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  • Symptomatic coronary atherosclerotic heart disease is often referred to as ischemic heart disease.  

  • Ischemic symptoms are the result of oxygen deprivation secondary to reduced blood flow to a portion of the myocardium.

  • Other conditions such as embolism, coronary ostial stenosis, coronary artery spacm and congenital abnormalities may also cause ischemic heart disease.

  • Atherosclerosis is the thickening of the intimal layer of the arterial wall caused by the accumulation of lipid plaques. This process results in narrowed arterial lumen, with diminished blood flow and oxygen supply.  

  • Atherosclerosis is the most common underlying cause for coronary heart disease (angina and myocardial infarction), cerebrovascular disease (transient ischemic attacks and stroke) and peripheral arterial disease (intermittent claudication).

  • Also known as hardening of the arteries.

Ischemic Heart Disease

Introduction

Risks to the dental patient

Management During Treatment

  • Angina attack

  • Myocardial infarction

  • Side effects of medications

Questions to Ask 

  • Occurrence of chest pain in a consistent, recurring and predictable pattern

  • Pain precipitated by typical physical activity (exercising, mowing the lawn)

  • Pain subsides within 5-15 minutes with rest or use of nitroglycerin

  • Pain occurs in a chronic, unchanging pattern over time

  • Patient is at intermediate cardiac risk and can undergo most routine and advanced dental treatment.

Stable Angina

  • Patient with unstable angina

  • Undiagnosed patients with symptoms of angina

  • Patient with stable angina who will be undergoing extensive and/or invasive dental procedures.

Clinical Findings 

  • In rare cases, patients with angina occurring as a manifestation of coronary atherosclerotic heart disease may experience pain referred to the neck, lower jaw, or teeth, which may bring them to the dentist for dental treatment. 

  • The pattern of onset of pain with physical activity and its disappearance with rest indicates pain of cardiac origin.

Prevention 

  • If patient uses nitroglycerin to treat acute symptoms, he/she should bring it to dental appointments and keep it close at hand during dental procedures.

  • Risk during dental treatment is dependent on

    • The severity of disease

    • The type of dental procedure

      • Longer dental appointments = increased risk

      • More invasive dental treatment = increased risk

    • The degree of patient anxiety

  • Stress reduction protocol, including oral and inhalation sedation

  • Patient with unstable angina may require treatment in hospital setting

References

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

Medical Consultation Recommended 

  • When were you diagnosed with angina?

  • What symptoms were you having when you were diagnosed?

  • Are you having any of those symptoms now?

  • How often do you have chest pain?  How many times have you had chest pain in the past 6 months?

  • Do you have more episodes of chest pain now than in the past?

  • Is the chest pain getting worse?

  • When did you last have chest pain?

  • What causes you to have chest pain?

  • What relieves the chest pain? How long does it take for the pain to subside?

  • Has your doctor recently changed your medications or increased the dosage?

  • Have you had a heart attack?

  • Can you climb a flight of stairs without chest pain, shortness of breath or fatigue?

  • Are you anxious or fearful of dental treatment?

 

​Patients with a history of ischemic heart disease treated with balloon angioplasty and a coronary artery stent or with coronary artery bypass surgery should be asked the following questions:

  • When did you have the procedure?

  • Following your procedure, were you free from chest pain?

  • Are you still symptom free?

Unstable Angina

  • Recent onset of chest pain

  • Progressively worsening chest pain that occurs with physical exertion, at rest or even during sleep

  • Pattern of increasing severity, frequency or duration of pain

  • Patient is a major cardiac risk and is not a candidate for elective dental care.

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