What advice should be given to a dentist for treating a patient with Myocardial Infarction (MI)?

From the Guidelines

For a patient with a history of myocardial infarction (MI), the dentist should prioritize minimizing cardiovascular stress and managing potential complications by postponing non-essential dental procedures for at least 6 months after the acute event, as recommended in general medical practice. When treating a patient with MI at the dental office, advise the dentist to first obtain a complete medical history including medications, especially anticoagulants like aspirin, clopidogrel, or warfarin 1. This comprehensive history is crucial for assessing the patient's current cardiovascular risk and guiding the dental treatment plan.

Key Considerations for Dental Treatment

• Recommend postponing elective dental procedures for at least 6 months after an acute MI, with only emergency treatments performed in consultation with the patient's cardiologist.
• For necessary procedures, suggest using stress reduction protocols including morning appointments, minimizing waiting time, and possibly anxiolytic premedication like diazepam 5mg the night before and 1 hour before the appointment.
• The dentist should limit epinephrine in local anesthetics to 0.04mg (about 2 carpules with 1:100,000 concentration) and avoid epinephrine-impregnated retraction cords, as these can increase cardiovascular stress.
• Vital signs should be monitored before, during, and after treatment to quickly identify any potential complications.
• Nitrous oxide-oxygen sedation can be beneficial for anxiety control, further reducing the risk of ischemic events triggered by stress.

Pain Management and Emergency Preparedness

• Pain management should be aggressive, with scheduled NSAIDs like ibuprofen 600mg every 6 hours for 2-3 days if not contraindicated, to minimize discomfort and stress.
• Short appointments are preferable to reduce overall stress and potential for complications.
• The dentist should be prepared for emergencies with oxygen, aspirin, and nitroglycerin available, as these can be critical in managing acute cardiovascular events.

By following these guidelines and considering the patient's specific medical history and current health status, as outlined in studies such as 1 and 1, the dentist can help ensure a safe and effective dental treatment experience for the patient with a history of MI.

From the Research

Dental Treatment Considerations for MI Patients

• The control of risk cardiovascular factors, including arterial hypertension, obesity, and diabetes mellitus, is crucial in preventing cardiovascular diseases 2.
• Patients with a history of cardiovascular disease require special consideration during dental treatment, including the control of pain, reduction of stress, and careful use of vasoconstrictors in dental anesthesia 2, 3.
• The timing and form of dental treatment should be carefully considered, and only urgent conditions should be treated in patients at risk of cardiac complications 4.

Medication Considerations

• Patients with cardiovascular disease often take antiplatelet, anticoagulant, and antihypertensive medications, which require caution during dental treatment 2, 5.
• The use of warfarin, aspirin, or both after myocardial infarction has been studied, with warfarin showing superiority to aspirin in reducing composite events, but with a higher risk of bleeding 5.
• Dentists should be aware of the medications their patients are taking and potential drug interactions and side effects 3.

Emergency Preparedness

• Dental surgeons should be prepared for emergency situations, including cardiovascular symptoms during dental treatment, and have a plan in place for instituting emergency measures if necessary 2, 3.
• Patients with angina pectoris should have a fresh supply of nitroglycerin available during dental treatment, and prophylactic nitroglycerin may be effective in preventing hypertension and angina pectoris 3.

Treatment Guidelines

• Short appointments (less than one hour) and the use of nitrous oxide and oxygen may be beneficial for patients with cardiovascular disease 3.
• Effective local anesthesia is important, but the use of epinephrine-impregnated gingival displacement cord should be avoided in patients with cardiovascular disease 3.
• A comprehensive assessment of each patient should be conducted to determine the acceptability of dental treatment 6.