High blood pressure and dental anaesthetic: adrenaline, treatment after a heart attack, pacemakers and other heart conditions

What should you tell your dentist if you have heart disease or high blood pressure?

Your dentist needs to know your cardiac diagnoses, the dates of any serious events and the full list of your medicines, because these determine the choice of anaesthetic, the timing of the procedure and any antibiotic prophylaxis. The simplest way is to bring the discharge summary from your last hospital stay and an up-to-date list of medicines.

Drugs used for heart conditions can also change the mouth. According to an ADA overview, beta-blockers can cause a dry mouth, while calcium channel blockers can cause a dry mouth and gum overgrowth.

• Diagnosis: high blood pressure, coronary heart disease, heart failure, heart rhythm disorders, valve disease.
• Dates of a heart attack, stroke, stent placement or heart surgery.
• All medicines, especially anticoagulants and antiplatelet drugs, including those bought without a prescription.
• A pacemaker or implantable cardioverter-defibrillator, and the device card.
• An artificial heart valve, a valve repair or previous infective endocarditis.
• Recent blood pressure readings and symptoms such as chest pain on exertion.

Heart disease and dental treatment: what does the dentist take into account?

Most people with heart disease are treated at the dentist without major changes, and the 2022 European Society of Cardiology (ESC) guidelines class dental procedures as low-risk, with a risk of cardiac death, heart attack or stroke within 30 days below 1%. The table shows what the dentist pays attention to in particular situations, according to the sources cited in this article.

At what blood pressure does the dentist postpone treatment?

With a systolic pressure below 160 mm Hg and a diastolic pressure below 100 mm Hg, dental treatment, both planned and urgent, goes ahead unchanged. These thresholds come from the American Dental Association (ADA) overview on high blood pressure (updated in 2022): with a systolic pressure above 160 mm Hg or a diastolic pressure above 100 mm Hg, the reading is repeated, and if the result is confirmed, planned treatment is postponed and the patient is referred to a doctor.

Under the ADA algorithm, urgent care, for example for pain or an abscess, can be considered at a systolic pressure of 160 to 180 mm Hg or a diastolic pressure of 100 to 109 mm Hg if toothache or other dental symptoms are contributing to the raised blood pressure; during the procedure, blood pressure is checked every 10 to 15 minutes. With a systolic pressure above 180 mm Hg or a diastolic pressure of 110 mm Hg or more, a medical consultation is needed before the procedure. If high blood pressure comes with symptoms, the patient needs urgent medical assessment.

These thresholds, however, are not based on research. The authors of a 2020 review in JADA found no accepted criteria or evidence showing at what blood pressure treatment has to be cancelled, and recommend assessing the patient on their general condition and previous readings. They also write that in people under a doctor’s care, cancelling a procedure because of the reading alone is rarely necessary.

Is an anaesthetic with adrenaline safe with high blood pressure and heart disease?

In selected patients with stable cardiovascular disease, local anaesthesia with small doses of adrenaline can be used after an individual assessment. A 2021 systematic review in BMJ Open (10 randomised trials, 478 participants) did not show adrenaline worsening the cardiovascular measures assessed, while pain and bleeding were more frequent without a vasoconstrictor; the certainty of the evidence was low. The trials cannot settle the risk of heart attack, stroke or death.

Effective anaesthesia also matters for the heart. The 2022 review points out that a greater strain can come from the body’s own adrenaline, released when pain and stress are not adequately controlled, and recommends using the smallest effective amount of vasoconstrictor.

The same review lists situations in which vasoconstrictors are not used in the anaesthetic: unstable angina, a recent heart attack, recent coronary artery bypass surgery, treatment-resistant arrhythmias, and untreated or uncontrolled severe high blood pressure and heart failure. The question of blood pressure medication and dental anaesthetic therefore comes down mainly to the choice of agent and the amount of adrenaline, which is decided by a clinician who knows all your conditions and medicines.

When can teeth be treated after a heart attack or stroke?

After a heart attack, planned dental treatment is postponed for at least 30 days. The 2022 review, citing the ADA guide, states that during this period urgent care is given after consultation with a doctor, preferably in a hospital setting, and that after a month without symptoms planned treatment is possible with appropriate caution. In the past, a wait of 6 months was recommended before surgical procedures.

After a stent has been placed and while taking antiplatelet drugs, treatment is not interrupted for a dental procedure without a cardiologist’s decision. The 2022 ESC guidelines class the removal of 1 to 3 teeth among the procedures with the lowest bleeding risk; details are in the article on anticoagulants and tooth extraction.

The timing of planned treatment after a stroke or a transient ischaemic attack is agreed by the dentist with the doctor in charge of your care, taking into account the patient’s condition and anticoagulants. If chest pain, shortness of breath or fainting occurs during the visit, the procedure is stopped, and if the symptoms do not go away, help is called on 112, the emergency number.

Pacemakers and the dentist: can dental equipment interfere with them?

Most dental equipment is safe for people with a pacemaker or implantable cardioverter-defibrillator, provided a suitable distance is kept. A 2023 ADA page, citing a 2020 systematic review, states that most dental instruments are safe in everyday practice when a proper distance from the device is maintained.

Interference was usually described at distances of up to 37.5 cm from the device or its leads, and the British Heart Rhythm Society (2022) considers it unlikely at a distance of at least 15 cm. Monopolar electrosurgery has the greatest potential for interference, and piezoelectric scalers are regarded as safer than magnetostrictive ones.

In studies involving patients, interference was minor: in a 2015 study (32 people) it occurred with the scaler less than 18 inches (about 46 cm) away and mainly affected the telemetry recording rather than the pacing itself. In a 2013 study (12 people), piezoelectric scalers did not interfere with cardioverter-defibrillators.

Endocarditis: who needs an antibiotic before dental treatment?

The 2023 ESC guidelines recommend an antibiotic before dental treatment, to protect against infective endocarditis, only for people in the high-risk group. This applies to at-risk procedures: tooth extraction, surgical procedures, implant placement and procedures that involve the gum or the area around the root tip.

For disease of your own valve without material used to repair it, and for a bicuspid aortic valve, hypertrophic cardiomyopathy or a pacemaker or cardioverter-defibrillator alone, the ESC does not recommend routine prophylaxis, while allowing an individual decision. The guidelines also recommend brushing twice a day and professional cleaning with a check-up at least twice a year in the high-risk group, and once a year in the other groups. The choice of drug is made by the doctor; the article on antibiotics at the dentist covers this in more detail.

• Previous infective endocarditis.
• An artificial heart valve implanted surgically or by catheter, and material used for surgical valve repair; after transcatheter mitral or tricuspid valve repair, prophylaxis should be considered.
• Some congenital heart defects, especially those repaired with prosthetic material.
• A mechanical ventricular assist device as destination therapy.

Is gum disease linked to heart disease?

Periodontitis (advanced gum disease) is associated with cardiovascular disease independently of other risk factors. This is the conclusion of the 2020 joint consensus of the European Federation of Periodontology (EFP) and the World Heart Federation, which recommends informing patients with periodontitis about this increased risk.

Periodontal treatment improves markers of inflammation, such as CRP, and the function of the lining of the blood vessels (endothelium), but there is no hard evidence that it prevents heart attacks or strokes. It is an association, not a proven cause, so treating your gums is best seen as part of looking after your health rather than as a way to prevent a heart attack.

How it works at DentalBlue

At DentalBlue in Białystok, at the first visit the dentist examines the teeth and gums, and the panoramic X-ray is taken in the clinic’s own radiology unit. In the clinic’s price list, “Wizyta bez bólu” (visit without pain: panoramic X-ray, consultation, examination and written treatment plan) costs 300 zł, and “Wizyta z bólem” (visit in pain: panoramic X-ray, consultation, examination and pain relief) 340 zł.

Bring your list of medicines, the discharge summary from your last hospital stay and your pacemaker card, if you have one. The final scope and cost are set at the consultation, and prices may change. The clinic is open Monday to Friday from 8:00 to 20:00 and on Saturdays from 8:00 to 16:00.