ISRN Hypertension
Volume 2013, Article ID 410740, 8 pages
http://dx.doi.org/10.5402/2013/410740
Review Article
Hypertensive Patients and Their Management in Dentistry
Copyright © 2013 Sanda Mihaela Popescu et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
cited.
Hypertension is a common disease encountered in dental setting. Its wide spreading, terrible consequences, and life-long treatment
require an attentive approach by dentists. Hypertension management in dental office includes disease recognition and correct
measurement, knowledge of its treatment and oral adverse effects, and risk assessment for dental treatment. Dentist role in screening
undiagnosed and undertreated hypertension is very important since this may lead to improved monitoring and treatment.
Table 1: Definitions and classification of office blood pressure levels (mmHg)a [1].
Table 2: JNC 7 classification of hypertension [2]. (i) age (over 55 years for men, over 65 years for women);
Classification SBP (mmHg) DBP (mmHg)
(ii) a family history of premature cardiovascular disease;
Normal <120 and <80 (iii) smoking;
Prehypertension 120–139 or 80–89 (iv) increased consumption of alcohol;
Stage I hypertension 140–159 or 90–99 (v) sedentariness;
Stage II hypertension ≥160 ≥100 (vi) cholesterol rich diet;
(vii) coexistence of other diseases (diabetes, obesity, dys-
lipidemia).
to high BP for a long time (chronic) without a known cause,
which is a very common form of hypertension, comprising
about 90–95% of all patients with hypertension [30]. 4. Treatment of Hypertension
Adopting a healthy lifestyle is critical in preventing high
2.2. Secondary Hypertension. Hypertension with an organic blood pressure. The major changes in lifestyle that could lead
cause, well established the following: to lower blood pressure include reduction of body weight
(i) renal (parenchyma or renal vascular) chronic py- in overweight or obese patients [34], adopting a low-salt
elonephritis, acute and chronic glomerulonephri- diet [35] rich in potassium and calcium [36], increasing
tis, polycystic kidney disease, renal vascular stenosis physical activity [37], moderate alcohol consumption [37],
or renal infarction, other severe kidney disease (arte- and smoking cessation [38].
riolar nephrosclerosis), renin-secreting tumors; Hypertension drug treatment depends on the stage of
(ii) endocrine: oral contraceptives, adrenal hyper func- hypertension, associated diseases, and risk factors present.
tion (Cushing’s syndrome, primary aldosteronism, Recommendations are based on the definition and classi-
congenital or hereditary adrenogenital syndrome), fication of hypertension adopted by The Seventh Report
pheochromocytoma, myxedema, acromegaly, thyroid of the Joint National Committee on Prevention, Detection,
and parathyroid hyper function; Evaluation and Treatment of High Blood Pressure in USA
in 2003 [2] and the conclusions of the European Society of
(iii) neurological: psychogenic “diencephalic syndrome,” Hypertension-European Society of Cardiology (ESH-ESC)
familiar dysautonomia (Riley-Day), polyneuritis in 2013 [1]. They determine the maximum physiological BP
(acute porphyria, lead poisoning), increased intracra- 130 mmHg systolic and 85 mmHg for diastolic, BP values
nial pressure; of 139 mmHg systolic, and 89 mmHg diastolic standing at
(iv) others: coarctation of the aorta, increased intravascu- the upper limit of normal. The recommendations emphasize
lar volume (transfusion excessive polycythemia vera), that the decision to drop blood pressure in a particular
polyarteritis, hypercalcemia, drugs (corticosteroids, patient should not rely solely on the values of BP but also on
cyclosporine), sleep apnea, pregnancy toxemia, acute total cardiovascular risk assessment of that patient (Table 3).
intermittent porphyria. From the meta-analysis by Staessen et al. [39] results show
that all classes of antihypertensive agents provide similar
3. Pathogenesis of Essential Hypertension cardiovascular protection. To prevent stroke and congestive
heart failure, feared complications of hypertension, the results
From family and epidemiological studies it is clear that of recently published trials suggest that some classes can
hypertension results from a complex interaction between achieve selective benefits.
genetic factors and the environment [31]. There are at least 50
known factors which increase blood pressure, among which 4.1. Total Cardiovascular Risk Assessment [1]. ESC-ESH
the most important are [32, 33]: report from June 2013 presents SCORE model of assessment
ISRN Hypertension 3
of total cardiovascular risk using charts and interactive site in the lung. One mechanism of increasing blood pressure
http://www.heartscore.org. The charts must be interpreted by angiotensin II is increasing renal sodium reabsorption,
considering physician’s knowledge and experience [1]. Risk producing vasoconstriction, and activating the sympathetic
may be higher than indicated in the charts in the following: nervous system [4]. But angiotensin II also increases the
production and secretion of aldosterone from the adrenal
(1) sedentary subjects and those with central obesity; the cortex, and aldosterone increases renal sodium reabsorp-
increased relative risk associated with overweight is tion [4]. Thus, the RAAS system increases blood pressure
greater in younger subjects than in older subjects; through increasing renal sodium reabsorption (which leads
(2) socially deprived individuals and those from ethnic to intravascular volume expansion) and vasoconstriction.
minorities; There are several classes of medications used to block
(3) subjects with elevated fasting glucose and/or an various components of the RAAS pathway, like 𝛽-Blockers
abnormal glucose tolerance test, who do not meet the such as propranolol, carvedilol, and metoprolol (decrease
diagnostic criteria for diabetes; renal renin release), direct renin inhibitor aliskiren (binds to
renin and thus prevents the conversion of angiotensinogen to
(4) individuals with increased triglycerides, fibrino- angiotensin I), ACE inhibitors (block ACE and prevent the
gen, apolipoprotein B, lipoprotein levels, and high- conversion of angiotensin I to angiotensin II), angiotensin II
sensitivity C-reactive protein; receptor blockers (prevent angiotensin II from binding to its
(5) individuals with a family history of premature CVD receptor, decreasing vasoconstriction and renal sodium reab-
(before the age of 55 years in men and 65 years in sorption), aldosterone-receptor blockers (such as spirono-
women). lactone and eplerenone), and other medications such as
amiloride (decrease the effects of aldosterone-mediated renal
Three important causes of primary hypertension are
sodium reabsorption) [4].
salt/volume overload, activation of the reninangiotensin-
Activation of the sympathetic nervous system (SNS) also
aldosterone system (RAAS), and activation of the sympa-
contributes to the development, maintenance, and progres-
thetic nervous system (Table 4) [4].
sion of hypertension. Therapies have been developed to target
Salt (sodium chloride) overload/volume overload is one
the central, peripheral, and renal SNS to improve the control
of the common causes of hypertension. Essential hyper-
of blood pressure: peripheral 𝛼1-receptor blockers (such
tension has been associated with high sodium intake in a
as terazosin and tamsulosin), central 𝛼2-agonist clonidine,
variety of scientific models, clinical studies and trials, and
and 𝛽-blockers, vasodilators such as minoxidil, nitrates, and
it is certified that decreasing the sodium intake ameliorates
hydralazine [2, 42].
this effect [40, 41]. High sodium intake increases blood
pressure by expanding intravascular volume and may have
direct neurohormonal effects on the cardiovascular system 5. Oral Manifestations Caused by the Adverse
[4, 41]. Thiazide diuretics are indicated by JNC 7 [2] as initial Effects of Antihypertensive Drugs
therapy for most patients with hypertension, either alone or
in combination with another class of antihypertensive agents. 5.1. Xerostomia. Many antihypertensives medications like
The “Renin Angiotensin Aldosterone System” (RAAS) ACEIs, thiazide diuretics, loop diuretics, and clonidine are
hormonal axis also contributes to hypertension in many associated with xerostomia [43–46]. Its likelihood increases
patients [4]. Renin, a hormone synthesized and released by with the number of concomitant medications. Xerostomia
the kidney in response to intravascular volume depletion and has many consequences, like decay, difficulty in chewing,
hyperkalemia, promotes the conversion of angiotensinogen swallowing, and speaking, candidiasis, and oral burning
(produced by the liver) to angiotensin I, which is converted to syndrome. Sometimes the feeling is transient and salivary
angiotensin II by the angiotensin-converting enzyme (ACE) function is adjusted by the patient itself. There are situations
4 ISRN Hypertension
Table 4: Mechanisms implicated in essential hypertension and antihypertensive medication classes targeting these mechanisms [4].
recommended dose of epinephrine in a patient with cardiac atenolol, amlodipine, and carteolol) as headaches, regional
risk is 0.04 mg, which is equal to that containing about two pain, renal failure, glaucoma, and congestive heart failure.
cartridges of LA with 1 : 100000 epinephrine or 4 cartridges
with 1 : 200000 epinephrine [60]. In patients with severe
disease it may be useful to measure BP and heart rate after 8. BP Measurement in the Dental Office
anesthetic injection. Slow administration and aspiration can
Patients with hypertension are at increased risk of developing
prevent undesirable reactions.
adverse effects in a dental office. Therefore, measuring BP
Other contraindications to vasoconstrictor AL include
severe uncontrolled hypertension, refractory arrhythmias, will be done in the dental office to every new patient, for
myocardial infarction or stroke by age less than 6 months, each visit. In patients with chronic systemic diseases, BP
unstable angina, coronary artery bypass graft under 3 measurement will be carried out during more complicated
months, congestive heart failure, and untreated hyperthy- dental interventions as oral surgery, restorative treatment
roidism [61]. complicated with longer sessions, placing dental implants,
Due to higher concentrations of epinephrine (almost 12 and periodontal surgery.
standard cartridges) in gingival retraction cords used for Routine measurement of BP may reduce the risk of
prosthetics impressions and its rapid uptake in circulation, cardiovascular events and acute complications during dental
the use of epinephrine for gingival eviction in patients with treatment, especially when conscious sedation or general
cardiovascular disease is contraindicated [4, 62]. anesthesia is required. BP monitoring is vital for emergency
treatment of patients who have side effects. Routine monitor-
ing of patients with known hypertension allows the dentist to
7. Hypertensive Patient Management in determine if BP is adequately controlled.
the Dental Office Best BP measurements were obtained with mercury
Initial evaluation of each patient with hypertension should sphygmomanometers, no longer available now. Aneroid
include detailed family history of cardiovascular disease and sphygmomanometers used should be checked every 6
other related diseases, history of hypertension, medications, months. Electronics BP units are simple to use but not as
duration and antihypertensive treatment history, severity of accurate as the aneroid.
disease, and its complications [61]. Before starting dental ESC-ESH guidelines in 2013 and JNC 7 in 2003 described
treatment, dentist has to assess the presence of hypertension, the method that health care professionals should use to obtain
to determine the presence of associated organ disease and office blood pressure measurements (Table 5) [1, 2].
determine dental treatment changes needed [63]. One must use a properly calibrated and validated blood
Particular attention should be given to accurate measure- pressure instrument. Patients should be seated in a chair
ment of BP in pregnant women, since pregnancy may alter the with their feet on the floor for 5 minutes in a quiet room.
patient BP values, more than 10% of pregnant women having Their arm should be supported at the level of the heart
clinically relevant hypertension [64]. BP monitoring is also and an appropriately sized blood pressure cuff (cuff bladder
necessary in diabetic patients, patients with autonomous dys- encircling at least 80% of the arm) must be used. Accurate
function, and elderly patients for which orthostatic hypoten- measurement of blood pressure is important to avoid over-
sion is a big problem [2]. The dentist must be familiar with diagnosis and underdiagnosis, as well as overtreatment and
other diseases treated with antihypertensive drugs (such as undertreatment, of hypertension [4].
6 ISRN Hypertension
Table 6: White-coat hypertension, the white-coat effect, and masked hypertension [4].
Diagnosis Office blood pressure Blood pressure outside office Associated with adverse outcomes
WCH Elevated Normal Controversial
WCE Elevated Normal or high Controversial
Masked hypertension Normal Elevated Yes
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