Periodontal Therapy

December, 2010 edition

Risk Assessment for Clients with Atrial Fibrillation

  
By Ann Eshenaur Spolarich, RDH, PhD, and JoAnn R. Gurenlian, RDH, PhD

Introduction

We are pleased to introduce the last of a series of four case studies that highlight the skills needed for dental hygiene risk assessment. In this case, we focus on a client with atrial fibrillation, a common cardiac condition with treatment implications for planning the process of dental hygiene care. While we focus primarily on systemic risks in our case studies, we will also demonstrate the importance of assessing potential drug complications and interactions, and the indications for oral care products to reduce and prevent oral disease risks. The opportunity to include education about the oral systemic link is also presented in this case.

CASE STUDY

Client Profile: Tim Wilkens is a 48-year-old male who presents to the office for his four-month recare appointment. He is well-loved by the entire office staff due to his infectious laugh and great sense of humor. He is employed by the local middle school as a health and physical education trainer. The client states that he believes that he is a role model to students and needs to demonstrate a healthy lifestyle. He is 6 feet tall, 180 pounds, with a past history of good overall health. He runs three miles every day while working with the students. Within the last year, he was remarried to a gym teacher who works within the same school district at the local high school.

Chief Concern: Tim reports that he has recently begun to experience pain with tooth #3. He states that the pain is intermittent, but can be sharp at times, and is sensitive to cold. He also requests a new athletic mouth guard, as his current one “has seen better days.”

Health History: Tim has an unremarkable health history. He reports receiving routine physical examinations on an annual basis by his general physician. In the past, he always showed tremendous pride when reporting that his cholesterol and blood pressure were within normal limits, which he attributed to regular exercise and “healthy living.” Today, he reports that his cholesterol has slightly increased, but is “still in the normal range at 200, but my blood pressure has gone up a bit. I guess I’m not 25 anymore.” He laughs when he says, “but it is getting harder to keep the pounds under control as I am getting older. And the fact that my wife is a great cook isn’t helping matters, so we both decided to start running more on the weekends to make up for all of those calories.”

Tim reports that, three months ago, he began to notice some symptoms that caused him to present for an evaluation with his physician. Specifically, he noticed that he was having difficulty maintaining his normal pace while running, and experienced more shortness of breath afterwards that persisted long after the amount of time that it usually took to cool down. He continued to feel fatigued for the remainder of the day and occasionally dizzy. His wife urged him to see his physician, who referred the client to a cardiologist. After performing a cardiac work-up with testing, the cardiologist diagnosed Tim with persistent atrial fibrillation (AF). The client reports that his grandfather had the same condition and eventually died of a myocardial infarction, “and I am terrified that I might follow in my grandfather’s footsteps.” The specialist has started the patient on medications, which appear to be keeping his cardiac rhythm under control. Tim says, “I may also have to undergo a surgical procedure to help get my heart back into rhythm. Did you ever think that this would happen to a health nut like me?”

Vital signs are right-arm blood pressure of 138/90 mm Hg, pulse at 88 beats per minute and respiration at 24 breaths per minute.
Medication List: The client reports taking the following medications:

Medication List

Allergies: The client is allergic to strawberries and latex. He does not report any drug allergies.

Dental History: Tim has received routine dental hygiene care for the past 10 years, and comes for his recare appointment every four months. The client is seen more frequently due to his history of chronic gingivitis, which was attributed to mouth breathing while running and sleeping, and poor compliance with his oral hygiene. The client successfully underwent scaling and root-planing four years ago, and since then, has demonstrated improved gingival health and good oral hygiene. “No way will I go through that again: I learned my lesson.” Tim chooses to remain on his four-month recall program because he has learned to value his good oral health. Tim also reports wearing his mouth guard at all times while playing sports with the students. “Besides, it sets a good example for them to follow,” he said.

After his last recare visit, the dentist replaced an old MO amalgam restoration on tooth #3 with a composite restoration, as the amalgam had an open margin with microleakage.

Tim reports using a sonic toothbrush (Sonicare®) as recommended by his hygienist four years ago, flossing four times per week, brushing with an antibacterial toothpaste in the morning, and brushing with Prevident® 5000 Plus prescription dentifrice at bedtime. Tim is compliant with his fluoride regimen, as he drinks sports drinks frequently to rehydrate and energize after exercise: “My mouth gets so dry and thirsty after I work out.”

Intraoral Assessment: The client presents with slightly enlarged gingiva on the facial surfaces of teeth #5–#12. These areas exhibit slight delayed bleeding upon probing, with no loss of attachment and pseudopocketing of 3–4 mm. All other areas of probing depth remain within normal limits. Tooth #3 exhibits 2 mm of new recession on the buccal surface over the predominant mesial root. There is a wear facet evident on the mesial buccal cusp of #3, as well as wear on the mouthguard in the same area. There is generalized slight demineralization along all of the buccal surfaces of the premolar and molar teeth, but it remains unchanged with no soft areas or additional surface pitting.

Radiographic Assessment: Four vertical bitewings and one periapical film of the maxillary right molar area were exposed today. There is no radiographic evidence of pathology, bone loss or new caries. An incipient lesion on the distal of tooth #28 remains unchanged from its initial diagnosis in 2006. There is no periapical pathology associated with tooth #3, but a slight thickening of the periodontal ligament is observed around the tooth.

Risk Factor Assessment: The client presents with several risk factors that should be considered during the development of the dental hygiene diagnosis and treatment plan. Take a moment and identify these risk factors below.

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DHDX: The following diagnoses were presented to the client:
Systemic Health – atrial fibrillation, hypertension, elevated respiratory rate
Oral Health – drug-induced gingival hyperplasia, gingival recession #3, primary occlusal trauma #3, enamel demineralization, incipient caries #28, drug-induced xerostomia

Systemic Health Risks
 
AF is the most common cardiac arrhythmia, and affects more than 2.2 million Americans.[1] It is a form of supraventricular tachycardia, and is characterized by disorganized electrical activity and abnormal firing patterns from the atria that eventually lead to progressive deterioration of cardiac function if not corrected. The exact mechanisms that explain the pathophysiology of AF are still being elucidated.[2,3]

AF can occur on its own or in conjunction with other types of cardiovascular disease. AF is strongly associated with hypertension, coronary artery disease, valvular disease and congestive heart failure, as well as with other co-morbidities like diabetes.[1] It is not completely understood how co-morbid cardiovascular disease serves as a risk factor for AF.[4] AF also can be initiated by thyrotoxicosis, acute alcohol intoxication, excessive catecholamine (e.g. epinephrine) release, use of stimulants (e.g. caffeine), electrolyte imbalances and pulmonary disease.[1]

One in four individuals 40 years of age and older will develop AF during their lifetime.[5] Incidence increases with age.[1] A family history of AF also increases the likelihood of developing AF, especially if AF affects a parent.[6]

Symptoms of AF include the sensation of abnormal heart rhythm or palpitations, chest pain, difficulty breathing (dyspnea), dizziness, fatigue and exercise intolerance.[7,8] AF can also lead to other cardiac complications including cardiomyopathy (inflammation of the heart muscle), hemodynamic dysfunction and decompensated heart failure.[8-10] Clients report a poor quality of life and difficulty functioning in their daily lives.[11] These symptoms often lead to frequent doctor visits and repeated hospitalization, with increased costs to the individual and the health care system.[12] Hospitalization may also include the need for more definitive care, including catheter or surgical ablation techniques to restore normal sinus rhythm.[1,8,9,12]

Among the most serious complications of AF is the risk for stroke and other cardiac co-morbidities including congestive heart failure (CHF).[4,7-9]

In fact, individuals with heart failure often develop AF and vice versa.[13] Risk for thromboembolism is high, as AF leads to a prothrombotic state.[4] Stroke is a leading complication of thromboembolism, as well as reduced cognitive function, decreased function, myocardial infarction and sudden death.[4] The Framingham heart study revealed that AF is associated with a 1.5- to 1.9-fold higher risk of death because of its strong association with thromboembolic events.[14] AF is responsible for approximately 15 percent to 25 percent of all strokes in the United States (75,000/year).15 Known risk factors for stroke in patients with AF include male sex, rheumatic valvular heart disease, hypertension, heart failure and diabetes.[15]

The RE-LY (Randomized Evaluation of Long-Term Anticoagulant Therapy) study has shown that strokes associated with AF are more likely to incapacitate the person or lead to the end of life.[16,17] Most clients diagnosed with AF are placed on anticoagulant therapy to reduce this risk.[4,8,15,18,19]

Risk Reduction Strategies

Treatment goals for AF include control of the rapid heart rate, restoration and maintenance of the normal sinus rhythm, and risk reduction of thromboembolism with anticoagulant therapy.[4] Treatment strategies used for AF are driven by safety, and include pharmacologic (e.g., antiarrhythmic medications) and non-pharmacologic methods (e.g., catheter or surgical ablation) to control both rate and rhythm. Decisions made about treatment take into account the client’s age, cardiac co-morbidities (e.g., hypertension, structural abnormalities) and adverse drug events including drug interactions and toxicities.[4,8]
 
The course of drug therapy differs depending upon the type and onset of AF. First, drugs are given to control cardiac rate by slowing conduction through the AV node of the heart and include beta blockers, calcium channel blockers, digoxin and amiodarone.[4] For clients who are also hypertensive, angiotensin-receptor blockers and ACE inhibitors may also be beneficial, although how they reduce risk for AF is currently unknown.[20] In younger individuals, especially for those with minimal heart disease or symptoms, initiating a rate control strategy with these drugs helps to restore normal firing patterns and reduce hypertension.[15,21,22]

Restoration and maintenance of normal sinus rhythm improves cardiac function, exercise tolerance and quality of life. Drugs for rhythm control (antiarrhythmics) are used in conjunction with drugs for rate control, or may be used as initial therapy.[8,15] Cardioversion, which uses a small electrical shock to put the abnormal rhythm back into sinus rhythm, may also be indicated.[8]

Medication Risks

Many of the drugs used for rate control are also used for other clinical indications, including hypertension and angina. Beta blockers, calcium channel blockers, ACE inhibitors and angiotension-receptor blockers may all be used in clients with AF. Some of these medications may cause xerostomia. Non-cardioselective beta blockers, like the sotolol used by this client, may interact with epinephrine, causing an initial episode of hypertension followed by bradycardia.[23] Sotolol is a beta blocker as well as an antiarrhythmic medication.[23] Antiarrhythmic medications are known to result in other potentially life-threatening arrhythmias.[4,8,23] These medications also cause side effects that significantly alter quality of life and ability to function.[4,8,23]

Digoxin is a cardiac glycoside as well as an antiarrhythmic medication. For AF, digoxin directly suppresses conduction through the AV node to slow down the heart and improves contractility of the heart.[23] Digoxin may also produce unwanted arrhythmias. The systemic antifungals and macrolide antibiotics used in dentistry interact adversely with digoxin, increasing its plasma concentration to toxic levels.[23]

The client has been placed on warfarin (Coumadin®) to reduce the risk of stroke associated with AF. While on warfarin, the client’s clotting time will be monitored closely, typically every 30 days. The International Normalized Ratio (INR) is the standardized form of the prothrombin time test, and is performed every month for clients taking this medication. Warfarin has a very low therapeutic index, meaning that there is a very narrow dosing range for therapeutic efficacy without compromising the client’s safety. Many variables, including changes in diet, fever, infection and the use of certain medications can shift the balance away from efficacy to a state of under- or over-anticoagulation.[24] The dental hygienist should observe the client to look for signs of over-anticoagulation, such as excessive bruising. The client should be questioned for the presence of observable gingival bleeding, either spontaneously, with eating or while performing oral self-care.[24]

Risk Reduction Strategies

Drugs for rate and rhythm control interact adversely with epinephrine, and local anesthetics containing epinephrine must be used with caution. Antiarrhythmic medications may cause other arrhythmias as a side effect, which may be worsened in the presence of epinephrine. When possible, avoid the use of vasoconstrictors and consult the client’s physician to ensure safety prior to their administration.[23]

Clients taking digoxin may experience an increased gag reflex, which is notable while taking impressions.[23] The amount of alginate impression material could be lessened, and/or a layer of impression wax placed along the back edge of the impression tray to reduce the amount of alginate that contacts the soft palate. Use of fast-set alginate should also be considered. A spray topical anesthetic agent, an ice cube for the patient to suck, or salt on the tongue may also help to reduce the gag reflex. The client should be placed in an upright position while the impression for the mouth guard is taken. Systemic antifungal medications and macrolide antibiotics should be avoided in clients taking digoxin.[23]

The dental hygienist must always remember to question clients taking warfarin about the current INR value and the date when the INR was performed, and record these findings in the treatment record. The target INR for AF is within the normal therapeutic range of 2.0–3.0.[8,23] The dental hygienist must determine whether the client is capable of accurately reporting his own INR. When in doubt, a consultation with the client’s physician is needed to confirm the test value. A copy of the laboratory test report may also be obtained for the treatment record with the client’s permission.]

Clients with an INR that falls within the range of 2.0–3.0 may safely receive dental treatment without any modifications.[24] The need to discontinue warfarin use prior to dental hygiene treatment is extremely rare, as the risk to the client for stroke or other adverse cardiac events far outweighs the risk for a bleeding complication at chairside. Dental hygienists should always have a topically applied clotting agent available to manage any excessive bleeding observed during treatment. Clients taking warfarin should not be dismissed from an appointment until all bleeding has completely stopped.[24]

Many drugs that are commonly used in dentistry may interact with warfarin, increasing its level to an overly anti-coagulated state. Systemic antifungals, some antibiotics (cephalosporins, macrolides, metronidazole, quinolones, tetracyclines), systemic corticosteroids, and analgesics for pain control (acetaminophen, aspirin, NSAIDS) must be administered cautiously to clients taking warfarin.[23]

Oral Disease Risks
 
Evidence of new localized recession and wear facets on both the new restoration and on the client’s mouth guard suggests that the bite should be evaluated by the dentist. Localized primary occlusal trauma on tooth #3 may also be contributing to the client’s sensitivity.

Tim reports xerostomia after running, but is also at risk for dry mouth due to his mouth breathing behavior. To counteract his dryness and thirst, Tim drinks sports beverages with a low pH and sugars, which increases his risk for demineralization, erosion and caries. There is evidence of generalized demineralization on all of the posterior teeth.

The client requests the fabrication of a new athletic mouthguard to replace his existing one. The mouth guard is necessary to prevent oral injury while playing sports.

Chronic oral inflammation has been associated with an increased risk for stroke, especially among individuals with periodontal disease. Both the NHANES and the NHANES Epidemiologic Follow-up Study (NHEFS) found that periodontal disease is an important risk factor for all forms of cardiovascular disease, including non-hemorrhagic stroke.[25] Further, increased carotid artery intimal-medial thickness, associated with both myocardial infarction and stroke, in subjects without a history of cardiovascular disease, often occurs in individuals with periodontitis.[26] This may indicate that subclinical atherosclerosis is present in many clients who present with periodontitis.[27,28] The control of oral inflammation is especially important in this client who is already at increased risk for stroke.

Risk Reduction Strategies
  
Pain and sensitivity are the client’s chief complaints, and should be addressed first. The dentist must evaluate the occlusion on tooth #3 and make adjustments as needed. If the new restoration required adjustment, the client’s sensitivity may diminish afterwards. However, the cold sensitivity may also be caused by root exposure on the buccal of #3. The dental hygienist has numerous treatment options that can be used to desensitize the area, and chooses to apply fluoride varnish. The client should be scheduled for re-evaluation in one week to assess the degree of resolution of the problem, and to determine the need for further intervention of the pain and sensitivity.

The client uses prescription strength neutral sodium fluoride daily, which is appropriate to increase the acid resistance of the enamel, reduce his caries risk and to help reverse his demineralization. Reinforcement of compliance with his fluoride regimen will be helpful to maintain his motivation. Counseling about alternative beverages, including substituting plain water for his sports drinks, is indicated. For continued dry mouth complaints, use of over-the-counter products such as moisturizing/moisture-retaining sprays, gels, or gum (e.g., Biotene®) can be recommended to provide additional lubrication and comfort.

Tim should be commended for wearing his mouth guard and for setting a positive example for his students.

The client should be educated about the correlation between chronic oral inflammation and stroke risk. Educating Tim about the need to maintain his good oral hygiene can help to sustain his motivation and ensure his ongoing compliance with his existing oral self-care routine.

Conclusion

Clients who are compliant with treatment recommendations can continue to benefit from education that encourages compliance and ongoing motivation. Many clients are unaware of the oral systemic link, and look to their dental hygienists for information that can be potentially life-changing and life-saving. The diagnosis of a new systemic condition often creates an opportunity for a teachable moment that can positively influence the client to improve his overall systemic health.

References

1. Kannel WB, Wolf PA, Benjamin EJ, et al. Prevalence, incidence, prognosis, and predisposing conditions for atrial fibrillation: population-based estimates. Am J Cardiol. 1998; 82(8A): 2N-9N.

2. Nakao K, Seto S, Ueyama C, et al. Extended distribution of prolonged and fractionated right atrial electrograms predicts development of chronic atrial fibrillation in patients with idiopathic paroxysmal atrial fibrillation. J Cardiovasc Electrophysiol. 2002; 13(10): 996-1002. 

3. Akyürek O, Sayin T, Dinçer I, et al. Lengthening of intraatrial conduction time in atrial fibrillation and its relation with early recurrence of atrial fibrillation. Jpn Heart J. 2001; 42(5): 575-84.

4. Kowey PR, Waldo AL, Ruskin JN. Managing rhythm control in atrial fibrillation: strategies for reducing morbidity and mortality. From: Medscape CME Cardiology. Available at: http://cme.medscape.com/viewarticle/715225. Accessed Mar. 15, 2010.

5. Lloyd-Jones DM, Wang TJ, Leip EP, et al. Lifetime risk for development of atrial fibrillation: the Framingham Heart Study. Circulation. 2004; 110(9): 1042-6.

6. Fox CS, Parise H, D’Agostino RB Sr, et al. Parental atrial fibrillation as a risk factor for atrial fibrillation in offspring. J Am Med Assoc. 2004; 291(23): 2851-5.
 
7. Narayan SM, Cain ME, Smith JM. Atrial fibrillation. Lancet. 1997; 350(9082): 943-50.

8. Rosenthal L, McManus DD. Atrial fibrillation. Available at: http://emedicine.medscape.com/article/151066. Accessed Mar. 15, 2010.

9. Van Gelder IC, Hemels ME. The progressive nature of atrial fibrillation: a rationale for early restoration and maintenance of sinus rhythm. Europace. 2006; 8(11): 943-9.

10. Favale S, Pappone C, Nacci F, et al. Sudden death due to atrial fibrillation in hypertrophic cardiomyopathy: a predictable event in a young patient. Pacing Clin Electrophysiol. 2003; 26(2 Pt 1): 637-9.

11. Wyse DG, Gersh BJ. Atrial fibrillation: a perspective: thinking inside and outside the box. Circulation. 2004; 109(25): 3089-95.

12. Wattigney WA, Mensah GA, Croft JB. Increasing trends in hospitalization for atrial fibrillation in the United States, 1985 through 1999: implications for primary prevention. Circulation. 2003; 108(6): 711-6.

13. Lubitz SA, Benjamin EJ, Ellinor PT. Atrial fibrillation in congestive heart failure. Heart Fail Clin. 2010; 6(2): 187-200.

14. Wolf P, Abbott R, Kannel W. Atrial fibrillation as an independent risk factor for stroke: The Framingham Study. Stroke. 1999; 22(8): 983-8.

15. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 Guidelines for the Management of Patients with Atrial Fibrillation: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and the European Society of Cardiology Committee for Practice Guidelines (Writing Committee to Revise the 2001 Guidelines for the Management of Patients With Atrial Fibrillation): developed in collaboration with the European Heart Rhythm Association and the Heart Rhythm Society. Circulation. 2006; 114(7): e257-354.

16. Ezekowitz MD, Connolly S, Parekh A, et al. Rationale and design of RE-LY: randomized evaluation of long-term anticoagulant therapy, warfarin, compared with dabigatran. Am Heart J. 2009; 157(5): 805-10, 810.e1-2.

17. Schirmer SH, van der Laan AM, Böhm M, Mahfoud F. Hotlines and clinical trial updates presented at the European Society of Cardiology Meeting 2009: data from RE-LY, PLATO, MADIT-CRT, PROTECT, SYNTAX, TRITON and more. Clin Res Cardiol. 2009; 98(11): 691-9.

18. Fuster V, Ryden LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of patients with atrial fibrillation—executive summary. Rev Port Cardiol. 2007; 26(4): 383-446.

19. Khoo CW, Lip GY. Insights from the dabigatran versus warfarin in patients with atrial fibrillation (RE-LY) trial. Expert Opin Pharmacother. 2010; 11(4): 685-7.

20. Schaer BA, Schneider C, Jick SS, et al. Risk for incident atrial fibrillation in patients who receive antihypertensive drugs: a nested case-control study. Ann Intern Med. 2010; 152(2): 78-84.

21. Wyse DG, Waldo AL, DiMarco JP, et al. A comparison of rate control and rhythm control in patients with atrial fibrillation. N Engl J Med. 2002; 347(23): 1825-33.

22. Hagens VE, Ranchor AV, Van Sonderen E, et al. Effect of rate or rhythm control on quality of life in persistent atrial fibrillation. Results from the Rate Control Versus Electrical Cardioversion (RACE) Study. J Am Coll Cardiol. 2004; 43(2): 241-7.

23. Wynn RL, Meiller TF, Crossley HL. Drug information handbook for dentistry, 15th ed. Hudson: Lexi-Comp, Inc., 2009.

24. Spolarich AE, Andrews L. An examination of the bleeding complications associated with herbal supplements, anti-platelet and anticoagulant medications. J Dent Hyg. 2007; 81(suppl): 1-26.

25. Wu T, Trevisan M, Genco RJ, et al. Periodontal disease and risk of cerebrovascular diseases: the First National Health and Nutrition Examination Survey and its follow-up study. Arch Intern Med. 2000; 160(18): 2749-55.

26. Howell TH, Ridker PM, Ajani UA, et al. Periodontal disease and risk of subsequent cardiovascular disease in U.S. male physicians. J Am Coll Cardiol. 2001; 37(2): 445-50.

27. Loesche WJ, Schork A, Terpenning MS, et al. Assessing the relationship between dental disease and coronary heart disease in elderly U.S. veterans. J Am Dent Assoc. 1998; 129(3): 301-311.

28. Arbes SJ Jr., Slade GD, Beck JD. Association between extent of periodontal attachment loss and self reported history of heart attack: an analysis of NHANES III data. J Dent Res. 1999; 78(12): 1777-82.

Ann Eshenaur Spolarich, RDH, PhD, is clinical associate professor, Herman Ostrow School of Dentistry of USC, and adjunct associate professor and course director of Clinical Medicine and Pharmacology at the Arizona School of Dentistry and Oral Health.

JoAnn R. Gurenlian, RDH, PhD, is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health care providers. She is a visiting scholar at Capella University, Department of Dental Hygiene, adjunct faculty at Burlington County College and graduate faculty at Idaho State University.

This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.