FACT SHEET: Angina (also known as “angina pectoris”; includes “stable angina” [also known “effort angina”], “unstable angina” [also known as “crescendo angina”, “preinfarction angina”, and “resting angina”], “variant angina” [also known as “Prinzmetal’s angina”, “vasospastic angina”, and “spasmodic angina”], “microvascular angina” [also known as “cardiac syndrome X”] and “atypical angina”)
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- Yes, in patients/clients with undiagnosed, untreated, or unstable angina.
Is medical consult advised?
- Yes, for the patient/client with unstable angina (i.e., new-onset, unpredictable, or worsening chest pain).
- Yes, if the patient/client reports a history of recent anginal pain lasting longer than 15 minutes that is not relieved by rest, especially if antianginal drugs are being taken. This suggests uncontrolled disease, and a medical consult should be obtained to determine the ability of the patient/client to withstand the stress of elective oral care.
- An initial consultation with the patient/client’s physician (cardiologist or primary care physician) is indicated to establish the diagnosis and treatment regimen for angina, which will inform subsequent dental/dental hygiene management.
Is the initiation of invasive dental hygiene procedures contra-indicated?**
- Yes, in patients/clients with undiagnosed, untreated, or unstable angina.
Is medical consult advised?
- See above. Also, consult is advised if the patient/client is taking prescribed drugs that may necessitate care plan alterations (e.g., antiplatelet agents such as clopidogrel, ticragelor, prasugrel, ticlopidine, or dipyridamole1).
Is medical clearance required?
- Yes, for patients/clients with unstable angina. Such patients/clients should be considered at major cardiac risk.2
- Yes, if the patient/client is taking an antiplatelet agent (other than low-dose ASA3) or an anticoagulant4 (e.g., warfarin5 or a direct oral anticoagulant6 [DOAC]) or, which increases risk of bleeding.
Is antibiotic prophylaxis required?
- No. (Antibiotic prophylaxis is not indicated for patients/clients who have had balloon angioplasty with placement of a coronary stent or who have undergone a coronary artery bypass graft — CABG — procedure.)
Is postponing treatment advised?
- Yes, for patients/clients with unstable angina. Such persons should not undergo elective (non-essential) dental/dental hygiene procedures, and emergency oral care should be performed in a hospital or office equipped with cardiac monitoring capability.
- Yes, if the patient/client has not taken any applicable pre-medication (e.g., nitrates) as directed by the prescribing physician.
- Yes, if the patient/client is taking an antiplatelet agent (other than low-dose ASA) for prevention of coronary stent thrombosis. Elective procedures involving significant bleeding should be deferred until either 1/ the antiplatelet agent is discontinued — which varies between one month to six months (and potentially substantially longer) following stent placement or 2/ until medical consult/clearance has been obtained.
- Patients/clients who have stable angina (i.e., chest pain that occurs in a predictable pattern) can generally safely receive routine outpatient dental/dental hygiene care. Such patients/clients pose an intermediate cardiac risk.
Oral management implications
- Similar to patients/clients with a previous myocardial infarction (MI), general management strategies for patients/clients with stable angina7 include the following: short appointments, comfortable chair position, pretreatment vital signs, and availability of nitroglycerin and oxygen in case a medical emergency should arise. The patient/client should be engaged to determine the best time of day for an appointment, which is often the morning when the patient/client is well rested and has a greater physical reserve. A stress reduction protocol may be utilized where indicated.
- All dental/dental hygiene procedures should be stopped with the onset of chest pain. The patient/client should be allowed to position himself/herself in the most comfortable position, which is usually sitting or standing upright. A member of the emergency team should immediately get the emergency kit and oxygen. Nitroglycerin should be administered sublingually (i.e., tablet, often the patient/client’s own) or transmucosally (i.e., spray)8. Emergency medical care should be sought if chest pain is not relieved by 3 nitroglycerin tablets or spray doses in conjunction with oxygen over a 10-minute period. In a person with previously unrecognized coronary disease (i.e., no history of angina), chest pain persisting more than 2 minutes is an indication for emergency medical assistance. If any doubt exists whether angina or myocardial infarction exists, 911 should be called for emergency medical services (EMS) and/or patient/client should be transported to hospital.
- After termination of an intra-office anginal episode, the factor(s) that might have caused it to occur should be determined. This will inform modification of future dental/dental hygiene treatment.
- While dental/dental hygiene treatment may resume at any time after termination of intra-office anginal pain in patients/clients with stable angina (including at the same visit if considered necessary), the patient/client should be allowed to rest until he or she is comfortable before resuming dental/dental hygiene care or discharge. (If unstable angina is suspected, treatment should not be resumed.) Vital signs should be monitored and recorded before discharging the patient/client. In the situation where doubt persists about the degree of recovery, medical assistance or consultation should be sought, or a friend or relative should be contacted to serve as an escort.
- Patients/clients with gingival hyperplasia (secondary to calcium channel blocker [CCB] use) will likely require more frequent cleanings and enhanced dental hygiene education. Gum surgery may occasionally be required.
- In addition to medical treatment, many persons experiencing angina undergo revascularization by coronary artery bypass surgery or increasingly by percutaneous coronary intervention (i.e., PCI: angioplasty + stent). To avoid stent thrombosis, patients/clients are typically placed on dual antiplatelet therapy (DAPT; e.g., ASA and clopidogrel) for varying lengths of times9 following stent placement in the coronary arteries, followed by single antiplatelet therapy (SAPT). For both bare metal and drug-eluting (DES) stents, ASA is generally continued for life, and there is virtually no dental hygiene indication to discontinue such ASA treatment.
- If the dental hygienist is concerned about potential peri-procedural or post-procedural bleeding, the patient/client’s cardiologist should be contacted regarding the patient/client’s antiplatelet regimen and optimal patient/client management should be discussed before discontinuing the antiplatelet medications. Such medications should not be discontinued prematurely given their importance in minimizing the risk of stent thrombosis, and discontinuation of these agents before dental hygiene procedures usually is unnecessary. However, if there is a concern that excessive bleeding may occur, clopidogrel, for example, may have to be stopped several days before dental hygiene care that involves tissue manipulation; medical consult/clearance should be sought in this regard. If scaling procedures are planned for a patient/client on the anticoagulant warfarin, the patient/client’s physician should be contacted to confirm that the PT ratio (prothrombin time) will be two times normal or less, or international normalized ratio (INR) is less than 3.0.
- Non-steroidal anti-inflammatory medications (NSAIDs) should generally be avoided in patients/clients with established cardiovascular disease (particularly COX-2 selective NSAIDs such as celecoxib). Of the non-selective NSAIDs (which include ibuprofen), naproxen may be safest, but a physician should be consulted before use. Acetaminophen is usually preferred as an oral analgesic in patients/clients with angina.
- Vasoconstrictor use (e.g., epinephrine in local anesthetic) poses potential problems for patients/clients with ischemic heart disease, including those with angina. Vasoconstrictors should be used sparingly, if at all, in dental procedures for patients/clients at intermediate cardiac risk (i.e., stable angina), and they should not be used in patients at higher risk (i.e., unstable angina) without clearance and planning with a physician. Vasoconstrictor use may also be contraindicated in patients/clients taking non-selective beta-blocker drugs (e.g., propranolol).
- Smoking cessation should be encouraged.
- There are no oral findings specific to angina (or coronary atherosclerotic heart disease in general); however, medications used to treat angina can result in oral changes.
- Dry mouth can result from sublingual nitroglycerin use.
- Gingival hyperplasia can be caused by calcium channel blockers (e.g., amlodipine, nifedipine, felodipine, verapamil, and diltiazem).
- Taste changes and lichenoid lesions10 can result from beta-blocker use (e.g., metoprolol and propranolol).
- Lupus-like oral and skin lesions can result from use of direct vasodilators (e.g., hydralazine).
- Bleeding — manifesting as petechiae, hematomas, or gingival bleeding — may occur in patients/clients receiving antiplatelet or anticoagulant treatment.
- Patients/clients with angina occurring as a manifestation of atherosclerotic heart disease may sometimes experience pain referred to the mandible or teeth. Its cardiac origin is suggested by a pattern of onset of pain with physical activity and its disappearance with rest. Craniofacial pain (jaw, teeth) may be the only symptom of cardiac ischemia in up to 6% of cases.
Related signs and symptoms
- More than 500,000 Canadians live with angina, with about 50,000 newly diagnosed each year.
- Angina is transient chest pain resulting from temporary inadequate blood supply to (and thus inadequate oxygenation of) the heart, usually secondary to narrowing, blockage, or spasm of one or more coronary (heart) arteries. It is not a myocardial infarction (in which heart muscle dies), but rather a phenomenon11 that signifies increased risk of myocardial infarction (MI), cardiac arrest, or sudden cardiac death.
- Anginal chest pain may be precipitated by physical activity, exercise, emotional stress, periods of extreme cold or hot temperatures, heavy meals, drinking alcohol, or smoking. Other causes include uncontrolled high blood pressure, aortic stenosis (narrowing of the aortic heart valve), hypertrophic cardiomyopathy (enlarged heart), severe anemia, abnormal heart rhythms (including atrial fibrillation and especially those that raise the heart rate), and hyperthyroidism.
- Symptoms of angina include:
- sharp, burning, or cramping pain that starts in the central chest and then radiates to the left arm, neck, back, throat, or jaw;
- pressure, tightness, squeezing and/or aching feeling in the chest or arm(s);
- retrosternal burning sensation similar to persistent severe gastroesophageal reflux;
- ache that starts in the neck, jaw, throat, shoulder, back, or arm(s);
- discomfort in neck or upper back, especially between the shoulder blades; and
- numbness in the arms, shoulders, or wrists.
- During acute anginal episodes, the patient/client may be apprehensive and diaphoretic (sweating heavily). Heart rate is usually elevated, as is blood pressure. Respiratory difficulty (i.e., dyspnea) and a feeling of faintness may also occur.
- Although most anginal episodes resolve without residual complication, myocardial infarction may occur (particularly in unstable angina), as may acute cardiac dysrhythmias.
- Stable angina, the most common type of angina, follows a predictable pattern of chest pain (lasting 1 to 15 minutes, and typically less than 10 minutes) and is usually relieved with rest or medication (e.g., sublingual nitroglycerin). Unstable angina12 is characterized by chest pain that is unpredictable, may happen at rest without precipitating physical activity, may be prolonged (up to 30 minutes), and is not readily relieved by nitroglycerin. Variant angina (caused by coronary artery spasm) usually happens at rest (particularly between midnight and 8 a.m., often awakening a person from sleep) without precipitating physical exertion of emotional stress. Microvascular angina (caused by improper functioning of coronary microcirculation) manifests as chest pain without any apparent blockage in a coronary artery. Atypical angina presents without the typical chest symptoms of angina, and instead may manifest as vague chest discomfort, shortness of breath, back or neck pain, retrosternal burning, or fatigue. Silent ischemia involves a period of coronary artery insufficiency in which no pain is experienced (unlike true angina), and it may be associated with a myocardial infarction that is clinically silent.
- Anginal symptoms in women can be different than classic angina symptoms. For example, females often experience nausea, abdominal pain, extreme fatigue, or shortness of breath with or without chest pain. Discomfort in the neck, jaw or back may occur, and chest pain, when present, may be stabbing in nature rather than the more typical pressure-like sensation.
- Risk factors for angina (and coronary artery disease in general) include diabetes mellitus, hypertension, tobacco use, high blood cholesterol or triglyceride levels, older age (greater than 45 years in men and 55 in women), inactive lifestyle, obesity, and stress.
References and sources of more detailed information
- CDHO Knowledge Network
- Tolle SL and Walters AN. Strategies for the Safe Treatment of Cardiovascular Patients. Dimensions of Dental Hygiene. March 2015;13(3):44–47.
- Rose LF, Mealey BM, Minsk L, Cohen DW. Oral care for patients with cardiovascular disease and stroke. JADA. 2002;133:37S-44S.
- Cruz-Pamplona M, Jimenez-Soriano Y, Sarrión-Pérez MG. Dental considerations in patients with heart disease. J Clin Exp Dent. 2011;3(2):e97-105.
- Peterson E. The Burden of Angina Pectoris and Its Complications. Clin Cardiol. 2007;30 (Suppl. I):I10-I15.
- Patrono C, Andreotti F, Arnesen H, et al. Antiplatelet agents for the treatment and prevention of atherothrombosis, European Heart Journal. 2011:32(23);2922–2932.
- 2018 Canadian Cardiovascular Society/Canadian Association of Interventional Cardiology Focused Update of the Guidelines for the Use of Antiplatelet Therapy. Can J Cardiol. 2018:34(3);214-233.
- Heart & Stroke
- Canadian Dental Association Oasis Discussions
http://oasisdiscussions.ca/2013/03/08/mi-2/ (How Can I Treat A Patient With A Previous Myocardial Infarction [MI]?)
- Canadian Cardiovascular Society
https://ccs.ca/app/uploads/2020/12/Ang_Gui_1976.pdf (CCS grading of angina pectoris)
- Public Health Agency of Canada
http://www.phac-aspc.gc.ca/publicat/2009/cvd-avc/pdf/cvd-avs-2009-eng.pdf (Tracking Heart Disease and Stroke in Canada)
- American Heart Association
- American Dental Association
http://emedicine.medscape.com/article/1080772-overview (Oral Manifestations of Drug Reactions)
- Mayo Clinic
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore: Wolters Kluwer Health, 2015.
- Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.
1 Dipyridamole is not typically used in patients/clients with ischemic heart disease or for prevention of coronary stent thrombosis.
2 An unstable angina episode often heralds an impending myocardial infarction.
3 ASA = acetylsalicylic acid (aspirin)
4 About 5–10% of the patients/clients scheduled for coronary artery stenting already take oral anticoagulants, usually for atrial fibrillation.
5 Warfarin is a vitamin K antagonist (VKA). Its effect on clotting is monitored by the international normalized ratio (INR). More information about warfarin is contained in the CDHO Knowledge Network’s Atrial Fibrillation Fact Sheet.
6 DOACs include dabigatran, rivaroxaban, apixaban, and edoxaban.
7 Vasoactive medications are used to treat angina, including nitrates (e.g., nitroglycerin and isosorbide), beta-blockers, and calcium channel blockers.
8 Nitroglycerin tablets lose potency unless stored in a tightly sealed container, and this is a possible explanation for failure of a patient/client’s sublingual tablet to relieve angina pain. Once opened, nitroglycerin tablets typically have a 6-month shelf life, and the patient/client’s medication should be examined for expiry date. Nitroglycerin spray is more stable, and it is generally preferred for in-office stocking.
9 The duration of DAPT varies according to the patient/client’s risk of bleeding, the type of stent implanted (i.e., bare metal or drug-eluting), and risk of thrombotic cardiovascular events.
10 lesions similar in appearance to lichen planus, typically manifesting intraorally on the buccal mucosa
11 The term acute coronary syndrome describes a continuum of myocardial ischemia that ranges from unstable angina to non-ST segment MI.
12 In unstable angina, blood clots block the heart’s blood vessels, sometimes in conjunction with rupturing of plaques (fat-containing deposits). Unstable angina is considered to be on the spectrum of acute coronary syndrome, which also includes myocardial infarction.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.