The Patient with a Cardiovascular Disease










The Patient with a
Cardiovascular Disease
Dianne Smallidge, RDH, MDH and Esther M. Wilkins, BS, RDH, DMD
CLASSIFICATION
INFECTIVE ENDOCARDITIS
I. Description
II. Etiology
III. Disease Process
IV. Prevention
CONGENITAL HEART DISEASES
I. The Normal Healthy Heart
II. Anomalies
III. Etiology
IV. Types of Defects
V. Prevention
VI. Clinical Considerations
RHEUMATIC HEART DISEASE
I. Rheumatic Fever
II. The Course of Rheumatic Heart Disease
MITRAL VALVE PROLAPSE
I. Description
II. Symptoms
HYPERTENSION
I. Etiology
II. Blood Pressure Levels
III. Clinical Symptoms of Hypertension
IV. Treatment
V. Hypertension in Children
ISCHEMIC HEART DISEASE
I. Etiology
II. Manifestations of Ischemic Heart Disease
ANGINA PECTORIS
I. Precipitating Factors
II. Treatment
III. Procedure During an Angina Attack
MYOCARDIAL INFARCTION
I. Etiology
II. Symptoms
III. Management During an Attack
IV. Treatment After Acute Symptoms
HEART FAILURE
I. Etiology
II. Clinical Manifestations
III. Treatment During Chronic Stages
IV. Emergency Care for Heart Failure and Acute Pul-
monary Edema
LIFESTYLE MANAGEMENT FOR THE PATIENT
WITH CARDIOVASCULAR DISEASE
SURGICAL TREATMENT
I. Coronary Dilation
II. Coronary Bypass
III. Cardiac Pacemaker and Implantable Cardioverter
Defibrillators
ANTICOAGULANT THERAPY
I. Clinical Procedures
II. Postprocedural Instructions
CARDIAC SURGERY
I. Presurgical
II. Postsurgical
DOCUMENTATION
EVERYDAY ETHICS
FACTORS TO TEACH THE PATIENT
REFERENCES
CHAPTER OUTLINE
67
LEARNING OBJECTIVES
After studying this chapter, the student will be able to:
1. Identify the cardiovascular conditions that may be
encountered in patients seeking oral health care.
2. Discuss the etiology, symptoms and risk factors associated
with cardiovascular conditions.
3. Discuss the impact of cardiovascular diseases on the oral
cavity and their relationship to oral health.
4. Plan dental hygiene treatment modifications for the
patient with cardiovascular disease.
Wilkins9781451193114-ch067.indd 1129 07/10/15 11:39 AM

1130 SECTION IX | Patients with Special Needs
Cardiovascular includes diseases of the heart and blood
vessels.
Patients with cardiovascular conditions are encoun-
tered frequently in a dental office or clinic and may be
from any age group, although the highest incidence is
among older people.
Although a causal relationship between periodontal
disease and coronary heart disease (CHD) has not been
proven, current data suggest the presence of periodon-
tal disease may be a marker for CHD risk.¹
Dental hygienists need to take responsibility to inform
patients of the significant relationship between oral and
systemic health and the related need for maintenance of
healthy oral tissues and prevention of periodontal disease.
The major cardiovascular diseases are included in this
chapter with their principle symptoms and treatments
as well as applications for dental hygiene care.
Key words and terminology are defined in Box 67-1.
Prefixes and suffixes to clarify the terminology are listed
in Appendix VII.
Aneurysm: sac formed by the localized dilatation of the wall
of an artery, a vein, or the heart.
Angina: a condition marked by spasmodic suffocative attacks.
Angina pectoris: acute pain in the chest from decreased
blood supply to the heart muscle.
Anoxia: absence of oxygen in the tissues; may be accompa-
nied by deep respirations, cyanosis, increased pulse rate,
and impairment of coordination.
Anticoagulant: a substance that suppresses, delays, or nulli-
fies coagulation of the blood.
Apnea: temporary cessation of breathing.
Arrhythmia: variation from the normal rhythm, especially
with reference to the heart.
Arthralgia: joint pain.
Arterial blood: oxygenated blood carried by an artery away
from the heart to nourish the body tissues.
Arteriosclerosis: group of diseases characterized by thicken-
ing and loss of elasticity of the arterial wall.
Asphyxia: a condition in which there is a deficiency of oxy-
gen in the blood and an increase in carbon dioxide.
Atheroma: lipid (cholesterol) deposit on the intima (lining) of
an artery; also called atheromatous plaque.
Atherosclerosis: disease process caused by the deposit of
atheromas on the inner lining of arteries that results in the
obstruction of blood flow.
Bradycardia: slowness of heartbeat with slowing of pulse
rate to less than 60 per minute.
Coronary heart disease: narrowing of the arteries that sup-
ply blood and oxygen to the heart caused by the buildup
of plaque in the arteries.
Cyanosis: bluish discoloration of the skin and mucous mem-
branes caused by excess concentration of reduced hemo-
globin in the blood.
Diaphoresis: profuse perspiration.
Dyspnea: labored or difficult breathing.
Echocardiography: recording of the position and motion
of the heart walls and internal structures of the heart and
neighboring tissue by the echo obtained from beams of
ultrasonic waves directed through the chest wall; used to
show valvular and other structural deformities; the record
produced is called an echocardiogram.
Edema: abnormal accumulation of fluid in the intercellular
spaces of the body.
Electrocardiography: the graphic recording from the
body surface of the potential of electric currents
generated by the heart as a means of studying the ac-
tion of the heart muscle; the record produced is called an
electrocardiogram.
Embolism: the sudden blocking of an artery by a clot of for-
eign material, an embolus, that has been brought to its site
of lodgment by the bloodstream; the embolus may be a
blood clot (most frequently) or an air bubble, a clump of
bacteria, or a fat globule.
Epistaxis: bleeding from the nose.
Heparin: anticoagulant; prevents platelet agglutination and
thrombus formation.
Hypoxia: diminished availability of oxygen to blood tissues.
Infarct: localized area of ischemic necrosis produced by oc-
clusion of the arterial supply or venous drainage of the
part.
Ischemia: deficiency of blood to supply oxygen in part result-
ing from functional constriction or actual obstruction of a
blood vessel.
Lumen: the cavity or channel within a tube or tubular organ,
such as a blood vessel or the intestine.
Murmur: irregularity of heartbeat caused by a turbulent flow
of blood through a valve that has failed to close.
Myocardium: the middle and thickest layer of the heart wall,
composed of cardiac muscle.
Occlusion: blockage; state of being closed.
Prolapse: when an organ falls out of its normal position due
to lack of support from ligaments and muscles.
Restenosis: recurrent stenosis.
Sclerosis: induration, hardening.
Shunt: abnormal communication between chambers or
blood vessels; verb, to bypass, divert.
Stenosis: narrowing or contraction of a body passage or
opening.
Tachycardia: abnormally rapid heart rate, usually taken to be
over 100 beats per minute.
Tetralogy: a group or series of four.
Tetralogy of fallot: congenital, cyanotic malformation of the
heart that includes pulmonary stenosis, ventricular septal
defect, hypertrophy of the right ventricle, and dextroposi-
tion of the aorta.
Thrombus: blood clot attached to the intima of a blood ves-
sel; may occlude the lumen; contrast with embolus, which
is detached and carried by the bloodstream.
Venous blood: nonoxygenated blood from the tissues; blood
pumped from the heart to the lungs for oxygenation.
BOX 67-1 KEY WORDS: Cardiovascular Diseases
Wilkins9781451193114-ch067.indd 1130 07/10/15 11:39 AM

CHAPTER 67 | The Patient with a Cardiovascular Disease 1131
CLASSIFICATION
Anatomic classification
• Diseases of the heart: pericardium, myocardium, en-
docardium, heart valves
• Diseases of the blood vessels and peripheral circulation
Etiologic classification
• Congenital anomalies
• Atherosclerosis, hypertension
• Infectious agents, immunologic mechanisms
INFECTIVE ENDOCARDITIS (IE)
2,3,4
Infective Endocarditis (IE) is a microbial infection of the
heart valves or endocardium with a high mortality rate.
I. Description
IE is a serious disease, the prognosis of which depends
on the degree of cardiac damage, the valves involved,
the duration of the infection, and the treatment.
IE is characterized by the formation of bacterial vegeta-
tions on the heart valves or surface of the heart lining
(endocardium).
When IE develops, it directly affects the function of the
heart.
II. Etiology
Microorganisms
• Streptococci and staphylococci are responsible for
IE in most cases, with alpha-hemolytic streptococci
being the most prevalent.
• As yeast, fungi, and viruses have been implicated,
the choice of the name “infective” endocarditis is
more inclusive than “bacterial” endocarditis.
• Incidence related to dental procedures: The majority of
IE cases related to oral microflora are random bacte-
remias that are a result of routine daily activities. An
exceedingly small number of cases are believed to
result from dental procedures.
Risk factors
• Preexisting cardiac abnormalities: Bacteria lodge on the
endocardial (valvular) surface during bacteremia.
• Prosthetic (artificial) heart valves: There is an increased
number of patients who have had valve replacement
surgery who are susceptible. Patients who have had
prosthetic valve replacements have a risk of devel-
oping prosthetic valve endocarditis.
• History of previous endocarditis.
• Intravenous drug abuse. Infected material is injected
by contaminated needles directly into the blood-
stream. Intravenous drug abusers are at high risk for
endocarditis, which can initiate on previously nor-
mal valves.
Precipitating factors
• Self-induced bacteremia: In the oral cavity, self-in-
duced bacteremias may result from eating, bruxism,
chewing gum, or any activity that can force bacteria
through the wall of a diseased sulcus or pocket. In-
terdental aids for oral hygiene can also cause self-
induced bacteremia.
• Infection at portals of entry: Infections at sites where
microorganisms may enter the circulating blood
provide a constant source of potential infectious mi-
croorganisms. In the oral cavity, organisms enter the
blood by way of periodontal and gingival pockets,
where multitudes of many species of microorgan-
isms are harbored. An open area of infection, such
as an ulcer caused by an ill-fitting denture, may also
provide a site of entry. Patients are exposed daily to
bacteremias.
• Trauma to tissues by instrumentation: Bacteremias are
created during general or oral surgery, endodontic
procedures, periodontal therapy, scaling, and any
therapy that causes bleeding.
III. Disease Process
2
Transient bacteremia initiated
• Trauma to a mucosal surface such as the gingival sul-
cus during instrumentation releases bacteria into the
bloodstream.
• Ease of entry of organisms directly relates to the se-
verity of tissue trauma, quantity of bacterial biofilm,
and the severity of inflammation or infection such
as periodontitis.
Bacterial adherence
• Circulating microorganisms attach to a damaged
heart valve, prosthetic valve, or other susceptible
area on the endocardium.
Proliferation of bacteria
• Microorganisms proliferate to form vegetative le-
sions containing masses of plasma cells, fibrin, and
bacteria.
• Heart valve becomes inflamed; function is
diminished.
• Clumps of microorganisms (emboli) may break off
and spread by way of the general circulation (embo-
lism); complications result.
Clinical course
• A small number of patients are symptomatic within
2 days, but usually symptoms appear within 2 weeks.
• Severe symptoms of fever, loss of appetite and
weight loss, weakness, arthralgia, and heart murmurs
require hospitalization. Diagnosis is based on symp-
toms, echocardiography, blood cell count, and posi-
tive blood cultures.
• Complications lead to eventual susceptibility to re-
infection with IE, congestive heart failure, and cere-
brovascular disease.
Wilkins9781451193114-ch067.indd 1131 07/10/15 11:39 AM

1132 SECTION IX | Patients with Special Needs
IV. Prevention
The basic areas for attention in dental and dental hygiene
care that contribute to the prevention of IE are shown in
Box 67-2.
Patient history
• Special content: Specific questions need to be directed
to elicit any history of congenital heart defects, car-
diac transplant, presence of prosthetic valves, ac-
quired valvular defects, or previous episode of IE.
• Consultation with patient’s physician: Consultation can
be assumed necessary for all patients with a history
of heart defects, and any other condition suggesting
the need for prophylactic antibiotic premedication.
• Withhold instrumentation: The use of a probe or ex-
plorer during assessment of the patient is withheld
until the medical status is cleared.
Prophylactic antibiotic premedication
• Recommended regimens: The current recommen-
dations of the American Heart Association are
followed.
3,4
• Boxes 10-2 and 10-3 and Table 10-4 include the spe-
cific information in Chapter 10.
• When premedication is indicated, question the pa-
tient at the time of the appointment to verify the an-
tibiotic was taken on schedule. In the patient record,
document the name of the antibiotic, time, and dos-
age taken by the patient.
Dental hygiene care
• Oral health: Maintenance of a high degree of oral
health is necessary for each patient susceptible to IE.
• Education: Instruction in oral self-care such as brush-
ing and flossing at initial appointments can be pro-
vided while the patient is under antibiotic coverage.
• Sequence of treatment: Biofilm removal instruction pre-
cedes instrumentation for scaling to bring the tissues
to a healthy state. The more severe the gingival or
periodontal inflammation, the higher the incidence
of bacteremia during and following instrumentation.
• Instrumentation: Reduce the microbial population
about the teeth and on the oral mucosa prior to
instrumentation by having the patient brush, floss,
and rinse thoroughly with an antimicrobial mouth
rinse such as 0.12% chlorhexidine.
CONGENITAL HEART DISEASES
5,6
I. The Normal Healthy Heart
A diagram of the normal heart is shown in Figure 67-1 to
provide a comparison with the anatomic changes that
may appear in a defective heart.
In the healthy heart, the blood flows in one direction as
each chamber contracts, with the valves acting as trap
doors that snap shut after each contraction to prevent
backflow of blood.
The right side of the heart contains deoxygenated
blood from the body cells on its way to the lungs for
reoxygenation. The left side of the heart contains oxy-
genated blood from the lungs being pumped out to the
aorta on its way to the cells of the body. The septal wall
divides the left and right sides of the heart.
II. Anomalies
Anomalies of the anatomic structure of the heart or
major blood vessels result following irregularities of de-
velopment during the first 9 weeks in utero.
The fetal heart is completely developed by the 9th week.
Early diagnosis is necessary, but not all defects require
treatment.
Treatment usually involves surgical correction.
III. Etiology
Causes may be genetic, environmental, or a combination
of both. Many are unknown.
Identification of risk patients
Medical and personal history
Consultation with physician
Prophylactic antibiotic coverage during appointments
Upgrading and maintenance of the patient’s oral health
Personal: daily dental biofilm removal
Professional: supervision, instruction, and motivation
Prevention of Infective Endocarditis
BOX 67-2
FIGURE 67-1 The Normal Heart. The major vessels and the location of the tricuspid,
pulmonary, aortic, and mitral valves are shown.
Wilkins9781451193114-ch067.indd 1132 07/10/15 11:39 AM

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The Patient with a Cardiovascular DiseaseDianne Smallidge, RDH, MDH and Esther M. Wilkins, BS, RDH, DMDCLASSIFICATIONINFECTIVE ENDOCARDITIS I. Description II. Etiology III. Disease Process IV. PreventionCONGENITAL HEART DISEASES I. The Normal Healthy Heart II. Anomalies III. Etiology IV. Types of Defects V. Prevention VI. Clinical ConsiderationsRHEUMATIC HEART DISEASE I. Rheumatic Fever II. The Course of Rheumatic Heart DiseaseMITRAL VALVE PROLAPSE I. Description II. SymptomsHYPERTENSION I. Etiology II. Blood Pressure Levels III. Clinical Symptoms of Hypertension IV. Treatment V. Hypertension in ChildrenISCHEMIC HEART DISEASE I. Etiology II. Manifestations of Ischemic Heart DiseaseANGINA PECTORIS I. Precipitating Factors II. Treatment III. Procedure During an Angina AttackMYOCARDIAL INFARCTION I. Etiology II. Symptoms III. Management During an Attack IV. Treatment After Acute SymptomsHEART FAILURE I. Etiology II. Clinical Manifestations III. Treatment During Chronic Stages IV. Emergency Care for Heart Failure and Acute Pul-monary EdemaLIFESTYLE MANAGEMENT FOR THE PATIENT WITH CARDIOVASCULAR DISEASESURGICAL TREATMENT I. Coronary Dilation II. Coronary Bypass III. Cardiac Pacemaker and Implantable Cardioverter DefibrillatorsANTICOAGULANT THERAPY I. Clinical Procedures II. Postprocedural InstructionsCARDIAC SURGERY I. Presurgical II. PostsurgicalDOCUMENTATIONEVERYDAY ETHICSFACTORS TO TEACH THE PATIENTREFERENCESCHAPTER OUTLINE67LEARNING OBJECTIVESAfter studying this chapter, the student will be able to:1. Identify the cardiovascular conditions that may be encountered in patients seeking oral health care.2. Discuss the etiology, symptoms and risk factors associated with cardiovascular conditions.3. Discuss the impact of cardiovascular diseases on the oral cavity and their relationship to oral health.4. Plan dental hygiene treatment modifications for the patient with cardiovascular disease.Wilkins9781451193114-ch067.indd 1129 07/10/15 11:39 AM 1130 SECTION IX | Patients with Special NeedsCardiovascular includes diseases of the heart and blood vessels. ▶ Patients with cardiovascular conditions are encoun-tered frequently in a dental office or clinic and may be from any age group, although the highest incidence is among older people. ▶ Although a causal relationship between periodontal disease and coronary heart disease (CHD) has not been proven, current data suggest the presence of periodon-tal disease may be a marker for CHD risk.¹ ▶ Dental hygienists need to take responsibility to inform patients of the significant relationship between oral and systemic health and the related need for maintenance of healthy oral tissues and prevention of periodontal disease. ▶ The major cardiovascular diseases are included in this chapter with their principle symptoms and treatments as well as applications for dental hygiene care. ▶ Key words and terminology are defined in Box 67-1. Prefixes and suffixes to clarify the terminology are listed in Appendix VII.Aneurysm: sac formed by the localized dilatation of the wall of an artery, a vein, or the heart.Angina: a condition marked by spasmodic suffocative attacks.Angina pectoris: acute pain in the chest from decreased blood supply to the heart muscle.Anoxia: absence of oxygen in the tissues; may be accompa-nied by deep respirations, cyanosis, increased pulse rate, and impairment of coordination.Anticoagulant: a substance that suppresses, delays, or nulli-fies coagulation of the blood.Apnea: temporary cessation of breathing.Arrhythmia: variation from the normal rhythm, especially with reference to the heart.Arthralgia: joint pain.Arterial blood: oxygenated blood carried by an artery away from the heart to nourish the body tissues.Arteriosclerosis: group of diseases characterized by thicken-ing and loss of elasticity of the arterial wall.Asphyxia: a condition in which there is a deficiency of oxy-gen in the blood and an increase in carbon dioxide.Atheroma: lipid (cholesterol) deposit on the intima (lining) of an artery; also called atheromatous plaque.Atherosclerosis: disease process caused by the deposit of atheromas on the inner lining of arteries that results in the obstruction of blood flow.Bradycardia: slowness of heartbeat with slowing of pulse rate to less than 60 per minute.Coronary heart disease: narrowing of the arteries that sup-ply blood and oxygen to the heart caused by the buildup of plaque in the arteries.Cyanosis: bluish discoloration of the skin and mucous mem-branes caused by excess concentration of reduced hemo-globin in the blood.Diaphoresis: profuse perspiration.Dyspnea: labored or difficult breathing.Echocardiography: recording of the position and motion of the heart walls and internal structures of the heart and neighboring tissue by the echo obtained from beams of ultrasonic waves directed through the chest wall; used to show valvular and other structural deformities; the record produced is called an echocardiogram.Edema: abnormal accumulation of fluid in the intercellular spaces of the body.Electrocardiography: the graphic recording from the body surface of the potential of electric currents generated by the heart as a means of studying the ac-tion of the heart muscle; the record produced is called an electrocardiogram.Embolism: the sudden blocking of an artery by a clot of for-eign material, an embolus, that has been brought to its site of lodgment by the bloodstream; the embolus may be a blood clot (most frequently) or an air bubble, a clump of bacteria, or a fat globule.Epistaxis: bleeding from the nose.Heparin: anticoagulant; prevents platelet agglutination and thrombus formation.Hypoxia: diminished availability of oxygen to blood tissues.Infarct: localized area of ischemic necrosis produced by oc-clusion of the arterial supply or venous drainage of the part.Ischemia: deficiency of blood to supply oxygen in part result-ing from functional constriction or actual obstruction of a blood vessel.Lumen: the cavity or channel within a tube or tubular organ, such as a blood vessel or the intestine.Murmur: irregularity of heartbeat caused by a turbulent flow of blood through a valve that has failed to close.Myocardium: the middle and thickest layer of the heart wall, composed of cardiac muscle.Occlusion: blockage; state of being closed.Prolapse: when an organ falls out of its normal position due to lack of support from ligaments and muscles.Restenosis: recurrent stenosis.Sclerosis: induration, hardening.Shunt: abnormal communication between chambers or blood vessels; verb, to bypass, divert.Stenosis: narrowing or contraction of a body passage or opening.Tachycardia: abnormally rapid heart rate, usually taken to be over 100 beats per minute.Tetralogy: a group or series of four.Tetralogy of fallot: congenital, cyanotic malformation of the heart that includes pulmonary stenosis, ventricular septal defect, hypertrophy of the right ventricle, and dextroposi-tion of the aorta.Thrombus: blood clot attached to the intima of a blood ves-sel; may occlude the lumen; contrast with embolus, which is detached and carried by the bloodstream.Venous blood: nonoxygenated blood from the tissues; blood pumped from the heart to the lungs for oxygenation.BOX 67-1 KEY WORDS: Cardiovascular DiseasesWilkins9781451193114-ch067.indd 1130 07/10/15 11:39 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1131CLASSIFICATION ▶ Anatomic classification• Diseases of the heart: pericardium, myocardium, en-docardium, heart valves• Diseases of the blood vessels and peripheral circulation ▶ Etiologic classification• Congenital anomalies• Atherosclerosis, hypertension• Infectious agents, immunologic mechanismsINFECTIVE ENDOCARDITIS (IE)2,3,4Infective Endocarditis (IE) is a microbial infection of the heart valves or endocardium with a high mortality rate.I. Description ▶ IE is a serious disease, the prognosis of which depends on the degree of cardiac damage, the valves involved, the duration of the infection, and the treatment. ▶ IE is characterized by the formation of bacterial vegeta-tions on the heart valves or surface of the heart lining (endocardium). ▶ When IE develops, it directly affects the function of the heart.II. Etiology ▶ Microorganisms• Streptococci and staphylococci are responsible for IE in most cases, with alpha-hemolytic streptococci being the most prevalent.• As yeast, fungi, and viruses have been implicated, the choice of the name “infective” endocarditis is more inclusive than “bacterial” endocarditis.• Incidence related to dental procedures: The majority of IE cases related to oral microflora are random bacte-remias that are a result of routine daily activities. An exceedingly small number of cases are believed to result from dental procedures. ▶ Risk factors• Preexisting cardiac abnormalities: Bacteria lodge on the endocardial (valvular) surface during bacteremia.• Prosthetic (artificial) heart valves: There is an increased number of patients who have had valve replacement surgery who are susceptible. Patients who have had prosthetic valve replacements have a risk of devel-oping prosthetic valve endocarditis.• History of previous endocarditis.• Intravenous drug abuse. Infected material is injected by contaminated needles directly into the blood-stream. Intravenous drug abusers are at high risk for endocarditis, which can initiate on previously nor-mal valves. ▶ Precipitating factors• Self-induced bacteremia: In the oral cavity, self-in-duced bacteremias may result from eating, bruxism, chewing gum, or any activity that can force bacteria through the wall of a diseased sulcus or pocket. In-terdental aids for oral hygiene can also cause self-induced bacteremia.• Infection at portals of entry: Infections at sites where microorganisms may enter the circulating blood provide a constant source of potential infectious mi-croorganisms. In the oral cavity, organisms enter the blood by way of periodontal and gingival pockets, where multitudes of many species of microorgan-isms are harbored. An open area of infection, such as an ulcer caused by an ill-fitting denture, may also provide a site of entry. Patients are exposed daily to bacteremias.• Trauma to tissues by instrumentation: Bacteremias are created during general or oral surgery, endodontic procedures, periodontal therapy, scaling, and any therapy that causes bleeding.III. Disease Process2 ▶ Transient bacteremia initiated• Trauma to a mucosal surface such as the gingival sul-cus during instrumentation releases bacteria into the bloodstream.• Ease of entry of organisms directly relates to the se-verity of tissue trauma, quantity of bacterial biofilm, and the severity of inflammation or infection such as periodontitis. ▶ Bacterial adherence• Circulating microorganisms attach to a damaged heart valve, prosthetic valve, or other susceptible area on the endocardium. ▶ Proliferation of bacteria• Microorganisms proliferate to form vegetative le-sions containing masses of plasma cells, fibrin, and bacteria.• Heart valve becomes inflamed; function is diminished.• Clumps of microorganisms (emboli) may break off and spread by way of the general circulation (embo-lism); complications result. ▶ Clinical course• A small number of patients are symptomatic within 2 days, but usually symptoms appear within 2 weeks.• Severe symptoms of fever, loss of appetite and weight loss, weakness, arthralgia, and heart murmurs require hospitalization. Diagnosis is based on symp-toms, echocardiography, blood cell count, and posi-tive blood cultures.• Complications lead to eventual susceptibility to re-infection with IE, congestive heart failure, and cere-brovascular disease.Wilkins9781451193114-ch067.indd 1131 07/10/15 11:39 AM 1132 SECTION IX | Patients with Special NeedsIV. PreventionThe basic areas for attention in dental and dental hygiene care that contribute to the prevention of IE are shown in Box 67-2. ▶ Patient history• Special content: Specific questions need to be directed to elicit any history of congenital heart defects, car-diac transplant, presence of prosthetic valves, ac-quired valvular defects, or previous episode of IE.• Consultation with patient’s physician: Consultation can be assumed necessary for all patients with a history of heart defects, and any other condition suggesting the need for prophylactic antibiotic premedication.• Withhold instrumentation: The use of a probe or ex-plorer during assessment of the patient is withheld until the medical status is cleared. ▶ Prophylactic antibiotic premedication• Recommended regimens: The current recommen-dations of the American Heart Association are followed.3,4• Boxes 10-2 and 10-3 and Table 10-4 include the spe-cific information in Chapter 10.• When premedication is indicated, question the pa-tient at the time of the appointment to verify the an-tibiotic was taken on schedule. In the patient record, document the name of the antibiotic, time, and dos-age taken by the patient. ▶ Dental hygiene care• Oral health: Maintenance of a high degree of oral health is necessary for each patient susceptible to IE.• Education: Instruction in oral self-care such as brush-ing and flossing at initial appointments can be pro-vided while the patient is under antibiotic coverage.• Sequence of treatment: Biofilm removal instruction pre-cedes instrumentation for scaling to bring the tissues to a healthy state. The more severe the gingival or periodontal inflammation, the higher the incidence of bacteremia during and following instrumentation.• Instrumentation: Reduce the microbial population about the teeth and on the oral mucosa prior to instrumentation by having the patient brush, floss, and rinse thoroughly with an antimicrobial mouth rinse such as 0.12% chlorhexidine.CONGENITAL HEART DISEASES5,6I. The Normal Healthy Heart ▶ A diagram of the normal heart is shown in Figure 67-1 to provide a comparison with the anatomic changes that may appear in a defective heart. ▶ In the healthy heart, the blood flows in one direction as each chamber contracts, with the valves acting as trap doors that snap shut after each contraction to prevent backflow of blood. ▶ The right side of the heart contains deoxygenated blood from the body cells on its way to the lungs for reoxygenation. The left side of the heart contains oxy-genated blood from the lungs being pumped out to the aorta on its way to the cells of the body. The septal wall divides the left and right sides of the heart.II. Anomalies ▶ Anomalies of the anatomic structure of the heart or major blood vessels result following irregularities of de-velopment during the first 9 weeks in utero. ▶ The fetal heart is completely developed by the 9th week. ▶ Early diagnosis is necessary, but not all defects require treatment. ▶ Treatment usually involves surgical correction.III. EtiologyCauses may be genetic, environmental, or a combination of both. Many are unknown. ▷ Identification of risk patients ▷ Medical and personal history ▷ Consultation with physician ▷ Prophylactic antibiotic coverage during appointments ▷ Upgrading and maintenance of the patient’s oral health ▷ Personal: daily dental biofilm removal ▷ Professional: supervision, instruction, and motivationPrevention of Infective EndocarditisBOX 67-2FIGURE 67-1 The Normal Heart. The major vessels and the location of the tricuspid, pulmonary, aortic, and mitral valves are shown.Wilkins9781451193114-ch067.indd 1132 07/10/15 11:39 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1133 ▶ Genetic• Heredity is apparent in some types of defects.• An example of a chromosomal defect is Down syn-drome, in which congenital heart anomalies occur frequently (described in Chapter 61). ▶ Environmental• Most congenital anomalies originate between the 5th and 8th weeks of fetal life, when the heart is developing.• Viral infections from the mother (rubella, cytomegalovirus).• Drugs (thalidomide; isotretinoin).• Drinking alcohol and use of cocaine.• Exposure to industrial chemical solvents.IV. Types of Defects4 ▶ The types of heart defects that occur most frequently are the ventricular septal defect, atrial septal defect, pulmonary stenosis, and patent ductus arteriosis. ▶ Defects (openings) in the septal wall cause a mixing of oxygenated and deoxygenated blood. ▶ Atrial and/or ventricular septal defects result in mixing of the blood from the left and right sides of the heart. ▶ Other defects include a passageway between the great arteries and veins, which also causes mixing of oxygen-ated and deoxygenated blood. Two of the more com-mon congenital heart defects are described here. ▶ Ventricular septal defect• In this type of defect, the left and right ventricles exchange blood through an opening in their divid-ing wall (septum).• The oxygenated blood from the lung, which is normally pumped by the left ventricle to the aorta and then to the entire body, can pass across to the right ventricle through the septal defect, as shown in Figure 67-2.• The severity of symptoms is directly related to the specific location and size of the defect. Small defects may close without surgical correction. ▶ Patent ductus arteriosus• A patent ductus arteriosus means the passageway (shunt) is open between the two great arteries that arise from the heart, namely, the aorta and the pul-monary artery.• Normally, the opening closes during the first few weeks after birth.• When the opening does not close, blood from the aorta can pass back to the lungs, as shown in Figure67-3.• The heart compensates in the attempt to provide the body with oxygenated blood and becomes overburdened.V. Prevention6 ▶ Vaccination with rubella for women of childbearing age is highly advised for those not vaccinated in childhood FIGURE 67-2 Ventricular Septal Defect. The right and left ventricles are connected by an opening that permits oxygenated blood from the left ventricle to shunt across to the right ventricle and then recirculate to the lungs. Compare with Figure 67-1, in which the septum separates the ventricles.FIGURE 67-3 Patent Ductus Arteriosus. An open passageway between the aorta and the pulmonary artery permits oxygenated blood from the aorta to pass back into the lungs. Arrows show directions of flow through the patent ductus. Compare with normal anatomy in Figure 67-1.or those without confirmation of immunity by a labora-tory test. ▶ No medications, including over the counter and herbal medications, are to be taken during pregnancy without prior consultation with the physician. ▶ Avoid tobacco use at least 1 month before pregnancy and throughout the pregnancy.Wilkins9781451193114-ch067.indd 1133 07/10/15 11:40 AM 1134 SECTION IX | Patients with Special Needs ▶ Attain and maintain a healthy weight prior to pregnancy. ▶ Genetic counseling.VI. Clinical Considerations ▶ Signs and symptoms of congenital heart diseaseGeneral conditions that may influence patient manage-ment include:• Easy fatigue• Exertional dyspnea; fainting• Cyanosis of lips and nail beds• Poor growth and development• Heart murmurs• Congestive heart failure. ▶ Dental hygiene concerns• Prevention of IE: Certain defective heart valves are at risk for endocarditis from bacteremia produced during oral treatments. The American Heart As-sociation Recommendations for premedication are consulted for procedure with this group of patients.2• Elimination of oral disease: Maintenance of a high level of oral health.RHEUMATIC HEART DISEASE7Rheumatic heart disease is a complication following rheu-matic fever. A rather high percentage of patients with a his-tory of rheumatic fever have permanent heart valve damage.I. Rheumatic Fever ▶ Incidence• Frequency of this condition in developed countries has declined significantly in the last several decades and is not common in the United States.• Primarily effects children between ages of 5 and 15. ▶ Etiology• The onset of acute rheumatic fever usually appears 2–3 weeks after a beta-hemolytic group A strepto-coccal pharyngeal infection.• Rheumatic fever and rheumatic heart disease are believed to be immunologic disorders caused by sensitization to antigens of beta-hemolytic group A streptococci. ▶ Prevention• The persistence and severity of the pharyngeal infec-tion are significant factors in determining whether rheumatic fever follows.• Early diagnosis and treatment of streptococcal throat and pharyngeal infections are necessary. ▶ Symptoms of acute rheumatic fever• Low grade fever. • Abdominal pain.• Shortness of breath and chest pain related to cardiac issues.• Joint pain with arthritis present in ankles, knees, el-bows and wrists as well as joint swelling with redness and warmth.• Nosebleeds.• Skin rash on trunk and upper parts of the arms and legs or nodules on skin.• Emotional instability.• Muscle weakness with quick uncontrolled jerky movements affecting the face, feet, and hands.II. The Course of Rheumatic Heart DiseaseFollowing the acute stage of rheumatic fever, usually symptoms do not persist except the effects of the valvular deformity. ▶ Symptoms• Stenosis or incompetence of valves; most commonly, the aortic and mitral valves.• Heart murmur influenced by the amount of scarring of the valves and myocardium.• Cardiac arrhythmias.• Late symptoms include shortness of breath, mur-mur, angina pectoris, epistaxis, elevation of diastolic blood pressure, enlargement of the left ventricle, and increasing signs of congestive cardiac failure. ▶ Practice applications• The American Heart Association no longer recom-mends antibiotic prophylaxis prior to dental treat-ment for patients with this condition due to their minimal risk of developing IE.2MITRAL VALVE PROLAPSE8I. Description ▶ The mitral valve is between the left atrium and the left ventricle (Figure 67-1). ▶ Oxygenated blood from the lungs passes from the pul-monary vein into the left ventricle, where it is pumped through the aortic valve and into the aorta for distribu-tion to the body cells. ▶ When the mitral valve leaflets are damaged, the clo-sure is imperfect and oxygenated blood can backflow or regurgitate. ▶ Mitral valve prolapse is the most common disorder of the valve that causes regurgitation. ▶ The mitral valve is prolapsed (becomes misaligned) backwards into the atrium during systole.II. Symptoms ▶ Most patients with mitral valve prolapse are without symptoms. ▶ A small number of cases will have symptoms of palpi-tations, fatigue, atypical chest pain, and a late systolic murmur.Wilkins9781451193114-ch067.indd 1134 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1135 ▶ When there is more severe involvement, an increase in frequency of palpitations and progressive mitral regurgi-tation is apparent along with a systolic click and murmur. ▶ Initial suspicion for diagnosis of valvular heart disease is the recognition of a heart murmur. ▶ The American Heart Association no longer recom-mends antibiotic prophylaxis during dental treatment for patients with this condition.2HYPERTENSION9,10Hypertension means an abnormal elevation of arterial blood pressure. It has been called the “silent killer,” as one-third of people who have it do not have symptoms. It is a contributing risk factor in many vascular diseases, or it may be a result or an effect of underlying pathologic changes. ▶ Detection of blood pressure for dental and dental hy-giene patients has become an essential step in patient assessment prior to treatment. ▶ Early detection, with referral for additional diagnosis and treatment when indicated, can prove to be lifesav-ing for certain people. ▶ Knowledge of the health problems of patients is needed to ensure treatment is safe and risk of emergencies.I. EtiologyA. Primary or Essential Hypertension ▶ Incidence: Approximately 90% of all hypertension is primary or essential. ▶ Predisposing or risk factors: Combinations of the factors listed are more significant than any one alone. Risk fac-tors for atherosclerosis are interrelated. ▶ Tobacco use ▶ Heredity ▶ Overweight ▶ Race: The incidence is higher among African-Ameri-cans than among white Americans, the illness is more severe, and the mortality rate is higher at a younger age. ▶ Salt: Particularly in excess in the diet. ▶ Sex: Men are more affected before age 45 years; women slightly more than men in later years. ▶ Age: General increase from birth to age 20 years; levels off until 40 years of age; then a slow increase into older age. ▶ Environment: Environmental conditions that increase stress factors.B. Secondary HypertensionAbout 10% of all hypertension is secondary to other un-derlying medical conditions. In secondary hypertension, usually both systolic and diastolic blood pressures are el-evated. Examples of causes are: ▶ Oral contraceptives8• Oral contraceptives may elevate blood pressure and is more likely to occur in women who are over-weight, have a history of hypertension during preg-nancy, have a family history, or have mild kidney disease.• The combination of birth control pills and cigarette use may be especially dangerous for some women. ▶ Renal disease• Renal artery obstruction• Pyelonephritis• Renal failure ▶ Endocrine disorders• Hyperthyroidism• Diabetes• Cushing’s syndrome• Thyroid or parathyroid disease ▶ Medications• Decongestants• SteroidsII. Blood Pressure Levels ▶ Blood pressure is documented in the patient’s record as the systolic pressure reading over the diastolic pressure reading (systolic/diastolic). ▶ The systolic blood pressure is the pressure exerted against the arterial walls during the ventricular con-traction. It is altered by the cardiac output, resistance of the capillary bed, and volume and viscosity of the blood. ▶ The diastolic blood pressure is the pressure exerted by the blood within the arteries during the total resting resistance after the contraction of the left ventricle. ▶ Diseases can have an effect on any of these factors, al-tering the blood pressure. ▶ Blood pressure fluctuates, so the baseline blood pres-sure needs to be measured two or three times and the average reading entered in the patient’s record when hypertension is suspected.A. Normal and High Blood Pressure9Table 67-1 lists the normal readings for blood pressure and the stages of hypertension for adults 18 years and over.B. Low Blood Pressure ▶ Many healthy people have a normal systolic pressure under 90 mm Hg, which may be considered “low blood pressure.” ▶ Such a level is normal for that person, and no clinical problems are evident.Wilkins9781451193114-ch067.indd 1135 07/10/15 11:40 AM 1136 SECTION IX | Patients with Special Needs• Any of the early symptoms of high blood pressure.• Blurring of vision; possible loss of sight.• Severe dyspnea.• Chest pains similar to angina pectoris.• Mental confusion leading to stupor, coma, convulsions.• Activate emergency procedures as the situation can be fatal if not treated immediately or may result in dam-age to multiple body systems.IV. Treatment9A. Goals ▶ Primary hypertension• Achieve and maintain diastolic pressure level below 80 mm Hg.• Lower the risk of serious complications and prema-ture death. ▶ Secondary hypertension• Medical treatment of underlying systemic disease is needed.B. Lifestyle Changes (Box 67-3) ▶ Weight and exercise: Control weight and exercise daily. ▶ Diet: Sodium restriction, in those who are salt sensitive, and modest weight loss of 5%–10% of body weight may be all that are needed for the control of mild elevations of blood pressure. ▶ Tobacco use: All forms of tobacco must be eliminated. ▶ Other risk factors: In addition to factors listed in Box 67-3, life activity contributions to stress and tension need to be minimized.V. Hypertension in Children12 ▶ Children 3 years of age and older need to have blood pressure determinations made at least annually. ▶ A marked sudden drop in blood pressure is usually as-sociated with an emergency, such as severe blood loss, shock, myocardial infarction, sepsis, or other medical problem. ▶ Procedures to following during specific medical emer-gencies can be found in Table8-4 in Chapter 8.III. Clinical Symptoms of HypertensionEssential hypertension is frequently recognized only by blood pressure readings. The condition may go unrecog-nized because of the lack of clinical symptoms. ▶ High blood pressureThose who have early symptoms may describe them as:• Occipital headaches• Dizziness • Visual disturbances• Weakness• Ringing in the ears• Tingling of the hands and feet ▶ Major sequela of long-standing elevation of blood pressure• The brain, eyes, heart, or kidney may undergo marked changes in function. • Hypertensive heart disease; enlarged heart with eventual cardiac failure.• Cerebral vascular accident (stroke, described in Chapter 59).• Hypertensive renal disease.• Ischemic heart disease. ▶ Malignant hypertension11• Malignant hypertension is a life threatening that comes on suddenly with a diastolic reading often above 130 mm/Hg.• This disorder affects about 1% of patients with hy-pertension and symptoms can include:TABLE 67-1 Classification of Blood Pressure for Adults Aged 18 Years or OlderBLOOD PRESSURE CATEGORYSYSTOLIC (mm Hg)DIASTOLIC (mm Hg)Normal ,120 ,80Prehypertension 120–139 80–89Stage 1 hypertension 140–159 90–99Stage 2 hypertension≥160 ≥100Data from National High Blood Pressure Education Program. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Bethesda, MD: U.S. National Heart, Lung, and Blood Institute; 2003. NIH Publication No. 03-5233. ▷ If overweight, lose weight 5%–10% of body weight. ▷ Limit alcohol intake to no more than 1 ounce of ethanol per day (24 ounces of beer, 8 ounces of wine, or 2 ounces of 100-proof whiskey). ▷ Exercise (aerobic) daily. ▷ Reduce sodium intake. ▷ Maintain adequate dietary potassium, calcium, and magnesium intake. ▷ Stop use of tobacco. ▷ Reduce dietary saturated fat and cholesterol intake for overall cardiovascular health. Reducing fat intake also helps to reduce caloric intake.Lifestyle Modifications for Hypertension Control and/or Overall Cardiovascular RiskBOX 67-3Wilkins9781451193114-ch067.indd 1136 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1137 ▶ If the BP of a child or adolescent is equal to or above the 90th percentile, the BP measurement is repeated during the visit to determine if the patient is hyper-tensive (see Chapter 11, Table 11-1 for blood pressure values for children and adolescents).ISCHEMIC HEART DISEASEIschemic heart disease is the cardiac disability, acute and chronic, that arises from reduction or arrest of blood sup-ply to the myocardium. ▶ The heart muscle (myocardium) is supplied through the coronary arteries, which are branches of the de-scending aorta. ▶ Because of the relationship to the coronary arteries, the dis-ease is often referred to as CHD or coronary artery disease. ▶ Ischemia means oxygen deprivation in a local area from a reduced passage of fluid into the area. ▶ Ischemic heart disease is the result of an imbalance of the oxygen supply and demand of the myocardium re-sulting from a narrowing or blocking of the lumen of the coronary arteries.I. EtiologyOther factors may be involved, but the principal cause of reduction of blood flow to the heart muscle is atheroscle-rosis of the vessel walls, which narrows the lumen, thus obstructing the flow of blood. ▶ Definition of atherosclerosis13• Atherosclerosis is an inflammatory disease of medium and large arteries in which atheromas deposit and thicken the intimal layer of the involved blood vessel.• An atheroma is a fibro-fatty deposit or plaque con-taining several lipids, especially cholesterol.• With time, the plaques continue to thicken and, eventually, close the vessel (Figure 67-4).• Some plaques calcify, whereas others may develop an overlying thrombus. ▶ Risk factors for atherosclerosis13• Inflammation plays a significant role in the forma-tion of atheromas. Low-grade chronic inflammation in other parts of the body, including chronic peri-odontitis, has been shown to have a relationship to adverse cardiovascular outcomes.• Pathogenic microorganisms from these inflamma-tory processes have been associated with atheroma formation in the blood and the subsequent progres-sion of atherosclerosis.• Many risk factors for periodontal disease are also risk factors for atherosclerosis.14• Each risk factor is significant alone. When these factors occur in combinations, the risk of atherosclerosis, and therefore that of ischemic heart disease, is increased.FIGURE 67-4 Atherosclerosis. An atheroma develops within the lining of the normal blood vessel. The atheroma is made of a fatty deposit containing cholesterol. At first, the atheroma is small and no symptoms are apparent, but eventually it enlarges and completely blocks the vessel, thus depriving the area served by the vessel of oxygen. (Source: National Institute of Health. Report of the Working Group on Arteriosclerosis of the National Heart, Lung, and Blood Institute, National Institutes of Health, United States Department of Health and Human Services. Bethesda, MD: National Institute of Health; 1981. NIH Publication No. 81-2034.)Wilkins9781451193114-ch067.indd 1137 07/10/15 11:40 AM 1138 SECTION IX | Patients with Special Needs• Risk factors include: elevated levels of blood lipids, the result of an increased dietary intake of choles-terol, saturated fat, carbohydrate (especially su-crose), alcohol, and calories.• Tobacco use, diabetes, obesity, insufficient physical activity, increased tensions, emotional stress, and family history may all be significant.• Genetic inheritance can be one factor along with the perpetuation of familial lifestyle habits such as diet, tobacco habits, tensions, and tendencies to-ward lack of exercise.• Prevention depends on educational programs along with early identification of persons at risk.II. Manifestations of Ischemic Heart Disease ▶ Angina pectoris ▶ Myocardial infarction ▶ Congestive heart failureANGINA PECTORIS15 ▶ Angina pectoris is chest pain, the most common symp-tom of coronary atherosclerotic heart disease. ▶ The pain is described as a heavy, squeezing pressure or tightness in the mid-chest region. ▶ The pain may radiate to the left or right arm and neck or even the mandible. On rare occasion, the pain may be limited to one of these areas and not occur in the chest area at all. ▶ The patient may be pale and also experience faint-ness, sweating, difficulty in breathing, anxiety, or fear. The pain lasts 1–5 minutes if precipitating factors are eliminated.I. Precipitating Factors ▶ Stable angina may be precipitated by exertion or exer-cise, emotion, or a heavy meal. In the dental office or clinic, a preventive atmosphere of calmness and quiet can do much to alleviate stress. Stable angina is pre-dictable and consistent in frequency, intensity, and duration. ▶ Unstable angina occurs without exertion or other pre-cipitating factors. The pain may occur while the pa-tient is at rest, and it may vary in intensity at each attack.II. Treatment ▶ A vasodilator, usually nitroglycerin, is administered sublingually. ▶ Basic life support that includes supplemental oxygen is part of the treatment provided in a dental office or clinic.III. Procedure During an Angina Attack ▶ Terminate treatment• Stop the dental or dental hygiene procedure.• Call for assistance and the emergency kit or cart. ▶ Position patient• Return the patient chair to a comfortable position.• Reassure the patient. ▶ Administer vasodilator• Administer nitroglycerin sublingually.• Use of the patient’s own supply is preferable. Prior to starting the appointment procedures make sure the patient’s supply is placed within reach.• The patient can be asked when the nitroglycerin was purchased because the potency is lost after 6 months out of a sealed storage container.• Patient with xerostomia may not have sufficient sa-liva to moisten the nitroglycerin. A few drops of wa-ter from the unit syringe can be placed on the tablet under the tongue. ▶ Check patient response• Give additional vasodilator. Usually, the first tablet relieves the condition within minutes.• When it is suspected that the patient’s supply may not be fresh and the first tablet has been ineffective, use of a second tablet from the dental office emer-gency kit may be advisable. ▶ Call for medical assistance• When the patient does not respond to the second dose of vasodilator, assume the attack to be a myo-cardial infarction.• Call emergency medical service (EMS).• Administer oxygen. ▶ Record vital signs• Use the Medical Emergency Report, Figure 8-1, Chapter 8.• Measure blood pressure, check pulse rate, and count respirations, as described in Chapter 11. ▶ Observe recovery• For the patient who recovers without additional medical assistance, allow a rest period before dismissal.• Record vital signs again. ▶ DocumentationThoroughly document the events that occurred and assessment data collected in the patient’s chart for future reference.MYOCARDIAL INFARCTION16 ▶ Myocardial infarction is the most extreme manifesta-tion of ischemic heart disease. ▶ Other names: heart attack, coronary occlusion, or coro-nary thrombosis.Wilkins9781451193114-ch067.indd 1138 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1139 ▶ The infarction results from a sudden reduction or arrest of coronary blood flow. ▶ The most common artery associated with a myocardial infarction is the anterior descending branch of the left coronary artery. That is also the most common site of advanced atherosclerosis.I. Etiology ▶ Immediate cause: can be a thrombosis that blocks an artery already narrowed by atherosclerosis. ▶ The blockage creates an area of infarction, which leads to necrosis of the area. ▶ Necrosis of the area can occur within a few hours. ▶ A few patients die immediately or within a few hours. Sudden death may be caused by ventricular fibrillation.II. Symptoms ▶ Pain• Location: Pain symptoms may start under the ster-num, with feelings of indigestion, or in the middle to upper sternum. Pain may last for extended periods, even hours.• When the pain is severe, it gives a pressing or crush-ing heavy sensation and is not relieved by rest or nitroglycerin.• Onset: The pain may have a sudden onset, sometimes during sleep or following exercise. The pain may be radial, similar to angina pectoris, which extends to the left or right arm, neck, and mandible. ▶ Other symptoms• Cold sweat, weakness and faintness, shortness of breath, nausea, and vomiting may occur.• Blood pressure falls below baseline.• Women do not always present with symptoms simi-lar to men and may not experience chest pain; faint-ing, pain in the upper back and lower abdomen, and extreme fatigue are chief symptoms.17III. Management During an Attack18 ▶ Terminate treatment• Sit the patient up for comfortable breathing.• Give nitroglycerin, and reassure the patient. ▶ Summon medical assistance• When nitroglycerin does not reduce the anginalike pain within 3 minutes, prepare for basic life support (Table 8-3, Chapter 8).• Call EMT. Administer oxygen.• Use Medical Emergency Report, Figure 8-1, and re-cord vital signs.• Apply basic life support measures, if indicated, while waiting for medical assistance.• Transport to hospital.IV. Treatment After Acute Symptoms19 ▶ Medical supervision• Current medical care for heart attack calls for a short-ened rest period with increased activity, in keeping with the strength and progress of the patient.• Most patients experience extreme fatigue during their convalescence. ▶ Lifestyle changes• Dietary changes and elimination of all forms of to-bacco and stressful activities, as well as control of diseases that exacerbate ischemic heart disease, are essential.• Periodontal health has particular significance.• Many patients need considerable education, reassur-ance, and motivation. ▶ Subsequent appointments• Elective dental appointments are postponed until the patient’s physician has given consent.HEART FAILURE20 ▶ Heart failure, often referred to as Congestive Heart Failure (CHF), is a syndrome in which an abnormality of cardiac function is responsible for the inability or failure of the heart to pump blood at a rate necessary to meet the oxygen needs of the body tissues. ▶ Considered an end-stage heart condition, it re-sults from many forms of cardiovascular diseases and can be related to a number of other systemic conditions.I. EtiologyExamples of diseases that contribute to heart failure are: ▶ Coronary heart disease ▶ Hypertension ▶ Diabetes ▶ Arrhythmias ▶ Congenital heart disease ▶ Thyroid disorders ▶ Alcohol or illegal drug use such as cocaine ▶ HIV/AIDS.II. Clinical Manifestations21 ▶ The clinical manifestations coincide with the parts of the heart involved. ▶ Signs and symptoms are different, depending, in gen-eral, on whether the left or the right side of the heart or both are affected. The general effects are extreme weakness, fatigue, fear, and anxiety.Wilkins9781451193114-ch067.indd 1139 07/10/15 11:40 AM 1140 SECTION IX | Patients with Special NeedsA. Left Heart Failure ▶ The left side of the heart receives oxygenated blood from the lungs and pumps the blood into the aorta to the rest of the body. ▶ A pathologic condition of the left ventricle or the mi-tral valve alters output, and causes respiratory difficulty because of the backup of serous fluid into the lungs. ▶ Most heart failure, and the conditions leading to it, are a result of left ventricular failure, which is followed by right ventricular failure. ▶ Clinical symptoms are more prominent at night. The patient rests better in a sitting or semisitting position with more than one pillow. ▶ Signs and symptoms of left heart failure include the following:• Weakness, fatigue• Dyspnea, particularly evident on exertion. Shortness of breath when lying supine, relieved when sittingup• Cough and expectoration• Nocturia• Pallor; sweating, cold skin• Diastolic blood pressure increased• Heart rate rapid• Anxiety, fear.B. Right Heart Failure ▶ The right heart receives the venous blood from the vena cava and pumps it to the lungs for oxygenation. ▶ Right heart failure shows evidence of systemic venous congestion with peripheral edema. ▶ When left heart failure precedes right heart failure, the heart is already congested. Resistance to receiving the venous blood is an additional factor. ▶ Signs and symptoms of right heart failure include the following:• Weakness, fatigue• Swelling of the feet and/or ankles. The edema pro-gresses to the thighs and abdomen (ascites) in ad-vanced stages of heart failure• Cold hands and feet• Clubbing of fingers• Cyanosis of mucous membranes and nail beds• Prominent jugular veins• Congestion with edema in various organs: enlarged spleen and liver; gastrointestinal distress with nausea and vomiting; central nervous system involvement with headache and irritability• Anxiety, fear.III. Treatment During Chronic Stages20A patient with an appointment in a dental office or clinic may be receiving a variety of medical treatments. These are revealed by questioning during preparation of histories. Nearly all patients with heart failure complications have the following in their medical treatment plan: ▶ Drug therapy• Physicians may prescribe many different medica-tions for patients with cardiovascular disease. ▶ Dietary control• Limited sodium intake to alleviate fluid retention• Limited fluid intake• Weight reduction. ▶ Limitation of activity• Activity is limited depending on the sever-ity of the health problem and the advice of the physician.IV. Emergency Care for Heart Failure and Acute Pulmonary EdemaA medical emergency that demands urgent attention may occur anywhere. The patient with heart failure or acute pulmonary edema is usually conscious. ▶ Position the patient upright for comfortable breathing (Table 8-3 in Chapter 8). ▶ Call EMS. Administer oxygen. ▶ Use the Medical Emergency Report, Figure 8-1, Chapter 8, and monitor vital signs (blood pressure, respiratory rate, and pulse). ▶ Reassure the patient.LIFESTYLE MANAGEMENT FOR THE PATIENT WITH CARDIOVASCULAR DISEASE22The recommendation for the following is appropriate for all patients with cardiovascular disease: ▶ Education: The patient is counseled to be reassured that lifestyle changes are necessary but a productive life can be led. ▶ Lifestyle changes (Box 67-3)• Reduction of blood pressure• Tobacco cessation• Reduction of low-density lipoprotein and total cholesterol• Increase physical activity• Eat a heart healthy diet, like the DASH (dietary approaches to stop hypertension), which is high in vegetables, fruits, whole grains, low-fat dairy, lean poultry and fish, legumes, and nuts with limited added sugar and red meats.23 ▶ Medications: A variety of medications may be required depending on individual needs.Wilkins9781451193114-ch067.indd 1140 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1141SURGICAL TREATMENT19I. Coronary Dilation ▶ Percutaneous transluminal coronary angioplasty• Widely used procedure to stretch the coronary blood vessel using fluoroscopic guidance allows various tools to be inserted.• An inflatable balloon widens the narrowed lumen.• An atherectomy may be used to remove atheroma-tous plaque from the vessel lining. ▶ Coronary stent• The stent is placed to maintain the open vessel lu-men. Stents are made of metal and become covered with endothelium.• The coronary stent provides a semirigid scaffolding within the lumen, which helps prevent restenosis or renarrowing of the lumen.II. Coronary Bypass ▶ Coronary artery bypass grafting (CABG)• Coronary bypass is primarily for patients with sig-nificant obstruction.• The purpose is to “jump-pass” over arteries that have been narrowed with atherosclerosis.• The beneficial effects are relief from anginal pain, less workload for the heart, and an increase of oxy-gen and blood supply to the myocardium.• Figure 67-5 shows the use of a saphenous vein graft and the internal mammary artery for bypasses.FIGURE 67-5 Coronary Bypass Surgery. A: Heart showing infarcted (shaded) areas created by coronary arteries narrowed by atherosclerosis. B: Vein graft from saphenous vein connected with aorta to bypass narrowed area of right coronary artery, and internal mammary artery used to bypass narrowed left anterior descending artery.III. Cardiac Pacemakers and Implantable Cardioverter Defibrillators (ICD)24,25A. Cardiac Pacemakers ▶ The natural pacemaker, or center where the normal heartbeat is initiated, is the sinoatrial (S-A) node lo-cated in the right atrium. ▶ From that node, impulses are sent along the muscle walls to stimulate and regulate the contractions of the ventricles, which pump the blood throughout the body. ▶ When the natural pacemaker cells are not able to main-tain a reliable rhythm, or when the impulses are inter-rupted because of heart block, cardiac arrest, various arrhythmias, or other disease conditions, treatment by a cardiologist may include the placement of an artificial pacemaker.1. Description• A cardiac pacemaker is an electronic stimulator used to send a specified electrical current to the myocardium to control or maintain a minimum heart rate.• It may be single-chambered (to ventricle or atrium) or dual-chambered to sense and pace both heart chambers.2. Parts and power• A permanently implanted pacemaker has elec-trodes inserted transvenously to the endocardium. Less commonly, the leads may go to the pericar-dium of the external heart wall.Wilkins9781451193114-ch067.indd 1141 07/10/15 11:40 AM 1142 SECTION IX | Patients with Special Needs• The electrodes are connected to the power source, a plastic- or metal-encased, hermetically sealed pulse generator containing a lithium anode battery.• The pulse generator is implanted under the skin in the thorax or upper abdomen. The area selected depends on the individual condition as deter-mined by the cardiologist (Figure 67-6).B. Implantable Cardioverter Defibrillator1. Description• An ICD is a device that is surgically placed in the chest or abdomen to help treat cardiac arrhythmias.• Patients with cardiac arrhythmias can experience life-threatening events that can result in sudden car-diac arrest.2. Parts and power• An ICD has wires with electrodes on the ends that connect to the heart chambers.• ICDs can detect when an arrhythmia has stopped the heart from beating and can automatically deliver a shock to the heart that will return the heart to a normal rate and rhythm.• ICDs use low-energy electrical pulses to restore a normal rhythm• If low-energy pulses do not restart heart rhythm, a high-energy pulse is delivered, which can be painful for the patient.C. Interferences and Their EffectsUse of ultrasonic and piezo powerscalers for patients with pacemakers and ICDs has previously been discour-aged due to concerns regarding electromagnetic inter-ference (EMI) and its disruptive impact on pacemakers and ICDs. ▶ However, current evidence indicates that EMI pro-duced from these technologies is not sufficient to dis-rupt the function of pacemakers and ICDs.25–27D. Prophylactic Antibiotic Premedication3,4 ▶ IE has occurred in patients with pacemakers and ICDs, and an increase in the incidence of infection following placement of these devices has prompted increased use of pre- and postantibiotic prophylaxis before and after implantation. ▶ Although evidence suggests the patient with a pace-maker is at low risk for endocarditis, the cardiologist may choose to use antibiotics to cover dental and den-tal hygiene procedures. Consultation with the patient’s physician regarding the need for antibiotic prophylaxis is necessary prior to providing dental treatment for the patient with a pacemaker or ICD.ANTICOAGULANT THERAPY28 ▶ Anticoagulants are used in the treatment of many car-diovascular diseases to prevent embolus and thrombus formation. ▶ A prescribed drug may be continued indefinitely by the patient as a preventive measure. ▶ Drugs most commonly used to prevent or delay blood coagulation are heparin (hospital-administered intra-venous) and coumarin derivatives. ▶ Although precautions are needed to prevent hemor-rhage, discontinuing the drug may be more hazard-ous for the patient than performing dental and dental hygiene therapy with precautions. ▶ Consultation with the patient’s physician must oc-cur prior to proceeding with invasive oral surgical procedures.I. Clinical ProceduresA. Consultation ▶ Information about the patient’s INR (international normalized ratio) is obtained from the primary care provider during an initial consultation. ▶ The INR is a test of the coagulation phase of blood clotting used to monitor therapy with anticoagulants.B. Treatment Planning ▶ Pretest for INR• Determine the INR within 24 hours before an ap-pointment. The patient can have the test made on the day of a dental appointment by preplanning with the physician and the laboratory.• Most patients have a routine appointment for moni-toring of the blood, and dental appointment dates can be planned to coincide.• Safe level for dental and dental hygiene procedures is considered to be 2–3, provided precautions are taken during instrumentation and postoperative care.FIGURE 67-6 Cardiac Pacemaker. The pulse generator is implanted under the skin in the thorax or upper abdomen. The lead electrodes may go to the ventricle or to the atrium or both to provide the necessary stimulus for regulation of the heartbeat.Wilkins9781451193114-ch067.indd 1142 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 1143 ▶ Quadrant nonsurgical periodontal therapy• Teach and emphasize daily dental biofilm control procedures in a series of appointments to prepare the gingival tissue for instrumentation. Healthy, healed tissue does not bleed as readily or as profusely.• Complete treatment, including removal of all cal-culus and subgingival biofilm and other irritants, is necessary to contribute to the goal of healthy tissue that does not bleed.C. Local Hemostatic Measures ▶ Instrumentation can be performed for most patients without complication, provided precautions are taken to minimize tissue trauma and control bleeding and not to dismiss the patient until bleeding has stopped. ▶ Pressure: Pressure with sponges or cotton pellets packed interdentally can aid in control.II. Postprocedural Instructions ▶ The practice by oral surgeons of closely observing patients for 6–8 hours following a surgical procedure has application following selected dental procedures. At the least, a check that postcare instructions are being followed is advisable. ▶ The patient is advised to avoid vigorous toothbrushing and rinsing on a treated area for several hours or until the next day. ▶ The use of extraoral icepacks may be helpful. ▶ General postcare instructions on for the care of an area with a periodontal dressing can be found in Table 43-2 in Chapter 43. ▶ The use of a soft diet, cool rather than hot foods. ▶ Moderation of physical activity may be advisable. ▶ Long-term instruction must emphasize the maintenance of gingival health to prevent future bleeding problems.CARDIAC SURGERY ▶ Patients in dental offices and clinics who have had or will have cardiac surgery such as CABG and heart trans-plantation are identified and need special procedures.I. Presurgical ▶ Before elective cardiac surgery, the patient is brought to a state of optimum oral health, with all sources of infection removed. ▶ All restorations and other dental procedures are completed. ▶ Patients requiring cardiac surgery need information and motivation relative to the importance of oral health in eliminating a potential source of IE. ▶ Vigilance in a preventive program that includes biofilm control and self-applied fluorides is essential.II. PostsurgicalA. Continuing Care AppointmentsFrequent appointments are necessary for supervision and dental hygiene care.B. Prophylactic Antibiotic3,4 ▶ Antibiotic coverage for all dental and dental hygiene procedures for patients with prosthetic cardiac valves is essential. Because of the high susceptibility to infections, a special regimen for high-risk patients may be indicated. ▶ Patients with implanted vascular autographs generally do not need antibiotic premedication before dental and dental hygiene appointments. An example of an im-planted vascular autograph is the use of a patient’s own blood vessel to provide a coronary bypass (Figure 67-5). Leo is a 68-year-old, obese, black male with a history of hypertension and hypercholesterolemia. He reminds Ker-stin, the dental hygienist, that he has an extreme dislike of dental appointments as he grasps very tightly to the armrests of the dental chair.During the medical history review, Leo admitted that he usually remembers to take his blood pressure medica-tions but since he does not feel well after the cholesterol-lowering medication, he does not take it regularly. Kerstin takes his right arm blood pressure of 165/90 mm Hg. Leo then starts rubbing his left arm, and Kerstin asks him how he is feeling. Leo says he is having heartburn from a spicy dinner last night and his left arm is sore, probably from doing some yard work a couple of days ago.Questions for Consideration1. What medical, legal, and ethical questions come to mind to be taken into account when a dental hygienist has a patient like Leo with a complicated medical his-tory that involves medications, patient symptoms, and is a nervous patient about any dental appointments?2. Which of the dental hygiene core values has applica-tion in this scenario? How does each of the core values selected affect the appointment plan?3. Using the questions in Table V-1 in Section V Introduc-tion, prepare at least three possible procedure outlines that Kerstin could consider as she decides steps in Leo’s treatment that day.EVERYDAY ETHICSWilkins9781451193114-ch067.indd 1143 07/10/15 11:40 AM 1144 SECTION IX | Patients with Special NeedsC. Immunosuppressive Therapy ▶ Principal drugs used for patients with transplants are cyclosporin, azathioprine, and prednisolone to prevent rejection of the transplant. ▶ Among the side effects, particularly of cyclosporin, is gingi-val enlargement.27 Many patients may receive medication with the nifedipine group, also effective in causing gingival enlargement. Special periodontal care will be needed.DOCUMENTATIONDocumentation for a routine dental hygiene continuing care or periodontal maintenance appointment for a pa-tient with a cardiovascular illness would need to include a minimum of the following items: ▶ Note and record the responses to health history review questions about visitations to the cardiologist, and in addition to the patient’s report on the state of health, answers from the MD concerning changes that could influence procedures. ▶ Note, record, and compare all findings with previous findings: blood pressure determination, findings in the extraoral and intraoral examination, and the gingival and periodontal clinical examination with complete probing. ▶ An example documentation note may be reviewed in Box 67-4.Example Documentation: Patient with Uncontrolled HypertensionS –Forty-six year old African-American patient arrives in the dental office for a 3-month periodontal continuing care appointment. He reports he has been diagnosed with high blood pressure and is taking Procardia.O – Vital signs: blood pressure: 180/100. Patient reports he cannot afford his medication so he takes it every other day. Contact his cardiologist and/or primary care pro-vider to ensure it is safe to proceed with treatment. The providers gives permission, but recommends no vaso-constrictor in the local anesthetic until the blood pres-sure is under control.A – A comprehensive periodontal and caries examination findings include localized moderate chronic periodonti-tis with bleeding on probing in molar areas along with recurrent caries MO-#14, MO-#15.P – Oral self-care is reviewed with a focus on use of an inter-dental brush in posterior interproximal areas. Periodon-tal maintenance is completed except for in the area of #14–15 where localized nonsurgical periodontal therapy (NSPT) with local anesthesia is recommended. Patient to follow-up with his primary care provider and return for localized NSPT once BP is controlled. Office will follow-up in 2 weeks.Signed: _____________________________________, RDHDate: _______________________________________BOX 67-4 ▷ Encourage patients who have been diagnosed as hypertensive to continue their prescribed therapy.Stress Reduction Procedures ▷ Select an appointment time that is optimum with re-spect to that time of the day when the patient is feeling best and may be less fatigued. Most anxious patients prefer a morning appointment. ▷ Get adequate sleep and rest, and engage in non-fatiguing activities during the 24 hours before the appointment. ▷ Use premedication as prescribed for sleeping the night before. A sedative may be prescribed to be taken 60 minutes before an appointment or at the dental office, if possible. When taken at home 1 hour before, it is not recommended for the patient to drive a car. ▷ Allow time to get to the dental office or clinic; bring own reading material, knitting or sewing, or other relax-ing activity in the event that waiting is unavoidable. ▷ Eat breakfast, lunch, or other usual between-meal food and take usual medications on schedule. ▷ When other family members, especially children, have dental or dental hygiene appointments, do not add to their stress by relaying personal negative feelings.Factors To Teach The PatientReferences1. Humphrey L, Fu R, Buckley D, et al. Periodontal Disease and coronary heart disease incidence: a systematic review and meta-analysis. J Gen Intern Med. 2008;23(12):2079–2086. 2. Glenny AM, Oliver R, Roberts GJ, et al. Antibiotics for the prophylaxis of bacterial endocarditis in dentistry. Cochrane Database Syst Rev. 2013;(10):CD003813.3. Wilson W, Taubert KA, Gewitz M, et al. Prevention of in-fective endocarditis: guidelines from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Qual-ity of Care and Outcomes Research Interdisciplinary Work-ing Group. Circulation. 2007. http://circ.ahajournals.org/ content/116/15/1736.full. Accessed August 2013.4. Nishimura RA, Otto CM, Bonow RO, et al. American Col-lege of Cardiology/American Heart Association Task Force on Practice Guidelines. 2014 AHA/ACC guideline for the management of patients with valvular heart disease: execu-tive summary: a report of the American College of Cardi-ology/American Heart Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2014;63(22):2438–2488.5. March of Dimes. Congenital heart defects. March of Dimes Foundation. 2008. http://www.marchofdimes.com/baby/congenital-heart-defects.aspx. Accessed August 2013.6. Centers for Disease Control and Prevention. Facts about congenital heart defects. http://www.cdc.gov/ncbddd/heart-defects/facts.html. Updated July 18, 2014. Accessed August 20, 2015.Wilkins9781451193114-ch067.indd 1144 07/10/15 11:40 AM CHAPTER 67 | The Patient with a Cardiovascular Disease 11457. National Institutes of Health, National Library of Medicine, Medline Plus. Rheumatic fever. http://www.nlm.nih.gov/medlineplus/ency/article/003940.htm. Updated May 11, 2014. Accessed August 30, 2015.8. National Institutes of Health, National Heart, Blood, and Lung Institute. What is mitral valve prolapse? http://www.nhlbi .nih.gov/health/health-topics/topics/mvp/. Updated July 1, 2011. Accessed August 30, 2015.9. James PA, Oparil S, Carter BL, et al. 2014 evidence-based guideline for the management of high blood pres-sure in adults: report from the panel members appointed to the Eighth Joint National Committee (JNC 8). JAMA. 2014;311(5):507–520.10. American Heart Association. High blood pressure. http://www.heart.org/HEARTORG/Conditions/High-BloodPressure/High-Blood-Pressure-or-Hypertension_UCM_002020_SubHomePage.jsp. Accessed June 30, 2014.11. National Institutes of Health, National Library of Medicine, Medline Plus. Malignant hypertension. http://www.nlm.nih.gov/medlineplus/ency/article/000491.htm. Updated April 5, 2013. Accessed August 30, 2015.12. Flynn JT, Daniels SR, Hayman LL, et al. American Heart Association Atherosclerosis, Hypertension and Obesity in Youth Committee of the Council on Cardiovascular Disease in the Young. Update: ambulatory blood pressure monitor-ing in children and adolescents: a scientific statement from the American Heart Association. Hypertension. 2014;63(5): 1116–1135.13. National Institutes of Health, National Heart, Lung, and Blood Institute. Atherosclerosis. http://www.nhlbi.nih.gov/health/health-topics/topics/atherosclerosis/atrisk.html. Up-dated August 4, 2014. Accessed August 30, 2015.14. Lockhart PB, Bolger AF, Papapanou PN, et al. Periodon-tal disease and atherosclerotic vascular disease: does the evidence support an independent association?: a scientific statement from the American Heart Association. Circula-tion. 2012;125(20):2520–2544.15. American Heart Association. Angina pectoris. http://www.heart.org/HEARTORG/Conditions/HeartAttack/SymptomsDiagnosisofHeartAttack/Angina-Pectoris-Chest-Pain_UCM_437515_Article.jsp. Updated May 15, 2015. Accessed August 30, 2015.16. National Institutes of Health, National Library of Medi-cine, Medline Plus. Heart attack. https://www.nlm.nih.gov/medlineplus/ency/article/000195.htm. Updated August 12, 2014. Accessed August 30, 2015.17. American Heart Association. Heart attack symptoms in women. http://www.heart.org/HEARTORG/Conditions/HeartAttack/WarningSignsofaHeartAttack/Heart-Attack-Symptoms-in-Women_UCM_436448_Article.jsp. Updated July 2015. Accessed August 30, 2015.18. Reed KL. Basic management of medical emergencies: recog-nizing a patient’s distress. J Am Dent Assoc. 2010;141 (Suppl 1):20S–24S.19. American Heart Association. Prevention and treat-ment of heart attack. http://www.heart.org/HEARTORG/Conditions/HeartAttack/PreventionTreatmentof-HeartAttack/Prevention-and-Treatment-of-Heart-At-tack_UCM_002042_Article.jsp. Updated August 21, 2015. Accessed August 30, 2015.20. National Institutes of Health, National Heart, Lung, and Blood Institute. What is heart failure? http://www.nhlbi.nih.gov/health/health-topics/topics/hf/. Updated March 27, 2014. Accessed August 30, 2015.21. American Heart Association. Types of heart failure. http://www.heart.org/HEARTORG/Conditions/HeartFailure/AboutHeartFailure/Types-of-Heart-Failure_UCM_306323_Article.jsp. Updated June 1, 2015. Accessed August 30, 2015.22. Eckel RH, Jakicic JM, Ard JD, et al. 2013 AHA/ACC guide-line on lifestyle management to reduce cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Cir-culation. 2014;129(25, Suppl 2):S76–S99.23. National Institutes of Health, National Heart, Lung, and Blood Institute. What is the DASH eating plan? http://www.nhlbi.nih.gov/health/health-topics/topics/dash/. Updated June 6, 2014. Accessed July 27, 2014.24. Wilson BL, Broberg C, Baumgartner JC, et al. Safety of electronic apex locators and pulp testers in patients with implanted cardiac pacemakers or cardioverter/defibrillators. J Endod. 2006;32(9):847–852.25. National Institutes of Health; National Heart, Lung and Blood Institute. What is a pacemaker? http://www.nhlbi.nih.gov/health/health-topics/topics/pace/. Updated February 28, 2012. Accessed August 20, 2015.26. Gomez G, Duran-Sindreu F, Roig M, et al. The effects of six electronic apex locators on pacemaker function: an in vitro study. Int Endod J. 2013;46(5):399–405.27. Uslan D, Gleva M, Poole J, et al. Cardiovascular implant-able electronic device replacement infections and pre-vention: results from the REPLACE Registry. Pacing Clin Electrophysiol. 2012;35(1):81–87.28. Douketis JD, Spyropoulos AC, Spencer FA, et al. Periopera-tive management of antithrombotic therapy: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Prac-tice Guidelines. Chest. 2012;141(2, Suppl):e326S–e350S.29. Dongari-Bagtzoglou A; and Research, Science and Ther-apy Committee, American Academy of Periodontol-ogy. Drug-associated gingival enlargement. J Periodontol. 2004;75(10):1424–1431.ENHANCE YOUR UNDERSTANDINGDIGITAL CONNECTIONS(see the inside front cover for access information)• Audio glossary• Quiz bankSUPPORT FOR LEARNING(available separately; visit lww.com)• Active Learning Workbook for Clinical Practice of the Dental Hygienist, 12th EditionINDIVIDUALIZED REVIEW(available separately; visit lww.com)• Adaptive quizzing with prepU for Wilkins’ Clinical Practice of the Dental HygienistWilkins9781451193114-ch067.indd 1145 07/10/15 11:40 AM Wilkins9781451193114-ch067.indd 1146 07/10/15 11:40 AM

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