Dental Considerations-cvs Diseases

Medical Diseases

Leading cause of death in the U.S. Includes diseases of the heart and blood vessels.

Disease Classification ❚ Anatomic System ❙ Diseases of pericardium, myocardium, endocardium, heart valves and blood vessels

❚ Etiologic System ❙ Diseases by causitive agent includes infectious agents, atherosclerosis, hypertension, immunologic mehanisms and congenital anomalies

Congenital Heart Disease ❚ Embryonic defects that occur during 1st nine weeks ❚ Accurate patient history to determine nature of lesion and degree of disability ❚ Medical consult ❚ May require premed

Rheumatic Heart Disease ❚ Complications following rheumatic fever - affects connective tissue especially heart, its valves and the joints of body ❚ Valves become chronically inflamed ❚ Patient may need premed ❚ Always consult physician to verify necessity of premedication if patient unsure

Infective Endocarditis ❚ Bacterial invasion of heart valve or endocardium that occurs in proximity to congenital or acquired defects ❚ Bacteria usually Streptococcus viridans that enters during dental treatment and settles on valve previously damaged ❚ Causes bacteremia-prognosis

Prevention of Infective Endocarditis ❚ Antibiotic premedication ❚ Accurate medical history ❚ Patient following approved prophylaxis regimen of antibiotic

Hypertension ❚ Results from increased load on the heart because of high blood pressure ❚ Can lead to enlarged heart, then heart failure ❚ Elevation of blood pressure is symptom of hypertension

HYPERTENSION ❚ PRIMARY (ESSENTIAL) Hypertension: Etiologic factors unknown-could be diet, obesity, smoking,etc. ❚ 90% of people have this type

❚ SECONDARY Hypertension: Specific causes can be identifiedincreased blood pressure is secondary to major disease - kidney disease,diabetes ❚ 10% of people have this type

Ischemic Heart Disease ❚ Coronary Heart Disease ❚ Caused by reduction or arrest of blood supply- usually because of atherosclerosis of the vessel walls ❚ Angina pectoris, myocardial infarction, congestive heart failure

Angina Pectoris ❚ Coronary arteries unable to supply sufficient blood to myocardium ❚ Result is pain in chest, mild to severe crushing pain which radiates from heart to left arm ❚ Unstable angina -increased intensity of attacks,serious sign of impending myocardial infarction ❚ Patients should carry own

Myocardial Infarction ❚ Heart attack, coronary occlusion, coronary thrombosis ❚ Results from sudden reduction of coronary blood flow ❚ Area affected by zero blood flow is said to be infarcted ❚ Need to know severity,residual damage, and time elapsed since attack

Congestive Heart Failure ❚ Occurs when ventricles fail to maintain an adequate output of blood for the needs of the body ❚ Assess degree of heart failure with help of medical consult and patient information ❚ Patient may not be able to breath if lowered too far back ❚ Administration of O2 may be

Cardiovascular Conditions Contraindicate Treatment ❚ ACUTE conditions of ❙ Angina pectoris ❙ Congestive heart failure ❙ Extreme hypertension

Prevention of Infective Endocarditis ❚ Identify high risk patients ❚ Prophylactic antibiotic coverage for appointments ❚ Working with patient to improve and maintain high level of oral health to diminish frequency or severity of bacteremia ❚ Bacteremia lasts only 15 minutes after prophy

Oral Tissue Characteristics ❚ Patient health history may not reveal blood disorders ❚ Oral manifestations of blood disorders are usually exaggerated when there is plaque and local irritating factors

Oral Findings of Blood Disorder ❚ Gingival bleeding or history of difficulty in controlling bleeding ❚ Bruises easily ❚ Numerous petechiae ❚ Marked pallor of mucous membranes

❚ Acute or chronic infections in mouth that do not respond to treatment ❚ Severe ulcerations gingival that do not respond to treatment ❚ Exaggerated gingival response

Normal Blood Composition ❚ 55% plasma fluid ❚ 45% formed element

❚ Three types of formed elements ❙ Erythrocytes - RBC ❙ Leukocytes - WBC ❙ Thrombocytes Platelets

Functions of Blood Cells ❚ RBC’s: sensitive,flexible and change shape readily; contain hemoglobincarries O2 to cells ❚ WBC’s: motile so pass into connective tissue; work in CT phagocytic and immunologic respond to invasion of microorganisms ❚ Platelets: 1/4 size of RBC’s, active in

Anemia ❚ Reduction of hemoglobin concentration-which carries O2, hematocrit (fraction of blood occupied by RBC’s) ❚ Causes of anemia ❙ Blood loss:iron deficiency anemia ❙ Increased hemolysis(destruction of RBC’s): sickle cell anemia ❙ Diminished production of RBC’s: ❘ nutritional iron deficiency

Characteristics of Anemia ❚ Pale and thin skin ❚ Weakness, malaise, easily fatigued ❚ Dyspnea on slight exertion, faintness ❚ Headache, vertigo, tinnitus

❚ Dimness of vision, spots before eyes ❚ Brittle nails with loss of convexity

Treatment Considerations ❚ Decreased ability of blood to carry oxygen throughout body ❚ Fainting may occur more easily ❚ IV sedation must have supplemental O2

Treatment Sickle Cell ❚ Hereditary hemolytic form ❚ Occurs primarily in blacks and mediterranean origin ❚ Concerned with SC crisis-acute stage ❚ Do not treat if in this stage

Treatment Sickle Cell ❚ Premed if not completely controlled ❚ Crisis seen in periods of unusual stress or when patient does not receive adequate oxygen supply ❚ When SC not controlled patient susceptible to infection ❚ Perio disease may be present even in children

Polycythemia ❚ An increase in number and concentrations of RBC’s above normal level ❚ Relative polycythemia- loss of plasma without loss of RBC’s so concentration of RBC’s increased ❙ caused by dehydration,diarrhea,repeated vomiting,sweating or fluid loss from burns

Polycythemia ❚ Primary polycythemia - actual increase in number of circulating RBC’s and platelets viscosity of blood increased,which affects oxygen transport to tissues ❘ results from bone disorder

❚ Secondary polycythemia - increase number of RBC’s ❘ causes are hypoxia(high altitudes and diseases or tumors

Leukopenia ❚ Decrease in number of WBC’s ❚ Results when cell production can’t keep pace with the turnover rate or when accelerated rate of removal occurs ( in certain diseases) ❚ Causes are typhoid fever, influenza,malaria, measles, German measles,chronic drug poisoning and radiation

Leukocytosis ❚ Increase in number of circulating WBC’s ❚ May be caused by inflammatory and infectious states, trauma,exercise ❚ Most extreme cause is Leukemia ❙ Malignant proliferation of WBC’s in bone marrow -results numerous immature WBC’s ❙ Oral complications, more severe tissue response

Hemorrhagic Disorders ❚ Diseases that have tendency spontaneous bleeding and/or moderate to excessive bleeding after trauma or surgical procedure

❚ Types due to: ❙ abnormalities of blood capillaries ❙ platelet dysfunction or deficiency ❙ blood clotting defects

Blood Capillary Disorder ❚ Vascular fragility increased which leads to petechial hemorrhages in skin or mucous membranes, includes gingiva ❚ May be caused by severe infections such as typhoid, drug reaction, scurvy

Platelet Deficiency and Dysfunction ❚ Thrombocytopenia ❙ Lowered number of platelets due to decreased production in bone marrow ❙ Leukemia or vitamin B12 deficiency

❚ Platelet Dysfunction ❙ Interferes with clotting mechanism and leads to prolonged bleeding time ❙ aspirin contraindicated

Blood Clotting Defect ❚ Possible irregularity or disorder is associated with each of the many clotting factors ❚ Examples include Vitamin K deficiency, liver disease, hereditary disorders - Hemophilia A and B

Characteristics of Hemophilia ❚ Congenital disorders of the blood clotting mechanism ❚ Severity varies ❚ Hemophilia A and B inherited by males ❚ Acceptable minimal surgical level of the clotting factor is 30% - includes subgingival scaling

Treatment of Hemophilia ❚ Must consult patient’s hematologist they may need clotting factor replacement therapy before and after appointment ❚ Susceptible to infection-may need premed ❚ Avoid nerve blocks since positive

Prosthetic Joint Replacement ❚ Replacement of hips, knees, and elbows with prosthetic devices is becoming common ❚ Common practice to premedicate to prevent bacteremia ❚ Consultation with orthopedic surgeon essential before proceeding with appt

Pulmonary Diseases ❚ Abnormal condition of the respiratory system, characterized by cough, chest pain, shortness of breath, sputum production, wheezing ❚ Diseases are Obstructive or Restrictive

Obstructive ❚ Result of an obstacle in airway that impedes the flow of air, especially during expiration ❚ May be caused by bronchospasms, edema, loss of lung elasticity or thick bronchial secretions ❚ Asthma, bronchitis, emphysema ❚ Asthmatics frequently allergic to aspirin

Restrictive ❚ Caused by conditions that limit lung expansion by an actual reduction of the volume of inspired air ❚ Increased work to breath and an inefficient exchange of gases ❚ Examples include pulmonary fibrosis or chest deformities

Treatment Considerations for Pulmonary Diseases ❚ Supplemental oxygen may be necessary ❚ Chair position may be important allow patient to feel comfortable about breathing

❚ Not suitable for nitrous oxide usage

❚ Asthmatics should have their own medications

Diabetes Mellitus ❚ Genetically heterogenous group of disorders that are characterized by glucose intolerance

❚ Three types of diabetic syndromes: ❙ Type I - Insulin Dependent ❙ Type II - Noninsulindependent ❙ Type III Gestational

Diabetes Type I ❚ Insulin dependent ❚ Patient has natural insulin deficiency ❚ Patient depends on insulin for survival ❚ Usually begins in childhood ❚ Abrupt onset of symptoms

Diabetes Type II ❚ Noninsulin dependent ❚ May or may not use insulin for symptom control but do not need it for survival ❚ Slow progression of disease ❚ Typically begins after 35 - 40 years of age ❚ Obese type - weight control and diet

Diabetes Type III ❚ Gestational ❚ Begins or is noticed during pregnancy ❚ Above average risk of perinatal complications ❚ Glucose intolerance may not last past pregnancy

Function of Insulin ❚ Hormone ❚ Facilitates conversion of glucose to fat in adipose tissue ❚ Speeds the conversion of glucose to glycogen in the liver and muscles ❚ Facilitates the transmission of glucose into cells ❚ Speeds the oxidation of glucose within the cells for energy

Effects of Decreased Insulin ❚ In diabetes, insulin is decreased in amount or function ❚ Less glucose is transmitted through cell walls into the cells ❚ Glucose increases in the circulating blood until a threshold is reached when glucose spills over into urine ❚ Without glucose in the cells to use for energy, the cells utilize fats

When cells utilize fats…. ❚ End products of fat metabolism (ketones) accumulate in the blood ❚ Acidosis results ❚ Acidosis can result in diabetic coma

Insulin Complications ❚ Insulin reaction hypoglycemia ❙ lowered blood glucose with excess insulin proportion ❙ sudden onset

❚ Diabetic coma ketoacidosis ❙ Too little insulin with excess ketones in blood ❙ gradual onset

Uncontrolled Diabetes ❚ Patient has symptoms known as Classic Triad ❘ Excess urine - polyuria ❘ Excessive thirst - polydipsia ❘ Increased appetite - polyphagia

Uncontrolled Diabetes Other Symptoms ❚ Dehydration from fluid loss ❚ General weakness,drowsiness,fatigue ❚ weight loss from inability to utilize foods ❚ elevated blood glucose ❚ glucose in urine ❚ slow wound healing, persistent infections

Infection and Diabetes ❚ More susceptible to infection ❚ Failure to treat an infection increases severity of diabetic state and intensifies the symptoms ❚ With infection present, insulin requirements increase, infection heals,insulin lowered ❚ Frequently seen infections-urinary tract infections, skin, lungs and oral

Diabetes ❚ Diet therapy- eliminate concentrated carbohydrates ❚ Appointment therapy: ❚ stress reduction critical- watch stress level ❚ best appt is in morning 1 to 3 hours after normal breakfast and medication

Diabetes - Appointment Considerations ❚ Antibiotic protection may be indicated for a patient who has history of slow healing from previous scaling or any surgical procedure ❚ May need to recheck tissues one week post-scaling appt for healing response ❚ May want to postpone fluoride application if scaling was difficulty

Diabetes - Progress of Periodontal Disease ❚ Patients with insulin dependent diabetes have a tendency to develop perio disease - even at early age ❚ Diabetes doesn’t cause disease just decreases resistance to bacteria

Reactive Hypoglycemia ❚ Low blood sugar, deficiency of sugar in blood ❚ Types: most common following meal, due to delayed insulin response in some mild maturity onset diabetes after carbo load ❚ alcohol induced, ❚ functional ( unknown causes)

Reactive Hypoglycemia ❚ Symptoms: lightheadedness, palpitations, sweating, hunger,nervousness ❚ Symptoms trigger a ripple effect of fatigue, depression, consciousness, convulsions, and coma ❚ Stress intensifies ripple ❚ Symptoms relieved by oral glucose

Hypothyroidism & Hyperthyroidism ❚ Most patients will be sensitive to temperature changes. ❚ Most people will have had the disease but be under control due to drugs or surgery.

Hypothyroidism & Hyperthyroidism ❚ HYPO ❙ atrophy of gland ❙ less secretions from thyroid ❙ sluggish ❙ decreases basal metabolism

❚ HYPER ❙ enlarged gland ❙ more secretions from thyroid ❙ increases basal metabolism ❙ nervous

Corticosteroid Therapy ❚ Hormonal steroid ❚ Used in the management of a wide variety of diseases including arthritis, allergic diseases, and pemphigus ❚ Corticosteroids depress the natural defensive responses including inflammation and alter connective tissue response to injury

Corticosteroid Therapy ❚ In dentistry, use corticoids for oral ulcerations, arthritis of TMJ ❚ Usually applied topically for suppression of local inflammation

❚ Treatment considerations: ❙ arthritis patients may be on long term treatment with CS ❙ dental treatment causes stress-need to ascertain if patient has complications with handling stress

Corticosteroid Therapy Treatment Considerations ❚ Patient may have high BP, salt and water retention ❚ Topical applications should be avoided in patients suffering from diabetes,hyper- tension,peptic ulcer,TB or viral infections ❚ For those on long term therapy, early signs of inflammation will be masked and correct diagnosis may be missed

Allergic Reactions ❚ Mild: Characterized by swelling,redness, itching- delayed ❚ Severe: Characterized by respiratory depression and circulatory system involvement-anaphylaxis-abrupt & immediate ❚ ANY allergies must be fully evaluated before the start of treatment and any drug administration

Mental Conditions ❚ Considerations for patients on antianxiety, antipsychotic, or antidepressants ❚ Usually under care of a physician ❚ May be taking multiple drugs for management of their disorders ❚ Side effects might include xerostomia and/or lack of mental alertness

Epilepsy ❚ Find out type of seizure activity, its frequency,drugs used to prevent seizures. ❚ Minimize and/or reduce stress level for patient. ❚ Gingiva may be enlarged from medications.

Pharmacological Considerations ❚ CENTRAL NERVOUS SYSTEM DEPRESSANTS: ❙ Barbituates:effective sedative and hypnotics - long acting barbs used fro seizure disorders and mild anxiety ❙ Narcotics: pain control in terminal disease ❙ Antianxiety:used in psychiatric treatment ❙ Treatment considerations: If patient has

Pharmacological Considerations ❚ CENTRAL NERVOUS SYSTEM STIMULANTS: ❙ Include antihistamines, diet pills, caffeine, cocaine ❙ Side effects include: • xerstomia - dry mouth • increase in vital signs • nervousness, talkative

❙ Severe overstimulation can cause heart failure

Cancer Patients ❚ Usually on anti-neoplastic (chemotherapy) drugs- in combination with surgery, and radiotherapy-may cause oral manifestations side effects ❘ oral ulcerations, mucosal sloughing, necrotic lesions ❘ increased susceptibility to infections such as candidiasis due to suppression of normal defense mechanisms ❘ bleeding problems from suppression of

Cancer Patients ❚ Pre-medication may be necessary; consult oncologist; immune system compromised; will be susceptible to infections ❚ Treatment problems ❙ When head and neck area radiated it may cause necrosis of bone in jaws and rampant caries ❙ Oncological treatment ❘ Before: prophy to decrease risk of infection

Liver Disease ❚ Caused by: ❙ hepatitis-drug induced,alcoholic,vi ral ❙ cirrhosisalcoholic,biliary ❙ infiltrationsglycogen,fat ❙ biliary obstruction ❙ severe vascular diseases

❚ Problems with treatment: ❙ serious bleeding problems may occur;may need replacement of clotting proteins ❙ Reduced capability to metabolize drugs-prolonged blood levels of drugs

Childbearing Age Females ❚ Oral contraceptives: usually mixture of estrogen and progesterone ❚ Tissues may mimic effects of pregnancy ❙ ❙ ❙ ❙

mild inflammation and edema loss of tissue tone spontaneous bleeding tenderness and ulcerations

Alcohol and Drug Addiction Patients ❚ Higher than normal incidence of liver disease ❚ Increase of valvular damage ❚ May need premedication ❚ Low tolerance for pain

Tuberculosis ❚ Contracted by inhalation of fresh droplets containing tubercle bacilli ❚ Predisposing factors - any debilitating or immunosuppressive condition-eg. HIV,diabetes.chronic lung disease, alcoholism ❚ Incubation period- up to 6 months

Tuberculosis ❚ Early symptoms: low grade fever, loss of appetite, weight loss, tire easily,slight cough ❚ Later symptoms: definite temperature elevations, night sweats, weakness and persistent cough ❚ Re-infection TB: infection may remain inactive and later produce a

Tuberculosis ❚ Clinical management: ❙ May have enlarged lymph nodes, ulcers on palate ❙ Chemotherapy can control patients contagious condition ❙ Consult physician to clarify if active- can usually treat patient if they have been on medication for 2-3 weeks

Hepatitis A ❚ Occurs most frequently in children and young adults ❚ Most common transmission is through close contact in unsanitary conditions (fecal-oral route) ❚ Prevention by universal precautions

Hepatitis B ❚ Occurs at any age ❚ Very different disease process than HepA ❚ Major source of HPB from patients with acute infection and symptomless chronic carriers ❚ Transmitted by blood, other bodily, perinatal transmission ❚ Prevention through immunization

Hepatitis D - Delta ❚ Can only cause infection in presence of HBV ❚ Occurs primarily in persons who have multiple exposures of HBV ❚ Transmission same as HBV ❚ More severe than HBV ❚ Prevention is same as HBV

HIV ❚ Infected patients have variety of symptoms since disease has 3 stages ❙ Asymptomatic ❙ AIDS related complex- ARC ❙ AIDS

HIV ❚ Damages immune and neurological system ❚ Transmission via blood,semen,vagin al secretions,breast milk ❚ Patient highly susceptible to infection

❚ Consult physicianmay need premed if abnormal white cell, fungslT-cell and/or platelet count ❚ Patient may have opportunistic diseases ❙ fungal-candidiasis ❙ bacterial-

HIV ❚ Neoplasms-Kaposi’s sarcoma,squamous cell carcinoma, Non-Hodgkin’s lymphoma ❚ Neurological disturbances- facial palsy ❚ Unknown etiological diseasesrecurrent apthous ulcers, delayed wound healing, salivary gland enlargement, xerostomia

Herpes Virus Diseases ❚ Varicella-zoster: ❙ Chicken pox - highly contagious; lesions on trunk ❙ Shingles- painful, burning and itching lesions that may be anywhere on the body

Herpes Virus Disease ❚ Epstein-Barr virus:Infectious Mononucleosis ❘ Characterized by fever, swollen lymph nodes and sore throat ❘ Transmitted orally by direct contact and droplets

Herpes Virus Diseases ❚ Cytomegalovirus: CMV- Salivary gland viruses❘ Occurs congenitally,postnatally, or at any age, ranges in severity from a slight infection without complications through disease manifested by fever, hepatitis, pneumonitis, and in neonates- severe brain damage resulting in stillbirth or perinatal deaths ❘ 60-90% adults have experienced infection ❘ Transmitted by blood transfusion, graft transplant,sexual transmission,respiratory

Herpes Simplex Virus ❚ Primary herpetic gingivostomatitisprimary infection may be asymptomatic or with symptomsusually painful lesions and flu-like symptoms ❚ Herpes labialis (HSV-1) or genital herpes (HSV-2)- cold sores,fever blister, both cause genital and oralfacial infections that can’t be distinguished clinically

Herpes Virus Disease ❚ Herpes labialis: ❙ Usually triggered by stress, sunlight, illness or trauma ❙ Healing may take 10 days ❙ Lesions are infectious and can be spread to eye, nose and genitals ❙ Treat after lesion has burst and dried, crusted appearance

Herpes Virus Disease ❚ Herpetic Whitlow: HSV infection of fingers that results from the virus entering through minor skin abrasions ❚ May be recurrent lesion of HSV-1 or HSV-2 ❚ Transmission results from direct contact with a vesicular lesion on patient’s lip or saliva- lesions are

Herpes Virus Diseases ❚ Ocular herpes- HSV-1 or HSV-2 in the eye ❚ Transmission by splashing saliva or fluid from lesion into eye, extension from facial lesion, or during birth

Herpes Virus Diseases ❚ Clinician with a herpetic lesion ❙ Herpetic Whitlow direct patient care should be avoided for duration ❙ Herpes Labialiscareful isolation with mask,care that mask does not become moist