1. DENTAL MANAGEMENT OF HYPERTENSION

2. DENTAL MANAGEMENT OF HYPERTENSION
นทพ. มนันยา เลิศลักขณวงศ์

3. Hypertension Definition
A statement that a given arterial pressure is above normal requires a knowledge of the range of normality

4. Blood pressure blood pressure = CO x TPR
The pressure of circulating blood against the wall of blood vessels ; results form systole of the left ventricle of the heart
blood pressure = CO x TPR
Note : blood pressure is depended on cardiac output, blood volume, blood viscosity, vessel elasticity

5. Blood pressure
Adult blood pressure is considered normal at 120/80 where the first number is the systolic pressure and the second is diastolic pressure

6. Blood pressure Systolic pressure
the blood pressure (as measure by sphygmomanometer) during the contraction of the left ventricle of the heart
It presents the elasticity of aorta

7. Blood pressure Diastolic pressure
the blood pressure (as measure by sphygmomanometer) after the contraction of heart while the chambers of the heart refill with blood
Diastolic pressure presents the resistance of peripheral vessel ; arteriole

8. What is borderline hypertension?
Systolic pressure > 160 mmHg.
Or Diastolic pressure > 95 mmHg.
(WHO)
Systolic pressure > 140 mmHg.
Or Diastolic pressure > 90 mmHg.
(American heart association)
Diastolic pressure > 90 mmHg.
(JNC IV)
Systolic pressure > age mmHg.
(อรสา ไวคกุล และคณะ พ.ศ..2537)

9. Classification of blood pressure in adults (JNC v,1993)
Category
Systolic pressure
Diastolic pressure
Normal BP
< 130
< 85
High normal BP
85-89
Hypertension
Stage I
90-99
Stage II
Stage III
Stage IV
≥ 210
≥ 120

10. Classification of blood pressure in adults (JNC VII,2003)
Category
Systolic pressure
Diastolic pressure
Normal BP
< 120
<80
Prehypertension
80-89
Hypertension
Stage I
90-99
Stage II
≥160
≥100

11. Essential Hypertension
Benign or Idiopathic Hypertension
No recognizable cause can be found
Associate with
Genetic
Age>50
Obesity
Sex ชาย>หญิง
emotion

12. Secondary Hypertension
Hypertension that is secondary to another disease
Renal disease : renal artery disease , glomerulonephritis , post-transplant
Endocrine disease : Cushing’s syndrome , hypoaldosteronism , Acromegaly
Cerebral disease : Cerebral edema (from stroke, head injury, tumor)
Coarctation of aorta (hypertension in upper
half of body only)

13. Malignant hypertension
Severe hypertension that runs a rapid course and damages the inner linings of the blood vessels, the heart , spleen, kidneys and brain
Young adult patient
The most lethal form of hypertension
Patients may died form nephrosclerosis, Ischaemic damage of kidneys or renal failure

14. White- coat hypertension
Temporary rise in blood pressure in doctor’s office

15. Sign and symptom Symptom Suboccipital headaches Ringing ear
Blurred vision
Fatigability and loss of energy
Angina pectoris
Palpitation , nausea , vomiting

16. Sign and symptom Sign 1. blood pressure 2. Retinas 3. Heart & arteries
4. Pulses
5. Cerebrum
6. Endocrine status
7. Coarctation of aorta
8.Renal artery stenosis

17. Pathogenesis
Due to increased peripheral arteriolar resistance of unknown mechanism
Due to varying combinations of increased cardiac output and peripheral resistance caused by Epinephine and norepinephrine

18. Complication form high blood pressure
Acute hypertensive crisis
may occurred when diastolic pressure > 150 mmHg.
Acute pulmonary edema
Angina pectoris
Myocardial infarction
Left ventricle failure
Cerebral thrombosis
Hemorrhagic stroke
Renal failure

19. Note
prognosis
Hypertension that no treatment maybe died in 20 years form
70% Heart failure or coronary heart disease
15% Cerebral hemorrhage
10% Uremia
(Marcus A.Krupp,1982 )

20. Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP > / 90-95
BP > /
BP >200 / >115
Medical referral

21. Technique for recording the blood pressure
Seat and relax the patient.
Place sphygmomanometer cuff on right upper arm with about 3 cm of skin visible at the antecubital fossa.
Palpate radial pulse.
Inflate cuff to about 200 to 250 mmHg, or until the radial pulse is no longer palpable.

22. Technique for recording the blood pressure
5. Deflate cuff slowly while listening with stethoscope over the brachial artery over skin on inside of arm below cuff.
6. Record the systolic pressure as the pressure when the first tapping sound (Korotkoff sound) appear.
7. Deflate cuff further until the tapping sounds become muffled (diastolic pressure).
8. Repeat. Record blood pressure as systolic/diastolic pressure.

23. Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP > / 90-95
BP > /
BP >200 / >115
Medical referral

24. Unknown case Mild hypertension
Blood pressure / mmHg.
Recheck blood pressure after 5 to 10 min.
Routine dental management
Stress reduction protocol
Consider sedation (Tranquilizers, sedative, hypnotic drug)

25. Unknown case Moderate hypertension
Blood pressure / mmHg.
Recheck blood pressure after 5 to 10 min.
If still elevated , medical consultation before dental therapy
Routine or emergency dental therapy
Stress reduction protocol ,Consider sedation
Use of anesthetic agent w/o vasoconstrictor

26. Unknown case Severe hypertension
Blood pressure >200 / >115 mmHg.
Recheck blood pressure after 5 to 10 min.
Immediate medical consultation and referral
Emergency dental therapy with drug
Refer to hospital if immediate dental therapy indicated

27. Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP > / 90-95
BP > /
BP >200 / >115
Medical referral

28. Known case Blood pressure must be >130/ >90 mmHg. Management
Timing of dental appointments
Anxiety control
Orthostatic hypotension
Anesthesia
Other dental concerns

29. Timing of dental appointments
Afternoon appointments
Because the increase of blood pressure in hypertensive patient is associated with hours surrounding awakening that peaks by midmorning. Blood pressure tends to be less likely in the afternoon.
Morning appointments
Because of stress less
Short period

30. Orthostatic hypotension
May be a problem in patients using antihypertensive agent that reduce sympathetic outflow
Avoiding sudden postural changes
The patient should also be instructed to stay seated for short period until such time that adequate cerebral perfusion has occurred

31. Anxiety control
Dental typically causes a rise in blood pressure and may precipitate cardiac arrest or a cerebrovascular accident
Use of sedatives the night before a procedure may also be used.
Relative analgesia technique
Nitrous oxide can also reduce both systolic and diastolic pressure by up mmHg. (after 10 min)

32. Anesthesia
Local anesthesia
General anesthesia

33. Local anesthesia
Dental patient with hypertension are best treated under local anesthesia being sure that the anesthesia is complete so that on anxiety induced elevation of blood pressure occurs.

34. Local anesthesia
Data in regard to epinephrine-containing local anesthetics has consistently shown that blood pressure and heart rate are minimally affected by the typically low dose and short duration of drug use in dentistry

35. Local anesthesia
The use of epinephrine- containing anesthetics in patients with uncontrolled hypertension, and elective dental procedures are contraindicated

36. Local anesthesia
when dental extractions were preformed using local anesthetic with 1:100,000 epinephrine , systolic blood pressure was 4 mmHg higher for hypertensive subjects and no higher for normotensive subjects than when the same produres were performed using local anesthetic without epinephrine
(James D. Bader,et.al. For review,2002)

37. Local anesthesia
Heart rate was higher in patients receiving epinephrine than those not receiving epinephrine ( 6 bpm and 5.6bpm, respectively) ,
whereas diastolic blood pressure was lower (1.0and 4.7mmHg, respectively) for hypertensive and normotensive patients.
(James D. Bader,et.al. For review,2002)

38. Local anesthesia Use of aspirating syringes Avoid
: Intravenous , Intrarterial , intrabony and intraligamentary injection

39. General anesthesia
All antihypertensive drugs are potentiated by general anesthetic agents, especially barbiturates.
Tends to cause vasodilatation
A fall in blood pressure adequate perfusion of vital organs such as the kidneys, can therefore be fetal.

40. Other dental concerns
Antihypertensive drugs can often cause side effects in oral cavity
Xerostomia
Gingival over growth
Salivary gland swelling or pain
Lichenoid drug reactions
Erythema multiforme
Taste sense alteration
Paresthesia

41. Other dental concerns Bleeding disorder in patient taking aspirin
Bacterial endocarditic

42. Antihypertensive drugs
Classification of drug
Diuretics
Non selective alpha and beta adrenergic blockers
Beta-adrenergic blockers
Central acting adrenergic inhibitors
Peripheral acting adrenergic inhibitors
Vasodilators
Angiotensin - converting enzyme (ACE) inhibitor
Calcium channel blockers

44. DIURETICS
Thiazides, Chlorothiazide, Hydrothiazide
increase the excretion of Na+, Cl-, and water by interfering with the transport of sodium ions across the renal tubular epithelium
reduce blood pressure by decreasing cardiac output

45. Diuretics Side effects: xerostomia orthostatic hypotension
increased thirst
polyuria
dizziness
fatigue, weakness

46. DIURETICS Loop diuretics
Furosemide, ethacrynic acid, bumetanide
inhibit Na+ and Cl- reabsorption in the descending limbs of the loop of Henle
andenhance excretion of K+, Mg++, and Ca++.
reduce blood pressure by decreasing fluid volume and thereby reducing cardiac output

47. Diuretics Loop diuretics Side effects: xerostomia
lichenoid drug reaction
orthostatic hypotension
increased thirst
neutropenia
leukopenia
anemia
renal failure

48. DIURETICS Potassium-sparing agents
Amiloride, spironolactone (Aldactone) ,
triamterene
competitive antagonism of the endogenous mineralocorticoid aldestrone change pressure levels
reduce blood pressure by reducing total fluid volume

49. Diuretics Potassium-sparing agent Side effects: xerostomia
lichenoid drug reaction
increase thirst
gingival bleeding (spironolactone)

50. DIURETICS Carbonic anhydrase inhibitors
acetazolamide, dichlorphenamide, methazolamide
inhibition of the enzyme carbonic anhydrase in the proximal and distal segments of the renal tubule so as to allow diuresis
reduce blood pressure by decreasing fluid volume and thereby reducing cardiac output

51. Diuretics Carbonic anhydrase inhibitors Side effects
orthostatic hypotension
xerostomia
sore throat
nasal stuffiness
asthma
drowsiness
depression
fluid retention

52. NONSELECTIVE ALPHA AND BETA ADRENERGIC BLOCKERS
labetalol (Normodyne, Trandate)
competitive blocking of both α and β adrenergic receptors (greater affinity for β receptors) on vascular smooth muscle
decrease blood pressure by decreasing peripheral vascular resistance

53. NONSELECTIVE ALPHA- AND BETA- ADRENERGIC BLOCKERS
Side effects:
xerostomia
taste changes
orthostatic hypotension
bronchospasm
nausea, Gl upset
nervousness
anxiety, depression
parasthesia

54. BETA-ADRENERGIC BLOCKERS
Acebutolol, atenolol, metoprolol, nadolol, propranolol
blocking beta-1 receptors, reduces rate of SA node firing rate, slows the conduction through AV node, and reduces contractile strength and automaticity
reduce blood pressure by reducing cardiac output and increasing peripheral resistance

55. BETA-ADRENERGIC BLOCKERS
Side effects
orthostatic hypotension
xerostomia
sore throat
nasal stuffiness
asthma
drowsiness
depression
fluid retention

56. CENTRAL-ACTING ADNERNERGIC INHIBITORS
clonidine, methldopa, guanabenz, guanfacine
direct effect on alpha-2 adrenoceptor (sympathetic vasomotor center in CNS), which reduces impulses in sympathetic nervous system
reduces blood pressure by decreasing peripheral resistance and by decreasing plasma renin levels

57. CENTRAL-ACTING ADNERNERGIC INHIBITORS
Side effects:
xerostomia
taste changes
salivary pain or swelling
palpitation
ECG abnormalities
insomnia
anxiety
drowsiness

58. PERIPHERAL-ACTING ADRENERGIC INHIBITORS
Guanadrel, guanethidine, Rauwolfia alkaloids (e.g. reserpine)
inhibits the active uptake of catecholamines into storage vesicles of the nerve terminal
decrease blood pressure by decreasing sympathetic tone, and by decreasing peripheral vascular resistance

59. PERIPHERAL-ACTING ADRENERGIC INHIBITORS
Side effects:
xerostomia
orthostatic hypotension
bleeding
thrombocytopenia purpura
drowsiness, fatigue, weakness

60. VASODILATORS
hydralazine (Apresoline)
minoxidil (Loniten)
direct relaxation (vasodilation) of arteriolar smooth muscle
decrease blood pressure by decreasing peripheral vascular resistance

61. VASODILATORS Side effects: nasal congestion lupus-like syndromes
leukopenia

62. ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
captopril (Capoten)
enalapril (Vasotec)
lisinopril (Zestril, Prinivil)
inhibits ACE preventing conversion of angiotension I to angiotensin II, resulting in dilation of arteriole, venous vessels
decrease blood pressure by removing the vasoconstricting effect of ACE and thereby decreasing peripheral vascular resistance

63. ANGIOTENSIN-CONVERTING ENZYME (ACE) INHIBITORS
Side effects:
xerostomia
loss of taste
angiodema
glossitis
oral ulceration (Stevens-Johnson syndrome - captopril, enapril)
lichenoid drug reaction
renal insufficiency

64. Slow Channel Calcium-Entry Blocking Agents
verapamil (Calan, Isoptin)
dilitiazen
nifedipine (Adalat, Procadia)
nitrendipine
direct relaxation (vasodilation) of coronary and peripheral arteriolar smooth muscles by blocking Ca++ influx

65. Slow Channel Calcium-Entry Blocking Agents
Side effects:
gingival hyperplasia
xerostomia
orthostatic hypotension
light-headedness, nausea
edema
flushing, skin reactions
congestive heart failure

66. REFERENCES
C. Scully, R.A. Cowson ; MEDICAL PROBLEMS IN DENTISTRY , 3rd edition, Red wood books ,1993
Marcus A. Krupp; CURRENT MEDICAL DIAGNOSIS & TREATMENT, Lange medical publication , 1982
Gordon W. Pederson ;ORAL SURGERY, W. B. company , 1988
Paul B. Beeson, N. McDermott ; TEXT BOOK OF MEDICINE , 14th edition , W.B. Saunders company, 1975
T.J. Bayley, S.J. Leinster ; SYSTEMIC DISEASE FOR DENTAL STUDENTS , John Wright& Sons Ltd., 1984

67. REFERENCES
ประไพ ศิวโมกษธรรม ,โรคทางระบบ ปัญหาและการจัดการทางทันตกรรม 1 , พิมพ์ครั้งที่ 4 , ภาควิชาทันตวิทยา-พยาธิวิทยาช่องปาก คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่, พ.ศ. 2539
อรสา ไวคกุล และคณะ, การวางแผนการรักษาทางทันตกรรมในผู้ป่วยที่มีโรคทางระบบ , พิมพ์ครั้งที่ 1 , Text & Journal Publication Co.,Ltd, พ.ศ. 2537
เอกสารประกอบการสอน วิชา ศัลยศาสตร์ช่องปาก 1 , ภาควิชาศัลศาสตร์ช่องปาก คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่,พ.ศ. 2545
เอกสารประกอบการสอนกระบวนวิชา เภสัชวิทยา สำหรับนักศึกษาทันตแพทย์เล่ม 1 , ภาควิชาเภสัชวิทยา คณะแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ , พ.ศ. 2546

68. REFERENCES www.dent.ucla.edu/pic/members/hypertension/
James D. Bader et.al; A systemic review of cardiovascular effects of epinephrine on hypertensive dental patients, oral surg oral path oral radio endo ;2002,93:647-53

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