1. Case Presentation Done by: Lara Abbar Hadeel Al-Shareef Sarah Ghassal Raghad Bajaber Alia Al-Sayed Raghdah Mandili

2. Gender: Female Age: 39 yrs Nationality: Saudi Occupation: House-wife Marital status: Married Personal Data

3. “I have spacing between my lower anterior teeth and I feel that they continued to move and I have discolored tooth” Chief Complaint

4. Medical History: Hypertensive, she takes Capotin® and Coumadin® Family History: ---- Dental History: Multiple extracted teeth 10 yrs ago RCT in several teeth 5 yrs ago C/B in several teeth 5 yrs ago History

5. Vital Signs Pulse rate= 75 beat / min. Respiration= 18 breath / min. Blood pressure= 150/95 mmHg

6. ASA classification ASA I : A normal, healthy patient ASA II : A patient with mild systemic disease or a health risk factor ASA III : A patient with severe systemic disease that is not incapacitating ASA IV : A patient with severe systemic disease that is a constant threat to life ASA V : A moribund patient who is not expected to survive without the operation ASA VI : A declared brain-dead patient whose organs are being removed for donor purposes.

7. ASA II, because she has a controlled systemic disease- hypertension

8. Further data to need to know regarding this patient medical history? *If the hypertension is controlled or not. *If she is go to any doctor. *If yes what kind of drug she take. *Does she has any other disease, such as diabetes mellitus.

9. Hypertension is a chronic medical condition in which the blood pressure in the arteries is elevated.

10. Hypertension is divided into: Underlying etiology can be found and often treated. Examples of the conditions responsible for secondary hypertension are renal disease, endocrinologic changes, and neurogenic disorders. Occurs when no underlying pathologic abnormality can be found to explain the disease. Approximately 95% of all hypertensive patients have primary hypertension. Primary (essential) hypertension Secondary hypertension

11. CLASSIFICATIONSYSTOLIC BLOOD PRESSURE DIASTOLIC BLOOD PRESSURE TREATMENT MODIFICATION NORMAL120<80No change in treatment PRE- HYPERTENSIVE 120-13980-89*No change in treatment *No changes in dental treatment; monitor blood pressure (BP) at each appointment SATGE 1 HYPERTENSIVE 140-15990-99*Inform patient of findings. *Routine medical consultation/referral. *Monitor BP at each appointment. *No changes in dental treatment; minimize stress. SATGE 2 HYPERTENSIVE ≥160≥100

12. Stage-2 Hypertension Treatment Modification: * 4- If systolic BP is <180 and diastolic is <110: Perform selective dental care (routine exam, prophylaxis, restorative nonsurgical endodontics and periodontics); minimize stress. * 5- If systolic BP ≥180 or diastolic ≥100: Give immediate medical consultation/referral, and perform emergency dental care only (to alleviate pain bleeding, infection); minimize stress. 6- Consider stress reduction protocol. 7- Risk of providing emergency dental care must outweigh risk of possible hypertensive complications. 3- Monitor BP at each appointment. 2- Medical consultation/referral. 1- Inform the patient.

13. *Dental treatment for hypertensive patients is generally safe as long as stress is minimized. *If a patient is currently receiving antihypertensive therapy, consultation with the physician may be needed regarding the current medical status, medications, periodontal treatment plan, and patient management.

14. Morning dental appointments were once suggested for hypertensive patients. However, recent evidence indicates that BP generally increases around awakening and peaks at midmorning. Lower BP levels occur in the afternoon; therefore, afternoon dental appointments may be preferred

15. No routine periodontal treatment should be given to a patient who is hypertensive and not under medical management. (For patients with systolic BP greater than 180 mm Hg or diastolic BP greater than 110 mm Hg, treatment should be limited to emergency care until hypertension is controlled.

16. Analgesics are prescribed for pain and antibiotics for infection.

17. Acute infections may require surgical incision and drainage, although the surgical field should be limited because excessive bleeding may be seen with elevated BP.

18. Local anesthesia without epinephrine may be used for short procedures (<30 minutes). In a patient with hypertensive disease, however, it is important to minimize pain by providing profound local anesthesia to avoid an increase in endogenous epinephrine secretion. The smallest possible dose of epinephrine should be used.

19. Intra-ligamentary injection is generally contraindicated because hemodynamic changes are similar to intravascular injection. If the hypertensive patient exhibits anxiety, use of conscious sedation in conjunction with periodontal procedures may be warranted.

20. It is an oral drug and a member of a class of drugs called angiotensin converting enzyme (ACE) inhibitors. ACE inhibitors are used for treating high blood pressure, heart failure, and for preventing kidney failure due to high blood pressure and diabetes. Capoten

21. ACE inhibitors are medications that slow (inhibit) the activity of the enzyme ACE and decrease the production of angiotensin II. As a result, blood vessels enlarge or dilate, and blood pressure is reduced. The lower blood pressure makes it easier for the heart to pump blood and can improve the function of a failing heart.

22. Thank you