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 62 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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 VOLUME 44 NUMBEP 1 JANUAPY 2013 63 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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 64 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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. VOLUME 44 NUMBEP 1 JANUAPY 2013 65 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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, 66 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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- VOLUME 44 NUMBEP 1 JANUAPY 2013 67 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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 68 VOLUME 44 NUMBEP 1 JANUAPY 2013 QUI NTESSENCE I NTERNATI ONAL Fi ndl er at al 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.