurbanthan
rural.
5
INTRODUCTION
es of heart and the vascular system.
30.5% of all deaths takes places globally according to the
global and regional estimates for 2008.
Compared with all other countries, India suffers thehighest
loss, due to dealths from CVDin people aged 35-64 years.
TheprevalenceofCVDis2-3timesmoreinurbanthan
rural.
5
INTRODUCTION
On the Indian subcontinent and in Africa, it is
predominantly due to rheumatic fever, whereas
calcificaorticvalvediseaseisthemostcommon
problem in developed countries.
Withover3milliondeathsowingtoCVD
everyyear,Indiaissettobethe“HEART
DISEASECAPITALOFTHEWORLD”in
fewyears,saiddoctorsontheeveofWORLD
HEARTDAY(Sept.29th2010).
6
predominantly due to rheumatic fever, whereas
calcificaorticvalvediseaseisthemostcommon
problem in developed countries.
Withover3milliondeathsowingtoCVD
everyyear,Indiaissettobethe“HEART
DISEASECAPITALOFTHEWORLD”in
fewyears,saiddoctorsontheeveofWORLD
HEARTDAY(Sept.29th2010).
6
Prompt recognition of the development of
heartdiseaseislimitedbytwokeyfactors:
1) Firstly,itisoftenlatent.
2) Secondly, the diversity of
symptomsattributable to heart disease
is limited.
heartdiseaseislimitedbytwokeyfactors:
1) Firstly,itisoftenlatent.
2) Secondly, the diversity of
symptomsattributable to heart disease
is limited.
7
Hypertension
CoronaryArtery
Disease
Myocardial
Infarction
Acutecoronary
Syndrome
CVD
Rheumatic heart
disease & fever
CardiacArrythmia
AnginaPectoris
Stroke
CongenitalCV
Disease
CongestiveHeart
8
Failure
CoronaryArtery
Disease
Myocardial
Infarction
Acutecoronary
Syndrome
CVD
Rheumatic heart
disease & fever
CardiacArrythmia
AnginaPectoris
Stroke
CongenitalCV
Disease
CongestiveHeart
8
Failure
DIAGNOSIS
OFCARDIOVASCUL
ARDISEASE
9
OFCARDIOVASCUL
ARDISEASE
9
1) Symptomsandhistoryofpresentingillness
2) Pasthistory
3) FamilyHistory
4) PersonalHistory
10
SCHEMEOFHISTORY TAKING
2) Pasthistory
3) FamilyHistory
4) PersonalHistory
10
SCHEMEOFHISTORY TAKING
SYMPTOMSANDHISTORYOF
PRESENTINGILLNESS
1. Dyspnoea
2. ChestPain
3. Palpitation
4. Syncope
5. CoughWithExpectorationAndHaemoptysis
6. Cyanosis
11
PRESENTINGILLNESS
1. Dyspnoea
2. ChestPain
3. Palpitation
4. Syncope
5. CoughWithExpectorationAndHaemoptysis
6. Cyanosis
11
7. RightHypocondrialPain,SwellingOfFeetAnd
DecreaseInTheUrineOutput
8. GastrointestinalSymptomsLikeAnorexia,Full
ness Of Abdomen And Vomiting
9. Fatigability
10. Fever
11. DiabetesMellitusAndHypertension
12
DecreaseInTheUrineOutput
8. GastrointestinalSymptomsLikeAnorexia,Full
ness Of Abdomen And Vomiting
9. Fatigability
10. Fever
11. DiabetesMellitusAndHypertension
12
PASTHISTORY
1. RheumaticFever
2. CyanoticSpells
3. RecurrentRespiratoryInfectionsSinceChildhood
4. DetectionOfMurmur/CardiacLesionAtSchool
5. Recent Dental Extraction, Genitourinary
Instrumentations
6. Hypertension,Diabetes Mellitus,IschaemicHeart
DiseaseOrAnyOtherSignificantMedicalIllness
7. Nifedipine-GingivalHyperplasia
13
1. RheumaticFever
2. CyanoticSpells
3. RecurrentRespiratoryInfectionsSinceChildhood
4. DetectionOfMurmur/CardiacLesionAtSchool
5. Recent Dental Extraction, Genitourinary
Instrumentations
6. Hypertension,Diabetes Mellitus,IschaemicHeart
DiseaseOrAnyOtherSignificantMedicalIllness
7. Nifedipine-GingivalHyperplasia
13
FAMILYHISTORY
1. Hypertension
2. IschaemicHeartDisease
3. CongentalHeartDisease
4. RheumaticHeartDisease
5. SuddenDeath
14
1. Hypertension
2. IschaemicHeartDisease
3. CongentalHeartDisease
4. RheumaticHeartDisease
5. SuddenDeath
14
PERSONALHISTORY
1. Appetite
2. WeightLoss
3. DisturbedSleep
4. BowelAndBladderDisturbances
5. Habits- Smoking And Alcoholism
6. ExposureToSyphilis
15
1. Appetite
2. WeightLoss
3. DisturbedSleep
4. BowelAndBladderDisturbances
5. Habits- Smoking And Alcoholism
6. ExposureToSyphilis
15
APPROACHTOA PATI
ENTOFCARDIACDISE
ASE
16
ENTOFCARDIACDISE
ASE
16
ANALYSISOFPRESENTING
SYMPTOMS
DEFINITION:-
Abnormalawarenessofbreathingwithdiscomfort.
Dyspnoea is a significant manifestation of
cardiacfailure.
Dyspnoeaismorecommonlyduetoleft-sided
cardiacfailurethanduetorightheartfailure.
17
SYMPTOMS
DEFINITION:-
Abnormalawarenessofbreathingwithdiscomfort.
Dyspnoea is a significant manifestation of
cardiacfailure.
Dyspnoeaismorecommonlyduetoleft-sided
cardiacfailurethanduetorightheartfailure.
17
SEVERITY (GRADING)
:FUNCTIONALGRADINGOFDYSPNOEA
GRADE I : No limitationn of any physial activity but
dyspnoea occurs on more than ordinary (unoccustomed)
exertion.
GRADE II: Dyspnoea on ordinary daily activity
GRADEIII:Dyspnoeaonlessthanordinarydaily
activities.
GRADEIV:Limitationsofallactivities(dyspnoeaatrest)
18
:FUNCTIONALGRADINGOFDYSPNOEA
GRADE I : No limitationn of any physial activity but
dyspnoea occurs on more than ordinary (unoccustomed)
exertion.
GRADE II: Dyspnoea on ordinary daily activity
GRADEIII:Dyspnoeaonlessthanordinarydaily
activities.
GRADEIV:Limitationsofallactivities(dyspnoeaatrest)
18
Mechanismunderlyingdyspnoea:
During Heart Failure Interstitial pulmonary
edema stimulates the J receptors reflex
rapidandshallowbreathing.
Respiratorymusclefatigue
Bronchialmucosaledema
Increasedbronchialmucosalproduction
19
During Heart Failure Interstitial pulmonary
edema stimulates the J receptors reflex
rapidandshallowbreathing.
Respiratorymusclefatigue
Bronchialmucosaledema
Increasedbronchialmucosalproduction
19
ParoxysmalNocturnalDyspnoea(PND)
Thisisanattackofsevereshortnessofbreathand
coughing usually occurring at night.
Awakeningthepatientfromsleep.
Persistaftersittingupright.
May be due to depression of the respiratory centre at
night.
Reduced adrenergic stimulation to the myocardium
at night.
20
Thisisanattackofsevereshortnessofbreathand
coughing usually occurring at night.
Awakeningthepatientfromsleep.
Persistaftersittingupright.
May be due to depression of the respiratory centre at
night.
Reduced adrenergic stimulation to the myocardium
at night.
20
Definition:
Dyspnoeathatoccursusuallyonlyingdown/recumbentposition.
Characteristicfeatures:
Usuallyoccurswithinminutesofassumptionofrecumbency.
Occurswhenapatientisawake.
Indicates the presence of severe left heart failure (pulmonary
oedema).
Manifestslater than PND.(in slowlyprogressiveleftheart disease).
21
Dyspnoeathatoccursusuallyonlyingdown/recumbentposition.
Characteristicfeatures:
Usuallyoccurswithinminutesofassumptionofrecumbency.
Occurswhenapatientisawake.
Indicates the presence of severe left heart failure (pulmonary
oedema).
Manifestslater than PND.(in slowlyprogressiveleftheart disease).
21
Dyspnoeaoccursonsitting(upright)ratherthanon
lying down position.
Example:leftatrialmyxoma,leftatrialballvalve
thrombus.
22
lying down position.
Example:leftatrialmyxoma,leftatrialballvalve
thrombus.
22
Occurs on breathlessness only when lying
downin lateral/decubitus position.
May be due to ventilation perfusion relationship
alteration in certain body position.
Occur in patients with pathology of one
lungand chronic congestive heart failure.
23
downin lateral/decubitus position.
May be due to ventilation perfusion relationship
alteration in certain body position.
Occur in patients with pathology of one
lungand chronic congestive heart failure.
23
There is severe periods characterised by alternating
hypopnoea and hyperpnoea follwed by periods of
apnoea sign ofsevere heart failure.
The patient lies motionless for 10-20 seconds and
again the cycle is repeated.
Conditions associated : HF, Increased intracranial
pressure,Uraemia,Severepneumonia,Chronic
hypoxia,Narcoticdrugpoisoning,Cerebraltrauma
and haemorrhage, Normal subjects livingathigh
altitudes.
24
hypopnoea and hyperpnoea follwed by periods of
apnoea sign ofsevere heart failure.
The patient lies motionless for 10-20 seconds and
again the cycle is repeated.
Conditions associated : HF, Increased intracranial
pressure,Uraemia,Severepneumonia,Chronic
hypoxia,Narcoticdrugpoisoning,Cerebraltrauma
and haemorrhage, Normal subjects livingathigh
altitudes.
24
25
Bluishdicolorationofskinandmucousmembrane.
Resulting from increased amount of reduced
haemoglobin.
Cyanosis appearing in infancy indicates the presence
ofcongenital cardiac anomalies with right to left
shunt(teratology of fallot).
Cyanosisbeginningtoappearafter6weeksofagemaybe an
indication of VSD with slowly progressive right
ventricuaroutflowobstruction.
Historyofcyanosisinasuspectedpatientofcongenital
heartdiseasebetween theage of5-20yearsindicates reversal
of left to right shunt (Eisenmeger Syndrome).
26
Resulting from increased amount of reduced
haemoglobin.
Cyanosis appearing in infancy indicates the presence
ofcongenital cardiac anomalies with right to left
shunt(teratology of fallot).
Cyanosisbeginningtoappearafter6weeksofagemaybe an
indication of VSD with slowly progressive right
ventricuaroutflowobstruction.
Historyofcyanosisinasuspectedpatientofcongenital
heartdiseasebetween theage of5-20yearsindicates reversal
of left to right shunt (Eisenmeger Syndrome).
26
27
Rightheartfailurecausessystemicvenous
congestionwithincreasedhydrostatic
pressureinthelowerlimbveins.Thisresults
inthetransudationoffluidcausingedema.
Ankle edema is more common in
ambulatorypatients. Bed-ridden patient
develop sacral edema.
28
congestionwithincreasedhydrostatic
pressureinthelowerlimbveins.Thisresults
inthetransudationoffluidcausingedema.
Ankle edema is more common in
ambulatorypatients. Bed-ridden patient
develop sacral edema.
28
29
This is due to enlarged and congested liver and
stretchingof its capsule, as in congestive heart failure.
Cardiac pain may occasionally present as upper
abdominal pain.
Pain from a dissecting abdominal aortic aneurysm isusually
most marked in the back and may originate in thechest
and spread down the legs. Other arteries can have
aneurysms and bleed.
This is due to enlarged and congested liver and
stretchingof its capsule, as in congestive heart failure.
Cardiac pain may occasionally present as upper
abdominal pain.
Pain from a dissecting abdominal aortic aneurysm isusually
most marked in the back and may originate in thechest
and spread down the legs. Other arteries can have
aneurysms and bleed.
Inthe presence ofcardiac failure due todecreased cardiac
output, renal blood flow decreases with decrease in the
glomerular fitration rate, this causes decrease of urine
output in patientswithcardiac failure.
Transientlossofconsciousnesswithposturalcollapse.
Expectoration (coughing up) of blood or of blood-
stained sputum.
Suggests uncomfortable awareness of heartbeat, which
may be unpleasant.
30
output, renal blood flow decreases with decrease in the
glomerular fitration rate, this causes decrease of urine
output in patientswithcardiac failure.
Transientlossofconsciousnesswithposturalcollapse.
Expectoration (coughing up) of blood or of blood-
stained sputum.
Suggests uncomfortable awareness of heartbeat, which
may be unpleasant.
30
EXAMINATIONO
F
CARDIOVASCUAR SYSTE
M
31
F
CARDIOVASCUAR SYSTE
M
31
1) Generalexamination
2) Externalmarkersofcardiacdisease
3) Examinationofperipheralcardiovascular
system
4) Examinationofprecordium
5) Examinationsincludingvariousother signs
6) Examinationsofface
7) Examinationsofmouth
8) Examinationsofear
9) Examinationsofeyes
10) Examinationsoffingers 32
2) Externalmarkersofcardiacdisease
3) Examinationofperipheralcardiovascular
system
4) Examinationofprecordium
5) Examinationsincludingvariousother signs
6) Examinationsofface
7) Examinationsofmouth
8) Examinationsofear
9) Examinationsofeyes
10) Examinationsoffingers 32
GENERALEXAMINATION
1. Build
2. Nourishment
3.Pallor
4.Cyanosis
5. Clubbing
6. Jaundice
7. PedalOdema
8. Lymphadenopathy
33
1. Build
2. Nourishment
3.Pallor
4.Cyanosis
5. Clubbing
6. Jaundice
7. PedalOdema
8. Lymphadenopathy
33
PALLOR
Severe anemiamaybe associatedwith:
1. ChronicCCF
2. Infectiveendocarditis
Severe anemia can itself cause- cardiac failure or
aggravate the underlying heart disease.
Patients with cyanotic congenital heart disease may
have polycythemia with suffused conjunctiva.
34
Severe anemiamaybe associatedwith:
1. ChronicCCF
2. Infectiveendocarditis
Severe anemia can itself cause- cardiac failure or
aggravate the underlying heart disease.
Patients with cyanotic congenital heart disease may
have polycythemia with suffused conjunctiva.
34
CYANOSIS
Centralcyanosisoccursin:
[Decreasedatrialoxygensaturation]
1. Cyanoticcongenitalheartdisease
2. Reversaloflefttorightshunt(Eisenmenger’ssyndrome)
3. TetralogyofFallot
4. Pulmonaryedema(leftheartfailure)
Peripheralcyanosisoccursin:
[Diminished peripheral blood flow = Reduced
Cardiacoutput]
1. Congenitalcardiacfailure
2. Peripheralvasculardisease
3. Shock
35
Centralcyanosisoccursin:
[Decreasedatrialoxygensaturation]
1. Cyanoticcongenitalheartdisease
2. Reversaloflefttorightshunt(Eisenmenger’ssyndrome)
3. TetralogyofFallot
4. Pulmonaryedema(leftheartfailure)
Peripheralcyanosisoccursin:
[Diminished peripheral blood flow = Reduced
Cardiacoutput]
1. Congenitalcardiacfailure
2. Peripheralvasculardisease
3. Shock
35
Differentialcyanosis:
• Feetand toes are bluebut hands and fingers are
not cynosed.
• e.g. PDA with pulmonary hypertension with
reversal of shunt.
Reversedifferentalcyanosis:
• Fingersaremorecyanosedthantoes.
• e.g.Transposition of great vesselswith
pulmonaryhypertensionwithpreductal
coarctationwithreversedflowthroughPDA.
36
• Feetand toes are bluebut hands and fingers are
not cynosed.
• e.g. PDA with pulmonary hypertension with
reversal of shunt.
Reversedifferentalcyanosis:
• Fingersaremorecyanosedthantoes.
• e.g.Transposition of great vesselswith
pulmonaryhypertensionwithpreductal
coarctationwithreversedflowthroughPDA.
36
CLUBBING
CARDIACCAUSES:
1. Cyanoticcongenitalheartdisease
2. Reversaloflefttorightshunt
3. Infectiveendocarditis
Clubbingoffingersalsoknownasdrumstickfingersandwatch-glassnails.
Clubbingdevelopsinfivesteps:
1) Fluctuationandsofteningofthenailbed.
2) Loss of the normal <165° angle (Lovibond angle) between the nailbed and the
fold (cuticula).
3) Increasedconvexityofthenailfold.
4) Thickeningofthewholedistal(endpartofthe)finger(resemblinga
drumstick).
5) Shinyaspectandstriationofthenailandskin.
37
CARDIACCAUSES:
1. Cyanoticcongenitalheartdisease
2. Reversaloflefttorightshunt
3. Infectiveendocarditis
Clubbingoffingersalsoknownasdrumstickfingersandwatch-glassnails.
Clubbingdevelopsinfivesteps:
1) Fluctuationandsofteningofthenailbed.
2) Loss of the normal <165° angle (Lovibond angle) between the nailbed and the
fold (cuticula).
3) Increasedconvexityofthenailfold.
4) Thickeningofthewholedistal(endpartofthe)finger(resemblinga
drumstick).
5) Shinyaspectandstriationofthenailandskin.
37
JAUNDICE
Following cardiac conditions may be
associatedwith jaundice:
1. Congestivecardiacfailurewithcongestive
hepatomegaly
2. Cardiaccirrhosis
3. Pulmonaryinfarction
38
Following cardiac conditions may be
associatedwith jaundice:
1. Congestivecardiacfailurewithcongestive
hepatomegaly
2. Cardiaccirrhosis
3. Pulmonaryinfarction
38
39
PEDALEDEMA
Pittingedemaoffeetcanoccurin:
1. congestivecardiacfailure
2. constrictivepericarditis
3. tricuspidvalvedisease
LYMPHADENPATHY
Condition associated with
generalizedlymphadenopathy
mayinvolve thecardiovascular system.
e.g.lymphoma,SLEetc.
PEDALEDEMA
Pittingedemaoffeetcanoccurin:
1. congestivecardiacfailure
2. constrictivepericarditis
3. tricuspidvalvedisease
LYMPHADENPATHY
Condition associated with
generalizedlymphadenopathy
mayinvolve thecardiovascular system.
e.g.lymphoma,SLEetc.
EXTERNALMARKERSOF
CARDIACDISEASE
VITALSIGNS
• Pulse
• BloodPressure
• RespiratoryRate
• Temperature
RADIALPULSE
• Rate
• Rythm
• Volume
• Character
40
CARDIACDISEASE
VITALSIGNS
• Pulse
• BloodPressure
• RespiratoryRate
• Temperature
RADIALPULSE
• Rate
• Rythm
• Volume
• Character
40
EXAMINATIONOF
• The Carotids & Jugular Venous Pulse And
Pressure
• PeripheralSignsOfInfectiveEndocarditis
• PeripheralSignsOfRheumaticFever
41
• The Carotids & Jugular Venous Pulse And
Pressure
• PeripheralSignsOfInfectiveEndocarditis
• PeripheralSignsOfRheumaticFever
41
JugularVenousPulse
42
42
43
44
EXAMINATIONOFTHEPRECORDIUM
INSPECTION
1. PrecordialBulge
• PositionOfApicalImpulse
Pulsations In The:-
A. LeftParasternalRegion
B. 2
nd
LeftIntercostalSpace
C. 2
nd
RightIntercostalSpace
D. EpigastricPulsation
E. SuprasternalPulsation
F. EngorgedVeinsOverTheChest
G. Spine(kyphoscoliosis)
45
INSPECTION
1. PrecordialBulge
• PositionOfApicalImpulse
Pulsations In The:-
A. LeftParasternalRegion
B. 2
nd
LeftIntercostalSpace
C. 2
nd
RightIntercostalSpace
D. EpigastricPulsation
E. SuprasternalPulsation
F. EngorgedVeinsOverTheChest
G. Spine(kyphoscoliosis)
45
PALPATION
• PERCUSSION
1) RightCardiacBorder
2) LeftCardiacBorder
3) Left And Right 2nd
Intercostal Space.
46
• PERCUSSION
1) RightCardiacBorder
2) LeftCardiacBorder
3) Left And Right 2nd
Intercostal Space.
46
AUSCULTATION
• Mitral, Tricuspid, Aortic, Pulmonary
AndOther Additional Areas For:-
A) 1
st
And2
nd
HeartSounds
B) AdditionalSounds
C) Murmurs
47
• Mitral, Tricuspid, Aortic, Pulmonary
AndOther Additional Areas For:-
A) 1
st
And2
nd
HeartSounds
B) AdditionalSounds
C) Murmurs
47
EXAMINATIONOFFACE
FollowingFeaturesMayBeIndicativeOfUnderlyingCardiacAbnormality
While Examination Of Face :
ABNORMALITIES CLINICALMANIF
ESTATIONS
CONDITIONS
ASSOCIATED
ELFINFACIES Recedingjaws,
Flarednostrils,
Pointedears
Supraventricular
aorticstenosis
HIGHARCHED
PALATE
Marfansyndrome
MITRALFACIES Malar flush and
pinkish purple
patchesoverthe
cheek
Mitral stenosis with
decreasedcardiac
outputandSystemic
vasoconstriction
48
FollowingFeaturesMayBeIndicativeOfUnderlyingCardiacAbnormality
While Examination Of Face :
ABNORMALITIES CLINICALMANIF
ESTATIONS
CONDITIONS
ASSOCIATED
ELFINFACIES Recedingjaws,
Flarednostrils,
Pointedears
Supraventricular
aorticstenosis
HIGHARCHED
PALATE
Marfansyndrome
MITRALFACIES Malar flush and
pinkish purple
patchesoverthe
cheek
Mitral stenosis with
decreasedcardiac
outputandSystemic
vasoconstriction
48
MALARFLUSH
MARFANS
YNDROME
TERATOLGYOF
FALLOT
49
MARFANS
YNDROME
TERATOLGYOF
FALLOT
49
EXAMINATIONOFMOUTH
Acutemacroglossia:
The tongue is diffusely enlarged and
brightredalongitslateralportion.The
patienthadbleedingintothetongue while
on anticoagulants.
Acutemacroglossia
Due to Enalapril: this 75-year-old Black
femaledeveloped 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
tongueandlipshavereturnedtotheirnormalsize.
50
Acutemacroglossia:
The tongue is diffusely enlarged and
brightredalongitslateralportion.The
patienthadbleedingintothetongue while
on anticoagulants.
Acutemacroglossia
Due to Enalapril: this 75-year-old Black
femaledeveloped 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
tongueandlipshavereturnedtotheirnormalsize.
50
GUMHYPERPLASIA
Due to dilantin. similar findings
maybeseeninpatientson
nifedipine
TANGIER DISEASE OF
THETONSILS:
Thetonsilsareenlargedwith
brightorange yellow streaks
(“tigerstripes”)(prematurecad).
51
Due to dilantin. similar findings
maybeseeninpatientson
nifedipine
TANGIER DISEASE OF
THETONSILS:
Thetonsilsareenlargedwith
brightorange yellow streaks
(“tigerstripes”)(prematurecad).
51
EXAMINATIONOFEYES:
• Exopthalmus:associatedwiththyroidartery
disease.
• Bluesclera:Osteogenesisimperfectawithaorticregulation.
• Opthalmicfundus:looks for
a. Arterioscleroticchanges
b. Hypertensiveretinopathy
c. Roth’sspots(ofinfectiveendocarditis)
d. Corkscrewarteries-coarctationofaorta.
ROTHSSPOT
BLUESCLERA
52
• Exopthalmus:associatedwiththyroidartery
disease.
• Bluesclera:Osteogenesisimperfectawithaorticregulation.
• Opthalmicfundus:looks for
a. Arterioscleroticchanges
b. Hypertensiveretinopathy
c. Roth’sspots(ofinfectiveendocarditis)
d. Corkscrewarteries-coarctationofaorta.
ROTHSSPOT
BLUESCLERA
52
EXAMINATIONOFFINGER
CLUBBING
CLUBING
NEGATIVE
53
CLUBBING
CLUBING
NEGATIVE
53
OSLERSNODEINENDOCARDITIS
SUBUNGALHAEMORRHAGES
JANEWAYLESIONS
54
SUBUNGALHAEMORRHAGES
JANEWAYLESIONS
54
CAUSESO
F
CARDIOVASCLAR
DISEASE
55
F
CARDIOVASCLAR
DISEASE
55
1. MYOCARDIAL
A. OverloadSecondaryTo HypertensonOr Valve
Disease
B. Coronary(Ischaemic)HeartDisease
C. Cardiomyopathies
2. ENDOCARDIAL
A. RheumaticHeartDisease
B. CongenitalAnomalies
C. InfectiveEndocarditis
3. PERICARDIAL
A. Pericarditis
B. PericardialEffusion
C. FunctionalDisorders
56
A. OverloadSecondaryTo HypertensonOr Valve
Disease
B. Coronary(Ischaemic)HeartDisease
C. Cardiomyopathies
2. ENDOCARDIAL
A. RheumaticHeartDisease
B. CongenitalAnomalies
C. InfectiveEndocarditis
3. PERICARDIAL
A. Pericarditis
B. PericardialEffusion
C. FunctionalDisorders
56
DUETOHYPERTENSION
DUETOABNORMALITIESINHEARTRATE
A. Tachycardia
B. Bradicardia
C. OtherDysrthymias
CHANGESINCIRCULATORYVOLUME
A. Hypovoloemia(ShockSyndrome)
B. Hypervolaemia(CirculatoryOverload)
C. Others
CONGENITALABNORMALITIES:
1) Patentductusarteriosus
2) Ventricularseptaldefect
3) Arterialseptaldefect
4) TetralogyofFallot,etc.
57
DUETOABNORMALITIESINHEARTRATE
A. Tachycardia
B. Bradicardia
C. OtherDysrthymias
CHANGESINCIRCULATORYVOLUME
A. Hypovoloemia(ShockSyndrome)
B. Hypervolaemia(CirculatoryOverload)
C. Others
CONGENITALABNORMALITIES:
1) Patentductusarteriosus
2) Ventricularseptaldefect
3) Arterialseptaldefect
4) TetralogyofFallot,etc.
57
FUNCTIONALCAPACITY
OBJECTIVE
ASSESSMENT
CLASSI.Patients With Cardiac Disease ButWithout
ResultingLimitation Of Physical Activity. Ordinary Physical
Activity
DoesNotCauseUndueFatigue,Palpitation,Dyspnea,Or
Anginal Pain.
A. No Objective
Evidence Of
Cardiovascular
Disease.
CLASS II. Patients With Cardiac Disease Resulting In
SlightLimitationOfPhysicalActivity.They Are ComfortableAt
Rest. Ordinary Physical Activity Results In Fatigue,
Palpitation, Dyspnea, Or Anginal Pain.
B. Objective Evidence
Of Minimal
Cardiovascular
Disease.
CLASSIII.Patients
WithCardiacDiseaseResultingInMarkedLimitationOf
PhysicalActivity. They Are Comfortable At Rest. Less Than
Ordinary Activity Causes Fatigue, Palpitation, Dyspnea, Or
Anginal Pain.
C. Objective Evidence
Of Moderately
Severe
Cardiovascular
Disease.
NYHACLASSIFIACTION
OBJECTIVE
ASSESSMENT
CLASSI.Patients With Cardiac Disease ButWithout
ResultingLimitation Of Physical Activity. Ordinary Physical
Activity
DoesNotCauseUndueFatigue,Palpitation,Dyspnea,Or
Anginal Pain.
A. No Objective
Evidence Of
Cardiovascular
Disease.
CLASS II. Patients With Cardiac Disease Resulting In
SlightLimitationOfPhysicalActivity.They Are ComfortableAt
Rest. Ordinary Physical Activity Results In Fatigue,
Palpitation, Dyspnea, Or Anginal Pain.
B. Objective Evidence
Of Minimal
Cardiovascular
Disease.
CLASSIII.Patients
WithCardiacDiseaseResultingInMarkedLimitationOf
PhysicalActivity. They Are Comfortable At Rest. Less Than
Ordinary Activity Causes Fatigue, Palpitation, Dyspnea, Or
Anginal Pain.
C. Objective Evidence
Of Moderately
Severe
Cardiovascular
Disease.
NYHACLASSIFIACTION
CLASSIV.PatientsWithCardiacDiseaseResultingInInability
To Carry On Any Physical Activity Without Discomfort.
SymptomsOfHeartFailureOrTheAnginalSyndromeMay Be
Present Even At Rest. If Any Physical Activity Is
Undertaken,DiscomfortIsIncreased.
D. Objective Evidence
Of Severe
Cardiovascular
Disease.
58
To Carry On Any Physical Activity Without Discomfort.
SymptomsOfHeartFailureOrTheAnginalSyndromeMay Be
Present Even At Rest. If Any Physical Activity Is
Undertaken,DiscomfortIsIncreased.
D. Objective Evidence
Of Severe
Cardiovascular
Disease.
58
59
HYPERTENSION
HYPERTENSION
CONTENTSOFHYPERTENSION
Definition
Classification
Types
Otherriskfactors
Effectsofhypertension
Complications
Symptoms
Oralmanifestations
Diagnosis
Whitecoathypertension
Dentalmanagement
Treatmentofhypertension
Oralmedicationsused
Conclusion
60
Definition
Classification
Types
Otherriskfactors
Effectsofhypertension
Complications
Symptoms
Oralmanifestations
Diagnosis
Whitecoathypertension
Dentalmanagement
Treatmentofhypertension
Oralmedicationsused
Conclusion
60
HYPERTENSION
HypertensionisknownasSilentKillerofmankind.
Most of the sufferers (85 %) are asymptomatic and
hence early diagnosis is a problem.
Normal or optimal blood pressure (BP) is defined
asthelevelabovewhichminimalvasculardamage occurs.
There is a continuous, consistent, and independent
relationship between elevated BP and risk of
cardiovascular events.
61
HypertensionisknownasSilentKillerofmankind.
Most of the sufferers (85 %) are asymptomatic and
hence early diagnosis is a problem.
Normal or optimal blood pressure (BP) is defined
asthelevelabovewhichminimalvasculardamage occurs.
There is a continuous, consistent, and independent
relationship between elevated BP and risk of
cardiovascular events.
61
Definition
• Hypertensionisusuallydefinedbythepresenceofachronic
elevation of systemic arterial pressure above a certain threshold
value.*
• AccordingtoDavidson:
• Hypertensionisdefinedashavingsystolicbloodpressure(SBP)
>/=140mmofHg.
(or)
Diastolicbloodpressure(DBP)>/=90mmofHg. (or)
Ashavingtouseantihypertensivemedications.
*ThomasD.Gilesetal.DefinitionandClassificationofHypertensio
n: An Update ; Emerging concept : 2009, 11:611–614.
62
• Hypertensionisusuallydefinedbythepresenceofachronic
elevation of systemic arterial pressure above a certain threshold
value.*
• AccordingtoDavidson:
• Hypertensionisdefinedashavingsystolicbloodpressure(SBP)
>/=140mmofHg.
(or)
Diastolicbloodpressure(DBP)>/=90mmofHg. (or)
Ashavingtouseantihypertensivemedications.
*ThomasD.Gilesetal.DefinitionandClassificationofHypertensio
n: An Update ; Emerging concept : 2009, 11:611–614.
62
The Seventh Joint National Committee Criteria
(JNCVII)classifies hypertension for adults aged
18yearsandolderintofollowingstages:
BloodPressureClassification SBP(mmHg) DBP(mmHg)
• Normal <120 & <90
• Prehypertension 120-139 & 80-89
• StageIhypertension 140-159 & 90-99
• StageIIhypertension >/=160 & >/=100
• IsolatedSystolichptn. >140 & <90
63
CLASSIFICATION
(JNCVII)classifies hypertension for adults aged
18yearsandolderintofollowingstages:
BloodPressureClassification SBP(mmHg) DBP(mmHg)
• Normal <120 & <90
• Prehypertension 120-139 & 80-89
• StageIhypertension 140-159 & 90-99
• StageIIhypertension >/=160 & >/=100
• IsolatedSystolichptn. >140 & <90
63
CLASSIFICATION
• “For individuals 40-70 years of age, each increment of
20mmHginsystolicBPor10mmHgindiastolicBPdoublesth
e riskof CVD across the entire BP rangefrom 115/75 to
185/115 mmHg”. [JNC VII. JAMA 2003;289:2560-2572 ]
ClassificationaccordingtoWHO
• GradeI:Hypertensionwithoutdamagestotheend
organ.
• Grade II: Hypertension with damages to the
endorgan(e.g..fundushypertonicus(GradeIandII),p
laqueformationinthelargerbloodvessels)
• GradeIII:Hypertensionwith
manifest cardiovascular secondary diseases
(e.g. angina pectoris,heart attack, stroke)
64
20mmHginsystolicBPor10mmHgindiastolicBPdoublesth
e riskof CVD across the entire BP rangefrom 115/75 to
185/115 mmHg”. [JNC VII. JAMA 2003;289:2560-2572 ]
ClassificationaccordingtoWHO
• GradeI:Hypertensionwithoutdamagestotheend
organ.
• Grade II: Hypertension with damages to the
endorgan(e.g..fundushypertonicus(GradeIandII),p
laqueformationinthelargerbloodvessels)
• GradeIII:Hypertensionwith
manifest cardiovascular secondary diseases
(e.g. angina pectoris,heart attack, stroke)
64
TYPES
PRIMARY(or)ES
SENTIALHYPERT
ENSION
• Which develops
graduallyovermany
years & has no
underlyingcause.
• 90% of people have this
type of hypertension
SECONDARYH
YPERTENSION
• Whichhasanunderlying
cause such as renal
disorders, endocrinal
disturbances, neurologic
causes etc.
• 10%ofpeoplehavethis
type of hypertension.
65
PRIMARY(or)ES
SENTIALHYPERT
ENSION
• Which develops
graduallyovermany
years & has no
underlyingcause.
• 90% of people have this
type of hypertension
SECONDARYH
YPERTENSION
• Whichhasanunderlying
cause such as renal
disorders, endocrinal
disturbances, neurologic
causes etc.
• 10%ofpeoplehavethis
type of hypertension.
65
OtherRiskFactorofHypertension
• Lackofexercise
• Increasedsaltintake
• Familyhistory
• Toolittlepotassium
• Alcohol
• Smoking
• Stress&
• Age
66
• Lackofexercise
• Increasedsaltintake
• Familyhistory
• Toolittlepotassium
• Alcohol
• Smoking
• Stress&
• Age
66
67
EffectofHypertension
The common target organs damaged by long
standing hypertension are:
• Brain
• Heart
• Kidneys
• Eyes &
• Peripheralarteries.
EffectofHypertension
The common target organs damaged by long
standing hypertension are:
• Brain
• Heart
• Kidneys
• Eyes &
• Peripheralarteries.
Complicationsofhypertension
Leftventricularhypertrophy
Heartfailure
Cerebralhemorrhage
Renalinsufficiency
Aorticdissection
Atheroscleroticdisease
68
Leftventricularhypertrophy
Heartfailure
Cerebralhemorrhage
Renalinsufficiency
Aorticdissection
Atheroscleroticdisease
68
Symptoms
Symptomsduetohypertension:
1. Headache-usuallyinmorninghours.
2. Dizziness
3. Epistaxis
Symptomsduetoaffectovertargetorgans:
1. CVS:
a. Dyspneaonexertion
b. Anginalchestpain
c. Palpitations
69
Symptomsduetohypertension:
1. Headache-usuallyinmorninghours.
2. Dizziness
3. Epistaxis
Symptomsduetoaffectovertargetorgans:
1. CVS:
a. Dyspneaonexertion
b. Anginalchestpain
c. Palpitations
69
2. Kidneys:Hematuria,nocturia,polyuria.
3. CNS:
a. Transientischemicattacks(TIAorStroke)
b. Hypertensive encephalopathy(headache ,
vomiting etc.)
c. Dizziness,Tinnitus&syncope.
4. Retina:
a. Blurredvisionor
b. suddenblindness.
70
3. CNS:
a. Transientischemicattacks(TIAorStroke)
b. Hypertensive encephalopathy(headache ,
vomiting etc.)
c. Dizziness,Tinnitus&syncope.
4. Retina:
a. Blurredvisionor
b. suddenblindness.
70
Diagnosis
• PhysicalExamination
• Laboratory and Additional Testing – it includes
Routinelaboratoryprocedureslike
hemoglobin,urinalysis,routineblood
chemistriesandfastinglipidprofile.
• Electrocardiography&Electroencephaloghy
• AmbulatoryBPMonitoring
• Plasmareninactivitytesting
• Radiologictesting
71
• PhysicalExamination
• Laboratory and Additional Testing – it includes
Routinelaboratoryprocedureslike
hemoglobin,urinalysis,routineblood
chemistriesandfastinglipidprofile.
• Electrocardiography&Electroencephaloghy
• AmbulatoryBPMonitoring
• Plasmareninactivitytesting
• Radiologictesting
71
WHITE
COATHYPERTENSI
ON
‘’White coat hypertension’’ is a
phenomenon in which
individualspresent with persistent
elevated BP in a clinical setting but
present withnon-elevated BP in an
ambulatory setting.
• 20% of mild hypertensive
individuals may present with
whitecoat hypertension.
COATHYPERTENSI
ON
‘’White coat hypertension’’ is a
phenomenon in which
individualspresent with persistent
elevated BP in a clinical setting but
present withnon-elevated BP in an
ambulatory setting.
• 20% of mild hypertensive
individuals may present with
whitecoat hypertension.
72
DentalManagement
• MeasureandrecordBPatinitialvisit
73
• MeasureandrecordBPatinitialvisit
73
Recheck:-
• Every 2 yrs for patient with BP <120/80 mm
Hg.
• Every1yrforpatient with BP120-139/80-89
mm Hg.
• EveryvisitforpatientwithBP>140/90mm
Hg.
• Every visit for patient with established
coronary artery disease, diabetesmellitusor
chronic renal disease with BP >135/85 mm Hg.
• Everyvisitforpatientwithestablished
hypertension.
Beforeinitiatingdentalcare:
• Assesspresenceofhypertension
• Determinepresenceoftargetorgandisease
• Determinedentaltreatmentmodifications
74
• Every 2 yrs for patient with BP <120/80 mm
Hg.
• Every1yrforpatient with BP120-139/80-89
mm Hg.
• EveryvisitforpatientwithBP>140/90mm
Hg.
• Every visit for patient with established
coronary artery disease, diabetesmellitusor
chronic renal disease with BP >135/85 mm Hg.
• Everyvisitforpatientwithestablished
hypertension.
Beforeinitiatingdentalcare:
• Assesspresenceofhypertension
• Determinepresenceoftargetorgandisease
• Determinedentaltreatmentmodifications
74
1. Asymptomatic BP <159/99 mm Hg, no history of target
organ disease
• Nomodificationsneeded
• Cansafelybetreatedindentalsetting
2. Asymptomatic BP 160-179/100-109 mm Hg, no history of
target organ disease
• Assessmentonanindividualbasiswithregardtotypeofdental
procedureBP>180/110mmHg,nohistoryoftargetorgandisease
• NoelectivedentalcareuntilBPiscontrolled.
3. Presenceoftargetorgandiseaseorpoorlycontrolled
diabetes mellitus
• NoelectivedentalcareuntilBPiscontrolled,preferablebelow140-90
mmHg.
75
organ disease
• Nomodificationsneeded
• Cansafelybetreatedindentalsetting
2. Asymptomatic BP 160-179/100-109 mm Hg, no history of
target organ disease
• Assessmentonanindividualbasiswithregardtotypeofdental
procedureBP>180/110mmHg,nohistoryoftargetorgandisease
• NoelectivedentalcareuntilBPiscontrolled.
3. Presenceoftargetorgandiseaseorpoorlycontrolled
diabetes mellitus
• NoelectivedentalcareuntilBPiscontrolled,preferablebelow140-90
mmHg.
75
TREATMENTOFHYPERTENSION
Non Pharmacological
TreatmentLifestyle Modifications
1. Saltrestriction
2. Weightreduction
3. Stopsmoking
4. Dietmodificationssuchas:
• ReduceintakeofCholesterol&
Saturated fat.
• AdequateintakeofCalcium&M
agnesium.
76
Non Pharmacological
TreatmentLifestyle Modifications
1. Saltrestriction
2. Weightreduction
3. Stopsmoking
4. Dietmodificationssuchas:
• ReduceintakeofCholesterol&
Saturated fat.
• AdequateintakeofCalcium&M
agnesium.
76
5. Avoid/Limitofalcoholintake
6. Relaxationsuchasyoga,psychotherapyetc.
7. Regularexercise.
77
6. Relaxationsuchasyoga,psychotherapyetc.
7. Regularexercise.
77
ORALMEDICATIONSUSEDFOR
TREATMENTOFHYPERTENSION
• Diuretics
• Beta-AdrenergicBlockers
• CentralActingInhibitors
• PeripheralActingInhibitors
• Non-Selectivealpha&betaAdrenergic
Inhibitors
• Vasodilators
• Angiotensin Converting Enzyme ACE
Inhibitors
78
TREATMENTOFHYPERTENSION
• Diuretics
• Beta-AdrenergicBlockers
• CentralActingInhibitors
• PeripheralActingInhibitors
• Non-Selectivealpha&betaAdrenergic
Inhibitors
• Vasodilators
• Angiotensin Converting Enzyme ACE
Inhibitors
78
ORALMANIFESTATIONOF
HYPERTENSION
There are no recognized manifestations of
hypertension but anti-hypertensive drugs can often
cause side affects ,such as:
• Xerostomia,
• Gingivalovergrowth,
• Salivaryglandswellingorpain,
• Lichenoiddrugreactions,
• Erythemamultiforme,
• Tastesensealteration,
• Paresthesia.
79
HYPERTENSION
There are no recognized manifestations of
hypertension but anti-hypertensive drugs can often
cause side affects ,such as:
• Xerostomia,
• Gingivalovergrowth,
• Salivaryglandswellingorpain,
• Lichenoiddrugreactions,
• Erythemamultiforme,
• Tastesensealteration,
• Paresthesia.
79
CONCLUSION
• HYPERTENSION has no cure, but it can be
controlled with proper diet, lifestyle changes,
andifnecessarymedications.
• Get regular health check ups. Think about
theconsequencesofuntreatedhighbloodpressure
.
• Do not take chances with the disease that can be
controlled.
• Lastly,Hypertensionisasilentdisease,butits
silenceisnot golden.
• HYPERTENSION has no cure, but it can be
controlled with proper diet, lifestyle changes,
andifnecessarymedications.
• Get regular health check ups. Think about
theconsequencesofuntreatedhighbloodpressure
.
• Do not take chances with the disease that can be
controlled.
• Lastly,Hypertensionisasilentdisease,butits
silenceisnot golden.
80
CORONARY
(ISHAEMIC) ARTERY
DISEASE
81
(ISHAEMIC) ARTERY
DISEASE
81
CORONARYARTERY DISEASES
1) Etiopathogenesis
2) Riskfactors
3) Diagnosis
4) Management
5) Dentalaspects
82
1) Etiopathogenesis
2) Riskfactors
3) Diagnosis
4) Management
5) Dentalaspects
82
• Atherosclerosis is the most common cause of
CAD
ETIOPATHOGENESIS
Variousriskfactorsinclude:
1. lipids(especiallyHDL)
2. hypertension
3. diabetesmellitus&glucoseintolerance
4. cigarettesmoking
5. lifestyle&dietaryfactors
6. exercise
7. obesity
83
CAD
ETIOPATHOGENESIS
Variousriskfactorsinclude:
1. lipids(especiallyHDL)
2. hypertension
3. diabetesmellitus&glucoseintolerance
4. cigarettesmoking
5. lifestyle&dietaryfactors
6. exercise
7. obesity
83
8. plasmafibrinogen
9. endothelialdysfunction
10. antioxidants
11. estrogendeficiency
84
9. endothelialdysfunction
10. antioxidants
11. estrogendeficiency
84
RISKFACTORS
Induce variety of pathological processes
Interaction & disruption of vascular
endotheliumPlaque formation
Effective arterial luminal area compromised
Myocardial ischaemia acuteplaquerupture
angina
thrombusformation
MI
85
Induce variety of pathological processes
Interaction & disruption of vascular
endotheliumPlaque formation
Effective arterial luminal area compromised
Myocardial ischaemia acuteplaquerupture
angina
thrombusformation
MI
85
86
87
DIAGNOSIS
1) Basedonclinicalpresentation:
chesttightness
Jawdiscomfort
Leftarmpain
Dyspnea
Epigastricdistress
2) E.C.G.
3) ExerciseE.C.G.
4) CoronaryAngiography
5) P.C.I.(PercutaneousCoronaryIntervention)
6) Incaseofcomplicationslikestroke/shock–EEG
7) Recentdevelopment:Oneminuteangiogram
88
1) Basedonclinicalpresentation:
chesttightness
Jawdiscomfort
Leftarmpain
Dyspnea
Epigastricdistress
2) E.C.G.
3) ExerciseE.C.G.
4) CoronaryAngiography
5) P.C.I.(PercutaneousCoronaryIntervention)
6) Incaseofcomplicationslikestroke/shock–EEG
7) Recentdevelopment:Oneminuteangiogram
88
MANAGEMENT
ManagementofCADdependson:
• Extentandseverity ofischemia
• Exercisecapacity
• Prognosisbasedonexercisetesting
• OverallLVfunction
• Associatedfeaturessuchasdiabetesmellitus
Patients with a small ischemic burden, normal
exercisetolerance, and normal LV function may be safely
treatedwith pharmacologic therapy.
Selected useofaspirin, β-blockers, ACEIs,and
HMG CoA reductaseinhibitors.
Nitrates and calcium channel blockers may be added
to primary agents to relieve symptoms of ischemia
inselected patients.
89
ManagementofCADdependson:
• Extentandseverity ofischemia
• Exercisecapacity
• Prognosisbasedonexercisetesting
• OverallLVfunction
• Associatedfeaturessuchasdiabetesmellitus
Patients with a small ischemic burden, normal
exercisetolerance, and normal LV function may be safely
treatedwith pharmacologic therapy.
Selected useofaspirin, β-blockers, ACEIs,and
HMG CoA reductaseinhibitors.
Nitrates and calcium channel blockers may be added
to primary agents to relieve symptoms of ischemia
inselected patients.
89
• SURGICAL
MANAGEMENT:
Percutaneous coronary
intervention (PCI) with
percutaneous transluminal
coronaryangioplasty(PTCA)
and intra coronary stenting
relieves symptoms in
chronicishchemia.
90
MANAGEMENT:
Percutaneous coronary
intervention (PCI) with
percutaneous transluminal
coronaryangioplasty(PTCA)
and intra coronary stenting
relieves symptoms in
chronicishchemia.
90
• Patientwithcomplex
multivessel CAD require
PCI with medical
therapyof surgical
revascularization.
• PatientswithreducedLV
function and severe
ischemia, often associated
with leftmainor
multivessel CAD, are
bestserved by coronary
artery bypass graft
(CABG) surgery.
91
multivessel CAD require
PCI with medical
therapyof surgical
revascularization.
• PatientswithreducedLV
function and severe
ischemia, often associated
with leftmainor
multivessel CAD, are
bestserved by coronary
artery bypass graft
(CABG) surgery.
91
DENTALASPECTS
• STRESS,ANXIETY,EXERTIONorPAIN
canprovokeangina.
• Short,minimallystressfuldentalappointments.
• Latemorningappointments.
• ExcessivedoseofLAcontainingadrenalineto
beavoidedinpatientstakingbetablockers.
• More Common - severe dental caries and
periodontaldiseaseinptsofIHD.
92
• STRESS,ANXIETY,EXERTIONorPAIN
canprovokeangina.
• Short,minimallystressfuldentalappointments.
• Latemorningappointments.
• ExcessivedoseofLAcontainingadrenalineto
beavoidedinpatientstakingbetablockers.
• More Common - severe dental caries and
periodontaldiseaseinptsofIHD.
92
93
ANGINAPECTORIS
ANGINAPECTORIS
• Namegiventoparoxysmsofseverechestpain
CLINICALFEATURES
1) 40TO60years,M>F
2) PainoftendescribedassenseofStrangling,choking,
Tightness, Heaviness ,Compression, or Constriction of
chest.
3) PAINMAYRADIATETOJAWorleftarm.
4) Rarelypaininmandible,teethorothertissues.
PRECIPITATINGFACTORS
• Physicalexertion(main)particularlyincoldweather
• Emotion(angeroranxiety)&stresscausedbyfearor
pain
TYPICALLYRELEIVEDBYREST
94
CLINICALFEATURES
1) 40TO60years,M>F
2) PainoftendescribedassenseofStrangling,choking,
Tightness, Heaviness ,Compression, or Constriction of
chest.
3) PAINMAYRADIATETOJAWorleftarm.
4) Rarelypaininmandible,teethorothertissues.
PRECIPITATINGFACTORS
• Physicalexertion(main)particularlyincoldweather
• Emotion(angeroranxiety)&stresscausedbyfearor
pain
TYPICALLYRELEIVEDBYREST
94
Dentalaspects
Preoprerative glyceryl trinitrate & oral sedation
advisedsometimes.
Dental care carried with minimal anxiety &oxygen
saturation
Monitorpulse&B.P.
POSTANGIOPLASTYelectivedentalcaredefferedfor6
months,emergencydentalcareinahospitalsetting.
Patients with BYPASS GRAFTS –anti bioticcover
against infective endocarditis .
-LAcontainingadrenalineis
contraindicated(maypptdysrhythmia)
95
Preoprerative glyceryl trinitrate & oral sedation
advisedsometimes.
Dental care carried with minimal anxiety &oxygen
saturation
Monitorpulse&B.P.
POSTANGIOPLASTYelectivedentalcaredefferedfor6
months,emergencydentalcareinahospitalsetting.
Patients with BYPASS GRAFTS –anti bioticcover
against infective endocarditis .
-LAcontainingadrenalineis
contraindicated(maypptdysrhythmia)
95
Patients with vascular stents – no
antibioticcover except during 1
st
6 week
postop for emergency dental care.
DRUGS used in t/t of angina may cause
oraladverseeffectslike:
-lichenoidreaction Cachannel
-gingivalswelling blockers
-ulcers(nicorandil)
96
antibioticcover except during 1
st
6 week
postop for emergency dental care.
DRUGS used in t/t of angina may cause
oraladverseeffectslike:
-lichenoidreaction Cachannel
-gingivalswelling blockers
-ulcers(nicorandil)
96
Gingival
hyperplasia in
patient consuming
Cachannelblockers
97
hyperplasia in
patient consuming
Cachannelblockers
97
98
MYOCARDIALINFA
RCTION
MYOCARDIALINFA
RCTION
• Synonyms–coronarythrombosisorheartattack
CLINICALFEATURES
1. Clinicalpictureisvariable
2. Morethan50%patients are symptomless
3. MImaybeprecededbyanginaoftenfeltasindigestion
likepain
4. anyanginalattacklastinglongerthan30minutesis
considered MI
5. Tachycardia&irregularpulse
6. Nausea,vomitting,sweating,restlessness,facialpallor
7. Breathlessness,cough
8. Lossofconciousness,shock&evendeath
9. Many pts die within 1
st
hour to few days after attack.
Thus,MIisaMEDICALEMERGENCY.
99
CLINICALFEATURES
1. Clinicalpictureisvariable
2. Morethan50%patients are symptomless
3. MImaybeprecededbyanginaoftenfeltasindigestion
likepain
4. anyanginalattacklastinglongerthan30minutesis
considered MI
5. Tachycardia&irregularpulse
6. Nausea,vomitting,sweating,restlessness,facialpallor
7. Breathlessness,cough
8. Lossofconciousness,shock&evendeath
9. Many pts die within 1
st
hour to few days after attack.
Thus,MIisaMEDICALEMERGENCY.
99
100
DIAGNOSIS
I. Basedonclinicalfeatures
II. ElevatedTLC&ESRduring1
st
wk
III. ECGchanges
IV. Riseinserum“cardiac”enzymes(CPK)
V. RiseintroponinTwithin4-
8hoursVI.Echocardiography
101
I. Basedonclinicalfeatures
II. ElevatedTLC&ESRduring1
st
wk
III. ECGchanges
IV. Riseinserum“cardiac”enzymes(CPK)
V. RiseintroponinTwithin4-
8hoursVI.Echocardiography
101
GeneralPrecautionsduringDentalProcedures
• Dentalclinicshouldhaveadvancedcardiaclifesupportorat
least basic cardiac life support.
• Useofpulseoximetertodeterminetheleveloxygenation.
• Automaticexternaldefibrillator.
• Determinationofvitalsignspriortodentalcare.
• BP&pulserate&rhythmshouldberecorded&any
abnormalfindingsshouldbeaddressed.
• Premedication with antianxiety drugs and inhalation nitrous
oxide in anxious patients.
• Elective procedures esp those requiring GA should
beavoidedforatleast4wksaftrMI.consult pt’s physician prior
to dental therapy
102
• Dentalclinicshouldhaveadvancedcardiaclifesupportorat
least basic cardiac life support.
• Useofpulseoximetertodeterminetheleveloxygenation.
• Automaticexternaldefibrillator.
• Determinationofvitalsignspriortodentalcare.
• BP&pulserate&rhythmshouldberecorded&any
abnormalfindingsshouldbeaddressed.
• Premedication with antianxiety drugs and inhalation nitrous
oxide in anxious patients.
• Elective procedures esp those requiring GA should
beavoidedforatleast4wksaftrMI.consult pt’s physician prior
to dental therapy
102
Managementondentalchair
1. Terminatealldentaltreatment
2. Positionptinsemireclineposition
3. Givenitroglycerin(TNG)(abt0.4mg)tabletorspray
4. Administeroxygen
5. Checkpulse&B.P.
Discomfortrelieved Discomfortcontinues3minsafter2
nd
TNG
6. Assume angina pectoris is 6. give 2
nd
TNG dose
present 7.monitorvitalsigns.
7. Slowly taper oxygen over
5 mins
8. Modifyt/ttopreventrecurrence discomfort discomfort
continues
relieved 3minsafterTNG
103
1. Terminatealldentaltreatment
2. Positionptinsemireclineposition
3. Givenitroglycerin(TNG)(abt0.4mg)tabletorspray
4. Administeroxygen
5. Checkpulse&B.P.
Discomfortrelieved Discomfortcontinues3minsafter2
nd
TNG
6. Assume angina pectoris is 6. give 2
nd
TNG dose
present 7.monitorvitalsigns.
7. Slowly taper oxygen over
5 mins
8. Modifyt/ttopreventrecurrence discomfort discomfort
continues
relieved 3minsafterTNG
103
8. give3
rd
TNGdose
9. Monitorvitals
10. Callformedicalassistance
Discomfortrelieved discomfortcontinues3minsafter 3
rd
TNGdose
11. Referptformedical 12.assumeMIisinprogress
evaluationbefore 13.starti.v.linewithdripofacrystalloid
solution
furtherdentalcare at30mL/hr
14. Ifdiscomfortseveretitratemorfinesulphate2mgs/cori/vevery3mins
untilreliefisobtained
15. Transporttoemergencycare.AdministerBasicLifeSupport,if
necessary.
104
rd
TNGdose
9. Monitorvitals
10. Callformedicalassistance
Discomfortrelieved discomfortcontinues3minsafter 3
rd
TNGdose
11. Referptformedical 12.assumeMIisinprogress
evaluationbefore 13.starti.v.linewithdripofacrystalloid
solution
furtherdentalcare at30mL/hr
14. Ifdiscomfortseveretitratemorfinesulphate2mgs/cori/vevery3mins
untilreliefisobtained
15. Transporttoemergencycare.AdministerBasicLifeSupport,if
necessary.
104
AnticoagulationTherapy&DentalCare
• Anticoagulant therapy is used both to treat & to
prevent throboembolism.
• 2majortypes:1.antiplateletmedications
2. antithrombinmedications
• Acetylsalicylic acid (ASA) +
clopidogrel(anticoagulant) given for 4
weeks after stent implantation.
• dailyaspirintypicallycontinuedlifelong.
• Mayincreaseriskoforalbleedingfollowingsurgical
procedures.
• Associated conditions which predispose patient to
uncontrolled hemostasis : uraemia or liver diseases or
use of NSAIDS.
• Ifemergencysurgeryneedstobedone,DDAVP(1-
desamino-8-D-arginine vasopressin)
isadministered{0.3 micro kg/body wt
parenterally}within1hrofsurgery.
105
• Anticoagulant therapy is used both to treat & to
prevent throboembolism.
• 2majortypes:1.antiplateletmedications
2. antithrombinmedications
• Acetylsalicylic acid (ASA) +
clopidogrel(anticoagulant) given for 4
weeks after stent implantation.
• dailyaspirintypicallycontinuedlifelong.
• Mayincreaseriskoforalbleedingfollowingsurgical
procedures.
• Associated conditions which predispose patient to
uncontrolled hemostasis : uraemia or liver diseases or
use of NSAIDS.
• Ifemergencysurgeryneedstobedone,DDAVP(1-
desamino-8-D-arginine vasopressin)
isadministered{0.3 micro kg/body wt
parenterally}within1hrofsurgery.
105
• Antithrombin medications are dicumarols (
eg.Warfarin),itinhibitsbiosynthesisofvit.–K
dependent coagulations protein.
- Efficacy monitoredbyprothrombintimeorthe
international normalized ratio (INR), which is
calculated on the basis of international
sensitivityindex(ISI).
- INR ranges from 2.0 – 3.5 & it should be performed
within 24 hrs of surgery.
- If INR is < 3.5, anticoagulation therapy should be
discontinued before minor surgical procedures.
106
eg.Warfarin),itinhibitsbiosynthesisofvit.–K
dependent coagulations protein.
- Efficacy monitoredbyprothrombintimeorthe
international normalized ratio (INR), which is
calculated on the basis of international
sensitivityindex(ISI).
- INR ranges from 2.0 – 3.5 & it should be performed
within 24 hrs of surgery.
- If INR is < 3.5, anticoagulation therapy should be
discontinued before minor surgical procedures.
106
3 different protocols used to treatpatientswith
elevated INR :
• Ist protocol– warfarin not discontinued
(minimizes thromboembolic events &
increasesriskofbleedingaftersurgery).
• IInd protocol– warfarin discontinued (drug
shouldbe discontinued 2-3 days prior to surgery,
during this period patient is at risk of developing
thromboembolic event but not bleeding).
• IIIrd protocol– warfarin discontinued &
patientplaced on alternative anticoagulant
therapy (thromboemboliceventminimized).
107
elevated INR :
• Ist protocol– warfarin not discontinued
(minimizes thromboembolic events &
increasesriskofbleedingaftersurgery).
• IInd protocol– warfarin discontinued (drug
shouldbe discontinued 2-3 days prior to surgery,
during this period patient is at risk of developing
thromboembolic event but not bleeding).
• IIIrd protocol– warfarin discontinued &
patientplaced on alternative anticoagulant
therapy (thromboemboliceventminimized).
107
108
RHEUMATICFEVER
RHEUMATICFEVER
• Rheumaticfeverisaninflammatorydisease
that may develop two to three weeks after a
GroupAstreptococcalinfection(suchasstrep
throatorscarletfever).Itisbelievedtobe
causedbyantibodycross-reactivityandcan
involve the heart, joints, skin, and
Brain.
• Acute rheumatic fever commonly appears
inchildren ages 5 through 15, with only 20% of
first timeattacksoccurringinadults.
109
that may develop two to three weeks after a
GroupAstreptococcalinfection(suchasstrep
throatorscarletfever).Itisbelievedtobe
causedbyantibodycross-reactivityandcan
involve the heart, joints, skin, and
Brain.
• Acute rheumatic fever commonly appears
inchildren ages 5 through 15, with only 20% of
first timeattacksoccurringinadults.
109
110
• Whatare the symptomsof strep
throat?
• Sudden onset of sore throat
(streptococcal oropharyngitis)
• Painonswallowing
• Fever,usually101–104°F
• Headache
• Redandedematoussoftpalateand
oropharynx.
• Areasoftonsillarulcerationand
exudation.
• Abdominal pain, nausea and
vomiting may also occur,
especially in children.
111
throat?
• Sudden onset of sore throat
(streptococcal oropharyngitis)
• Painonswallowing
• Fever,usually101–104°F
• Headache
• Redandedematoussoftpalateand
oropharynx.
• Areasoftonsillarulcerationand
exudation.
• Abdominal pain, nausea and
vomiting may also occur,
especially in children.
111
What are the symptoms/clinical features of
rheumatic fever?
Symptomsmayinclude:
• fever
• painful,tender,redswollenjoints
• paininonejointthatmigratestoanotherone
• heartpalpitations
• chestpain
• shortnessofbreath
• skinrashes
• fatigue
• small,painlessnodulesundertheskin
112
rheumatic fever?
Symptomsmayinclude:
• fever
• painful,tender,redswollenjoints
• paininonejointthatmigratestoanotherone
• heartpalpitations
• chestpain
• shortnessofbreath
• skinrashes
• fatigue
• small,painlessnodulesundertheskin
112
113
• Minorcriteria
• Fever
• Arthralgia
• Laboratoryabnormalities:increased
Erythrocyte sedimentation rate
• Electrocardiogramabnormalities
• Evidence of Group A Strep infection:
elevatedorrisingAntistreptolysinOtitre.
114
• Fever
• Arthralgia
• Laboratoryabnormalities:increased
Erythrocyte sedimentation rate
• Electrocardiogramabnormalities
• Evidence of Group A Strep infection:
elevatedorrisingAntistreptolysinOtitre.
114
LABINVESTIGATIONS
• RaisedESR
• Culture studies of throat
swabsisalwaysnegativein
RF.
• High anti sterptolysin
o(ASO)titre-300 micro
units
• Chest radiograph-
enlargementofheart
• ECG-prolongedPR
interval
• Echocardiogram-confirms
ventricular dilatation n
pericardial effusion
115
• RaisedESR
• Culture studies of throat
swabsisalwaysnegativein
RF.
• High anti sterptolysin
o(ASO)titre-300 micro
units
• Chest radiograph-
enlargementofheart
• ECG-prolongedPR
interval
• Echocardiogram-confirms
ventricular dilatation n
pericardial effusion
115
• TREATMENT:
• Oralphenoxymthylpenicillin500mguntilage
of 20 yrs.
• Allergic to penicillin,sulfadimidine by
mouth.
• Aspirin for fever and pain 50mg/kg in 4 hrly
doses
• Corticosteroids60-80mgprednisolone
• Digoxinanddiureticsforheartfailure
• Ballonvalvuloplasty,usinginoueballoon,if
mitral valves damage.
116
• Oralphenoxymthylpenicillin500mguntilage
of 20 yrs.
• Allergic to penicillin,sulfadimidine by
mouth.
• Aspirin for fever and pain 50mg/kg in 4 hrly
doses
• Corticosteroids60-80mgprednisolone
• Digoxinanddiureticsforheartfailure
• Ballonvalvuloplasty,usinginoueballoon,if
mitral valves damage.
116
DENTALCONSIDERATION
• Dental extractions and local
anesthesia in consent with
physician.
• Theprophylacticuseof
antibiotics prior to a dental
procedure is now
recommended ONLY for
those patients with the
highest risk of adverse
outcome resulting from
endocarditis.
• GA should be avoided if
essentialmustbegivenin
hospital.
117
• Dental extractions and local
anesthesia in consent with
physician.
• Theprophylacticuseof
antibiotics prior to a dental
procedure is now
recommended ONLY for
those patients with the
highest risk of adverse
outcome resulting from
endocarditis.
• GA should be avoided if
essentialmustbegivenin
hospital.
117
118
RHEUMATIC
HEARTDISEASE
RHEUMATIC
HEARTDISEASE
Rheumaticheartdisease:
• History ofrheumatic feverduringchildhoodor
adolescence can act as a predisposing
factorforRHDafterseveralyears.
• Common signs-murmur
duetovalvulardamage n later
enlargement of heart.
• History ofrheumatic feverduringchildhoodor
adolescence can act as a predisposing
factorforRHDafterseveralyears.
• Common signs-murmur
duetovalvulardamage n later
enlargement of heart.
119
120
ORALMANIFESTATIONS
• Most prominent during acute
phase
• Pharyngitis
• Incoraltemperature
• Distendedneckveinsanda
bluish color of the skin.
121
• Most prominent during acute
phase
• Pharyngitis
• Incoraltemperature
• Distendedneckveinsanda
bluish color of the skin.
121
DENTALCONSIDERATIONS
• To prevent complication of infective
endocarditis ,all dental procedures should be
carriedunderantibioticcover.
• Amoxicillin prophylaxis-1 hour beforeand
6hours after the initial dose.
• Good oral hygiene measures ,fluoride
treatment, chlorhexidine rinses and routine
cleaningsto reduce harmful bacteremias.
122
• To prevent complication of infective
endocarditis ,all dental procedures should be
carriedunderantibioticcover.
• Amoxicillin prophylaxis-1 hour beforeand
6hours after the initial dose.
• Good oral hygiene measures ,fluoride
treatment, chlorhexidine rinses and routine
cleaningsto reduce harmful bacteremias.
122
• Proper history should be taken to
identifyhistoryofrheumaticfeverduringchildh
ood.
• Suspicious cases should be referred to
cardiologist for cardiac evaluation prior to
dental procedures.
• Clindamycin or erythromycin prophylaxis
duringdentaltreatment.
• Elective dental treatment under physician
consultation.
identifyhistoryofrheumaticfeverduringchildh
ood.
• Suspicious cases should be referred to
cardiologist for cardiac evaluation prior to
dental procedures.
• Clindamycin or erythromycin prophylaxis
duringdentaltreatment.
• Elective dental treatment under physician
consultation.
123
124
HEARTFAILURE
HEARTFAILURE
HEARTFAILURE
• Heart failure (HF) is a
condition in which a
problemwiththestructure
orfunction of the heart
impairsitsability tosupply
sufficient blood flow to
meetthebody'sneeds.
• Commoncausesofheart
failure–
• ischemicheartdiseases
• Hypertension
• Valvulardiseases
125
• Heart failure (HF) is a
condition in which a
problemwiththestructure
orfunction of the heart
impairsitsability tosupply
sufficient blood flow to
meetthebody'sneeds.
• Commoncausesofheart
failure–
• ischemicheartdiseases
• Hypertension
• Valvulardiseases
125
Left-sidedfailure(MORECOMMON)
• Failure of the left ventricle causes congestion of the
pulmonaryvasculature,andsothesymptomsare
predominantlyrespiratoryinnature.Thepatient
willhavedyspnea(shortnessofbreath)onexertion
and in severe cases, dyspnea at rest.
Increasingbreathlessnessonlyingflat,called
orthopnea.
• Another symptom of heart failure is
paroxysmanocturnal dyspnea also known as
"cardiac asthma", a sudden nighttime attack of
severe breathlessness, usually several hours after
going to sleep.
• Inadequate cerebral oxygenation leads to loss of
c
o
• Failure of the left ventricle causes congestion of the
pulmonaryvasculature,andsothesymptomsare
predominantlyrespiratoryinnature.Thepatient
willhavedyspnea(shortnessofbreath)onexertion
and in severe cases, dyspnea at rest.
Increasingbreathlessnessonlyingflat,called
orthopnea.
• Another symptom of heart failure is
paroxysmanocturnal dyspnea also known as
"cardiac asthma", a sudden nighttime attack of
severe breathlessness, usually several hours after
going to sleep.
• Inadequate cerebral oxygenation leads to loss of
c
o
ncentration,restlessness and irritability.
126
126
Right-sidedfailure
• Failure of the right ventricle leads to
congestion of systemic capillaries. This
helpsto generate excess fluid accumulation in
the body. This causes swelling under the
skin(termed peripheral edema or anasarca)
• If occurswith Mitralstenosisis called
congestiveheartfailure.
127
• Failure of the right ventricle leads to
congestion of systemic capillaries. This
helpsto generate excess fluid accumulation in
the body. This causes swelling under the
skin(termed peripheral edema or anasarca)
• If occurswith Mitralstenosisis called
congestiveheartfailure.
127
• Biventricularfailure,faiure
ofonesideofheartleadsto
failure of other.
CLINICALFEATURES
• Pedaledema
• Dyspnea
• Congestionofneckveins
• Cynosis
• Fatigue
128
ofonesideofheartleadsto
failure of other.
CLINICALFEATURES
• Pedaledema
• Dyspnea
• Congestionofneckveins
• Cynosis
• Fatigue
128
DIAGNOSIS
• Imaging
Echocardiography
• Electrophysiology
electrocardiogram
(ECG/EKG)
• Bloodtests
• Angiography
• Monitoring
129
• Imaging
Echocardiography
• Electrophysiology
electrocardiogram
(ECG/EKG)
• Bloodtests
• Angiography
• Monitoring
129
TREATMENTMODALITIES
• Dietandlifestylemeasures
• Weightreduction
• Monitorweight
• Sodium restriction -excessive sodium intake
mayprecipitate or exacerbate heart failure
• Fluid restriction – patients with CHF have a
diminished ability to excrete free water load.
• stressreduction,rest
• Stopsmoking
130
• Dietandlifestylemeasures
• Weightreduction
• Monitorweight
• Sodium restriction -excessive sodium intake
mayprecipitate or exacerbate heart failure
• Fluid restriction – patients with CHF have a
diminished ability to excrete free water load.
• stressreduction,rest
• Stopsmoking
130
Pharmacologicalmanagement
• Diuretic
• Loopdiuretics(e.g.furosemide,bumetanide)
• ACEinhibitor/AngiotensinIIreceptorantagonistPositi
ve inotropes
• Digoxin
• Betablockers
• Alternativevasodilators
• Thecombinationofisosorbiddinitrate/hydralazine
131
• Diuretic
• Loopdiuretics(e.g.furosemide,bumetanide)
• ACEinhibitor/AngiotensinIIreceptorantagonistPositi
ve inotropes
• Digoxin
• Betablockers
• Alternativevasodilators
• Thecombinationofisosorbiddinitrate/hydralazine
131
ORALMANIFESTATIONS
• Distentionoftheexternal
jugular viens.
• Compensatory polycythemia
–ruddy complexion and
bleeding tendencies.
• Abnormalproductionof
clotting factors
• Bleedingcanbespontaneous
orextravasational.
132
• Distentionoftheexternal
jugular viens.
• Compensatory polycythemia
–ruddy complexion and
bleeding tendencies.
• Abnormalproductionof
clotting factors
• Bleedingcanbespontaneous
orextravasational.
132
DENTALASPECTS
• The dental chair should be kept in
partiallyreclining or erect position and patient
should be raisedslowlyinuprightposition.
• Emergency dental care should be conservative,
principallywithanalgesicsandantibiotics.
• Appointmentsshouldbeshort
• Nonstressfulappointments
• Patientsarebesttreatedinlate morningbecause of
epinephrinelevelspeakinearlymorning.
133
• The dental chair should be kept in
partiallyreclining or erect position and patient
should be raisedslowlyinuprightposition.
• Emergency dental care should be conservative,
principallywithanalgesicsandantibiotics.
• Appointmentsshouldbeshort
• Nonstressfulappointments
• Patientsarebesttreatedinlate morningbecause of
epinephrinelevelspeakinearlymorning.
133
• Bupivacaineshouldbeavoidedasitis
cardiotoxic.
• Anaspiratingsyringeshouldbeusedtogive
localanesthetic
• Epinephrine containing LA should be not
given in large doses to patients taking beta
blockers.
• Gingival retraction cords
containingepinephrine should be
avoided
cardiotoxic.
• Anaspiratingsyringeshouldbeusedtogive
localanesthetic
• Epinephrine containing LA should be not
given in large doses to patients taking beta
blockers.
• Gingival retraction cords
containingepinephrine should be
avoided
134
• SupplementalO2shouldbeavailable
• Rubber dam is contraindicated when it
contributestobreathingdifficulty.
• NSAIDSotherthanaspirinshouldbe
avoidedinptstakingACEinhibitors(renaldama
ge).
• Erythromycinandtetracyclinetobeavoided
as they may induce digitalis toxicity
135
• Rubber dam is contraindicated when it
contributestobreathingdifficulty.
• NSAIDSotherthanaspirinshouldbe
avoidedinptstakingACEinhibitors(renaldama
ge).
• Erythromycinandtetracyclinetobeavoided
as they may induce digitalis toxicity
135
• GAiscontraindicatedincardiacfailure.untilunder
control(venousthrombosisandpulmonary
embolism)
• ACEinhibitorscansometimescauseerythema
multiforme,angioedemaorburningmouth.
• Antibioticprophylaxisrequiredfordentalcare.
• History of recent MI ,required delay of
electivedental care for 6 months.
136
control(venousthrombosisandpulmonary
embolism)
• ACEinhibitorscansometimescauseerythema
multiforme,angioedemaorburningmouth.
• Antibioticprophylaxisrequiredfordentalcare.
• History of recent MI ,required delay of
electivedental care for 6 months.
136
137
CARDIACARRHYTHMIA
CARDIACARRHYTHMIA
CARDIACARRHYTHMIA:
• Cardiac arrhythmia (also
dysrhythmia) is a term for
any of a large and
heterogeneous group of
conditionsinwhichthereis
abnormalelectrical activity
in the heart.
• The heart beat may be too
fast or too slow, and may be
regular or irregular .
• Accordinglythereare2types
:
1) Atrialarrhythmia
2) Ventriculararrhythmia
138
• Cardiac arrhythmia (also
dysrhythmia) is a term for
any of a large and
heterogeneous group of
conditionsinwhichthereis
abnormalelectrical activity
in the heart.
• The heart beat may be too
fast or too slow, and may be
regular or irregular .
• Accordinglythereare2types
:
1) Atrialarrhythmia
2) Ventriculararrhythmia
138
• TACHYCARDIA :Anyheartratefasterthan
100 beats/minute is labelled tachycardia.
• BRADYCARDIAS:Aslowrhythm,(lessthan
60 beats/min), can lead to syncope.
• HEART BLOCK:Blockage of cardiac
impulseanywhereintheconductionsystem.
139
100 beats/minute is labelled tachycardia.
• BRADYCARDIAS:Aslowrhythm,(lessthan
60 beats/min), can lead to syncope.
• HEART BLOCK:Blockage of cardiac
impulseanywhereintheconductionsystem.
139
140
TREATMENT
AA:
• Digoxin
• Propanolol
• Quinidinesulphate
• Anticoagulantsuchas
warfarin
VA:
• Procainamide
• Phenytoin
• Dispyramide
• Propanolol
141
AA:
• Digoxin
• Propanolol
• Quinidinesulphate
• Anticoagulantsuchas
warfarin
VA:
• Procainamide
• Phenytoin
• Dispyramide
• Propanolol
141
• Physicalmaneuvers
• Antiarrhythmicdrugs
• Electricity
• Electricalcautery
142
• Antiarrhythmicdrugs
• Electricity
• Electricalcautery
142
ORALMANIFESTATIONS
• Procainamide can cause
agranulocytosis,oral
ulcerations.
• Quinidine-infrequentoral
ulcerations.
• Disopyramide is
anticholinergic agent capable
of producing xerostomia.
• verapamil,enalapril can cause
gingival hyperplasia.
143
• Procainamide can cause
agranulocytosis,oral
ulcerations.
• Quinidine-infrequentoral
ulcerations.
• Disopyramide is
anticholinergic agent capable
of producing xerostomia.
• verapamil,enalapril can cause
gingival hyperplasia.
143
DENTALCONSIDERATION
S
• Aproperhistorytobe
taken.
• Stressandanxiety
be minimized.
• Shortappointments
• Use of epinephrine to be
minimized.
• Properchairpositionis
important,SUPINE.
• At end of appointment
chair should be raised
slowly to minimize
orthostatic hypotension.
144
S
• Aproperhistorytobe
taken.
• Stressandanxiety
be minimized.
• Shortappointments
• Use of epinephrine to be
minimized.
• Properchairpositionis
important,SUPINE.
• At end of appointment
chair should be raised
slowly to minimize
orthostatic hypotension.
144
• Use of vasoconstrictors should be
minimizedinptstakingdigitalisglycosides.
• The equipments like pulp testers
,ultrasonicscalers ,electrosurgical units
,should not be in closeproximity.
• Prophylactic antibiotics before and after
treatment in recently placed pacemaker
patients.
• Pts who report palpitations or skipped beats
mustbeevaluatedbyphysician.
145
minimizedinptstakingdigitalisglycosides.
• The equipments like pulp testers
,ultrasonicscalers ,electrosurgical units
,should not be in closeproximity.
• Prophylactic antibiotics before and after
treatment in recently placed pacemaker
patients.
• Pts who report palpitations or skipped beats
mustbeevaluatedbyphysician.
145
• Sustained sinus tachycardia above 100
beats/min inrestingposition
isindicativeofsinus tachycardia.
• Dental treatment shd not be carried out in
patients withirregularpulse.
• Long use of procainamide can cause a lupus
like syndrome.
• Druglikequinidinecancauseerythema
multiforme.
• CAmaybeinducedbygeneralanesthesia
and vagal reflex.
146
beats/min inrestingposition
isindicativeofsinus tachycardia.
• Dental treatment shd not be carried out in
patients withirregularpulse.
• Long use of procainamide can cause a lupus
like syndrome.
• Druglikequinidinecancauseerythema
multiforme.
• CAmaybeinducedbygeneralanesthesia
and vagal reflex.
146
147
ORAL
HEALTHCONSIDERATION
& ORALMANIFESTATION
ORAL
HEALTHCONSIDERATION
& ORALMANIFESTATION
• Valvular heart disease that compromises cardiac output
produces signs of hypoxemia.
• Cyanosisoflipsandoralmucosaisthemostprominentoral sign
of tissue hypoxia.
AccordingtoAmericanheartassociationguidelines:
• Antibiotic prophylaxis should be administered to
patientswho have undergone mitral or aortic valve repair
or replacement.
• Patientswithapriorhistoryofinfectiveendocarditis.
• Patientswithmitraloraorticregurgigationorstenosis.
• Patientswithmitral valvularprolapsewithvalvular
regurgigation.
148
produces signs of hypoxemia.
• Cyanosisoflipsandoralmucosaisthemostprominentoral sign
of tissue hypoxia.
AccordingtoAmericanheartassociationguidelines:
• Antibiotic prophylaxis should be administered to
patientswho have undergone mitral or aortic valve repair
or replacement.
• Patientswithapriorhistoryofinfectiveendocarditis.
• Patientswithmitraloraorticregurgigationorstenosis.
• Patientswithmitral valvularprolapsewithvalvular
regurgigation.
148
• Prostheticheartvalves.
• Previousbacterialendocarditis.
• Acquiredvalvulardysfunction.
• Complexcyanoticcongenitalheartdisease.
• Surgicallyconstructedsystemicpulmonary
shunts.
149
• Previousbacterialendocarditis.
• Acquiredvalvulardysfunction.
• Complexcyanoticcongenitalheartdisease.
• Surgicallyconstructedsystemicpulmonary
shunts.
149
ORALPROCEDURES&NEEDFOR
ANTIBIOTIC PROPHYLAXIS TO
MINIMISERISKOF
BACTERIALENDOCARDITIS
• Extractions.
• Periodontal procedures including surgery,subgingival,placement
of antibiotic fibers or Strips,scaling &root planning.
• Implantplacement.
• Toothreimplantation.
• Placementoforthodonticbands(notbrackets).
• Endodonticinstrumentation.
• Intraligamentaryinjection.
• Prophylaticcleaningofteethwherebleedingisanticipated.
• Otherprocedureinwhichsignificantbleedingisanticipated.
ANTIBIOTIC PROPHYLAXIS TO
MINIMISERISKOF
BACTERIALENDOCARDITIS
• Extractions.
• Periodontal procedures including surgery,subgingival,placement
of antibiotic fibers or Strips,scaling &root planning.
• Implantplacement.
• Toothreimplantation.
• Placementoforthodonticbands(notbrackets).
• Endodonticinstrumentation.
• Intraligamentaryinjection.
• Prophylaticcleaningofteethwherebleedingisanticipated.
• Otherprocedureinwhichsignificantbleedingisanticipated.
150
STANDARDREGIMENSFORPROPHYLAXIS
TO MINIMISE RISK OF
BACTERIALENDOCARDITIS
• Oralmedication.
• Adults&childrennotallergictopenicillin-amoxicillin.
• Adults&childrenallergictopenicillin-clindamycin.
• Nonoralmedication.
• Adults&Childrensnotallergictopenicillin-ivorim
ampicillin.
• Adults&childrenalergictopenicillin-ivclindamycin.
151
TO MINIMISE RISK OF
BACTERIALENDOCARDITIS
• Oralmedication.
• Adults&childrennotallergictopenicillin-amoxicillin.
• Adults&childrenallergictopenicillin-clindamycin.
• Nonoralmedication.
• Adults&Childrensnotallergictopenicillin-ivorim
ampicillin.
• Adults&childrenalergictopenicillin-ivclindamycin.
151
152
153
PREGNANCY
&CARDIOVASCULA
RDISEASES
154
&CARDIOVASCULA
RDISEASES
154
• Diagnosis of congenital cardiac
malformationscan be made as early as 13
weeks, and, in families with heart disease.
• Early examination in pregnancy allows parents
toconsideralloptions,includingterminationof
pregnancy,iftherearemajormalformations.
• Hypertensive disorders during pregnancy
occurin women with pre-existing primary
orsecondary chronic hypertension, and in
women who develop new-onset hypertension in
the second half of pregnancy.
155
malformationscan be made as early as 13
weeks, and, in families with heart disease.
• Early examination in pregnancy allows parents
toconsideralloptions,includingterminationof
pregnancy,iftherearemajormalformations.
• Hypertensive disorders during pregnancy
occurin women with pre-existing primary
orsecondary chronic hypertension, and in
women who develop new-onset hypertension in
the second half of pregnancy.
155
156
157
158
CONGENITAL
HEARTDISEASES
CONGENITAL
HEARTDISEASES
• Congenital heart disease usually manifests in
childhood but may pass unrecognised and not
present until adult life.
• The fetus has only a small flow of bloodthrough
the lungs, as it does not breathe in utero. The
fetal circulation allows oxygenatedblood from
the placenta to pass directly to the left side of
the heart through the foramen ovale
withouthavingtoflowthroughthelungs.
159
childhood but may pass unrecognised and not
present until adult life.
• The fetus has only a small flow of bloodthrough
the lungs, as it does not breathe in utero. The
fetal circulation allows oxygenatedblood from
the placenta to pass directly to the left side of
the heart through the foramen ovale
withouthavingtoflowthroughthelungs.
159
PersistentDuctusArteriosus
• During fetal life, before the lungs begin
tofunction, most of the blood from the
pulmonary artery passes through the ductus
arteriosus into the aorta.
• Normally, the ductus closes soon after
birthbut sometimes fails to do so.
• Since the pressure in the aorta is higher than
that in the pulmonary artery, there will be a
continuous arteriovenous shunt.
160
• During fetal life, before the lungs begin
tofunction, most of the blood from the
pulmonary artery passes through the ductus
arteriosus into the aorta.
• Normally, the ductus closes soon after
birthbut sometimes fails to do so.
• Since the pressure in the aorta is higher than
that in the pulmonary artery, there will be a
continuous arteriovenous shunt.
160
161
Management:
• Apatentductusisclosedatcardiac
catheterisation with an implantable occlusive
device.
• When the ductus is structurally intact,
aprostaglandin synthetase inhibitor
(indometacinor ibuprofen) may be used in the
first week
oflifeandalsoimprovingoxygenationtoinduce
• Apatentductusisclosedatcardiac
catheterisation with an implantable occlusive
device.
• When the ductus is structurally intact,
aprostaglandin synthetase inhibitor
(indometacinor ibuprofen) may be used in the
first week
oflifeandalsoimprovingoxygenationtoinduce
closure.
162
162
Coarctationoftheaorta
• Narrowing of the aorta occurs in the
regionwhere the ductus arteriosus joins the
aorta, i.e. at the isthmus just below the origin
of the left subclavian artery.
• Management : In untreated cases, death may
occur from left ventricular failure, dissection
ofthe aorta or cerebral haemorrhage.
163
• Narrowing of the aorta occurs in the
regionwhere the ductus arteriosus joins the
aorta, i.e. at the isthmus just below the origin
of the left subclavian artery.
• Management : In untreated cases, death may
occur from left ventricular failure, dissection
ofthe aorta or cerebral haemorrhage.
163
Atrialseptaldefect
• ‘Ostiumprimum’defectsresultfromadefectin
the atrioventricular septum and are associated
witha‘cleftmitralvalve’(splitanteriorleaflet).
• As a result there is gradual enlargement of the
right side of the heart and of the pulmonary
arteries.
164
• ‘Ostiumprimum’defectsresultfromadefectin
the atrioventricular septum and are associated
witha‘cleftmitralvalve’(splitanteriorleaflet).
• As a result there is gradual enlargement of the
right side of the heart and of the pulmonary
arteries.
164
165
• Management : Closure can also be
accomplished at cardiac catheterisation using
implantable closure devices.
• Severe pulmonary hypertension and shunt
reversal areboth contraindications to surgery
166
accomplished at cardiac catheterisation using
implantable closure devices.
• Severe pulmonary hypertension and shunt
reversal areboth contraindications to surgery
166
Ventricularseptaldefect
• Congenital ventricular septal defect occurs as a result
of incomplete septation of the ventricles.
• Management:Smallventricularseptaldefects
requirenospecifictreatment.Cardiacfailurein
infancy is initially treated medically with digoxin
anddiuretics.Persistingfailureisanindicationfor
surgical repair of the defect. Percutaneous closure
devices are under development.
167
• Congenital ventricular septal defect occurs as a result
of incomplete septation of the ventricles.
• Management:Smallventricularseptaldefects
requirenospecifictreatment.Cardiacfailurein
infancy is initially treated medically with digoxin
anddiuretics.Persistingfailureisanindicationfor
surgical repair of the defect. Percutaneous closure
devices are under development.
167
168
TetralogyOfFallot
169
169
170
171
STUDIES
SHOWINGASSOCIATIONOFPE
RIODONTITISANDCARDIOVA
SCULARDISEASES
172
SHOWINGASSOCIATIONOFPE
RIODONTITISANDCARDIOVA
SCULARDISEASES
172
Periodontalinfectionsand cardiovascular
disease.Theheartofthematter
• Journal:TheJournaloftheAmericanDentalAssociation(October2006)1
37,14S-20S.
• Author:RyanT.Demmer
• Conclusions. Evidence continues to support an association
amongperiodontal infections, atherosclerosis and vascular disease.
Ongoing observational and focused pilot intervention studies may inform
thedesign of large-scale clinical intervention studies.
Recommendingperiodontal treatment for the prevention of
atherosclerotic CVD is notwarranted based on scientific evidence.
Periodontal treatment must be recommended on the basis of the value
of its benefits for the oral health of patients, recognizing that patients are
not healthy without good oral health. However, the emergence of
periodontal infections as a potential riskfactorfor CVD
isleadingtoaconvergenceinoralandmedicalcare that can only benefit the
patients and public health.
disease.Theheartofthematter
• Journal:TheJournaloftheAmericanDentalAssociation(October2006)1
37,14S-20S.
• Author:RyanT.Demmer
• Conclusions. Evidence continues to support an association
amongperiodontal infections, atherosclerosis and vascular disease.
Ongoing observational and focused pilot intervention studies may inform
thedesign of large-scale clinical intervention studies.
Recommendingperiodontal treatment for the prevention of
atherosclerotic CVD is notwarranted based on scientific evidence.
Periodontal treatment must be recommended on the basis of the value
of its benefits for the oral health of patients, recognizing that patients are
not healthy without good oral health. However, the emergence of
periodontal infections as a potential riskfactorfor CVD
isleadingtoaconvergenceinoralandmedicalcare that can only benefit the
patients and public health.
173
Associationbetweendentalhealthand
acutemyocardialinfarction.
• Journal:BMJ2009;298:779.
• Authors:K.J.Mattilaetal.
• Abstract
Knownriskfactorsforcoronary heartdiseasedonotexplainalloftheclinical and
epidemiological features of the disease. To examine the role of chronic bacterial
infections as risk factors for the disease the association between poor dental
health and acute myocardial infarction was investigated in two separate case-
control studies of a total of 100 patients with acute myocardial infarction and 102
controls selected from the community at random. Dental health was graded by
using two indexes, one of which was assessed blind. Based on these
indexesdentalhealth wassignificantly worsein patientswithacute myocardial
infarction thanincontrols. Theassociation remainedvalidafteradjustmentfor age,
social class, smoking, serum lipid concentrations, and the presence of diabetes.
Further prospective studies are required in different populations to confirm the
association and to elucidate its nature.
174
acutemyocardialinfarction.
• Journal:BMJ2009;298:779.
• Authors:K.J.Mattilaetal.
• Abstract
Knownriskfactorsforcoronary heartdiseasedonotexplainalloftheclinical and
epidemiological features of the disease. To examine the role of chronic bacterial
infections as risk factors for the disease the association between poor dental
health and acute myocardial infarction was investigated in two separate case-
control studies of a total of 100 patients with acute myocardial infarction and 102
controls selected from the community at random. Dental health was graded by
using two indexes, one of which was assessed blind. Based on these
indexesdentalhealth wassignificantly worsein patientswithacute myocardial
infarction thanincontrols. Theassociation remainedvalidafteradjustmentfor age,
social class, smoking, serum lipid concentrations, and the presence of diabetes.
Further prospective studies are required in different populations to confirm the
association and to elucidate its nature.
174
175
SUMMARY
SUMMARY
176
• Cardiovascular problems are non-communicable
diseases which are growing in India and other
partsof the world very fast.
• The dental considerations for such cases are required
withproperinvestigationsandmedications.
LETSJOINHANDSFORSAVINGTHEHEARTS
OFTHENATION!
177
CONCLUSION
diseases which are growing in India and other
partsof the world very fast.
• The dental considerations for such cases are required
withproperinvestigationsandmedications.
LETSJOINHANDSFORSAVINGTHEHEARTS
OFTHENATION!
177
CONCLUSION
• Davidson’sPrincipleandPracticeofMedicine–
21
st
Edition
• Burket’sBookofOralMedicine–11
th
Edition
• Emerging risk factors for
cardiovasculardiseases:Indiancontext. Sushilet al.
Indian Journalof Endocrinology and Metabolism /
Sep-Oct 2013 /Vol 17 | Issue 5
• HeartDiseaseandStrokeStatistics--2010Update:A
Report From the American Heart Association
178
REFERENCES
21
st
Edition
• Burket’sBookofOralMedicine–11
th
Edition
• Emerging risk factors for
cardiovasculardiseases:Indiancontext. Sushilet al.
Indian Journalof Endocrinology and Metabolism /
Sep-Oct 2013 /Vol 17 | Issue 5
• HeartDiseaseandStrokeStatistics--2010Update:A
Report From the American Heart Association
178
REFERENCES
• Oral Health, Atherosclerosis, And
Cardiovascular Disease. Jukka H. Meurman
EtAl.CritRevOralBiolMed;15(6):403-413
(2004).
• 2007 Guidelines For The Management
OfArterialHypertension.EuropeanHeartJou
rnal(2007)28,1462–1536.
• Dental Disease And Risk Ofcoronary Heart
Disease And Mortality. Frank Destefano Et
Al. Bmj Volume 306 13 March 1993.
179
Cardiovascular Disease. Jukka H. Meurman
EtAl.CritRevOralBiolMed;15(6):403-413
(2004).
• 2007 Guidelines For The Management
OfArterialHypertension.EuropeanHeartJou
rnal(2007)28,1462–1536.
• Dental Disease And Risk Ofcoronary Heart
Disease And Mortality. Frank Destefano Et
Al. Bmj Volume 306 13 March 1993.
179
• CoronaryArteryDisease.MuntherK.
Homoud.SeminarByMdOfTufts-new
EnglandMedicalCenterSpring2008.
• Hypertension In Pregnancy:the Management
Of Hypertensive Disorders During Pregnancy.
Royal College Of Obstetricians And
Gynaecologists. National Collaborating Centre
For Women’s And Children’s Health.Aug 2010.
• Relationship Between Oral Health Lars Frithiof
EtAl.JClinPeriodontol2001;28:762–768.
180
Homoud.SeminarByMdOfTufts-new
EnglandMedicalCenterSpring2008.
• Hypertension In Pregnancy:the Management
Of Hypertensive Disorders During Pregnancy.
Royal College Of Obstetricians And
Gynaecologists. National Collaborating Centre
For Women’s And Children’s Health.Aug 2010.
• Relationship Between Oral Health Lars Frithiof
EtAl.JClinPeriodontol2001;28:762–768.
180
• DefinitionAndClassificationOfHypertension: An
Update. Emerging Concept.
ThomasD.GilesEtAl.TheJournalOfClinicalHypert
ension.Vol.11No.11November 2009.
• PreventionOfInfectiveEndocarditis:Guidelines
FromTheAmericanHeart
Association.AGuidelineFromTheAmericanHeart
Association.
• Dental Considerations In Patients With Heart
Disease. Marta Cruz-pamplona Et Al. J
ClinExpDent.2011;3(2):e97-105.
181
Update. Emerging Concept.
ThomasD.GilesEtAl.TheJournalOfClinicalHypert
ension.Vol.11No.11November 2009.
• PreventionOfInfectiveEndocarditis:Guidelines
FromTheAmericanHeart
Association.AGuidelineFromTheAmericanHeart
Association.
• Dental Considerations In Patients With Heart
Disease. Marta Cruz-pamplona Et Al. J
ClinExpDent.2011;3(2):e97-105.
181
• HypertensionGuidelines:RevisitingTheJNC7
Recommendations. The Journal Of Lancaster
GeneralHospital•Fall2008•Vol.3–No.3.
• ESCGuidelinesOnTheManagementOfCardiov
ascularDiseasesDuringPregnancy.EuropeanH
eartJournal(2011)32,3147–3197.
• PeripheralSignsOfEndocarditis.FrankL.Urba
no.HospitalPhysicianMay2000.
182
Recommendations. The Journal Of Lancaster
GeneralHospital•Fall2008•Vol.3–No.3.
• ESCGuidelinesOnTheManagementOfCardiov
ascularDiseasesDuringPregnancy.EuropeanH
eartJournal(2011)32,3147–3197.
• PeripheralSignsOfEndocarditis.FrankL.Urba
no.HospitalPhysicianMay2000.
182
THANKYOU
183
183
Tags
Download
Download Slideshow Get the original presentation fileQuick Actions
Statistics
- Views 86
- Slides 195
- Age 529 days
Related Slideshows
36
Clinical approach Dyspnoea A simple and practical approach.pptx
ShajahanPS
37 views
238
Cancer Awareness therapy for public by Dr Kanhu Charan Patro
kanhucpatro
36 views
41
Prof Satyadas Memorial oration Kozhikode.pptx
ShajahanPS
33 views
26
Viral Conjunctivitis and it;s managment.pptx
ZaidAzhar
43 views
30
Essential Thrombocythemia 15 Years of Experience at the Hematology Department, Algies, Algeria.pdf
sbelakehal
40 views
10
Hypertension sign symptoms cmdt style with regime
androiddabest
41 views