CONGESTIVE HEART FAILURE AND DENTAL MANAGEMENT

General description. Congestive heart failure represents a symptom complex that can be caused by a number of specific disease processes. The three most common causes are:

• hypertensive disease (the dominant cause, preceding cardiac failure in 75% of cases)
• cardiac valvular disease
• coronary artherosclerotic heart disease and its complications

Other causes include thyrotoxicosis, rheumatic fever, congenital heart disease, severe anemia, chronic obstructive lung disease, and pulmonary hypertension.^1-3

Congestive heart failure may involve failure of the left ventricle, right ventricle, or both ventricles. By the time most patients are seen for medical treatment, failure of both sides of the heart has usually occurred.

Epidemiology. Congestive heart failure is one of the most common causes of death in the U.S.^1,4-5

• Over 2 million Americans have congestive heart failure
• About 400,000 new cases occur each year
• Once overt signs and symptoms appear, 50% of the patients will die within 5 years

Clinical Presentation. Evidence of systemic venous congestion may be detected by the presence of distended neck veins, a large tender liver, peripheral edema, ascites, and cyanosis. The retention of fluid will cause weight gain and may increase body girth. In addition, the patient may appear ruddy due to polycythemia and may show clubbing of the fingers.

Exertional dyspnea and fatigue suggest the possibility of beginning left-side heart failure. Symptoms of overt hear failure include:

• orthopnea
• paroxysmal nocturnal dyspnea
• periodic breathing consisting of alternate periods of hyperventilation and apnea and weakness

Treatment. The type of treatment a patient receives, as well as the prognosis, depends on the underlying cardiac disease. In general, medical management comprises attempts to:

• increase cardiac output and decrease the work load on the heart
• improve myocardial contractility
• mobilize excess tissue fluid
• correct the cause whenever possible^3-6

Treatment involves the use of numerous drugs. Those most commonly used are:

• digoxin (increases myocardial contractility)
• diuretics (decrease congestion by reducing the cardiac preload)
• venous vasodilators (reduce the cardiac preload pressure)
• arterial vasodilators (decrease the afterload and increase cardiac output)
• angiotension-converting enzyme (ACE) inhibitors

Medical considerations. Patients with untreated congestive heart failure should not undergo routine dental therapy until they have been referred for medical management.^6-8 Once the congestive heart failure is under control and the underlying cause has been identified, dental care can be provided. In general, patients with congestive heart failure who are under good medical management can receive any indicated treatment as long as the dental management plans deal effectively with the problems presented by the heart failure. Practitioners should, however, be prepared to deal with any of the medical emergencies that could arise during a dental visit.

Problems that must be considered are those that are relative to the specific underlying causes of heart failure. Other problems relating to the management of all cases of congestive heart failure are:

• Patients taking digitalis are prone to nausea and vomiting during dental treatment. Procedures that cause gagging should thus be done with extra care.
• If signs and symptoms of digitalis intoxication (nausea, vomiting, blurred vision, tachycardia, headache, neuralgia, delirium) occur during a dental visit, the patient should be referred for immediate medical evaluation. If surgical procedures are planned or the patient develops an oral infection, dehydration must be prevented, since thrombosis may occur that could result in infarction of various organs.
• If pulmonary congestion develops while the patient is in a supine chair position, the patient should be raised to an upright chair position for the remaining dental treatment.
• If a patient complains of weakness or fatigue during the dental appointment, the appointment should be terminated and the patient rescheduled. It is advisable to discuss the best time for an appointment with the patient's physician.

Local anesthetic with 1:100,000 epinephrine can be used, except in patients with severe arrhythmias. Nitrous oxide-oxygen inhalation sedation should be used with caution.

Side effects of drugs. Drugs commonly used to treat congestive heart failure cause a wide range of side effects. Those that may be apparent during dental treatment include: xerostomia, arrhythmias, nausea, vomiting, anorexia, blurred or yellow vision, headache, weakness, orthostatic hypotension, dehydration, drowsiness, or dizziness.

Oral Complications.⁸

• Infection
• Spontaneous gingival bleeding
• Ecchymoses
• Petechiae

PRIMARY REFERENCE

Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St. Louis, MO: Mosby Year Book, Inc; 1993:341-360.

ADDITIONAL REFERENCES

1. Kannel WB, Thom TJ. Incidence, prevalence, and mortality of cardiovascular disease. In JW Hurst, ed. the Heart, Arteries, and Veins, 7th ed. New York: McGraw-Hill; 1990, 627-638.
   
   
2. Braunwald E. Heart failure. In Wilson JD et al, eds. Harrison's Principles of Internal Medicine, 12th Edition. New York: McGraw-Hill; 1991, 890-900.
   
   
3. Spann JF, Hurst JW. The recognition and management of heart failure. In Hurst JW, ed. the Heart, Arteries, and Veins, 7th ed. New York: McGraw-Hill; 1990, 418-422.
   
   
4. Levy RI. Prevalence and epidemiology of cardiovascular disease. In Wyngaarden JB, Smith LH, eds. Cecil Textbook of Medicine, 17th ed. Philadelphia: WB Saunders; 1985.
   
   
5. Ross RS, et al. Management of the patient with congestive heart failure. In Harvey A, et al, eds. the Principles and Practice of Medicine, 19th edition, New York: Appleton-Century Crofts; 1976.
   
   
6. Sonis ST, Fazio RC, Fang L. Congestive heart failure. In Sonis ST, Fazio RC, Fang L, eds. Principles and Practice of Oral Medicine. Philadelphia: WB Saunders; 1984.
   
   
7. Accepted Dental Therapeutics, 39th ed. Chicago: American Dental Association; 1982.
   
   
8. Lynch MA. Diseases of the cardiovascular system. In Lynch MA, ed. Burket's Oral Medicine, Diagnosis, and Treatment, 8th ed. Philadelphia: JB Lippincott; 1984.