Hypertension High blood pressure (HBP) or hypertension means high pressure (tension) in the arteries.

Arteries are vessels that carry blood from the pumping heart to all the tissues and organs of the body. High blood pressure does not mean excessive emotional tension, although emotional tension and stress can temporarily increase blood pressure. Normal blood pressure is below 120/80; blood pressure between 120/80 and 139/89 is called "pre-hypertension", and a blood pressure of 140/90 or above is considered high. The top number, the systolic blood pressure, corresponds to the pressure in the arteries as the heart contracts and pumps blood forward into the arteries. The bottom number, the diastolic pressure, represents the pressure in the arteries as the heart relaxes after the contraction. The diastolic pressure reflects the lowest pressure to which the arteries are exposed. An elevation of the systolic and/or diastolic blood pressure increases the risk of developing heart (cardiac) disease, kidney (renal) disease, hardening of the arteries (atherosclerosis or arteriosclerosis), eye damage, and stroke (brain damage). These complications of hypertension are often referred to as end-organ damage because damage to these organs is the end result of chronic (long duration) high blood pressure. For that reason, the diagnosis of high blood pressure is important so efforts can be made to normalize blood pressure and prevent complications. It was previously thought that rises in diastolic blood pressure were a more important risk factor than systolic elevations, but it is now known that in people 50 years or older systolic hypertension represents a greater risk. The American Heart Association estimates high blood pressure affects approximately one in three adults in the United States - 73 million people. High blood pressure is also estimated to affect about two million American teens and children, and the Journal of the American Medical Association reports that many are under-diagnosed. Hypertension is clearly a major public health problem.

a pressure gauge. avoid eating. the pressure at which the pulsation finally stops is the diastolic pressure (the bottom number). and caffeine intake. and the pressure of the cuff on the arm and artery is gradually released. The pressure at which the practitioner first hears a pulsation from the artery is the systolic pressure (the top number). For at least one hour before blood pressure is taken. a health practitioner listens with a stethoscope over the artery at the front of the elbow. strenuous exercise (which can lower blood pressure). The arm is then extended at the side of the body at the level of the heart. smoking. such as in patients with long duration (chronic) kidney diseases that spill (lose) protein into the urine (proteinuria). blood pressure readings lower than 140/90 may be a more appropriate normal cut-off level. in certain situations. and a manometer measures pressure. so it is important to standardize the environment when blood pressure is measured. The instrument measures the blood pressure in units called millimeters of mercury (mm Hg). As the cuff pressure decreases further. For example. (Sphygmo is Greek for pulse. and a rubber cuff. For some people. Other stresses may alter the blood pressure and need to be considered when blood pressure is measured. Individuals with so-called pre-hypertension (defined as a blood pressure between 120/80 and 139/89) may benefit from lowering of blood pressure by life style modification and possibly medication especially if there are other risk factors for end-organ damage such as diabetes or kidney disease (life style changes are discussed below). Defining High Blood Pressure Blood pressure can be affected by several factors.) The blood pressure cuff consists of an air pump. the blood pressure is ideally .Measuring Blood Pressure The blood pressure usually is measured with a small. The cuff is placed around the upper arm and inflated with an air pump to a pressure that blocks the flow of blood in the main artery (brachial artery) that travels through the arm. As the pressure in the cuff decreases. portable instrument called a blood pressure cuff (sphygmomanometer).

especially when associated with an elevated diastolic pressure (over 90). and death from heart disease or a stroke. African Americans. as in isolated systolic hypertension. or even lower. Borderline high blood pressure Borderline hypertension is defined as mildly elevated blood pressure higher than 140/90 mm Hg at some times. statistical analysis reveals that beginning at a blood pressure of 115/75 the risk of cardiovascular disease doubles with each increase in blood pressure of 20/10. In addition. Clinical studies in patients with isolated systolic hypertension have indicated that a reduction in systolic blood pressure by at least 20 mm to a level below 160 mm Hg reduces these increased risks. Patients with diabetes (diabetes mellitus) may also benefit from blood pressure that is maintained at a level lower than 130/80. patients with borderline hypertension need to have their blood pressure taken on several occasions and their end-organ damage assessed in order to establish whether their hypertension is significant. and lower than that at other times. A systolic blood pressure that is persistently higher than 140 mm Hg is usually considered elevated. An elevation of the systolic pressure without an elevation of the diastolic pressure. a heart attack (myocardial infarction). who have an increased risk for developing the complications of hypertension. The pulse pressure is the difference between the systolic and diastolic blood pressures. People with borderline hypertension may have a tendency as they get older to develop more sustained or higher elevations of blood pressure. a stroke (brain damage). a high pulse pressure is now considered an important precursor or indicator of health problems and potential end-organ damage. Isolated systolic hypertension. Therefore. The purpose of reducing the blood pressure to this level in these patients is to slow the progression of kidney damage. Once considered to be harmless. therefore. As in the case of white coat hypertension. is defined as a systolic pressure that is above 140 mm Hg with a diastolic pressure that still is below 90. Isolated systolic hypertension is associated with a two to four times increased future risk of an enlarged heart. In line with the thinking that the risk of end-organ damage from high blood pressure represents a continuum. increases the pulse pressure. Isolated systolic high blood pressure Remember that the systolic blood pressure is the top number in the blood pressure reading and represents the pressure in the arteries as the heart contracts and pumps blood into the arteries. and what the goals of treatment should be.kept at 130/80. They have a modestly increased risk of developing heart-related (cardiovascular) disease. Stiffening of the arteries contributes to this widening of the pulse pressure. This disorder primarily affects older people and is characterized by an increased (wide) pulse pressure. This type of analysis has led to an ongoing "rethinking" in regard to who should be treated for hypertension. even if the hypertension does not . may decrease this risk by reducing their systolic blood pressure to less than 135 and the diastolic blood pressure to 80 mm Hg or less. however.

African American background.8 grams daily. If. (Genes are tiny portions of chromosomes that produce the proteins that determine the characteristics of individuals. the blood pressure becomes persistently higher than 140/ 90 mm Hg. during the follow-up of a patient with borderline hypertension. (Secondary hypertension is discussed further in a separate section later. which accounts for 5% of hypertension.8 grams of salt to replace the average amount lost daily through perspiration and to achieve a diet that provides sufficient amounts of other essential nutrients. that is. certain unusual genetic disorders affecting the hormones of the adrenal glands may lead to hypertension. the incidence of high blood pressure is greater among African Americans than among Caucasians or Asians. there are several factors whose combined effects produce hypertension. yet persistently above 85) treatment may be started in certain circumstances. Even if the diastolic pressure remains at a borderline level (usually under 90 mm Hg. certain associations have been recognized in people with essential hypertension. in the United States. The vast majority of patients with essential hypertension have in common a particular abnormality of the arteries: an increased resistance (stiffness or lack of elasticity) in the tiny . This system helps to regulate blood pressure by controlling salt balance and the tone (state of elasticity) of the arteries. people with borderline hypertension should have continuing follow-up of their blood pressure and monitoring for the complications of hypertension. in individuals who have one or two parents with hypertension. and excess salt may be involved in the hypertension that is associated with advancing age.) Essential hypertension affects approximately 72 million Americans. Also. an anti-hypertensive medication is usually started. yet its basic causes or underlying defects are not always known. the genes for hypertension have not yet been identified. Genetic factors are thought to play a prominent role in the development of essential hypertension. Nevertheless. However. Approximately 30% of cases of essential hypertension are attributable to genetic factors. and kidney failure (renal insufficiency). The Institute of Medicine of the National Academies recommends healthy 19 to 50-year-old adults consume only 3. The cause of essential hypertension is multifactorial.) The current research in this area is focused on the genetic factors that affect the renin-angiotensin-aldosterone system. high blood pressure is twice as common as in the general population. Essential hypertension is a far more common condition and accounts for 95% of hypertension. For example. exceeding 5. the high blood pressure is secondary to (caused by) a specific abnormality in one of the organs or systems of the body. obesity.appear to be significant initially. In secondary hypertension. Causes of High Blood Pressure Two forms of high blood pressure have been described: essential (or primary) hypertension and secondary hypertension. Salt intake may be a particularly important factor in relation to essential hypertension in several situations. For example. hereditary (genetic) susceptibility. Rarely. essential hypertension develops only in groups or societies that have a fairly high intake of salt.

ultrasonographic (sound wave) imaging. which results in high blood pressure. the narrowed renal artery impairs the circulation of blood to the affected kidney. or aortic artery. the narrowing is caused by a thickening of the muscular wall of the arteries going to the kidney (fibromuscular hyperplasia). if the ultrasonic assessment indicates a high resistive index within the kidney (high resistance to blood flow). obesity. In younger individuals. Renal hypertension is usually first suspected when high blood pressure is found in a young individual or a new onset of high blood pressure is discovered in an older person. adrenal gland. However. This type of secondary hypertension is called renal hypertension because it is caused by a problem in the kidneys. These hormones. the narrowing generally is due to hard. First. cause a constriction and increased stiffness (resistance) in the peripheral arteries throughout the body. which returns the blood to the heart and lungs. This deprivation of blood then stimulates the kidney to produce the hormones. In older individuals. The purpose of these tests is to determine whether there is a restricted blood flow to the kidney and whether angioplasty (removal of the restriction in the renal arteries) is likely to be beneficial. usually women. fat-containing (atherosclerotic) plaques that are blocking the renal artery. angioplasty may not improve the blood pressure because chronic damage in the kidney from long-standing hypertension already exists.arteries that are most distant from the heart (peripheral arteries or arterioles). overuse of salt. If any of these tests are abnormal or the . renin and angiotensin. lack of exercise. The arterioles are connected by capillaries in the tissues to the veins (the venous system). and aging. Yet. The arterioles supply oxygen-containing blood and nutrients to all of the tissues of the body. Renal (kidney) hypertension Diseases of the kidneys can cause secondary hypertension. This means that the hypertension in these individuals is secondary to (caused by) a specific disorder of a particular organ or blood vessel. Causes of Secondary High Blood Pressure As mentioned previously. along with aldosterone from the adrenal gland. One important cause of renal hypertension is narrowing (stenosis) of the artery that supplies blood to the kidneys (renal artery). 5% of people with hypertension have what is called secondary hypertension. or magnetic resonance imaging (MRI) of the renal arteries. this increased peripheral arteriolar stiffness is present in those individuals whose essential hypertension is associated with genetic factors. such as the kidney. Just what makes the peripheral arteries become stiff is not known. Inflammation also may play a role in hypertension since a predictor of the development of hypertension is the presence of an elevated C reactive protein level (a blood test marker of inflammation) in some individuals. Screening for renal artery narrowing then may include renal isotope (radioactive) imaging.

kidney failure. Therefore. Symptoms of High Blood Pressure Uncomplicated high blood pressure usually occurs without any symptoms (silently) and so hypertension has been labeled "the silent killer. The presence of symptoms can be a good thing in that they can prompt people to consult a doctor for treatment and make them more compliant in taking their medications. It is important to remember that not only can kidney disease cause hypertension. Any of the other types of chronic kidney disease that reduces the function of the kidneys can also cause hypertension due to hormonal disturbances and/or retention of salt. Management In Clinical Dental Situations Dentists have a unique opportunity to detect cases of hypertension since patient visits at routine intervals are encouraged. shortness of breath. Angiography is the ultimate test to actually visualize the narrowed renal artery. salivary gland swelling or pain. gingival overgrowth. stroke. including appropriate referrals. such as: y y y xerostomia. a person visits or is brought to the doctor or an emergency room with a heart attack. or even decades. . however. however. There are no recognized oral manifestations of hypertension but antihypertensive drugs can often cause side-effects. but hypertension can also cause kidney disease. dizziness. and blurred vision. all patients with high blood pressure should be evaluated for the presence of kidney disease so they can be treated appropriately.doctor's suspicion of renal artery narrowing is high enough." It is called this because the disease can progress to finally develop any one or more of the several potentially fatal complications of hypertension such as heart attacks or strokes. may experience symptoms such as headache. a person's first contact with a physician may be after significant damage to the end-organs has occurred. This happens when there are no symptoms. Uncomplicated hypertension may be present and remain unnoticed for many years. renal angiography (an X-ray study in which dye is injected into the renal artery) is done. In many cases. Some people with uncomplicated hypertension. Often. or impaired vision (due to damage to the back part of the retina). It is a professional responsibility of a dental clinician to inform the patient of their hypertensive state and to offer medical advice. Greater public awareness and frequent blood pressure screening may help to identify patients with undiagnosed high blood pressure before significant complications have developed. and those affected fail to undergo periodic blood pressure screening.

. intrarterial. B. A fall in blood pressure below the critical level needed for adequate perfusion of vital organs such as the kidneys. "the benefits of the small doses of epinephrine used in dentistry. intraligamentary and intrabony injections. according to numerous clinical studies. especially barbiturates. 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 the drug use in dentistry. The use of vasoconstrictors such as epinephrine in local anesthetic agents is known to have negligible influences on blood pressure in hypertensive patients. Hypokalemia as a result of diuretics may be associated with arrhythmias. Nonetheless. interactions and adverse effects of the antihypertensive medications. but in the hypertensive person with vascular disease there is greater risk as the tissues have become adapted to a raised blood pressure which is needed to overcome the resistance of the vessels and maintain adequate perfusion. the use of epinephrine-containing anesthetics in patients with uncontrolled hypertension.y y y y lichenoid drug reactions. Some inhalant anesthetics (halothane. Local Anesthesia Dental patients with hypertension are best treated under local anesthesia being sure that the anesthesia is complete so that no anxiety induced elevation of blood pressure occurs. taste sense alteration. when administered properly. Dental clinician must focus on the actions. erythema multiforme. and elective dental procedures are contraindicated. A severely reduced blood supply to vital organs can be dangerous in healthy individuals. General Anesthesia All antihypertensive drugs are potentiated by general anesthetic agents. and paresthesia. both in healthy and those with existing cardiovascular conditions.far outweigh the cardiovascular disadvantages" The use of aspirating syringes in local anesthetics is imperative to avoid intravenous. ANESTHESIA A. which could potentially precipitate further anxiety and thus rise in pressure and possible arrhythmias. as well as the overall management of blood pressure of the patient in the dental chair. can therefore be fatal. According to Muzyka & Glick (JADA 1997). General anesthesia tends to cause vasodilation. and isoflurane) are similar in action to calcium slow channel antagonists and so reduce blood pressure significantly. 1. enfluane.

Preoperative reassurance and oral sedation may help in alleviating anxiety related rise in pressure. after approximately 10 minutes of use. TIMING OF DENTAL APPOINTMENTS The increase of blood pressure in hypertensive patient is associated with the hours surrounding awakening that peaks by midmorning. Use of sedatives the night before a procedure may also be used. ORTHOSTATIC HYPOTENSION Orthostatic hypotension may be a problem in patients using antihypertensive agents that reduce sympathetic outflow or peripheral vasodilatory actions. Management of orthostatic hypotension includes avoiding sudden postural changes. OTHER DENTAL CONCERNS Aspirin is now commonly taken by patients with hypertension to decrease associated coronary or cerebral vascular thrombotic disease. 5. a-1-adrenergic antagonists. such as return to sitting position from the supine operating position. Use of oral sedation or nitrous oxide sedation may reduce blood pressure to acceptable levels. Many patients with hypertension develop systolic heart murmurs. ANXIETY CONTROL The anxiety and stress associated with dental treatment typically causes a rise in blood pressure and may precipitate cardiac arrest or a cerebrovascular accident. preoperatively. allowing initiation of local anesthesia (with or with vasoconstrictor). and aspirin may cause bleeding problems. in which case prophylaxis for endocarditis . such as centrally acting a-2-adrenergic agonists.2. post-ganglionic adrenergic inhibitors. and diuretics. 3. The patient should also be instructed to stay seated for a short period until such time that adequate cerebral perfusion has occured. Relative analgesia technique using nitrous oxide (N2O) can also reduce both systolic and diastolic pressure by up to 10-15mm Hg. This fluctuation of blood pressure tends to be less likely in the afternoon. 4. Afternoon appointments are recommended over mornings for this reason.