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CDHO Advisory: Myocardial Infarction and Cardiac Arrest

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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 myocardial infarction or cardiac arrest, or who have a history of either of these.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Myocardial Infarction and Cardiac Arrest, 2023-10-15

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)

Myocardial infarction or cardiac arrest

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 with myocardial infarction or cardiac arrest, or who have a history of either of these, 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

Child (2 to 12 years)
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 children, young persons and adults with myocardial infarction or cardiac arrest, or who have a history of either of these.

MAJOR OUTCOMES CONSIDERED

For persons who have myocardial infarction or cardiac arrest or who have a history of either of these: 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

  1. Angina pectoris (CDHO Advisory)
    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 a heart attack but rather 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. Arrhythmia, disorder of the heart rate or heart rhythm, which 
    1. may be fatal if not treated promptly
    2. causes the ventricles to quiver irregularly
    3. involves the heart beating
      1. too quickly, tachycardia 
      2. too slowly, bradycardia 
      3. irregularly.
  3. 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 plaques
    2. may cause a blood clot to form at the site of the narrowing, which 
      1. completely blocks the artery
      2. in a coronary artery, causes myocardial infarction.
  4. 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.
  5. Cardiac arrest, sudden cardiac arrest, sudden cardiac death, a medical emergency of the first order, which
    1. occurs when 
      1. the heart stops beating
      2. breathing stops
    2. is not the same things as a heart attack.
  6. Cardiovascular disease (CVD), comprises various diseases of the circulatory system which
    1. involve blood vessels of the heart 
    2. involve blood vessels supplying the 
      1. lungs
      2. brain
      3. kidneys or other parts of the body
    3. are the leading cause of death in adult Canadian men and women.
  7. Cholesterol, is
    1. a waxy fat called a lipid that is produced naturally in the body
    2. essential for the body to make
      1. cell membranes
      2. vitamin D
      3. hormones
    3. of two primary 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.
  8. Coronary heart disease (CHD), coronary artery disease (CAD), narrowing
    1. of the small blood vessels that supply blood and oxygen to the heart 
    2. most likely to be caused by atherosclerosis.
  9. Diaphoresis, excessive sweating, commonly associated with shock and other conditions of medical emergency such as myocardial infarction.
  10. Heart attack, myocardial infarction, 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 cause heart muscle death
    2. lead to disability or death of the persons depending on the extent of the heart muscle damage.
  11. Ischemia, decrease or restriction in blood supply to an organ or body part, often resulting in pain.
  12. Myocardial infarction, acute myocardial infarction, heart attack, 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. 
  13. Myocardium, thick muscle layer of the heart that forms the bulk of the heart wall that contracts as heart beats.
  14. Negative affectivity, Type D Personality, the full spectrum of negative emotions, including
    1. anger
    2. anxiety
    3. depression
    4. guilt
    5. sadness.
  15. Peripheral vascular disease, peripheral arterial disease, peripheral artery occlusive disease, the narrowing or blockage of blood vessels in the limbs.
  16. Prevalence, total of persons in a given population with a health-related condition during a specified period of time, usually expressed as a percentage.
  17. Prinzmetal’s or variant angina, the rarest form of angina which usually occurs at rest during sleeping hours and is usually easily treated with medication.  
  18. 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.
  19. 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.
  20. Syncope, temporary loss of consciousness and posture, which
    1. is described as fainting or passing out
    2. is usually related to temporarily insufficient blood flow to the brain
    3. most often occurs 
      1. with hypotension
      2. when the heart fails to provide a normal supply of oxygen to the brain.
  21. Triglycerides, the chemical form, which
    1. are the chemical makeup of most fat in food as well as in the body
    2. are present in blood plasma
    3. in association with cholesterol form the plasma lipids.
  22. Unstable angina
    1. is a serious condition that may herald an impending myocardial infarction
    2. does not follow a predictable pattern
    3. can happen during strenuous activity or at rest
    4. is not always relieved by rest and medication.
  23. Variant angina, chest pain originating in coronary artery spasm, a sudden constriction of a coronary artery depriving the myocardium of blood and oxygen.

Overview of myocardial infarction 

Resources consulted

Myocardial infarction

  1. is not the same thing as cardiac arrest 
  2. is a medical emergency of the first order in which the immediate medical history 
    1. is critical in recognizing the condition and therefore invoking appropriate emergency medical procedures
    2. sometimes may provide the only clues that lead to the diagnosis in the initial phases of the emergency
  3. is characterized by warning signs and symptoms, including
    1. pain
      1. located in one site, or several sites, or that moves between the sites that include the
        1. chest which
          1. is a major focal point of symptoms of heart attack that 
            1. are usually across the anterior precordium
            2. are typically described as tightness, pressure, or squeezing
            3. may radiate to the jaw, neck, arms, back, and epigastrium
            4. are more frequently experienced in the left arm though they do occur in both arms
          2. may be the site of vague or barely noticeable symptoms in
            1. elderly persons
            2. persons with diabetes
            3. women 
        2. neck
        3. jaw
        4. shoulder
        5. arms
        6. back 
        7. abdomen
        8. teeth
      2. experienced as
        1. a tight band around the chest
        2. burning
        3. heaviness, akin to something heavy placed on the chest
        4. severe indigestion
        5. tightness, squeezing or heavy pressure
      3. that 
        1. may vary in intensity
        2. usually persists for more than 20 minutes
        3. is incompletely relieved  or not relieved at all or by 
          1. nitrates
          2. rest
      4. that is 
        1. sudden 
        2. not relieved with rest
    2. breathing problems, which 
      1. include
        1. shortness of breath
        2. difficulty breathing 
        3. cough
        4. wheezing
      2. may accompany chest pain or occur as an isolated complaint
      3. indicate that the heart’s performance is impaired by acute ischemia
      4. may be the equivalent of angina in the particular patient
      5. may be the only complaint in a person who
        1. is elderly
        2. has diabetes
    3. intestinal discomfort
      1. nausea, with or without
        1. vomiting 
        2. abdominal pain
      2. indigestion 
    4. skin
      1. diaphoresis
      2. cool, clammy skin 
    5. fear
      1. anxiety 
      2. denial 
    6. circulation-related
      1. fainting
      2. light-headedness, dizziness
      3. palpitations 
    7. symptoms that differ from the usual because of particularly subtle presentations in elderly patients and persons with diabetes, such as 
      1. fatigue
      2. syncope
      3. weakness 
      4. altered mental state or dementia resulting in absence of
        1. recollection of recent symptoms 
        2. complaints relating to symptoms
    8. symptoms lacking the classic patterns and which
      1. are clinically silent 
      2. may 
        1. describe as many as 50 percent of all myocardial infarctions 
        2. be unrecognized by the patient, which calls for a high index of suspicion for myocardial infarction especially in the evaluation of 
          1. women
          2. older persons
          3. persons with
            1. diabetes
            2. dementia
            3. histories of heart failure
            4. permanent pacemakers
  4. is rare in childhood and adolescence, when the cause is usually on or other of
    1. acute inflammatory condition of the coronary arteries
    2. an anomalous origin of the left coronary artery
  5. occurs when the blood supply to the heart is slowed or stopped because of a blockage
    1. caused 
      1. in 90 percent of myocardial infarctions by plaque buildup associated with atherosclerosis which 
        1. almost or completely blocks a coronary artery
        2. may be associated with a blood clot in a coronary artery
      2. occasionally by sudden, significant emotional or physical stress, including an illness
    2. may also occur when a coronary artery temporarily contracts or goes into spasm severe enough to
      1. cut off the flow of blood to the heart
      2. damage the heart to a degree determined by the duration of time the blood supply is cut off
  6. is associated with risk factors that also relate to coronary artery disease, including
    1. abnormal cholesterol levels
    2. age over 65 years
    3. diabetes (CDHO Advisory)  
    4. excessively fatty diet
    5. family history of coronary artery disease
    6. hypertension (CDHO Advisory)
    7. kidney disease (CDHO Advisory)
    8. male 
    9. smoking
  7. is investigated by means of
    1. pulse rate, likely to be rapid
    2. blood pressure, which may be normal, high, or low
    3. coronary angiography
    4. CT scan
    5. echocardiography
    6. electrocardiogram (ECG)
    7. magnetic resonance imaging (MRI)
    8. nuclear ventriculography
    9. blood tests for heart tissue damage or high risk for heart attack
  8. is treated with hospital care, including some combination of
    1. intensive care involving 
      1. close ECG monitoring for arrhythmias, the leading cause of death in the first few hours of a heart attack
      2. oxygen
      3. IV administration of medications and fluids
      4. urinary catheterization
    2. medication
    3. surgery and other procedures, including
      1. ablation 
      2. angioplasty with stent, percutaneous coronary intervention (PCI)
      3. cardioversion therapy
      4. coronary artery bypass surgery
      5. heart transplant surgery
      6. heart valve surgery: repair and replacement
      7. implantable cardioverter defibrillator (ICD)
      8. implantable pacemaker 
      9. mechanical assist device
      10. ventricular resection or remodeling 
  9. has incidence and mortality that are positively associated with advanced age and lower socioeconomic status, and negatively associated with improvements in treatment and decreases in risk factors (particularly smoking in men) in that
    1. four out of five patients with coronary artery disease are 65 years or older 
    2. there exists an association with socio-economic gradient in all age groups; for
      1. older adults (age 45 to 64) the rate of heart attacks in the least affluent neighbourhoods was 1.6 times higher (p<0.05) than in the most affluent neighbourhoods
      2. smaller ratios were observed for young adults (age 20 to 44) and seniors (age 65 and older)
    3. age-standardized rates of hospitalized acute myocardial infarction or cardiac arrest events in Canada 
      1. decreased from 251 per 100,000 in 2003–2004 to 217 per 100,000 in 2008−2009 
      2. varied from 255 per 100,000 population from the least affluent neighbourhoods to 186 per 100,000 from the most affluent neighbourhoods
    4. age-standardized mortality rates for heart disease (including myocardial infarction) decreased in 2020 from previous years to 118 per 100,000, representing a general downward trend for the past 20 years
  10. is associated with gender in that
    1. men are 
      1. at higher risk of myocardial infarction or cardiac arrest than women
      2. more likely to suffer myocardial infarction or cardiac arrest earlier in life
    2. women
      1. die in greater numbers from myocardial infarction or cardiac arrest than from any other specific disease, including breast cancer 
      2. following menopause are more likely  than men to die within the first year of having a myocardial infarction or cardiac arrest  
      3. prior to menopause
        1. may be safeguarded from heart disease because of the protective effect of estrogen 
        2. with diabetes have similar myocardial-infarction risk to men of the same age because diabetes impairs the protective effect of estrogen
      4. may not perceive heart disease as the greatest threat to their health even though heart disease is the leading cause of death among both women and men 
      5. may or may not differ from men in the nature or interpretation warning signals of heart attack, because
        1. the evidence is conflicting
        2. women and men may experience typical and non-typical symptoms such as nausea, sweating, pain in the arm, throat, jaw, or other pain that is unusual
        3. women may describe their pain differently than men, though the most common symptom in women is chest pain
    3. most of the risk factors, signs and symptoms are the same in women as they are in men, the unique aspects of female heart health include
      1. menopause, which is associated with an increased risk of 
        1. heart disease because of the declining production of estrogen
        2. increase
          1. in LDL cholesterol
          2. triglyceride levels (triglycerides), which 
            1. may increase the risk of heart disease
            2. often rise in level as 
              1. total cholesterol and LDL rise
              2. HDL falls
              3. diabetes risk rises
        3. decrease HDL leading to
          1. hypertension
          2. increase in body fat above the waist
          3. impairment of
            1. blood clotting
            2. metabolism of sugar, a precursor to diabetes
      2. oral contraception which, in a small percentage of women, may increase the risk of hypertension and blood clots, especially
        1. in combination with smoking 
        2. with age above 35 years
        3. with other risk factors for heart disease 
        4. an existing blood-clotting problem
      3. cholesterol which
        1. despite the presence of natural estrogen in women, is too high in 45 percent of women between the ages of 18 to 74
        2. after menopause, as natural estrogen levels drop, is too high among 80 percent of women between the ages of 65 to 74
    4. in both sexes, risk factors, such as
      1. smoking
        1. cigarette smokers are twice as likely to experience myocardial infarction or cardiac arrest compared to non-smokers
        2. smokers also have a two to four times higher risk of sudden cardiac death (within an hour of a heart attack)
      2. hypertension alone or in association with obesity, smoking, abnormal blood cholesterol levels or diabetes increases the risk of myocardial infarction or cardiac arrest 
      3. abnormal cholesterol levels alone increase the risk of myocardial infarction or cardiac arrest
      4. obesity, which increases
        1. the risk of coronary artery disease, myocardial infarction or cardiac arrest, and stroke
        2. strain on the heart, which raises blood pressure and cholesterol
        3. the risk of diabetes
      5. diabetes
        1. some two-thirds of persons with diabetes die from heart or blood vessel disease
        2. adults with diabetes are three to seven times more likely to develop heart disease
      6. physical activity; insufficiency of exercise deprives the body of an important means for reducing the risks of some or all of
        1. coronary artery disease
        2. myocardial infarction or cardiac arrest 
        3. abnormal cholesterol levels
        4. obesity
        5. diabetes
        6. hypertension
      7. stress, which may be linked to
        1. coronary artery disease
        2. myocardial infarction or cardiac arrest
        3. hypertension
        4. abnormal cholesterol levels
        5. increased tendencies to one or more of
          1. smoking
          2. gaining weight 
          3. decreasing physical activity
  11. is associated with factors reflective of Canada’s ethnic diversity; a 2010 study of 154,653 Whites, 3,364 South Asians, 3,038 Chinese and 2,742 Blacks who represented people living in Ontario between 1996 and 2007 found that
    1. the prevalence of
      1. heart disease or stroke in South Asians was almost twice that in Chinese
      2. hypertension was in comparison with Whites
        1. 44 percent higher in Blacks
        2. 24 percent higher in the South Asians
    2. the risk of diabetes among the South Asian and Black groups was twice as high as among the Whites and Chinese
    3. with the cardiovascular risk-factor profile, which included two or more major cardiovascular risk factors (current smoking, obesity, diabetes, hypertension) the most favourable profile overall in descending order of reporting was 
      1. Chinese, 4.3 percent
      2. South Asian, 7.9 percent
      3. White, 10.1 percent
      4. Black, 11.1 percent
    4. smoking was
      1. almost three times higher in the Whites than in Chinese and South Asians 
      2. more common in men than women, but the difference between men and women was much smaller in Whites and Blacks than in Chinese and South Asians
    5. obesity was five times more prevalent in Whites and Blacks than in Chinese 
    6. Blacks had a higher prevalence for cardiovascular risk factors, but a lower prevalence of heart disease
    7. Black women had higher prevalence of obesity, diabetes, hypertension and heart disease than Black men
    8. 63 percent to 75 percent of the study respondents
      1. did not participate in at least 15 minutes of daily physical activity
      2. the non-participation was greatest among
        1. South Asian men (70 percent), women (75 percent)
        2. Chinese men (71 percent), women (75 percent)
        3. Black women (71 percent).
  12. exhibits risk factors
    1. risk factors that can be controlled, which include
      1. alcohol consumption that is excessive
      2. atherosclerotic plaque
        1. diabetes
        2. high blood cholesterol
        3. hypertension
        4. smoking
      3. overweight
      4. physical inactivity
      5. risk factors that cannot be controlled
      6. stress
    2. risk factors that may or may not be controllable but which may adversely influence recovery, which include
      1. personality type: high negative affectivity and social inhibition, which appear to be 
        1. strong predictors of adverse effect on health outcomes after myocardial infarction or cardiac arrest
        2. important psychosocial factors to watch for in persons following myocardial infarction 
        3. associated with a distinct profile of illness beliefs, which may help explain the adverse effect on health outcomes following myocardial infarction or cardiac arrest
        4. associated with
          1. lower-priority emergency department triage scores than those with other comorbidities
          2. lower performance on quality indicators in acute myocardial infarction or cardiac arrest care
      2. sedentary lifestyle, which is considered a risk factor but so too is episodic physical and sexual activity because these appear to be associated with myocardial infarction and other acute cardiac events to a greater extent than for persons with high levels of habitual physical activity
    3. risk factors for myocardial infarction or cardiac arrest and atherosclerosis that cannot be controlled, which include
      1. age
      2. ethnicity
      3. family history
      4. history of stroke or transient ischemic attack
      5. sex
  13. presents a mixed prognosis because of
    1. a death rate as rate as high as 30 percent, with more than half of the deaths occurring in the pre-hospital setting
    2. its relation to the
      1. survival time: if death does not occur within the first two hours of the attack, the person is likely to survive though complications
        1. may occur
        2. may or may not fully recover
      2. extent of the infarct
      3. timing and nature of intervention
      4. success of the intervention
      5. post-infarction management
      6. rehabilitation, regular follow-up care and attention to controllable and other risk factors
    3. recovery which may be sufficient for return to normal activities.

Overview of cardiac arrest

Resources consulted

Cardiac arrest

  1. is a first-order medical emergency
  2. not the same thing as myocardial infarction
  3. causes death in some 95 percent of persons who experience it
  4. may be occurring when a person is 
    1. suddenly not responsive, especially when called or tapped on the shoulder
    2. apparently pulseless and without heart beat
    3. not breathing when the head is 
      1. tilted back
      2. checked for at least five seconds
  5. likely results in death if 
    1. diagnosis is delayed
    2. appropriate action is not taken
    3. inappropriate treatment is given 
  6. is caused by
    1. ventricular fibrillation, a type of arrhythmia
    2. coronary artery disease 
    3. abnormal electrical activity in the heart associated with 
      1. severe physical stress
      2. inherited disorders that disrupt the heart’s electrical activity 
      3. structural changes in the heart that cause electrical signals to spread abnormally. 

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with myocardial infarction or cardiac arrest 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. 

Comorbid conditions, complications and associated conditions include the following.

  1. Arrhythmia.
  2. Cardiogenic shock, the state in which the heart has been damaged so much that it is unable to supply enough blood to the organs of the body.
  3. Heart failure, the condition in which the heart can no longer pump enough blood to the rest of the body.
  4. Damage to heart valves or the septum between the two sides of the heart.
  5. Infarct extension, damage extending past heart tissue, possibly leading to rupture of the heart.
  6. Irregular heartbeats, including ventricular tachycardia and ventricular fibrillation.
  7. Mental health conditions, which
    1. may not always be adequately recorded
    2. include
      1. dementia (CDHO Advisory)
      2. depression (CDHO Advisory)
      3. post-traumatic stress disorder
      4. negative affectivity.
  8. Pericarditis, inflammation around the lining of the heart.
  9. Pulmonary embolism, blood clot in the lungs.
  10. Side effects of medications.
  11. Stroke (CDHO Advisory). 

Oral health considerations

Resources consulted

Myocardial infarction

  1. is a major concern for all healthcare professionals because
    1. it is a medical emergency of the first order
    2. it is the commonest cause of death for men and women
    3. many of the deaths could be prevented
    4. deaths occur when medical treatment is not provided quickly enough
    5. of high rates of severe, residual complications in many of those who survive
  2. is therefore a point of clinical focus for dental hygienists, who should be able to
    1. recognize signs of possible myocardial infarction 
    2. take the medical history, which may 
      1. be critical for the diagnosis of myocardial infarction 
      2. sometimes provide the only clues that lead to the diagnosis in the initial phases of the patient presentation
    3. react quickly and appropriately to initiate the interventions that will ultimately prevent or limit damage to the myocardium by 
      1. calling 911 with the first symptoms or signs of angina 
      2. seeking on-the-spot medical attention if circumstances permit 
  3. and its risk factors are a high priority for health promotion and prevention for all healthcare professionals, which requires dental hygienists to
    1. encourage patients/clients to manage their own control controllable risk factors
    2. be attentive to controllable risk factors within the scope of oral healthcare, including, in particular, monitoring
      1. blood pressure as a contribution to the overall health of patients/clients by referring them to their physicians when blood pressure levels signal that investigation is indicated (CDHO Advisory)
      2. the various types of periodontal disease in elderly patients/clients because of the
        1. growing evidence linking periodontal disease and 
          1. cardiovascular disease generally
          2. coronary artery disease in particular
        2. high level of unmet dental needs apparently existing in the elderly population, whose cardiac conditions and the comorbidities, complications and associated conditions decrease their accessibility to oral healthcare 
    3. take clinical account of key factors such as that
      1. cardiovascular diseases are the leading cause of death among Canadian men and women 
      2. psychological conditions, such as negative affectivity, that affect patients post-infarction may also act to discourage some patients/clients from obtaining oral healthcare or pursuing oral self-care
      3. the association between tooth loss and increased risk of death from cardiovascular disease likely applies to non-smokers as well as smokers
      4. evidence suggests that annual influenza vaccination may be associated with some degree of protection against myocardial infarction, which should lead dental hygienists to
        1. encourage patients/clients with cardiac risk factors to receive an annual influenza vaccination
        2. view annual influenza vaccinations for themselves and their patients/clients as an important component of health promotion and prevention.
      5. myocardial injury (including MI) can be caused by COVID-19 infection, and therefore immunization against this emerging disease should be considered for patients/clients and dental hygienists in accordance with prevailing recommendations of the National Advisory Committee on Immunization and the Ontario Ministry of Health.

Cardiac arrest is an uncommon but nevertheless foreseeable emergency in an oral healthcare office for which dental hygienists should be prepared.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  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

Types of medications

Resources consulted

Guidelines 

  1. Apart from medications used to treat angina (angina pectoris) the patient/client may also 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 for persons requiring single-tooth extraction or the Procedures
    2. antiplatelet therapy with aspirin 
      1. has been shown to reduce cardiac events after coronary stenting
      2. but patients and health care providers may prematurely discontinue dual antiplatelet therapy, which 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. Thrombolytics2 (a form of anti-thrombotic therapy, used in management of acute MI to break up clots in coronary arteries)
    alteplase (t-PA)
    reteplase
    streptokinase
    tenecteplase
  2. Anti-platelets (a form of anti-thrombotic therapy, used long-term for secondary prevention3 via reduction in clot formation)
    aspirin (ASA)
    clopidogrel (Plavix®)
    dipyridamole (Permole®, Persantine®)
    prasugrel (Effient®)
    ticlopidine (Ticlid®)
    ticagrelor (Brilinta®)
  3. Anticoagulants (a form of anti-thrombotic therapy, used to reduce clot formation)
    1. direct oral anticoagulants (DOACs)
      1. apixaban (Eliquis®)
      2. dabigatran (Pradaxa®)
      3. rivaroxaban (Xarelto®)
    2. 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®)
    nitroglycerin transdermal (Minitran®, Nitro-Dur®)
  5. Beta-blockers
    Heart failure and hypertension
    carvedilol (Coreg®)
    labetalol oral (Normodyne®, Trandate®)
    metoprolol (Lopressor®, Toprol®)
    pindolol (Visken®)
    propranolol oral (Inderal®) 
  6. Calcium channel blockers
    Hypertension and angina
    amlodipine (Norvasc®)
    diltiazem (Cardizem®)
    nifedipine (Procardia®)
    verapamil (Calan®, Isoptin®)
  7. Cholesterol absorption inhibition and dietary restriction
    ezetimibe (Zetia®)
    niacin (Niacor®)
  8. Resins (bile acid sequestrants)
    Promote formation of bile, which reduces LDL-cholesterol_LDL
    cholestyramine resin (Questran®) 
    colestipol (Colestid®)
  9. Statins
    Lower cholesterol and other fats
    atorvastatin (Lipitor®)
    fluvastatin (Lescol®)
    lovastatin (Mevacor®)
    pravastatin (Pravachol®)
    simvastatin (Zocor®)
  10. Angiotensin-converting enzyme (ACE) inhibitors
    Hypertension and heart failure
    captopril (Capoten®)
    enalapril (Vasotec®)
    lisinopril (Prinivil®, Zestril®)
    ramipril (Altace®)
  11. Metabolic modulators
    Treat angina
    ranolazine (Ranexa®)
  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®)
    methyclothiazide (Duretic®)
    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®) 
    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, hypertension
    digoxin oral (Cardoxin®)
    spironolactone (Aldactone®)
  16. Fibrates (Fibric Acid Derivatives)
    Reduce cholesterol and triglycerides, increase HDL
    fenofibrate (Lipidil®)
    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 decision 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. pointers in the history of myocardial infarction or cardiac arrest that signal the need for medical advice before implementing the Procedures, such as a recent history of intensive medical investigation and care
    2. symptoms  indicative of
      1. instability in the heart condition, such as unstable angina
      2. stability in the heart condition, such as stable angina
    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 (2023)
  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 has any of the following
    1. has a recent history of intensive medical investigation and care
    2. is currently under intensive medical investigation and care
    3. has had an MI within the past 4 to 6 weeks or has functional capacity less than four METs post-MI (see Post-Myocardial Infarction Fact Sheet for more details)
    4. is experiencing 
      1. unstable angina 
      2. pain or discomfort which could be attributable to heart disease
      3. signs/symptoms of acute MI (AMI constitutes a medical emergency)
  2. may postpone the Procedures pending medical advice if the patient/client 
    1. appears debilitated 
    2. is experiencing  symptoms suggestive of comorbidities, complications or associated conditions
    3. has not complied with pre-medication, including antibiotic prophylaxis, as directed by the prescribing physician 
    4. has recently changed significant medications, under medical advice or otherwise
    5. recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is unable to provide the dental hygienist with sufficient information about
      1. current medications
      2. current investigations and treatment
      3. his or her recent medical history
    7. has symptoms or signs with which the dental hygienist is insufficiently unfamiliar and which could be related to myocardial infarction
    8. has not recently or ever sought and received medical advice relative to oral healthcare procedures
    9. is deeply concerned about any aspect of his or her medical condition

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

  1. 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.
  2. First-aid provisions and responses as required for current certification in first aid.
  3. Medical emergencies, resources and general principles

Resources

Death and rates of severe, residual complications are significantly reduced if healthcare professionals, such as dental hygienists, and patients/clients and bystanders shorten the time to definitive treatment by prompt action according to pre-arranged plans and procedures.

Myocardial infarction

Requires urgent actions by the dental hygienist, who should

  1. be able to recognize symptoms early
  2. immediately stop the Procedures
  3. promptly activate the emergency medical service (EMS) system by immediately calling 911 or the local emergency number 
  4. instruct the patient/client to
    1. stop all activity
    2. sit or lie down, in whatever position is most comfortable, while awaiting the ambulance with emergency medical personnel 
    3. take the normal dosage of nitroglycerin if either
      1. this is already prescribed for him/her 
      2. the dental hygienist has nitrates in an emergency kit
    4. combat chest pain by chewing and swallowing ASA (acetylsalicylic acid, Aspirin) in a dose of
      1. one adult 325 mg tablet
      2. or two 80 mg tablets
    5. be advised that pain medication such as acetaminophen (commonly known as Tylenol®) or ibuprofen (commonly known as Advil®) do not act in the same way as ASA (Aspirin) and therefore will not help in a myocardial infarction emergency situation. 

Cardiac arrest

Requires urgent actions by the dental hygienist, who should

  1. immediately stop the Procedures
  2. if there are bystanders 
    1. instruct someone to immediately call 911 or the local emergency number 
    2. instruct someone to immediately 
      1. get an Automated External Defibrillator (AED) if one is available 
      2. use the Automated External Defibrillator (AED)  as soon as it arrives 
    3. begin CPR 
  3. if are there no bystanders
    1. immediately call 911 or the local emergency number 
    2. then get an Automated External Defibrillator (AED) if one is available, and start using it as soon as it is in hand
    3. if no Automated External Defibrillator (AED) is available, begin CPR

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 myocardial infarction or cardiac arrest, 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

Resources consulted
Cardiovascular conditions: Colgate Oral Care Centre

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 (angina pectoris)
    2. is taking medication
  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. should discuss, as appropriate 
    1. the patient/clients use of medications, including
      1. use
        1. most recent
        2. for sub-lingual nitrates, combatting dry mouth with moistening of area under tongue
      2. 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
    6. for persons at an advanced stage of debilitation
      1. 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
    7. comfort level while reclining, and stress and anxiety related to the Procedures
    8. medication side effects such as dry mouth, and recommend treatment
    9. mouth ulcers and other conditions of the mouth relating to disorders of the adrenal gland, comorbidities, complications or associated conditions, medications or diet
    10. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promoting health through oral hygiene for persons with myocardial infarction or cardiac arrest who have a history of either of these.
  2. Reducing the adverse effects, such as failure to recognize the medical emergency by
    1. recognizing the possibility of  myocardial infarction or cardiac arrest
    2. acting appropriately and promptly
  3. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

  1. Failing to take opportunities to promote health protection and prevention.
  2. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client should receive medical advice before the Procedures are implemented
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  3. Disturbing the normal dietary and medications routine of a person receiving care in connection with myocardial infarction or cardiac arrest.
  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

2019-09-06; 2023-10-15

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, MBA, MHSc, DTM&H, CHE, CCFP, FCFP, LFACHE, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Kyle Fraser
RDH, BComm, BEd, 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, 2019, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children
2 Thrombolytics are also known as fibrinolytics or clot busters.
3 In this context, secondary prevention means prevention of MI reoccurrence.