• Yes, in patients/clients with undiagnosed, untreated, or poorly managed HF.

Is medical consult advised?  

• Yes, for patients/clients with symptoms of HF (i.e., decompensated heart failure — NYHA¹ class II, III, or IV). As well, an initial consultation with the patient/client’s physician (cardiologist or primary care physician) is indicated to establish the level of HF control and the underlying cause(s), which will inform subsequent dental/dental hygiene management.

• Yes, in patients/clients with undiagnosed, untreated, or poorly managed HF. A major risk in providing treatment for a patient/client with symptomatic (decompensated) HF is that signs/symptoms could suddenly worsen with resultant acute pulmonary edema, a serious arrhythmia, unstable angina, stroke, or myocardial infarction.

Is medical consult advised? 

• See above.

Is medical clearance required? 

• Yes, for patients/clients with symptoms of HF (i.e., decompensated heart failure — NYHA class II, III, or IV). Many patients/clients with NYHA class II HF and some with class III may undergo routine treatment in an outpatient setting after clearance by their cardiologist. Supplemental oxygen and/or vasodilatory drugs such as lingual spray or sublingual formulations of nitroglycerin may be part of the dental/dental hygiene treatment plan.
• Yes, if there is the potential for equipment-related electromagnetic interference of a cardiac implantable electronic device (CIED). Patients/clients with HF may have pacemakers and/or implanted cardioverter defibrillators (ICDs).
• Yes, if the patient/client has received a heart transplant.

Is antibiotic prophylaxis required?  

• No, in the absence of cardiac valvular pathology or atrial fibrillation.

Is postponing treatment advised?

• Yes, for patients/clients with symptoms of HF (i.e., decompensated heart failure — NYHA class II, III, or IV), who are generally not candidates for elective dental/dental hygiene care. For such persons, treatment should be postponed until medical consultation has been obtained, medical management has been optimized, and medical clearance has been given.
• No, for many patients/clients who have a history of HF but who are asymptomatic (i.e., have compensated HF, designated NYHA class I) with good functional capacity and reserve, as demonstrated by ability to climb a flight of stairs; they generally can safely receive routine outpatient dental/dental hygiene care.
• Yes, if prescribed heart failure medications have not been taken properly. 

• HF often goes undiagnosed, with patients/clients not knowing that they have the condition. Therefore, the dental hygienist should be particularly aware of signs and symptoms.
• Patients/clients with untreated or poorly managed HF are at elevated risk during dental and dental hygiene treatment for complications such as myocardial infarction, cardiac arrest, and stroke. Even asymptomatic HF patients/clients (NYHA class I) are at intermediate risk of the occurrence of a serious event due to potential decompensation.
• At each dental hygiene appointment, determination of HF severity, level of HF control, and the patient/client’s ability to tolerate oral procedures is indicated. The patient/client who requires an upright position to sleep, who awakens from sleep with breathing difficulty, or who is unable to accomplish activities requiring minor exertion poses an increased risk for a medical emergency during treatment. The dental hygienist should also ensure that the patient/client is taking prescribed HF medications properly, because the most common reason for decompensation during a dental/dental hygiene procedure is medication non-compliance.
• Factors associated with the cause of HF should be considered in the care plan. These causative factors may include hypertension, valvular heart disease, coronary heart disease, and myocardial infarction.
• The dental hygienist should ascertain if the patient/client with HF has a cardiac implantable electronic device (such as a biventricular pacemaker [cardiac resynchronization therapy — CRT] or implanted cardiac defibrillator]), which are used in the management of some forms of heart failure. There may be the potential for electromagnetic interference (EMI) from dental/dental hygiene equipment or nearby consumer devices, and appropriate precautions should be taken. 
• The HF-associated medical emergency most likely to occur in the dental hygiene setting is acute pulmonary edema (APE). Although the onset of the emergency is sudden, careful questioning of the patient/client at the beginning of the appointment will likely reveal that the HF has been worsening in recent weeks (e.g., increasing shortness of breath and cough). Dental hygiene procedures should be postponed until medical treatment has been optimized and medical clearance obtained. 
• Close monitoring of the patient/client, as appropriate, and being prepared for an emergency are prerequisites for dental hygiene treatment. In particular, blood pressure should be monitored, because it may significantly increase or decrease in patients/clients with poorly controlled HF.
• Stress/anxiety reduction techniques may be indicated, particularly for patients/clients with untreated or poorly controlled HF, who may appear anxious and are at risk of a cardiac crisis. Ultrasonic instrumentation in such patients/clients should be limited so that fluid does not back up in the oral cavity; this will minimize anxiety and facilitate breathing. Appointments should be brief (i.e., ideally less than 30 minutes).
• While chair positioning is not usually an issue if the patient/client has compensated (i.e., NYHA class I) HF, the dental hygienist should be alert for orthopnea (i.e., positional dyspnea experienced while in recumbent or semi-recumbent position), particularly in persons with decompensated HF. Furthermore, a patient/client who has pulmonary congestion or is becoming hypotensive and syncopal from cardiac stress may not tolerate the supine position; semi-supine or upright chair position is indicated.
• When orthopnea and paroxysmal dyspnea are severe, the patient/client may require supplemental oxygen 24 hours a day. Such patients/clients typically carry portable O₂ cylinders with a nasal cannula.
• Orthostatic hypotension may result from drug treatment of HF, including diuretics², angiotensin-converting enzyme inhibitors (ACEIs)³, angiotensin receptor blockers (ARBs)⁴, beta-blockers⁵, and vasodilators⁶. Therefore, the back of the dental chair should be raised slowly from the supine/semi-supine position, and the patient/client should be allowed to sit upright for a few minutes before standing.
• Nausea and vomiting are risks in patients/clients taking digitalis-derived drugs⁷, who are also prone to accentuated gag reflex. Procedures that may trigger gagging should be performed with extra care.
• Non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided, because they can exacerbate symptoms of HF. 
• Excessive bleeding may occur in patients/clients with HF if their medical regimen includes anticoagulants⁸ for management of commonly coexisting atrial fibrillation.
• Epinephrine and other vasoconstrictors should be used cautiously, and they should be avoided in patients/clients with class III or IV HF without prior physician consultation.⁹  
• Nutritional counseling (to decrease sodium intake and hence alleviate fluid retention) and smoking cessation (to decrease further cardiac damage) should be recommended, as appropriate.

• Mucous membranes may be grayish-blue in patients/clients with more severe heart failure. There may also be cyanosis (bluish tinge) of the lips and ashen-gray appearance of perioral (and other) skin. Frothy pink sputum can occur in HF-associated acute pulmonary edema. Otherwise, there are no oral manifestations of HF per se, but drug treatment can cause oral signs/symptoms.
• Xerostomia is a side effect of diuretics.
• Angioedema of the lip, face, or tongue; taste changes; and burning mouth may result from ACEIs.
• Lichenoid lesions¹⁰ may occur with ACEI and beta-blocker use.
• Gingival overgrowth may occur with calcium channel blockers.
• Increased gag reflex and hypersalivation may occur with digitalis-derived drugs (e.g., digoxin and digitoxin, which are used to improve myocardial contractility).
• Lupus — like oral lesions may infrequently result from hydralazine.

• More than 600,000 Canadians live with heart failure, and 50,000 persons are newly diagnosed each year. Given that heart failure is the end result of many cardiovascular diseases and is primarily a condition of the elderly, these numbers are increasing as more persons survive myocardial infarctions and other cardiovascular events and as the population ages.
• Chronic heart failure is the preferred term representing the persistent and progressive nature of the disease, whereas acute heart failure is defined as a gradual or acute change in HF signs/symptoms requiring urgent therapy. 
• Heart failure is serious and progressive syndrome in which the heart muscle has been damaged or weakened by disease¹¹. This results in a decreased ability to eject blood, especially during increased activity or under stress. In addition, the cardiac muscle may not relax enough to accommodate the flow of blood back from the lungs to the heart. These abnormalities can result in fluid back-up (“congestion”) in the lungs — systolic dysfunction known as left-sided ventricular heart failure — and fluid accumulation (“congestion”) in peripheral tissues — diastolic dysfunction known as right-sided ventricular heart failure. In addition, HF may result from a variety of other cardiac conditions — including disorders of heart rhythm or rate — or by states in which the heart is unable to compensate for increased metabolic requirements or increased peripheral blood flow. 
• Right-sided ventricular heart failure¹² is usually preceded by failure of the left ventricle, even if overt signs/symptoms of left-sided HF are absent. Emphysema (a form of chronic obstructive pulmonary disease usually secondary to smoking) is the most common cause of pure right-sided HF. 
• Dyspnea (perceived shortness of breath) and fatigue (especially muscular) are the cardinal manifestations of left-sided HF. The dyspnea results from congestion of blood in the pulmonary vessels. Inspiratory “crackles” can be heard upon stethoscope auscultation of the bases of the lungs.
• Peripheral dependent edema (e.g., swelling of ankles and feet, which “pits” upon depression with a fingertip) and systemic venous congestion (including distended neck veins — classically jugular vein distention) are outcomes of right ventricular failure.
• Other signs/symptoms of HF are: weakness; paroxysmal nocturnal dyspnea (which awakens patient/client from sleep); acute pulmonary edema (manifesting as progressive dyspnea or cough); exercise intolerance (e.g., inability to climb a flight of stairs); weight gain and/or increased abdominal girth (from fluid accumulation, including ascites); right upper quadrant abdominal pain (liver congestion); rapid, shallow breathing; Cheyne-Stokes respiration¹³; nausea, vomiting, decreased appetite, and constipation (due to bowel edema); heart murmur; pulsus alternans¹⁴; jaundice; cold hands and feet; cyanosis; and clubbing of fingers. Cognitive impairment and altered mentation/delirium, while unusual clinical presentations, may be more common in elderly patients/clients.
• Compensated HF (NYHA Class I) means that a variety of physiological responses to HF (including increases in heart rate, myocardial contractility, and efficiency in oxygen utilization by tissues) have eliminated symptoms (at least temporarily).
• Decompensated HF (NYHA Classes, II, III, and IV) means that HF is symptomatic.
• The prognosis for patients/clients with heart failure is poor, with 50% dying within 5 years of diagnosis (including 20% within the first year). Sudden death occurs 6 to 9 times more frequently than for the general population.

• 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.
  http://www.medicinaoral.com/odo/volumenes/v3i2/jcedv3i2p97.pdf  
• Canadian Cardiovascular Society
  https://www.onlinecjc.ca/article/S0828-282X(17)30973-X/fulltext (2017 Comprehensive Update of the Canadian Cardiovascular Society Guidelines for the Management of Heart Failure)
  https://www.onlinecjc.ca/article/S0828-282X(21)00055-6/fulltext (CCS/CHFS Heart Failure Guidelines Update: Defining a New Pharmacologic Standard of Care for Heart Failure With Reduced Ejection Fraction)
• Heart and Stroke Foundation of Canada
  https://www.heartandstroke.ca/heart-disease/conditions/heart-failure
  https://www.heartandstroke.ca/-/media/pdf-files/canada/health-information-catalogue/en-living-with-heart-failure.ashx?rev=af2ec16a96d44cffa3a930a3ac27d67f https://www.heartandstroke.ca/-/media/pdf-files/canada/2017-heart-month/heartandstroke-reportonhealth-2016.ashx?la=en
• Mayo Clinic
  https://www.mayoclinic.org/diseases-conditions/heart-failure/diagnosis-treatment/drc-20373148  
• WebMD
  http://www.webmd.com/oral-health/dental-care-heart-disease#1
  https://www.webmd.com/heart-disease/heart-failure/right-sided-heart-failure   
• Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services
  https://healthit.ahrq.gov/sites/default/files/docs/resource/James_Fricton_IQHIT_Q1_HP_Recommendations_for_Preventing_Complications_for_Chronic_Illnesses.pdf (Dental Recommendations)
• RDH Magazine, Dentistry IQ Network
  http://www.rdhmag.com/articles/print/volume-16/issue-2/columns/periodontics/drug-therapy-for-congestive-heart-failure-poses-several-risks-during-dental-treatment.html  
• Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5^th edition). St. Louis: Elsevier; 2020.
• Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9^th edition). St. Louis: Elsevier; 2018.
• Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3^rd edition). Baltimore: Wolters Kluwer Health, 2015.
• Malamed SF. Medical Emergencies in the Dental Office. St. Louis: Elsevier Mosby; 2015.

¹ Severity of heart failure is often gauged according to the New York Heart Association (NYHA) classification system of functional capacity. In Class I, there are no symptoms (i.e., no limitation of physical activity, and no dyspnea, fatigue, or palpitations with ordinary physical activity). In Class II, symptoms occur with ordinary activity (i.e., slight limitation of physical activity, with patients/clients experiencing fatigue, palpitations, and dyspnea with ordinary physical activity but being comfortable at rest). In Class III, symptoms occur with less than ordinary activity (i.e., marked limitation of activity, but patients/clients are comfortable at rest). In Class IV, symptoms are present at rest or with any minimal activity, with any physical exertion exacerbating the symptoms.
² Diuretics include furosemide, hydrochlorothiazide, chlorthalidone, amiloride, and spironolactone.
³ ACEIs include captopril, enalapril, lisinopril, and ramipril.
⁴ ARBs include candesartan, irbesartan, losartan, telmisartan, and valsartan.
⁵ Beta-blockers include atenolol, metoprolol, propranolol, and timolol.
⁶ Vasodilators include hydralazine and isosorbide dinitrate.
⁷ Digitalis glycoside drugs include digoxin and digitoxin, which are used to improve myocardial contractility.
⁸ Anticoagulants include warfarin, clopidogrel, dabigatran, apixaban, rivaroxaban, and edoxaban.
⁹ Vasoconstrictors should also be avoided, if possible, in patients/clients taking digitalis glycosides (such as digoxin), because the combination can cause cardiac dysrhythmias.
¹⁰ lesions similar in appearance to lichen planus, typically manifesting intraorally on the buccal mucosa
¹¹ The most common causes of heart failure are hypertension; ischemic heart disease resulting in myocardial infarction; cardiomyopathy; cardiac valvular disease; myocarditis; infective endocarditis; congenital heart disease; pulmonary hypertension; pulmonary embolism; and diabetes mellitus. Other causes include chronic obstructive pulmonary disease (COPD), severe anemia, hyperthyroidism, rheumatic fever, and excessive use of alcohol or certain drugs.
¹² Right-sided heart failure is also known as cor pulmonale.
¹³ abnormal pattern of breathing characterized by hyperventilation followed by a gradual decrease culminating in apnea, with each cycle typically occurring over 30 seconds to 2 minutes
¹⁴ alteration of strong and weak pulse beats (associated with left-sided heart failure)

* 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.