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Dental management of patients with recent MI and/or cardiovascular surgery

Originally published in the August/September 2015 issue of Dispatch

Dentists frequently encounter medically compromised patients, so the need for dental management of patients with a number of medical conditions is common. A comprehensive medical history, including a Review of Systems (ROS) where indicated, is a prerequisite for the delivery of safer dental treatment. Medical consultation to determine the severity and stability of the patient’s condition is often necessary. This medical information, together with the anticipated complexity and urgency of the dental procedures, is relevant in decisions regarding the type and timing of treatment and which precautions, if any, are necessary.

Many cardiovascular diseases, such as ischemic heart disease and cerebrovascular disease, are manifestations of atherosclerosis. Particular consideration is needed for patients who present for dental care after having a heart attack (myocardial infarction) or stroke (cerebrovascular accident).

Patients who have had an MI may be taking a number of medications, including antihypertensives, anticoagulants or antiplatelet agents. They may also use a vasodilator such as nitroglycerin to treat stable or unstable angina. If a patient is taking medications, whether prescription or over-the-counter, consideration must be given to their therapeutic effects, and also to potential drug interactions and side effects.

For example, drugs which affect hemostasis may require additional precautions with a dental procedure that might cause bleeding. These patients often have other medical conditions and/or risk factors, such as diabetes, hypertension, hyperlipidemia, prosthetic heart valve, or a smoking history. They may reveal additional systemic and/or oral complications and associated medications.

At some point following an MI, patients may attend the dental office for a variety of treatment needs. Practitioners may be concerned about whether it is safe to proceed with dental treatment or whether such treatment should be postponed for a particular period of time. Damaged myocardium may be electrically unstable, susceptible to re-infarction, and possibly predispose the patient to heart failure. For these reasons, and depending on a number of other factors, a waiting period is often suggested. A medical consultation is also advisable to determine the optimal timing for dental care.

Following a myocardial infarction or in order to manage stable or unstable angina, some patients may undergo either an angioplasty procedure, with or without placement of a stent, or a coronary artery bypass graft (CABG). Although antibiotic prophylaxis (AP) is normally not required after either procedure, some physicians may recommend AP following stent placement in the immediate perioperative period or whenever incision and drainage of infected tissue (e.g. dental abscess) is contemplated.

In addition, patients who have had a stent placed will usually be taking an anticoagulant or antiplatelet medication. Those with a drug-eluting stent are likely to be taking these medications for a longer period of time than those who have a bare metal stent. To avoid the possibility of significant morbidity, including stent thrombosis or MI, such medications must never be changed or discontinued without consultation with the physician.

As noted, following a heart attack, or as a result of other cardiac abnormalities, there may be electrical instability of the myocardium. This might be managed by antiarrhythmic medications, and some patients may present with a cardiac implantable electronic device such as a pacemaker or cardioverter-defibrillator. According to the current American Heart Association guidelines on the prevention of infective endocarditis, antibiotic prophylaxis is generally not required for these types of devices.

As with the post-MI patient, after any cardiac surgery (CABG, angioplasty, stent placement or implantation of a pacemaker/defibrillator) a waiting period before dental treatment is often suggested. As noted previously, it is recommended to establish optimal timing through consultation with the patient’s physician and/or medical specialist.

Once medical clearance has been received, it is advisable to implement a stress reduction protocol, which may include shorter appointments, consideration for use of sedation, effective local anesthesia while limiting exogenous epinephrine to 0.04 mg (equivalent to 2 cartridges of local anesthetic containing 1:100,000 epinephrine and avoiding use of epinephrine-impregnated retraction cord) and excellent post-operative analgesia.

Baseline vital signs and ongoing monitoring during treatment is a requirement for patients receiving sedation, and is generally good practice for all medically compromised patients. When pain medication is required for patients with a history of MI, it has been suggested that analgesics other than non-steroidal anti-inflammatories (NSAIDs) be considered.

If a patient is deemed medically unstable or the dentist is unsure whether it is safe to proceed with dental care, it may be best to refer the patient to a hospital dental clinic setting, where possible, or to delay treatment pending optimum medical management.

Depending on the patient’s medical condition and the stress involved in a given procedure, the potential exists for development of a medical emergency. All dentists and dental office staff must be prepared to recognize and treat adverse responses using appropriate emergency equipment and appropriate current drugs when necessary.

The learning points
  • A patient who has experienced a myocardial infarction or undergone a cardiovascular surgical procedure may be medically unstable for a period of time and therefore require a waiting period before safer dental treatment can be provided.
  • Cardiovascular patients may have comorbid conditions and may be taking several medications. These factors must be taken into consideration in the management of such individuals.
  • Once medical clearance has been received, a stress reduction protocol would be advisable.
  • If a patient is not deemed medically stable, referral to an appropriate facility is recommended.
  • Dentists must always be prepared to manage a medical emergency in their dental office.