Case Report

Supervisor :

dr. A. Yudho S. Akp, Sp.PD, FINASIM

by :

Fatimatuz Zahroh 131611101051

Natasha Destanti H. 131611101063
Safira Niza U. 131611101087

Faculty Of Dentistry Jember University

Departement of Internal Medicine
Balung General Hospital
Jember
2018
Case 2

Name Mr. M
Age 4 y.o
Sex Male
Chief Complaint (S) Patient visited to Emergency Room RSD
Balung on May 20th , 2018 at 11.30 p.m. with
dyspnea since 3 days before, cough, fatigue
and difficult to speak.
Clinical observation Patient looks dyspnea, fatigue and pale. The
blood pressure is 147/99 mmHg/dL
Temporary diagnosis Coronary Artery Disease

Introduction
Cardiovascular disease (CVD) is one of the primary reasons of death in adult men and
women (Kamath M et al., 2016). CVD is caused by disorders of heart and blood vessels which
result in coronary artery disease (CAD), heart failure, cardiac arrest, and sudden cardiac death
(Mastoi et al., 2018). Ischemic heart disease, hypertension, dysrhythmias, and infective
Endocarditis are some another examples of the cardiovascular conditions most commonly seen
among the population. If, in addition, the patients have to undergo dental treatment, it will add to
their stress. This makes treatment planning in these patients for any health problems, including
dental problems. Cardiac patients may collapse in dental clinics due to various cardiac
emergencies or drug interactions (Chaudhry et al., 2016).

The dental management of these medically compromised patients can be problematic in

terms of oral complications, dental therapy, and emergency care (Singh et al., 2017). The first
step in managing the patient with medical problems is acquiring a thorough health history. A
comprehensive health history questionnaire should include questions about the patients
cardiovascular, hematologic, neural and sensory, gastrointestinal, respiratory, dermal,
mucocutaneous, and musculoskeletal, endocrine, and urinary systems as well as questions related
to sexually transmitted diseases, drug use (eg, alcohol, tobacco), allergies, x-ray exposure or
treatment, medications, and hospitalizations the second step is for the clinician to fully
understand the significance of the disease. Each identified condition can affect dental care in a
unique manner. For example, medication prescribed for a medical condition might produce a
problem during the administration of a local anesthetic, or it could interact with pain medication
prescribed post intervention. The dental clinician needs to understand the potential complications
that can occur as a consequence of dental treatment of a medically compromised patient and
when pretreatment or post-treatment medication or emergency care is indicated (Tsvetanov,
2017).

Oral and Dental Manifestation of Coronary Artery Disease

Fact Reference Solution
1. Xerostomia 1. Xerostomia was related to the Clinical Dental Practice has a
potential for transmission of
2. Gingival sustained increase in both
various infections from patient to
enlargement systolic as well as diastolic Dentist, patient to patient as well as

3. Periodontitis blood pressure (Kumar, 2012) Dentist to patient due to close

proximity to
4. Dental caries and also in patients who were
the nasal and oral cavities of the
5. Tooth loss under medication especially patient.

6. Oral candidiasis antihypertensive drugs like Thus, a barrier should be created to

prevent the transmission of infections
ACEIs, thiazide diuretics,
and to make the clinical procedures
loop diuretics, and clonidine. safe

Xerostomia has many from the threat of cross infections A

detailed history of TB should prompt
consequences, like decay,
the dental practitioner
difficulty in chewing, to discern whether the person is an

swallowing, and speaking, active case under treatment, active

case without treatment or previously
candidiasis, and oral burning
infected
syndrome. Sometimes the but currently disease free. The non-

feeling is transient and treated active cases

pose maximum risk to the dental
salivary function is adjusted
healthcare personnel.
by the patient itself (Popescu, Dental healthcare professionals are at

2013). the constant risk of

being exposed to TB by means of
2. Gingival enlargement is also
splatter, aerosols or infected blood.
one of the most common Dental treatment for those with active

clinical finding in patients tuberculosis

with medication especially should be limited to urgent and
essential procedures.
calcium channel blockers.
As numerous serious diseases are air-
Gingival enlargements appear borne, blood-borne

clinically as firm nodules of or can spread through the contact of

other body fluids, and
gingival overgrowth seen on
it is impossible to know which
either buccal or facial aspects certain patients are infected,

and lingual or palatal aspects it is pertinent to avoid direct contact

with blood, body fluids
of the marginal gingiva.
and mucous membranes. High
Sometimes they may even the standards of operatory disinfection

entire crown causing and instrument sterilization should be

maintained.
difficulty in eating. The drugs,
Rubber dams can be used to
which cause the gingival minimize aerosol contact however, if

enlargement are amlodipine, coughing is evident, rubber dam

should not be used.
nifedipine (Kumar, 2012).
Maintenance of proper hand hygiene,
personal protective
equipment (eye shields, face masks,
headcaps, gloves
and surgical gowns) and proper
sterilization procedures
should be followed. Standard surgical
face masks do not
protect against TB transmission;
dental healthcare personnel should
use particulate face masks. Masks
should
be changed at regular intervals, inter-
appointments (between patients) and
intra-appointments (during patient
treatment) if the mask becomes wet.
Reusable facial protective equipment
(protective eyewear
or face shields) should be cleaned
and disinfected between patients.
Handpieces and other oral
instruments
should be cleaned and autoclaved
regularly.
 The goal of the dental infection-
control program is to provide a safe
working environment that reduces the
risk of
both healthcare-associated infections
among patients and
occupational exposures among dental
team members.

What should I do for this patient ?

Patients with a suspect medical history, untreated cardiovascular disease, high blood
pressure, high C-reactive protein levels, or any uncertain disease status can be referred to their
physician. Depending upon the patient’s medical history, risk factors, and vital signs, the
physician and/or cardiologist should be consulted before dental treatment. Elective dental
treatment should be postponed on patients with severe or uncontrolled high blood pressure
(Collins, 2007).

Stress reduction protocol

Dental treatment has the potential to induce stress. Such stress can be either physiological
(pain) or psychological (anxiety, fear). The body responds to the stress by increased release of
catecholamines (epinephrine and norepinephrine) from the adrenal medulla into the
cardiovascular system. This, in turn, can increase the workload on the heart (that is, increased
heart rate and strength of myocardial contraction and an increased myocardial oxygen
requirement) in patients with hypertension or coronary artery disease. Therefore patients with
some forms of cardiovascular disease are vulnerable to physical or emotional stress that may be
encountered during dental treatment. The various steps taken to minimize the stress encountered
during dental treatment procedure, referred to as stress reduction protocol, are as follows;

 Patients should be given reassurance to prevent or reduce anxiety.

 Medically compromised patients are better able to tolerate stress when rested. Therefore,
the ideal time to schedule dental treatment is in the morning.
 Patients should be seated comfortably (semi-supine) in the dental chair.
 Intermittent rest should be provided to the patient for reducing fatigue.
  A medically compromised patient should not undergo unduly long appointments (Kamath
M et al., 2016).

Caution with the use of vasoconstrictors

Vasoconstrictors are used in local anesthetics, retraction cords, and as hemostats.

Vasoconstrictors added to local anesthetics improve the depth of local anesthesia and its duration
and reduce bleeding at the site. Epinephrine stimulates both alpha and beta adrenergic receptors.
Beta receptors increase the heart rate, conduction velocity, and contractile force of the
cardiovascular system. Depending upon the antihypertensive drug involved, the use of
vasoconstrictors can lead to hypertension, hypotension, or the onset of angina. Vasoconstrictors
interact with several classes of drugs used to treat CVD, including beta blockers, antiadrenergic
drugs and digitalis glycosides. It has been recommended that in patients with signifcant disease
reduced doses or no vasoconstrictor should be used, clinicians strongly consider strict avoidance
of vasoconstrictor use in patients with coronary heart disease, heart failure, tachyarrhythmias, or
stroke, and that the use of vasoconstrictors in patients on adrenergic blockers should be avoided.
Where local anesthetics containing vasoconstrictors are used in patients with CVD, there are
guidelines limiting the amount of vasoconstrictor to the equivalent of two to three carpules of
lidocaine (1:100,000 epinephrine). The use of vasoconstrictor should be limited in individuals
with cardiac disease, taking care not to exceed 0.04 mg of adrenaline (4.5ml of standard local
anaesthetic solution containing 0.009mg of Adrenaline tartrate per ml) The American Heart
Association’s position from 1991 on the use of vasoconstrictors in local anesthetic for dental
treatment in general is that if they are necessary, “care should be taken to use the smallest
effective dose” and “only when it is clear that the procedure will be shortened or the analgesia
rendered more profound (Collins, 2007). In turn, if anesthetic reinforcement is needed, it should
be provided without a vasoconstrictor. It is also important to eliminate intravascular
administration therefore careful aspiration before any injection is mandatory (Kamath M et al.,
2016).

Refference :
1. Chaudhry, Swantika., Ritika Jaiswal., Surender Sachdeva. 2016. Review Article: Dental
considerations in cardiovascular patients: A practical perspective. Indian Heart Journal
68 572–575.
2. Collins, Fiona M. 2007. Cardiovascular Disease and the Dental Office. ADA CERP.
3. Kamath M, Madhav., Kundabala Mala,, Manuel S. Thoma. 2016. Modifcation of Dental
Care for Patients with Cardiac Disease. OHDM- Vol. 15 No.5.
4. Kumar, Prashant., Ramesh Chowdhary, and Shanmugam. 2012. Oral manifestations in
hypertensive patients: A clinical study. J Oral Maxillofac Pathol. May-Aug; 16(2): 215–
221.
5. Popescu, Sanda Mihaela., Monica Scrieciu, Veronica Mercuţ, Mihaela Ţuculina,
and Ionela Dascălu. 2013. Hypertensive Patients and Their Management in Dentistry.
Hindawi Journals.
6. Singh, Saurabh., Khushboo Gupta, Kavita Nitish Garg, Neeraj Kumar Fuloria, Shivkanya
Fuloria, Teerthesh Jain. 2017. Dental Management of the Cardiovascular Compromised
Patient: A Clinical Approach. J Young Pharm 9(4): 453-456.
7. Tsvetanov, Tsvetan. 2017. Dental Management Of The Medically Compromised Patients.
https://www.researchgate.net/publication/32116221.