Page 7 - GP Spring 2022

Case Presentation
Patient Information & Clinical Findings
A 55-year-old female presented to the clinic for a periodic dental examination with a chief complaint of, “My mouth is falling apart.”
The patient had a long medical history involving cardiac complications: ongoing high blood pressure, a congestive heart failure diagno-
sis, two open-heart surgeries, and a left ventricular assist device (LVAD). The patient also had a history of chronic bronchitis, asthma,
rheumatoid arthritis, and hypothyroidism secondary to thyroidectomy due to treated thyroid cancer. Besides the hospitalizations for the
surgeries, the patient was hospitalized for an episode of nosebleeds.

Medications included: Aldactazide (spironolactone-hydrochlorothiazide), Aspirin (acetylsalicylic acid), Coumadin (warfarin), Klono-
pin (clonazepam), Lanoxin (digoxin), Lasix (furosemide), Lipitor (atorvastatin), metoprolol, Percocet (oxycodone-acetaminophen),
Synthroid (levothyroxine), Trelegy Ellipta (fluticasone-umeclidinium-vilanterol; maintenance medication) and Ventolin HFA (albuterol
sulfate; rescue medication) (Table 2).
Table 2. Medications Class and Dental Implications

Name Class Dosage Dental Implications
Aldactezide (Spironolactone-Hydrochlorothiazide) Antihypertensive 25mg/day No
Aspirin (Acetylsalicylic acid) NSAID/Antiplatelet 325mg/day Yes
Klonopin (Clonazepam) Benzodiazepine/anxiolytic 1mg/PRN No
Lanoxin (Digoxin) Antiarrhythmic 250mg/day Yes
Lasix (Furosemide) Antihypertensive 40mg/day No
Lipitor (Atorvastatin) Antilipemic 40mg/day No
Metoprolol Antihypertensive 50mg/day No
Percocet (oxycodone-acetaminophen) Opioid/pain killer PRN No
Synthroid Thyroid hormone 125mcg/day No
Trelegy Ellipta (Fluticasone-Umeclidinium-Vilanterol) Steroid/Anticholinergic/Bronchodilator PRN Yes
Ventolin HFA (Albuterol sulfate) Beta-2 agonist PRN Yes
Warfarin (Coumadin) Anticoagulant/Vitamin K antagonist 3mg/day Yes

The patient was distressed at the initial presentation and reported high dental anxiety (10/10 on Likert-type scale) related to prior negative dental
experiences and a fear of needles. Due to her LVAD, as is typical in patients that have an LVAD, she did not have a palpable peripheral pulse,
nor could her blood pressure be measured by automated cuffs. Because of this, her mean arterial pressure (MAP) was recorded, and further
clarified by her LVAD coordinator as being ~80mmHg. A normal MAP is 60-90 mm Hg. MAP, or mean arterial pressure, is defined as the
average pressure in a patient’s arteries during one cardiac cycle. It is considered a better indicator of perfusion to vital organs than systolic blood
pressure (SBP). Her last INR was 2.0.
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Diagnostic Assessment
Clinical exam revealed heavy plaque and calculus, multiple missing teeth, multiple untreated carious lesions, and multiple previous res-
torations. Carious lesions and periodontal health of the patient were further assessed with radiographic images and periodontal probing.
Treatment planning took several visits due to patient limitations, transportation problems, and non-compliance.

Treatment Plan and Clinical Dilemma
The treatment plan accepted by the patient included a full mouth scaling and root planing, extractions, root canals, restorations, and
crowns.
The risks that were considered with this patient’s medical condition combined with the type of dental procedures proposed are as fol-
lows:
-Risk of infective endocarditis
-Medication interactions and side effects
-Risk of prolonged bleeding
-Selection of postoperative analgesia and other medications
-Other important considerations
1. Risk of Infective Endocarditis:

A 2021 Scientific Statement for the American Heart Association reviewed the current recommendations and evidence for antibiotic
prophylaxis before dental treatment for patients with LVAD. Because the risk of morbidity and mortality is so high from an infection of
these devices caused by any microorganism, antibiotic prophylaxis (AP) for a dental procedure is suggested. 10

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