CLINICAL REPORT

Australian Dental Journal 2002;47:(3):259-261

Chest pain in the dental surgery: A brief review and practical points in diagnosis and management
PJ Chapman*

Abstract If a dental patient develops chest pain it must always be managed promptly and properly, i.e., the practitioner immediately stops the procedure and, being aware of the patients medical history, questions the patient regarding the nature of the pain to help determine the likely diagnosis. It will most likely be a manifestation of coronary artery disease (synonymous with ischaemic heart disease), i.e., angina pectoris or acute myocardial infarction, most usually the former. Angina will usually resolve with proper intervention whereas up to about onehalf of myocardial infarction cases will develop cardiac arrest, mostly in the first few hours, and this will be fatal in up to two-thirds of cases. As health care professionals, dental practitioners have an inherent duty of care to be able to initiate appropriate care if such a medical emergency occurs.
Key words: Chest pain, dental patient. (Accepted for publication 28 November 2001.)

with the patients medical practitioner where indicated, plus provision of adequate local anaesthesia and stress minimization. Cardiac arrest patients should also be identified, e.g., history of moderate or severe hypertension, heart failure, insulin dependant diabetes, hyperlipidaemia, etc.4,5 Medical advice may need to be sought and in some cases this may involve referral to a specialist, i.e., physician or cardiologist.4,5 Accepted practices4-11 The practitioner should refamiliarize himself/herself regarding the medical history and current medication of all cardiac risk patients at the start of an appointment. The practitioner should recall that ischaemic cardiac pain is usually located in the centre of the front of the chest, i.e., retrosternal, is of variable intensity, often described as a feeling of tightness or heaviness of the chest and can radiate to the left shoulder and arm and, less commonly, to the left side of the neck and mandible. Anginal pain tends to be similar for each individual each time it occurs whereas the pain of AMI is generally of greater intensity than that of angina and is often described as crushing in nature. Also the AMI patient may be cyanotic while nausea and vomiting are also common these features are rarely seen in angina. For the patient with a history of angina, administer a prophylactic dose of glyceryl trinitrate (GTN) a few minutes before commencing the appointment. (GTN presentations: tablet dose 0.6mg; spray dose 0.4mg.) It is generally recommended that GTN be kept as an emergency drug and GTN spray is the preferred presentation because of its longer shelf-life. If they experience their typical anginal chest pain later in the appointment, sublingual GTN should be administered in the recommended fashion, i.e., one dose about every five minutes, up to a maximum of three doses until the pain is relieved and administer supplemental oxygen. However, because GTN may cause hypotension with reflex tachycardia, the practitioner, who is monitoring basic signs (consciousness, colour, pulse and blood pressure (BP)), will check the systolic BP before subsequent doses if this is <100mmHg, withhold subsequent doses of GTN as otherwise myocardial
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INTRODUCTION The occurrence of chest pain in a dental patient is uncommon. A recent estimate from an Australian survey of medical emergencies in the dental office is that a practitioner would experience one case of angina in a career of 40 years whereas the incidence of acute myocardial infarction (AMI) was about one-in-ten dentists, also in a 40 year career.1 These and other results are recorded in Table 1 and compared to the results of two similar surveys.2,3 Responding immediately to a patient with chest pain is critical to a successful outcome. This will be outlined in the following section. DISCUSSION The basis of safe practice is a complete and up-todate medical history for all patients, plus, especially for patients with coronary artery disease (CAD), liaison

*Senior Lecturer (Oral and Maxillofacial Surgery) and Medical Officer, School of Dentistry, The University of Queensland.
Australian Dental Journal 2002;47:3.

Table 1. Occurrence of angina, AMI and cardiac arrest in dental practice1-3

Country No of dentists surveyed Frequency of chest pain cases per dentist per year % of chest pain cases which were angina Frequency of cardiac arrest cases per dentist per year % survival of cardiac arrest cases % of medical emergencies experienced which were cardiac arrests* Australia (1997)1 811 0.03 93 <0.005 75 UK (1999)2 302 0.2 96 <0.005 100 UK (1999)3 1093 0.03 90 <0.005 53

<0.01

0.45

1.0

(*medical emergencies does not include vasovagal syncope or hyperventilation).

oxygen consumption will be increased by the reflex tachycardia and more doses will increase the myocardial ischaemia. The risk of hypotension occurring is minimized if the patient is initially placed in a semi-reclined position (the preferred position for all patients experiencing chest pain). Of course, in the case where reflex hypotension occurs and the pain persists, call 000 immediately. If the pain is relieved by GTN and basic signs are normal, and the patient so desires, it would generally be considered safe to continue the appointment. Otherwise, consider contacting the patients medical practitioner and discuss additional measures to prevent recurrence, e.g., slow release GTN skin patches applied at least four hours before the appointment, oral sedation, etc. However, if in the previous scenario the pain is not considerably eased within 10 minutes from commencing the trial of GTN, or fully relieved within 15 minutes, or recurs, presume an AMI and call 000 immediately; continue administering oxygen and prepare for possible cardiac arrest. If the chest pain experienced by the anginal patient is of a different character than usual, or more severe than ever before, or requires a higher dose of GTN than usual for relief, presume an AMI and contact 000 immediately. If a patient with a history of both AMI and angina develops chest pain in the surgery, always presume it is an AMI and call 000 immediately. If a patient develops chest pain for the first time, always presume it is an AMI. Medical aid should be sought immediately if there is any doubt as to the cause of the patients chest pain. If the practitioner suspects an AMI at the start, then, after calling 000 and awaiting their arrival a dose of GTN can be administered but only after confirming that the systolic BP is above 100mm Hg. Otherwise do not administer. The GTN will only partially or
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temporarily diminish the pain of an AMI, but will reduce myocardial oxygen consumption as well as increasing myocardial perfusion, thereby improving the prognosis. A second dose can be given (after confirming the BP) about five minutes later. Nitrous oxide, e.g., Entonox can also be used for continuing pain. Additionally, in the same scenario, administer a soluble aspirin tablet (300mg) early because of its antithrombotic effect, i.e., it will limit the area of infarction of course do not administer if there are contraindications, e.g., allergy, bleeding disorder, etc. Oral absorption occurs rapidly (as first-pass metabolism is by-passed) and the patient is told to hold the tablet under the tongue, or in the buccal sulcus, and to avoid swallowing it. If this is not practical at the time, e.g., the patient is nauseous, the patient is given a dissolved soluble aspirin tablet which will be effective within 20-30 minutes. Do not perform elective treatment within the first six months on a patient who has suffered an AMI. Any emergency work in this time must be done as a medically monitored case, because the risk of reinfarction is greatly increased in this period with a corresponding increased mortality rate. The medically monitored case is usually done with intravenous sedation and local anaesthesia with an anaesthetist in attendance in a hospital facility the patient is kept on supplemental oxygen via nasal prongs under continuous electrocardiogram and pulse oximetry monitoring with provision for advanced cardiac life support including a defibrillator. After six months, general dental treatment can be performed if there has been an uncomplicated recovery, but with close monitoring. However, the patients medical practitioner must always be contacted prior to the first appointment and preventive measures discussed. Finally, the AMI patient with continuing serious post-infarction complications, e.g., severe heart failure, unstable angina will need to be done as a medically monitored case no matter how long since the AMI occurred because of the continuing high risk of reinfarction and cardiac arrest. The patients medical practitioner therefore must be consulted before any treatment is considered. REFERENCES
1. Chapman PJ. Medical emergencies in dental practice and choice of emergency drugs and equipment: a survey of Australian dentists. Aust Dent J 1997;42:103-108. 2. Girdler NM, Smith DG. Prevalence of emergency events in British dental practice and emergency management skills of British dentists. Resuscitation 1999;41:159-167. 3. Atherton GJ, McCaul JA, Williams SA. Medical emergencies in general dental practice in Great Britain. Part 1: Their prevalence over a 10-year period. Br Dent J 1999;186:72-79. 4. Jowett NI, Cabot LB. Patients with cardiac disease: considerations for the dental practitioner. Br Dent J 2000;189:297-302. 5. Chapman PJ. A case report of acute heart failure caused by a patient delaying taking his diuretic medication. Aust Dent J 2002;47:66-67.
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6. Malamed SF, KS Robbins. Medical emergencies in the dental office. 5th edn. Minneapolis: Mosby, 2000: Ch 27-29. 7. Scully C, Cawson RA. Medical problems in dentistry. 4th edn. New Delhi: Wright, 1998:61-63. 8. Bochner F (ed). Australian Medicines Handbook. Adelaide: AMH Pty Ltd, 2000:612-619. 9. Fauci AS. Principles of Internal Medicine. 14th edn. Auckland: McGraw-Hill, 1998: Ch 243. 10. Rees TD, Rose LF. Periodontal management of patients with cardiovascular disease. J Periodontol 1996;67:627-635.

11. Weaver T, Eisold JF. Congestive heart failure and disorders of the heart. Dent Clin North Am 1996;40:543-561.

Address for correspondence/reprints: Dr PJ Chapman School of Dentistry The University of Queensland 200 Turbot Street Brisbane, Queensland 4000

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