Hypertension

Prof Salah Yassin

In adults, a sustained systolic blood pressure of 140 mm Hg or greater and/or a sustained

diastolic blood pressure of 90 mm Hg or greater is defined as hypertension.

The patients can experience symptomatic damage to several target organs, including kidneys,
heart, brain, and eyes.

“normal” blood pressure is defined as 120/80 mm Hg and introduces a new category of “pre -
hypertension” (systolic blood pressures ranging from 120 to 139 and diastolic pressures ranging from
80 to 89 mm Hg), which encompasses the previously designated categories of “normal” and
“borderline” hypertension.

This revision reflects the findings that health risks are increased with blood pressures higher
than 115/75 mm Hg and that lowering blood pressure in patients with what was formerly considered
“normal” or “borderline” blood pressure can result in decreased frequency of adverse vascular events
such as stroke and myocardial infarction (MI)

In children and adolescents, hypertension is defined as elevated blood pressure that persists
on repeated measurement at the 95th percentile or greater for age, height, and gender.

Management of the dental patient with hypertension poses several potentially significant
considerations. These include

1. identification of disease,
2. monitoring, stress and anxiety reduction,
3. prevention of drug interactions.
4. awareness and management of adverse drug side effects.

Diagnosis and treatment of hypertension were once based largely on diastolic blood
pressure; with growing recognition of the importance of systolic blood pressure, however, this is no
longer the case. Isolated systolic hypertension gradually increases with age such that among patients
older than 50 years of age, it is the most prevalent form of hypertension
 Systolic blood pressure continues to rise throughout life, but diastolic blood pressure rises
until around age 50 and then levels off or falls; as a result, after the age of 50, isolated systolic
hypertension becomes the more prevalent pattern

Etiology

1.primary (essential) hypertension About 90% of patients have no readily identifiable cause
for their disease, ..

2. Secondary hypertension .an underlying cause or condition may be identified.

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.

Pathophysiology and Complications

In primary hypertension, the basic underlying defect is a failure in the regulation of vascular
resistance. .

Control of vascular resistance is multifactorial, and abnormalities may exist in one or more
areas. Mechanisms of control include:

Neural reflexes.

2. Ongoing maintenance of sympathetic vasomotor tone

3. Effects mediated by: neurotransmitters such as norepinephrine, extracellular fluid, and sodium
stores; the renin-angiotensin-aldosterone pressor system; and locally active hormones and
substances such as prostaglandins, kinins, adenosine, and hydrogen ions (H+).

In isolated systolic hypertension, which commonly is seen in elderly persons, the underlying
problem is one of central arterial stiffness and loss of elasticity.

Pathophysiology and Complications

In primary 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 and other effects mediated by
neurotransmitters such as norepinephrine, extracellular fluid, and sodium stores; the renin-
 angiotensin-aldosterone pressor system; and locally active hormones and substances such as
prostaglandins, kinins, adenosine, and hydrogen ions (H +). In isolated systolic hypertension, which
commonly is seen in elderly persons, the underlying problem is one of central arterial stiffness and
loss of elasticity.

CLINICAL PRESENTATION
Signs and Symptoms
Hypertension may remain an asymptomatic disease for many years, with the only sign being
an elevated blood pressure.

Systolic pressure. Pressure at the peak of ventricular contraction.

The Diastolic pressure represents the total resting resistance in the arterial system after
passage of the pulsating force produced by contraction of the left ventricle.

pulse pressure The difference between diastolic and systolic pressures.

Mean arterial pressure is defined as the sum of the diastolic pressure plus one-third the pulse pressure

Labile hypertension is the term that was previously used to describe the status of a subgroup of
patients with wide variability in blood pressure readings; however, this term has fallen into disuse
because it is now recognized that variability in blood pressure is the norm rather than the exception.

white coat hypertension, which is defined as persistently elevated blood pressure only in the presence
of a health care worker but not elsewhere.6 In these patients, accurate blood pressure readings may
require self-measurement at home or 24-hour ambulatory monitoring.
Before the age of 50, hypertension typically is characterized by an elevation in both diastolic
and systolic pressures.

Isolated diastolic hypertension, defined as a systolic pressure of 140 or less and a diastolic
pressure of 90 or greater, is uncommon and most often is found in younger adults. Although the
prognostic significance of this condition remains unclear and controversial, it appears that it may
be relatively benign.15

Isolated systolic hypertension is defined as a systolic pressure of 140 or higher and a diastolic
blood pressure of 90 or less; it generally is found in older patients and constitutes an important risk
factor for cardiovascular disease.

Late signs and symptoms are related to involvement of various target organs, including
kidney, brain, heart, or eye
Laboratory Findings
1. twelve-lead electrocardiogram,
2. urinalysis,
3. blood glucose,
4. hematocrit,
5. serum potassium,
6. Creatinine, calcium, and lipid profile.

Medical management
The JNC 71 suggests that all people with hypertension— stages 1 and 2—should be treated.
The treatment goal for most patients with hypertension is to reduce blood pressure to less than 140/90
mm Hg. For hypertensive patients with diabetes or kidney disease, however, the goal is less than
130/80 mm Hg.

DENTAL MANAGEMENT
Medical Considerations
The first task of the dentist is to identify patients with hypertension, both diagnosed and
undiagnosed. A medical history, including the diagnosis of hypertension, how it is being treated,
identification of antihypertensive drugs, compliance status, presence of hypertension-associated
symptoms and signs, and level of stability of the disease, should be obtained

Patients also may be receiving treatment for complications of hypertensive disease, such as
congestive heart failure, cerebrovascular disease, MI, renal disease, peripheral vascular disease,
or diabetes mellitus.
 In addition to a medical history, all patients should undergo blood pressure measurement
(see Chapter 1). Blood pressure measurements should be routinely performed for all new
patients and at recall appointments.

When a patient with upper-level stage 2 blood pressure is receiving dental treatment,
consideration should be given to leaving the blood pressure cuff on the patient’s arm and
periodically checking the pressure during the appointment.

The primary concern in dental management of a patient with hypertension is that during the
course of treatment, a sudden, acute elevation in blood pressure might occur, potentially leading
to a serious outcome such as stroke or MI. Such acute elevations in blood pressure may 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 anesthetic, or from
absorption of a vasoconstrictor from the gingival retraction cord

Other concerns include potential drug interactions between the patient’s antihypertensive
medications and the drugs used in dental practice, and oral adverse effects that may be caused
by antihypertensive medications.

Two important questions should be answered before dental treatment is provided for a patient with
hypertension:
• What are the associated risks of treatment in this patient?
• At what level of blood pressure is treatment unsafe for the patient?

In the practice guidelines,19 the determination of risk includes the evaluation of three factors:
(1) the risk imposed by the patient’s cardiovascular disease, (2) the risk imposed by the surgery or
procedure, and (3) the risk imposed by the functional reserve or capacity of the patient.

The risk imposed by the presence of a specific cardiovascular condition or disease is

stratified into major, intermediate, and minor risk categories
 Risk imposed by the type of surgery (or procedure) also is stratified into high (>5% risk),
intermediate (<5% risk), and low (<1% risk) risk categories.

In general, risk is greatest with :

1. vascular or emergency surgery,

2. prolonged procedures,
3. procedures associated with excessive blood loss
4. general anesthesia

1.Head and neck surgery, which may include major oral and maxillofacial procedures and extensive
periodontal procedures, is classified as intermediate risk.

2. Superficial surgical procedures, which include minor oral and periodontal surgery and nonsurgical
dental procedures, are classified as low risk.

3.Thus, it would appear that the risk associated with most general, outpatient dental procedures is
very low.

The third factor involved in risk assessment is determination of the ability of the patient to perform
certain physical activities (functional capacity) and is defined in metabolic equivalents (METs) (see
Chapter 1). Perioperative cardiac risk is increased in patients who are unable to meet a 4-MET
demand during most normal daily activities, which is equivalent to climbing a flight of stairs.

For patients found to have asymptomatic blood pressure of 180/110 mm Hg or greater (uncontrolled
hypertension), elective dental care should be deferred, and a physician referral for evaluation and
treatment within 1 week is indicated. Patients with uncontrolled blood pressure associated with
symptoms such as headache, shortness of breath, or chest pain should be referred to a physician for
immediate evaluation. In patients with uncontrolled hypertension, certain problems such as pain,
infection, or bleeding may necessitate urgent dental treatment. In such instances, 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. The decision must always be made as to whether the benefit of proposed treatment outweighs
the potential risks.

Stress management is important for patients with hypertension to lessen the chances of
endogenous release of catecholamines during the dental visit.

1.Long or stressful appointments are best avoided.

2.Short morning appointments seem best tolerated.

3.If the patient becomes anxious or apprehensive during the visit, the appointment may be
terminated and rescheduled for another day.

4.Anxiety can be reduced for many patients by oral premedication with a short-acting benzodiazepine
such as triazolam , taken 1 hour before the start of the dental appointment.
5.Nitrous oxide plus oxygen for inhalation sedation is an excellent intraoperative anxiolytic for use in
patients with hypertension.

Care is indicated to ensure adequate oxygenation at all times, avoiding post diffusion hypoxia
at the termination of administration. Hypoxia is to be avoided because of the resultant rebound
elevation in blood pressure that may occur.

During treatment of a patient with upper-level stage 2 hypertension, it may be advisable to

leave the blood pressure cuff on the patient’s arm, and to periodically check the pressure. If the blood
pressure rises above 179/109 mm Hg, the procedure should be terminated, the patient referred to his
or her physician, and the appointment rescheduled.

Because many of the antihypertensive agents tend to produce orthostatic hypotension as a

side effect, rapid changes in chair position during dental treatment should be avoided.

Use of Vasoconstrictors. Concerns have emerged, however, that the use of local anesthetic
with a vasoconstrictor in a patient with hypertension could result in a potentially serious spike in
blood pressure. The cardiovascular response to conventional doses of injected epinephrine, both in
patients who are healthy and in those with hypertension, usually is of little clinical importance.

Thus, the existing evidence indicates that use of modest doses (one or two cartridges of 2%
lidocaine with 1 : 100,000 epinephrine) carries little clinical risk in patients with hypertension, the
benefits of its use far outweighing any potential problems. Use of more than this amount at one time
may be tolerated, but with increasing risk for adverse hemodynamic changes.

Levonordefrin should be avoided in patients with hypertension, however, because of its

comparative excessive α1 stimulation. The use of epinephrine generally is not advised in patients with
uncontrolled hypertension, in whom elective dental care should be deferred.

An additional concern when patients with hypertension are treated is the potential for
adverse drug interactions between vasoconstrictors and antihypertensive drugs—specifically, the
nonselective β-adrenergic blocking agents.

The basis for concern with use of nonselective β-adrenergic blocking agents (e.g.,
propranolol) is that the normal compensatory vasodilatation of skeletal muscle vasculature mediated
by β2 receptors is inhibited by these drugs, and injection of epinephrine, levonordefrin, or any other
pressor agent may result in uncompensated peripheral vasoconstriction because of unopposed
stimulation of α1 receptors. This vasoconstrictive effect could potentially cause a significant elevation
in blood pressure and a compensatory bradycardia

Also, erythromycin and clarithromycin can exacerbate the hypotensive effect of calcium
channel blockers. Anxiolytics and sedatives may be used for patients who take these antihypertensive
medications; however, the usual dosage may need to be reduced. The efficacy of antihypertensive
drugs may be decreased by the prolonged use of nonsteroidal antiinflammatory drugs—an interaction
that should be considered if these drugs are used for analgesia, although the use of nonsteroidal
antiinflammatory drugs for a few days is of little clinical importance

Treatment Planning Modifications

1.Patients with blood pressures less than 180/110 mm Hg can receive any indicated dental
treatment

2.elevated blood pressures (140/90 and above) should be encouraged to see their physician for
further investigation.

3. Elective dental procedures should be deferred for the patient who has uncontrolled
hypertension (blood pressure of 180/110 or higher).