Common Medical Conditions in Elderly Dental Patients. Part One: Cardiovascular Implications and Management

Common Medical Conditions in Elderly Dental Patients. Part One: Cardiovascular Implications and Management

Satbir Grover, B.D.S., * and Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D.**:

Introduction
In the Post World War II era from 1946 to 1964 commonly known as the “Baby Boom” years, approximately 78 million babies were born in the United States. This has had a tremendous impact on the lifestyle and cultural trends in today’s “gray American” generation. With a total expenditure of approximately $2.3 trillion dollars, these older adults serve as the key drivers of all the major U.S.  markets. Current estimates indicate nearly 11,000 Boomers are turning 50 on a daily basis. According to the 2010 Census, there were 40.3 million people age 65 and older in the U.S. in 2010, an  approximate 5.3 million increase since the 2000 Census (http://2010.census.gov). 
 
In this two-part series, common systemic conditions are presented to update dentists regarding the most common medical conditions of which they should be aware for any elderly patient who walks  into the clinic. This will help them prepare a plan to provide optimal dental treatment for this patient population. It will as well help them train their staffs in either preventing or managing any emergency in the dental office.1 
 
Elderly patients are expected to have one or more chronic medical conditions. In fact, current data show that greater than 50% of patients over age 60 have an average of three chronic medical  conditions.1 While most dental offices are well prepared for treating children and adults, some modifications in treatment methods are required to accommodate the frail and elderly adult. It is of  prime importance to review and update the medical history on every visit to the dental clinic. Information regarding all types of medical conditions and medications as well as contact information for  the patient’s physician should be collected on the first visit.2 
 
Covered in this article will be cardiovascular conditions including hypertension, congestive heart failure, ischemic heart disease, and valvular conditions.
 
Hypertension
Hypertension (HTN), or high blood pressure, is the term used to describe elevated blood pressure higher than the normal levels of 120/80mm. It is most commonly, but not solely, controlled by an  individual’s lifestyle, genetic background, age, and sometimes race. According to the new guidelines in the American Heart Association’s 7th report of the Joint National Committee, a patient is considered to have pre-hypertension with blood pressure ranging above 120-139/80-89 and high blood pressure (hypertension) when blood pressure is or remains above 140/90 mm Hg most of the  time.3 
 
The American Society of Hypertension (ASH) after considering the ever-increasing prevalence of HTN and cardiovascular diseases as a direct or in-direct sequel of HTN, concluded it to be much  bigger than a single disease entity. With the most common conditions to follow onset likely to be stroke and kidney failure, HTN is a topic that demands far more research. It is most commonly associated with obesity, diabetes, and poor lifestyle choices.4 
 
Etiology
The pathogenesis of primary (essential) hypertension is generally considered to be multifactorial. With modern society and its attendant technologies, changes in lifestyle leading to increased stress are major factors leading to HTN. As well, genetics play a very important role the list of major causative factors. It is commonly recognized that children have higher blood pressure when one or both  parents are hypertensive. Environmental factors, increased salt intake, and obesity have long been incriminated.5 
 
Epidemiology
It is estimated that hypertension occurs in 10-15% of white and 20-30% of black adults in the United States, with chances being even greater for people who are unaware of the underlying disease due to neglected health concerns. The latest statistics on the prevalence of HTN in the U.S. indicate that more than 30% of adults have HTN (67 million). Thirty-six million (or 54%) did not have  their HTN under control, and 15 million (or 40%) were not even aware that they had HTN. These are very important figures because HTN has such a significant impact upon dental treatment.6
 
Signs  and Symptoms
As widely reported, mild to moderate primary or essential hypertension is largely asymptomatic for many years. Accelerated hypertension is often associated with, but not limited to: 
• Severe headache
• Fatigue or confusion
• Chest pain
• Irregular heart rhythm
• Difficulty breathing
• Vision problems
• Blood in the urine
• Pounding in the chest, neck, or ears
 
HTN is considered to be affected by the patient’s Circadian rhythm, so fluctuations can be expected throughout the day. Any unusual rise in blood pressure due to either exertion or anxiety can be  expressed by patients in many different patterns, and has to be reported immediately to the primary physician. The patient needs to be kept under constant observation, with treatment regimens ranging from simple change in lifestyle to anti-hypertensive medications or any combinations, depending upon the severity of the underlying disease and patient motivation.1,7 
 
Dental Considerations
Blood pressure screening at both initiation and end of dental treatment seems to be the most effective method of observing any fluctuation from the baseline blood pressure.1,8 Dentist and staff  should be trained in observing the physical signs of the patient’s discomfort and how to intervene in case of an emergency. 
 
Experts believe that any procedure in a known hypertensive patient can be complicated, especially dental treatment. Because dental procedures are considered more stress-producing, they come  with the possibility of elevating the baseline blood pressure and precipitating acute complications such as cardiac arrest or cerebrovascular accident. Sudden emotions such as anxiety or impatience  are commonly known to cause a transient rise in blood pressure by the release of catecholamines (epinephrine and norepinephrine) in the blood stream. About 40% of hypertensive patients do have  raised levels of circulating catecholamines leading to abnormal sympathetic activity.1,9
 
Oral manifestations of the most common medications — among them diuretics, B-blockers, central-acting adrenergic inhibitors, Ca-channel blockers — include: 
• Xerostomia
• Gingival overgrowth
• Lichenoid drug reactions
• Taste sense alteration
• Paresthesia
• Erythema multiforme
 
The most important precaution to reduce any complication associated with HTN is to have a detailed plan in place to reduce any anxiety in the patient. The steps in order to successfully treat any  hypertensive patient include:
• Possibly short and morning appointments
• Stress and anxiety reduction with establishment of good rapport
• Premedication with sedative or anxiolytic agents
• Optimized use of local anesthesia with moderate amount of epinephrine
• Periodic monitoring of BP before, during, and at the end of any procedure 46
 
Anxiety Control
As mentioned earlier, the fear of any dental procedure (the “white coat” phenomenon) is considered a major cause leading to rise in blood pressure in a majority of such patients, and can therefore  precipitate acute cardiac arrest or any cerebrovascular accident in the dental clinic. Preoperative reassurance with the use of effective local anesthesia (with or without epinephrine) may help in  alleviating the related anxiety and thus reduce the chances of rise in blood pressure. Use of oral sedatives the night before or during the procedure (pharmacosedation) are also considered to be 
effective. 
 
Even nitrous oxide (N2O) has evolved considerably in reducing the anxiety level of patients, resulting in possible reduction of blood pressure by 10-15mm.1,9 
 
Orthostatic Hypotension 
The consensus  definition of orthostatic hypotension is a “reduction of systolic blood pressure of at least 20mm Hg or a reduction of diastolic blood pressure of at least 10mm Hg within three minutes  of erect standing”.10 Orthostatic hypotension can be due to both neurogenic and non-neurogenic causes and is a very common problem in elderly patients. This prevalence depends upon factors  such as age, use of medications, and co-morbidities known to be associated with the condition. Orthostatic hypotension can manifest through a variety of symptoms, but commonly causes lightheadedness, dizziness, weakness, difficulty thinking, headache, and even syncope. Management includes instructing patients to avoid sudden postural changes such as return from supine to the  sitting position in the operatory and instructing the patient to stay seated for a short period so as to regain optimal levels cerebral perfusion.10
 
Congestive Heart Failure
Heart failure, also known as congestive heart failure (CHF), means the heart cannot pump enough blood to meet the body’s needs. Over time, conditions such as narrowed arteries in the heart  (coronary artery disease) or high blood pressure gradually leave the heart too weak or stiff to fill and pump efficiently.1,11 Heart failure is the pathophysiologic state in which the heart via an  abnormality of cardiac function, detectable or not, fails to pump blood at a rate commensurate with the requirements of the metabolizing tissues or is able to do so only with an elevated diastolic filling pressure. While heart failure may be caused by myocardial failure, it may also occur in the presence of near normal cardiac function under conditions of high demand. To maintain the pumping  function of the heart, compensatory mechanisms increase blood volume, cardiac filling pressure, heart rate, and cardiac muscle mass. However, despite these mechanisms, there is progressive decline in the ability of the heart to contract and relax, resulting in worsening heart failure. 
 
In order to determine the best course of therapy, physicians often assess the stage of heart failure by the use of two different screening systems: a system relating the symptoms to the patient’s  everyday activities and quality of life,1,12 and a system reflecting the progression of disease.1,11 
 
Pathophysiology
The common pathophysiologic state that perpetuates the progression of heart failure is extremely complex regardless of the precipitating event. Compensatory mechanisms exist on every level of  organization, from subcellular through organ-to-organ interactions. Only when this network of adaptations becomes overwhelmed does heart failure arise.14 
 
In acute heart failure, the finite adaptive mechanisms that may be adequate to maintain the overall contractile performance of the heart at relatively normal levels become maladaptive when trying  to sustain adequate cardiac performance.15 
 
The primary myocardial response to chronic increased wall stress is myocytic hypertrophy, death/ apoptosis, and regeneration. 
 
Etiology
Heart failure often develops after other conditions have damaged or weakened the heart. Over time, the heart can no longer keep up with normal demands placed on it to pump blood to the rest of  the body. The main pumping chambers, the ventricles, may become stiff and do not fill properly between beats. As well, the heart muscle may weaken, and the ventricles stretch (dilate) to the point  the heart cannot pump blood efficiently throughout the body. The term “congestive heart failure” comes from blood backing up into, or congesting, the liver, abdomen, lower extremities, and lungs.1,11 
 
Epidemiology
According to the American Heart Association, heart failure affects nearly 5.7 million Americans of all ages, with 500,000 new cases diagnosed each year.16 
 
Signs and Symptoms
Congestive heart failure is characterized by three specific symptoms. Those suffering from CHF have difficulty exercising or engaging in other forms of physical activity such as routine household chores. This is because the heart is unable to pump the blood needed to produce the necessary nutrients. Problems breathing, retaining fluid (and subsequent weight gain), and swelling of the legs  and feet are other significant signs.17
 
Symptoms of heart failure include:
• Chest pain
• Fatigue and weakness
• Rapid or irregular heartbeat
• Shortness of breath (dyspnea) upon exertion or lying down
• Reduced ability to exercise
• Persistent cough or wheezing with white or pink blood-tinged phlegm
• Swelling (edema) in abdomen, legs, ankles, and feet
• Increased heart rate1,11,12
• Difficulty concentrating or decreased alertness1,11
 
If there is active history of heart failure, any change in symptoms should be reported to the primary physician for a thorough evaluation. 
 
Dental Consideration
Dentists need to be alert to and place a high priority on careful evaluation of both medical history and current status of patients with CHF. As with every patient, baseline blood pressure should be measured at each visit and monitored throughout the visit. In scenarios of high fluctuation in the baseline vitals, dental treatment should be deferred, with urgent referral to the primary physician for  evaluation. Short appointments at the start of the day should be scheduled. Chair position should be adjusted to the patient’s comfort, and care should be taken while changing chair position to  avoid the possibility of orthostatic hypotension.1,18
 
Dental patients with a history of any cardiovascular complication require special attention at the time of administering local anesthetic. Care should be taken with the dosages of potent vasopressors  such as epinephrine, which should be adjusted depending upon the severity of the patient’s current status. 
 
Some conditions may not require any antibiotic prophylaxis prior to dental procedures (AHA guidelines).1,21,30 Cross-reactions of the non-steroidal anti-inflammatory drugs (NSAIDs) such as aspirin with antihypertensive drugs taken by the patient should be discussed with either the primary physician or the pharmacist before long-term administration. As well, druginduced reactions by many  xerogenic medications should be considered and treated so as to reduce the chances of caries and periodontal conditions.19,20 
 
Ischemic Heart Disease  (Coronary Artery Disease)
As defined by the Johns Hopkins Heart and Vascular Institute, 
“Coronary Artery Disease, or CAD, is a narrowing of the coronary arteries, the vessels that supply blood to the heart muscle, generally due to the buildup of plaques in the arterial walls, a process  known as atherosclerosis. Plaques are composed of cholesterolrich fatty deposits, collagen, other proteins, and excess smooth muscle cells.”1,22 
 
The most common sequellae to atherosclerosis can manifest as angina pectoris or myocardial infarction. 
 
Angina is a very common presentation from an oxygen-deprived heart, manifesting as a  recurring discomfort or pain in the chest region. It results from an interruption of blood supply to the heart muscle, much lower than the amount required for the normal sustenance of heart functions  during elevated physical activities. Angina may not be as serious as heart attack; however, it serves as a warning symptom of a more serious underlying condition.22 
 
Myocardial infarction (MI), or heart attack, is partial or complete blockage of the coronary artery by blood clots for a prolonged period of time, creating interrupted blood flow to the heart, leading to  either damage or death of a heart muscle.23 
 
Epidemiology
Approximately 9.8 million Americans are estimated to experience angina annually, with 500,000 new cases of angina occurring every year. 
 
Approximately 1.5 million cases of myocardial infarction occur annually in the United States. The yearly incidence rate is approximately 600 cases per 100,000 people. 
 
Signs and Symptoms
Angina symptoms include:
• Chest pain or discomfort
• Pain in arms, neck, jaw, shoulder, or back accompanying chest pain
• Nausea
• Fatigue
• Shortness of breath
• Anxiety
• Sweating
• Dizziness
 
Common heart attack symptoms include:
• Chest pain or pressure, tightness, squeezing, burning, aching, or heaviness in the chest lasting longer than 10 minutes. The pain or discomfort is usually located in the center of the chest just  under the breastbone and may radiate down the arm, especially the left, up into the neck, or along the jaw line. 
• Increasing episodes of chest pain 
• Prolonged pain in the upper abdomen
• Shortness of breath or difficulty Sweating
• Impending sense of doom or a choking sensation
• Fainting
• Nausea and vomiting
• Profuse sweating
• Dizziness
• Muscle weakness
 
In cases of “silent heart” attacks, however, no symptoms have been reported by the survivors.22 
 
Dental Consideration 
As has often been said, “Prevention is better than cure.” Any medical emergency in a dental office can be best avoided by its early detection. Dentist and staff should be appropriately trained to  recognize any change in a patient’s presenting symptoms and respond quickly. Ischemic cardiac attacks can take place in parking lots, waiting areas, and even dental chairs. Quick reaction by dental  staff plays a vital role in saving patients’ lives as well as avoiding any permanent system damage. 
 
Every measure should be taken to reduce any treatment-induced stress to the patient. Ideally, offices should be at comfortable locations which have easy access. Staff should observe any change  in patients’ behavior as soon they enter the clinic. Patients’ medical histories should be updated at every appointment. All dental clinics should be equipped with first aid kits, to include emergency  drugs such as nitroglycerin (tablet or spray), considered the gold standard to reduce exertion-induced cardiac attacks. If a patient should experience acute angina or an MI, the EMS should be activated (911), the patient should lie in a comfortable position, and 0.5mg nitroglycerin tablet should be placed sub-lingually for maximum efficiency and oxygen can also be admininstered. This  procedure can be repeated three times before considering the episode an MI attack. In this scenario, the patient should be immediately transferred to the nearest hospital to increase his or her  chance of survival.22-25
 
The entire incident should be carefully documented in the medical records, and precautions should be taken during future dental appointments. The patient’s primary physician should be consulted for  a thorough evaluation, and the current status should be updated. All elective dental care should be deferred. In the case of any further treatment provided, precautions should be taken to reduce  stress by the use of prophylactic nitroglycerin, oral sedation, and 100% oxygen supply. Possible use of a pulse oximeter along with constant monitoring of blood pressure can also prove to be helpful in avoiding future incidences of angina or MI in the dental clinic.1 
 
Valvular Heart Conditions
Valvular heart disease is characterized by the John Hopkins Heart and Vascular Institute as “damage to or a defect in one of the four heart valves: mitral, aortic, tricuspid, or pulmonary”. The valves  are genetically programmed to steer the right amount of blood in the right direction at the right time with the right amount of force to ensure smooth functioning of other organ systems. The mitral  and tricuspid valves control the flow of blood between atria and ventricles. The aortic valve controls flow between the heart and aorta, therefore to the whole body, whereas the pulmonary valve  governs the flow of blood from the heart to the lungs. The mitral and aortic are considered the valves most commonly affected by the valvular heart diseases.1,22 
 
Etiology
Valvular stenosis is the hardening of the cardiac valves due either to induced stiffness or fusing of the valves’ leaflets. This leads to narrowing of the valvular lumen through which the blood passes  from one chamber to another, resulting in extra work by the cardiac muscles in order to maintain optimal blood flow. Any of the four valves can be stenotic. The conditions are called mitral stenosis,  tricuspid stenosis, aortic stenosis, or pulmonary stenosis.26
 
Valvular insufficiency, also referred to as regurgitation, incompetence, or even “leaky valve” by some authors, is a condition where the valves fail to seal tightly, which is required to avoid leaking  or back-flow of blood from the next level chamber. To compensate, the heart has to work harder to maintain proper blood flow in the right direction. Depending upon the severity of the condition, this may result in a reduced amount of blood to the rest of the body, leading to various degrees of organ dysfunction. The conditions are named for the affected valves: mitral, tricuspid, aortic, or  pulmonary regurgitation.26
 
In order to compensate for its poor pumping action due to valvular stenosis/regurgitation, the cardiac muscle thickens or enlarges, with serious reduction to its elasticity and thus efficiency. In some  cases, this pooling of blood in the cardiac chambers can result in clotting of blood, thus increasing the risk of patients suffering from either pulmonary embolism or even cardiovascular accidents such  as stroke.22,24 
 
Types of Valvular Heart Disease
• Aortic regurgitation
• Aortic stenosis
• Infective endocarditis
• Mitral regurgitation
• Mitral stenosis
• Mitral valve prolapse
• Primary pulmonary hypertension
• Pulmonic regurgitation
• Pulmonic stenosis
• Pulmonic valvular stenosis
• Rheumatic fever
• Tricuspid regurgitation
• Tricuspid stenosis 
 
Infective Endocarditis
Infective endocarditis (IE) or bacterial endocarditis (BE) is “an infection caused by bacteria that enter the bloodstream and settle in the heart lining, a heart valve, or a blood vessel”.1,12 IE is  expected to produce a wide range of systemic signs and symptoms through number of different mechanisms, which include “both sterile and infected emboli and various immunological phenomena”.25-27
 
Etiology
Of cases of identified IE, 80% to 90% are caused by streptococci and staphylococci.46 
 
Epidemiology
In the United States, the incidence of IE is approximately two to four cases per 100,000 persons per year. This rate has not changed in the past 50 years.25-27 
 
Signs and Symptoms
The severity of the presenting symptoms seems not to have any exact correlation with the severity of the underlying cardiac valvular disorder. It can range from slow and gradual to much quicker development and sudden presentation of symptoms, possibly depending upon the progression of the disease and adjustment by the cardiac muscles to reduce its impact. However, some major  valvular conditions present with no severe consequences or manifest as life-threatening even from a gentle leak in one of the valves. 
 
The most common symptoms associated with IE are:
• Fatigue with aching joints and muscles
• Night sweats
• Chills and fever
• Shortness of breath
• Paleness
• Persistent cough
• Swelling in feet, legs, or abdomen
• Unexplained weight loss
• Red, tender spots under the skin of fingers, also known as Osler’s nodes27,29
 
Dental Consideration
For a long time, the American Heart Association (AHA) and the American Dental Association (ADA) recommended that patients with certain heart conditions should be provided with antibiotic  prophylaxis shortly before any dental treatment in order to prevent any chances of infective endocarditis. However, a statement was released and new revised guidelines were introduced by the AHA  in 2008 which state that patients with a history of only selected cardiac disorders need to have antibiotic prophylaxis before dental procedures. 
 
The purpose of the statement was to update the recommendations by the AHA, last published in 1997, for the prevention of infective endocarditis. The major changes in the updated recommendations include the following: 
• Only a small number of IE cases were preventable by antibiotic prophylaxis even with 100% effect by the medication
• Antibiotics should be prescribed only for patients who are at the highest risk of adverse outcomes from IE 
• Antibiotic prophylaxis should be provided to patients who undergo any perforation of the oral mucosa or manipulation of the gingival tissue/periapical region 
• Lifetime risk of acquisition of IE does not qualify for any prophylaxis 
• Patients with history of genitourinary or gastrointestinal tract procedures were not recommended for any antibiotic coverage.30 
 
Preventive antibiotics prior to a dental procedure are advised for patients with:
• Artificial heart valves
• History of infective endocarditis
• Certain specific, serious congenital (present from birth) heart conditions, including unrepaired or incompletely repaired cyanotic congenital heart disease, including: 
- Those with palliative shunts and conduits
- A completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure 
- Any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device 
• A cardiac transplant that develops a problem in a heart valve 
 
The new recommendations apply to many dental procedures, including teeth cleaning and extractions. Patients were advised to consult their cardiologists for more information regarding their specific category and their requirements for antibiotic prophylaxis before dental procedures.30,31
 
Dental procedures for which prophylaxis is not advised: 
• Routine anesthetic injections through non-infected tissue
• Taking dental radiographs 
• Placement of removable prosthodontic or orthodontic appliances
• Adjustment of orthodontic appliances
• Shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa.1
 
Conclusion/Summary
Part two of this article will deal with diabetes, stroke and breathing problems.
 
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*Dr. Grover is a Senior Dental Fellow, University of Minnesota School of Dentistry, and Walker Dental Clinic, Walker Methodist Health Center, Minneapolis, MN. 
*Dr. Rhodus is professor and Director, Division of Oral Medicine, School of Dentistry, and adjunct professor, Department of Otolaryngology, School of Medicine, University of Minnesota, Minneapolis, 
MN 55455.