Dental Treatment may provoke an angina attach or an MI.
In all cases liaison with the patient’s doctor is sensible.
Take a detailed history and record all medication prescribed.
The practitioner’s responsibility to a patient with a history of angina is to use all available preventive measures, thereby reducing the possibility that the Clinical/Surgical procedures will precipitate an anginal episode.
Preventive measures begin with taking a careful history of the patient’s angina.
The patient should be questioned about:
- The events that produce angina
- Frequency
- Duration
- Severity
- Response to medications or diminished activity
Management For General Dental Treatment:
- Stable angina (angina of exertion)
- It is predictable; it occurs under reproductive conditions, respond to rest and medication.
- Stable angina represents an ASA III risk.
- Any factor, such as anxiety or inadequate pain control, that increase myocardial oxygen requirements may provoke an anginal episode.
- The judicious use of vasopressors in local anesthetics is NOT contraindicated in stable angina
- Patients with stable angina CAN be treated in dental practice under adequate local anesthesia (2% lidocaine with adrenaline 1:80000)
- It is good practice to request that the patient takes their GTN (Glyceryl Trinitrate) before you commence treatment, avoid prolonged procedures and minimize stress.
- Unstable angina (preinfarction angina)
- Occurs in an unpredictable manner, it may get progressively worse and occur at rest.
- Unstable angina represents an ASA IV risk
- The ASA IV cardiovascular risk patient in NOT a candidate for vasopressor or elective dental care.
- Patients with unstable angina should not be treated until their condition has been brought under-control.
- These patients should be referred to their doctor for management.
- Rarely, Patients may suffer with decubitis angina which is brought on by lying flat.
There patients must not be treated supine.
Management for Oral and Maxillofacial surgery:
If the patient’s angina arises only during moderately vigorous exertion and responds readily to oral nitroglycerin administration, and if no recent increase in severity has occurred, ambulatory oral surgery procedures are usually safe when performed with proper precautions…- However, if anginal episodes occur with only minimal exertion, if several doses of nitoglycerin are needed to relieve chest discomfort, or if the patient has unstable angina elective surgery should be deferred until a medical consultation is obtained.
Once the decision is made that ambulatory elective oral surgery can safely proceed, the patient should be prepared for surgery and the patient’s myocardial oxygen demand should be lowered or prevented from rising.
The increased oxygen demand during ambulatory oral surgery is the result primarily of patient’s anxiety. An anxiety reduction protocol should therefor be used.
In addition, during surgery that patient can be given supplemental oxygen and can be premedicated with nitroglycerin (if the patient is extremely pron to angina).
Profound local anesthesia is the best means of limiting patient anxiety.
Although some controversy exists over the use of local anesthetics containing epinephrine in patients with angina, the benefits (e.g, prolonged and accentuated anesthesia) outweigh the risks.
However, care should be taken to avoid excessive epinephrine administration by using proper injection techniques.
Some clinicians also advise giving no more that 4ml of a local anesthetic solution with a 1:100000 concentration of epinephrine for a total adult dose of 0,04 mg in any 30 minute period.
Before and during surgery, vital signs should be monitored periodically. In addition, regular verbal contact with the patient should be maintained.
The use of nitrous oxide or other conscious sedation methods for anxiety control in patients with ischemic heart disease should be considered.
Fresh nitroglycerin should be nearby for use if necessary.
The introduction of balloon-tipped catheters into narrowed coronary arteries for the purpose of reestablishing adequate blood flow and stenting arteries open is becoming common-place.
If the angioplasty has been successful (based on cardiac stress testing), oral surgery can proceed soon thereafter, with the same precautions as those used for patients with angina.
Management of Patient with History of Angina Pectoris:
- Consult patient’s physician
- Use an anxiety reduction protocol
- Have nitroglycerin tablets or spray readily available. Use nitroglycerin pre-medication if indicated
- Administer supplemental oxygen
- Ensure profound local anesthesia before starting surgery
- Consider use of Nitrous oxide sedation
- Monitor vital signs closely
- Consider possible limitation of amount of epinephrine used (0,04mg MAXIMUM)
- Maintain verbal contact with patient throughout procedure to monitor status
Sources:
- Contemporary Oral and Maxillofacial Surgery, 5th Edition
Hupp. Ellis III. Tucker - Handbook of Local Anesthesia 5th Edition Stanley F. Malamed
- Essential Human Disease for Dentists
Sproat. Burke. McGurk - Pharmacology and Dental Therapeutics, 3rd Edition
Seymour. Meechan. Yates
