Special Patient Series: Dental Treatment in Cardiac Patients

Cardiovascular disease (CVD) is the leading global cause of death, claiming an estimated 17.9 million lives and representing 32% of all deaths worldwide in 2019.¹ In Europe alone, 3.9 million deaths can be attributed to CVD.² As the prevalence of CVD continues to rise and the connection between oral and cardiovascular health becomes more established, it is more important than ever for dental professionals to possess the skills and knowledge to manage CVD patients in dental practice.

Cardiovascular disease and oral health

Cardiovascular diseases are those that affect the heart and blood vessels. There is now a well-established connection between oral and cardiovascular health, with recent research finding that:

• Advanced dental caries has been associated with an increase in coronary heart disease risk.⁴
• People with untreated tooth infections are 2.7 times more likely to have CVD than those with untreated infections.⁵
• Periodontal disease and tooth loss have been associated with a greater risk of cardiovascular events and mortality.^2,6

Managing the CVD patient’s oral health is therefore vital in managing their cardiovascular health, but dental care itself can pose challenges. Before discussing the management of such challenges, we will identify the cardiovascular diseases the dental professional is most likely to encounter in daily practice.

Common cardiovascular diseases

Hypertension

Hypertension is defined as consistently elevated blood pressure, based on an average of two or more measurements taken on separate occasions. According to the European Society of Cardiology/European Society of Hypertension (ESC/ESH) joint guidelines, blood pressure can be considered elevated with a systolic measurement ≥ 140 mmHg and/or a diastolic measurement ≥ 90 mmHg.⁷

Primary hypertension believed to comprise 90% of cases, is hypertension that has no apparent underlying cause.⁸ Secondary hypertension can be attributed to a specific cause, such as thyroid disease. Both primary and secondary hypertension can ultimately lead to heart attack, stroke, and organ failure.

An estimated 1.28 billion adults (aged 30-79) worldwide suffer from hypertension.⁹ It affects one in three adults in the United Kingdom and causes approximately 75,000 deaths per year.¹⁰ Prevalence is slightly lower in the EU, with 22% of people believed to have hypertension.

Coronary heart disease

Coronary heart disease (CHD), also known as ischaemic heart disease (IHD), is characterized by restriction of the blood supply and therefore oxygen to the heart muscles, or cardiac ischemia. It occurs due to narrowing or blockage of the coronary arteries, most often caused by an accumulation of atherosclerotic plaque.

CHD is typically asymptomatic in the early stages. As the condition progresses, patients may experience symptoms like fatigue, breathlessness, or angina pectoris. The latter is precipitated by exertion, increasing the oxygen requirement to the heart which cannot then be met. It is experienced as a sudden pain in the chest that may radiate to the left arm, back, jaw, or neck, that is not associated with myocardial infarction or tissue necrosis. It can be classed as:

• Stable — induced by exertion or stress and lasting less than 15 minutes.
• Unstable — occurs at rest, feels more intense, and lasts longer.
• Prinzmetal/variant — occurs at rest due to coronary artery spasm and varies in intensity.

When one or more of the coronary arteries become completely blocked, the patient can experience irreversible myocardial tissue necrosis and myocardial infarction.

CHD is the most common type of heart disease, affecting 49 million people in the European Union and 2.3 million people in the UK.^11,12 It is the leading cause of mortality worldwide, responsible for 16% of all deaths.¹³

Heart valve disease

Heart valve disease may lead to the dysfunction of one or more of the heart’s four valves. Common causes include:

• A congenital or acquired valve abnormality, e.g., aortic stenosis, or mitral regurgitation.
• Cardiomyopathy.
• Myocardial infarction.Age-related degeneration.Rheumatic fever.
• Infective endocarditis.

Damage to the heart valves can cause impairments to cardiac function, such as leakage or turbulent flow, and increase the patient’s risk of arrhythmia, stroke, infective endocarditis, and heart failure. Symptomatic patients may present with dizziness, breathlessness, fatigue, palpitations, and generalized weakness. In cases of advanced valve disease, patients will often require repair of the valve or replacement with a mechanical or bioprosthetic valve.  

Heart valve disease primarily affects the older population, with prevalence increasing after 65. It is believed to affect 13% of people aged 75 and older in high-income countries.¹⁴

Arrhythmia

Cardiac arrhythmia refers to a disturbance of the cardiac electrical system, creating an abnormal or disrupted heart rhythm. Common abnormalities include:

• Atrial fibrillation — a rapid and irregular heartbeat affecting the atria.
• Ventricular fibrillation — a rapid and irregular heartbeat affecting the ventricles.
• Bradycardia — an abnormally slow heartbeat.
• Supraventricular tachycardia — an abnormally fast heartbeat at rest.

Atrial fibrillation is the most common type of arrhythmia, with approximately 46.3 million people affected worldwide.¹⁵ It predominantly affects the elderly population, with 9% of people over 80 diagnosed.¹⁶ Rising in prevalence, it is predicted that it will affect an estimated 6-12 million Americans by 2050 and 17.9 million Europeans by 2060.¹⁷

Symptoms of atrial fibrillation include dizziness, breathlessness, weakness, fainting, and chest pain. In patients with frailty or co-morbidities, atrial fibrillation can precede myocardial ischemia and congestive heart failure.

Considerations for dental treatment in the CVD patient

1. Risk assessment

To safely treat a CVD patient, it is recommended to complete a full medical and drug history and assess cardiovascular risk factors prior to undertaking any dental treatment.

Vital signs

Despite its high prevalence, an estimated 46% of hypertension cases go undiagnosed, presenting an unexpected risk during dental treatment.⁹ A cardiovascular risk assessment should therefore establish the patient’s blood pressure and proceed as follows:¹⁸

• Patients with blood pressure up to 160/100 mmHg are eligible to receive dental treatment.
• Readings above 160/100 mmHg should be repeated to confirm.
• If an acceptable blood pressure is achieved, treatment can be commenced.
• If an acceptable blood pressure cannot be achieved, elective treatment should be postponed and the patient should be referred to their physician.
• Emergency treatment may proceed with measurements up to 180/109 mmHg. Blood pressure should be measured every 10-15 minutes throughout.
• Patients with blood pressure above 180/109 mmHg should be referred to a physician before any procedure is commenced.

The dental professional should also take the patient’s heart rate and oxygen saturation. It is advisable to proceed with caution if the patient’s SpO₂ is 94% or lower.¹⁸

Cardiovascular disease status

Patients with hypertension, angina, arrhythmia, or previous myocardial infarction (MI) may be at a greater risk of adverse cardiovascular events in dental practice. The status and stability of these conditions must be confirmed before proceeding with treatment.

If the patient displays any of the following, the British Dental Association (BDA) advises that may not be stable enough to undergo treatment:¹⁹

• Unstable angina.
• Symptomatic valve disease.
• Myocardial infarction in the past 60 days.
• Significant arrhythmia.

Following an MI, patients are at a higher risk of a second MI, with one-third occurring within the first month.²⁰ The BDA recommends deferring non-urgent treatment where possible and contacting the patient’s cardiologist for advice. Urgent treatment in the three months immediately after an MI, when it is important to avoid pain and distress, may need to be undertaken in a supported medical setting.

Risk factors and comorbidities

The dental professional should take into account other cardiac risk factors and comorbidities when planning the patient’s treatment, such as:¹⁸

• Chronic heart failure.
• History of stroke or transient ischaemic attack (TIA).
• Kidney disease.
• Diabetes mellitus.
• Obesity (a BMI of >35).
• Sleep apnoea.

If risk factors and comorbidities are few and/or well-controlled, treatment should be able to proceed with caution. However, in the presence of multiple and/or poorly controlled risk factors and comorbidities, the dental professional should defer treatment where possible and seek the advice of the patient’s physician or cardiologist.

2. Management of fear, anxiety, and pain

Dental treatment is often associated with pain, stress, fear, and anxiety, provoking an exaggerated release of endogenous catecholamines (adrenaline and noradrenaline) in the patient. This response involves changes such as increased blood pressure, raised heart rate, and increased oxygen demand in the myocardium, which may not be met in cardiovascular-impaired patients. The likelihood of cardiac complications like angina, arrhythmia, ischemic events, and hypertensive crisis is therefore increased. For that reason, it is imperative that the anxiety and pain of cardiac patients are carefully managed.

Sedation

Unless contraindicated, very anxious patients may benefit from sedation to reduce anxiety and stress. The National Institute for Health and Care Excellence (NICE) stipulates that this should be limited to conscious sedation for all patients.²¹

For oral sedation, current guidelines suggest that 5-10 mg of diazepam the night before and/or 1-2 hours before treatment is suitable for most cardiovascular patients, although care should be taken to establish any possible drug interactions.²² NICE states that temazepam is also suitable.²³

During the appointment, the anxious patient may require inhalation sedation to complete the treatment. Nitrous oxide is an effective and safe method for most cardiovascular patients, with minimal respiratory depression and rapid onset of action and recovery.

Excessive sedation can lead to respiratory depression, hypoxia, and myocardial ischemia. Supplemental oxygen should therefore be considered even with mild sedation.²⁴ The dental professional should also ensure the availability of airway management equipment, venous access, and appropriate intraoperative monitoring.²³

Local anesthesia

Maintaining profound anesthesia throughout the dental procedure can minimize the release of endogenous catecholamines and reduce the risk of stress-induced cardiovascular events.

Amide anesthetics, such as lidocaine, articaine, mepivacaine, bupivacaine, and prilocaine, are generally suitable — even beneficial — for use in stable cardiovascular patients. Lidocaine has a mildly depressant action on the myocardium, reducing hyper-excitability and the risk of arrhythmia.

When choosing a local anesthetic for a cardiovascular patient, the elevated potential for toxicity is a prime concern. All injectable local anesthetics are eventually absorbed into the cardiovascular system, but amide local anesthetics undergo biotransformation at a slower rate in patients with impaired hepatic blood flow, such as those with congestive heart failure. In such patients, the mean total body clearance rate of lidocaine, for example, is reduced by a third.25 This results in higher blood levels of local anesthetic and increased risk of toxicity. To reduce the risks, the cardiovascular patient should always receive the lowest clinically effective dose.

For longer or more traumatic procedures, it is important to choose a longer-acting local anesthetic to maintain adequate anesthesia for the duration. Bupivacaine has the longest half-life of the commonly used amide anesthetics at 3.5 hours, while mepivacaine, lidocaine, and articaine have respective half-lives of 1.9, 1.6, and 0.5 hours.²⁵ Further, the isomer of bupivacaine, levobupivacaine, is less cardiotoxic than bupivacaine.

3. Use of vasoconstrictors

The addition of vasoconstrictors like epinephrine to local anesthetics has been controversial in cardiac patients. Epinephrine mildly increases heart rate and blood pressure, and moderately increases cardiac output and stroke volume, increasing the risk of adverse cardiovascular events when used excessively.²⁵

However, for many patients with stable or well-managed CVD, vasoconstrictors can be considered safe and beneficial when used judiciously. The risk of endogenous catecholamine release due to insufficient anesthesia is considered a greater risk to cardiovascular patients than the potential risks of vasoconstrictors like epinephrine, which prolong the duration of the local anesthetic.22 They also slow the absorption of local anesthetic into the cardiovascular system, reduce the risk of systemic toxicity, and offer optimal bleeding control.²⁵

Nevertheless, epinephrine should be used sparingly. Dental professionals should use the lowest required dose and concentration of vasoconstrictor to achieve the treatment goals, taking care not to exceed 0.04 mg (40 μg) of epinephrine per appointment.^22,25 For the following epinephrine concentrations, this translates to:²⁵

• 1 cartridge of 1:50,000.
• 1-2 cartridges of 1:80,000.
• 2 cartridges of 1:100,000.
• 4 cartridges of 1:200,000.

Low-epinephrine anesthetic solutions of 1:200,000 have been shown to be equally efficacious as 1:80,000 solutions in achieving pulpal anesthesia and are ideal for patients with compromised cardiac status.²⁶

In addition to a conservative dose of vasoconstrictor, careful aspiration and a slow injection technique are necessary to reduce systemic absorption of epinephrine and avoid accidental intravascular injection.

Contraindications

Racemic gingival retraction cords impregnated with epinephrine are contraindicated in all cardiovascular patients due to the high epinephrine concentration and lack of strict dosage control.²⁵ Intraosseous injections should also be avoided, along with intraligamentary and intrabony injections, which are similarly intraosseous in their action.

All vasoconstrictors are contraindicated in patients with significant and/or unstable cardiovascular disease.²⁵ Examples include:

• Unstable angina.
• Recent myocardial infarction.
• Recent coronary bypass surgery.
• Uncontrolled severe hypertension.
• Uncontrolled congestive heart failure.
• Refractory arrhythmias.

Where vasoconstrictors are absolutely contraindicated, a plain anesthetic solution, such as mepivacaine without epinephrine, may be used.

4. Antithrombotic therapies

Antithrombotic drugs are often used to manage cardiovascular conditions like myocardial infarction, atrial fibrillation, stroke, and prosthetic valve implantation. However, in preventing the risk of thrombosis, such drugs also present the risk of uncontrolled bleeding in the dental setting.

In their updated Management of Dental Patients Taking Anticoagulants or Antiplatelet Drugs document, the gold-standard Scottish Dental Clinical Effectiveness Programme (SDCEP) provides the following guidance for treatment planning according to the patient’s drug regime.²⁷

General guidelines

SDCEP recommends against interrupting anticoagulant or antiplatelet therapy for patients with prosthetic metal heart valves, coronary stents, or a recent (< three months) history of pulmonary embolism or deep vein thrombosis. Anticoagulant therapy for patients with cardioversion should be continued.

Vitamin K antagonists

For patients taking vitamin K antagonist anticoagulants such as warfarin, it is advisable to obtain their international normalized ratio (INR) value up to 24 hours before the procedure. INR measures the time taken for the blood to clot, with a higher INR value representing a greater bleeding risk.

If the INR is below 4, treatment can proceed without interrupting medication. If the INR is 4 or above, invasive treatment should be deferred and advice sought from the prescribing physician.

Direct oral anticoagulants (DOACs)

For those taking DOACs (e.g., apixaban, dabigatran, rivaroxaban, edoxaban), treatments with low bleeding risk can proceed without interrupting medication. For higher-risk procedures, patients should be treated early in the day and advised to miss or delay the morning dose prior to treatment.

Injectable anticoagulants

For low prophylactic doses of injectable anticoagulants (e.g., dalteparin, enoxaparin, tinzaparin), treatment may proceed without interrupting medication. For higher doses, consult with the prescribing physician.

Antiplatelet drugs

Patients taking aspirin alone can be treated without medication interruption. Those taking clopidogrel, dipyridamole, prasugrel, or ticagrelor (alone or in combination with aspirin) may also continue to take medication, but prolonged bleeding should be expected.

Combination anticoagulant/antiplatelet therapy

Patients taking a combination of anticoagulant and antiplatelet drugs should not be treated without prior consultation with the prescribing physician.

Bleeding control

In patients taking anti-thrombotic drugs, perioperative and postoperative bleeding during low-risk procedures can usually be managed with the following local hemostatic measures:

• Limiting the surgical area initially and assessing bleeding before proceeding.
• Minimizing surgical trauma and treating atraumatically where possible.
• Using packing materials and sutures to control bleeding and close the surgical wound.
• Using additional local hemostatic measures (e.g., tranexamic acid bite swabs, fibrin sealants).

Hemostasis should be achieved before the patient is discharged with appropriate advice to minimize post-operative bleeding.

5. Electromagnetic interference

An estimated 1.4 million people worldwide are fitted with cardiac implantable electronic devices (CIEDs) every year.²⁸ Used to manage cardiovascular conditions such as ventricular fibrillation, ventricular tachycardia, and heart failure, these devices include pacemakers and implantable defibrillators.

In the past, there has been concern that electronic dental instruments, such as ultrasonic scalers, electrosurgical units, and apex locators, could pose a risk to patients with CIEDs by way of electromagnetic interference. It is true that earlier technology was more vulnerable to such interference, but newer technology has lowered the risks significantly. Pacemakers, for example, were previously unipolar and poorly shielded from electromagnetic interference, if at all. Modern models are bipolar and well-shielded, greatly reducing this risk.

That said, the following precautions should still be taken when using electronic devices on patients with CIEDs:²²

• The patient’s cardiologist should be involved in the treatment plan.
• The patient should provide full manufacturer and model details of their device.
• Manual tools (e.g., hand scalers) should be used where available and appropriate.
• Unshielded pacemakers should be covered with a lead apron.
• Electrical cords should never be placed over the patient’s chest.

Electrosurgical units are best avoided in patients with pacemakers. If diathermy is necessary, bipolar diathermy is preferred. If unipolar diathermy is required, the pacemaker should be turned off during surgery and must not lie within the electric field between the ground pad and the unit.²²

6. Infective endocarditis

Infective endocarditis is a bacterial infection of the endocardium of the heart affecting one or more valves. While the infection is rare, treatment is complex and around 50% of those affected require surgical intervention.²⁹ Complications can be severe, with patients at risk of sepsis, embolism, stroke, and heart failure, and the mortality rate is high at approximately 25-30%.^29,30

Infective endocarditis is more commonly seen in cardiac patients with prosthetic valves, but can also affect native valves in people with CVD. When valvular tissue is damaged by, for example, rheumatic heart disease, congenital heart disease, mitral valve prolapse, or valve surgery, the tissue is vulnerable to colonization by bacteria circulating in the bloodstream.

Dental treatment has been linked to infective endocarditis via the introduction of oral bacteria into the bloodstream during procedures such as scaling, periodontal therapy, or tooth extraction. On that basis, previous guidelines recommended antibiotic prophylaxis for patients with cardiac conditions prior to dental treatment. However, it is now believed that only a small proportion of cases actually originate from dental procedures.²⁹ Of greater significance are more routine activities such as daily toothbrushing, flossing, and chewing.

After a review in 2008, NICE withdrew their recommendations for antibiotic prophylaxis due to a lack of evidence supporting its effectiveness in preventing infective endocarditis. However, in 2016, they revised their recommendations again to advise antibiotic prophylaxis in certain high-risk patients, a position echoed by the SDCEP, the European Society of Cardiology (ESC), and the American Heart Association (AHA). ²⁹ According to the ESC and ADA, high-risk patients are those with “underlying cardiac conditions associated with the highest risk of adverse outcomes from infective endocarditis.”²⁹ They include cardiac transplant patients and those with:

• Prosthetic valves or prosthetic valve repair material.
• A prior history of infective endocarditis.
• Congenital heart disease.

While the ESC and AHA acknowledge that efficacy is still unclear, recent research is adding support for the use of antibiotic prophylaxis in high-risk cardiac patients. In 2022, a case-crossover analysis and cohort study found a significant association between antibiotic prophylaxis prior to invasive dental procedures and a reduction in infective endocarditis incidence.³¹

On balance, the ESC and AHA believe that the severity of adverse outcomes that such vulnerable patients might experience far outweighs the drawbacks of antibiotic administration. For at-risk patients, antibacterial prophylaxis is recommended for any procedure associated with significant bleeding, gingival or periapical tissue manipulation, or mucosal perforation. It can be administered 30-60 minutes before or up to two hours after the procedure. Amoxycillin is the antibiotic of choice for adults and children, with azithromycin or clarithromycin favored in patients with amoxicillin allergies. However, there are notable drug-drug interactions between some antibiotics and drugs commonly prescribed for cardiovascular conditions.

7. Drug interactions

Dental professionals should be aware of the potential interactions between drugs used to manage cardiovascular conditions and drugs commonly used in dentistry. Further, it is important to note the oral manifestations of common cardiovascular drugs. The following table aims to summarise this information ^{19, 21, 27, 32, 33, 34}

Learn more about dental treatment in cardiac patients in this exclusive interview with Ian Corbett

References

[1] https://www.who.int/en/news-room/fact-sheets/detail/cardiovascular-diseases-(cvds)

[2] https://onlinelibrary.wiley.com/doi/full/10.1111/jcpe.13189

[3] https://www.sciencedirect.com/science/article/pii/S0735109720377755

[4] https://www.nature.com/articles/s41598-019-47029-3

[5] https://pubmed.ncbi.nlm.nih.gov/27466397/

[6] https://academic.oup.com/eurheartj/article/40/14/1138/5251907

[7] https://www.escardio.org/Guidelines/Clinical-Practice-Guidelines/Arterial-Hypertension-Management-of

[8] https://www.google.com/url?sa=t&rct=j&q=&esrc=s&source=web&cd=&ved=2ahUKEwj5-KiRk6n8AhUjQUEAHVJcCVoQFnoECDIQAQ&url=https%3A%2F%2Feujournal.org%2Findex.php%2Fesj%2Farticle%2Fview%2F15570%2F15495&usg=AOvVaw21e9jHsdg7yW_dTWenEeh6

[9] https://www.who.int/news-room/fact-sheets/detail/hypertension

[10] https://www.bloodpressureuk.org/news/media-centre/blood-pressure-facts-and-figures/

[11] https://www.bhf.org.uk/-/media/files/research/heart-statistics/bhf-cvd-statistics—uk-factsheet.pdf

[12] https://ehnheart.org/cvd-statistics.html

[13] https://www.who.int/news-room/fact-sheets/detail/the-top-10-causes-of-death

[14] https://www.escardio.org/The-ESC/Press-Office/Press-releases/European-valvular-heart-disease-Guidelines-published-today

[15] https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000659

[16] https://jamanetwork.com/journals/jama/article-abstract/193807

[17] https://pubmed.ncbi.nlm.nih.gov/31955707/

[18] https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/hypertension

[19]  https://bda.org/events/Documents/MEDICAL%20MAGIC%20-%20Cardiac%20diagram%20Version%2011.pdf

[20] https://heart.bmj.com/content/heartjnl/107/4/313.full.pdf

[21] https://bnf.nice.org.uk/treatment-summaries/sedation-anaesthesia-and-resuscitation-in-dental-practice/

[22] https://www.jyoungpharm.org/sites/default/files/10.5530jyp.2017.9.89_2.pdf

[23] https://bnf.nice.org.uk/treatment-summaries/hypnotics-and-anxiolytics/

[24] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993866/

[25] The Handbook of Local Anaesthesia (7th edition) by Dr. Stanley F. Malamed

[26] https://pubmed.ncbi.nlm.nih.gov/18022467/

[27] https://www.sdcep.org.uk/published-guidance/anticoagulants-and-antiplatelets/

[28] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8756057/

[29] https://www.sdcep.org.uk/media/qvpj2kfb/sdcep-antibiotic-prophylaxis-implementation-advice.pdf

[30] https://www.frontiersin.org/articles/10.3389/fmed.2022.774224/full

[31] https://pubmed.ncbi.nlm.nih.gov/35987887/

[32] https://www.sdcep.org.uk/media/2wleqlnr/sdcep-drug-prescribing-for-dentistry-3rd-edition.pdf

[33] https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118991473.app2

[34] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213250/