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Atherosclerotic vascular disease (AVD) is a chronic process that occurs when the blood vessels carrying oxygen and nutrients from the heart to the rest of the body develop a buildup of plaques formed by fat, cholesterol and other substances in the blood.39 These plaque deposits cause narrowing of the blood vessels, a decrease in the elasticity of the vessel musculature, and changes in the smooth flow of blood through the lumen of the vessels.39 The formation of these plaques occur in response to inflammatory stimuli, which increase the expression of endothelial adhesion molecules. This allows for the recruitment and firm attachment of leukocytes to the vessel wall.39-41 Monocytes in the circulating blood attach to the vessel walls and then enter the intima of the vessels. They are then activated and mature in macrophages and scavenge the lipoproteins modified by inflammation.41,42 As low-density lipoproteins (LDLs) accumulate in the macrophages, they become “foam cells,” which characterize the initial plaque formations or fatty streaks.42 The macrophages and foam cells produce pro-inflammatory mediators, such as interleukin-1ß (IL-1ß) and tumour necrosis factor alpha which amplify the local inflammatory response. A feedback loop develops that leads to atherosclerosis. Apoptosis of the foam cells then results in a release and accumulation of lipids in the intima of the blood vessels.42
There are around 7.4 million people living with heart and circulatory diseases in the UK according to the British Heart Foundation (Figure 1).33 AVD leads to high rates of morbidity and mortality. There is significant overlap of the risk factors for periodontal disease and for AVD. Dental care providers aware of the interactions will be able to adequately counsel their patients and customise treatment protocols. Additionally, dental health care providers should be aware of current pharmacotherapeutic management strategies for cardiovascular diseases and their implications on periodontal therapies (Table 2).
| Drug | Mechanism of Action | Potential Oral Manifestations | Other Considerations |
|---|---|---|---|
| α Adrenergic blockers | Produce dilation due to antagonizing alpha receptors on blood vessels | Xerostomia | Orthostatic Hypotension Prolonged NSAID use can decrease anti-hypersensitivity effects |
| α, β-Adrenergic blockers | Alpha and nonselective beta-adrenergic receptor blockade | Xerostomia Altered taste Lichenoid reaction |
Orthostatic hypotension Prolonged NSAID use can decrease anti-hypertensive effects |
| β- Adrenergic blockers | Compete with catecholamines for beta-adrenergic receptor sites; may be cardioselective (CS) or nonselective (NS) | Xerostomia | NS may have a possible interaction with sympathomimetics Orthostatic hypotension |
| Central sympatholytics | Inhibition of sympathetic outflow from the central nervous system | Xerostomia Lichenoid reaction Parotid pain/swelling |
Orthostatic hypotension Nausea/vomiting Enhance CNS depressants Prolonged NSAID use can decrease anti-hypersensitive effects |
| Peripheral adrenergic antagonists (seldom used) | Deplete tissue stores of catecholamines and serotonin | Xerostomia | Orthostatic hypotension Enhance CNS depressants Prolonged NSAID use can decrease anti-hypersensitive effects |
| Anglotensin-converting enzyme (ACE) inhibitors | Block conversion of angiotensin II to angiotensin II | Cough Angioedema of lips, face, tongue Altered/decreased taste |
Prolonged NSAID use can decrease anti-hypertensive effects Neutropenia, thrombocytopenia |
| Angiotensin receptor blockers | Competitively block angiotensin II at blood vessels and renal receptors | Angioedema of lips, face, tongue | Nausea/vomiting Dizziness |
| Calcium channel blockers | Inhibit calcium-ion influx into the cardiac and vascular smooth muscle | Xerostomia gingival overgrowth |
Orthostatic hypotension Drowsiness Nausea/vomiting |
| Nitrates | venous and arterial dilation; reduction of oxygen demand by myocardium | Facial flushing | May decrease effects of epinephrine and levonordefrin Orthostatic hypotension Headache dizziness Nausea/vomiting |
