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Guided By:
DR. NEELKAMALDR. VERMA
Submitted By:
Nishtha Singhal (45)
Nidhi Nagar (46)
Neha Sachdeva (47)
Pallavi Singh (48)
BDS Final Year
Batch 2005-06
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CARDIOVASCULAR
DISEASES
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A)SYMPTOMS AND HISTORY OF PERSENT ILLNESSA)SYMPTOMS AND HISTORY OF PERSENT ILLNESS
B)PAST HISTORYB)PAST HISTORY
C)FAMILY HISTORY
D)PERSONAL HISTORY
E)TREATMENT HISTORY
SCHEME OF HISTORY TAKING
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A)SYMPTOMS AND HISTORY OF PERSENT ILLNESS1. DYSPNOEA
2. CHEST PAIN
3. PALPITATION4. SYNCOPE
5. COUGH WITH EXPECTORATION AND HAEMOPTYSIS
6. CYANOSIS
7. RIGHT HYPOCONDRIAL PAIN, SWELLING OF FEET AND DECREASE IN THE URINEOUTPUT
8. GASTROINTESTINAL SYMPTOMS LIKE ANOREXIA, FULLNESS OF ABDOMEN ANDVOMITING
9. FATIGABILITY10. FEVER
11. DIABETES MELLITUS AND HYPERTENSION
B)PAST HISTORY
1. RHEUMATIC FEVER
2. CYANOTIC SPELLS
3. RECURRENT RESPIRATORY INFECTIONS SINCE CHILDHOOD
4. DETEC
TION OF MU
RMU
R/CARDIA
CLESION AT S
CHOOL5. RECENT DENTAL EXTRACTION, GENITOURINARY INSTRUMENTATIONS
6. HYPERTENSION, DIABETES MELLITUS, ISCHAEMICHEART DISEASE OR ANY OTHERSIGNIFICANT MEDICAL ILLNESS
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C)FAMILY HISTORY
1. HYPERTENSION
2. ISCHAEMICHEART DISEASE
3. CONGENTAL HEART DISEASE4. RHEUMATICHEART DISEASE
5. SUDDEN DEATH
D)PERSONAL HISTORY
1. APPETITE
2. WEIGHT LOSS
3. DISTURBED SLEEP
4. BOWEL AND BLADDER DISTURBANCES5. HABITS- SMOKING AND ALCOHOLISM
6. EXPOSURE TO SYPHILIS
E)TREATMENT HISTORY
NIFEDIPINE- GINGIVAL HYPERPLASIA
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APPROACH TO A PATIENT OF CARDIAC DISEAASEANALYSIS OF PRESENTING SYMPTOMS
1)DYSPNOEA
DEFINITION:-ABNORMAL AWARENESS OF BREATHING WITH DISCOMFORT.
DYSPNOEA IS A SIGNIFICANT MANIFESTATION OF CARDIAC FAILURE.
DYSPNOEA IS MORE COMMONLY DUE TO LEFT-SIDED CARDIAC FAILURETHAN DUE TO RIGHT HEART FAILURE.
SEVERITY (GRADING)FUNCTIONAL GRADING OF DYSPNOEA
GRADE I : NO LIMITATN OF ANY PHYSIAL ACTIVITY BUT DYSPNOEA OCCURSON MORE THAN ORDINARY (UNOCCUSTOMED) EXERTION.GRADE II: DYSPNOEA ON ORDINARY DAILY ACTIVITYGRADE III : DYSPNOEA ON LESS THAN ORDINARY DAILY ACTIVITIES.GRADE IV : LIMITATIONS OF ALL ACTIVITIES( DYSPNOEA AT REST)
2)ORTHOPNOEA
DEFINITION: DYSPNOEA THAT OCCURS USUALLY ON LYING DOWN.CHARACTERISTIC FEATURES: USALLY OCCURS WITHIN MINUTES OF
ASSUMPTION OF RECUMBENCY.
OCCURS WHEN A PATIENT IS AWAKE.
INDICATES THE PRESENCE OF SEVERE LEFT HEART FAILRE (PULMONARYOEDEMA).
MANIFESTS LATER THAN PND. (IN SLOWLY PROGRESSIVE LEFT HEART
DISEASE).
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3)PLATYPNEA: DYSPNOEA OCCURS ON SITTING (UPRIGHT) RATHER THAN ON
LYING DOWN POSITION.
EXAMPLE: LEFT ATRIAL MYXOMA,LEFT ATRIAL BALL VALVE THROMBUS
4)TREPOPNEA: OCCURS ON BREATHLESSNESS ONLY WHEN LYING DOWN IN LATERALPOSITION.
MAY BE DUE TO VENTILATION PERFUSION RELATIONSHIP
ALTERATION IN CERTAIN BODY POSITION.
5)PROXIMAL NOCTURNAL DYSPNOEA
ATTACK OF BREATHLESSNESS AT NIGHT.SIGN OF SEVERE
DEGREE OF LEFT HEART FAILURE.
6)CHEYNES-STROKE BREATHING
THERE IS SEVERE PERIODS OF HYPERVENTILATION FOLLWEDBY PERIODS OFAPNOEA.SIGN OF SEVERE HEART FAILURE.
7)CYANOSIS
A)CYANOSIS APPEARING IN INFANCY INDICATES THE PRESENCE OF CONGENITAL
CARDIAC ANOMALIES WITH RIGHT TO LEFT SHUNT(TERATOLOGY OF FALLOT)B)CYANOSIS BEGINNING TO APPEAR AFTER 6 WEEKS OF AGE MAY BE AN INDICATION
OF VSD WITH SLOWLY PROGRESSIVE RIGHT VENTRICUAR OUTFLOWOBSTRUCTION.
C)HISTORY OF CYANOSIS IN A SUSPECTED PATIENT OF CONGENITAL HEART DISEASEBETWEEN THE AGE OF 5-20 YEARS INDICATES REVERSAL OF LEFT TO RIGHTSHUNT(EISENMEGER)
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8)SWELLING OF FEET (PEDAL ODEMA)
RIGHT HEART FAILURE CAUSES SYSTEMIC VENOUS CONGESTION
WITH INCREASED HYDROSTATIC PRESURE IN THE LOWER
LIMB VEINS. THIS RESULT IN THE TRANSUDATION OF FLUID
CAUSING EDEMA.ANKLE EDEMA IS MORE COMMON IN AMBULATORY PATIENTS. BED-RIDDEN
PATIENT DEVELOP SACRAL EDEMA.
9) RIGHT HYPOCHODRAL PAIN
THIS IS DUE TO ENLARGED AND CONGESTED LIVER AND STREACHING OF ITSCAPSULE.
10) DECREASED URINE OUTPUT
IN THE PRESENCE OF CARDIAC FAILURE DUE TO DECREASED CARDIACOUTPUT, RENAL BLOOD FLOW DECREASES WITH DECREASE IN THEGLOMERULAR FITRATION RATE, THIS CAUSES DECREASE OF URNEOUTPUT IN PATIENTS WITHCARDIAC FAILURE.
11)SYNCOPE
TRANSIENT LOSS OF CONSCIOUSNESS WITH POSTURAL COLLAPSE.
12)COUGH AND EXPECTORATION
13)PALPITATION
SUGGESTS AWARENESS OF HEARTBEAT,WHCH MAY BE UNPLEASANT.
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EXAMINATION OF CARDIOVASCUAR SYSTEM
SCHEME OF EXAMINATION
GENERAL EXAMINATION
1. BUILD
2. NOURISHMENT
3.PALLOR
4.CYANOSIS
5. CLUBBING
6. JAUNDICE
7. PEDAL ODEMA
8. LYMPHADENOPATHY
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EXTERNAL MARKERSOF CARDIAC
DISEASE
EXAMINATION OF :-FACE
EYES
EARS
SKIN AND MUCOSA
EXTREMITIES
VITAL SIGNS:-
PULSE
BLOOD PRESSURE
RESPIRATORY RATE
TEMPERATURE
EXAMINATION OF PERIPHERALCARDIOVAS
CUAR SYSTEM
RADIAL PULSE:-
RATE
RTHYM
VOLUME
CHARACTER
CONDITION OF VESSEL WALL
EXAMINATION OF:-
THE CAROTIDS
THEIR PERIPHERAL PULSES
JUGULAR VENOUS PULSE AND PRESSURE
PERIPHERAL SIGNS OF WIDE PULSE
PRESSU
RE(IN RELEVANT SITUATION)PERIPHERAL SIGNS OF INFECTIVE
ENDOCARDITIS
PERIPHERAL SIGNS OF RHEUMATIC FEVER
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EXAMINATION OF THE PRECORDIUM
INSPECTION
1. PREC
ORDIAL BU
LGEPOSITION OF APICAL IMPULSE
PULSATIONS IN THE:-
A. LEFT PARASTERNAL REGION
B. 2ND LEFT INTERCOSTAL SPACE
C. 2ND RIGHT INTERCOSTAL SPACE
D. EPIGASTRIC PULSATIONE. SUPRASTERNAL PULSATION
F. ENGORGED VEINS OVER THE CHEST
G. SPINE(KYPHOSCOLIOSIS)
PALPATION1)APICAL IMPULSE- POSITION AND
CHARACTER
2)LEFT PARASTERNALHEAVE
3) OF EPIGASTRIC PULSATION
TH
RILLS4)PALPABLE SOUNDS
PERCUSSION1)RIGHT CARDIAC BORDER
2)LEFT CARDIAC BORDER
3)LEFT AND RIGHT 2ND INTERCOST
SPACE.
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AUSCULTATION
MITRAL, TRICUSPID, AORTIC, PULMONARY AND OTHER ADDITIONAL
AREAS FOR:-
A. 1STAND 2ND HEART SOUNDS
B. ADDITOINAL SOUNDS C. MURMURS
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EXAMINATION ALSO INCLUDES THEFOLOWING SIGNS
A)PALLOR
SEVERE ANEMIA MAY BE ASSOCIATED WITH:
1.CH
RONIC
CC
F2. INFECTIVE ENDOCARDITIS
SEVERE ANEMIA CAN ITSELF CAUSE- CARDIAC FAILURE ORAGGRAVATE THE UNDERLYING HEART DISEASE.
PATIENTS WITHCYANOTICCONGENITAL HEART DISEASE MAYHAVE POLYCYTHEMIA WITH SUFFUSED CONJUNCTIVA.
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B)CYANOSIS:
CENTRAL CYANOSIS OCCURS IN:
1. CYANOTICCONGENITAL HEART DISEASE 2. REVERSAL OF LEFT TO RIGHT SHUNT
3. INTRAPULMONARY RIGHT TO LEFT SHUNT
4. PULMONARY EDEMA (LEFT HEART FAILURE)
PERIPHERAL CYANOSIS OCCURS IN:
1. CONGENITAL CARDIAC FAILURE 2. PERIPHERAL VASCULAR DISEASE
DIFFERENTIALCYANOSIS:
1. FEET AND TOES ARE BLUE BUT HANDS AND FINGERS ARE NOT CYNOSED. E.G. PDA WITH PULMONARY HYPERTENSION WITH REVERSAL OF SHUNT.
REVERSE DIFFERENTALCYANOSIS:
1. FINGERS ARE MORE CYANOSED THAN TOES.
E.G. TRANSPSITION OF GREAT VESSELS WITH PULMONARY HYPERTENSIONWITH PREDUCTAL COARCTATION WITH REVERSED FLOW THROUGH PDA.
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C))CLUBBING
CARDIACCAUSES:
1. CYANOTICCONGENTAL HEART DISEASE
2. REVERSAL OF LEFT TO RIGHT SHUNT
3. INFECTIVE ENDOCARDITIS
CYANOTICCONGENITAL HEART DISEASE MAY BE ASSOCIATED WITHHYPERTROPHIC PULMONARY OSTEOARTHROPATHY.
D)JAUNDICE
FOLLOWING CARDIACCONDITIONS MAY BE ASSOCIATED WITHJAUNDICE:
1.C
ONGESTIVECARDIA
CFAIL
URE WIT
HC
ONGESTIVEH
EPATOMEGALY2. CARDIACCIRRHOSIS
3. PULMONARY INFARCTION
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E)PEDAL EDEMAPITTING EDEMA OF FEET CAN OCCUR IN:
1. CONGESTIVE CARDIAC FAILURE
2. CONSTRICTIVE PERICARDITIS
3. TRICUSPID VALVE DISEASE
F)LYMPHADENPATHY:CONDITION ASSOCIATED WITH GENERALIZED
LYMPHADENOPATHY MAY INVOLVE THE CARDIOVASCULARSYSTEM. E.G. LYMPHOMA, SLE ETC.
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EXAMINATION OF FACE
FOLLOWING FEATURES MAY BE INDICATIVE OF UNDERLYINGCAARDIAC ABNORMALITY WHILE EXAMINATION OF FACE.
ABNORMALITIES CONDITION
ASSOCIATED
ELFIN FACIES RECEDING JAWS,
FLARED NOSTRILS,
POINTED EARS
SUPRAVENTRICULARAORTIC STENOSIS
HIGH ARCHED PALATE MARFAN SYNDROME
MITRAL FACIES MALAR FLUSH ANDPINKISH PURPLE
PATCHES OVER THE
CHEEK
MITRAL STENOSISWITH DECREASED
CARDIAC OUTPUT AND
SYSTEMIC
VASOCNSTRICTION
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MALAR FLUSH
MARFAN SYNDROME
TERATOLGY OF FALLOT
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Acute macroglossia:
the tongue is diffusely
enlarged and bright red along its lateral
portion. The patient had bleeding into the
tongue while on anticoagulants.
Acute macroglossia due to Enalapril: this
75-year-old Black female developed 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
tongue and lips have returned to their normal size.
EXAMINATION OF MOUTH
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GUM HYPERPLASIA
DUE TO DILANTIN. SIMILAR FINDINGS
MAY BE SEEN IN PATIENTS ON
NIFEDIPINE
TANGIER DISEASE OF THE TONSILS:
THE TONSILS ARE ENLARGED WITH
BRIGHT
ORANGE YELLOW STREAKS (TIGER
STRIPES)(PREMATURE CAD).
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EXAMINATION OF EAR:EXAMINATION OF EAR:
PRESENCE OF CREASE IN THE PINNA OF THE EARPRESENCE OF CREASE IN THE PINNA OF THE EAR--
ASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERYASSOCIATED WITH INCREASED INCIDENCE OF CORONARY ARTERY
DISEASE.DISEASE.
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EXAMINATION OF EYES:
EXOPTHALMUS: ASSOCIATED WITH THYROID ARTERY
DISEASE.
BLUE SCLERA: OSTEOGENESIS IMPERFECTA WITH AORTICREGULTATION.
OPTHALMIC FUNDUS: LOOK FOR
A. ARTERIOSCLEROTICCHANGES
B. HYPERTENSIVE RETINOPATHY C. ROTHS SPOTS( OF INFECTIVE ENDOCARDITIS)
D. ARTERIAL PULSATION IN AR
E. CORK SCREW ARTERIES- COARCTATION OF AORTA.
BLUE SCLERAROTHS SPOT
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EXAMINATION OF FINGER
CLUBBING
CLUBING NEGATIVE
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OSLERS NODE IN ENDOCARDITIS
SUBUNGAL HAEMORRHAGES
JANEWAY LESIONS
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CAUSES OF CARDIOVASCLAR DISEASE
ORGANIC DISEASE OF HEART
1. MYOCARDIAL
A. OVERLOAD SECONDARY TO HYPERTENSON OR VALVE DISEASEB. CORONARY( ISCHAEMIC) HEART DISEASE
C. CARDIOMYOPATHIES
2. ENDOCARDIAL
A. RHEUMATIC HEART DISEASE
B. CONGENITAL ANOMALIES
C. INFECTIVE ENDOCARDITIS
3. PERICARDIAL
A. PERICARDITIS
B. PERICARDIAL EFFUSION
C. FUNCTIONAL DISORDERS
DUE TO HYPERTENSION
DUE TO ABNORMALITIES IN HEART RATEA. TACHYCARDIA
B. BRADICARDIA
C. OTHER DYSRTHYMIAS
CHANGES IN CIRCULATORY VOLUME
A. HYPOVOLOEMIA (SHOCH SYNDROME)
B. HYPERVOLAEMIA ( CIRCULATORY OVERLOAD)
C. OTHERS
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FUNCTIONAL CAPACITY OBJECTIVE ASSESSMENT
CLASS I. PATIENTS WITHCARDIAC DISEASE BUT WITHOUT RESULTINGLIMITATION OF PHYSICAL ACTIVITY. ORDINARY PHYSICAL ACTIVITY
DOES NOT CAUSE UNDUE FATIGUE, PALPITATION, DYSPNEA, ORANGINAL PAIN.
A. NO OBJECTIVEEVIDENCE OFCARDIOVASCULARDISEASE.
CLASS II. PATIENTS WITHCARDIAC DISEASE RESULTING IN SLIGHTLIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE ATREST. ORDINARY PHYSICAL ACTIVITY RESULTS IN FATIGUE,PALPITATION, DYSPNEA, OR ANGINAL PAIN.
B. OBJECTIVE EVIDENCEOF MINIMALCARDIOVASCULARDISEASE.
CLASS III. PATIENTS WITHCARDIAC DISEASE RESULTING IN MARKEDLIMITATION OF PHYSICAL ACTIVITY. THEY ARE COMFORTABLE ATREST. LESS THAN ORDINARY ACTIVITYCAUSES FATIGUE,
PALPITATION, DYSPNEA, OR ANGINAL PAIN.
C. OBJECTIVE EVIDENCEOF MODERATELYSEVERE
CARDIOVASCULARDISEASE.
CLASS IV. PATIENTS WITHCARDIAC DISEASE RESULTING IN INABILITY TOCARRY ON ANY PHYSICAL ACTIVITY WITHOUT DISCOMFORT.SYMPTOMS OF HEART FAILURE OR THE ANGINAL SYNDROME MAYBE PRESENT EVEN AT REST. IF ANY PHYSICAL ACTIVITY ISUNDERTAKEN, DISCOMFORT IS INCREASED.
D. OBJECTIVE EVIDENCEOF SEVERECARDIOVASCULARDISEASE.
NYHACLASSIFIACTION
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HYPERTENSION
Hypertension is known as
Silent Killer of mankind.
Most of the sufferers (85 %)
are asymptomatic and hence
early diagnosis is a problem.
More than 65 lakh
Americans and over 1 billion27
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Definition
Hypertension is defined
as having systolic blood
pressure (SBP) >/=
140mm ofHg or
diastolic blood pressure
(DBP) >/= 90mm ofHgor
as having to use antihypertensive
medications.28
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Classification
The Seventh Joint National Committee Criteria
(JNC VII) classifies hypertension for adults aged
18 years and older into following stages:
Blood Pressure Classification SBP(mm Hg)
DBP(mmHg)
Normal
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Types
PRIMARY (orESSENTIAL)
HYPERTENSION
Which developsgradually over many
years & has nounderlying cause.
90% of people have thistype of hypertension.
SECONDARYHYPERTENSION
Which has anunderlying cause such
as renal disorders,endocrinal disturbances,
neurologic causes etc.
10% of people have thistype of hypertension.
30
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Other Risk Factor of
HypertensionLack of exercise
Increased salt intake
Family historyToo little potassium
Alcohol
SmokingStress &
Age31
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Effect of hypertension
The common target organs damaged by
long standing hypertension are:
Brain
H
eartKidneys
Eyes &
Peripheral arteries.32
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Complications of hypertension
Left ventricular hypertrophy
Heart failure
Cerebral hemorrhage
Renal insufficiency
Aortic dissection
Atherosclerotic disease
33
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Symptoms
Symptoms due to hypertension:1. Headache - usually in morning hours.
2. Dizziness
3. Epistaxis
Symptoms due to affection oftarget organs:
1. CVS:a. Dyspnea on exertion
b. Anginal chest pain
c. Palpitations34
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2. Kidneys: Hematuria , nocturia , polyuria .
3.CNS:
a. Transient ischemic attacks ( TIA or Stroke)
b. Hypertensive encephalopathy(headache ,
vomiting etc.)
c. Dizziness, Tinnitus & syncope.
4. Retina:a. Blurred vision or
b. sudden blindness.
35
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Diagnosis
Physical Examination
Laboratory and Additional Testing it
includes
Routine laboratory procedures like
hemoglobin, urinalysis, routine blood
chemistries and fasting lipid profile.
Electrocardiography Ambulatory BP Monitoring
Plasma renin activity testing
Radiologic testing36
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WHITE COAT HYPERTENSION
White coat hypertension is a
phenomenon in which individuals
present with persistent elevated
BP in a clinical setting but presentwith non-elevated BP in an
ambulatory setting.
20% of mild hypertensive
individuals may present with white
coat hypertension. 37
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Dental Management
Measure and record BP at initial visit
38
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39
Recheck :-Every 2 yrs for patient with BP 140-90 mm
Hg.
Every visit for patient with establishedcoronary artery disease, diabetes mellitus
or chronic renal disease with BP >135-85
mm Hg.
Every visit for patient with established
hypertension.Beforeinitiating dental care:
Assess presence of hypertension
Determine presence of target organ disease
Determine dental treatment modifications
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1. Asymptomatic BP 180/110 mm Hg, no history of target organ disease
No elective dental care
3. Presence of target organ disease or poorlycontrolled diabetes mellitus
No elective dental care until BP is controlled , preferable below140-90 mm Hg.
40
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TREATMENT OF HYPERTENSION
NON PHARMACOLOGICAL
TREATMENT LIFESTYLE
MODIFICATIONS
1. Salt restriction
2. Weight reduction
3. Stop smoking
4. Diet modifications such as:
Reduce intake ofCholesterol
& Saturated fat.
Adequate intake ofCalcium &
Magnesium.
41
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42
5. Limit of alcohol intake
6. Relaxation such as yoga, psychotherapyetc.
7. Regular exercise.
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ORAL MEDICATIONS USED FOR
TREATMENT OF HYPERTENSION
Diuretics
Beta-Adrenergic Blockers
Central Acting Inhibitors
Peripheral Acting Inhibitors
Non-Selective alpha & beta Adrenergic
Inhibitors
Vasodilators
Angiotensin Converting Enzyme ACE
Inhibitors43
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ORAL MANIFESTATION OF
HYPERTENSION
There are no recognized manifestations ofhypertension but anti-hypertensive drugs canoften cause side affects , such as:
Xerostomia,Gingival overgrowth,
Salivary glandswelling orpain,
Lichenoid drug reactions,
Erythema multiforme,
Tastesense alteration,
Paresthesia.44
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CONCLUSION
HYPERTENSION has no cure, but it can
be controlled with proper diet, lifestyle
changes, and if necessary medications.
Get regular health check ups. Think about
the consequences of untreated high blood
pressure.
Do not take chances with the disease that
can be controlled.
Lastly, Hypertension is a silent disease,
but its silence is not golden.45
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CORONARY
(ISHAEMIC)ARTERY DISEASE
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Atherosclerosis is the most common
cause ofCAD
ETIOPATHOGENESIS
Various risk factors include:
1. lipids (especially HDL)
2. hypertension
3. diabetes mellitus & glucose intolerance
4. cigarette smoking
5. lifestyle & dietary factors
6. exercise
7. obesity
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8. vitamins & homocystiene
9. plasma fibrinogen
10. endothelial dysfunction
11. antioxidants
12. estrogen deficiency
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RISK FACTORS
Induce variety of pathological processes
Interaction & disruption of vascular endothelium
Plaque formation
Effective arterial luminal area compromised
Myocardial ischaemia acute plaque rupture
thrombus formation
angina
M I
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DIAGNOSIS
1) Based onclinical presentation :
chest tightness
Jaw discomfort
Left arm pain
Dyspnea
Epigastric distress
2) E.C.G.
3) Exercise E.C.G.
4) Coronary Angiography
5) P.C.I.(Percutaneous Coronary Intervention)
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MANAGEMENT
Management ofCAD depends on:
Extent and severity of ischemia
Exercise capacity
Prognosis based on exercise testing
Overall LV function Associated features such as diabetes mellitus
Patients with a small ischemic burden, normal exercisetolerance, and normal LV function may be safelytreated with pharmacologic therapy.
Selected use of aspirin, -blockers, ACEIs, and HMG CoAreductase inhibitors.
Nitrates and calcium channel blockers may be added toprimary agents to relieve symptoms of ischemia inselected patients.
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Percutaneous coronary
intervention (PCI) with
percutaneous
transluminal coronary
angioplasty (PTCA) andintra coronary stenting
relieves symptoms
chronic ishchemia.
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Patient with complexmultivessel CAD requirePCI with medical therapyof surgical
revascularization. Patients with reduced LV
function and severeischemia, oftenassociated with left main
or multivessel CAD, arebest served by coronaryartery bypass graft(CABG) surgery.
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DENTAL ASPECTS
STRESS, ANXIETY, EXERTION or PAINcan provoke angina
Short, minimally stressful dental
appointments Late morning appointments
Excessive dose of LA containing
adrenaline to be avoided in patients takingbeta blockers
More severe dental caries and periodontaldisease in pts of IHD
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Acute Coronary Syndromes
Represent a continuous spectrum of
disease ranging from unstable angina to
MI
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Angina pectoris
Name given to paroxysms of severe chest pain
CLINICAL FEATURES1) 40 TO 60 years , M > F
2) pain often described as sense of Strangling, choking , Tightness,
Heaviness ,Compression, orConstriction of chest3) PAIN MAY RADIATE TO JAW or left arm
4) rarely pain in mandible, teeth or other tissues
PRECIPITATING FACTORS
Physical exertion(main) particularly in cold weather
Emotion(anger or anxiety) & stress caused by fear or pain
TYPICALLY RELEIVED BY REST
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Dental aspects
Preoprerative glyceryl trinitrate & oral sedation advised
sometimes
dental care carried with minimal anxiety & oxygen
saturation
Monitor pulse & B.P.
POST ANGIOPLASTY elective dental care deffered for 6
months , emergency dental care in a hospital setting
PTS with BYPASS GRAFTS no anti biotic cover
against infective endocarditis
- LA containing adrenaline is
contraindicated (may ppt dysrhythmia)
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PTS with vascular stents no antibiotic
cover
except during 1st 6 week postop foremergency dental care
DRUGS used in t/t of angina may causeoral adverse effects like :
-lichenoid reaction Ca channel
- gingival swelling blockers
- ulcers (nicorandil)
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Gingival hyperplasia
in patient consumingCa channel blockers
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Myocardial infarction
Synonyms coronary thrombosis or heart attack
CLINICAL FEATURES1. Clinical picture is variable
2. More than 50% patients are symptomless
3. MI may be preceded by angina often felt as indigestion likepain
4. any anginal attack lasting longer than 30 minutes isconsidered MI
5. Tachycardia &irregular pulse
6. nausea, vomitting, sweating ,restlessness, facialpallor
7. breathlessness, cough
8. Loss of conciousness, shock & even death
9. Many pts die within 1st hour to few days after attack
THUS, MI is a MEDICAL EMERGENCY
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DIAGNOSIS
I. Based on clinical features
II. Elevated TLC & ESR during 1st wk
III. EC
G changesIV. Rise in serum cardiac enzymes ( CPK)
V. Rise in troponin T within 4-8 hours
VI. echocardiography
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General Precautions during Dental
Procedures
Dental clinic should have advancedcardiac life supportor at least basic cardiac life support.
Use ofpulse oximeter to determine the leveloxygenation.
Automatic external defibrillator. Determination ofvital signs prior to dental care.
BP & pulse rate & rhythm should be recorded & anyabnormal findings should be addressed.
Premedication with antianxiety drugs and inhalationnitrous oxide in anxious patients.
Elective procedures esp those requiring GA should beavoidedforatleast 4 wks aftrMI. consult pts physicianprior to dental therapy
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Management on dental chair
1. Terminate all dental treatment
2. Position pt in semirecline position
3. Give nitroglycerin(TNG) (abt 0.4 mg) tablet or spray
4. Administer oxygen
5. Check pulse & B.P.
Discomfort relieved Discomfort continues 3 mins after 2nd TNG
6. Assume angina pectoris is 6. give 2nd TNG dose
present 7. monitor vital signs.
7. Slowly taper oxygen over5 mins
8. Modify t/t to prevent recurrence discomfort discomfortcontinues
relieved 3 mins afterTNG
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8. give 3rd TNG dose
9. Monitor vitals
10. Call for medical assistance
Discomfort relieved discomfort continues 3 mins after 3rd TNG
dose
11. Refer pt for medical 12.assume MI is in progress
evaluation before 13. start i.v. linewith drip of a crystalloid
solution
further dental care at 30 mL/ hr
14. If discomfort severe titrate morfinesulphate2mg s/c or i/v every 3
mins until relief is obtained
15. Transport to emergency care. AdministerBasic Life Support ,if
necessary.
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Anticoagulation Therapy & Dental
Care Anticoagulant therapy is used both to treat & to
prevent throboembolism. 2 major types : 1. antiplatlet medications
2. antithrombin medications Acetylsalicylic acid (ASA) + clopidogrel (
anticoagulant) given for 4 weeks after stentimplantation
daily aspirin typically continued lifelong. May increase risk of oral bleeding following
surgical procedures Associated conditions which predispose patient to
uncontrolled hemostasis : uraemia or liverdiseases or use of NSAIDS If emergency surgery needs to be done,DDAVP(1-
desamino-8-D-arginine vasopressin) isadministered{0.3 micro kg/body wt parenterally}within 1 hr of surgery
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Antithrombin medications are dicumarols ( eg.
Warfarin), it inhibits biosynthesis of vit. K
dependent coagulations protein.
- Efficacy monitored by prothrombin time or the
international normalized ratio (INR), which is
calculated on the basis of international sensitivity
index (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.
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3 different protocols used to treat patients withelevated INR :
Ist protocol warfarin not discontinued(minimizes thromboembolic events & increasesrisk of bleeding after surgery).
IIndprotocol warfarin discontinued (drug
should be discontinued 2-3 days prior tosurgery, during this period patient is at risk ofdeveloping thromboembolic event but notbleeding).
IIIrdprotocol warfarin discontinued & patientplaced on alternative anticoagulant therapy(thromboembolic event minimized).
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We always plan a t/t by comparing
potential risk for excessive bleeding
after procedures if anticoagulationtherapy is not reduced or stopped v/s
risk of pt experiencing a
thromboembolic event ifanticoagulation therapy is altered.
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Rheumaticfeveris an inflammatory disease
that may develop two to three weeks after a
Group A streptococcal infection (such as
strep throat orscarlet fever). It is believed to
be caused by antibody cross-reactivity andcan involve the heart,joints, skin, and
Brain
Acute rheumatic fever commonly appears inchildren ages 5 through 15, with only 20% of
first time attacks occurring in adults
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Rheumatic fever
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What are thesymptoms ofstrep throat?
sudden onset of sore throat
(streptococcal oropharyngitis)
pain on swallowing
fever, usually 101104F
Headache
Red and edematous soft palateand oropharynx.
Areas of tonsillar ulceration andexudation.
abdominal pain, nausea andvomiting may also occur,especially in children
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What are thesymptoms/clinical features ofrheumaticfever?
Symptoms may include: fever
painful, tender, red swollen joints
pain in one joint that migrates to another one
heart palpitations chest pain
shortness of breath
skin rashes
fatigue
small, painless nodules under the skin
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Diagnosis
Two majorcriteria, or
onemajor and twominorcriteria,
Majorcriteria(jones)
Joints (Migratory
polyarthritis): O [imagine heart-shaped
O] (carditis):
Nodules (subcutaneous
nodules - a form of
Aschoff bodies):
Erythema marginatum:
Sydenham's chorea
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mnemonic: C.A.N.C.ER
C: Carditis A: Arthritis
N: Nodules (sub cutaneous)
C: Chorea
ER: ERythema Marginatum
Another way of remembering it is CASES
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Minor criteria
Fever: Arthralgia
Laboratory abnormalities: increased
Erythrocyte sedimentation rate Electrocardiogram abnormalities
Evidence ofGroup A Strepinfection:
elevated or risingAntistreptolysin O titre,
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LAB INVESTIGATIONS-
raised ESR
culture studies of throatswabs is always negativein RF
High anti sterptolysino(ASO)titre-!300 todd
units
Chest radiograph-enlargement of heart
ECG-prolonged PR
interval Echocardiogram-confirms
ventricular dilatation npericardial effusion
TREATMENT
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TREATMENT-
Oral phenoxymthylpenicillin 500 mguntil
age of 20 yrs. Allergic to penicillin,sulfadimidine by
mouth.
Aspirin for fever and pain 50mg/kg bwt in 4hrly doses
Corticosteroids 60-80mg prednisolone
Digoxin and diuretics for heart failure
Ballon valvuloplasty,using inoue balloon,ifmitral valves damage.
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DENTALCONSIDERATION-
Dental extractions and localanesthesia in consent withphysician.
The prophylactic use of antibioticsprior to a dental procedure is nowrecommended ONLY for those
patients with the highest risk ofadverse outcome resulting fromendocarditis
No2 used with approval ofphysician.
GA shd be avoided if essentialmust be given in hospital.
Rhe matic heart disease
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Rheumatic heart disease-
History of rheumatic fever during
childhood or adollescence can act as apredisposing factor for RHD after several
years.
Common signs-murmur due to valvulardamage n later enlargement of heart.
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ORAL
MANIFESTATIONS
Most prominent duringacute phase,
Pharyngitis
Inc oral temperature Distended neck veins
and a bluish color of the
skin.
DENTAL CONSIDERATIONS
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DENTAL CONSIDERATIONS-
To prevent complication of infective
endocarditis ,all dental procedures shouldbe carried under antibiotic cover.
Amoxicillin prophylaxis-1 hour before and6 hours after the initial dose.
Good oral hygiene measures ,fluoride
treatment, chlorhexidine rinses and routinecleanings to reduce harmful bacteremias.
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Proper history should be taken to identify
history of rheumatic fever during
childhood.
Suspicious cases should be referred to
cardiologist for cardiac evaluation prior to
dental procedures. Clindamycin or erythromycin prophylaxis
during dental treatment.
Elective dental treatment under physicianconsultation.
HEART FAILURE
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HEARTFAILURE-
Heart failure (HF) is a
condition in which a
problem with the structure
or function of the heart
impairs its ability to
supply sufficient blood
flow to meet the body'sneeds .
Common causes of heart
failure
ischemic heart diseases Hypertension
Valvular diseases
L ft id d f il (MORE COMMON)
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Left-sidedfailure(MORE COMMON)
Backward failure of the left ventricle causes congestionof the pulmonary vasculature, and so the symptoms are
predominantly respiratory in nature. The patient willhave dyspnea (shortness of breath) on exertion and insevere cases, dyspnea at rest. Increasingbreathlessness on lying flat, called orthopnea.
Another symptom of heart failure is paroxysmal
nocturnal dyspnea also known as "cardiac asthma", asudden nighttime attack of severe breathlessness,usually several hours after going to sleep
Inadequate cerebral oxygenation leads to loss ofconcentration,restlessness and irritability.
Ri ht id d f il
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Right-sidedfailure
Backward failure of the right ventricle
leads to congestion of systemic capillaries.This helps to generate excess fluid
accumulation in the body. This causes
swelling under the skin (termed peripheraledema oranasarca)
IF occurs with MS is called congestive
heart failure.
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Biventricular failure
,faiure of one side of
heart leads to failure of
other.
CLINICAL FEATURES
pedal edema
Dyspnea
Congestion of neck veins
Cynosis
Fatigue
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DIAGNOSIS
ImagingEchocardiography
Electrophysiology
electrocardiogram
(ECG/EKG) Blood tests
Angiography
Monitoring
TREATMENT MODALITIES-
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TREATMENT MODALITIES
Diet and lifestyle measures
Weight reduction Monitor weight
Sodium restriction -excessive sodium intake may
precipitate or exacerbate heart failure
Fluid restriction patients with CHF have a
diminished ability to excrete free waterload
stress reduction,rest
Stop smoking
Ph l i l t
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Pharmacological management
diuretic
Loop diuretics (e.g. furosemide, bumetanide)
ACE inhibitor/Angiotensin II receptor antagonist
Positiveinotropes Digoxin
Beta blockers
Alternativevasodilators
The combination ofisosorbide
dinitrate/hydralazine
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ORAL MANIFESTATIONS
Distention of the externaljugular viens.
Compensatory polycythemia ruddy complexion and
bleeding tendencies.
Abnormal production of clottingfactors
Bleeding can be spontaneousor extravasational.
DENTAL ASPECTS-
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The dental chair should be kept in partiallyreclining or erect position and patient should be
raised slowly in upright position.
Emergency dental care should be conservative,principally with analgesics and antibiotics.
Appointments should be short
Non stressful appointments
Patients are best treated in late morningbecause of epinephrine levels peak in earlymorning.
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Bupivacaine should be avoided as it is
cardiotoxic.
An aspirating syringe should be used to
give local anesthetic
Epinephrine containing LA should be not
given in large doses to patients taking beta
blockers.
Gingival retraction cords containing
epinephrine should be avoided
Supplemental o2 shd be available
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Supplemental o2 shd be available
Rubber dam is contraindicated when itcontributes to breathing difficulty.
NSAIDS other than aspirin shd be avoidedin pts taking ACE inhibitors(renaldamage).
Erythromycin and tetracycline to be
avoided as they may induce digitalistoxicity
GA is contraindicated in cardiac
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GA is contraindicated in cardiac
failure.until under control(venous
thrombosis and pulmonary embolism)
ACE inhibitors can sometimes cause
erythema multiforme,angioedema orburning mouth.
Antibiotic prophylaxis req for dental care
History of recent MI ,req delay of elective
dental care for 6 months
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Ortho static hypotension
CARDIAC
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CARDIACARRHYTHMIA -Cardiacarrhythmia (also
dysrhythmia) is a termfor any of a large andheterogeneous group ofconditions in which thereis abnormal electricalactivity in the heart. The
heart beat may be toofast or too slow, and maybe regular or irregular
Accordingly there r 2types-
Atrial arrhythmia Ventricular arrhythmia
More fatal than AA
TACHYCARDIA-
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TACHYCARDIA-
Any heart rate faster than 100
beats/minute is labelled tachycardia.BRADYCARDIAS
A slow rhythm, (less than 60 beats/min),
can lead to syncope. HEART BLOCK-blockage of cardiac
impulse anywhere in the conduction
system.
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TREATMENT
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TREATMENT
AA-
Digoxin
Propanolol
qUinidine sulphate
Anticoagulant such as
warfarin
VA-
Procainamide
Phenytoin
Dispyramide
Propanolol
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Physical maneuvers
Antiarrhythmic drugs Electricity
Electrical cautery
ORAL MANIFESTATIONS
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ORAL MANIFESTATIONS
Procainamide can causeagranulocytosis,oralulcerations
Quinidine-infrequent oral
ulcerations
Disopyramide is anticholinergicagent capable of producingxerostomia.
verapamil,enalapril can causegingival hyperplasia.
DENTAL
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CONSIDERATIONS-
A proper history to be
taken Stress and anxiety
be minimized
Short appointments
U
se of epinephrine to beminimized
Proper chair position isimportant, SUPINE
At end of appointment
chair should be raisedslowly to minimizeorthostatic hypotension.
Use of vasoconstrictors should be
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minimized in pts taking digitalis glycosides.
The equipments like pulp testers,ultrasonic scalers ,electrosurgical units,should not be in close proximity.
Prophylactic antibiotics before and aftertreatment in recently placed pacemaker
patients.
Pts who report palpitations or skippedbeats must be evaluated by physician
Sustained sinus tachycardia above 100
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beats/min in resting position is indicative of
sinus tachycardia Dental treatment shd not be carried out in
patients with irregular pulse
Long use of procainamide can cause a
lupus like syndrome
Drug like quinidine can cause erythema
multiforme
CA may be induced by general anesthesia
and vagal reflex
ORAL HEALTH CONSIDERATION & ORAL
MANIFESTATION
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MANIFESTATION
Valvular heart disease that compromises cardiac output produces
signs of hypoxemia. Cyanosis of lips and oral mucosa is the most prominent oral sign of
tissue hypoxia.
According to Americanheart association guidelines:Antibiotic
prophylaxis should be administered to patitents who have
undergone mitral or aortic valve repair or replacement.
Patients with a prior history of infective endocarditis.
Patients with mitral or aortic regurgigation or stenosis.
Patients with mitral valvular prolapse with valvular regurgigation.
Prosthetic heart valves. Previous bacterial endocarditis.
Acquired valvular dysfunction.
Complex cyanotic congenital heart disease.
Surgically constructed systemic pulmonary shunts.
ORAL PROCEDURES & NEED FOR ANTIBIOTIC
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PROPHYLAXIS TO MINIMISE RISK OF
BACTERIAL ENDOCARDITIS
Extractions.
Periodontal procedures includingsurgery,subgingival,placement of antibiotic fibers orStrips,scaling &root planning.
Implant placement. Tooth reimplantation.
Placement of orthodontic bands(not brackets).
Endodontic instrumentation.
Intra ligamentary injection.
Prophylatic cleaning of teeth where bleeding is anticipated. Other procedure in which significant bleeding is anticipated.
STANDARD REGIMENS FOR PROPHYLAXIS
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TO MINIMISE RISK OF BACTERIAL
ENDOCARDITIS
Oral medication.
Adults & children not allergic to penicillin-amoxicillin.
Adults & children allergic to penicillin-clindamycin. Non oral medication.
Adults & Childrens not allergic to penicillin-iv or im ampicillin.
Adults & children alergic to penicillin-iv clindamycin.