Hypertension

1. Effect on oral health 2. Medications effect on oral health 3. Effect on treatment/ management 4. Assess severity/ level of control 5. Symptoms of loss of control/ attack 6. Precautions in place 7. Drug prescription/ interactions 8. Antibiotic prophylaxis 9. Change in current medication 10. Effect on blood pressure/ bleeding 11. Allergies 12. Patient instruction 13. GP consultation 14. Effect of treatment on oral health General description Hypertension is an abnormal elevation in arterial pressure that can be fatal if sustained and untreated. People with hypertension may not display symptoms for many years but eventually can experience symptomatic damage to several target organs, including kidneys, heart, brain, and eyes. In adults, a sustained systolic blood pressure of 140mm Hg or greater and/or a sustained diastolic blood pressure of 90mm Hg or greater is defined as hypertension. Dentist is important in detecting and monitoring of hypertension, as patients who are receiving treatment for hypertension may not be adequately controlled because of poor compliance or inappropriate drug selection or dosing. Dentist cannot make a diagnosis of hypertension but should detect abnormal blood pressure measurements, which then become the basis for referral. The dental patient with hypertension poses several potentially significant management considerations. These include: identification of disease, monitoring, stress and anxiety reduction, prevention of drug interactions, and awareness and management of drug adverse effects. Etiology About 90% of patients have no identifiable cause for their disease, which is referred to as essential, primary or idiopathic hypertension. For the remaining 10% of patients, an underlying cause or condition may be identified; for these patients, the term secondary hypertension is applied. They most common cause of secondary hypertension is renal parenchymal disease, followed by renovascular disease and various adrenal disorders. Lifestyle can play an important role in the severity and progression of hypertension; obesity, excessive alcohol intake, excessive dietary sodium, and physical inactivity are significant contributing factors. Many patients with secondary hypertension may be cured with treatment of the underlying condition e.g. patients with secondary hypertension caused by

unilateral renal disease such as renal artery obstruction or pyelonephritis may be cured by surgical correction of the defect or removal of the diseased kidney. Pathophysiology and complications In sustained essential hypertension, the basic underlying defect is a failure in the regulation of vascular resistance. The pulsating force is modified by the degree of elasticity of the walls of larger arteries and the resistance of the arteriolar bed. Control of vascular resistance is multifactorial, and abnormalities may exist in one or more areas. Mechanisms of control include neural reflexes and ongoing maintenance of sympathetic vasomotor tone; neurotransmitters such as NA, extracellular fluid and sodium stores; the renin-angiotensinaldosterone pressor system; and locally active hormones and substances such as prostaglandins, kinins, adenosine, and hydrogen ions. Medical management Thiazide diuretics, angiotensin-converting enzyme inhibitors (ACEIs), angiotensive receptor blockers (ARBs), beta blockers (BBs), and calcium channel blockers (CCBs). Other drugs that are less frequently used include alpha 1 blockers, central alpha 2 agonists and other centrally acting drugs, and direct vasodilators. If lifestyle modification is ineffective at lowering blood pressure adequately, then thiazide diuretics are most often the first drugs of choice, give either alone or in combination with ACEIs, ARBs, BBs, or CCBs, depending on the degree of elevation of blood pressure. For stage 1 hypertension, single-drug therapy may be effective; however, for stage 2 hypertension, two-drug combinations are recommended. Additional drugs may be added as needed. Most people require more than one drug to effectively lower their blood pressure. The presence of certain comorbid conditions such as heart failure, post MI, diabetes, or kidney disease may be a compelling reason to select specific drugs or classes of drugs that have found beneficial in clinical trials. Effect on oral health o No oral complications associated with hypertension itself Medications effect on oral health o Antihypertensives, especially diuretics, may report dry mouth o Mercurial diuretics may cause oral lesions on an allergic or toxic basis o Lichenoid reactions reported with thiazides (diuretics), methyldopa, propranolol (beta blocker) and labetalol. o ACE inhibitors may cause neutropenia, resulting in delayed healing or gingival bleeding; may also cause nonallergic angioedema and burning mouth o All calcium channel blockers may cause gingival hyperplasia Effect on treatment/ management o The primary concern when one is providing dental treatment for a patient with hypertension is that during the course of treatment, the patient might experience an acute elevation in blood pressure that could lead to a serious outcome such as stroke or MI. This acute elevation in BP could

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result from the release of endogenous catecholamines in response to stress and anxiety, from injection of exogenous catecholamines in the form of vasoconstrictors in the local anaesthetic, or from absorption of a vasoconstrictor from the gingival retraction cord. Stress/ anxiety reduction to lessen the chances of endogenous release of catecholamines (e.g. adrenaline) during the appointment) Establishment of good rapport encourage patient to express and discuss their fears, concerns and questions about dental treatment Short, morning appointments seem best tolerated If patient becomes anxious or apprehensive during the appointment, the appointment may be terminated and rescheduled for another day Consider premedication with sedative/ anxiolytic Consider intraoperative use of nitrous oxide/ oxygen Obtain excellent local anaesthesia (OK to use adrenaline in small amounts) TG p. 112: If LA is used without a vasoconstrictor (e.g. adrenaline or felypressin), it is more likely that px will experience pain and therefore produce substantial amounts of endogenous adrenaline. Cautious use of adrenaline in local anaesthetic in patients taking nonselective beta blockers or peripheral adrenergic antagonists; use modest doses and take care to avoid inadvertent intravascular injections. The potential danger in administering a vasoconstrictor-containing LA to a patient with hypertension or other CVS disease lies in the potential to cause an acute increase in blood pressure or an arrhythmia. The CVS response to conventional doses of injected adrenaline in patients who are healthy and in those with hypertension is usually of little concern. Although large doses of adrenaline may cause a significant rise in blood pressure and heart rate, small doses such as those contained in one or two cartridges of lidocaine with 1:100,000 adrenaline may cause minimal pharmacologic change. This fact is due to a preponderance (superior in power or influence) of action among beta 2 receptors and a decrease in diastolic pressure; thus, mean arterial pressure is essentially unchanged with only a minimal increase in heart rate. Avoid the use of adrenaline-impregnated gingival retraction cord Consider periodic intraoperative blood pressure monitoring for patients with upper level stage 2 hypertension Slow position changes to prevent orthostatic hypotension (caused by some antihypertensive agents, especially alpha blockers, alpha/beta blockers, and diuretics) allow patients time to adjust to the change in posture, and physically support them while slowly getting out of the chair and obtain good balance and stability; if they complain of dizziness or lightheadedness, they should sit back down until they recover equilibrium. These drugs may also potentiate the actions of anxiolytic and sedative drugs. Reduce their dosage. Topical vasoconstrictors generally should not be used for local hemostasis in patients with hypertension. When performing crown and bridge procedures for patients with hypertension, the dentist should avoid using gingival retraction cord that contains adrenaline because these cords contain highly concentrated adrenaline, which can be quickly absorbed through the gingival sulcular tissues, resulting in tachycardia

and elevated blood pressure. Use alternative hemostatic agents with minimal CVS side effects e.g. Hemodent aluminum chloride is the active ingredient. Assess severity/ level of control o Medical history o When were they diagnosed o How is it being treated o Identification of antihypertensive drugs o Compliance of patient o Presence of symptoms associated with hypertension o Level of stability of the disease o Blood pressure measurement routinely performed for all new patients and at recall appointments; more frequent measurements are indicated for patients who are not compliant with treatment, who are poorly controlled, or who have comorbid conditions such as heart failure, previous MI, or stroke. Symptoms of loss of control/ attack EARLY o Elevated blood pressure readings o Narrowing and sclerosis of retinal arterioles o Headache o Dizziness o Tinnitus ADVANCED o Rupture and haemorrhage of retinal arterioles o Papilledema o Left ventricular hypertrophy o Proteinuria o Congestive heart failure o Angina pectoris o Renal failure o Dementia o Encephalopathy Precautions in place o Patients with uncontrolled hypertension elective dental care should be deferred and patient referred to a physician as soon as possible for evaluation and treatment o Patients with elevated blood pressure and symptoms such as headache, shortness of breath, chest pain, nosebleeds, or severe anxiety (severe hypertension) may require more urgent medical attention o In patients with uncontrolled or severe hypertension, the need for urgent dental treatment (pain, infection or bleeding) may necessitate treatment. In this instance the patient should be managed in consultation with the physician, and measures such as intraoperative blood pressure

monitoring, electrocardiogram monitoring, establishment of an intravenous line, and sedation may be used. o Nitrous oxide plus oxygen inhalation sedation is an excellent intraoperative anxiolytic for patients with hypertension o Care should be taken to ensure adequate oxygenation at all times, especially at the termination of administration; hypoxia is to be avoided because of the resultant elevation in blood pressure that may occur o When patients with upper level stage 2 hypertension are treated, it may be advisable to leave the blood pressure cuff on the patients arm, and to periodically check the pressure during treatment. If the blood pressure rises above 179/109, the appointment should be terminated and the patient rescheduled. Drug prescription/ interactions o Check if patient is also taking antiplatelet/ anticoagulants o NSAIDs should be used with caution in patients with hypertension as they can cause renal impairment o Risk of renal impairment is increased if a patient is taking an NSAID in combination with a diuretic plus an angiotensin converting enzyme inhibitor (e.g. perindopril) or an angiotensin II receptor blocker (e.g. candesartan); the end result of concurrent use of these three drug classes may be renal failure (TG p. 142) o Potential for adverse drug reactions between vasoconstrictors and antihypertensive drugs, specifically, the adrenergic blocking agents. The basis for concern with nonselective beta-adrenergic blocking agents (e.g. propranolol beta blocker) is that the normal compensatory vasodilatation of skeletal muscle vasculature mediated by beta 2 receptors is inhibited by these drugs, and injection of adrenaline or any other pressor agent may result in uncompensated peripheral vasoconstriction because of unopposed stimulation of alpha 1 receptors. This may cause a significant elevation in blood pressure and a compensatory bradycardia. Adverse reactions are less likely to occur in patients who take cardioselective beta blockers. See Little page. 45 for explanation of alpha and beta receptors. Although the potential exists for adverse interactions between vasoconstrictors and the nonselective beta blockers or peripheral adrenergic antagonists, available reports and clinical experience suggest that adrenaline in small doses of one or two cartridges containing 1:100 000 adrenaline can be used safely in most patients. o Local anaesthetics clinically have no significant hypertensive effects Effect on blood pressure o Severe longstanding dental pain can increase hypertension, so appropriate dental treatment should be instituted promptly (Therapeutic Guidelines) o Severe anxiety associated with dental phobia may increase blood pressure consider sedatives o Local anaesthetics clinically have no significant hypertensive effects