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VOLUME 44 NUMBEP 1 JANUAPY 2013 61

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ORAL MEDICINE
It has been estimated that 4.7 million
individuals, or 1.5% to 2% of the total popu-
lation, in the United States suffer from heart
failure. Approximately 550,000 new cases
are initially diagnosed each year.
2
Coronary
artery disease is responsible for 60% to 75%
of all cases, while hypertension causes 75%,
including most of the patients with coronary
artery disease. The remaining heart failure
cases are of unknown etiology, but have
been attributed to cardiomyopathies of vari-
ous typos. Pnoumatio noart disoaso romains
a major cause of heart failure in Africa and
Asia. Congenital heart malformations,
acquired heart disease, toxic agents, and
metabolic diseases are also considered eti-
ologic factors for heart failure.
3
Pooognizod prooipitating oausos aro
myocardial ischemic events; rapid elevation
of systemic blood pressure that may lead to
an abrupt deterioration of failing heart func-
Heart failure is a clinical syndrome in which
any change in cardiac structure or function
may impair the ability of the heart ventricles
to ll with or eject blood.
1
1
Senior Lecturer, Department of Hospital Oral Medicine, Hebrew
University-Hadassah School of Dental Medicine, Jerusalem,
Israel; formerly, Head, Department of Oral Medicine and
Hospital Dentistry, Assuta Hospital, Tel Aviv, Israel.
2
Professor and Chair, Division of Oral Medicine, Eastman
Institute of Oral Health, University of Rochester Medical Center,
Rochester, New York, USA.
3
Professor, Head, Department of Hospital Oral Medicine, Hebrew
University-Hadassah School of Dental Medicine, Jerusalem,
Israel.
4
Professor and former Dean, Head, Department of Hospital
Oral Medicine, Hebrew University-Hadassah School of Dental
Medicine, Jerusalem, Israel.
Correspondence: Dr Mordechai Findler, Department of
Hospital Oral Medicine, Hebrew University-Hadassah School
of Dental Medicine, PO Box 12000, Jerusalem, Israel. Email:
fndler@inter.net.il
Dental treatment for high-risk patients with
refractory heart failure: A retrospective
observational comparison study
Mordechai Findler, MD, DMD, MSc, MBA, LLB
1
/Sharon Elad, DMD,
MSc
2
/Eliezer Kaufman, DMD
3
/Adi A. Garfunkel, DMD
4
Objective: Heart failure affects large population groups. The understanding of the etiol-
ogy, pathophysiology, and treatment of heart failure has changed considerably within the
last few years. The changes have signicant implications for the medical management of
the disease, as well as on the ability to provide proper dental treatment for these patients.
Method and Materials: A retrospective observational study of the outcome following den-
tal treatment of 54 patients was performed: 32 with refractory heart failure stage D (study
group) and 22 patients at risk for heart failure stages A to C (control group). Dental man-
agement of these patients concentrated on the prevention of iatrogenic, dental
settinginduced, and precipitating factors of heart failure. To prevent deterioration of
patients medical condition, a comprehensive, tailored treatment including adequate anx-
iolysis, close monitoring, profound dental anesthesia, and close follow-up was used. A
previously described three-step gradual level protocol (at home, waiting room, and dental
chair) was adopted. Results: All the planned dental procedures were successfully com-
pleted. Six patients experienced respiratory distress during treatment, and ve patients
demonstrated arrhythmias during dental treatment. Only minute differences were found
between the groups regarding blood pressure and heart rate. Conclusion: Use of the
suggested protocol facilitated the completion of planned dental treatments for all patients.
Thus, providing essential dental treatment for severe heart failure patients with special
attention to their medical problems and the use of medications and supporting means to
prevent health-compromising situations is recommended. (Quintessence Int 2013;44:6170)
Key words: chronic heart failure, medically complex patient
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tion; infection; suboptimal medical treat-
ment; arrhythmia; tachycardia or bradyar-
rhythmia; pulmonary embolism; fever;
anemia; thyrotoxicosis; pregnancy; myocar-
ditis; and infectious diseases.
2

Excessive physical activities, environ-
mental and emotional stress, and dietary
and uid imbalance may decompensate the
borderline controlled myocardial function.
1

The understanding of the patho physi-
ology of heart failure has changed dramati-
cally over the past decade. Various known
and new models were combined to form a
comprehensive approach toward the diag-
nosis and treatment of patients. Patients
suffering from heart failure exhibit either
depressed ejection fraction (EF), known as
systolic failure, or heart failure with pre-
served EF (HFPEF), ie, diastolic failure.
4
The
hemodynamic model of the failing heart
demonstrates specic patterns of ventricu-
lar remodeling as a consequence of chronic
damage due to either volume or pressure
overload. Pressure overload in sustained
untreated high blood pressure increases
systolic wall tension, which leads to hyper-
trophy of myobrils, changes in wall thick-
ness, and concentric hypertrophy. In vol-
ume overload, similar to heart valve
regurgitation, the increased diastolic pres-
sure and diastolic wall stress engender the
addition of new sarcomeres, chamber
enlargement, and eccentric hypertrophy.
5

Heart failure may also be divided into right
or left ventricular failure, high vs low cardiac
output failure, backward vs forward failure,
and acute vs chronic.
4
Acute heart failure
may be exacerbated by any abrupt chang-
es in blood pressure or heart rate, such as
that experienced during dental treatment,
imposing extreme burden on the failing
noart. To provont nazardous oonsoquonoos
resulting from dental treatment, patients
with heart failure should be referred to and
receive their dental care in special dental
setups: dental clinics equipped with the
necessary cardiovascular monitoring
devices and advanced life-support equip-
ment with a well-trained team for medical
emergencies.
6
The medications used for treatment are of
serious concern to the dental care provider. It
is of great importance to design a well-struc-
turod individualizod plan or ovory pationt.
The medical status of patients with heart
failure stage D, heart failure classication
American Heart Association/American
College of Cardiologists (AHA/ACC), is
oquivalont to tno Now York Hoart Assooiation
(NYHA) v.
5
For those patients with severe
heart failure, it is recommended that they
avoid surgical procedures and solve all
dental problems by palliation with analge-
sics and antibiotics.
7
No otnor olootivo don-
tal care should be provided.
8
The goal of this article was to present a
retrospective review of patients series diag-
nosed with severe heart failure vs patients
at risk for heart failure who underwent differ-
ent dental treatments, and follow their out-
comes. The changes in the management,
eventual complications, preventive mea-
sures, and emergency treatment applied to
patients in the former group do not differ
from those of nonsymptomatic patients.
METHOD AND MATERIALS
Study design
This retrospective observational compara-
tive study included groups of dental patients
between January 1990 and December
2007. The study was approved by the
Etnioal Poviow Board, Hadassan Modioal
Center, Jerusalem, Israel. The study group
included 43 patients who were diagnosed
by their attending cardiologists with refrac-
tory NYHA v. Dospito tno maximal modioal
therapy received, they were all symptomat-
ic. The records of 11 patients lacked vari-
ous essential details regarding their
cardiovascular response to dental treat-
ment and were therefore excluded from the
study. The remaining 32 patients with stage
D NYHA v noart ailuro oomprisod tno
study group. The study group patients were
actively symptomatic, and despite maximal
anticongestive treatment, they all suffered
from dyspnea during rest. All of these
patients were unable to do any physical
activity beyond climbing ve steps, equiva-
lent to fewer than four metabolic equiva-
lonts. O tnom, 11 pationts woro nospitalizod
during the treatment, while the other 21
patients were transferred by ambulance
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services from home. They were brought to
the dental chair by wheelchair. The control
group included 22 patients at heart failure
stages A to C (AHA/ACC), matching the
noart ailuro olassihoation NYHA to .
5

They were asymptomatic and ambulatory
and arrived at the dental clinic from their
homes.
All patient data in this study were col-
lected from the records in three clinics: the
Oral Medicine Department of the Hebrew
University-Hadassah Hospital in Jerusalem,
Israel, the Oral Medicine Department at
Assuta Hospital in Tel Aviv, Israel, and a
private special Oral Medicine Dental Clinic
in Tel Aviv, Israel. They were equipped with
the necessary cardiovascular monitoring
devices and advanced life support equip-
ment, as well as a well-trained team for the
treatment of medical emergencies.
All 32 study group patients underwent
only essential dental treatments for pain
relief or elimination of oral focal infections.
Some of the patients were candidates for
heart transplantation. The control group
patients had elective dental treatments
including complex dental procedures in
accordance with regular treatment plans.
The gradual three-level mode of medical
predental therapy was applied to all the
patients.
6
The at-home level consisted of
anxiolytio (proorably oxazopam 10 mg)
and diuretic-anticongestion medication
administered the night and morning prior to
dental treatment. The insertion of an intrave-
nous line and initiation of cardiovascular
monitoring constituted the waiting room
level. At the dental chair level, supportive
drug treatments were administered after
medical consultation, and emergency med-
ications were added when needed.
The etiologies of cardiovascular dis-
ease, as well as the cardiac pharmacologic
medication taken by the patients in both
groups, are described in Table 1.
Statistical analysis
The changes in hemodynamic values before
and after dental treatment between the
study and oontrol groups woro analyzod by
the chi-square test. For a comparison
between small categoric variables, the
Fisher exact test was used. The level of
statistical signicance was set at P < .05.
All variables are presented as mean (
standard deviation [SD]), and medians and
ranges were used where appropriate.
RESULTS
In both groups, the planned dental proce-
dures were successfully completed. The
study group comprised 24 (75%) men and
8 (25%) women (mean age, 61.8 13.1
years). In the control group, there were 18
(82%) men and 4 (18%) women, with an
age range of 42 to 82 years (mean,
61.0 10.4 years) (P = .81). In the study
group, patients elective dental treatments
were postponed. The left ventricular ejec-
tion fraction (LVEF) value was available for
only 23 of 32 (72%) patients. Two patients
had an LVEF between 30% and 40%, 5
patients had an LVEF between 20% and
30%, and 16 had an LVEF of < 20%. All the
control group patients had a well-preserved
cardiac contractility (LVEF > 40%) (see
Table 1).
Etiologies
Coronary artery disease was by far the most
prevalent condition responsible for heart
failure, affecting 81% of the study group.
Valvular heart disease affected 25% of this
population, followed by cardiomyopathy
and hypertensive heart disease with 19%
each. Congenital heart disease was respon-
sible for only 6.3% of all cases in the study
group. In the control group, the dominant
risk factor for developing heart failure was
hypertensive heart disease (diagnosed in
50% of the patients), followed by coronary
artery disease (36%) and rheumatic heart
disease (18%) (see Table 1).
Medical treatment
The drug inventories of the study group
included diuretics: furosemide (100%), spi-
ronolaotono (38%), and tniazido (19%).
Other drugs taken by patients of the study
group included angiotensin-converting
onzymo innibitors (ACE) and angiotonsin
roooptor blookors (APBs) (75%), bota-
adrenergic antagonists (31%), digoxin
(41%), and calcium channel antagonists
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Table 1 Patients characteristics, etiology, medication, dental treatment, and cardiovascular response
P
value
CONTROL group
(n = 22)
STUDY
group
(n = 32)
.74 18:4 24:8 Sex (M:F)
.81 61.0 10.4 61.8 13.1 Age (y) (mean SD)
4282 3983 Age range (y)
22 (100%) 0 Stage A-C Heart failure
(No. o pationts |%]) 0 32 (100%) Stage D
22 (100%) 0 NYHA -
0 32 (100%) NYHA v
22 (100%) 0 LVEF > 40
0 2 (9%) LVEF 3040
0 5 (22%) LVEF 2030
0 16 (69%) LVEF < 20
NS 20.7 Mean LVEF
.0008 8 (36%) 26 (81%) CAD Etiologic background
(No. o pationts |%]) > .999 4 (18%) 5 (16%) PHD
.016 0 8 (25%) Valvular
.015 11 (50%) 6 (19%) Hypertension
.07 0 6 (19%) Cardiomyopathy
> .999 0 2 (6%) Congenital
< .0001 0 32 (100%) Furosemide Medications
(No. o pationts |%]) .52 6 (27%) 6 (19%) Tniazido
< .0001 0 12 (38%) Spironolactone
.63 10 (45%) 24 (75%) ACE + APB
> .999 3 (14%) 5 (16%) Ca ch antag
.09 12 (55%) 10 (31%) Bota-blookors
.14 3 (14%) 10 (31%) Anticoagulant
.17 17 (77%) 19 (59%) Antiplatelet
.09 2 (9%) 10 (31%) Nitro
.003 1 (4.5%) 13 (41%) Digoxin
0 0 Endodontics Dental treatment
(No. o pationts |%]) 22 (100%) 8 (25%) Prosthodontics
0 20 (62.5%) Exodontia
0 4 (12.5%) Periodontics
0 0 NS
22 (100%) 8 (25%) Lidocaine 72 mg with epinephrine 36 mcg Local anesthetic
(No. o pationts |%]) 0 24 (75%) Mepivacaine 108 mg
0 0 NS
.007 7 (32%) 22 (69%) Stable Change in
blood
pressure
Cardiovascular
reaction
(No. o pationts |%])
7 (32%) 8 (25%) Decrease
8 (36%) 2 (6%) Increase
.009 19 (86%) 18 (56%) Stable Change in
pulse rate 1 (5%) 6 (19%) Decrease
2 (9%) 8 (25%) Increase
0 8 (25%) Arrhythmia
0 6 (19%) Pulmonary
congestion
0 5 (16%) Treatment
of pulmonary
congestion
NYHA, Now York Hoart Assooiation, LvEF, lot vontrioular o|ootion raotion, CAD, ooronary artory disoaso, PHD, rnoumatio noart disoaso, ACE,
angiotonsin-oonvorting onzymo innibitors, APB, angiotonsin roooptor blookors, Ca on antag, oaloium onannol antagonists, nitro, nitrato propara-
tion, NS, unspooihod.
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Table 2 Cardiovascular response to treatment
Prostho-
dontics
Prostho-
dontics Exo dontia
Prostho-
dontics
Perio-
dontics Exo dontia
Control
group
Study
group
Study
group
Study
group
Study
group
Study
group
n = 22 n = 4 n = 4 n = 4 n = 4 n = 16
Epinephrine 36 mcg 36 mcg 36 mcg 0 mcg 0 mcg 0 mcg
Change in blood pressure
Stable 7 2 4 3 4 11
Decrease 7 2 0 1 0 5
Increase 8 0 0 0 0 0
Change in pulse rate
Stable 19 2 2 4 3 7
Decrease 1 2 0 0 1 3
Increase 2 0 2 0 0 6
(16%). Anticoagulant therapy and antiplate-
let agents were used by 31% and 59%,
respectively. A supplement of nitroglycerin
was prescribed to 31% of the patients.
In the control group, the preferred
diurotio troatmont was tniazidos (27%).
Fifty-ve percent of the patients were treat-
ed with beta-adrenergic antagonists. ACEI
and APBs woro usod by 45%. Tno ma|ority
(77%) of the control group patients were
treated by an antiplatelet agent, whereas
anticoagulant therapy was prescribed for
14%. Calcium channel antagonists were
usod by 14%. Nino poroont woro troatod
with nitrates and 4.5% were treated with
digoxin (see Table 1).
The use of local anesthetic
medication
When indicated, local anesthesia was
administered. Only 8 of the 32 patients in
the study group received local anesthetic
solution with 3.6 mL lidocaine 2% (72 mg)
with epinephrine 1:100,000 (36 mcg). All
other patients received 3.6 mL mepiva-
caine 3% (108 mg) without epinephrine.
The use of lidocaine 2% with epinephrine
1:100,000 was restricted to two cartridges.
Lidocaine 2% with epinephrine
1:100,000 was administrated to all the con-
trol group patients (see Table 1).
Dental treatment
The treatment performed in the study group
consisted of dental extractions for 20
patients (62.5%), prosthodontic procedures
for 8 patients (25%), and periodontal treat-
ment for 4 patients (12.5%). All patients
were treated for two main reasons: elimina-
tion of infection as preparation for heart
transplantation or pain relief. The control
group patients received routine dental treat-
ments and were treated according to the
proposed treatment plan (Table 2).
Observed cardiovascular
effects
During the immediate 48-hour follow-up
period, no cases of severe, life-threatening
exacerbation in any of the existing heart
conditions were recorded in either group.
Pulmonary congestion developed in 6 of
32 study group patients (18.8%) compared
with none in the control group. Four of the
patients (12.5%) developed shortness of
breath during the treatment, and two already
were experiencing it in the waiting room.
Patients were examined by a physician, and
when rales were heard on auscultation,
supplementary oxygen (5 liters/minute) was
given and furosamid 40 mg was adminis-
trated via the intravenous line. All patients
experienced immediate relief. Surprisingly,
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Table 3 Patients who experienced pulmonary congestion
No. Sex Age (y) Diagnosis Dental treatment L + E Blood pressure Heart rate LVEF (%)
1 F 83 CVD Exodontia Y Stable Increase 40
2 F 72 CVD Periodontics N Stable Stable 18
3 F 47 CVD Exodontia N Decrease Increase 10
4 M 56 Valvular Exodontia N Stable Stable < 20
5 M 73 CVD Exodontia N Stable Stable 35
6 M 47 CVD Periodontics N Decrease Decrease NS
L+E, lidooaino witn opinopnrino 1:100,000, LvEF, lot vontrioular o|ootion raotion, CvD, oardiovasoular disoaso, NS, not spooihod.
Table 4 Patients with arrhythmias
No. Sex Age (y) Diagnosis
Dental
treatment L + E
Blood
pressure Heart rate Arrhythmias
Preventive
treatment
LVEF
(%)
1 M 48 CAD Exodontia N Stable Stable vPB N 16
2 M 73 CAD Exodontia N Stable Stable vPB N 25
3 M 55 CAD Exodontia N Stable Stable vPB N 16
4 M 60 CAD Exodontia N Increase Increase vPB N 10
5 M 40 CAD Exodontia N Stable Increase vPB N 22
6 M 73 CAD Exodontia N Stable Stable vPB N 35
7 M 68 Cardio Prosthodontics Y Decrease Decrease AFlu Y NS
8 M 47 CAD Exodontia N Decrease Decrease vPB Y NS
L+E, lidooaino witn opinopnrino 1:100,000, LvEF, lot vontrioular o|ootion raotion, CAD, ooronary artory disoaso, Cardio, oardiomyopatny, vPB,
vontrioular promaturo ootopio boats, Ahu, atrial huttor, NS, not spooihod.
no correlation was found between the
patients who developed acute pulmonary
congestion and the initial low LVEF (10% to
40%) (Table 3).
Arrhythmias were recorded in 8 patients
from the study group: Two patients suffered
from chronic arrhythmia (atrial brillation)
long before initiation of dental treatment.
The other six patients developed arrhyth-
mias during dental treatment. All of those
received mepivacaine 3% without epineph-
rine for tooth extractions. The arrhythmias
recorded in these patients were exclusively
ventricular ectopic complexes. The LVEF in
these patients was 10% to 35% (Table 4).
In the study group, a decrease in blood
pressure was recorded in 25% of patients,
while 6% experienced an increase in blood
pressure. This compared with a decrease in
blood pressure in 32% and an increased
blood pressure in 36% of the control group
(P = .007) (Fig 1).
In the study group, for the eight patients
treated with lidocaine 2% and epinephrine
1:100,000, changes in blood pressure were
recorded only in three patients: Two patients
experienced a decrease in blood pressure,
while one experienced an increase. Of the
24 patients who were treated with mepiva-
caine 3%, 7 demonstrated a change in
blood pressure: Six patients (25%) showed
a mild decrease, while only 1 (4%) was
observed with an increased blood pressure.
In the study group, a change in heart
rate was recorded in 18 (56%): 6 (19%)
with bradycardia and 8 (25%) with tachy-
cardia, compared with a total of 3 patients
(14%) in the control group: (5%) with bra-
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Increase Decrease No change
P = .007
Study group
Control group
100
90
80
70
60
50
40
30
20
10
0
100
90
80
70
60
50
40
30
20
10
0
Increase
P
a
t
i
e
n
t
s

(
%
)
P
a
t
i
e
n
t
s

(
%
)
Decrease No change
P = .009
Study group
Control group
Fig 1 Changes in blood pressure following dental
treatment.
Fig 2 Changes in heart rate following dental treat-
ment.
dycardia and 2 (9%) with tachycardia
(P = .009) (Fig 2).
Changes in heart rate among the 8
patients who were treated with lidocaine 2%
and epinephrine 1:100,000 were recorded
in 4 (50%): 2 (25%) showed bradycardia
and 2 (25%) developed tachycardia. In the
mepivacaine 3% group, of 24 patients, the
heart rate changed in 10 patients (42%): 4
patients (12.5%) experienced bradycardia
and 6 (25%) tachycardia.
Implanted defbrillators
Only one patient in the study group, heart
failure stage D, had an indwelling implant-
able cardioverter-debrillator (ICD) for the
prevention of fatal heart arrhythmias. The
ICD was not changed to monitoring position
during dontal troatmont. No intororonoo
was noted during treatment.
DISCUSSION
All 32 patients suffering from refractory
noart ailuro stago D - NYHA v undorwont
only mandatory dental treatmentselimina-
tion of dental pain and eradication of infec-
tion as preparation for heart transplantation.
Elective procedures in these patients were
postponed until their medical conditions
improved.
8,9
Dontal troatmont or NYHA v
HF was considered to be contraindicated in
the dental literature, and there are therefore
no evidence-based or other protocols for
the management of such treatments.
7,9,10

The only clinical article in the English litera-
ture that described an experience in provid-
ing dental treatment for severe heart failure
patients does not recommend any specic
treatment protocol.
11
The protocol employed in the present
sudy consisted of a three-step gradual
approach: at home, waiting room, and den-
tal chair levels. This protocol was applied to
patients suffering from unstable ischemic
heart disease.
12
However, this mode of
treatment underwent modications applica-
ble to our heart failure patients subjected to
dental surgical procedures.
13

Following medical consultation, the rst
at-home predental treatment stage was
necessary to ascertain that patients had no
signs or symptoms of acute disease and to
initiate a stress-control protocol. In cases
in which signs of volume overload were
present, it was necessary to initiate or
increase the diuretic medication, with an
additional dose of furosemide. As a stress-
reduction procedure, the anxiolytic non-
myooardial doprossant modioation oxazo-
pam 10 mg PO was administered in the
evening and again in the morning prior to
the intervention.
According to the protocol, the waiting
room treatment level requires the institution
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of patient monitoring: one lead electrocar-
diogram, pulse rate, blood pressure, and
pulse oxymetry. The rationale lies in the
early diagnosis of eventual cardiac arrhyth-
mias or decrease in oxygen saturation, both
of which endanger patients lives. In all
patients, intravenous lines were introduced
for possible emergency treatments.
At the dental chair level, management
guidelines are stricter. The sit-up back posi-
tion was considered mandatory for the pre-
vention of pulmonary distress, and in
extreme cases, a face-to-face sitting posi-
tion was used (feet on the oor). This
unusual position proved to be very bene-
cial for the prevention of pulmonary edema.
Fluid redistribution and increased abdomi-
nal pressure in a supine position, observed
especially in patients with hepatospleno-
megaly and ascites, may aggravate respi-
ratory distress. Oxygen was administered
with a face mask, providing an enriched
oxygen atmosphere before treatment, or
with

a

nasal cannula with a ow of 5 liters/
minute
14
during treatment. Continuous mon-
itoring was conducted throughout the entire
length of dental treatment.
Pulmonary congestion and
cardiac arrhythmias during
treatment
The striking differences between the study
and control groups were in the dramatic
development of pulmonary congestion and
heart arrhythmias in the former. Despite the
application of the three-level protocol, 6 of
the 32 patients developed signs of respira-
tory distress. In the control group, none of
the patients experienced pulmonary con-
gestion. The signs of pulmonary congestion
were alla-nasi respiration, a decrease in
oxygen saturation, and crepitations over the
lung elds upon auscultation. Immediately,
furosemide 40 mg was administered intra-
venously and provided prompt benecial
response. Dental treatment was performed
to completion.
In these six patients, LVEF ranged
between 10% and 40% but was not among
the lowest in the study group. This may
imply that LVEF is not the only predictor for
possible congestion during treatment in a
dental setup. Only one of these patients
received an anesthetic solution with epi-
nephrine 1:100,000, whereas the other ve
received mepivacain 3%. Thus, epineph-
rine was not considered to be the cause of
their instability. This concurs with the
American Heart Association recommended
protocols and those reported regarding the
use of epinephrine in cardiac patients.
9,10,14

Six of the 32 patients in the study group
developed arrhythmias during dental treat-
ment compared with none in the control
group. All arrhythmias were ventricular pre-
maturo ootopio boats (vPBs). n two otnor
patients, arrhythmia was detected with the
institution of monitoring. Of the six patients
wno oxnibitod vPBs during dontal troat-
ment, two also showed an increase in heart
rato and ono a riso in blood prossuro. Nono
of these were treated with a local anesthetic
solution oontaining opinopnrino. vPBs aro
known to occur frequently in patients with
heart failure.
4
Surprisingly, only six patients
oxnibitod vPBs in tnis group, wnion is lowor
than expected.
4

The LVEF values in patients with arrhyth-
mias were between 10% and 35%, but
those were not among the lowest in the
study group, thus challenging the connec-
tion between arrhythmias and LVEF values.
These ndings are consistent with the
observation previously described,
11
where-
in 5 of 20 patients with severe heart failure
oxnibitod vPBs.
It is worth mentioning that only one
patient in the study group suffered from
concomitant arrhythmia and pulmonary
congestion. The risk of life-threatening car-
diac arrhythmias is well known; therefore,
an ICD is advocated for patients with low
LVEF (< 35% to 40%).
15
After implantation
of an ICD, the dental team should be more
secure in providing dental treatment.
Hemodynamic changes during
dental treatment
Heart rate and blood pressure were record-
ed in all study group patients, and their
hemodynamic parameters were compared
with those of the control group.
The results did not show a direct con-
nection between dental treatment and the
hemodynamic changes in the groups men-
tioned. Moreover, 69% of the study group
maintained a stable blood pressure com-
pared with only 32% of the control group
VOLUME 44 NUMBEP 1 JANUAPY 2013 69
QUI NTESSENCE I NTERNATI ONAL
Fi ndl er at al
patients. The differences in blood pressure
response were statistically signicant.
This relative stability in blood pressure of
patients with severe heart failure was previ-
ously reported in the literature.
11
These nd-
ings may imply intrinsic limitations of the
failing heart to react during stress inducing
situations or the efcacy of the comprehen-
sive medical treatment.
The relative heart rate stability in the
control group, despite the fact that these
changes were not statistically signicant,
contradict observations previously reported
that heart rate was signicantly increased in
the control group. This inconsistency may
be explained by virtue of different dental
treatments: prosthodontics treatments in
the control vs mainly extractions in the
study group.
11

CONCLUSION
The present paper describes 17 years of
experience with successful dental treat-
ments for patients with refractory heart fail-
ure. This group required adjustments of the
usual three-level, high-risk patient protocol.
Dental treatment should be conducted only
after close consultation with the attending
cardiologist. Only clearly indicated dental
treatments should be performedie, eradi-
cation of infection and elimination of pain
and stross. Poraining rom troating tnis
group of patients is not in accordance with
the cradle of the health profession. The
dental profession must adapt itself to the
increasing needs of medically complex
patients, the aging of the population, and
the sophistication of modern dental and
medical treatments. This article demon-
strates that with proper medicodental pre-
treatment, cardiovascular monitoring, and
professional medical support, dental treat-
ment should not be withheld from these
patients.
ACKNOWLEDGMENT
The study was self-funded by the authors and their
institution.
REFERENCES
1. Hunt SA, Abraham WT, Chin MH, et al. 2009 focused
update incorporated into the ACC/AHA 2005
Guidelines for the Diagnosis and Management of
Heart Failure in Adults: a report of the American
College of Cardiology Foundation/American Heart
Association Task Force on Practice Guidelines:
developed in collaboration with the International
Society for Heart and Lung Transplantation.
Circulation 2009;119:e391e479.
2. Mann DL. Management of heart failure patients
with reduced ejection fraction. In: Libby P, Bonow
RO, Mann DL, Zipes DP (eds). Braunwald`s Heart
Disease, ed 8. Philadelphia: Saunders Elsevier,
2008:611639.
3. Mann DL, Chakinala M. Heart failure and cor pulmo-
nale. In: Longo DL, Fauci AS, Kaspar DL, Hauser SL,
Jameson JL, Loscalzo J (eds). Harrissons Principals
of Internal Medicine, ed 18. New York: Mc Graw Hill
Medical, 2012:19011915.
4. Dickstein K, Cohen-Solal A, Filippatos G, et al.
European Society of Cardiology; Heart Failure
Association of the ESC (HFA); European Society of
Intensive Care Medicine (ESICM), ESC guidelines for
the diagnosis and treatment of acute and chronic
heart failure 2008: the Task Force for the diagnosis
and treatment of acute and chronic heart fail-
ure 2008 of the European Society of Cardiology.
Developed in collaboration with the Heart Failure
Association of the ESC (HFA) and endorsed by
the European Society of Intensive Care Medicine
(ESICM). Eur J Heart Fail 2008;10:933989.
5. Hess OM, Carroll JD. Clinical assessment of heart
failure. In: Libby P, Bonow RO, Mann DL, Zipes DP
(eds). Braunwalds Heart Disease, ed 8. Philadelphia:
Saunders Elsevier, 2008:561580.
6. Findler M, Garfunkel AA, Galili D. Review of very high
risk cardiac patients in dental setting. Compendium
1994;15:5865.
7. Scully C. Medical Problems in Dentistry, ed 6.
Edinburgh: Churchill Livingstone Elsevier, 2010.
8. Herman WW, Ferguson HW. Dental care for patients
with heart failure. J Am Dent Assoc 2010;141:
845853.
9. Little JW, Falace DA, Miller CS, Rhodus NL. Dental
Management of the Medically Compromised
Patient, ed 8. St Louis: Mosby Evolve Elsevier,
2013:89.
QUI NTESSENCE I NTERNATI ONAL
Fi ndl er at al
10. Warburton G, Caccamese JF. Valvular heart disease
and heart failure: Dental management consider-
ations. Dent Clin North Am 2006;50:493512.
11. Montebugnoli L, Prati C. Circulatory dynamics dur-
ing dental extraction in normal cardiac and trans-
plant patient. J Am Dent Assoc 2002;133:468472.
12. Findler M, Galili D, Meidan V, Yakirevitch, Garfunkel
AA. Dental treatment in very high-risk patients with
active ischemic heart disease. Oral Surg Oral Med
Oral Pathol 1993;76:298300.
13. Keith G, Allman KG Wilson IH. Oxford Handbook
of Anesthesia. Oxford: Oxford University Press,
2002:2425.
14. Malamed SF. Medical Emergencies in the Dental
Ofce, ed 6. St Louis: Mosby, 2007:226240.
15. Moss AJ, Hall WJ, Cannom DS, et al. Improved
survival with an implanted defbrillator in patients
with coronary disease at high risk for ventricu-
lar arrhythmia. Multicenter Automatic Defbrillator
Implantation Trial Investigators. N Engl J Med
1996;335:19331940.

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