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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 3
 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 Classification Systolic BP Diastolic
BP
 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 13
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)  Non-Selective (β-
 acebutol (Sectral) 1&2)
 atenolol (Tenormin)  cartelol (Cartrol)
 betaxolol (Kerlone)  labetalol
 bisoprolol (Zebeta) (Trandate)
 metoprolol  nadolol (Corgard)
(Lopressor)  penbutolol
 metoprolol (Levatol)
extended release  pindolol (Visken)
(Toprol XL)
 propanolol
(Inderal)
 propanolol long-
acting
 (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 • Moexipril
(Lotensin) (Univasc)
• Captopril (Capoten) • Perindopril
• Enalapril (Vasotec) (Aceon)
• Fosinopril • Quinipril
(Monopril) (Accupril)
• Lisinopril (Zestril; • Ramipril (Altace)
Prinivil) • 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:

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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 27
“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 cyclo-
oxygenase (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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