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= Coronary Artery Disease =

Oral Manifestation of Coronary Artery Disease
Coronary artery disease does not directly induce oral lesions or oral complications. However, carotid calcifications can de detected on panoramic images in about one third of patients who have atherosclerosis. Also, an association between ischaemic heart disease and periodontal disease, poor oral health, chronic apical periodontitis and tooth loss has been documented. Drugs used in the treatment of ischaemic heart disease may produce oral changes such as dry mouth, taste aberrations, and stomatitis. Calcium channel blockers can induce gingival overgrowth when plaque control is less than optimal and is more prominent at anterior interproximal sites. In rare cases, patients with angina or acute coronary syndrome may experience pain referred to the neck, shoulder, lower jaw or teeth. The pattern of onset of pain with physical activity and its disappearance with rest usually serves as a diagnostic clue as to its cardiac origin.

Dental management of angina pectoris patients
Coronary heart disease is very common in the general population, and it is therefore likely that a dentist will meet such a patient in clinical practice. Treatment sequence should start with taking a complete medical history, followed by short morning appointments, premedication with anxiolytics or prophylaxis nitroglycerin, nitrous oxide-oxygen sedation, and slow delivery of an anaesthetic with epinephrine (1:1,00,000) coupled with aspiration.

Angina pain is often felt in the mandible, with secondary radiation to the neck and throat. Therefore, the patient may initially suspect the pain to be of dental origin. The dental environment increases the likelihood of an angina attack because of fear, anxiety, and pain. A patient who has an angina episode in the dental chair should receive the following emergency dental treatment:

Dental procedure is discontinued and patient is allowed to attain a comfortable position. Patient is reassured and restrictive garments are loosened. Patient is encouraged to have his own nitroglycerin (NTG) spray 1 or 2 metered sprays depending on his usual requirement (up to 3 doses of NTG spray can be given in 15 minutes). If angina signs and symptoms do not resolve with this treatment within 2-3 minutes, administer another dose of nitroglycerin, monitor the patient's vital signs, call his or her physician, and be ready to accompany the patient to the emergency department. Oxygen is administered 4-6 lit/min. Dental procedure may be restarted if it is the usual type of experience for the patient. If no improvement within 3 minutes, myocardial infarction (MI) is suspected and patient is sent to the hospital.

If any doubt exists about whether angina or myocardial infarction exists (i.e., pain continues, worsens or subsides but then returns), activate emergency medical services or transport patient to hospital. Once the nitroglycerin tablet container has been opened, the remaining tablets have a poor shelf life (30 days); a new supply should be stocked.

Dental management of myocardial infarction (MI) patients
Although relatively uncommon in the dental settings, cardiac arrest as a result of MI can occur.

A careful medical history with short appointments along with anxiety reduction should be carried out. Supplemental oxygen via nasal cannula will help meeting the extra oxygen requirements of the myocardium: 4 lit/min. Caution should be taken if more than 3 ml of 2% lignocaine hydrochloride with 1:80,000 adrenaline solution is required. Drug interactions with potential adverse reactions need to be taken into account after treatment (e.g. interaction between NSAIDs, Penicillin, Tetracycline, Metronidazole, and anticoagulants) because prophylactic antibiotic may need to be considered to prevent infection. In patients with pacemakers, electrocautery and the use of cavitron should be avoided. Within 6 months, if any urgent invasive treatment is required such as extractions/RCT, with 6 months of infarction, the treatment should be delivered in a hospital setting where facilities exist should there be another attack of MI. After 6 months, myocardial infarction patients can usually be treated using techniques similar to the stable angina patient.