Running head: DENTAL TREATMENT 1

Administering Dental Treatment to Patients with Cardiac Disease and Pulmonary Hypertension

Name

Professor’s Name

Course name

Date

DENTAL TREATMENT 2

Administering Dental Treatment to Patients with Cardiac Disease and Pulmonary

Hypertension

Background

Hypertension and cardiovascular complications are common diseases in dental setting

that need special consideration. The wide spread of these diseases, life-long treatment required as

well as the terrible consequences associated with them demands attentive approach by dentists.

Cardiac disease and high blood pressure management in dental clinic entails correct

measurement, disease diagnosis and recognition, oral adverse effects, knowledge of its treatment

and risks assessment for dental treatment. For this reason, it is the responsibility of the dentists to

screen undertreated and undiagnosed high blood pressure and cardiovascular complications in

order to improve monitoring and dental treatment (Scully & Cawson, 2005). The administration

of dental treatment under sedation and local anesthesia has good safety record. Unfortunately,

high prevalence of high blood pressure and cardiac disease in the today’s population as well as

high proportion of children with congestive heart disease are some of major medical challenges

faced by many medical dentists.

As a health professional and as a trainee under internship in one of a local hospital in my

area, I have come to realize that oral health care in dentistry is an integral part of medical care

that needs to be considered and given a thought. This is particularly apparent when administering

dental treatment to patients who are presented with a systemic illness such as high blood pressure

and cardiovascular complications. As a trainee back in college, I realized that dentists must be

able to identify patients with high blood pressure and various cardiovascular complications

which can be exacerbated by various dental treatment procedures. Unfortunately, ability of the

DENTAL TREATMENT 3

dental practitioners to provide proper dentistry practice is usually challenged in the health care

system. This has been as a result of inappropriate identification of a patient with high blood

pressure, cardiovascular complications and other compromising systemic condition due to

improper or inadequate history taking and poor interpretation of the results which have been

resulting to detrimental or ineffective dental procedure, increasing the risks of mortality and

morbidity.

During my stay at the hospital, I undertook a research to determine the most effective

dental administration treatment that could be effective for patient with cardiac complications.

During my research and conversation with some of the dentists at the dental unit, I was able to

pinpoint some of the potential problems that are associated with dental care for those patients

with congestive heart failure. This included cerebrovascular accident, sudden death due to

arrthymia and cardiac arrest, infection, breathing difficulties and drug side effects as well as

increased high blood pressure during treatment a case that will lead to increased blood loss and

anemia. For this reason, it is essential for the dental surgeons and specialists to understand the

proper diagnosis methods as well as be informed on the suitable methods for administering

dental treatment for patients with cardiac complications.

It is during my stay at the clinic that I came across one case history that is related to

administration of dental treatment. In this case, the patient A (unanimous) who was 50 years old

woman with a 5 years history of high blood pressure was presented to the hospital in the

consultation department where she was seeking for more information regarding high blood

pressure self-management strategies. The reason for doing this is because she had a difficult time

controlling her high blood pressure for the past 1 year as she was referred to the hospital

complaining of headache, nausea and vomiting, blurred vision, dizziness and chest pain. All

DENTAL TREATMENT 4

these being some of the symptoms of markedly elevated high blood pressure. Patient A past

medical history indicated high blood pressure with 30 years of tobacco use. A week later, patient

A visited the dental clinic. At the clinic, the dentists on duty indicated signs of gingivitis, cracked

tongue and presence of halitosis. The patient had gone to the dental clinic as she needed one of

her left upper jaw molar to be removed through surgery.

At the dental clinic, the patient high blood pressure was 140 mmHg with a diastolic blood

pressure of 90 mmHg. According to the patient past history, she has been using antihypertensive

drugs which were meant to lower her high blood pressure condition. In this case, the dentist who

was handling the patient recommended anxiolytic premedication and use of good local anesthetic

technique. Unfortunately, the specialist who handled the surgical procedure for the patient failed

to abide to the patient provided medical history of high blood pressure and the recommended

anesthetic procedure. Due to this mistake and failure to abide to the required procedure, the

patient after dental treatment started experiencing vasovagal reaction including fainting and

dizziness when the patient was in the upright position. In addition, the patient indicated

cardiovascular manifestation characterized by hypotension and Bradycardia. According to the

dentist, the patient symptoms demonstrated some depressed cardiovascular function and the

patient needed urgent medical care to prevent cardiac arrest and sudden death.

With the advancement in technology and the expansion of the medical field, many

patients with systemic illness are now in a better position to obtain competent, efficient and safe

dental care through understanding the drugs being used and the medical condition the patient is

suffering from. For this reason, information pertaining to administering of dental treatment

should be made available to the dentists. The injection of the local anesthetic agent as indicated

in the above case example is an important procedure apart from being commonly performed that

DENTAL TREATMENT 5

needs careful consideration (Daniel, 2011). From what I have learnt both in the field and in the

hospital setting is that it is important for the dentists before performing a dental procedure or

before administering a dental medication to take complete medical history, consult the patient

doctor and follow up any questions necessary pertaining to the patient’s health and feeling after

dental procedure. As a professional nurse and increased emergency issues from dental clinic

pertaining to dental treatment of a cardiovascular system compromised patients, I have realized

that local anesthetics if not well monitored and controlled during dental treatment can be unsafe

at therapeutic dose. For this reason, it has been necessary for the dental practitioners to address

two basic issues when using local anesthetic agents (Cynthia and Thompson, 2004). This

includes the cardiovascular and high blood pressure medications that may result to adverse

reactions as well as the existing cardiovascular or any other systemic disease which may be

exacerbated by the used agent.

From my past clinical knowledge, I have had an opportunity to learn some of the

assessment for prevention of medical problems that may result during administration of dental

treatment for a patient with high blood pressure and cardiovascular complications. The first

assessment strategy is the classification of the condition the patient is suffering from and which

may be exacerbated by the local anesthetic agent if not properly used (Yuzuru Kaneko, 2007). If

the patient has a history of cardiovascular complications, it is important for the patient to receive

good medical management while any other complications need to be brought under control

before any dental care. Such diseases include valvular disease, renal failure, myocardial

infarction and congestive heart disease. The dentist need also to assess the oral manifestation

associated with cardiovascular and high blood pressure prior to administrating a dental treatment.

This manifestation includes bleeding, ecchymoses, petechiae and drug related Xerostomia and

DENTAL TREATMENT 6

mucosal lesions (Becker & Haas, 2011). Following dental treatment, it is important for the

professional dentists to assess the patient for adverse reactions from the used local anesthetic

conditions which include nausea and vomiting.

In a separate case history within the same hospital while being an attached student at the

dental unit, I witness another case that happened to pose a challenge to some of the junior

dentists at the unit. Early one morning about two months from the day of the first incidence, a

patient B was presented to the dental hospital complaining of a painful toothache. According to

the recommendation of the dentist on duty during that day, the tooth had decayed and it was

supposed to be removed through a minor surgery. According to the patient medical history, he

has had ischemic heart disease for the past 6 months and under medication to control the

condition. Some of the past history questions the patient was placed under include what is your

high blood pressure, is there reactions or side effects that have resulted following the use of high

blood pressure medication, have you ever had episodes of hypertension or postponed dental

treatment due to high blood pressure (Popescu, Scrieciu, Mercuţ, Ţuculina & Dascălu, 2013).

After obtaining the medical history, the dentists carried out additional diagnostic test to ascertain

that the patient was for sure suffering from ischemic heart failure. During dental surgery, the

anxiolytic agent was administered before the treatment in order to reduce anxiety within the

patient and puts his blood pressure under control. The local aesthetic agent was administered

without the use of intravascular injection. In addition, the dental surgeon suggested to the dental

team to ensure every person works in corroboration so as to prevent excessive local bleeding

during the dental surgery and to constantly monitor the patient high blood pressure to ensure it

was in a stable level.

DENTAL TREATMENT 7

In a patient who is receiving antiplatelet or anticoagulant treatment, oral manifestation

may include gingival bleeding, petechiae and hematomas. In dental practice, a six month safety

period has been established before administering oral surgical process for a patient with ischemic

heart disease. However, emergency treatment can be provided but this should involve a

minimally invasive procedure. To ensure proper administration of dental treatment for patient

with ischemic heart disease, a dentist must first consult the patient’s physician so as to evaluate

the type of heart disease the patient is suffering from, the clinical complication, the time elapsed

since the onset of the condition, treatment being given to the patient and the severity of the heart

disease (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). Premedication should be

administered to an anxious patient using 5 mg diazepam so as to reduce stress and anxiety. The

visit should be brief, 30 minutes maximum and must be placed in the most comfortable position

so as to avoid orthostatic hypertension. For such a patient, it is important to monitor the patient’s

blood pressure during dental treatment and excessive local bleeding should be controlled. In

addition to this, it is important to monitor the patient after treatment for symptoms that may

suggest complications (Mingarro-de-Leon, Chaveli-Lopez & Gavalda-Esteve, 2014). In case of

this, the patient should be placed under emergency medical conditions. Furthermore, the patient

need to be advised on the need to maintain a good oral hygiene and provide this complete

medical history to the dentists in order to indicate complications that may result from under

diagnosed high blood pressure.

The management of patients with pulmonary hypertension and with the co-existing dental

condition can be a challenge to dental practitioners. Providing the dental treatment using local

anesthesia and sedation has an excellent safety record. The high incidences of cardiovascular

disease is revealed as the most common medical problem encountered in the dental office

DENTAL TREATMENT 8

(Health Partners Research Foundation, 2009). Most dental care providers feel confident in

performing cardio-pulmonary resuscitation. However, treating patients with the coexisting

pulmonary hypertensive disease often causes concerns over potential problems during treatment.

A combination of intervention with caution and choosing the appropriate medications depending

upon patient condition is the best plan of treatment.

The dental management of patients with medically compromising condition such as high

blood pressure and cardiovascular complication is sometime a complex issue in dental practice

that demands integral and multidisciplinary actions. For this reason as a professional in health

care I believe that the hospital is the most ideal place for administrating dental treatment to

patient with high blood pressure and who have cardiovascular complications (Daskalov and

Vladimirova-Kitova, 2009). The reason for considering the hospital as an ideal place is because

of the availability of specialized human resources and technical tool that allows the dental

practice to interrelate with other surgical as well as the clinical specialties. Some dentists treat

the patient in the office setting similar to regular patients without many precautions. Due to

severity and complexity of pulmonary hypertension, there can be some unforeseen problems that

can arise. The best way to get evidence-based information is to research randomized clinical

trials related to pulmonary hypertension to improve the value of life (Jowett & Cabot, 2005).

Finally, to effectively manage patients with these problems once they visit the dental clinic, a

dentist must first examine the patients’ medical history and establish their underlying treatment

and condition. This is important as it will ensure that the dentist carries out treatments that result

into better outcome.

DENTAL TREATMENT 9

Bibliography

To efficiently and effectively provide strong background pertaining to administration of

dental treatment to patient with cardiac problems and high blood pressure, the following are

some of the bibliographies that will be used to provide a strong foundation for the paper. Some

of these bibliographies include;

Budenz A,. (2000). Local Anesthetics and Medically Complex Patients. Journal of the

California Dental Association. Retrieved 20 October 2015, from

http://www.endoexperience.com/filecabinet/clinical%20endodontics/anesthesia/local

%20anesthesia%20and%20med%20compromised%20pts%20jcda%202000.pdf

According to Budenz, medically compromised patients continue to increase as the

population ages and as the prevalence of various body compromising disease increases. As a

result, the medical institutions including the dental clinics within the local areas need to

implement effective strategies for treating dental patient with cardiovascular complications. This

article is important for this paper as it provides the best method which needs to be adopted by the

dental practitioners in order to minimize the emergency issues during dental minor surgeries.

Burgess J, (2015). Dental Management in the Medically Compromised Patient: Overview,

Diabetes, Drug Reactions. Retrieved 29 September 2015, from

http://emedicine.medscape.com/article/2066164-overview

This is a peer reviewed article from Medscape that provide more information pertaining

to dental management of patient with high blood pressure and who is medically compromised.

The article focuses on some of the medical problems that a dentist is likely to come across and

DENTAL TREATMENT 10

which may result to potential complications and interfere with the outcome of the dental

treatment.

Carlos M and Bruno C,. (2003). Recommendations to use vasoconstrictors in dentistry and

Oral surgery. Retrieved 20 October 2015, from

http://societechirorale.com/documents/Recommandations/recommandations_vasoco

nstricteurs_gb.pdf

In this article, the authors provide some of the recommendations which will ensure

effective use of vasoconstrictors in oral and dentistry surgery. The article is important as it

provides a strong foundation for the paper by providing more information regarding to the use of

the vasoconstrictors during dental surgery. This article provides information regarding to how

effective one should use the local anesthetics and prevent some of the complications reported

among patients with cardiac problems and with high blood pressure.

Cruz-Pamplona, M., Jimenez-Soriano, Y., & Sarrion-Perez, M. (2010). Dental

considerations in patients with heart disease. Journal of Clinical and Experimental

Dentistry, e97-e105. http://dx.doi.org/10.4317/jced.3.e97

In this paper, Cruz-Pamplona provides some of the dental consideration a dentist needs to

abide by and which are effective in ensuring comprehensive, effective and competent dental

treatment for a patient with heart disease. This peer reviewed article is important for this case as

it provides comprehensive information pertaining to cardiovascular disease and some of the

procedure which are important to prevent exacerbation of the condition during dental treatment.

DENTAL TREATMENT 11

Jowett, N., & Cabot, L. (2000). Medical matters: Patients with cardiac disease:

considerations for the dental practitioner. British Dental Journal, 189(6), 297-302.

http://dx.doi.org/10.1038/sj.bdj.4800750

According to Jewett in his article, “the dentists need to follow some of the consideration

when managing or administering a dental treatment to patient with cardiac disease.” The article

provides a highlight of the prevalence of cardiac problems and high blood pressure among the

current population and provides information pertaining to dental management of such patients.

This article is important in this paper as it provides a breakdown of the procedure that need to be

abided while providing dental treatment to patient with cardiac disease.

Silvestre-Rangil, J., Silvestre, F., & Espin-Galvez, F. (2014). Hospital dental practice in

special patients. Med Oral, e163-e169. http://dx.doi.org/10.4317/medoral.19553

In this paper, Silvestre-Rangil and his colleague provides information pertaining to

administering of dental treatment to patient with special needs including those with severe

mental and physical disabilities, multiple disorders and different systemic diseases. This paper

advocate the hospital setting to be the most effective place for providing dental treatment to

those with special needs. “This is because the hospital setting has the required human and

technical resources necessary to ensure effective services and reduced complications.”

DENTAL TREATMENT 12

Introduction

Cardiovascular disease for the last one decade has become the leading cause of deaths in

the developed and developing countries, with the leading cause being ischemic heart disease,

heart failure and the cerebrovascular disease. Along with their associated morbidity,

cardiovascular diseases are of significance to this study due to the number of patients subjected

to these treatments, some among whom attend dental hospitals for checkups, treatment or

surgery. For this reason, it is important for dentists to first identify the underlying patient

problem, the possibilities for dental treatment and the treatment being received. Furthermore,

dental surgeons should identify requirements for medical emergencies and adopt measures to

effectively and quickly treat patients with high cardiovascular complications.

The high prevalence of cardiac conditions across the world means that dentists in their

daily management will encounter patients with these conditions. According to Jowett & Cabot

(2000) approximate 50% of patients who attend dental clinics have a history of cardiovascular

disease among other diseases such as anaphylaxis and hypoglycemia. Among the patients

referred with oral and maxilla-facial surgery, Co-existent cardiovascular disease has been a

highly cited medical condition indicating a greater concern over increased complication during

dental treatment including presence of heart murmurs, safety of administering vaso-constrictor

drugs, hypertension and need for antibiotic therapy. Since the incidence of cardiac disorders is

continuously increasing, the dentists need to evaluate the patient medical history in order to

ensure safe treatment and to prevent any complications. For this reason, this paper focuses on a

number of cardiovascular diseases a dentist encounters and which necessitate extra care to

prevent dental complications which may cause unnecessary mortality and morbidity. The

hypothesis adopted by this paper is understanding how proper administration of dental treatment

DENTAL TREATMENT 13

to patients with various cardiac diseases and pulmonary hypertension may be effective in

managing such patients.

The management of patients with pulmonary hypertension, with the co-existing dental

condition, can be a challenge to dental practitioners. Providing the dental treatment using local

anesthesia and sedation has an excellent safety record. The high incidences of cardiovascular

disease, reveals it as most common medical problem encountered in the dental office. Most

dental care providers feel confident in performing cardio-pulmonary resuscitation. However

treating patients with the coexisting pulmonary hypertensive disease often causes concerns over

potential problems during treatment. For example, while treating patients, prophylactic care with

antibiotics should be taken, and close monitoring is required. Prevention of dental disease by

regular dental check-ups and proper dental hygiene is very beneficial. Understanding the clinical

characteristics and oral facial involvement due to underlying systemic disease is crucial for safe

and effective treatment. Treating patients with co-existent congenital heart disease can cause

potential problems during treatment. Such patients are on anti coagulants like warfarin that needs

to be stopped to reduce excessive bleeding. This condition is usually treated at a hospital setting

under must specialty expertise available round the clock in case of emergencies. In university

hospitals, various clinical studies take place simultaneously along with treatment to help in

further understanding the patient's condition. Pulmonary hypertension patients with dental

disease can be well managed with regular visits to dentist and specialists like pulmonologist and

cardiologist.

Claim of fact

As a professional nurse and having worked in the dental unit as a trainee, I have realized that as

life expectancy increases, more and more patients are suffering from both dental problems and

DENTAL TREATMENT 14

cardiovascular diseases. As a result, there is need for the dentists and the patients to work in

collaboration to ensure the dental treatment does not cause advance effect to the cardiovascular

system. The fact is that when the dental treatment is properly performed, then the patient with

any cardiovascular complications will be safe. As a result, the management of dental problem to

a patient with cardiovascular complication or pulmonary hypertension is important and calls for

mutual cooperation and understanding between the patient and the dentists. For example, the

physician should understand the type as well as the extend of the dental procedure, discuss the

patient’s medical problem, and the dentist as well as the patient physician should understand the

type of drugs to be used during dental management.

From my professional background, I explicitly understand that the dental management of

patients with various cardiovascular diseases especially with ischemic disease and hypertension

is complex and demands an integral and multidisciplinary approach. For this reason, I have come

to realize that the hospital is the most suitable setting for providing dental treatment due to

availability of human resources and specialized technical resources. In addition, a hospital set up

provides an interrelation between dental practice with their surgical specialties facilitating proper

diagnosis and treatment of such patients. Such integration is crucial especially in Oral and

Maxillofacial surgery department and stomatology. ‘A number of potential problems have

continued to be identified that are related to dental care for patients with various cardiac

complications’ (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). This include sudden

death following cardiac arrest, infection, breathing difficulties, and drug side effects as well as

increased high blood pressure during treatment a case that will lead to increased blood loss and

anemia. For this reason, it is essential for the dental surgeons and specialists to understand the

DENTAL TREATMENT 15

proper diagnosis methods as well as be well informed on the suitable methods for administering

dental treatment for patients with cardiovascular complications.

As medical science advances and as the population ages, many individuals with complex

medical histories are now able to seek dental treatment in private dental facilities. As a result,

dentists must be ready to provide such patients with competent, efficient and safe dental care by

analyzing their current medications and their underlying medical conditions. This information

should be made available to the pharmacology of the dentistry medications and in the dentists’

knowledge of dental procedures. One of the commonly used procedures in dental clinic is the

injection of a local anesthetic solution. Due to availability of many individuals with

cardiovascular problems and pulmonary hypertension Budenz (2000) indicates that “dentists

should take patient complete medical history before administering any medication” (Budenz A,

2000). In addition to this, the dentists need to consult with the patient physician in order to

understand the current medication the patient is using. For this reason, a dentists before treating a

patient with a cardiovascular or hypertension problem should address two basic concerns;

medications being used by the patient which may interact with the used local anesthetic agent

and the existing cardiovascular or systemic disease that may be made worse by the used local

anesthetic

During my training, I appreciated the importance of medical history. Since most

cardiovascular diseases can be diagnosed from medical history, I therefore encourage all dentists

to take the patient history and carryout a thorough dental examination before providing any

dental treatment. In addition, the dentists should consult the patient physician and the patient

who has cardiac problem or hypertension should receive period dental checkups. As Burgess,

(2015) indicated, “the patients have a right to understand the type of dental procedure to be used

DENTAL TREATMENT 16

as well as the risk associated.” For this reason, the patient should be advice on some of the risks

involved and the expected outcomes.

According to Carlos and Bruno (2003), “local anesthetic agent especially when used at a

higher dose can adversely affect or exacerbate the cardiovascular disease.” When a patient with

any cardiovascular disease is provided with local anesthetic agent during a dental treatment, such

a patient is shown to suffer from cardiovascular manifestation including hypotension,

cardiovascular collapse, Bradycardia, resulting into cardiac arrest and eventually death.

According to Cruz-Pamplona in the dental Consideration for those with various heart diseases,

“drugs used by dental patients can result to oral manifestations such as burning mouth sensation,

Lichenoid reactions, Xerostomia, loss of taste sensation, bleeding, gingival hyperplasia and

extraoral manifestation” (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). Cruz arrived

at this conclusion after reviewing a total of 31 past literatures. For this reason, Cruz concluded

that dental surgeons must take into account certain aspects before managing a patient with

cardiovascular problem in order to avoid complications. A dentist needs to review the patient

complete medical history and consult his or her physician. If the patient is medically unstable,

the dentist need to defer such a patient until their condition is stable and their stability should be

confirmed by their physician.

Approximate 50 million individuals in America are undertaking antihypertensive

medications to lower their high blood pressure. For this reason, dental practitioners need to

ensure they have evaluated the patients’ status and measure their blood pressure at every visit to

ascertain that their blood pressure is in a stable level and to ensure no complication will result

after dental treatment due to exacerbation of blood pressure following the use of local anesthesia.

A major concern among dentists is whether a local anesthetic agent that has a vasoconstrictor

DENTAL TREATMENT 17

should be injected to a patient with hypertension. The rational approach to this dentistry concern

is to first understand the action of a vasoconstrictor. In dentistry, “a vasoconstrictor such as

epinephrine and levonordefrin delays the local anesthetic absorption to the systemic circulation”

(Budenz A, 2000). This is in order to reduce the risk of toxic reaction and increase the duration

of anesthesia. According to American Dental Association and American Heart Association, the

vasoconstrictor concentration available in a local anesthetic agent cannot trigger high blood

pressure as long as only the smallest effective agent dose is administered and as long as the agent

is injected slowly. However, if the patient has severe hypertension, it is important to delay the

dental treatment in order to allow the physician to control the patient blood pressure condition.

Another major concern among the dentists relate to adverse reaction which may result

following the interaction between the used antihypertensive medication and the local anesthetic

agent. This concern result following claim that nonselective beta-adrenergic drug may increase

high blood pressure. For patients using these antihypertensive drugs, administration of local

anesthetic containing vasoconstrictor may result to peripheral vasoconstriction which could lead

to increased blood pressure to dangerous levels.

Due to increased challenges in treating dental patients with cardiovascular disease and

pulmonary hypertension, there is a need for the dentists to adopt simple guidelines which will

prevent adverse reaction caused by vasoconstrictors or the local anesthetic during patient

treatment. Such guidelines include use of reducing the local anesthetic dose and use of

nonvasoconstrictor local anesthetics (Carlos and Bruno, 2003). In addition to this, a detailed

examination and analysis of the patient history may be effective at analyzing the patient

underlying condition and may facilitate the dental practitioner to determine the best medication

strategy which will prevent adverse reaction. To conclude this claim of fact, it is important for

DENTAL TREATMENT 18

dental patients with cardiac disease or pulmonary hypertension to receive dental treatment in a

hospital setting. This is in order to provide a suitable avenue for the dentists to follow the patient

dental outcome and to ensure immediate treatment in case of an emergence.

Method

A qualitative research was carried out where 20 dentist surgeons were subjected into a

questionnaire. Each participating dentist had to answer all the questions within the questionnaire

in order to understand some of the challenges they face when managing patients with various

cardiovascular diseases. The aim of the questionnaire was to evaluate some of the treatment

protocol that has been put in place to ensure that the cardiovascular compromised patients with

dental problems do not suffer from any form of morbidity or do not lose their lives following

infection or cardiovascular arrest (Burgess, 2015). In addition, the questionnaire seeks to identify

some of the emergency measures that have been put in place to ensure dental patients with any

underlying cardiovascular condition are immediately attended to and their situation brought into

normal state.

The qualitative research was carried out in a hospital setting and the investigator had no

control over the participants in the study. In addition, all the observations and dentists views

were recorded appropriately. All the interviews and questionnaires will be carried out for a

period of one month and patients who have been diagnosed with cardiovascular diseases will be

followed up for a period of two months after dental treatment to ensure there are no

complications after treatment. All the interview data will be processed and interpreted

accordingly.

DENTAL TREATMENT 19

Analysis

Cardiovascular complications have been shown to be the leading cause of dental

complications and increased morbidity and mortality following dental treatment. According to

the participants’ response, a dental care does not affect or compromise the patient’s health.

Analysis from the interview indicates that the first step to manage the patient with cardiovascular

complications is by obtaining their medical history. After this, the dentist must clearly

understand the patient’s underlying cardiovascular condition since each condition requires

different dental treatment regime (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). For

example, a local anesthetic could interact with pain medications that were administered before

the patient attended the dental clinic. Furthermore, the interview and questionnaires showed that

the dentists need to understand the complications which may occur following dental treatment

for a patient with a certain cardiovascular disease.

Cardiovascular compromised patients requiring dental treatment should also be managed

in a hospital setting in order to make it easy to manage emergency situations. From the

questionnaire, it is clear that examination of patients’ history should be extensive with the

physical assessment comprising of activities such as the assessment of patient’s general

appearance (eg, nails, skin, posture and weight), pulse rate, respiratory rate, blood pressure and

temperature as well as a thorough assessment of neck and head inspection. In a patient with an

additional problem that was not reflected within the patient history, the dentists should refer the

patient to the hospital for further medical evaluation. From the general view of all the dentists

subjected into the qualitative study, planning of the dental treatment for patients with

cardiovascular disease involves having a clear understanding of the patient’s underlying disease

and assessment of how the underlying cardiovascular disease can impact the patient’s physiology

DENTAL TREATMENT 20

and how that can respond to dental treatment and post-dental healing (Silvestre-Rangil, Silvestre

& Espin-Galvez, 2014). In addition, all the participants in the descriptive study agree that

description of necessary dental treatment to patient with cardiovascular condition is important in

reducing the incidences of mortality and morbidity following complications during dental

treatment.

“A good physician treats the disease; the best physician treats the patient” (Bliss,

1999).This quote by William Osler brings to mind the need to approach the treatment of diseases

with the main interest of the patient in mind as compared to the accomplishments that might

come with the achievements of successfully treating the disease.Achievements associated with

medical practitioners as a result of good records in the treatment of diseases include

recommendations, promotions among other things. Focusing on treating the patient however

other than the disease implies not considering such extrinsic rewards. It involves caring for the

patient and paying attention to their particular unique needs. The most satisfying rewards for a

medical practitioner should be intrinsic. In this case, one gains peace in knowing that they

prevented the death of an individual and possibly millions through research and experimentation

thus contributing to development of personal, satisfying traits such as self-confidence and

inquisitiveness (Bliss, 1999). In the administration of dental treatment for patients with cardiac

disease and pulmonary hypertension, special attention is given to a unique group of people.

Dental treatments may be for any person having dental issues. In this case, however, research

into the needs of cardiac and hypertension patients reveals the need to approach their treatment

as the treatment of the ‘patient’ and not just the ‘disease.'

The claims made above have been backed by some research items.An example is a report

on dental surgery in ant coagulated patients written by Michael Wahl. The report presents an

DENTAL TREATMENT 21

analysis of twelve documented cases of over bleeding as well as their treatment after dental

procedures. According to the report, there are significant dangers associated with performing the

oral operation on patients taking the anticoagulant drugs. Consequently, there have been

proposals to withdraw anticoagulant therapy for a period that allows the procedure to take place.

Results from the twelve documented cases, however, show that this is not necessarily the best

solution. The risk of performing the procedure while treatment still going on can however, be

minimized. This is possible by using local measures such as blood transfusion only if the dentist

is aware of the condition and ongoing treatment. Moreover, the Health Partners Research

Foundation got a grant from The Agency for Health Research and Quality that aimed at

improving the safety of dental care for patients with chronic diseases. Some of the problems

they listed as related to dental care as a result of heart problems included infections, difficulty

breathing, infective endocarditis and even death. Among the treatment recommendations made

included the monitoring of blood pressure to which treatment should be terminated in case of a

considerable rise in blood pressure as a result of fatigue and stress. For the patient, they

recommended good oral hygiene, monitoring of symptoms as well as informing dentists of

medical histories. These related literature help to highlight the importance of specializing

medical care for cardiac disease and pulmonary hypertension patients.

Creating awareness of the above issues is not adequate at an individual level for

managing treatment of the cases. It is not possible for greatawareness to be created when only a

few individuals are working on it. More research is necessary into the possibilities of

centralizing treatment. By making all treatments for this unique group of people gets offered at

one particular place, it may be possible to improve the quality of treatment. However, patients

still need to be informed of the implications of their conditions on medical care. I also feel that

DENTAL TREATMENT 22

more stakeholders need to be involved in creating awareness. Instead of just treating the

patients, each doctor can help by informing their patients what their treatment may imply for

dental procedures. It also helps to have awareness posters and adverts on hospital and dentist

rooms. Dentists can also help by not just inquiring about medical histories but also informing

patients of the reason for this inquiry. Patients who are not affected are then likely to share this

information with others who may or may not be affected thus creating awareness among a larger

group.

It appears that Osler was right about the need to treat the patient. In this case, we are not

just treating cardiac and pulmonary hypertension cases. We are also treating the patient by

making them aware of the dental implications of their treatment. This ensures that we maintain

the health and lives of patients to the maximum limit possible by limiting the risks to which they

are exposed.

Consideration regarding administration of dental treatment for patients with

cardiovascular complications

Cardiovascular disease represents major conditions that are seen in dental practice. These

conditions include ischemic heart disease and hypertension

Arterial hypertension

For a patient with arterial hypertension, antihypertensive drugs can lead to adverse effects

within the oral cavity. For example, diuretics drugs such as Thiazides can cause Xerostomia

while adrenergic blocking agents can induce Lichenoid reaction. Through the use of different

antihypertensive drugs, a patient can be presented with different oral manifestation such as

burning mouth sensation, gingival hyperplasia and loss of taste sensation. To effectively manage

DENTAL TREATMENT 23

such a patient’s dental issues, it is important first to consult the physician on the medication the

patient is using and the patient’s blood pressure should be measured and recorded before dental

treatment. If the patient’s blood pressure is relatively high, the treatment should be postponed

until when the blood pressure will be in the acceptable level. However, the prescription of

anxiolytic agents for a patient with fear (5 mg of diazepam 2 hours before appointment) may be

necessary before dental treatment (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). A

local aesthetic should be administered without the use of intravascular injection. In addition,

sudden changes in the body during dental treatment should be avoided. This is because body

changes may cause orthostatic hypertension due to the administered blood pressure lowering

drugs. In case of hypertensive emergency during dental treatment, 40 mg of flurosemide and 25

mg of captopril should be administered. In a hospital setting however, nitrites in physiological

saline should be used.

Ischemic heart disease

For a patient who is receiving antiplatelet or anticoagulant treatment, oral manifestation

may include gingival bleeding, petechiae and hematomas. In dental practice, a six month safety

period has been established before administering oral surgical process for a patient with ischemic

heart disease. However, emergency treatment can be provided but this should involve a

minimally invasive procedure. To ensure proper administration of dental treatment for patient

with ischemic heart disease, a dentist must first consult the patient’s physician so as to evaluate

the type of heart disease the patient is suffering from, the clinical complication, the time elapsed

since the onset of the condition, treatment being given to the patient and the severity of the heart

disease (Cruz-Pamplona, Jimenez-Soriano & Sarrion-Perez, 2010). Premedication should be

administered to an anxious patient using 5 mg diazepam so as to reduce stress and anxiety. The

DENTAL TREATMENT 24

visit should be brief, 30 minutes maximum and must be placed in the most comfortable position

so as to avoid orthostatic hypertension. For such a patient, it is important to monitor the patient’s

blood pressure during dental treatment and excessive local bleeding should be controlled.

Conclusion

Patients with various cardiovascular complications such as ischemic heart disease and

hypertension are faced with a number of complications when they attend the dental clinic. Such

patients have been shown to face a number of potential problems which include sudden death

resulting in arrthymia and cardiac arrest. Other problems facing these patients following dental

treatment include cerebrovascular accident, infection and drug side effects. Patients with various

cardiovascular diseases have been shown to manifest various oral problems such as bleeding and

dug related to Lichenoid and mucosal lesions. To effectively manage patients with these

problems once they visit the dental clinic, a dentist must first examine the patients’ medical

history and establish their underlying treatment and condition. This is important as it will

facilitate the dentist to organize dental treatment which will ensure better dental treatment

outcome.

Patients with cardiac disease and pulmonary hypertension ought to receive special dental

treatment. This is not an entirely new policy as it has applications in several health centers.

However, most people are not aware of the need for special treatments for this group of people.

Consequently, we need to create awareness of the need for special dental treatments for patients

with pulmonary hypertension and cardiac diseases. People with heart diseases, for instance, have

particular special needs when it comes to dental treatment. An example is a patient who seeks

dental care after having recently had a heart attack. This patient has been taking anticoagulants

DENTAL TREATMENT 25

as a result of the attack. During the oral surgery, there is excessive bleeding and the patient dies.

An analysis of this situation reveals that the excessive bleeding was greatly contributed to by the

blood thinning drugs. Furthermore, some high blood pressure drugs have been known to affect

the sense of taste in patients as well as lead to dry mouths. Strokes, on the other hand, may lead

to the impairment of the ability to produce adequate saliva. All these are problems that are likely

to face such unique dental patients and hence the need for creation of awareness and special

treatment.

Doctors should be made aware of any drugs cardiac and hypertensive patients are using

before treatment. It is also essential to contemplate the availability of oxygen and even blood at

the hospital in case of an emergency. This is also necessary for patients experiencing chest pain

(Wahl, 1998). Doctors can recommend detailed oral hygiene and drugs to solve the problem of

dry mouths caused by blood pressure drugs. These observations reveal the need to have dental

services for cardiac and hypertension patients centralized and centers made known to the public.

This is important in case the patient fails to communicate their unique needs to the dentist.

Alternatively, a policy should be developed for patient medical histories to be recorded in special

files that all doctors who ever get to treat the patient can gain access to. This is in case the

patient leaves out important details. Furthermore, dentists should always seek to know the

medical histories of their patients even without the records. In creating awareness, however,

patients need to note three important things they always need to tell their dentists. First, dentists

need to have a complete list of prescriptions in case of a heart condition. The names and

contacts of the doctor are also necessary incase the dentist needs to seek more information on the

patient’s case. Finally, feelings of nervousness are better shared with the dentist as they can help

alleviate the fears by explaining the procedures, important points and precautions (Wahl, 1998).

DENTAL TREATMENT 26

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