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4 CE credits
This course was written for dentists, dental hygienists, and assistants.

Cardiovascular Disease and the Dental Office

A Peer-Reviewed Publication Written by Fiona M. Collins, BDS, MBA, MA

PennWell is an ADA CERP recognized provider ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. PennWell is an ADA CERP Recognized Provider Concerns of complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/goto/cerp.

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Educational Objectives
Upon completion of this course, the clinician will be able to do the following: 1. Define cardiovascular disease and understand its occurrence in various demographic groups 2. Understand the need for an updated medical history and risk factors to consider when screening and counseling each patient 3. Understand procedural precautions that need to be taken in the dental office due to a patients medical history 4. Understand the current drug therapies for cardiovascular treatment and the implications of these medications for dental office treatment including potential side effects, drug interactions, and adverse oral drug reactions

aging population, increasing survival rates, and patients who remain ambulatory due to improvements in treatment. An increase in risk factors such as obesity and diabetes in the general population is likely to increase the proportion developing CVD and influence the age at which it occurs in the future, further compounding the problem.

Prevalence Of Cardiovascular Disease and Trends

Disease Prevalence Cardiovascular diseases include high blood pressure, coronary heart diseases, stroke, heart failure, diseases of the arteries, such as peripheral arterial disease, congenital heart defects, and rheumatic heart disease. NHANES (19992002) data indicates the prevalence of CVD reaches 77.8 percent of men and 86.4 percent of women over age 75. In the 4554 age group, the prevalence is approximately 36 percent for both men and women; in the 5564 age group, 52.9 percent and 56.5 percent, respectively; and in the 6574 age group, 68.5 percent and 75 percent, respectively.4 The incidence of coronary heart disease (CHD) and diagnosed heart attacks, Table 1. Prevalence of CHD, Stroke, and Heart Failure in Men

Abstract
Cardiovascular disease trends, complications, and associated therapeutics impact dental health and treatment. More dental patients are being seen with cardiovascular disease and taking medications for its treatment, and an increasing number are taking multiple medications and have more severe cardiovascular disease. Cardiovascular patients require special consideration with regard to when and which dental treatment is appropriate and what precautions are required. Alertness to potential oral adverse drug reactions enables referral of the patient to his physician and/or cardiologist if these are suspected. Cardiovascular drugs are also known to have potential drug interactions ranging from mild to potentially fatal with medications commonly used or prescribed in the dental setting, and a current medication history allows selection of appropriate medications for dental patients. Dental professionals may be the first line of defense in the detection and referral of a patient suspected of having cardiovascular disease, an uncontrolled disease status, or oral adverse drug reactions, and they have a key role to play in oral and systemic disease prevention and treatment, in partnership with the patient and his physician.

20 75+ age population, % 15 5564 6574 10 5 0 2034 3544

4554

Table 2. Prevalence of CHD, Stroke, and Heart Failure in Women

14 12 age population, % 10 8 6 4 2 0
Stroke

75+

Overview
Fifty years ago, it was hoped that modern prevention and treatments would reduce both the incidence and outcomes of cardiovascular disease (CVD). Today, cardiovascular disease is the largest killer in both men and women in North America, responsible for 38 percent of all deaths,1 and is the most common medical condition that dental professionals confront.2 Cardiovascular disease trends, complications, and associated therapeutics affect dental health and treatment.3 Dental professionals are seeing an increasing number of patients with symptomatic and hidden cardiovascular disease and a history of acute CVD. Some factors contributing to these increases include the
2

6574 4554 5564

2034

3544

Heart Failure

CHD

Tables 1 and 2. Adapted from Heart Disease Statistics 2006 Update, American Heart Association.

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stroke, PAD, and heart disease all increase in prevalence with age (Tables 1 and 2).5 High blood pressure, which is also related to future acute and severe chronic CVD,6 increases in prevalence steadily with age, affecting over 60 percent of the population 6574 years of age, and 69 percent of men and 83 percent of women 75 years of age and older.7 Atrial fibrillation affects an estimated 2.2 million people in the United States, 70 percent of whom are aged 6585 and affects 10 percent of patients in their 80s.8 Angina has been estimated to affect around 1 percent of the population.9 In addition, surgery has become common for the treatment of valval disease, congenital heart disease, and end-stage heart disease. Population Demographics Since the prevalence of CVD increases with age, U. S. population demographics represent a negative trend for health. In 2005, there were 78.2 million baby boomers in the country and 35 million people aged 65 and older. By 2050, the number of people aged 65 and older is projected to reach over 86 million. The 4564 age group is anticipated to increase by 50 percent, from 62 million to 93 million.10 Barring unforeseen changes in lifestyle, prevention, and intervention, the absolute number of patients with CVD will increase. Furthermore, it is estimated from studies that those over 55 have a 90 percent risk of developing hypertension.11 Cardiovascular Disease Mortality and Morbidity Cardiovascular disease is the leading cause of death in adult men and women. Preliminary data from the CDC and NHLBI indicates that cardiovascular disease was responsible for the deaths of 427,000 men and 484,000 women in 2003 (the next closest single cause of death was cancer, with 287,000 and 268,000 deaths, respectively).12 Of the approximately 0.9 million deaths due to cardiovascular disease in 2003, 53 percent were due to coronary heart disease (Table 4). The number of patients surviving strokes increased by almost 0.5 million between 1988 and 2002, reaching an estimated 6.78 million; and for myocardial infarction, by more than a million, at 4.96 million survivors (up from 3.85 million).13 Antihypertensive medications in combination with lifestyle adjustments in patients with high blood pressure have reduced myocardial infarction by 2025 percent, stroke by 3540 percent, and heart failure by over 50 percent.14 High mortality and morbidity rates exist for heart failure, underscored by the Framingham study, which found a 25 percent mortality rate at two years.15 Atrial fibrillation is the most common risk factor for stroke and increases the risk of experiencing an episode by 500 percent compared to the general population.16 Mortality rates for congenital heart disease have declined, leading to increased numbers of children surviving into adulthood, with implications for future dental and medical treatments.17
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Table 3. U.S. Population Age 45 and Over

No. of people in the U.S., thousands
60,000 50,000 40,000 30,000 20,000 10,000 0 Men 4564 Women 4564 Men over 65 Men over 65 2000 2050

Table 4. Percentage of Cardiovascular Deaths by Disease Type

53%

Coronary Heart Disease 18% Other Stroke Heart Failure 17% High Blood Pressure

6%

6%

Adapted from Heart Disease Statistics 2006 Update, American Heart Association.

These increased survival rates mean that there are more patients attending dental offices with a history of severe CVD and an increase in the number of patients at risk for severe episodes due to underlying pathologies.

CvD Manifestation and Patient Presentation

Patients attending the dental office who have cardiovascular disease fall into two basic groups those who are aware of their condition and those who are not. In the latter group, the disease may be asymptomatic or, if not, the patient is aware of the symptoms but not aware that these symptoms are related to cardiovascular disease. Hypertension Despite being the most commonly diagnosed medical condition in the United States, hypertension has low patient awareness. Within the population with high blood pressure, estimates from the CDC indicate that only 49 percent of ages 2039 are aware of their blood pressure status. That number rises to 73 percent in the over-40 demographic. Other studies have indicated that as few as 32 percent of patients are aware of their blood pressure status18 and that it is controlled in under 50 percent of individuals suffering from it.19,20 Hypertensive patients present with systolic and diastolic pressures of at least 140mmHg and 90mmHg, respectively, and it is now believed that the risk starts above 115/75mmHg.21
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The majority of patients with straightforward hypertension are asymptomatic22 until the pressure is high for an extended period of time. While asymptomatic, the patient is at increased risk for further disease including stroke, myocardial infarction, ischemic heart disease, unstable angina, and renal damage. Early symptoms can include fatigue, nose bleeds, palpitations, facial flushing, and changes in vision.23 Awareness, treatment, and control also vary by age, ethnicity, and gender.24 Ischemic Heart Disease The majority of patients with stable ischemic heart disease who present in the dental office either have angina pectoris or heart failure. In ischemic heart disease, an imbalance exists between the supply of and demand for oxygen, and the results can range from angina to myocardial infarction and sudden death. Angina Pectoris The patient suffering from this condition presents with a deep pain substernally that can be relieved with medication. Attacks usually last about five minutes and can be precipitated by stress, increased blood pressure, and exertion. Patients should be asked whether angina attacks only happen upon exertion (stable angina) or while at rest (unstable angina), as this has implications for any potential dental treatment. Angina occasionally presents as mandibular pain, possibly leading the patient to believe that he has a dental problem. Myocardial Infarction This involves ventricular muscle death and varies from small areas that will heal to large infarctions that result in death and high morbidity. There are not always warning signs of this condition.25 Congestive Heart Failure Signs and symptoms vary depending upon the areas of the heart affected and can range from peripheral edema (when located in the right ventricle, sometimes manifested by swollen ankles) to pulmonary symptoms (when the left ventricle is affected). The heart does not pump effectively, and there is an increased heart rate and intravascular volume that result in hypertrophy of the myocardium, redirection of blood from other areas of the body, and cardiac dilation, causing further deterioration of the heart.26 Atrial Fibrillation This can be asymptomatic or present with palpitation, fatigue, increased urination, and lightheadedness, or more severely with stroke, edema, heart failure, or shortness of breath. Signs include heart rates that are irregular and changes to heart sounds and jugular venous pulse. The most common cause of atrial fibrillation in the United States is hypertension.27 Congenital Heart Disease A common birth defect, more children survive today than in the past to attend for
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dental treatment as children and later as adults with septal defects and stenosis.28

Risk Factors
Risk factors for cardiovascular disease include age, race, family history, lack of exercise, sodium intake, obesity, smoking, high LDL and low HDL cholesterol levels, hypertension, heavy alcohol consumption, cocaine use, diabetes, previous history of CVD, and gender. Recent research also shows an association between periodontal disease and cardiovascular disease.29 Smoking prevalence in the American population over age 18 varies by ethnicity and gender, ranging from 17.8 percent and 11.3 percent in Asian men and women, respectively, to 37.3 percent and 33.4 percent for American Indian or Alaska Native men and women, with other major ethnic groups falling within this range.30 High LDL and low HDL cholesterol levels have also been shown to vary by ethnic group, with the highest overall levels in non-Hispanic Whites. Diabetes is present in 7 percent of the U.S. population, with 14.6 million diagnosed cases and 6.2 million undiagnosed cases. Its prevalence varies by age and ethnicity, with nonHispanic Whites having the lowest prevalence among major ethnic groups.31 The Framingham study estimates the risk of a patient developing coronary heart disease over a 10-year period based upon several risk factors, and is a useful reference point for dental professionals in assessing the risk and likelihood of CHD in their patient population. At age 55, nonsmokers with normal blood pressure and cholesterol levels and who are not diabetic have a 5 percent risk of coronary heart disease over 10 years. In contrast, smokers with blood pressure at or above 140/90 and HDL 40 or less and who are diabetic have a 37 percent risk if male and 27 percent risk if female of developing the disease over 10 years.32

Identification of CvD and At-risk Patients in the Dental Office

Medical History A thorough medical history is necessary for all prospective patients. It should include: A current and previous history of medication use (including self-medication) Medical conditions, as well as any symptoms the patient is experiencing (including shortness of breath and chest pain) A family history for medical conditions, including cardiovascular disease Regular medical record revisions every time the patient is recalled
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 Medical record revisions in the event of a change in the patients medical condition or use of medication since the previous visit Risk Factors and Testing Risk factors to consider when screening patients are diabetes, obesity, and cholesterol levels, as well as alcohol, tobacco smoking, recreational drug use (particularly cocaine) and any current or previous use of drugs such as ephedra or fen-phen (which is associated with valvular defects). Recreational use of cocaine has been shown to cause myocardial infarction, arrhythmias, heart blockage, and other serious cardiovascular effects, including death.33 A C-reactive protein test is an option to help screen patients at risk. High C-reactive protein levels are produced in response to systemic inflammation, including of periodontal origin, and are associated with an increased risk of myocardial infarction and CVD. Depending upon the medical history, it may also be prudent to refer the patient to a medical clinic for fasting blood glucose tests for diabetes screening. Blood Pressure and Counseling Blood pressure and pulse measurements at patient recall appointments enable patients with high readings to be referred to their physician immediately for diagnosis and treatment. If patients have high blood pressure or known risk factors, it has been recommended that their blood pressure be taken at every visit.34,35

or early afternoon may be better. Patients with congestive heart failure should not be placed in a supine position, and for other patients, the chair should be raised gently.3942 Separate consideration is required for patients with valval disease, heart transplants, prosthetic valves, previous bacterial endocarditis, pacemakers, or implanted defibrillators. Guidelines are available from the American Heart Association regarding the need for antibiotic prophylaxis to prevent bacterial endocarditis for heart conditions, and they are not addressed further here.43

CvD Medications
CVD drug therapy and potential side effects, interactions, and oral adverse drug reactions are important for the dental office setting, with implications for treatment. Currently Available Drug Therapies Drug therapies for cardiovascular disease are complex and may involve combinations of drugs. Classes of drugs used in the treatment of cardiovascular disease include alpha and beta adrenergic blockers, calcium channel blockers, sodium channel blockers, potassium channel blockers, diuretics, ACE inhibitors, phenytoin, anticoagulants, angiotensin inhibitors, nitrates, platelet aggregation inhibitors, and recently statins. Many of these are used to treat several cardiovascular diseases. Combination drugs containing both diuretics and other antihypertensives have recently been introduced to treat hypertension. Combination calcium channel blockers and ACE inhibitors have also been introduced to treat CVD.44 In heart transplant patients, immunosuppressives are used to prevent rejection. Which classes of drugs and specific drugs patients are or were taking is essential information, as is when and for how long they were or are taking them, potential interactions and side effects for that class of drugs or specific drug, and potential oral adverse drug reactions. If necessary, the PDR or a similar reference resource can be reviewed (including the product insert for the drug, if the patient has it) and/or the patients physician can be consulted. A number of specific side effects and potential drug interactions in the dental office are addressed here.

Considerations for Dental Treatment

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 patients medical history, risk factors, and vital signs, the physician and/or cardiologist should be consulted prior to treatment. It has been recommended that patients with a history of myocardial infarction in the previous six months should not be treated as outpatients, and that elective dental treatment should be postponed on patients with severe or uncontrolled high blood pressure.36,37 If a patient reports angina attacks at rest that are changing or increasing in severity, or that were diagnosed within the last 30 days, it has been recommended that they not receive elective dental care until their angina is stable,38 and patients with stable angina should be advised to bring their medication with them in case it is needed during treatment. Minimizing stress achieved through patient management, pain-free dentistry techniques, and, where appropriate, the use of sedatives and analgesics (taking into consideration potential drug interactions) is important. It has been recommended that appointments should be less than one hour to minimize stress, and traditionally in the morning, although research now suggests late morning
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Implications of CvD Medication for Dental Office Treatment

Side Effects and Drug Interactions Statins The introduction of statins has had a significant impact on the treatment of cardiovascular disease.45 While generally considered safe, statins potential side effects and drug interactions include peripheral neuropathy and muscular problems ranging from myalgia to rhabdomyolysis, which is potentially fatal and involves lysis of the muscle cell walls and systemic release of the cells contents.46
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There have been reports of drug interactions between statins and erythromycin prescribed prior to dental treatment. In one patient prescribed erythromycin prior to treatment, the patient developed multiple organ toxicity including acute renal failure, pancreatitis, and rhabdomyolysis. In three other cases, rhabdomyolysis was reported in all three, and acute renal failure in two, patients.47 While rare, a statin-erythromycin interaction is potentially fatal. The potential for interaction varies with the specific statin-antiobiotic combination. Three other antibiotics used in dental offices and known to have potential adverse drug interactions with statins are clarithromycin, azithromycin, and telithromycin.48 Azole antifungal agents are also known to have the ability to interact with statins. These antifungals include miconazole, fluconazole, and itraconazole, as well as ketoconazole.4952 A case of rhabdomyolysis has been reported with concurrent use of a statin and fluconazole.53 Miconazole, fluconazole, and itraconazole are treatments for oral and other candidal infections, and the antiobiotics known to have the potential for statin drug interactions are used in dental settings.54 This underlines the importance of a current medication history for dental patients, here with regard to statins prior to determining which antifungal agents or antibiotics should be avoided and which are appropriate in the treatment and prevention of oral and systemic disease. Anticoagulants Anticoagulants are widely used to treat deep vein thrombosis, heart failure, atrial fibrillation, valvar disease, and prosthetic heart valves. Depending upon the indication, the patient may be on anticoagulants temporarily or for life. Intravenous heparin is used to help prevent stroke recurrence in patients with atrial fibrillation. Warfarin is the most commonly used for outpatients.55 The patients physician should be contacted to find out whether anticoagulant dosage can or should be adjusted prior to dental treatment, or whether a careful surgical technique and wound closure, along with the use of pressure and local hemostats, will be sufficient when surgery is performed.56,57 Certain antibiotics, including metronidazole, tetracyclines, erythromycin, and clarithromycin, increase prothrombin time, thereby affecting clotting. It has been recommended that these should not be used in patients who are or recently were on anticoagulants.58 Immunosuppressives Used in heart transplant patients, immunosuppressives can mask early infections. With vigilance these may be detected and treated. If treating a heart transplant patient, the patients cardiologist should be consulted.59,60 Vasoconstrictors in the Dental Office Vasoconstrictors are used in local anesthetics, retraction cords, and as hemostats. Vasoconstrictors added to local anesthetics
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improve the depth of local anesthesia and its duration and reduce bleeding at the site.61 Epinephrine stimulates both alpha and beta adrenergic receptors. Beta receptors increase the heart rate, conduction velocity, and contractile force of the cardiovascular system. Increased or decreased peripheral resistance occurs, with increases caused by constriction (alpha receptor activity) and decreases by dilation (beta receptor activity) of veins and coronary arterioles. Levonordefrin is more specific increasing peripheral resistance and reducing cardiac output and heart rate.62 Depending upon the antihypertensive drug involved, the use of vasoconstrictors can lead to hypertension, hypotension, or the onset of angina.63 Vasoconstrictors interact with several classes of drugs used to treat CVD, including beta blockers, antiadrenergic drugs and digitalis glycosides.64 It has been recommended that in patients with significant disease reduced doses or no vasoconstrictor should be used,65,66 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.67 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).68 The American Heart Associations 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. When a vasoconstrictor is indicated, extreme care should be taken to avoid intravascular injection.69 Retraction cord impregnated with epinephrine exposes patients to uptake of potentially large amounts of the vasoconstrictor systemically. Its use is controversial, and it has been recommended that dental professionals do not use epinephrine-impregnated retraction cord in patients with cardiovascular disease.70 Nonsteroidal Antiinflammatory Drugs (NSAIDS) NSAIDS can interfere with the regulation of blood pressure. Their use interferes with prostaglandin and prostacyclin production, which are involved in the regulation of blood pressure.71 Opioids Opioids used in dentistry for sedation, pain relief, and general anesthesia carry risks for patients on antihypertensive medication and can cause hypotension due to their additive effect. Oral Adverse Drug Reactions In addition to potential side effects and drug interactions, cardiovascular drugs have been associated to varying
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degrees with adverse oral drug reactions. The exact incidence of adverse drug reactions and oral adverse drug reactions is not known.72 Women have been reported as having a higher incidence than men. This may be due to a higher reporting rate by women, more use of medications, and/or hormonal and pharmacological factors.73,74 Oral adverse drug reactions associated with cardiovascular drugs include xerostomia, gingival overgrowth, aphthae/ oral ulcerations, scalded mouth syndrome, taste disturbances, cheilitis, glossitis, angioedema, thrombocytopenia, epithelial sloughing, and lichenoid/lichen planus reactions. Drugs proven, likely, or suspected of causing these oral adverse drug reactions include all of the major classes of CVD drug therapies: alpha and beta adrenergic blockers, ACE inhibitors, calcium channel blockers, diuretics, antiarrhythmics, statins, potassium-channel openers, and angiotensinreceptor blockers. Certain CVD drugs have proven associations with oral adverse drug reactions (Table 6).7580 Table 6. Oral Adverse Drug Reactions Condition Cardiovascular Drug Alpha-adrenergic blockers Beta-adrenergic blockers Lisinopril Sodium channel blockers Calcium channel blockers Diuretics Anti-cholesterol drugs Calcium-channel blockers Phenytoin Cyclosporin (immunosuppressive drug) Calcium channel blockers Captopril, Enalapril (ACE inhibitors) Beta-adrenergic blockers ACE inhibitors Angiotensin II antangonists

Figure 1. Patient with severe gingival hyperplasia

Image courtesy of Dr. Richard Nejat

Xerostomia

Gingival Overgrowth

Taste Disturbances

Angioedema

Glossitis, Stomatitis, Gingivitis Anti-cholesterol drugs

CvD and the Role of the Dental Professional

The dental professionals role with CVD patients may variously include detection of CVD, patient referral, education and counselling, postponement of dental treatment, and prevention and treatment of oral conditions. Dental professionals are in a position to detect blood pressure issues during routine or screening visits and to counsel patients on risk factors such as diet, smoking, and lifestyle. Where cardiovascular disease is suspected
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but not being treated or controlled, the dentist and dental hygienist can refer the patient to treating physician. The use of a C-reactive protein test may be the first indication the patient has of his condition, and referring the patient to his physician as a result of this and other screening is a service to the patient. An understanding of individual patient medication and cardiovascular health status enables appropriate treatment and avoidance of potential drug interactions. The awareness of oral adverse drug reactions to cardiovascular medications and detection of a suspected reaction enables dental professionals to refer the patient back to his physician or cardiologist, who can then determine whether it is appropriate to prescribe an alternative therapy or to continue with the same treatment. Calcium channel blockers can cause gingival hyperplasia so severe that the patients physician may prescribe a different drug.81 Managing and treating the conditions experienced as oral adverse drug reactions alleviates discomfort, promotes healing, and where the drug therapy in question must be continued, is important to help prevent further oral disease. Xerostomia is one of the more common reactions and, if of more than transient duration, can result in rapidly advancing carious lesions. Appropriate therapy for xerostomia can be prescribed, including the use of in-office and home fluorides to help prevent hard tissue destruction, antimicrobials, and saliva replacements, and the patient can be educated and counselled. Other conditions, such as oral ulcerations, can be treated to alleviate pain and promote healing. Topical gels or octylcyanoacrylate liquid (SootheN-Seal, Colgate Oral Pharmaceuticals) can be applied to relieve the pain of oral ulcerations, and some have been shown to help promote healing. Oral rinses (Rincinol, Sunstar Butler, and Gelclair, OSI Pharmaceuticals) are also available to relieve pain and treat oral ulcerations. These are particularly useful where there are multiple widespread intraoral ulcerations. Glossitis, cheilitis, and gingivitis may also require treatment. Gingival hyperplasia physically impacts the patients ability to perform adequate oral hygiene and may necessitate more frequent
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professional prophylaxis and guidance. Maintaining periodontal health and good oral hygiene, educating the patient on this, and recommending specific oral hygiene aids and devices are important components of care for the patient with cardiovascular disease. Should a cardiovascular emergency occur in patients during dental treatment, the dental team will be the first to deal with it. CPR and emergency training must be current, and emergency medical equipment and kits must be up to date, complete, and readily available for use while emergency services are en route.

Summary
The number of cardiovascular patients presenting in dental offices is increasing, patients are surviving serious cardiovascular disease, and treatment of CVD is increasingly complex. By understanding the risks for these patients and the implications of relevant treatment and drugs, dental professionals can provide dental care tailored to the individual patients circumstances that is both safe and effective. Drug interactions can be avoided and treatment provided for oral reactions to cardiovascular drugs. The dental professional may be the first line of defense in the detection and referral of a patient suspected of having CVD and which the patient may be unaware of, or of a patient whose disease is not being treated or does not appear to be controlled. Cardiovascular disease status influences the care and treatment of dental patients and is an important determinant in treatment planning, acceptance of patients for elective treatment, and treatment methodology.

References
1.

Hansson, G.K. Inflammation, atherosclerosis, and coronary artery disease. N Engl J Med. 2005;352(16):16851695. 2. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 3. Waters, B.G. Providing dental treatment for patients with cardiovascular disease. Ontario Dentist 1995 JulyAug:2532. 4. American Heart Association, Heart Disease and Stroke Statistics 2006 Update. Available at: www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed April 12, 2006. 5. Ibid. 6. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752. 7. American Heart Association, Heart Disease and Stroke Statistics 2006 Update. Available at: www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed April 12, 2006. 8. Feinberg, W.M. et al. Prevalence, age distribution and gender of patients with atrial fibrillation. Analysis and implications. Arch Intern Med. 1995 Mar 13;155(5):469473. 9. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 10. Available at: www.census.gov /ipc/www/usinterimproj/natprojtab02a. Accessed April 14, 2006. 11. 7th report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure. JAMA 2003;289;2560 2572. 12. American Heart Association, Heart Disease and Stroke Statistics 2006 Update. Available at: www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed April 12, 2006.

13. Muntner, P., et al. Trends in the prevalence, awareness, treatment and control of cardiovascular disease risk factors among noninstitutionalized patients with a history of myocardial infarction and stroke. Am J Epidemio 2006 Apr5; (Epub ahead of print). 14. Neal, B.,MacMahon, S., Chapman, N. Effects of ACE inhibitors, calcium antagonists, and other blood-pressure lowering drugs: Results of prospectively designed overviews of randomized trials. Blood pressure lowering treatment trialists collaboration, Lancet 2000;356:19551964. 15. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 16. Verheugt, F.W. Stroke prevention in atrial fibrillation. Neth J Med 2006 Feb;64(2):3133. 17. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 18. Lee, Y.S. Awareness of blood pressure among older adults: A cross-sectional descriptive study. Int J Nurs Stud 2006 Mar 26 (Epub). 19. Am J Managed Care 2005 Nov;11 (13 Suppl):S383S385. 20. Colhoun, H.M., Dong, W., Poulter, N.R. Blood pressure screening, management and control in England 1994. J Hypertension 1998;16:747753. 21. The seventh report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressur. Bethesda, MD: NIH/ NHLBI;May 2003. 22. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752. 23. Little, J.W., et al (eds). Dental management of the medically compromised patient, 2002, ed. 6. St. Louis:Mosby, Inc. 24. Heart Disease Statistics 2006 Update. Available at www.americanheart.org. Accessed April 12, 2006. 25. Waters, B.G. Providing dental treatment for patients with cardiovascular disease. Ontario dentist 1995 JulyAugust;2432. 26. Ibid. 27. Russo. Overview of the contemporary evaluation and management of patients with atrial fibrillation: what every general practitioner should know. 28. Available at:www.americanheart.org/downloadable/heart/1075_russo.pdf. 28. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 29. Slavkin, H.C. Does the mouth put the heart at risk? J Am Dent Assoc 1999;130:109113. 30. MMWR 2005;54(44).CDC/NCHS. 31. www.cdc.gov/diabetes/pubs/estimates05.htm#prev4. Accessed May 8, 2006. 32. American Heart Association, Heart Disease and Stroke Statistics 2006 Update. Available at: www.americanheart.org/presenter.jhtml?identifier=3018163. Accessed April 12, 2006. 33. Kloner, R.A., et al. The effect of acute and chronic cocaine use on the heart. Circulation 1992;85(2):407419. 34. Waters, B.G. Providing dental treatment for patients with cardiovascular disease. Ontario dentist 1995 JulyAugust;2432. 35. Glick, M. New guidelines for prevention, detection, evaluation, and treatment of high blood pressure. J Am Dent Assoc 1998;129:15881594. 36. Aubertin, M.A. The hypertensive patient in dental practice: Updated recommendations for classification, prevention, monitoring, and dental management. Gen Dent 2004 NovDec;544552. 37. Waters, B.G. Providing dental treatment for patients with cardiovascular disease. Ontario Dentist 1995 JulyAug:2532. 38. MacAfee, K.A. et al. Angina pectoris diagnosis and treatment in the outpatient setting. Compendium 1993;14:892896. 39. Aubertin, M.A. The hypertensive patient in dental practice: Updated recommendations for classification, prevention, monitoring, and dental management. Gen Dent 2004 NovDec;544552. 40. Academy Report. Periodontal management of patients with cardiovascular diseases. J Periodontol 2002;73:954968. 41. Waters, B.G. Providing dental treatment for patients with cardiovascular disease. Ontario Dentist 1995 JulyAug:2532. 42. Raab, F.J. et al. Interpreting vital sign profiles for maximizing patient safety during dental visits. J Am Dent Assoc 1998;129:461469. 43. Dajani, A.S. et al. Prevention of bacterial endocarditis. Recommendations of the American Heart Association. JAMA 1997;277:17941801.

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44. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752. 45. Wong, P.W., Dillard, T.A., Kroenke, K. Multiple organ toxicity from addition of erythromycin to long-term lovastatin therapy. South Med J 1998 Feb;91(2):202205. 46. Pasternak, R.C., et al. ACC/AHA/NHLBI clinical advisory on the use and safety of statin. J Am Coll Cardiol 2002;40:567572. 47. Ibid. 48. Stevenson, H., Longman, L.P., et al. The statins: drug interactions of significance to the dental practitioner. Dent Update 2006;33:1420. 49. Janssen-Cilag, Sep 2003. Summary of product characteristics, Daktarin oral gel. 50. Janssen-Cilag, Sep 2003. Summary of product characteristics, Nizoral. 51. Pfizer, Sep 2002. Summary of product characteristics, Diflucan. 52. Janssen-Cilag, Nov 2002. Summary of product characteristics, Sporanox. 53. Shaukat, A. et al. Simvastatin-fluconazole causing rhabdomyolysis. Ann Pharmacother 2003;37:10321035. 54. Stevenson, H., Longman, L.P., et al. The statins: drug interactions of significance to the dental practitioner. Dent Update 2006;33:1420. 55. Russo. Overview of the contemporary evaluation and management of patients with atrial fibrillation: what every general practitioner should know. Available at:www.americanheart.org/downloadable/heart/1075_russo.pdf. Accessed April 12, 2006. 56. Academy Report. Periodontal management of patients with cardiovascular diseases. J Periodontol 2002;73:954968. 57. Weibert, R.T. Oral anti-coagulation therapy in patients undergoing dental surgery. Clin Pharmacy 1992;11:857864. 58. Glasser, S. The problems of patients with cardiovascular disease undergoing dental treatment. J Am Dent Assoc 1977;94:11581162. 59. Rees, D.D. Periodontal considerations in patients with bone marrow or solid organ transplants. In: Rose, L.F. et al eds. Periodontal Medicine. Toronto: Decker Inc.;1999. 60. Academy Report. Periodontal management of patients with cardiovascular diseases. J Periodontol 2002;73:954968. 61. Naftalin, L.W., Yagiela, J.A. Vasoconstrictors: indications and precautions. Dent Clin N Am 2002;46:733746. 62. Jastak, J.T., Yagiela, J.A., Donaldson, D. Local anesthesia of the oral cavity. Philadelphia:WB Saunders 1995;6185. 63. Aubertin, M.A. The hypertensive patient in dental practice: Updated recommendations for classification, prevention, monitoring, and dental management. Gen Dent 2004 NovDec;544552. 64. Naftalin, L.W., Yagiela, J.A. Vasoconstrictors: indications and precautions. Dent Clin N Am 2002;46:733746. 65. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the dental practitioner. British Dental Journal 2000;189:297302. 66. Pallasch, T.J. Vasoconstrictors and the heart. J Calif Dent Assoc 1998;26(9):668673. 67. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752. 68. Academy Report. Periodontal management of patients with cardiovascular diseases. J Periodontol 2002;73:954968. 69. Dajani, A.S., et al. Cardiovascular disease in dental practice. American Heart Association, Dallas, 1991. 70. Pallasch, T.J. Vasoconstrictors and the heart. J Calif Dent Assoc 1998;26(9):668673. 71. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752. 72. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev

Oral Biol Med 2004;15(1):2846. 73. Shah, M.R., et al. Sex-related differences in the use and adverse effects of angiotensin-converting enzyme inhibitors in heart failure: the study of patients intolerant of converting enzyme inhibitors registry. Am J Med 2000;109:489492. 74. Tran, C., et al. Gender differences in adverse drug reactions, J Clin Pharmacol 1998;38:10031008. 75. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev Oral Biol Med 2004;15(1):2846. 76. Sreebny, L.M., Schwartz, S.S. A reference guide to drugs and dry mouth, 2nded. Gerodontology 1997;13;3337. 77. Wright, J.M. Oral manifestations of drug reactions, Dent Clin North Am 1984;28:529379. 78. Baum, B., Ferguson, M., et al. Medication-induced salivary gland dysfunction. Perspectives on the 3rd World Workshop on Oral Medicine. BMC Medical Services, 2000:288292. 79. Bullon, P., et al. Clinical assessment of gingival hyperplasia in patients treated with nifedipine. J Clin Periodontol 1994;21:256259. 80. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev Oral Biol Med 2004;15(1):2846. 81. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha Omegan 2003 Dec;96(4):4752.

Author Profile
Dr. Fiona M. Collins has over 20 years of clinical, marketing, education and training, and professional relations experience. She has practiced as a general dentist for 13 years, written and given CE courses to dental professionals and students, and conducted market research projects. Dr. Collins is a past- member of the Academy of General Dentistry Health Foundation Strategy Board and has been a member of the British Dental Association, the Dutch Dental Association, and the American Dental Association. In her spare time she can be found walking in the foothills of Colorado with her husband and dog, or playing music. Dr. Collins holds a dental degree from Glasgow University and an MBA and MA from Boston University.

Disclaimer
The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course.

Reader Feedback
We encourage your comments on this or any PennWell course. For your convenience, an online feedback form is available at www.ineedce.com.

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Questions
1. Cardiovascular disease is responsible for what percentage of all deaths in North America?
a. b. c. d. 77.8 38.0 36.0 60.0

11. Hypertensive patients are those whose blood pressure is at least:

a. b. c. d. 140/75 140/90 115/90 115/75

21. A patient found to have high blood pressure before dental treatment should be referred to his physician for diagnosis and treatment:
a. b. c. d. Immediately After the dental procedure has been completed Only if the patient doesnt feel well b and c

2. Which of these is NOT considered a cardiovascular disease?

a. b. c. d. Congenital heart defects High blood pressure Stroke All of these are cardiovascular diseases

12. Angina pectoris involves:

a. A deep substernal pain b. Ventricular muscle death c. Changes in heart sounds and jugular venous pulse d. Hypertrophy of the myocardium a. b. c. d. A deep substernal pain Pulmonary symptoms Ventricular muscle death Hypertrophy of the myocardium

22. Patients with _______ should not be placed in a supine position.

a. b. c. d. Congenital heart disease Congestive heart failure Angina Atrial fibrillation

3. According to NHANES data from 2002, men over age 75 are more likely to have CVD than women of the same age.
a. True b. False

13. Myocardial infarction involves:

4. In this same report, the prevalence of CVD in the 4554 age bracket is 36 percent for men and ______ percent for women.
a. b. c. d. 38 60 36 10

14. Congestive heart failure in the left ventricle involves:

a. Changes in heart sounds and jugular venous pulse b. Pulmonary symptoms c. Ventricular muscle death d. Hypertrophy of the myocardium a. Changes in heart sounds and jugular venous pulse b. Pulmonary symptoms c. Ventricular muscle death d. Hypertrophy of the myocardium

23. In addition to the Physicians Desk Reference, what other resource does the author recommend for learning about a medications side effects and possible interactions?
a. b. c. d. The patients physician Any physician The medications product insert a and c

15. Atrial fibrillation involves:

24. Adverse interactions between statins and erythromycin can potentially result in which of the following?
a. b. c. d. Renal failure Rhabdomyolysis Pancreatitis All of the above

5. Angina has been estimated to affect what percent of the population?

a. b. c. d. 1.0 0.1 10.0 None of these

6. According to estimates, by 2050 the over-65 population in the United States is expected to exceed:
a. b. c. d. 78.2 million 35 million 86 million 62 million

16. Which of these is a risk factor for CVD?

a. b. c. d. Diabetes Cocaine use Heavy alcohol consumption All of the above

25. According to the article, in at least one reported instance the interaction of a statin and fluconazole has resulted in:
a. b. c. d. Renal failure Rhabdomyolysis Pancreatitis All of the above

7. According to estimates, those over age 55 have a ____ percent chance of developing hypertension.
a. b. c. d. 60 36 90 50

17. According to the article, the American demographic least likely to be at risk of CVD from tobacco use is:
a. b. c. d. Caucasian men Asian women Native American men Alaska Native women

26. Tetracyclines should not be used in patients who are or recently were on anticoagulants.
a. True b. False

27. In patients with CVD, which of the following should NOT be used?
a. b. c. d. All vasoconstrictors. Epinephrine-impregnated retraction cord Levonordefrin-impregnated retraction cord Lidocaine

8. The CDC and NHLBI estimate that in 2003, cardiovascular disease was responsible for approximately _____ deaths in the United States.
a. b. c. d. 911,000 427,000 484,000 287,000

18. Over a period of 10 years, a nondiabetic 55-year-old male who smokes is more than _____ times more likely to develop coronary heart disease than a non-diabetic 55-year-old male who does not smoke.
a. b. c. d. 4 5 6 7

28. The use of _______ interferes with prostaglandin and prostacyclin production.
a. b. c. d. NSAIDS Retraction cords Opioids Epinephrine

9. Of these deaths, approximately what percentage were due to coronary heart disease?
a. b. c. d. 25 percent 35 percent 53 percent 63 percent

19. A complete medical history should include any self-medication on the part of the patient in addition to prescribed medications.
a. True b. False

29. Which of these can cause hypotension in patients on antihypertensive medication?

a. b. c. d. NSAIDS Retraction cords Opioids Epinephrine

10. Hypertension is known as the silent killer because:

a. Its symptoms are impossible to detect b. Relatively few Americans are aware of their blood pressure status c. Until recently, the medical community has denied its existence d. All of the above

20. Recreational cocaine use has been shown to cause:

a. b. c. d. Myocardial infarction Arrhythmia Death All of the above

30. Prolonged xerostomia has been known to cause:

a. b. c. d. Oral ulcerations. Carious lesions Aphthae Glossitis

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ANSWER SHEET

Cardiovascular Disease and the Dental Office

Name: Address: City: Telephone: Home ( ) Title: E-mail: State: Office ( ) ZIP: Specialty:

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.

Educational Objectives
1. Define cardiovascular disease and understand its occurrence in various demographic groups 2. Understand the need for an updated medical history and risk factors to consider when screening and counseling each patient 3. Understand procedural precautions that need to be taken in the dental office due to a patients medical history 4. Understand the current drug therapies for cardiovascular treatment and the implications of these medications for dental office treatment including potential side effects, drug interactions, and adverse oral drug reactions

Mail completed answer sheet to

Academy of Dental Therapeutics and Stomatology,

A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026 or fax to: (440) 845-3447

For immeDiate results, go to www.ineedce.com and click on the button take tests Online. answer sheets can be faxed with credit card payment to (440) 845-3447, (216) 398-7922, or (216) 255-6619. P  ayment of $59.00 is enclosed. (Checks and credit cards are accepted.) If paying by credit card, please complete the following: MC Visa AmEx Discover Acct. Number: _______________________________ Exp. Date: _____________________ 0 0 0 0 0 0 Charges on your statement will show up as PennWell

Course Evaluation
Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0. 1. Were the individual course objectives met? Objective #1: Yes No Objective #2: Yes No 2. To what extent were the course objectives accomplished overall? 3. Please rate your personal mastery of the course objectives. 4. How would you rate the objectives and educational methods? 5. How do you rate the authors grasp of the topic? 6. Please rate the instructors effectiveness. 7. Was the overall administration of the course effective? 8. Do you feel that the references were adequate? 9. Would you participate in a similar program on a different topic? 5 5 5 5 5 5 4 4 4 4 4 4 Yes Yes Objective #3: Yes No Objective #4: Yes No 3 3 3 3 3 3 2 2 2 2 2 2 No No 1 1 1 1 1 1

10. If any of the continuing education questions were unclear or ambiguous, please list them. ___________________________________________________________________ 11. Was there any subject matter you found confusing? Please describe. ___________________________________________________________________ ___________________________________________________________________ 12. What additional continuing dental education topics would you like to see? ___________________________________________________________________ ___________________________________________________________________ PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.
AUTHOR DISCLAIMER The author of this course has no commercial ties with the sponsors or the providers of the unrestricted educational grant for this course. SPONSOR/PROVIDER This course was made possible through an unrestricted educational grant. No manufacturer or third party has had any input into the development of course content. All content has been derived from references listed, and or the opinions of clinicians. Please direct all questions pertaining to PennWell or the administration of this course to Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com. COURSE EVALUATION and PARTICIPANT FEEDBACK We encourage participant feedback pertaining to all courses. Please be sure to complete the survey included with the course. Please e-mail all questions to: macheleg@pennwell.com. INSTRUCTIONS All questions should have only one answer. Grading of this examination is done manually. Participants will receive confirmation of passing by receipt of a verification form. Verification forms will be mailed within two weeks after taking an examination. EDUCATIONAL DISCLAIMER The opinions of efficacy or perceived value of any products or companies mentioned in this course and expressed herein are those of the author(s) of the course and do not necessarily reflect those of PennWell. Completing a single continuing education course does not provide enough information to give the participant the feeling that s/he is an expert in the field related to the course topic. It is a combination of many educational courses and clinical experience that allows the participant to develop skills and expertise. COURSE CREDITS/COST All participants scoring at least 70% (answering 21 or more questions correctly) on the examination will receive a verification form verifying 4 CE credits. The formal continuing education program of this sponsor is accepted by the AGD for Fellowship/Mastership credit. Please contact PennWell for current term of acceptance. Participants are urged to contact their state dental boards for continuing education requirements. PennWell is a California Provider. The California Provider number is 3274. The cost for courses ranges from $49.00 to $110.00. Many PennWell self-study courses have been approved by the Dental Assisting National Board, Inc. (DANB) and can be used by dental assistants who are DANB Certified to meet DANBs annual continuing education requirements. To find out if this course or any other PennWell course has been approved by DANB, please contact DANBs Recertification Department at 1-800-FOR-DANB, ext. 445. RECORD KEEPING PennWell maintains records of your successful completion of any exam. Please contact our offices for a copy of your continuing education credits report. This report, which will list all credits earned to date, will be generated and mailed to you within five business days of receipt. CANCELLATION/REFUND POLICY Any participant who is not 100% satisfied with this course can request a full refund by contacting PennWell in writing. 2008 by the Academy of Dental Therapeutics and Stomatology, a division of PennWell

AGD Code 149

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