Dentists are properly concerned to avoid cardiovascular collapse or deterioration in patients with pre-existing heart disease undergoing dental treatment, particularly under general anaesthesia, even though other forms of emotional or physical stress (or even exercise testing by physicians!) are likely to be dangerous. The special risk of infective endocarditis arising from dental bacteremia is important, but ischemic heart disease and hypertension are much more common. While patients may volunteer a history of heart problems, inferences from the drug history may be most useful source of information to the dentist and the dental patient should take special interest in such.

The risk of harm from dental treatment generally arises more from inadequate control of anxiety and pain than from the treatment itself. “Tender loving care” is of prime importance and a kind, confident and sympathetic approach is therapeutic in itself. Sedation with oral diazepam, or nitrous oxide and oxygen inhalation (relative analgesia) is safe, if needed, but intravenous agents should be used very cautiously and general anesthesia should be avoided. Local anesthesia using lignocaine 2%, with 1/80 000 adrenaline is safe and effective. I do not know any dentist who does not use it routinely. Adrenaline-free local anesthetic solutions are not effective, noradrenalin is unsafe, and prilocaine with felypressin produces less reliable anesthesia than lignocaine with adrenaline.
Sensible management should include preventative dentistry and treatment planning to avoid lengthy or difficult procedures. It is important to ensure that patients have taken their normal medication on the day of their visit to the surgery, and they should ideally be accompanied by a responsible adult. The surgery should ideally be equipped for resuscitation and the staff trained to cope with any emergency which might arise.
Hypertensive patients do not bleed excessively after dental operations and should simply be treated as described. Anti coagulated patients are at risk of prolonged bleeding after oral surgery and they should ideally be tested for prothrombin to determine their current level of anticoagulation. The dentist must be available to provide control of bleeding by local methods in the first 24 hours, if required.
Patients with angina should bring their anti-angina medication and keep it available during the dental appointment. Dental treatment in those with a recent heart attack (myocardial infarction) is probably best left until after 6 months, especially if general anaesthesia is needed. Ultrasonic scalers, electric pulp testers, diathermy or electro-surgery, can upset pacemaker function, and this type of dental equipment should not be used for patients whose cardiac rhythm is controlled by a pacemaker. Patients who have had coronary artery bypass grafts do not risk infective endocarditis following dental surgery and are usually fitter to withstand dental treatment after than they were before the cardiac operation.
Valvular heart disease is usually either congenital or arises from rheumatic carditis following rheumatic fever. It predisposes patients to infective endocarditis. The bacteremia that occurs when a tooth is extracted, or when the periodontium is damaged in scaling or flap surgery ect., may result in oral micro-organisms settling upon, and infecting minute, transient vegetations on the already damaged valves (infective endocarditis). Oral organisms involved are usually streptococci of the viridians group.
Other uncommon but important risk groups, such as patients who have had valve-replacement surgery and those who have already suffered an attack of endocarditis, are important not so much in having enhanced susceptibility but in having a poor prognosis should they contract endocarditis. The hospital mortality for those 1 in 8 streptococcal cases associated with dentistry is quite low, but the figures conceal a considerable long-term morbidity. These underline the need for patients to inform their dentist if they have a heart ailment.

(Dr. BERTRAND R. STUART D.D.S)