Hypertension – if the patient’s systolic blood pressure is > 180 mmHg, then elective dental care should be deferred and the patient need to be referred to GDP/specialist.
Patients with Stage 1 (140-159/90-99) and Stage 2 hypertension (160-179/100-109mmHg) should be referred to medical specialist if BP maintains elevated (> 140/90 mmHg)
BP recording before and after invasive dental procedure (eg. extraction) in patient with unstable BP is a part of a good dental practice. It needs to be done in a gentle manner, as some patients can become distressed because of this and subsequently their BP might elevate.
Be aware of potential sudden rise of BP following stressful dental procedure – to monitor a patient for a while (15-30 mints)
Postural hypotension especially in elderly patients, gradual dental chair reclining and sitting up with caution, slow move from dental chair in to wheelchair, patient observation all the way
Patients with ASA > II (ASA III, eg. unstable angina, low HR < 45 per min) should be seen in a secondary care with a direct access to critical care facilities, crash team, etc.
Wrist BP monitor very helpful for initial BP screening. However, less reliable readings (discrepancy +/-5mmHg compared to arm cuffed BP monitor). Be aware that wrist needs to be within a heart level, limitations in obese patients with a large wrist diameter. Much more comfortable for specials needs patients, patients with arms spasms (cerebral palsy,dementia), frail elderly patients with very skinny and thin arms. NICE approved.
New wireless pulseoximeter displays also ‘pulse strength and rhythm’, apart from O2 saturation and HR. This may give additional information about patient’s heart problems (eg. AF, dysrhythmia, etc).
If doubts regarding valid RR readings (not reproducible) – change a hand/arm for measurement, try another equipment
Small, wireless pulseoximeters and wrist BP monitors less ‘threatening’ than standard hospital equipment, esp. for phobic patients
Vitally important – when using wrist BP monitor – patient wrist has to be on the heart level! otherwise inaccurate readings.
Dental assessment prior heart operation vitally important ! All available preventative measures should be implemented: fluoride appl, high-concentrated TP prescription, TB demo, reassurance, infiltration with ‘Icon’ resin, etc.
If patients suffers from complex cardiovascular condition, it is a good practice to write letter to patient’s cardiologist prior to dental tx.
Do not underestimate even mild heart problems, such as tachycardia, bradycardia. Amide-based LA’s have cardiodepressive effect.
For patients with heart conditions, eg. angina, arrhythmia, etc. – to use LA without epinephrine, eg. 3% mepivacaine plain (not very effective for some types of local anaesthesia), Citanest 3% with felypressine (felypressine is a safer, less-selective vasoconstrictor compared to epinephrine) or LA with the smallest concentration of epinephrine (articaine with epinephrine (1:200 000).
Is prilocaine with felypressine indicated for patients with acute coronary syndromes such as: unstable angina, refractory arrhythmia? Controversial opinions.
Some patient with congenital heart problems and special needs (eg. Down Syndrome, Tetrallogy Fallot, etc) and poor oral hygiene may need AB cover for even minor invasive dental procedures due to increased risk of infective endocarditis. Particularly with existing acute/active infection: periodontitis, pericoronitis, etc. To contact patient’s cardiologist and get a second opinion. Current UK guidelines do not recommend AB cover for vast majority of cases but there are some exemptions.
Patients with severe cardiovascular condition may benefit from continuous blood pressure monitoring throughout the invasive dental procedure
Is pregnant patient, second trimester, otherwise healthy, with RR 88/56 blood pressure and single episode of faint fit for routine xla?
Kardia Alivecor portable ECG device can be useful to monitor patient heart rhythm at home, also prior dental treatment.
Conflicting, or even contradictory guidelines regarding pre-op recommendations for patient on new oral anticoagulants (NOAC): local hospital guidelines for general surgery vs for invasive dental procedures vs SDCEP
Age factor significantly complicates dental care. Extraction for medically compromised patient at the age of nearly 100, with previous stroke and TIA history, currently on anticoagulants vs much younger patient with similar medical conditions.
Bypasses (sometimes multiple), pacemaker
Ischemic heart disease
Transient Ischemic Attack (TIA), “mini-stroke”
Cerebrovascular Accident (CVA)
Arteriovenous malformation (AVM), risk of stroke, if congenital also in children
Cardiomyopathy (dilated, non-dilated)
Sick sinus syndrome
Stroke – elective invasive dental care should be deferred for sic months after a stroke, toothbrush adaptations in case of haemiplegia or loss of manual dexterity, the use of gauze wrapped round the fingers to maintain oral hygiene, often associated with dysphagia, risk of pulmonary aspiration and chest infection following USS scaling, poor control of the dentures
Atrial fibrillation – caution as patient usually is anticoagulants, including new oral anticoagulant(s). Kardia Alivecor monitor dedicated for a home monitoring of heart rhythm.
Recent valve replacement, eg. due to infective endocarditis, to double check the current guidelines regarding antibiotic cover
Deep vein thrombosis (DVT)
Congenital heart condition, eg. ASD/VSD (Atrial Septal Defect/Ventral Septal Defect), usually children under specialist care of cardiologist. Regular dental check ups, OHI and TB reinf., thorough regular dental assessments, preventative care including periodical fluoride varnish appl. to avoid any risk of caries development and subsequent complications.
Presence of next of kin vitally important to calm patient down and reduce anxiety, esp. or elderly patients, preventing from eg. heart problems during dental procedures.
Domiciliary dental care facilitates less stressful dental procedures, especially for elderly and medically compromised patients who require an ambulance transport and they are chair/bed bound on daily basis. Simple dental extraction in a home environment for the anxious patient with severe but stable heart condition, who has not been to dentist for a long period of time, carries less risk of potential systemic complications compared to similar treatment carried out in dental office or hospital setting. This can be vitally important for phobic patient who may become distressed and anxious attending a routine dental surgery appointment. Dom risk assessment essential.
FAST protocol to follow: F – Face change, A – Arm numbness, S – Speech deterioration, T – Time is crucial to call 999.
- patient on combined anticoagulant politherapy eg. antiplatelet meds and new oral anticoagulants
- patient with complex cardiovascular problems: heart failure, pacemaker, on warfarin
- patient recently resuscitated due to stroke, caused by pulmonary embolism and deep vein thrombosis
- rare heart conditions: eg. sick sinus syndrome
- patient awaiting serious cardiac operation eg. heart surgery, mitral valve replacement and on anticoagulant poly-pharmacy
- unstable blood pressure, sudden BP changes
- severe heart cardiomyopathy, dilated left ventricle
- aortic aneurysm, severe
- multiple anticoagulants
- is there any need to verify blood pressure before invasive dental procedures ?
- avoid postural hypotension by changing slowly the position of the dental chair, adequate time to adjust the position
- are local anaesthetic with epinephrine addition contraindicated/not recommended for patients with HBP ?
- is articaine with epinephrine 1:200000 ‘safer’ than lidocaine with 1:80000 epinephrine ?
- what would be
- can USS scaling be carried out for patient with fitted modern pacemaker and stable angina ?
- is it safer to use 3% Citanest with felypressin or 3% mepivacaine plain without vasoconstrictor in patients with hypertension, angina or arrhythmia?
- is it recommended to carry on with extraction in patient with increased systolic BP (140<-160) if patient is on antihypertensive meds and has taken a normal dose on the day of dental treatment?
- what are the maximum systolic and diastolic RR values above which a non-surgical extraction is not recommended? (eg. patient with well controlled hypertension?)
- is it ‘rational’ to provide a constant (or frequent) BP check/monitoring during an invasive dental procedure
- severe cardiomyopathy and LA choice; what sort of LA would be optimal (safetes and effiecient) for severely medically compromised middle age patient with pacemaker? Is it rational to avoid articiane with adrenaline (articane always in combination with adren.) and use plain lidocaine or mepivacaine (with potentially more cardiotoxic side effects) without adrenaline ?
- patient with permanently low HR and pacemaker fitted: 48-55. Xla in a safe hospital setting.
- is portable, mobile app. based ECG/heart rhythm monitor (eg. Kardia) useful for dental patients xla pre-asessment?
An evidence that up to 2 cartridges of local anaesthetic containing 1:80000 adrenaline has a little effect on blood pressure in patients taking beta-blockers and diuretics
Antihypertensive medications may have an impact on dental patient’s condition during dental treatment.
There is the risk of interaction between some of anti-hypertensive drugs: ACE inhibitors, calcium channel blockers, beta-blockers and NSAIDs (Ibuprofen) with subsequent potential reduction of antihypertensive effect
Diuretics may potentially cause xerostomia
Beta-blockers (propranolol) may potentially cause dry mouth, lichenoid reaction
Beta-blockers increase the toxicity of amide local anaesthetics (lidocaine)
Lidocaine can increase the myocardial depression of the beta-blockers
Calcium channel blockers (amlodypine, verapamil) may be a causative factors of gingival hypertrophy, gingival hyperplasia (overgrowth) – similar fashion to phenytoin (anti-convulsive) and cyclosporine (immunosupressant)
Some antihypertensive drugs can induce nausea, vomiting and stimulate excessive gag reflex
BP monitor should be always used in case of any doubts regarding patient’s systolic and diastolic values
The standard/occasional use of pulseoximeter to monitor blood oxygen saturation during more invasive dental procedure, particularly under IV and if patient appears to be medically compromised. Example: patient with severe heart condition.
If INR value between 3.5 and 4 , despite of still “safety range”, it is better to avoid multiple xla’s same day, even simple, non-surgical ones. If non-urgent, post-op bleeding risk assessment, start from a single xla then decide to proceed further
New generation of pulseoximeters can measure ‘vessels condition’ (degree of blockage) using APG scale from 1 (ideal) -6 (the worst)
Patient with history of CVA often PEG fed if associated haemiplegia and problems with swallowing
Low blood pressure may also contribute to some complications during dental treatment
wrist BP monitors more comfortable for some patients, but less reliable frail elderly patients
Novel oral anticoagulants can be prescribed for the patients who have:
- artificial heart valve/prosthetic heart valve
- previous deep vein thrombosis
- pulmonary embolism
- coronary heart disease
- peripheral vascular disease
- atrial fibrillation (A/F) resistant to standard medications
Dental emergency, spontaneous bleeding from patient’s ‘mouth, unknown origin
Carers phoned saying that patient profoundly bleeding from his mouth for a few hours, never had any probls so far and patient did no have and dental Tx recently. Urgent appt. arranged same day. Patient with blood on his chin and shirt, looking distressed and anxious. Elderly, wheelchair bound patient, on new oral anticoagulant Rivaroxaban NAOC for 2 years now due to AF and two strokes in the past, living in a care home. On examination (head light used as pt could not be transferred into dental chair): lots blood clots in patient’s mouth, mainly RHS, removed carefully and partially using gauze, plastic apron and disposable kidney dish used to protect pt’s clothes. Single upper molar very mobile, severe gign recessions, signs of advanced chronic periodontitis. Initial diagnosis: traumatized gingivae and perio pocket bleeding poss. due to biting/eating caused by mobile molar. Patient was biting on sterile throat pack with a string (risk of swallowing as dysphagia and poor muscles control) for 30 mints, gauze replaced twice. Reassured, tranexamic acid mouthwash unavailable, woudl be an efficient measure to arrest ging bleeding. Contacted patient’s GP re: oral anticoagulants alteration and pre-op advise prior dental extraction. Options discussed re: xla following SDCEP guidelines (omit a morning dose of NAOC). Referral to oral surgery dep. for molar tooth extraction to be considered, to be carried it out in a safe hospital setting.
Phobic patient, unstable heart rhythm
Patient suffers from high level of anxiety, was complaining of irregular heart rhythm, otherwise nil, not on medications. Additional health check did not reveal anything. Heart rhythm prior to dental procedure fluctuating a lot – from 85-125 per min. Extraction postponed, requested a second GP opinion, full blood count check, including thyroid hormones level (hyperthyroidism?).
Heart problems and difficult extraction
Frail elderly patient, myocardial infarction a few years ago, stable, well controlled angina, on anti-hypertensive meds, GTN spray in case of heart probl. Patient needs urgent extraction of lower molar tooth under IANB LA. What kind of LA agent would be optimal? First choice – mepivacaine plain 3%, IA block 2x cartridge, plus long buccal infiltr. If not LA not efficient – additional prilocaine 3% with felypressine PDL LA.
Few episodes of CVA’s, patient is currently on NOAC (apixaban or rivaroxaban)
Cognitive impairment, lack of mental capacity. No family members and next of kin. Support worker noticed mobile lower incisor (not sever, grade 1), periodontally involved, patient indicates some discomfort, unable to express main complaint. Haemiplegic, and PEG fed. Diagnosis: advanced localized periodontitis. Decision to monitor as low risk of complications (choking)
Atrial fibrillation, severe COPD
Frail, elderly patient in pain. Fluctuating HR (min 55- max 115/min) and o2 % saturation (min 68 – max 99%). UL2 periapical periodontitis. Opening and drainage under LA, oxygen administration during procedure, post-op observation. Postponed xla – if necessary – in a safe hospital setting with critical care facilities Risk discussed.
Patient with history of unstable angina, on beta-blockers
Emergency appt., tooth broke and causing a pain. Patient feels a bit tired, did not sleep well last night and has been rushing to come to dental surgery. co: pain front middle and LHS of his mandible, points to lower incisors, io: retained roots, TTP++, pt opted to go ahead with extraction. After LA administration (Scandonest 3% plain, labial/lingual infiltration) patient became not well, sweaty, hot, woozy and light-headed, still conscious and able to talk, speaking not affected, reported that feels sick. RR: 181/86, HR: 53-56, oxygen supplied 6 l/min for 15 minutes, no improvement for at lease 30 minutes. Patient had a few similar episodes at home but nothing as severe as here. Reported spreading ‘pain within lower jaw’ mainly LHS, no chest pain. Called ambulance 911 as susp. myocardial infarc. Aspirin 300mg given orally as per protocol. Patient got better after an hour and wanted to get out the surgery as feels claustrophobic, and to get a fresh air, was still reporting ‘pain within lower jaw’ mainly LHS. Recommended ECG check, blood pressure and HR re-checked, 165/84, HR: 56. Decision to abandon procedure and carry out further xla’s in a safe hospital setting with the access to critical care facility. Ambulance came, pt had ECG check, acc. to paramedics, ECG may indicate some ischaemic probls. as pt feels more comfortable in a home and nothing indicating acute myocardial infarction, they decided not to take him to the hospital. Appt. arranged. decision to change LA nv.
Non-verbal patient following stroke episode.
Haemiplegic patient indicates some sort of severe pain originating from facial area, points to whole left hand side of his face, UL3, UL4 and also LL4, LL5 perio involved, otherwise sound, with gingival recessions, patient cannot distinguish which tooth causes the pain. Unable to tolerate intraoral radiographs due to his medical condition and tremor. Local anaesthesia test utilized to figure out the causative tooth.