MANAGEMENT OF

CARDIAC AND
PEPTIC ULCER
PATIENT
WAJIHA SHEIKH.
CARDIOVASCULAR
DISEASES
Cardiovascular disease is
the leading cause of death
globally. It includes:
1. Hypertension
2. Heart failure
3. Cardiac arrhythmias
4. Infective endocarditis
5. Ischemic heart disease
 HYPERTENSION:
Hypertension is high blood pressure. Hypertension is defined as values
>140 mmHg systolic pressure and/or >90 mmHg diastolic pressure.
DENTAL MANAGEMENT:
1. A well-controlled hypertensive patients does not pose a risk in clinical practice.
2. The patient is to be instructed to take his or her medication as usual on
the day of dental treatment. Prior to such treatment, the patient blood
pressure should be recorded.
3. It is preferable for the visits to be brief and in the morning. The
prescription of anxiolytic agents may prove necessary in particularly
anxious patients (5-10 mg of diazepam the night before and1-2 hours before
the appointment) before dental treatment, or alternatively sedation with
nitrous oxide may be considered.
4. In the case of emergency dental visits, treatment should be conservative,
with the use of analgesics and antibiotics. NSAIDs should not be prescribed
or longer than this five-day period.
5. Patients with cardiovascular disease are at a greater risk of massive
adrenalin release secondary to deficient local anesthesia than of reaction to
the small amount of vasoconstrictor used in local anesthetics .
Nevertheless, vasoconstrictor use should be limited, taking care not to
exceed 0.04 mg
Heart failure
Heart failure (HF) is defined as the incapacity of the heart to function properly,
pumping insufficient blood towards the tissues and leading to fluid accumulation within
the lungs, liver and peripheral tissues.

Dental management:
1. Dental treatment is to be limited to patients who are in stable condition.
2. The patient should be placed in the semi-supine position in a chair, with control of
body movements (which should be slow), in order to avoid orthostatic hypotension.
3. In patients administered digitalis agents (digoxin, methyldigoxin), the
vasoconstrictor dose is to be limited to two anesthetic carpules, since this drug
combination can favor the appearance of arrhythmias.
4. Aspirin (acetylsalicylic acid) can lead to sodium and fluid retention, and therefore
should not be prescribed in patients with heart failure.
5. In the event of an emergency and after contacting the emergency service, the
patient should be placed seated with the legs lowered, and receiving nasal oxygen
at a rate of 4-6 liters/minute. Sublingual nitroglycerin tablets are indicated (0.4-0.8
mg), and the dose may be repeated every 5 or 10 minutes if blood pressure is
maintained.
CARDIAC
ARRHYTHMIA:
1. Anxiolytics can be used to lessen stress and
anxiety.
2. Although modern pacemakers are more resistant
to electromagnetic interferences, caution is required
when using electrical devices (eg ultrasound and
electric scalpels)
If arrhythmia develops during dental treatment, the
procedure should be suspended, oxygen is to be
provided, and the patient vital signs are to be
assessed. Sublingual nitrites are to be administered
in the event of chest pain. The patient should be
placed in the Trendelenburg position, with vagal
maneuvering where necessary.
INFECTIVE
ENDOCARDITIS:
Endocarditis is a life-threatening disease, although
it is relatively uncommon. Endocarditis usually
develops in individuals with underlying structural
cardiac defects who develop bacteremia with
organisms likely to cause endocarditis. Some
surgical and dental procedures and
instrumentations involving mucosal surfaces or
contaminated tissue cause transient bacteremia
that rarely persists for more than 15 minutes.
Blood-borne bacteria may lodge on damaged or
abnormal heart valves or on the endocardium or
the endothelium near anatomic defects, resulting
in bacterial endocarditis or endarteritis.
Streptococcus viridans (α-hemolytic streptococci) is
the most common cause of endocarditis following
dental or oral procedures.
INFECTIVE ENDOCARDITIS
Dental Management:
1. Individuals who are at risk for developing bacterial
endocarditisshould establish and maintain the best possible oral
health to reduce potential sources of bacterial seeding.
2. In general, antimicrobial prophylaxis is recommended for
procedures associated with significant bleeding from hard or soft
tissues, periodontal surgery, scaling, and professional teeth
cleaning. In such an event, data from experimental animal models
suggest that antimicrobial prophylaxis administered within 2 h
following the procedure will provide effective prophylaxis
ISCHEMIC HEART
DIEASE:
Ischemic heart disease is characterized by a
reduction (partial or total) in coronary blood flow.
In 90% of all cases, his occurs following thrombus
formation secondary to an atheroma plaque that
occludes the arterial lumen, though other factors
such as cold, physical exercise or stress can act as
coadjuvant factors or (less frequently) trigger the
event themselves. Chest pain (angina) occurs
when coronary occlusion is partial and no
myocardial necrosis is produced, while acute
myocardial infarction is observed when coronary
occlusion is total and necrosis is produced as a
result. In turn, sudden death may also occur,
generally as a result of arrhythmias.
Dental management:
1. In dental practice a minimum safety period of 6 months has been established before any oral
surgical procedure can be carried out . After this safety period, the treatment decision should be
established on the basis of the situation and medical condition of each individual patient. If
nitrates are used, the patient should bring them to each visit to the dental clinic, in case chest
pain develops.

2. In the case of very anxious patients, premedication can be administered to lessen anxiety
and stress (5-10 mg of diazepam the night before and 1-2 hours before treatment).

3. The patient should be placed in the position most comfortable for him or her (semi-supine),
and should get up carefully in order to avoid orthostatic hypotension. Depending on the patient,
blood pressure and pulsioxymetric monitoring may be required before and during dental
treatment.

4. If the patient is receiving anticoagulants, the international normalized ratio (INR) on the day
of treatment should be determined, and treatment should be provided within the recommended
limits (< 3.5), with local hemostasis if surgery is planned. If the patient is receiving antiplatelet
medication, excessive local bleeding is to be controlled.

5. The local hemostatic measures that can be used comprise bone wax , sutures, gelatin of
animal origin, regenerated oxidized cellulose , collagen, platelet rich plasma, thrombin, fibrin
sealants, electric or laser scalpels, antifibrinolytic agents such as tranexamic acid.
CONCLUSION
Cardiovascular disease is one of the most common disease in the
developed and developing countries as well. In most developing
countriesit is the most common cause of death followed by cancer and
cerebro vascular disease. It is therefore important for dental surgeons to
know the medical problems of each individual patient, the treatments
received, and the possibilities for dental treatment. In addition, dental
surgeons must be able to identify medical emergencies and adopt the
opportune measures to avoid them or treat them quickly and effectively.
PEPTIC ULCER :
• Peptic ulcer disease refers to a group of
ulcerative disorders of upper GI tract that
require acid and pepsin for formation.
• Ulcers differ from gastritis and erosion in
that they extend deeper into the
muscularis mucousa .
• Three common forms are :
• Helicobacter pylori associated
• NSAID induced
• Stress related mucosal damage.
Clinical presentation :
Abdominal pain is the most frequent symptom of peptic ulcer. The pain is epigastric
and describes as burning but can present as vague discomfort , abdominal fullness ,
or cramping.

A typical nocturnal pain may awaken patient from sleep especially between 12 AM
to 3 AM.

DENTAL MANAGEMENT:
- NaHCO3 mouthrinse to minimize dysgeusia due to acid reflu.
- Adequate restoration on affected teeth t prevent further damage.
- Topical fluoride application to ensure the optimal mineralization.
- Advise patient to intake adequate fluid .
- Patient may take H2 receptor antagonist.
- Minimize stress.
- Avoid using NAIDs
- maintain oral hygiene
- Untreated patients should be referred to a doctor.