Diseases of the Heart

Diseases of the heart such as ischemic heart disease, myocardial infarction, and hypertension have remained the number one cause of death for the past 5 decades. Given that these diseases are common chronic ailments affecting the elderly, any oral manifestations of the conditions, as well as their treatments, will become more common in the future with the expansion of the older population.

Some cardiovascular conditions and their subsequent treatment have oral-facial signs and symptoms and therefore have oral treatment considerations. Anginal pain can appear as referred pain to the neck, clavicle, and mandible, and it can be localized to the mandible and teeth. A comprehensive differential diagnosis must include consideration of dental-alveolar origin (e.g., caries, periodontal disease), temporomandibular joint (TMJ) disease, referred musculoskeletal pain, central or peripheral nervous system pain, and myocardial infarction.

Several recent epidemiologic studies have demonstrated an association, but not a causal relationship, between heart disease and dental/periodontal diseases.^1–5 Periodontal pathogens and certain serologic proteins found in the gingival sulcus (particularly C-reactive proteins) have been found in carotid atheromas and shown to induce platelet aggregation. However, the role of periodontal infection as a risk factor for cardiovascular disease requires further scientific validation. Recent data have further demonstrated a possible link between periodontal conditions and systemic measures of inflammation. Intensive periodontal treatment resulted in acute, short-term systemic inflammation (increased levels of C-reactive protein, interleukin-6, and the endothelial-activation markers soluble E-selectin and von Willebrand factor), as well as mild endothelial dysfunction. However, importantly, 6 months after therapy, without any adverse events, marked benefits in periodontal health were statistically associated with improvement in endothelial function.⁶

The treatment of cardiovascular diseases with drugs also has deleterious oral consequences. For example, antihypertensive medications have been shown to cause salivary dysfunction (as in the cases of diuretics, calcium channel blockers, β-blockers), gingival enlargement (calcium channel blockers), lichenoid mucosal reactions (thiazide diuretics), and disturbances in taste (ACE inhibitors, calcium channel blockers). Higher salt detection thresholds have also been observed in persons with hypertension.⁷ Consideration of possible alteration of drug regimens is appropriate.

Persons who have undergone cardiac transplantation and are receiving postoperative immunosuppressive pharmacologic regimens must be evaluated for potential oral complications. Immunosuppressive therapy increases the prevalence of oral opportunistic infections such as reactivation of herpes simplex virus and overgrowth of C. albicans. Cyclosporine, a frequently used antirejection drug, has been reported to cause gingival enlargement in up to 13% to 85% of patients.⁸

Consideration must be given to cardiac conditions before dental treatment is undertaken. Patients receiving anticoagulation therapy may present with hemorrhagic lesions of oral mucosal tissues (see “Cerebrovascular Diseases” later). Antibiotic prophylaxis is recommended for persons with cardiac valvular abnormalities at risk for developing subacute bacterial endocarditis (Table 92-3). Recent modification of the antibiotic recommendations simplified and clarified the regimen to reduce overuse of antibiotics, potential adverse effects, and drug resistance.⁹ Dental procedures for which endocarditis prophylaxis is reasonable (see Table 92-3) are events that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. The regimen for antibiotic prophylaxis is provided in Table 92-4.

Table 92-3 Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for Which Prophylaxis with Dental Procedures Is Reasonable

* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

† Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.

Table 92-4 Antibiotic Regimens for a Dental Procedure as Recommended in Table 92-3

Although the dental office environment and dental treatment can increase heart rates and blood pressures, treatment can be safely rendered to patients with ischemic heart disease with adequate anxiety and pain control.¹⁰ The use of local anesthetics with epinephrine can be a concern in the treatment of cardiac patients because of the effect of increased heart rate, stroke volume, and cardiac output. However, at low doses, epinephrine has been found to have few of these systemic effects and in stable cardiovascular patients it can be safely used. For patients with a questionable cardiac history, 0.04 mg of epinephrine should be the maximum dose given (≈two 1.8-mL carpules of local anesthetic with 1 : 100,000 epinephrine), whereas unstable cardiac patients should receive epinephrine only for emergency dental treatment.

Malignant Neoplasms

Oropharyngeal cancer involves the soft palate, tonsil, base of the tongue, and vallecula and is diagnosed in nearly 9000 men and women in the United States annually.¹¹ Cancers of the oral cavity and pharynx, which represent 2.1% of all neoplasms in the United States, have a direct and frequently permanent deleterious effect on oral health and function. Although men experienced a much greater likelihood of developing oral-pharyngeal cancer in the past, the male-female ratio is now 2 : 1. The prevalence and mortality of oral cancers increase with age, and the major preventable risk factors are tobacco use and excessive alcohol consumption.

Common signs include nonhealing crusting and ulcerated leukoplakic and erythemic lesions. Pain is not necessarily a symptom of oral cancers, and patients should be advised to see their dentists or physicians for definitive diagnosis if a lesion or swelling has not resolved within a 2- to 3-week period.

Most of the remaining 10% of head and neck tumors are salivary gland tumors or lymphomas; further, approximately 1% of all tumors originate below the clavicles and metastasize to the head and neck.¹² Accordingly, visual inspection and palpation of the head and neck region must include lymph nodes, muscles of mastication and facial expression, and salivary glands. Furthermore, a histopathologic examination is required of all nonhealing head, neck, and oral lesions.

Early detection of oral cancer is critical because patients with early-stage tumors have considerably better survival rates than those with late-stage cancers that have already spread to regional tissues and the lymphatic system. For example, 5-year survival rates for small and localized tongue cancers (stage I and II) and those tongue cancers with lymph node involvement and possible metastasis (stage III and IV) are 67% and 30%, respectively. Accordingly, since 1980, the American Cancer Society has recommended a cancer-related checkup every 3 years for persons aged 20 to 39 years and annually for individuals 40 years and older.¹³ This is particularly relevant for the elderly population, which sees their dental practitioner less frequently than their younger counterparts, and in particular, older edentulous adults.

The treatment of most cancers will indirectly or directly affect oral health and function. Chemotherapy causes reversible mucositis, stomatitis, salivary hypofunction, smell and taste dysfunction, diminished appetite, and increased susceptibility to oral microbial infections. Clinically significant nutritional deficiencies and dehydration can occur in the presence of severe oral and pharyngeal mucositis and recurrent microbial infections. Because of the significant morbidity and mortality of antineoplastic therapies, these patients require frequent and long-term follow-up by dental professionals.

Treatment for oral-pharyngeal neoplasms includes surgery, radiation therapy, and chemotherapy, depending on the tumor stage and extent of regional spread.¹⁴ Extensive removal of the cancerous growth and affected lymph nodes can result in significant facial disfiguration, dysphagia, altered speech and mastication, trismus, facial and oral paresthesia, salivary gland dysfunction, and diminished neck and shoulder mobility. Head and neck radiation is frequently used after surgery for the treatment of residual and microscopic disease; however, it also has significant adverse effects. These sequelae include mucositis, stomatitis, dysphagia, permanent salivary gland dysfunction, smell and taste dysfunction, oral microbial infections (e.g., reactivation of herpes simplex and varicella zoster viruses, C. albicans infections), and increased risk of developing osteoradionecrosis.¹⁴

Importantly, these patients must undergo preoperative dental evaluation and treatment before definitive therapy so as to remove oral pathology (e.g., dental caries, periodontal disease, nonrestorable teeth) before developing the common oral sequelae of surgery, chemotherapy, and radiotherapy. Both dentate and edentate postoperative patients must continue to perform scrupulous oral hygiene and maintain a regular recall schedule with their oral health professionals to reduce the risk of developing osteoradionecrosis, oral microbial infections, and other oral pathologies.

Recent findings of osteonecrosis of the maxilla and mandible have been associated with the bisphosphonate class of antiosteoclastic medications. A majority of the reported cases were found in patients being treated for osteometastatic breast carcinoma or multiple myeloma. The pathophysiology of the disease has not yet been determined.¹⁵

Cerebrovascular Diseases

The motor, sensory, and cognitive alterations that accompany cerebrovascular diseases have deleterious effects on oral health and function. A cerebrovascular accident (CVA) can cause permanent oral sensory and motor deficits, resulting in poor tongue function and lip seal, difficulty eating and drinking, impaired use of dentures, and visuospatial problems with adverse social and psychologic consequences.¹⁶ Nutritional deficiencies and diminished quality of life can result from impaired food and fluid intake.

The location of the CVA determines the oral-facial deficits. Left cerebral cortex lesions cause right-sided paralysis and difficulty with auditory memory, speech, language, and the oral phase of swallowing. Right cortex lesions cause left-sided paralysis with subsequent neglect of affected sites, pharyngeal dysfunction with potential for aspiration, and difficulty with memory and performing certain tasks (such as tooth brushing). Oral-facial motor and sensory impairments can lead to improper dental and denture hygiene and food accumulation or pocketing around teeth, in the buccal vestibules, and underneath the tongue. Ultimately, this can lead to dental and periodontal diseases and oral microbial infections that can become exacerbated by the lack of sensory detection by the patient. Some patients experience problems with communication, judgment, and memory, which inhibit accurate solicitation of the patient’s pertinent medical history, chief complaint, and compliance with home care instructions.

Anticoagulation therapy, the standard preventive treatment after a stroke, will produce hemorrhage, petechiae, ecchymoses, and purpura of all oral mucosal tissues. Dental treatment can be safely performed if the prothrombin time is within twice the normal range or if the international normalized ratio (INR) is less than 3.¹⁷ However, if excessive dental-alveolar surgery is planned, conversion to low-molecular-weight heparin or heparinization in a hospital setting is recommended. Aspirin use is popular in adults at risk for cardiovascular thrombotic events, and low-dose aspirin is an excellent preventive agent; however, its antiplatelet properties have contributed to a perceived increased risk for bleeding after dental extractions. For most patients requiring simple oral surgical procedures, if local hemostatic and conservative surgical techniques are used, discontinuation of aspirin may not be necessary.¹⁷

Head and neck radiographic findings and oral/periodontal status may aid in identification of persons at risk of CVAs. Carotid calcifications of atherosclerotic plaques have been found on 4% of panoramic radiographs of asymptomatic persons older than 55 years.¹⁸ In addition, periodontal disease and tooth loss are associated with increased risk of stroke.^19,20 It is hypothesized that the infectious burden of oral disease can initiate proliferation of inflammatory cells and clotting factors resulting in atherogenesis and thromboembolic events.²⁰ In addition, periodontal bacteria have been isolated from the atheromatous plaques after a CVA. The evidence to support a CVA-periodontal disease relationship is stronger than that found in investigations of cardiovascular and oral diseases.

Pulmonary Diseases

A common link between pulmonary diseases (COPD; bronchitis, asthma, and emphysema) and oral health is smoking. Smoking, one of the two preventable causes of oral cancer (see “Malignant Neoplasms” earlier), is also associated with benign oral mucosal pathology (nicotinic stomatitis, oral fungal infections). Little is known regarding the direct effects of COPD on oral health, yet it is well established that a common treatment modality of COPD (corticosteroids) has many oral consequences.²¹ Chronic use of corticosteroids suppresses the hypothalamic-pituitary-adrenal axis that can result in acute adrenal insufficiency during stress. Therefore steroid replacement therapy is sometimes required for extensive dental and surgical procedures.²¹ Many patients use steroid inhalers that should be brought to all dental appointments for use if necessary to ensure protection of a patent airway. Chronic use of systemic and inhaled corticosteroids also predisposes patients to oral fungal infections. Finally, nitrous oxide use is contraindicated in persons with severe COPD, secondary to oxygen-driven respiratory function.

Aspiration pneumonia, a common condition, particularly in hospitalized and older adults with compromised host defense mechanisms, is caused by the aspiration of gastric or oropharyngeal secretions. Oropharyngeal swallowing dysfunction, a consequence of neuromuscular and cerebrovascular diseases, debilitation, salivary hypofunction, and medications, is a frequent risk factor for aspiration pneumonia.²² Colonization of the oropharynx with gram-negative bacilli predisposes to bacillary pneumonia.²³ A major source of anaerobe infection is the gingival crevice. Furthermore, the prevalence of bacterial colonization increases with poor oral hygiene and periodontal disease. Therefore patients at risk should receive routine dental examinations and treatment, and they may benefit from daily antimicrobial rinses.²⁴ Broad-spectrum antibiotics are the standard treatment regimen for pneumonia. Extended antibiotic use increases the risk of developing oral fungal infections and antibiotic resistance.

Tuberculosis, a major global health problem caused by the spread of Mycobacterium tuberculosis, manifests infrequently in the oral cavity. The classic oral mucosal lesion is a painful, deep, irregular ulcer on the dorsum of the tongue, with additional sites including the palate, lips, buccal mucosa, and gingival.²⁵ M. tuberculosis can also infect the cervical and submandibular lymph nodes (referred to as scrofula) and rarely affects the salivary glands.²⁶

Oral tuberculosis lesions require diagnosis and appropriate antimicrobial management, as well as education on possible transmission via infected oral sites. A recent investigation reported positive oral cultures of M. tuberculosis from samples of saliva, dental plaque, caries lesions, and denture plaque collected from tuberculosis patients, demonstrating the possibility of oral infectivity of these patients.²⁷ Interestingly, detection rates from these oral sites using polymerase chain reaction techniques were considerably higher (between 89% and 100% detection rates) than traditional culture methods (0% to 17%).²⁸ With the growing rate of human immunodeficiency virus/acquired immunodeficiency syndrome in the world, a disease that frequently manifests with tuberculosis, clinicians must be familiar with infection control procedures to protect workers against exposure to pathologic and possibly aerosolized microorganisms.

Endocrine and Exocrine Disorders

Adrenal Diseases

Oral manifestations of Addison’s disease, caused by primary adrenal insufficiency or hypoadrenalism, include diffuse, cutaneous pigmentation of the skin and mucous membranes. However, this presentation is not found in persons with secondary adrenal insufficiency, the result of chronic corticosteroid administration.

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