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Cardiovascular Disease
and the Dental Office
A Peer-Reviewed Publication
Written by Fiona M. Collins, BDS, MBA, MA

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Abstract
Cardiovascular disease trends, complications, and associated therapeutics impact dental health and treatment. More
dental patients are being seen with cardiovascular disease
and taking medications for its treatment, and an increasing
number are taking multiple medications and have more
severe cardiovascular disease. Cardiovascular patients
require special consideration with regard to when and
which dental treatment is appropriate and what precautions are required. Alertness to potential oral adverse drug
reactions enables referral of the patient to his physician
and/or cardiologist if these are suspected. Cardiovascular
drugs are also known to have potential drug interactions
ranging from mild to potentially fatal with medications
commonly used or prescribed in the dental setting, and a
current medication history allows selection of appropriate
medications for dental patients. Dental professionals may
be the first line of defense in the detection and referral of
a patient suspected of having cardiovascular disease, an
uncontrolled disease status, or oral adverse drug reactions,
and they have a key role to play in oral and systemic disease
prevention and treatment, in partnership with the patient
and his physician.

Overview
Fifty years ago, it was hoped that modern prevention and
treatments would reduce both the incidence and outcomes
of cardiovascular disease (CVD). Today, cardiovascular
disease is the largest killer in both men and women in
North America, responsible for 38 percent of all deaths,1
and is the most common medical condition that dental
professionals confront.2 Cardiovascular disease trends,
complications, and associated therapeutics affect dental
health and treatment.3 Dental professionals are seeing an
increasing number of patients with symptomatic and hidden cardiovascular disease and a history of acute CVD.
Some factors contributing to these increases include the
2

aging population, increasing survival rates, and patients

who remain ambulatory due to improvements in treatment.
An increase in risk factors such as obesity and diabetes in
the general population is likely to increase the proportion
developing CVD and influence the age at which it occurs
in the future, further compounding the problem.

Prevalence Of Cardiovascular Disease

and Trends
Disease Prevalence
Cardiovascular diseases include high blood pressure,
coronary heart diseases, stroke, heart failure, diseases of the
arteries, such as peripheral arterial disease, congenital heart
defects, and rheumatic heart disease. NHANES (19992002)
data indicates the prevalence of CVD reaches 77.8 percent
of men and 86.4 percent of women over age 75. In the 4554
age group, the prevalence is approximately 36 percent for
both men and women; in the 5564 age group, 52.9 percent
and 56.5 percent, respectively; and in the 6574 age group,
68.5 percent and 75 percent, respectively.4 The incidence of
coronary heart disease (CHD) and diagnosed heart attacks,
Table 1. Prevalence of CHD, Stroke, and Heart Failure in Men

20
75+
age population, %

Upon completion of this course, the clinician will be able

to do the following:
1. Define cardiovascular disease and understand its
occurrence in various demographic groups
2. Understand the need for an updated medical history
and risk factors to consider when screening and
counseling each patient
3. Understand procedural precautions that need
to be taken in the dental office due to a patients
medical history
4. Understand the current drug therapies for
cardiovascular treatment and the implications of these
medications for dental office treatment including
potential side effects, drug interactions, and adverse
oral drug reactions

15
5564 6574
10
5
0

4554
2034

3544

Table 2. Prevalence of CHD, Stroke, and Heart Failure in Women

75+

14
12
age population, %

Educational Objectives

10
8

6574

6
4
2
0

Stroke

2034

3544

4554

5564

Heart Failure

CHD

Tables 1 and 2. Adapted from Heart Disease Statistics 2006 Update,

American Heart Association.

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Population Demographics
Since the prevalence of CVD increases with age, U. S. population demographics represent a negative trend for health. In
2005, there were 78.2 million baby boomers in the country
and 35 million people aged 65 and older. By 2050, the number of people aged 65 and older is projected to reach over
86 million. The 4564 age group is anticipated to increase
by 50 percent, from 62 million to 93 million.10 Barring unforeseen changes in lifestyle, prevention, and intervention,
the absolute number of patients with CVD will increase.
Furthermore, it is estimated from studies that those over 55
have a 90 percent risk of developing hypertension.11
Cardiovascular Disease Mortality and Morbidity
Cardiovascular disease is the leading cause of death in
adult men and women. Preliminary data from the CDC
and NHLBI indicates that cardiovascular disease was
responsible for the deaths of 427,000 men and 484,000
women in 2003 (the next closest single cause of death was
cancer, with 287,000 and 268,000 deaths, respectively).12
Of the approximately 0.9 million deaths due to cardiovascular disease in 2003, 53 percent were due to coronary
heart disease (Table 4).
The number of patients surviving strokes increased
by almost 0.5 million between 1988 and 2002, reaching
an estimated 6.78 million; and for myocardial infarction,
by more than a million, at 4.96 million survivors (up from
3.85 million).13 Antihypertensive medications in combination with lifestyle adjustments in patients with high blood
pressure have reduced myocardial infarction by 2025
percent, stroke by 3540 percent, and heart failure by over
50 percent.14 High mortality and morbidity rates exist
for heart failure, underscored by the Framingham study,
which found a 25 percent mortality rate at two years.15
Atrial fibrillation is the most common risk factor for
stroke and increases the risk of experiencing an episode
by 500 percent compared to the general population.16
Mortality rates for congenital heart disease have declined,
leading to increased numbers of children surviving
into adulthood, with implications for future dental and
medical treatments.17
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Table 3. U.S. Population Age 45 and Over

No. of people in the U.S.,
thousands

stroke, PAD, and heart disease all increase in prevalence with

age (Tables 1 and 2).5 High blood pressure, which is also related to future acute and severe chronic CVD,6 increases in
prevalence steadily with age, affecting over 60 percent of the
population 6574 years of age, and 69 percent of men and 83
percent of women 75 years of age and older.7 Atrial fibrillation
affects an estimated 2.2 million people in the United States,
70 percent of whom are aged 6585 and affects 10 percent
of patients in their 80s.8 Angina has been estimated to affect
around 1 percent of the population.9 In addition, surgery has
become common for the treatment of valval disease, congenital heart disease, and end-stage heart disease.

2000
2050

60,000
50,000
40,000
30,000
20,000
10,000
0

Men
4564

Women
4564

Men
over 65

Men
over 65

Table 4. Percentage of Cardiovascular Deaths by Disease Type

Coronary Heart Disease

53%

18%

Other
Stroke
Heart Failure

17%
6%

High Blood Pressure

6%

Adapted from Heart Disease Statistics 2006 Update, American Heart Association.

These increased survival rates mean that there are more

patients attending dental offices with a history of severe
CVD and an increase in the number of patients at risk for
severe episodes due to underlying pathologies.

Cvd Manifestation and Patient Presentation

Patients attending the dental office who have cardiovascular disease fall into two basic groups those who are
aware of their condition and those who are not. In the latter group, the disease may be asymptomatic or, if not, the
patient is aware of the symptoms but not aware that these
symptoms are related to cardiovascular disease.
Hypertension Despite being the most commonly
diagnosed medical condition in the United States, hypertension has low patient awareness. Within the population
with high blood pressure, estimates from the CDC indicate that only 49 percent of ages 2039 are aware of their
blood pressure status. That number rises to 73 percent in
the over-40 demographic. Other studies have indicated
that as few as 32 percent of patients are aware of their
blood pressure status18 and that it is controlled in under
50 percent of individuals suffering from it.19,20 Hypertensive patients present with systolic and diastolic pressures
of at least 140mmHg and 90mmHg, respectively, and it is
now believed that the risk starts above 115/75mmHg.21
3

The majority of patients with straightforward hypertension are asymptomatic22 until the pressure is high for an
extended period of time. While asymptomatic, the patient
is at increased risk for further disease including stroke,
myocardial infarction, ischemic heart disease, unstable
angina, and renal damage. Early symptoms can include
fatigue, nose bleeds, palpitations, facial flushing, and
changes in vision.23 Awareness, treatment, and control
also vary by age, ethnicity, and gender.24
Ischemic Heart Disease The majority of patients with
stable ischemic heart disease who present in the dental office either have angina pectoris or heart failure. In ischemic
heart disease, an imbalance exists between the supply of
and demand for oxygen, and the results can range from
angina to myocardial infarction and sudden death.
Angina Pectoris The patient suffering from this
condition presents with a deep pain substernally that
can be relieved with medication. Attacks usually
last about five minutes and can be precipitated by
stress, increased blood pressure, and exertion.
Patients should be asked whether angina attacks only
happen upon exertion (stable angina) or while at
rest (unstable angina), as this has implications for
any potential dental treatment. Angina occasionally
presents as mandibular pain, possibly leading the
patient to believe that he has a dental problem.
Myocardial Infarction This involves ventricular muscle death and varies from small areas that
will heal to large infarctions that result in death and
high morbidity. There are not always warning signs
of this condition.25
Congestive Heart Failure Signs and symptoms vary
depending upon the areas of the heart affected and can
range from peripheral edema (when located in the right
ventricle, sometimes manifested by swollen ankles) to
pulmonary symptoms (when the left ventricle is affected).
The heart does not pump effectively, and there is an increased heart rate and intravascular volume that result in
hypertrophy of the myocardium, redirection of blood from
other areas of the body, and cardiac dilation, causing further deterioration of the heart.26
Atrial Fibrillation This can be asymptomatic or present with palpitation, fatigue, increased urination, and
lightheadedness, or more severely with stroke, edema,
heart failure, or shortness of breath. Signs include heart
rates that are irregular and changes to heart sounds and
jugular venous pulse. The most common cause of atrial
fibrillation in the United States is hypertension.27
Congenital Heart Disease A common birth defect,
more children survive today than in the past to attend for
4

dental treatment as children and later as adults with septal

defects and stenosis.28

Risk Factors
Risk factors for cardiovascular disease include age, race,
family history, lack of exercise, sodium intake, obesity,
smoking, high LDL and low HDL cholesterol levels, hypertension, heavy alcohol consumption, cocaine use,
diabetes, previous history of CVD, and gender. Recent
research also shows an association between periodontal
disease and cardiovascular disease.29
Smoking prevalence in the American population over
age 18 varies by ethnicity and gender, ranging from 17.8
percent and 11.3 percent in Asian men and women, respectively, to 37.3 percent and 33.4 percent for American
Indian or Alaska Native men and women, with other
major ethnic groups falling within this range.30
High LDL and low HDL cholesterol levels have also
been shown to vary by ethnic group, with the highest
overall levels in non-Hispanic Whites.
Diabetes is present in 7 percent of the U.S.
population, with 14.6 million diagnosed cases and
6.2 million undiagnosed cases. Its prevalence varies
by age and ethnicity, with nonHispanic Whites
having the lowest prevalence among major ethnic
groups.31 The Framingham study estimates the risk
of a patient developing coronary heart disease over a
10-year period based upon several risk factors, and
is a useful reference point for dental professionals
in assessing the risk and likelihood of CHD in their
patient population.
At age 55, nonsmokers with normal blood pressure
and cholesterol levels and who are not diabetic have a
5 percent risk of coronary heart disease over 10 years.
In contrast, smokers with blood pressure at or above
140/90 and HDL 40 or less and who are diabetic have
a 37 percent risk if male and 27 percent risk if female
of developing the disease over 10 years.32

Identification of Cvd and At-risk Patients

in the Dental Office
Medical History
A thorough medical history is necessary for all prospective
patients. It should include:
A current and previous history of medication use
(including self-medication)
Medical conditions, as well as any symptoms the
patient is experiencing (including shortness of breath
and chest pain)
A family history for medical conditions, including
cardiovascular disease
Regular medical record revisions every time the
patient is recalled
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 Medical record revisions in the event of a change in

the patients medical condition or use of medication
since the previous visit
Risk Factors and Testing
Risk factors to consider when screening patients are diabetes, obesity, and cholesterol levels, as well as alcohol, tobacco smoking, recreational drug use (particularly cocaine)
and any current or previous use of drugs such as ephedra or
fen-phen (which is associated with valvular defects). Recreational use of cocaine has been shown to cause myocardial
infarction, arrhythmias, heart blockage, and other serious
cardiovascular effects, including death.33
A C-reactive protein test is an option to help screen patients at risk. High C-reactive protein levels are produced in
response to systemic inflammation, including of periodontal
origin, and are associated with an increased risk of myocardial infarction and CVD. Depending upon the medical history, it may also be prudent to refer the patient to a medical
clinic for fasting blood glucose tests for diabetes screening.
Blood Pressure and Counseling
Blood pressure and pulse measurements at patient recall
appointments enable patients with high readings to be
referred to their physician immediately for diagnosis and
treatment. If patients have high blood pressure or known
risk factors, it has been recommended that their blood
pressure be taken at every visit.34,35

Considerations for Dental Treatment

Patients with a suspect medical history, untreated cardiovascular disease, high blood pressure, high C-reactive protein levels, or any uncertain disease status can be referred
to their physician. Depending upon the patients medical
history, risk factors, and vital signs, the physician and/or
cardiologist should be consulted prior to treatment. It has
been recommended that patients with a history of myocardial infarction in the previous six months should not be
treated as outpatients, and that elective dental treatment
should be postponed on patients with severe or uncontrolled high blood pressure.36,37 If a patient reports angina
attacks at rest that are changing or increasing in severity,
or that were diagnosed within the last 30 days, it has been
recommended that they not receive elective dental care until their angina is stable,38 and patients with stable angina
should be advised to bring their medication with them in
case it is needed during treatment.
Minimizing stress achieved through patient management, pain-free dentistry techniques, and, where appropriate, the use of sedatives and analgesics (taking into
consideration potential drug interactions) is important.
It has been recommended that appointments should be
less than one hour to minimize stress, and traditionally in
the morning, although research now suggests late morning
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or early afternoon may be better. Patients with congestive

heart failure should not be placed in a supine position, and
for other patients, the chair should be raised gently.3942
Separate consideration is required for patients with valval disease, heart transplants, prosthetic valves, previous
bacterial endocarditis, pacemakers, or implanted defibrillators. Guidelines are available from the American Heart
Association regarding the need for antibiotic prophylaxis
to prevent bacterial endocarditis for heart conditions, and
they are not addressed further here.43

Cvd Medications
CVD drug therapy and potential side effects, interactions,
and oral adverse drug reactions are important for the dental
office setting, with implications for treatment.
Currently Available Drug Therapies
Drug therapies for cardiovascular disease are complex and
may involve combinations of drugs. Classes of drugs used
in the treatment of cardiovascular disease include alpha
and beta adrenergic blockers, calcium channel blockers,
sodium channel blockers, potassium channel blockers, diuretics, ACE inhibitors, phenytoin, anticoagulants, angiotensin inhibitors, nitrates, platelet aggregation inhibitors,
and recently statins. Many of these are used to treat several
cardiovascular diseases. Combination drugs containing
both diuretics and other antihypertensives have recently
been introduced to treat hypertension. Combination calcium channel blockers and ACE inhibitors have also been
introduced to treat CVD.44 In heart transplant patients,
immunosuppressives are used to prevent rejection.
Which classes of drugs and specific drugs patients are
or were taking is essential information, as is when and for
how long they were or are taking them, potential interactions and side effects for that class of drugs or specific drug,
and potential oral adverse drug reactions. If necessary, the
PDR or a similar reference resource can be reviewed (including the product insert for the drug, if the patient has it)
and/or the patients physician can be consulted. A number
of specific side effects and potential drug interactions in
the dental office are addressed here.

Implications of CVD Medication for

Dental Office Treatment
Side Effects and Drug Interactions
Statins The introduction of statins has had a significant impact on the treatment of cardiovascular disease.45
While generally considered safe, statins potential side
effects and drug interactions include peripheral neuropathy and muscular problems ranging from myalgia to
rhabdomyolysis, which is potentially fatal and involves
lysis of the muscle cell walls and systemic release of the
cells contents.46
5

There have been reports of drug interactions between

statins and erythromycin prescribed prior to dental treatment. In one patient prescribed erythromycin prior to
treatment, the patient developed multiple organ toxicity
including acute renal failure, pancreatitis, and rhabdomyolysis. In three other cases, rhabdomyolysis was reported
in all three, and acute renal failure in two, patients.47 While
rare, a statin-erythromycin interaction is potentially fatal.
The potential for interaction varies with the specific
statin-antiobiotic combination. Three other antibiotics used
in dental offices and known to have potential adverse drug
interactions with statins are clarithromycin, azithromycin,
and telithromycin.48
Azole antifungal agents are also known to have the
ability to interact with statins. These antifungals include
miconazole, fluconazole, and itraconazole, as well as ketoconazole.4952 A case of rhabdomyolysis has been reported
with concurrent use of a statin and fluconazole.53
Miconazole, fluconazole, and itraconazole are treatments
for oral and other candidal infections, and the antiobiotics
known to have the potential for statin drug interactions are
used in dental settings.54 This underlines the importance of a
current medication history for dental patients, here with regard to statins prior to determining which antifungal agents
or antibiotics should be avoided and which are appropriate in
the treatment and prevention of oral and systemic disease.
Anticoagulants Anticoagulants are widely used to
treat deep vein thrombosis, heart failure, atrial fibrillation,
valvar disease, and prosthetic heart valves. Depending
upon the indication, the patient may be on anticoagulants
temporarily or for life. Intravenous heparin is used to help
prevent stroke recurrence in patients with atrial fibrillation.
Warfarin is the most commonly used for outpatients.55 The
patients physician should be contacted to find out whether
anticoagulant dosage can or should be adjusted prior to
dental treatment, or whether a careful surgical technique
and wound closure, along with the use of pressure and
local hemostats, will be sufficient when surgery is performed.56,57 Certain antibiotics, including metronidazole,
tetracyclines, erythromycin, and clarithromycin, increase
prothrombin time, thereby affecting clotting. It has been
recommended that these should not be used in patients
who are or recently were on anticoagulants.58
Immunosuppressives Used in heart transplant patients, immunosuppressives can mask early infections.
With vigilance these may be detected and treated. If treating a heart transplant patient, the patients cardiologist
should be consulted.59,60
Vasoconstrictors in the Dental Office Vasoconstrictors are used in local anesthetics, retraction cords, and as
hemostats. Vasoconstrictors added to local anesthetics
6

improve the depth of local anesthesia and its duration and

reduce bleeding at the site.61
Epinephrine stimulates both alpha and beta adrenergic
receptors. Beta receptors increase the heart rate, conduction
velocity, and contractile force of the cardiovascular system.
Increased or decreased peripheral resistance occurs, with
increases caused by constriction (alpha receptor activity)
and decreases by dilation (beta receptor activity) of veins
and coronary arterioles. Levonordefrin is more specific
increasing peripheral resistance and reducing cardiac output and heart rate.62 Depending upon the antihypertensive
drug involved, the use of vasoconstrictors can lead to hypertension, hypotension, or the onset of angina.63
Vasoconstrictors interact with several classes of drugs
used to treat CVD, including beta blockers, antiadrenergic
drugs and digitalis glycosides.64 It has been recommended
that in patients with significant disease reduced doses or
no vasoconstrictor should be used,65,66 clinicians strongly
consider strict avoidance of vasoconstrictor use in patients
with coronary heart disease, heart failure, tachyarrhythmias,
or stroke, and that the use of vasoconstrictors in patients
on adrenergic blockers should be avoided.67 Where local
anesthetics containing vasoconstrictors are used in patients
with CVD, there are guidelines limiting the amount of
vasoconstrictor to the equivalent of two to three carpules of
lidocaine (1:100,000 epinephrine).68 The American Heart
Associations position from 1991 on the use of vasoconstrictors in local anesthetic for dental treatment in general is
that if they are necessary, care should be taken to use the
smallest effective dose and only when it is clear that the
procedure will be shortened or the analgesia rendered more
profound. When a vasoconstrictor is indicated, extreme care
should be taken to avoid intravascular injection.69
Retraction cord impregnated with epinephrine exposes
patients to uptake of potentially large amounts of the vasoconstrictor systemically. Its use is controversial, and it has
been recommended that dental professionals do not use
epinephrine-impregnated retraction cord in patients with
cardiovascular disease.70
Nonsteroidal Antiinflammatory Drugs (NSAIDS)
NSAIDS can interfere with the regulation of blood
pressure. Their use interferes with prostaglandin and prostacyclin production, which are involved in the regulation
of blood pressure.71
Opioids Opioids used in dentistry for sedation, pain
relief, and general anesthesia carry risks for patients on
antihypertensive medication and can cause hypotension
due to their additive effect.
Oral Adverse Drug Reactions
In addition to potential side effects and drug interactions,
cardiovascular drugs have been associated to varying
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degrees with adverse oral drug reactions. The exact incidence of adverse drug reactions and oral adverse drug
reactions is not known.72 Women have been reported as
having a higher incidence than men. This may be due to a
higher reporting rate by women, more use of medications,
and/or hormonal and pharmacological factors.73,74 Oral
adverse drug reactions associated with cardiovascular
drugs include xerostomia, gingival overgrowth, aphthae/
oral ulcerations, scalded mouth syndrome, taste disturbances, cheilitis, glossitis, angioedema, thrombocytopenia, epithelial sloughing, and lichenoid/lichen planus
reactions. Drugs proven, likely, or suspected of causing
these oral adverse drug reactions include all of the major
classes of CVD drug therapies: alpha and beta adrenergic blockers, ACE inhibitors, calcium channel blockers,
diuretics, antiarrhythmics, statins, potassium-channel
openers, and angiotensinreceptor blockers. Certain CVD
drugs have proven associations with oral adverse drug
reactions (Table 6).7580
Table 6. Oral Adverse Drug Reactions
Condition

Cardiovascular Drug

Xerostomia

Alpha-adrenergic blockers
Beta-adrenergic blockers
Lisinopril
Sodium channel blockers
Calcium channel blockers
Diuretics
Anti-cholesterol drugs

Gingival Overgrowth

Calcium-channel blockers
Phenytoin
Cyclosporin
(immunosuppressive drug)

Taste Disturbances

Calcium channel blockers

Captopril, Enalapril
(ACE inhibitors)

Angioedema

Beta-adrenergic blockers
ACE inhibitors
Angiotensin II antangonists

Glossitis, Stomatitis, Gingivitis Anti-cholesterol drugs

Cvd and the Role of the Dental Professional

The dental professionals role with CVD patients may
variously include detection of CVD, patient referral, education and counselling, postponement of dental treatment,
and prevention and treatment of oral conditions.
Dental professionals are in a position to detect blood
pressure issues during routine or screening visits and to
counsel patients on risk factors such as diet, smoking,
and lifestyle. Where cardiovascular disease is suspected
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Figure 1. Patient with severe gingival hyperplasia

Image courtesy of Dr. Richard Nejat

but not being treated or controlled, the dentist and dental

hygienist can refer the patient to treating physician. The
use of a C-reactive protein test may be the first indication
the patient has of his condition, and referring the patient
to his physician as a result of this and other screening is a
service to the patient.
An understanding of individual patient medication
and cardiovascular health status enables appropriate treatment and avoidance of potential drug interactions. The
awareness of oral adverse drug reactions to cardiovascular
medications and detection of a suspected reaction enables
dental professionals to refer the patient back to his physician or cardiologist, who can then determine whether it is
appropriate to prescribe an alternative therapy or to continue with the same treatment. Calcium channel blockers
can cause gingival hyperplasia so severe that the patients
physician may prescribe a different drug.81
Managing and treating the conditions experienced as
oral adverse drug reactions alleviates discomfort, promotes
healing, and where the drug therapy in question must be
continued, is important to help prevent further oral disease.
Xerostomia is one of the more common reactions and, if of
more than transient duration, can result in rapidly advancing carious lesions. Appropriate therapy for xerostomia
can be prescribed, including the use of in-office and home
fluorides to help prevent hard tissue destruction, antimicrobials, and saliva replacements, and the patient can be
educated and counselled. Other conditions, such as oral
ulcerations, can be treated to alleviate pain and promote
healing. Topical gels or octylcyanoacrylate liquid (SootheN-Seal, Colgate Oral Pharmaceuticals) can be applied to
relieve the pain of oral ulcerations, and some have been
shown to help promote healing. Oral rinses (Rincinol,
Sunstar Butler, and Gelclair, OSI Pharmaceuticals) are
also available to relieve pain and treat oral ulcerations.
These are particularly useful where there are multiple
widespread intraoral ulcerations. Glossitis, cheilitis, and
gingivitis may also require treatment. Gingival hyperplasia physically impacts the patients ability to perform
adequate oral hygiene and may necessitate more frequent
7

professional prophylaxis and guidance. Maintaining periodontal health and good oral hygiene, educating the patient
on this, and recommending specific oral hygiene aids and
devices are important components of care for the patient
with cardiovascular disease.
Should a cardiovascular emergency occur in patients
during dental treatment, the dental team will be the first
to deal with it. CPR and emergency training must be current, and emergency medical equipment and kits must be
up to date, complete, and readily available for use while
emergency services are en route.

Summary
The number of cardiovascular patients presenting in dental offices is increasing, patients are surviving serious cardiovascular disease, and treatment of CVD is increasingly
complex. By understanding the risks for these patients and
the implications of relevant treatment and drugs, dental professionals can provide dental care tailored to the
individual patients circumstances that is both safe and
effective. Drug interactions can be avoided and treatment
provided for oral reactions to cardiovascular drugs. The
dental professional may be the first line of defense in the
detection and referral of a patient suspected of having CVD
and which the patient may be unaware of, or of a patient
whose disease is not being treated or does not appear to be
controlled. Cardiovascular disease status influences the
care and treatment of dental patients and is an important
determinant in treatment planning, acceptance of patients
for elective treatment, and treatment methodology.

References

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J Med. 2005;352(16):16851695.
2. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
dental practitioner. British Dental Journal 2000;189:297302.
3. Waters, B.G. Providing dental treatment for patients with cardiovascular disease.
Ontario Dentist 1995 JulyAug:2532.
4. American Heart Association, Heart Disease and Stroke Statistics 2006 Update.
Available at: www.americanheart.org/presenter.jhtml?identifier=3018163.
Accessed April 12, 2006.
5. Ibid.
6. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.
7. American Heart Association, Heart Disease and Stroke Statistics 2006 Update.
Available at: www.americanheart.org/presenter.jhtml?identifier=3018163.
Accessed April 12, 2006.
8. Feinberg, W.M. et al. Prevalence, age distribution and gender of patients
with atrial fibrillation. Analysis and implications. Arch Intern Med. 1995 Mar
13;155(5):469473.
9. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
dental practitioner. British Dental Journal 2000;189:297302.
10. Available at: www.census.gov /ipc/www/usinterimproj/natprojtab02a.
Accessed April 14, 2006.
11. 7th report of the Joint National Committee on Prevention, Detection, Evaluation
and Treatment of High Blood Pressure. JAMA 2003;289;2560 2572.
12. American Heart Association, Heart Disease and Stroke Statistics 2006 Update.
Available at: www.americanheart.org/presenter.jhtml?identifier=3018163.
Accessed April 12, 2006.

13. Muntner, P., et al. Trends in the prevalence, awareness, treatment and control
of cardiovascular disease risk factors among noninstitutionalized patients with
a history of myocardial infarction and stroke. Am J Epidemio 2006 Apr5; (Epub
ahead of print).
14. Neal, B.,MacMahon, S., Chapman, N. Effects of ACE inhibitors, calcium
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designed overviews of randomized trials. Blood pressure lowering treatment
trialists collaboration, Lancet 2000;356:19551964.
15. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
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16. Verheugt, F.W. Stroke prevention in atrial fibrillation. Neth J Med 2006
Feb;64(2):3133.
17. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
dental practitioner. British Dental Journal 2000;189:297302.
18. Lee, Y.S. Awareness of blood pressure among older adults: A cross-sectional
descriptive study. Int J Nurs Stud 2006 Mar 26 (Epub).
19. Am J Managed Care 2005 Nov;11 (13 Suppl):S383S385.
20. Colhoun, H.M., Dong, W., Poulter, N.R. Blood pressure screening, management
and control in England 1994. J Hypertension 1998;16:747753.
21. The seventh report of the Joint National Committee on Prevention, Detection,
Evaluation, and Treatment of High Blood Pressur. Bethesda, MD: NIH/
NHLBI;May 2003.
22. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.
23. Little, J.W., et al (eds). Dental management of the medically compromised
patient, 2002, ed. 6. St. Louis:Mosby, Inc.
24. Heart Disease Statistics 2006 Update. Available at www.americanheart.org.
Accessed April 12, 2006.
25. Waters, B.G. Providing dental treatment for patients with cardiovascular disease.
Ontario dentist 1995 JulyAugust;2432.
26. Ibid.
27. Russo. Overview of the contemporary evaluation and management of patients
with atrial fibrillation: what every general practitioner should know. 28. Available
at:www.americanheart.org/downloadable/heart/1075_russo.pdf.
28. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
dental practitioner. British Dental Journal 2000;189:297302.
29. Slavkin, H.C. Does the mouth put the heart at risk? J Am Dent Assoc
1999;130:109113.
30. MMWR 2005;54(44).CDC/NCHS.
31. www.cdc.gov/diabetes/pubs/estimates05.htm#prev4. Accessed May 8, 2006.
32. American Heart Association, Heart Disease and Stroke Statistics 2006 Update.
Available at: www.americanheart.org/presenter.jhtml?identifier=3018163.
Accessed April 12, 2006.
33. Kloner, R.A., et al. The effect of acute and chronic cocaine use on the heart.
Circulation 1992;85(2):407419.
34. Waters, B.G. Providing dental treatment for patients with cardiovascular disease.
Ontario dentist 1995 JulyAugust;2432.
35. Glick, M. New guidelines for prevention, detection, evaluation, and treatment of
high blood pressure. J Am Dent Assoc 1998;129:15881594.
36. Aubertin, M.A. The hypertensive patient in dental practice: Updated
recommendations for classification, prevention, monitoring, and dental
management. Gen Dent 2004 NovDec;544552.
37. Waters, B.G. Providing dental treatment for patients with cardiovascular disease.
Ontario Dentist 1995 JulyAug:2532.
38. MacAfee, K.A. et al. Angina pectoris diagnosis and treatment in the outpatient
setting. Compendium 1993;14:892896.
39. Aubertin, M.A. The hypertensive patient in dental practice: Updated
recommendations for classification, prevention, monitoring, and dental
management. Gen Dent 2004 NovDec;544552.
40. Academy Report. Periodontal management of patients with cardiovascular
diseases. J Periodontol 2002;73:954968.
41. Waters, B.G. Providing dental treatment for patients with cardiovascular disease.
Ontario Dentist 1995 JulyAug:2532.
42. Raab, F.J. et al. Interpreting vital sign profiles for maximizing patient safety
during dental visits. J Am Dent Assoc 1998;129:461469.
43. Dajani, A.S. et al. Prevention of bacterial endocarditis. Recommendations of the
American Heart Association. JAMA 1997;277:17941801.

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44. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.
45. Wong, P.W., Dillard, T.A., Kroenke, K. Multiple organ toxicity from addition
of erythromycin to long-term lovastatin therapy. South Med J 1998
Feb;91(2):202205.
46. Pasternak, R.C., et al. ACC/AHA/NHLBI clinical advisory on the use and safety of
statin. J Am Coll Cardiol 2002;40:567572.
47. Ibid.
48. Stevenson, H., Longman, L.P., et al. The statins: drug interactions of significance
to the dental practitioner. Dent Update 2006;33:1420.
49. Janssen-Cilag, Sep 2003. Summary of product characteristics, Daktarin oral gel.
50. Janssen-Cilag, Sep 2003. Summary of product characteristics, Nizoral.
51. Pfizer, Sep 2002. Summary of product characteristics, Diflucan.
52. Janssen-Cilag, Nov 2002. Summary of product characteristics, Sporanox.
53. Shaukat, A. et al. Simvastatin-fluconazole causing rhabdomyolysis. Ann
Pharmacother 2003;37:10321035.
54. Stevenson, H., Longman, L.P., et al. The statins: drug interactions of significance
to the dental practitioner. Dent Update 2006;33:1420.
55. Russo. Overview of the contemporary evaluation and management of patients
with atrial fibrillation: what every general practitioner should know. Available
at:www.americanheart.org/downloadable/heart/1075_russo.pdf. Accessed
April 12, 2006.
56. Academy Report. Periodontal management of patients with cardiovascular
diseases. J Periodontol 2002;73:954968.
57. Weibert, R.T. Oral anti-coagulation therapy in patients undergoing dental
surgery. Clin Pharmacy 1992;11:857864.
58. Glasser, S. The problems of patients with cardiovascular disease undergoing
dental treatment. J Am Dent Assoc 1977;94:11581162.
59. Rees, D.D. Periodontal considerations in patients with bone marrow or solid
organ transplants. In: Rose, L.F. et al eds. Periodontal Medicine. Toronto: Decker
Inc.;1999.
60. Academy Report. Periodontal management of patients with cardiovascular
diseases. J Periodontol 2002;73:954968.
61. Naftalin, L.W., Yagiela, J.A. Vasoconstrictors: indications and precautions. Dent
Clin N Am 2002;46:733746.
62. Jastak, J.T., Yagiela, J.A., Donaldson, D. Local anesthesia of the oral cavity.
Philadelphia:WB Saunders 1995;6185.
63. Aubertin, M.A. The hypertensive patient in dental practice: Updated
recommendations for classification, prevention, monitoring, and dental
management. Gen Dent 2004 NovDec;544552.
64. Naftalin, L.W., Yagiela, J.A. Vasoconstrictors: indications and precautions. Dent
Clin N Am 2002;46:733746.
65. Jowett, N.I., Cabot, L.B. Patients with cardiac disease: considerations for the
dental practitioner. British Dental Journal 2000;189:297302.
66. Pallasch, T.J. Vasoconstrictors and the heart. J Calif Dent Assoc
1998;26(9):668673.
67. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.
68. Academy Report. Periodontal management of patients with cardiovascular
diseases. J Periodontol 2002;73:954968.
69. Dajani, A.S., et al. Cardiovascular disease in dental practice. American Heart
Association, Dallas, 1991.
70. Pallasch, T.J. Vasoconstrictors and the heart. J Calif Dent Assoc
1998;26(9):668673.
71. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.
72. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev

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Oral Biol Med 2004;15(1):2846.

73. Shah, M.R., et al. Sex-related differences in the use and adverse effects of
angiotensin-converting enzyme inhibitors in heart failure: the study of patients
intolerant of converting enzyme inhibitors registry. Am J Med 2000;109:489492.
74. Tran, C., et al. Gender differences in adverse drug reactions, J Clin Pharmacol
1998;38:10031008.
75. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev
Oral Biol Med 2004;15(1):2846.
76. Sreebny, L.M., Schwartz, S.S. A reference guide to drugs and dry mouth, 2nded.
Gerodontology 1997;13;3337.
77. Wright, J.M. Oral manifestations of drug reactions, Dent Clin North Am
1984;28:529379.
78. Baum, B., Ferguson, M., et al. Medication-induced salivary gland dysfunction.
Perspectives on the 3rd World Workshop on Oral Medicine. BMC Medical Services,
2000:288292.
79. Bullon, P., et al. Clinical assessment of gingival hyperplasia in patients treated
with nifedipine. J Clin Periodontol 1994;21:256259.
80. Torpet, L.A., et al. Oral adverse drug reactions to cardiovascular drugs. Crit Rev
Oral Biol Med 2004;15(1):2846.
81. Boyd, B.C. Review of antihypertensive agents for the dental clinician. Alpha
Omegan 2003 Dec;96(4):4752.

Author Profile
Dr. Fiona M. Collins has over 20
years of clinical, marketing, education and training, and professional relations experience. She
has practiced as a general dentist
for 13 years, written and given
CE courses to dental professionals and students, and conducted
market research projects. Dr.
Collins is a past- member of the Academy of General
Dentistry Health Foundation Strategy Board and has been
a member of the British Dental Association, the Dutch
Dental Association, and the American Dental Association.
In her spare time she can be found walking in the foothills
of Colorado with her husband and dog, or playing music.
Dr. Collins holds a dental degree from Glasgow University
and an MBA and MA from Boston University.

Disclaimer
The author of this course has no commercial ties with the
sponsors or the providers of the unrestricted educational
grant for this course.

Reader Feedback
We encourage your comments on this or any PennWell course.
For your convenience, an online feedback form is available at
www.ineedce.com.

Questions
1. Cardiovascular disease is responsible
for what percentage of all deaths in
North America?
a. 77.8
b. 38.0
c. 36.0
d. 60.0

2. Which of these is NOT considered a

cardiovascular disease?
a. Congenital heart defects
b. High blood pressure
c. Stroke
d. All of these are cardiovascular diseases

3. According to NHANES data from

2002, men over age 75 are more
likely to have CVD than women of
the same age.
a. True
b. False

4. In this same report, the prevalence of

CVD in the 4554 age bracket is 36
percent for men and ______ percent
for women.
a. 38
b. 60
c. 36
d. 10

5. Angina has been estimated to affect

what percent of the population?
a. 1.0
b. 0.1
c. 10.0
d. None of these

6. According to estimates, by 2050 the

over-65 population in the United
States is expected to exceed:
a. 78.2 million
b. 35 million
c. 86 million
d. 62 million

7. According to estimates, those over

age 55 have a ____ percent chance of
developing hypertension.
a. 60
b. 36
c. 90
d. 50

8. The CDC and NHLBI estimate that

in 2003, cardiovascular disease was
responsible for approximately _____
deaths in the United States.
a. 911,000
b. 427,000
c. 484,000
d. 287,000

9. Of these deaths, approximately what

percentage were due to coronary
heart disease?
a. 25 percent
b. 35 percent
c. 53 percent
d. 63 percent

10. Hypertension is known as the silent

killer because:
a. Its symptoms are impossible to detect
b. Relatively few Americans are aware of their
blood pressure status
c. Until recently, the medical community has
denied its existence
d. All of the above

10

11. Hypertensive patients are those

whose blood pressure is at least:
a. 140/75
b. 140/90
c. 115/90
d. 115/75

12. Angina pectoris involves:

a. A deep substernal pain

b. Ventricular muscle death
c. Changes in heart sounds and jugular
venous pulse
d. Hypertrophy of the myocardium

13. Myocardial infarction involves:

a. A deep substernal pain
b. Pulmonary symptoms
c. Ventricular muscle death
d. Hypertrophy of the myocardium

14. Congestive heart failure in the left

ventricle involves:
a. Changes in heart sounds and jugular
venous pulse
b. Pulmonary symptoms
c. Ventricular muscle death
d. Hypertrophy of the myocardium

15. Atrial fibrillation involves:

a. Changes in heart sounds and jugular

venous pulse
b. Pulmonary symptoms
c. Ventricular muscle death
d. Hypertrophy of the myocardium

16. Which of these is a risk factor

for CVD?
a. Diabetes
b. Cocaine use
c. Heavy alcohol consumption
d. All of the above

17. According to the article, the

American demographic least likely to
be at risk of CVD from tobacco use is:
a. Caucasian men
b. Asian women
c. Native American men
d. Alaska Native women

18. Over a period of 10 years, a nondiabetic 55-year-old male who smokes

is more than _____ times more likely
to develop coronary heart disease
than a non-diabetic 55-year-old male
who does not smoke.
a. 4
b. 5
c. 6
d. 7

21. A patient found to have high blood

pressure before dental treatment
should be referred to his physician for
diagnosis and treatment:
a. Immediately
b. After the dental procedure has been completed
c. Only if the patient doesnt feel well
d. b and c

22. Patients with _______ should not be

placed in a supine position.
a. Congenital heart disease
b. Congestive heart failure
c. Angina
d. Atrial fibrillation

23. In addition to the Physicians Desk

Reference, what other resource does
the author recommend for learning
about a medications side effects and
possible interactions?
a. The patients physician
b. Any physician
c. The medications product insert
d. a and c

24. Adverse interactions between statins

and erythromycin can potentially
result in which of the following?
a. Renal failure
b. Rhabdomyolysis
c. Pancreatitis
d. All of the above

25. According to the article, in at least

one reported instance the interaction
of a statin and fluconazole has
resulted in:
a. Renal failure
b. Rhabdomyolysis
c. Pancreatitis
d. All of the above

26. Tetracyclines should not be used

in patients who are or recently were
on anticoagulants.
a. True
b. False

27. In patients with CVD, which of the

following should NOT be used?
a. All vasoconstrictors.
b. Epinephrine-impregnated retraction cord
c. Levonordefrin-impregnated retraction cord
d. Lidocaine

28. The use of _______ interferes with prostaglandin and

prostacyclin production.
a. NSAIDS
b. Retraction cords
c. Opioids
d. Epinephrine

19. A complete medical history should

include any self-medication on the
part of the patient in addition to
prescribed medications.

29. Which of these can cause

hypotension in patients on
antihypertensive medication?

20. Recreational cocaine use has been

shown to cause:

30. Prolonged xerostomia has been

known to cause:

a. True
b. False

a. Myocardial infarction
b. Arrhythmia
c. Death
d. All of the above

a. NSAIDS
b. Retraction cords
c. Opioids
d. Epinephrine

a. Oral ulcerations.
b. Carious lesions
c. Aphthae
d. Glossitis

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ANSWER SHEET

Cardiovascular Disease and the Dental Office

Name:

Title:

Address:

E-mail:

City:

State:

Telephone: Home (

Office (

Specialty:

ZIP:
)

Requirements for successful completion of the course and to obtain dental continuing education credits: 1) Read the entire course. 2) Complete all
information above. 3) Complete answer sheets in either pen or pencil. 4) Mark only one answer for each question. 5) A score of 70% on this test will earn
you 4 CE credits. 6) Complete the Course Evaluation below. 7) Make check payable to PennWell Corp.
Mail completed answer sheet to

Educational Objectives

Academy of Dental Therapeutics and Stomatology,

1. Define cardiovascular disease and understand its occurrence in various demographic groups

A Division of PennWell Corp.

P.O. Box 116, Chesterland, OH 44026

or fax to: (440) 845-3447

2. Understand the need for an updated medical history and risk factors to consider when screening and counseling
each patient
3. Understand procedural precautions that need to be taken in the dental office due to a patients medical history
4. Understand the current drug therapies for cardiovascular treatment and the implications of these medications for dental
office treatment including potential side effects, drug interactions, and adverse oral drug reactions

For immediate results, go to www.ineedce.com

and click on the button Take Tests Online. Answer
sheets can be faxed with credit card payment to
(440) 845-3447, (216) 398-7922, or (216) 255-6619.
P ayment of $59.00 is enclosed.
(Checks and credit cards are accepted.)

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Please evaluate this course by responding to the following statements, using a scale of Excellent = 5 to Poor = 0.

If paying by credit card, please complete the

following:
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1. Were the individual course objectives met? Objective #1: Yes No

Objective #3: Yes No

Acct. Number: _______________________________

Objective #2: Yes No

Objective #4: Yes No

Exp. Date: _____________________

2. To what extent were the course objectives accomplished overall?

3. Please rate your personal mastery of the course objectives.

4. How would you rate the objectives and educational methods?

5. How do you rate the authors grasp of the topic?

6. Please rate the instructors effectiveness.

7. Was the overall administration of the course effective?

8. Do you feel that the references were adequate?

Yes

No

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Yes

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10. If any of the continuing education questions were unclear or ambiguous, please list them.
___________________________________________________________________
11. Was there any subject matter you found confusing? Please describe.
___________________________________________________________________
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12. What additional continuing dental education topics would you like to see?
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AGD Code 149

PLEASE PHOTOCOPY ANSWER SHEET FOR ADDITIONAL PARTICIPANTS.

AUTHOR DISCLAIMER
The author of this course has no commercial ties with the sponsors or the providers of
the unrestricted educational grant for this course.
SPONSOR/PROVIDER
This course was made possible through an unrestricted educational grant. No
manufacturer or third party has had any input into the development of course content.
All content has been derived from references listed, and or the opinions of clinicians.
Please direct all questions pertaining to PennWell or the administration of this course to
Machele Galloway, 1421 S. Sheridan Rd., Tulsa, OK 74112 or macheleg@pennwell.com.
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INSTRUCTIONS
All questions should have only one answer. Grading of this examination is done
manually. Participants will receive confirmation of passing by receipt of a verification
form. Verification forms will be mailed within two weeks after taking an examination.
EDUCATIONAL DISCLAIMER
The opinions of efficacy or perceived value of any products or companies mentioned
in this course and expressed herein are those of the author(s) of the course and do not
necessarily reflect those of PennWell.
Completing a single continuing education course does not provide enough information
to give the participant the feeling that s/he is an expert in the field related to the course
topic. It is a combination of many educational courses and clinical experience that
allows the participant to develop skills and expertise.

COURSE CREDITS/COST
All participants scoring at least 70% (answering 21 or more questions correctly) on the
examination will receive a verification form verifying 4 CE credits. The formal continuing
education program of this sponsor is accepted by the AGD for Fellowship/Mastership
credit. Please contact PennWell for current term of acceptance. Participants are urged to
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2008 by the Academy of Dental Therapeutics and Stomatology, a division
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