Dental Management Considerations for the Patient with High Blood Pressure

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Blood Pressure
• The pressure exerted by the blood against the interior walls of the arterial system • Sounds produced by turbulent blood flow are called Korotkoff sounds, after the Russian physician who

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Korotkoff sounds: First appearance of sounds is the systolic pressure; the complete disappearance of sounds is the diastolic pressure.

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Blood Pressure and Cardiovascular Risk
• For individuals aged 40-70 years, each increment rise of 20 mm Hg in systolic BP or 10 mm Hg in diastolic BP doubles the risk of cardiovascular disease across the entire range from 115/75 to 185/115 mm Hg

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Major Cardiovascular Risk Factors
• • • • • • • • • • Hypertension Age (>55 ♂; > 65 ♀) Diabetes mellitus Elevated LDL (or total) cholesterol or low HDL cholesterol Estimated GFR < 60 mL/min Family history of premature CVD (men <age 55 or women aged <65) Microalbuminuria Obesity (BMI >30; weight in kilograms ÷ height in meters squared) Physical inactivity Tobacco usage, particularly cigarettes

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Causes of Hypertension
• 95%: cause undetermined (essential hypertension)

• 5%: identifiable and potentially correctable causes of hypertension – Chronic kidney disease – Coarctation of the aorta – Cushing syndrome; chronic steroid therapy – Drug induced or drug related – Obstructive uropathy – Pheochromocytoma – Primary aldosteronism – Renovascular disease – Thyroid or parathyroid disease – Sleep apnea
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Hypertension is an insidious disease and may remain completely asymptomatic for many years Measurement of blood pressure is the only means of detection

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Target Organ Damage
(occurs after many years of elevated blood pressure)
• Heart – Left ventricular hypertrophy – Angina/prior MI – Prior coronary revasculariza tion – Heart failure • Brain – Stroke or TIA – Dementia • Chronic kidney disease • Peripheral arterial disease • Retinopathy

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Classification of High Blood Pressure: JNC 7

BP
     

BP Classification Systolic BP

Diastolic

Normal <120 <80 Prehypertension 120-139 80-89 Stage 1 140-159 90-99 Stage 2 >160 >100 Based on 2 or more properly measured seated BP readings on each of 2 or more office visits
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Treatment of Hypertention
• Treatment Goal Blood Pressures:
– BP < 140/90 for most people – BP <130/80 for people with diabetes or renal disease

• • Life-style Modification

• Pharmacologic Management
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Lifestyle Modifications
Weight loss if overweight Adopt DASH (dietary approaches to stop hypertension) eating plan; fruits, vegetables, lowfat dairy, reduced cholesterol, saturated and total fat, adequate potassium and calcium Reduce sodium intake (<2.4 g/day) Regular aerobic physical activity Limit alcohol intake (< 1-2 drinks/day) Stop smoking

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Oral Antihypertensive Drugs

Decision to prescribe depends upon:
 

Degree of BP elevation Presence of target organ damage Presence of cardiovascular disease Risk factors

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Diuretics
• Thiazides (Diuril, hydrochlorthiazide, HCTZ) • Loop Diuretics (Lasix) • K-Sparing Diuretics (Midamor, Dyrenium) • Combination (Aldactazide, Dyazide)
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Beta Blockers

    

Cardioselective (β-1)
acebutol (Sectral) atenolol (Tenormin) betaxolol (Kerlone) bisoprolol (Zebeta) metoprolol (Lopressor) metoprolol extended release (Toprol XL)
 

Non-Selective (β1&2)
cartelol (Cartrol) labetalol (Trandate) nadolol (Corgard) penbutolol (Levatol) pindolol (Visken) propanolol (Inderal) propanolol longacting (Inderal LA) sotalol (Betapace) timolol (Blocadren) 15

 

 

  

Combined Alpha-Beta Blockers
Carvedilol (Coreg) Labetalol (Normodyne; Trandate)

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ACE (angiotensin converting enzyme) Inhibitors
• Benazepril (Lotensin) • Captopril (Capoten) • Enalapril (Vasotec) • Fosinopril (Monopril) • Lisinopril (Zestril; Prinivil)

• Moexipril (Univasc) • Perindopril (Aceon) • Quinipril (Accupril) • Ramipril (Altace) • Trandolapril (Mavik)
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Angiotensin Receptor Blockers (ARBs) Candesartan (Atacand) Eprosartan (Teveten) Irbesartan (Avapro) Losartan (Cozaar) Olmesartan (Benicar) Telmisartan (Micardis) Valsartan (Diovan)

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Calcium Channel Blockers
Amlodipine (Norvasc) Bepridil (Bepadin; Vascor) Diltiazem (Cardizem) Felodipine (Plendil) Isradipine (DyanCirc) Nicardipine (Cardene) Nifedipine (Procardia) Nimodipine (Nimotop) Verapamil (Calan; Isoptin)

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Alpha-1 Blockers
Doxazosin (Cardura) Prazosin (Minipress) Terazosin (Hytrin)

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Central Alpha-2 Agonists and Other Centrally Acting Drugs
• • • • • Clonidine (Catapres) Clonidine patch (Catapres-TTS) Methyldopa (Aldomet) Reserpine (generic) Guanfacine (Tenex)

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Direct Vasodilators
• Hydralazine (Apresoline) • Minoxidil (Loniten)

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Decisions
• • Elective dental treatment is permissible for patients with BP <180/110 (low risk) Encourage patient to see MD for evaluation if BP > 140/90 in untreated patient; explain the linear relationship of BP and CVD


• • • Encourage patient to see MD for evaluation if BP is not being controlled in known/medicated patients (target BP<140/90 or 130/80 in DM or renal disease)


• Defer elective dental treatment if BP is >180/110 and urge immediate referral


• If urgent dental treatment is necessary: 23

Stress Reduction Protocol
• • • • • Good patient rapport Minimize waiting time Short, morning appointments Ensure physical comfort If anxious or fearful:
– Oral sedation ( night before and/or 1 hour before appt) with pre, intra, & post-op vital signs and use of pulse oximeter – N2O/O2 sedation intra-operatively

• “Painless” injection technique (use topical, slow administration, ensure adequate anesthesia) • Post-op pain control • Evening phone call

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Options for Oral Sedation/Anxiolysis
• • • • • Triazolam (Halcion) 0.125-0.25 mg Oxazepam (Serax) 10-30 mg Lorazepam (Ativan) 2-3 mg Alprazolam (Xanax) 0.25-0.5 mg Diazepam (Valium) 2-10 mg Hydroxyzine (Vistaril) 50-100 mg Zolpidem (Ambien) 5-10 mg hs Zaleplon (Sonata) 5-10 mg hs


• • •


• •
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Use of Epinephrine in Local Anesthetics in Hypertensives
Numerous studies have demonstrated that 1 or 2 carpules with 1:100,000 epi cause a rise in plasma levels of epi but without significant cardiovascular effects In controlled hypertensives, or even in poorly controlled hypertensives, epinephrine can be used safely in modest amounts With uncontrolled BP > 180/110, use is somewhat controversial; modest use justified if it will provide improved pain control to allow required treatment

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Bader, JD, et al: A systematic review of cardiovascular effects of epinephrine on antihypertensive dental patients OOOO&E 2002;93:647-53 (Cited in JNC 7 Report)

• “The increased risk for adverse events among uncontrolled hypertensive patients was found to be low and the reported occurrence of adverse events in hypertensive patients associated with the use of

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“Potential” Adverse Drug Interactions with Epinephrine:
• Non-selective beta blockers

• (Epinephrine may be used cautiously, if needed, in modest amounts [.018-.036 mg])

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Other side-effects or interactions of antihypertensive drugs
• Orthostatic hypotension • NSAIDs (long term use) may interfere with antihypertensive effects due to interference with cyclooxygenase (COX) mediated prostaglandin formation • Short-term use of a few days is not clinically significant
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Oral Manifestations of Antihypertensives

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