This course was published in the March 2011 issue and expires March 2014. The authors have no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Discuss the causes and effects of hypertension, coronary artery disease, heart failure, and stroke.
- List the main issues encountered when treating patients with cardiovascular disease and stroke.
- Define the suggested oral health care interventions for patients with cardiovascular disease and stroke.
The United States Census Bureau estimates that by 2050, 21% of Americans will be 65 years of age or older. As people live longer, the prevalence of age-related chronic diseases, such as cardiovascular disease and stroke, also increases. Cardiovascular disease is responsible for 38.5% of all deaths in the United States each year and 70% of deaths among those older than 75 years.1 More than 74 million Americans have hypertension, 17.6 million have coronary artery disease, and 5.8 million experience heart failure.1 Each year about 795,000 people experience a stroke and approximately 137,000 of those strokes are deadly.2 These cardiovascular problems and the medications used to treat them profoundly affect patients’ oral health and the provision of professional oral health care.3
Hypertension or high blood pressure is defined as an arterial pressure greater than 140/90 mmHg and is a risk factor for cerebrovascular accident (stroke), atherosclerosis, myocardial infarction (heart attack), congestive heart failure, and chronic renal failure.1,4,5 Individuals with blood pressure of 120/80 mmHg or lower are 50% less likely to have a stroke than those with high blood pressure.1 The direct cause of hypertension is not known, however, contributing factors include: smoking, high salt intake, high alcohol consumption, adrenal and thyroid problems, kidney disease, stress, older age, genetics, being overweight or obese, sedentary lifestyle, and family history of hypertension.5 Lifestyle changes are recommended in the treatment of hypertension in addition to antihypertensive medications for those whose blood pressure is higher than 139/89 mmHg.5
CORONARY ARTERY DISEASE
Coronary artery disease is a condition in which the coronary arteries harden and narrow due to plaque build-up. This hardening and narrowing of the arteries causes angina (chest pain) and myocardial infarction. Coronary artery disease can weaken the heart muscle over time, eventually causing heart failure. Coronary artery disease is the number one cause of death among American men and women.6-9 Age, genetics, high cholesterol, smoking, hypertension, high triglyceride levels, kidney disease, history of stroke, alcohol abuse, sedentary lifestyle, and high levels of stress are all risk factors for coronary artery disease. Inflammation, including higher levels of C-reactive protein, is currently being investigated as an additional risk factor. Management of the disease includes getting cholesterol and blood pressure levels under control, which may include medications, such as angiotensin-converting enzyme (ACE) inhibitors, aspirin, beta-blockers, calcium channel blockers, diuretics nitrates, and statins. Angioplasty and stent placement, coronary artery bypass surgery, and minimally-invasive heart surgery are procedures used to treat coronary artery disease.6-10
Heart failure is most common in men older than 65 years and among African-Americans. Heart failure starts with a damaged heart muscle that can result from coronary artery disease, hypertension, or complications from diabetes. The arteries that supply blood to the heart become hardened and narrowed. Diagnosis is usually confirmed by swelling of the ankles, feet, legs, and sometimes in the abdomen. Shortness of breath or difficulty breathing and fatigue are also symptoms. Fluid builds up in the lungs because the heart muscle is working extremely hard to pump the blood throughout the body.
Heart failure has no cure, but the underlying conditions can be controlled. Patients with heart failure should limit their fluids, watch for daily weight gain, and maintain a diet low in salt. Medications commonly taken are diuretics, ACE inhibitors, beta blockers, metoprolol, and digoxin.
A cerebrovascular accident is the interruption of the body’s blood supply to the brain due to the blockage or bursting of a blood vessel in the brain. Stroke is most often caused by chronic hypertension, but the following risk factors may also contribute: atrial fibrillation (inability of the heart’s two upper chambers to beat effectively), diabetes, family history of stroke, high cholesterol, and advancing age. The third leading cause of death in the United States, stroke is a significant contributor to both physical and cognitive disability in adults.11 Two-thirds of all strokes occur in people age 65 years and older.11 According to the Centers for Disease Control and Prevention, however, the incidence of stroke among young and middle-aged people is increasing, which may be related to the rise in obesity rates.12 Strokes often result in loss of motor control and coordination, which in turn cause dysphagia (difficulty swallowing) and/or dysarthria (difficulty speaking). Stroke can also weaken the tongue, soft palate, pharynx, and muscles of mastication.13 Treatment may include thrombolytic therapy, blood thinners, and/or surgery.
A 78-year-old widow, Mrs. Potts (her name has been changed), who lives with her daughter and has a full-time caregiver, visits our faculty practice for oral health care. The patient suffered a stroke in 1997 resulting in hemiplegia (paralysis) on her left side and aphasia (inability to speak). Before initial treatment, both her primary physician and cardiologist were consulted and her medical history was reviewed. Among older adult patients, it is imperative to update medical histories at every visit, even if appointments are only days apart. Medications and medical conditions can change frequently. Dental hygienists need to inform caregivers that any change in health status or medications can affect dental treatment plans and should be reported.
Mrs. Potts’ medical history includes common risks for stroke: chronic hypertension, osteoporosis, atherosclerosis, smoking (35 years), and heart disease. She also has a history of depression, kidney stones, and deep vein thrombosis, in addition to a seizure disorder caused by her stroke. Mrs. Potts’ medications are listed in Table 1 along with indications for use and possible interactions.
The first oral exam revealed that Mrs. Potts had severe root caries and moderate periodontitis. After consultation with her physician, hospitalization was recommended for extraction of teeth numbers 3, 13, 19, and 31. Four quadrants of scaling and root planing and an amalgam on #18 were also completed. The patient was then placed on 4-week recall for ultrasonic debridement and fluoride varnish treatments. No partial denture was planned to replace the extracted teeth because stroke patients often have paresthesia (numbness) and thus cannot tell when a prosthesis causes trauma to the oral tissues. Additionally, loss of muscle tone and reduced chewing efficiency and lip force on the affected side can make retention of a lower partial difficult.13 Treatment needs to consider the patient’s unique situation and capabilities instead of being based on the achievement of an ideal oral health status.14
infarction and hypertension, we limit the administration of any vasoconstrictor during the provision of local anesthesia. Aspiration and the slow injection of the minimal effective dose (not to exceed 0.04 mg of epinephrine within a 15-minute period or more than two cartridges of 1:100,000 epinephrine-containing anesthesia) are recommended in patients with cardiovascular problems.15 Her appointments are always scheduled for late morning or early afternoon because circadian patterns elevate vascular tone and increase fibrinolytic activity and platelet aggregation between the hours of 6:00 AM and 9:00 AM, which increases the risk of myocardial infarction and stroke.16
Short appointments are scheduled to avoid overstressing the patient. Additionally, care is taken to sit her up slowly in order to avoid orthostatic hypotension (low blood pressure caused by a sudden change in body position, eg, moving from a prone position to a standing position). Oxygen is always on hand because stress from dental procedures can increase cardiac oxygen demand. Her blood pressure is routinely checked at the end of each appointment. Due to Mrs. Potts’ chronic bilateral carotid artery occlusions, her circulation is dependent on vertebral arteries and external carotid artery collaterals. Care to avoid extreme flexion and extension of her head is taken during dental procedures. When treating patients who present with this condition or neck problems, an inflatable travel pillow is helpful for support. At the start of one appointment, Mrs. Potts’ blood pressure was high (185/98 mmHg) so her cleaning was rescheduled for another time.
Mrs. Potts has severe xerostomia. Often when sensory deficits are present and there is difficulty swallowing, a concurrent reduction in fluid intake occurs. This along with medication use, such as antibiotics and anticonvulsants, can result in xerostomia. Her reduced ability to chew and swallow also led to anemia and a 30-pound weight loss. If a patient is on oxygen therapy, the potential for xerostomia is further increased. An unfortunate consequence of dry mouth is halitosis, which may lead to social isolation.17 In addition, speech problems and taste alterations due to xerostomia may impact the quality of life for many stroke victims.18
Mrs. Potts is incapable of performing any of her own self-care due to the severity of her stroke. Oral hygiene education should be provided to both the patient and caregiver to assure comprehension and capability. In the hospital, Mrs. Potts’ caregiver was advised to use petroleum jelly to relieve the dryness of the patient’s oral tissues, but petroleum products actually dehydrate the tissues.19 Lemon glycerine swabs containing acetic and citric acids were also recommended to combat xerostomia. We advised against the use of these swabs because of the risk of tooth decalcification. The caregiver was instructed by a nurse to crush Mrs. Potts’ pills and mix them in fruit jam to administer because she could not swallow them whole. Again, we advised the caregiver about the risk of dental caries. Oral products considered the standard of care in many hospitals and long-term care facilities often contain acids and sugars that can decalcify the teeth and burn the soft tissues. Health care workers in the hospital setting often use hydrogen peroxide as a mouthrinse without properly diluting it with water to reduce the acidity. We advised the caregiver to use an alcohol-free alternative containing xylitol and moisturizing ingredients to alleviate Mrs. Potts’ xerostomia. Some of her medications contained sugar predisposing her to dental and root caries. Medications designed for people with diabetes are appropriate alternatives because they are sugar-free.20
We provided detailed oral health instruction to Mrs. Potts’ caregiver. Many stroke patients need help clearing their mouths after they eat since they often cannot feel food or medication remaining in their cheeks or just inside their lips. The mouth should be kept moist by applying cocoa butter to patient’s lips and oral moisturizers to the inside of the cheeks. Foam swabs or toothettes, which are typically used to clean the mouth in hospitals, may remove food debris but they do not remove biofilm adequately to prevent periodontal diseases or caries. Caregivers need to be instructed on how to brush the patient’s teeth. A power toothbrush is often easier for caregivers to use and the larger handle is good for gripping. The risk of caries and periodontal diseases is extremely high in this type of patient, so the use of a 5,000 ppm fluoride toothpaste, xylitol products (if tolerated gastrointestinally), and an antimicrobial mouthrinse are indicated.21 If patients cannot rinse their mouths, a small amount of mouthrinse can be applied intraorally with gauze, a cotton swab, or a toothette. Caregivers should aim to brush the teeth after each meal with particular attention paid at bedtime. Again, a small of amount of toothpaste can be used and swallowed if the patient cannot rinse or expectorate.
Mrs. Potts is very fortunate to have a full-time caregiver and a daughter who is concerned about her oral health. Every appointment with Mrs. Potts affords us a new learning experience and requires that we adapt our care to her changing needs. At some point, she will be unable to visit our office so we will perform her routine oral hygiene and exams in her home with our newly purchased mobile equipment.
As the American population ages, dentistry will be called upon to treat a greater number of geriatric patients, many of whom will be home-bound or institutionalized. Unfortunately, this population is often not considered during access-to-care strategizing and educational efforts. The link between oral and systemic health emphasizes the need for dental professionals to meet the oral health care needs of this vulnerable population.
- Scully C, Ettinger R. The influence of systemic diseases on oral health care in older adults. J Am Dent Assoc. 2008;139:252-253.
- Centers for Disease Control and Prevention. Stroke. Available at www.cdc.gov/stroke. Accessed February 7, 2011.
- American Heart Association. Heart Disease and Stroke Statistics, 2010 Update. Available at www.americanheart.org/downloadable/heart/1265665152970DS-3241%20HeartStrokeUpdate_2010. pdf. Accessed February 7, 2011.
- Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St. Louis: Mosby; 1993.
- Krapp K. Hypertension. In: Encyclopedia of Nursing and Allied Health. Farmington Hills, Mich: Gale Cengage; 2002.
- Mosca L, Banka CL, Benjamin EJ, et al. Evidence-based guidelines for cardiovascular disease prevention in women: 2007 update. . 2007;115:1481-1501.
- Morrow DA, Gersh BJ. Chronic coronary artery disease. In: Libby P, Bonow RO, Mann DL, Zipes DP, eds. Braunwald’s Heart Disease: A Textbook of Cardiovascular Medicine. 8th ed. Philade lphia: Saunders Elsevier; 2007.
- Becker RC, Meade TW, Berger PB, et al. The primary and secondary prevention of coronary artery disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest. 2008;133(6 Suppl):776S-814S.
- Serruys PW, Morice MC, Kappetein AP, et al. Percutaneous coronary intervention versus coronary-artery bypass grafting for severe coronary artery disease. N Engl J Med. 2009; 360:961-972.
- US Preventive Services Task Force. Aspirin for the prevention of cardiovascular disease: US Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;150:396-404.
- Wolfe CD. The impact of stroke. Br Med Bull. 2001;56:75-286.
- Tong X, Kuklina EV, Gillespie C, George MC, CDC. Trends of acute ischemic stroke hospitalizations by age and gender in the United States: 1994-2007. Presented at: International Stroke Conference, February 8-11, 2011; Los Angeles.
- Schimmel M, Leemann B, Christou P, et al. Oral health-related quality of life in hospitalized stroke patients. Gerodontology. 2009;10:1741- 1750.
- Linquist TJ, Ettinger RL. The complexities involved with managing the care of an elderly patient. J Am Dent Assoc. 2003;134;593-600.
- Jeske AH. Mosby’s Dental Drug Reference. 9th ed. St. Louis: Mosby Elsevier; 2010:40-41.
- Panza JA, Epstein SE, Quyyumi AA. Circadian variation in vascular tone and its relation to alpha-sympathetic vasoconstriction activity. N Engl J Med. 1991;325;986-990.
- Koshimune S, Awano S, Gohara K, Kurihara E, Ansai T, Takehara T. Low salivary flow and volatile sulfur compounds in mouth air. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003;96:38-41.
- Habbab KM, Moles DR, Porter SR. Oral diseases. Potential oral manifestations of cardiovascular drugs. Oral Dis. 2010;16:769-773.
- Wiseman M. The treatment of oral problems in the palliative patient. J Can Dent Assoc. 2006;72:453-458.
- Abidia RF. Oral care in the intensive care unit: A review. J Comtemp Dent Pract. 2007,1:76-82.
- Featherstone JDB, Domejean-Orliaguet S, Jenson L, Wolff M, Young DA. Caries risk assessment in practice for age 6 through adult. J Calif Dent Assoc. 2007;35:703-713.
From Dimensions of Dental Hygiene. March 2011; 9(3): 75-77, 79.