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CDHO Advisory: Angina (Angina Pectoris)

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with angina (angina pectoris).

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Angina (Angina Pectoris), 2022-01-24

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Angina (angina pectoris)

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have angina (angina pectoris), chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Keeping records.
  9. Advising the patient/client.

TARGET POPULATION

Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged 80 and over
Male
Female
Parents, guardians, and family caregivers of young persons and adults with angina.

MAJOR OUTCOMES CONSIDERED

For persons who have angina: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted

Note about terminology

‘Angina’ in this Advisory always refers to ‘angina pectoris’ to describe chest pain originating from insufficient oxygen to the heart muscle because in some clinical usages ‘angina’ also refers to conditions of the oral cavity, such as 

  1. Ludwig’s angina 
  2. Plaut’s angina
  3. herpes angina.

 

  1. Angina, angina pectoris
    1. is recurring symptoms of pressure, tightness or pain in the chest, arm, neck, back or jaw owing to ischemia 
    2. is pain or discomfort that is spasmodic and that may  produce sensations of
      1. cramp-like choking 
      2. suffocation 
    3. results from insufficient oxygen supply to the myocardium, commonly caused by coronary artery disease 
    4. is not an actual heart attack but pain and discomfort that results when the heart muscle temporarily receives too little blood
    5. is usually a symptom of underlying heart disease, such as coronary artery disease
    6. occurs chiefly as
      1. stable angina
      2. unstable angina.
  2. Atherosclerosis, disease of large and medium-sized arteries in muscles, which
    1. is characterized by hardening and narrowing of the arteries caused by the accumulation of fatty deposits called plaque
    2. may cause a blood clot to form at the site of the narrowing, which completely
      1. blocks the artery
      2. and, in a coronary artery, causes myocardial infarction (CDHO Advisory).
  3. Blood clots 
    1. form if plaque in an artery ruptures or breaks open
    2. may form, partially dissolve and form again
    3. may create a larger blockage, with clots becoming large enough to completely block the artery
    4. cause pain when an artery is blocked.
  4. Cardiovascular disease (CVD), comprises various diseases of the circulatory system which
    1. are the leading cause of death in adult Canadian men and women 
    2. involve blood vessels of the heart 
    3. involve blood vessels supplying other parts of the body, including
      1. brain
      2. kidneys 
      3. lungs.
  5. Cholesterol, is
    1. a waxy fat called a lipid produced naturally in the body
    2. essential for the body to make
      1. cell membranes
      2. hormones
      3. vitamin D
    3. of two types 
      1. low-density lipoprotein (LDL), the ‘bad’ cholesterol which when in excess causes atherosclerosis
      2. high-density lipoprotein (HDL), the ‘good’ cholesterol because it carries LDL away from the arterial walls where the atherosclerosis accumulates.
  6. Coronary heart disease (CHD), coronary artery disease (CAD) is
    1. narrowing of the small blood vessels that supply blood and oxygen to the heart 
    2. most likely to be caused by atherosclerosis.
  7. Heart attack, myocardial infarction (CDHO Advisory), occurs when there is a blockage in one of the coronary arteries which obstructs the blood supply to a part of the heart, which may
    1. damage the heart and lead to death of heart muscle
    2. lead to disability or death depending on the extent to which the heart muscle is damaged.
  8. Heart failure, when the heart is no longer able pump sufficient blood to supply the body.
  9. Herpes angina, a viral infection usually in young children, characterized by 
    1. sore throat, headache, anorexia, and pain in the abdomen, neck, and extremities 
    2. papules or vesicles in the pharynx and on the tongue, the palate, or the tonsils
    3. lesions which evolve into shallow ulcers that heal spontaneously. 
  10. Hypertriglyceridemia, where triglyceride levels are elevated, a common disorder in North America, often caused or exacerbated by 
    1. uncontrolled diabetes
    2. obesity
    3. sedentary habits.
  11. Ischemia, decrease or restriction in blood supply to an organ or body part, often resulting in pain.
  12. Inflammatory biomarkers 
    1. proteins or enzymes which are measured in serum, plasma, or blood
    2. of which, for coronary artery disease, the most notable is C-reactive protein (CRP). 
  13. Ludwig’s angina, a type of cellulitis that 
    1. involves the floor of the mouth, under the tongue
    2. often occurs after an infection of the roots of the teeth, such as tooth abscess, or a mouth injury.
  14. Myocardial infarction, heart attack, (CDHO Advisory), when arteries that supply blood to the heart are blocked, preventing enough oxygen from getting to the heart; the heart muscle dies or becomes permanently damaged. 
  15. Myocardium, thick muscle layer of the heart that forms the bulk of the heart wall that contracts rhythmically to create heart beats.
  16. Peripheral vascular disease, peripheral arterial disease, peripheral artery occlusive disease, the narrowing or blockage of blood vessels in the limbs.
  17. Plaut’s angina, another name for necrotizing ulcerative gingivostomatitis.
  18. Prevalence, total number of individuals in a given population with a health-related condition during a specified period of time, usually expressed as a percentage.
  19. Pseudomembranous angina, another name for necrotizing ulcerative gingivostomatitis.
  20. Silent ischemia (sometimes referred to as silent angina), an episode of coronary artery insufficiency
    1. in which no pain is experienced
    2. which may be associated with  myocardial infarction that is 
      1. silent clinically
      2. unrecognized by the person, families or healthcare providers.
  21. Stable angina, angina of effort, which
    1. is the most common form of angina
    2. is stable in pattern
    3. occurs when the heart is working harder than usual
    4. is often predictable because of its association with particular types of activity
    5. is usually relieved with rest or with angina medications.
  22. Stent, a wire mesh tube sometimes used in angioplasty, that is inserted into an artery to open it, prevent re-blockage and allow blood flow needed by the heart.
  23. Unstable angina
    1. is a serious condition that may herald an impending myocardial infarction (CDHO Advisory)
    2. does not follow a predictable pattern
    3. can happen during strenuous activity or at rest
    4. is not always relieved with rest and medication. 
  24. Variant angina, Prinzmetal’s angina, the rarest form of angina, which 
    1. is chest pain originating in coronary artery spasm, a sudden constriction of a coronary artery depriving the myocardium of blood and oxygen
    2. usually occurs at rest during sleeping hours and is usually easily treated with medication.

Overview of angina 

Resources consulted

Occurrence

Angina in its occurrence relates to

  1. age, which correlates with the
    1. prevalence of angina 
    2. rates of death from coronary heart disease
  2. sex differences, in which
    1. angina is more often the presenting symptom of coronary artery disease in women than in men, with a female-to-male ratio of 1.7:1
    2. atypical presentations may be more common among women than men 
    3. women have a slightly higher death rate from coronary artery disease than men, in part because of 
      1. older age at presentation
      2. frequent absence of lack of classic angina symptoms
  3. ethnic factors affecting coronary heart disease rates, which 
    1. vary among ethnic groups in Canada, and which are
      1. highest in incidence among individuals of South Asian ancestry, a phenomenon partly explained by the prevalence of
        1. glucose intolerance
        2. hypertriglyceridemia
        3. low levels of ‘good’ cholesterol
        4. obesity
      2. high among individuals of First Nations ancestry, who are at increased risk for diabetes and coronary heart disease
      3. lowest among individuals of Chinese ancestry
    2. call for greater focus on overweight and obese individuals aimed at identification of modifiable cardiovascular risks across all of Canada’s communities.

Types

of angina include

  1. stable angina, which 
    1. is the most common type of angina 
    2. is not a myocardial infarction  (CDHO Advisory) but which is associated with increased likelihood of future myocardial infarction
    3. is most commonly the result of physical exertion
    4. may also be associated with 
      1. emotional stress
      2. exposure to extreme hot or cold
      3. heavy meals
      4. smoking
    5. is explained by severe narrowing of the coronary arteries, which 
      1. is caused by atherosclerosis 
      2. allows enough oxygenated blood to reach the heart when demand for oxygen is low, but not during periods of exercise, stress, or excitement during which oxygen demand is increased
    6. is characterized by 
      1. a consistent pattern which the person is often able to recognize and respond to appropriately 
      2. pain which usually subsides after a few minutes following 
        1. rest
        2. for some persons, use of angina medications
  2. unstable angina 
    1. is a serious medical condition that requires immediate medical attention because it indicates that a myocardial infarction (CDHO Advisory) may be imminent
    2. arises when blood clots partially or completely obstruct an artery 
    3. may arise without physical exertion
    4. is 
      1. not characterized by a regular pattern
      2. not relieved by rest or medication 
  3. variant angina 
    1. is uncommon
    2. arises independently of atherosclerosis
    3. arises at rest and is unrelated to excessive work by heart muscle
    4. is caused by coronary artery spasm of insufficient duration or intensity to cause an actual myocardial infarction  (CDHO Advisory); such spasm
      1. causes the coronary artery to constrict thus creating the angina 
      2. narrows the coronary artery, slowing or stopping blood flow to the heart
      3. may be caused by 
        1. cocaine use (CDHO Advisory)
        2. emotional stress
        3. exposure to cold
        4. smoking
        5. vasoconstrictor medications 
    5. is treated with nitrates to dilate the coronary arteries.
  4. silent angina, which is more properly referred to as silent ischemia, because no pain is experienced.

Causes and risk factors

of angina include

  1. coronary heart disease, angina’s most common cause, the risk factors of which include
    1. age, the major determinant of risk of coronary heart disease
    2. atherosclerosis
    3. cigarette smoking
    4. diabetes (CDHO Advisory)
    5. family history of coronary heart disease before age 50
    6. hypercholesterolemia 
    7. hypertension (CDHO Advisory)
    8. inflammatory biomarker abnormalities
    9. insufficient exercise
    10. male gender
    11. obesity
  2. abnormal heart rhythms, especially those which raise the heart rate
  3. anemia (CDHO Advisory)
  4. cold weather
  5. emotional stress
  6. exercise
  7. heart failure
  8. heart valve disease
  9. heavy meals
  10. hyperthyroidism (CDHO Advisory

Signs and symptoms

Angina’s pain or discomfort

  1. is often described as pressure, squeezing, burning or tightness in the chest
  2. may feel like heartburn or indigestion
  3. usually begins behind the sternum and may also occur in one or more of the locations
    1. arm(s)
    2. back
    3. jaw
    4. neck
    5. shoulder(s)
    6. throat
  4. may be variously accompanied by 
    1. anxiety
    2. dizziness
    3. fatigue
    4. light-headedness
    5. nausea
    6. shortness of breath
    7. sweating
    8. weakness 
  5. for women may
    1. differ from the ‘classic’ angina symptoms and lead to delays in their seeking or receiving appropriate treatment
    2. be unnoticeable because of silent myocardial infarction
    3. variously includes
      1. dizziness with weakness 
      2. nausea, vomiting or severe indigestion 
      3. pain, pressure, fullness, discomfort or squeezing in the center of the chest 
      4. panic with feeling of impending doom 
      5. pounding heartbeats (palpitations) or feeling extra heartbeats 
      6. radiating pain to shoulder(s), neck, back, arm(s) or jaw 
      7. shortness of breath or difficulty breathing 
      8. stabbing chest pain 
      9. sudden extreme fatigue 
      10. sweating for no apparent reason 
      11. upper abdominal pain 
    4. be deceptively mild, leading to under-reporting or delayed recognition of emergency, which affects
      1. a third of women who experience no chest pain when having a heart attack
      2. two thirds of women who report flu-like symptoms for two to four weeks prior to experiencing 
        1. significant chest discomfort
        2. severe shortness of breath 
  6. in stable angina 
    1. occurs when the heart must work harder, usually during physical exertion 
    2. is expected because it arises as episodes that are consistent in pattern
    3. usually lasts 5 minutes or less 
    4. is relieved by rest or medication
    5. may feel like gas or indigestion 
    6. may spread to the arms, back, or other areas 
  7. in unstable angina 
    1. often occurs at rest, while sleeping at night, or with little physical exertion 
    2. is unexpected and therefore unpredictable
    3. is more severe, lasting 
      1. as long as 30 minutes
      2. longer than the 5-minute episodes typical of stable angina 
    4. is not usually relieved by rest or nitrates
    5. may continuously worsen 
  8. in variant angina 
    1. usually occurs at rest and during the night or early morning hours 
    2. tends to be severe
    3. is relieved by angina medication.

Medical investigation

of angina 

  1. for initial diagnosis is usually based on the history of type and pattern of symptoms
  2. usually involves testing
    1. to
      1. confirm or exclude angina 
      2. determine the severity of the underlying heart disease
    2. with methods such as
      1. electrocardiogram
      2. chest x-ray
      3. exercise stress test, to 
        1. elicit symptoms of angina
        2. investigate the functioning of the heart 
        3. track blood pressure 
        4. view by scanning the blood flow in the heart muscle during the most intense time of exercise, and after rest
      4. angiogram (angiography), which involves
        1. imaging of a coronary artery
        2. catheterization of the artery
        3. use of dyes
        4. sequencing of images to view dynamic changes
      5. echocardiogram, using ultrasound for dynamic analysis of heart function and blood flow
      6. blood tests for
        1. biomarkers
        2. blood cholesterol levels
        3. blood sugar levels
        4. hemoglobin levels
      7. transesophageal echocardiogram, which involves a transducer in the esophagus to direct high frequency sound waves for examination of the structure of the heart
      8. thallium scan, which uses a radioactive tracer to see how much blood is reaching different parts of the heart.

Treatment

of angina 

  1. aims to reduce the frequency and severity of symptoms while striving to prevent or lower the risk of myocardial infarction and death
  2. includes 
    1. medication
    2. surgery
      1. angioplasty, a procedure to open blocked or narrowed coronary arteries, that
        1. improves blood flow to the heart
        2. relieves chest pain
        3. may prevent myocardial infarction (CDHO Advisory)
        4. may require a stent (percutaneous coronary intervention [PCI], formerly known as angioplasty with stent) within the artery to keep it open following surgery
      2. coronary artery bypass, which  
        1. uses arteries or veins from other parts of the body to bypass blocked coronary arteries
        2. increases blood flow to the heart
        3. relieves chest pain
        4. may help prevent myocardial infarction (CDHO Advisory)
    3. cardiac rehabilitation, including
      1. exercise training to safely strengthen muscles and improve daily stamina
      2. education, counseling and training to help the person
        1. deal with fears about the future
        2. learn ways to reduce risk of future heart problems
        3. understand his or her condition 
    4. changes to lifestyle, such as 
      1. self-pacing for exertion-related angina 
      2. weight loss
      3. prescribed exercise 
      4. avoiding heavy meals and rich foods 
      5. healthy diet to combat
        1. hypertension (CDHO Advisory)
        2. raised cholesterol
        3. obesity
      6. strict adherence to prescribed medications to reduce
        1. angina 
        2. cholesterol 
        3. hypertension (CDHO Advisory)
      7. in diabetes, strict adherence to control of blood sugar (CDHO Advisory)
      8. cessation of smoking 
      9. reduction of stress or emotional factors through
        1. avoidance of stressful situations
        2. coping mechanisms. 

Prevention

of angina hinges on the control of 

  1. coronary heart disease (CDHO Advisory)
  2. causes and risk factors.

Prognosis

of angina reflects the outlook for ischemic heart disease, which

  1. is the second leading cause of death in Canada 
  2. displays steady declines 
    1. in rates of occurrence over many years (45% decline in age standardized incidence between 2000–2001 and 2012–2013) 
    2. in death rates, which have decreased by 24% (all-cause mortality rate) between 2000–2001 and 2012–2013  
    3. which are attributed to 
      1. improvements in the control of risk factors, especially 
        1. cholesterol
        2. hypertension
        3. smoking
      2. improved medical management of patients with cardiovascular diseases
    4. is increasing in absolute numbers in Canada, chiefly because 
      1. relative to hypertension and other risk factors for cardiovascular disease 
        1. persons with these risk factors now live longer
        2. increased awareness is leading to more frequent diagnosis
      2. of increasingly sedentary lifestyle
      3. of increases in 
        1. obesity
        2. diabetes.

Social considerations

of angina highlight the importance of attention to a woman’s concerns about her symptoms because her cardiac-related symptoms may result in incorrect clinical interpretation arising from

  1. erroneous beliefs on the part of physicians and other healthcare professionals that angina is less common in women than in men
  2. possible differences in women’s cardiac symptoms from those in men leading to insufficient recognition by women and by their healthcare providers
  3. women’s tendencies to under-report their cardiac symptoms.

Multimedia and images

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with angina  but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 

  1. Elderly persons with unstable angina or myocardial infarction (CDHO Advisory) commonly have as many as three or even more comorbidities, such as 
    1. kidney diseases (CDHO Advisory) 
    2. heart failure
    3. hypertension (CDHO Advisory)
    4. neurological diseases
    5. obesity
    6. type 2 diabetes (CDHO Advisory).
  2. Comorbidities for adults generally include
    1. asthma (CDHO Advisory)
    2. chronic obstructive pulmonary disease (CDHO Advisory)
    3. diabetes (CDHO Advisory)
    4. emphysema (CDHO Advisory)
    5. hypercholesterolemia
    6. peripheral vascular disease associated with  
      1. atherosclerosis
      2. blood clots.

Oral health considerations

Resources consulted

A pre-planned and informed approach to recognition and management of angina is an integral part of the clinical responsibilities of health care professionals generally and dental hygienists in particular because

  1. angina pectoris and myocardial infarction are the two most likely cardiac problems in a conscious patient/client who is exhibiting chest pain during oral healthcare
  2. psychological and physiological stress during the Procedures has the potential to significantly and adversely affect the supply of oxygen to the heart, and therefore produce chest pain or discomfort, which
    1. may indicate unstable angina and thus signal imminent myocardial infarction (CDHO Advisory), a medical emergency, if it 
      1. lasts longer than a few minutes
      2. is not relieved by rest or angina medication 
    2. may occur if cardiac stress suddenly increases because the coronary oxygen supply is overcome by the myocardium’s oxygen demand which causes episodes of chest pain or discomfort that
      1. are likely to be stable angina
      2. may be precipitated by the stress of the Procedures
      3. disappear when the cardiac stress is reduced
    3. may not feature prominently or at all during or prior to a myocardial infarction (CDHO Advisory) because, in some instances, the sole symptom of the cardiac ischemia may be craniofacial pain 
    4. may have causes unrelated to the heart or the cardiovascular system
  3. the primary management goal of oral healthcare for the patient/client with angina 
    1. is to ensure that any effects on the circulation of oxygen-bearing blood to the heart produced by dental treatment do not exceed the cardiovascular reserve of the patient
    2. is achieved by monitoring the patient/client’s 
      1. blood pressure, which has the associated benefit of screening for undiagnosed hypertension (CDHO Advisory) for subsequent referral for medical evaluation 
      2. heart rate and rhythm 
    3. requires the dental hygienist to take the medical history 
      1. with the intention of identifying patients/clients 
        1. who may be at particular risk of myocardial infarction (CDHO Advisory) during or as a result of the Procedures
        2. whose hypertension (CDHO Advisory) is not sufficiently under control
        3. for whom medical clearance for the Procedures is required, chiefly those 
          1. with unstable angina
          2. with a recent history of myocardial infarction (CDHO Advisory)
          3. who may benefit from pre-medication 
            1. to alleviate anxiety
            2. with nitrates
      2. to identify the patients/client’s medications, including
        1. prescription medications and, where appropriate, dose and timing 
        2. over-the-counter medications
        3. herbal, supplements and other remedies
        4. drug interactions and side effects
    4. to consider stress-reduction techniques, such as short appointments, ideally in the morning when the patient is well-rested and has a greater physical reserve 
    5. to control pain
      1. as an essential prevention for patients/clients with cardiac conditions such as
        1. atherosclerosis
        2. recent myocardial infarction 
        3. stable angina  
      2. which may require effective local anesthesia to avoid undue stress during the Procedures, subject to the guidelines for the use of epinephrine, because patients/clients who may be at particular risk from the effects of epinephrine include those with
        1. unstable angina 
        2. a history of recent myocardial infarction
      3. post-Procedure with appropriate pain relief 
    6. to ensure that emergency procedures are in place, understood and followed, and include
      1. early recognition of medical emergencies, which relies on perceiving and understanding early symptoms
      2. as required
        1. appropriate positioning of the patient/client
        2. assessments of 
          1. airways
          2. breathing
          3. circulation
        3. administration of 
          1. oxygen 
          2. nitrates 
        4. termination of the Procedures or the appointment if
          1. angina symptoms intensify 
          2. the patient/client becomes overly anxious 
  4. oral healthcare, along with matters of diet and lifestyle, is important 
    1. in prevention of cardiovascular disease because 
      1. of possible links between
        1. infections of the mouth and coronary artery disease
        2. periodontal disease and atherosclerosis
      2. moderate to severe periodontitis may require medical evaluation and possible treatment especially for patients/clients with other risk factors, such as
        1. atherosclerosis 
        2. cardiovascular disease 
    2. in cardiac rehabilitation following myocardial infarction or surgical treatment for atherosclerosis.

 

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect databases
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Complementary and alternative medicine

Types of medications

Resources consulted

Guidelines 

  1. Apart from medications used to treat angina  the patient/client may be prescribed medications for comorbidities, complications and associated conditions of angina.
  2. Aspirin
    1. there is no indication to discontinue aspirin treatment of patient/clients with a history of myocardial infarction in connection with
      1. single-tooth extraction
      2. the Procedures 
    2. antiplatelet therapy with aspirin 
      1. has been shown to reduce cardiac events after coronary stenting
      2. should not be discontinued because doing so increases the risk of stent thrombosis, myocardial infarction and death. 
  3. Epinephrine in local anesthesia in oral healthcare
    1. Pain and other stressors can provoke sudden and significant release of epinephrine, which can adversely affect the diseased heart. 
    2. The addition of epinephrine to local anesthetics improves both the depth and duration of anesthesia. Given the importance of good local anesthesia technique, use of some exogenous epinephrine may be beneficial for some patients/clients with angina, but the dose needs careful consideration.
    3. One of the most frequently quoted suggestions for a safe dose specifies a maximum dose of 40 µg epinephrine per oral healthcare appointment. Nevertheless, epinephrine should
      1. be used with caution with patients/clients with a history of stable angina
      2. not be used with patients/clients with a history of unstable angina or myocardial infarction without clear medical concurrence. 
  4. Guidelines for prevention of heart disease no longer recommend
    1. hormone replacement therapy 
    2. vitamins E or C
    3. antioxidants
    4. folic acid.

Specific Medications

  1. Anti-platelets
    Prevent blood clots from forming
    aspirin (ASA)
    clopidogrel (Plavix®)
    dipyridamole (Permole®,  Persantine®)
    prasugrel (Effient®)
    ticlopidine (Ticlid®)
    ticragelor (Brilinta®)
  2. Direct oral anticoagulants (DOACs)
    apixaban (Eliquis®
    dabigatran (Pradaxa®)
    edoxaban (Savaysa®)
    rivaroxaban (Xarelto®) 
  3. Vitamin K-based anticoagulants (VKAs)
    warfarin (Coumadin®) 
  4. Nitrates
    Prevent or treat angina
    isosorbide (Dilatrate®-SR, Imdur®, Ismo®, Ismotic®, Isoditrate®, Isordil®, Monoket®) 
    nitroglycerin (Nitromist®, Nitrostat®, Nitro-Time®)
    nitroglycerin topical (Nitro-Bid®, Rectiv®)
    nitroglycerin transdermal (Minitran®, Nitro-Dur®)
  5. Anti-anginals – non-nitrates
    ranolazine (Ranexa®)
  6. Beta-blockers
    Heart failure, hypertension, and angina
    atenolol (Tenormin®)
    carvedilol (Coreg®)
    labetalol oral (Normodyne®, Trandate®)
    metoprolol (Lopressor®, Toprol®) 
    pindolol (Visken®) 
    propranolol oral (Inderal®) 
  7. Calcium channel blockers
    Hypertension and angina
    amlodipine (Katezia®, Norvasc®)
    diltiazem (Cardizem®, Tiazac®)  
    felodipine (Plendil®)
    nifedipine (Adalat®, Procardia®)
    verapamil (Calan®, Isoptin®, Verelan®)
  8. Cholesterol absorption inhibition and dietary restriction 
    ezetimibe (Zetia®)
    niacin (Niacor®, Niaspan®)
  9. Resins (bile acid sequestrants)
    Promote formation of bile, which reduces LDL-cholesterol
    cholestyramine resin (Questran®) 
    colestipol (Colestid®)
  10. Statins
    Lower cholesterol and other fats
    atorvastatin (Lipitor®)
    fluvastatin (Lescol®) 
    lovastatin (Altoprev®, Mevacor®
    pitavastatin (Livalo®, Zypitamag®)
    pravastatin (Pravachol®) 
    rosuvastatin (Crestor®, Ezallor®)
    simvastatin (Flolipid®, Zocor®)
  11. Angiotensin-converting enzyme (ACE) inhibitors
    Hypertension and heart failure
    benazepril (Lotensin®)
    captopril (Capoten®)
    enalapril (Vasotec®)
    fosinopril (Monopril®)
    lisinopril (Prinivil®, Zestril®, Qbrelis®)
    moexipril (Univasc®)
    perindopril (Aceon®)
    quinapril (Accupril®)
    ramipril (Altace®)
  12. Thiazide diuretics
    Thiazide diuretics are used to treat high blood pressure by reducing the amount of sodium and water in the body. Thiazides are the only type of diuretic that dilates the blood vessels, which also helps to lower blood pressure.
    chlorthalidone (Thalitone®, Hygroton®)
    hydrochlorothiazide (Hydrodiuril®, Microzide®, Oretic®)
    methyclothiazide (Aquatensen®,  Enduron®) 
    metolazone (Zaroxolyn®)
  13. Potassium-sparing diuretics
    Potassium-sparing diuretics are used to reduce the amount of water in the body. Unlike the other diuretic medications, these do not cause the body to lose potassium.
    amiloride and hydrochlorothiazide (Moduretic®)
    spironolactone (Aldactone®, Carospir®) 
    triamterene (Dyrenium®) 
  14. Loop-acting diuretics
    Loop-acting diuretics cause the kidneys to increase the flow of urine. This helps reduce the amount of water in the body and lower the blood pressure.
    ethacrynic acid (Edecrin®)
    furosemide (Lasix®) 
  15. Heart failure, arrhythmia
    digoxin oral (Cardoxin®)
  16. Fibrates (Fibric Acid Derivatives)
    Reduce cholesterol and triglycerides, increase HDL
    fenofibrate (Lipidil® + others)
    gemfibrozil (Lopid®)

Side effects of medications

See the links above to the specific medications. 

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical  and medications history-taking should 

  1. focus on screening the patient/client prior to treatment decisions relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities
    6. associated conditions
  2. explore the need for advice from the primary or specialized care provider(s)
  3. inquire about
    1. symptoms and pointers in the recent history to identify symptoms suggestive of unstable angina, which is a 
      1. contraindication to the Procedures
      2. potential medical emergency
    2. symptoms suggestive of stable angina, which is not a contraindication to the Procedures provided that the patient/client is receiving appropriate medical care
    3. the patient/client’s understanding and acceptance of the need for oral healthcare
    4. medications considerations, including over-the-counter medications, herbals and supplements, with specific reference to nitrates
    5. problems with previous dental/dental hygiene care
    6. problems with infections generally and specifically associated with dental/dental hygiene care
    7. the patient/client’s current state of health
    8. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

The dental hygienist should

  1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number
  2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider
  3. use a consent/medical consultation form, and be prepared to securely send the form to the provider 
  4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

The dental hygienist 

  1. should not implement the Procedures without prior consultation with the appropriate primary or specialist care provider(s) if the patient/client’s history or present condition appears suggestive of unstable angina and/or if the patient/client is taking an antiplatelet agent (other than low-dose ASA) — as often happens with cardiac stenting — or an anticoagulant2 (e.g., warfarin3 or a direct oral anticoagulant), which increases risk of bleeding.
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. is experiencing symptoms suggestive of stable angina and is not receiving routine medical care
    2. has not complied with pre-medication, such as nitrates, as directed by the prescribing physician 
    3. has recently changed significant medications, under medical advice or otherwise
    4. recently experienced changes 
      1. in his/her medical condition
      2. such as effects of medication or other  treatment
    5. is unable to provide the dental hygienist with sufficient information about the medical history relating to coronary artery disease or cardiovascular disease
    6. has symptoms or signs of 
      1. exacerbation of the medical condition
      2. comorbidity, complication or an associated condition 
    7. not recently or ever sought and received medical advice relative to oral healthcare procedures
    8. is deeply concerned about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of angina , the dental hygienist should specifically record

  1. a summary of the medical and medications history
  2. any advice received from the physician/primary care provider relative to the patient/client’s condition
  3. the decision made by the dental hygienist, with reasons
  4. compliance with the precautions required
  5. all Procedure(s) used
  6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienists should 

  1. urge the patient/client to alert any healthcare professional who proposes any intervention or test that he or she 
    1. has a history of angina 
    2. is taking medication
    3. should as a matter of routine take any prescribed nitrates
  2. explain to the patient/client that some cardiovascular diseases may
    1. affect oral health
    2. may require 
      1. medical advice before the Procedures are implemented
      2. changes to oral health care
  3. advise the patient/client to bring angina-related medications, such as nitrates, to oral health appointments
  4. discuss, as appropriate 
    1. the patient/client’s medications, including
      1. most recent use of required medications in relation the dental hygiene
      2. sub-lingual nitrates, where appropriate, with advice for combating dry mouth with moistening of the area under the tongue
      3. effects
        1. nature
        2. duration
    2. the importance of the patient/client’s
      1. self-checking the mouth regularly for new signs or symptoms
      2. reporting to the appropriate healthcare provider any changes in the mouth
    3. the need for regular oral health examinations and preventive oral healthcare 
    4. oral self-care including information about 
      1. choice of toothpaste
      2. tooth-brushing techniques and related devices
      3. dental flossing
      4. mouth rinses
      5. management of a dry mouth 
    5. the importance of an appropriate diet in the maintenance of oral health
      1. for persons at an advanced stage of debilitation
        regimens for oral hygiene as a component of supportive care and palliative care
      2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
      3. scheduling and duration of appointments to minimize stress and fatigue 
    6. comfort level while reclining, and stress and anxiety related to the Procedures
    7. medication side effects such as dry mouth, and recommend treatment
    8. mouth ulcers and other conditions of the mouth, comorbidities, complications or associated conditions, medications or diet
    9. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons who have angina.
  2. Reducing the adverse effects, such as inappropriately implementing the Procedures because of failure to obtain medical advice or urgent care for a patient/client with unstable angina.
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Causing stress with adverse consequences for the patient/client with stable angina.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client’s angina  is unrecognized 
    2. in the presence of complications for which prior medical advice is required.
  3. Disturbing the normal dietary and medications routine of a person with angina.
  4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2011-03-01

DATE OF LAST REVIEW

2011-11-01; 2017-02-01; 2022-01-24

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow
MD, MHSc, DTM&H, CHE, CCFP, DABPM, LFACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2011, 2017, 2022 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children
2 About 5–10% of the patients/clients scheduled for coronary artery stenting already take oral anticoagulants, usually for atrial fibrillation.
3 Warfarin’s effect on clotting is monitored by the international normalized ratio (INR). More information about warfarin, including “dentally safe” INRs, is contained in the CDHO Knowledge Network’s Angina Fact Sheet and  Atrial Fibrillation Fact Sheet.