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  • A cardiac arrhythmia refers to any variation in the normal heartbeat, including rhythm, rate or conduction pattern.  

  • Although most arrhythmias are of little concern for dentist or patient, some can produce symptoms and a few are lifethreatening.

  •  Potentially fatal arrhythimas can be triggered by strong emotions such as anxiety or anger, and by drugs used in dentistry.

  • Causes of arrhythmias

    • Primary cardiovascular disorders

    • Pulmonary disorders (embolism, hypoxia)

    • Systemic disorders (thyroid disease)

    • Drug related adverse effects

    • Electrolyte imbalances

 

In a general dental practice 17.2% of patients will have cardiac arrhthmias and 4% of those were life-threatening.  

Cardiac Arrhythmias

Introduction

Risks to the dental patient

Management During Treatment

  • Stress associated with dental treatment or use of excessive amounts of epinephrine may lead to a life threatening arrhythmia is susceptible dental patients.

Questions to Ask 

  • Bradycardia

  • Tachycardia

  • Irregular rate

Signs

  • Patient is untreated or continues to have symptoms

  • An abnormal heart rate is noted on your examination

  • Patient has an arrhythmia that places them at major risk for cardiac event

Symptoms

Note:  Symptoms alone cannot be relied on to dermine the seriousness of an arrhythmia. A patient may have NO symptoms and have a serious arrhythmia.

 

  • Palpitations

  • Feeling faint, light-headed or dizzy

  • Syncope

  • Fatigue

  • Shortness of breath

  • Orthopnea

  • Peripheral edema

  • Exercise intolerance

Prevention 

  • Stress reduction protocol

  • Pre-operative sedation (short acting benzodiazepine the night before the appointment and/or one hour before appointment)

  • Take pretreatment vital signs

  • High-risk patients should be treated in hospital setting.

Post-Operative Care

  • Good postoperative analegsia to minimize pain and stress

  • If patient is taking coumadin, some antibiotics can increase INR 

References

Dental Management of the Medically Compromised Patient.  Little, Falace, Miller and Rhodus. 8th Edition

Medical Consultation Recommended 

  • What type of arrhythmia do you have?

  • Do you know what triggers the episodes of arrhythmia?

  • How often do you have an episode of arrhythmia?

  • What medications are you taking?

  • How often do you see your physician?

  • Do you take your medications every day as directed?  Did you take your medication today?

  • Do you have an implanted cardiac pacemaker and defibrillator?

  • Are your symptoms (see below) controlled?

  • Do you have any other cardiovascular (previous MI, CHF) or pulmonary (COPD) problems?  

  • Are you taking Coumadin or other blood thinner?  What is your INR?

  • How do you feel about having dental treatment? Do you feel anxious or fearful?

Medications of Concern (that dentist may administer or the patient MAY be taking)

  • Vasoconstrictor

    • Local anesthetic without vasoconstrictor can be used as needed

    • Patients in the low to intermediate risk category OR those taking nonselective beta blockers can safely be given up to 0.036 mg epinephrine.  

    • Patients in the high risk - consult with physician prior to treastment

    • Greater quantities may be tolerated with increased risk

    • Avoid in patients taking digoxin - increased risk for arrhythmias

  • Warfarin (Coumadin)

    • Used in patients with atrial fibrillation to prevent thrombus formaion, embolism and stroke.  Target INR = 2-3 (some say 3.5).  Studies have shown that minor oral surgery can be performed without altering or stopping the coumadin regimen if the INR is in therapeutic range.

  • Dabigatran (Pradaxa)

    • Newer anticoagulant used in place of coumadin.  Reported to cause less bleeding.

    • Elderly patients and those with kidney function impairment are at increased risk for major bleeding.

    • Advanced local hemostatic measures are advised.

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