KAMINENI INSTITUTE OF DENTAL SCIENCES

DEPARTMENT OF PROSTHODONTICS

DATE: 03-03-2021

SEMINAR ON

HYPERTENSION

MODERATOR PRESENTOR

Dr. TARUNA.N BHARATHI GUDAPATI

SIGNATURE OF MODERATOR SIGNATURE OF HOD

 CONTENTS

• DEFINITION

• TYPES OF HYPERTENSION

• ETIOLOGY

• GRADING OF BLOOD PRESSURE

• CLINICAL FEAUTURE

• COMPLICATION

• INVESTIGATION

• TREATMENT

• HYPERTENSION MANAGEMENT IN DENTISTRY

INTRODUCTION

Hypertension , also known as high blood pressure (HBP), is a long-term medical condition in which

the blood pressure in the arteries is persistently elevated.

TYPES OF HYPERTENSION

 PRIMARY HYPERTENSION

 SECONDARY HYPERTENSION

Causes
There are two types of high blood pressure.

1)Primary (essential) hypertension

For most adults, there's no identifiable cause of high blood pressure. This type of high
blood pressure, called primary (essential) hypertension, tends to develop gradually over
many years.

 Intake of excessive salt

 Abnormal arteries
  Increased blood volume

 Genetic disorders

 Stressful life

2)SECONDARY HYPERTENSION

 Health conditions

 certain medications

 Recreational drugs

 Pregnancy

 Hormonal therapy

Blood pressure is classified by two measurements, the systolic and diastolic pressures,which are

the maximum and minimum pressures, respectively.

When yoUR heart beats the pressure of theblood on the walls of the artery is called systolic
pressure.

When the heart relaxes between the beats the pressure on the walls is called diastolic pressure.

For most adults, normal blood pressure at rest is within the range of 100–130  (mmHg) systolic and
60–80 mmHg diastolic.

Classification in adults (Persons with systolic and diastolic in different categories are assigned to the higher category.

Category Systolic, mmHg Diastolic, mmHg

Hypotension < 90 < 60

Normal 90–119 60–84

Prehypertension
120–129 85–89
(high normal, elevated)
Stage 1 hypertension 130-159 90–99

Stage 2 hypertension 160–179 100–109

Hypertensive crisis ≥ 180 ≥ 120

Isolated systolic hypertension ≥ 140 < 90

Isolated diastolic hypertension < 140 ≥ 90

 For most adults, high blood pressure is present if the resting blood pressure is persistently
at or above 130/80 or 140/90 mmHg. Different numbers apply to children.

 Ambulatory blood pressure monitoring over a 24-hour period appears more accurate than
office-based blood pressure measurement .

What are common symptoms of hypertension?

 Hypertension is called a "silent killer". Most people with hypertension are unaware of the
problem because it may have no warning signs or symptoms. For this reason, it is essential
that blood pressure is measured regularly.

 When symptoms do occur, they can include early morning headaches, nosebleeds,
irregular heart rhythms, vision changes, and buzzing in the ears. Severe hypertension can
cause fatigue, nausea, vomiting, confusion, anxiety, chest pain, and muscle tremor.

SYMPTOMS IN CHILDREN
  Failure to thrive, seizures, irritability,  lack of energy, and difficulty in breathing

can be associated with hypertension in newborns and young infants.

 In older infants and children, hypertension can cause headache, unexplained

irritability, fatigue, failure to thrive, blurred vision, nosebleeds, and facial paralysis.

HYPERTENSIVE CRISES

HYPERTENSIVE EMERGENCIES

High BP associated with target organ damage.

Requires treatment in ICU with constant monitoring of BP

HYPERTENSIVE URGENCIES

High BP but no organ damage.

Treatment :-Sodium nitroprusside

-Nifedipine

-Nitroglycerin

-Hydralazine

-Labetolol

Pregnancy hypertension
Hypertension occurs in approximately 8–10% of pregnancies. Two blood pressure measurements

six hours apart of greater than 140/90 mm Hg are diagnostic of hypertension in pregnancy. 

High blood pressure in pregnancy can be classified as pre-existing hypertension,

 gestational hypertension, or pre-eclampsia.

Pre-eclampsia is a serious condition of the second half of pregnancy and following
delivery characterised by increased blood pressure and the presence of protein in the urine.

It occurs in about 5% of pregnancies and is responsible for approximately 16% of all maternal

deaths globally.

Pre-eclampsia also doubles the risk of death of the baby around the time of birth.Usually there are
no symptoms in pre-eclampsia and it is detected by routine screening.

When symptoms of pre-eclampsia occur the most common are headache, visual disturbance
(often "flashing lights"), vomiting, pain over the stomach, and swelling.

In contrast, gestational hypertension is defined as new-onset hypertension during pregnancy

without protein in the urine.

White-coat hypertension
 White-coat hypertension (WCH).

 white-coat effect(WCE).

 Masked hypertension.

home blood pressure monitoring and 24-hour ambulatory blood pressure

monitoring.

WCH and masked hypertension are important for clinicians to recognize. It is

controversial as to whether WCH is associated with increased cardiovascular

risk, but patients with masked hypertension are at increased cardiovascular

risk.

Risk factors
High blood pressure has many risk factors, including:

• Age. The risk of high blood pressure increases as you age. Until about age 64, high
blood pressure is more common in men. Women are more likely to develop high
blood pressure after age 65.

• Race. High blood pressure is particularly common among people of African

heritage, often developing at an earlier age than it does in whites. Serious
complications, such as stroke, heart attack and kidney failure, also are more
common in people of African heritage.

• Family history. High blood pressure tends to run in families.

 • Being overweight or obese. The more you weigh, the more blood you need to
supply oxygen and nutrients to your tissues. As the amount of blood blow through
your blood vessels increases, so does the pressure on your artery walls.

• Not being physically active. People who are inactive tend to have higher heart
rates. The higher your heart rate, the harder your heart must work with each
contraction and the stronger the force on your arteries. Lack of physical activity
also increases the risk of being overweight.

• Using tobacco. Not only does smoking or chewing tobacco immediately raise your
blood pressure temporarily, but the chemicals in tobacco can damage the lining of
your artery walls. This can cause your arteries to narrow and increase your risk of
heart disease. Secondhand smoke also can increase your heart disease risk.

• Too much salt (sodium) in your diet. Too much sodium in your diet can cause your
body to retain fluid, which increases blood pressure.

• Too little potassium in your diet. Potassium helps balance the amount of sodium in
your cells. A proper balance of potassium is critical for good heart health. If you
don't get enough potassium in your diet, or you lose too much potassium due to
dehydration or other health conditions, sodium can build up in your blood.

• Drinking too much alcohol. Over time, heavy drinking can damage your heart.
Having more than one drink a day for women and more than two drinks a day for
men may affect your blood pressure.

• If you drink alcohol, do so in moderation. For healthy adults, that means up to one
drink a day for women and two drinks a day for men. One drink equals 12 ounces
of beer, 5 ounces of wine or 1.5 ounces of 80-proof liquor.

• Stress. High levels of stress can lead to a temporary increase in blood pressure.

Stress-related habits such as eating more, using tobacco or drinking alcohol can
lead to further increases in blood pressure.

• Certain chronic conditions. Certain chronic conditions also may increase your risk
of high blood pressure, including kidney disease, diabetes and sleep apnea.

Increased blood pressure can damage the walls of the arteries. This damage can lead to
life threatening conditions. For example an artery wall may become weak and form an
enlarged area called an aneurysm. The wall may burst and bleed into the tissue around it.

In another example damage to the artery wall may attract certain substances in the blood
like fats , cholesterol ,calcium. They may build up and is called a plaque.as the plaque gets
bigger the blood flow in the artery is reduced. Blood cells constrict to the plaque and form
solid clumps called clot. The blood clots further reduce or completely block the blood
flow.

If this happens in the brain it can lead to a stroke.

If it happens in the heart, it leads to heart attack.

Damage to the arteries in the kidneys reduce their ability to work properly. This can lead
to kidney disease.

Finally the damage to the blood vessels raise the blood pressure even more which can
lead to heart failure.

Complications
The excessive pressure on your artery walls caused by high blood pressure can damage
your blood vessels as well as your organs. The higher your blood pressure and the longer
it goes uncontrolled, the greater the damage.

Uncontrolled high blood pressure can lead to complications including:

• Heart attack or stroke. High blood pressure can cause hardening and thickening of
the arteries (atherosclerosis), which can lead to a heart attack, stroke or other
complications.

• Aneurysm. Increased blood pressure can cause your blood vessels to weaken and
bulge, forming an aneurysm. If an aneurysm ruptures, it can be life-threatening.

• Heart failure. To pump blood against the higher pressure in your vessels, the heart
has to work harder. This causes the walls of the heart's pumping chamber to
thicken (left ventricular hypertrophy). Eventually, the thickened muscle may have a
hard time pumping enough blood to meet your body's needs, which can lead to
heart failure.

• Weakened and narrowed blood vessels in your kidneys. This can prevent these
organs from functioning normally.

• Thickened, narrowed or torn blood vessels in the eyes. This can result in vision
loss.

• Metabolic syndrome. This syndrome is a group of disorders of your body's

metabolism, including increased waist size, high triglycerides, decreased high-
density lipoprotein (HDL) cholesterol (the "good" cholesterol), high blood pressure
and high insulin levels. These conditions make you more likely to develop diabetes,
heart disease and stroke.
• Trouble with memory or understanding. Uncontrolled high blood pressure may
also affect your ability to think, remember and learn. Trouble with memory or
understanding concepts is more common in people with high blood pressure.

• Dementia. Narrowed or blocked arteries can limit blood flow to the brain, leading
to a certain type of dementia (vascular dementia). A stroke that interrupts blood
flow to the brain also can cause vascular dementia.

INVESTIGATION
 1) Urinalysis for glucose, blood , protein

 2) Blood urea , Blood glucose level

 3) Serum total & HDL cholesterol level

 4) ECG

 5) Echocardiogram

 6) Chest X-ray

 7) Renal Ultrasonography

How can the burden of hypertension be reduced?

Prevention
• Reducing salt intake (to less than 5g daily)

• Eating more fruit and vegetables

• Being physically active on a regular basis

• Avoiding use of tobacco

• Reducing alcohol consumption

• Limiting the intake of foods high in saturated fats

• Eliminating/reducing trans fats in diet

 Management
• Reducing and managing mental stress

• Regularly checking blood pressure

• Treating high blood pressure

• Managing other medical conditions

Non drug theraphy:

 Life style modfication

 -Relief of stress

 -Salt restriction

 -Weight reduction

 -Reduced alcohol intake

 -Stop smoking

 -Regular physical exercise

DRUG THERAPHY :

DIURETICS called as water pills cause the kidneys to move more salt and water from the blood into
the urine.which reduces the blood volume and pressure.
Beta blockers reduce the work load on the heart by decreasing pulse rate of the heartbeat and the
strength of the hearts contractions.

Medications that relax the blood vessels which increases the diameter.

these drugs include

ace inhibitors,

angiotensin 2 receptor blockers,

calcium channel blockers,

Direct acting vasodilators.

Thiazide & other diuretics:- Hydrochlorothiazide , cyclopenthiazide-Furosemide , bumetanide

Ace inhibitor:-Enalapril , ramipril , lisinopril

Angiotensin receptor blocker -Valsartan , losartan

Calcium channel blocker -Amlodipine , nifedipine , verapamil

Beta blocker -Proponalal , atenolol , metoprolal

Mixed alpha & beta blocker -Labetalol , carvedilol

Other drugs

-Prazosin , terazosin ,

-hydralazine , sodium nitroprusside

RENIN ANGIOTENSIN ALSOSTERONE SYSTEM

The raas system is a classic endocrine system that helps to regulate long term blood pressure and
extracellular volume in the body.

This system begins with the release of angiotensinogenin to circulation by the liver.

this may be in response to low bp and reverse changes in sodium concentrations.

An enzyme renin is secreted which cleaves angiotensinogen to form the inactive angiotensin 1 .

Further transformation of angiotensin is carried out by angiotensin converting enzyme or ace.

This is predominantly found in the pulmonary circulation .however ace is also produced in the
vascular endothelium of many tissues including the kidney,Adrenal gland ,brain and heart.

The ace converts the inactive precursor angiotensin 1 to vasoactive peptide angiotensin 2.
Ace also degrades bradykinin which is required for synthesis of a major vaso dilator nitric oxide.

Angiotensin 2 binds at1 receptor expressed on the surface of vascular endothelium and impairs
nitric oxide synthesis as well.

Reduced bioavailability of nitric oxide combined with at1 receptors in smooth muscle cells causes
vaso constriction.

In addition to this, stimulation of at1 receptor causes the adrenal gland to release the hormone
aldosterone resulting in sodium retention combined with vasoconstriction ,increases bp.

In the final stages kidney reduces the production of renin.

HYPERTENSION MANAGEMENT IN DENTISTRY

PRE OPERATIVE MEDICATION & MANAGEMENT

 Patient BP should be monitored & controlled within normal.

 To hypertensive patient morning dose of medication prior to surgery must be given.

INTRA AND POST OPERATIVE MANAGEMANT

 Blood pressure should be monitored continuously.

 Patient cardiac status also monitored.

 Antihypertensive must be continued.

 If the procedure is performed under local anesthesia , the local anesthetic without

Adrenaline is to be used.

Hypertension and Prosthodontic Care

1. The oral cavity is an ideal breeding area for bacteria and those affected by periodontal
disease are at an increased risk for potentially fatal bacteria entering the bloodstream via
infected oral tissue. Hypertensive patients are at a higher risk of developing septicaemia
following prosthodontic treatments

2. History should cover specific aspects like the duration of hypertension, medication and
patient compliance with regard to antihypertensives, other associated co-morbid
conditions, current oral disease, past dental treatment including its outcome,
complications during treatment and post-treatment medication.
3. Accurate measurement of blood pressure is mandatory. Detection of hypertension in the
office requires blood pressure measuring equipment that is Functioning adequately and
ideally validated.

4. In patients who are newly diagnosed with hypertension, dental treatment should be
commenced only after consultation with the physician.
5. Particular attention should be given for accurate measurement of blood pressure in
pregnant women, since pregnancy may alter the patient BP values with more than 10% of
pregnant women having clinically relevant hypertension.

6. Hyposalivation was also found as one of the clinical manifestations in hypertensive

patients. This hyposalivation was related to the sustained increase in both systolic as well
as diastolic blood pressure and also in patients who were under antihypertensive
medication especially with diuretics.
7. The unstipulated salivary flow will be reduced. Xerostomia has many consequences like
decay, difficulty in chewing, swallowing and speaking, candidiasis and oral burning
syndrome.

8. Lichen planus like lesions or lichenoid reactions are white lesions characterized by linear
striations occurring o the buccal mucosa. They are seen bilaterally and usually posteriorly.

9. Gingival hyperplasia is also one of the most common clinical findings in patients with
hypertension taking anti-hypertensive medication especially calcium channel blockers like
nifidipine.

10. Due to higher concentrations of epinephrine (almost 12 standard cartridges) in gingival

retraction cords used for prosthetics impressions and its rapid uptake in circulation, the
use of epinephrine for gingival eviction in patients with cardiovascular disease is
contraindicated.

11. Fabricating a complete denture demands utmost care to avoid causing soft tissue abrasion.
Certain antihypertensive drugs are associated with xerostomia which in turn hamper the
retention and stability of the complete dentures.

12. The sharp edges of the removable partial dentures should be trimmed off. Removable
partial denture should be polished well and preferably should be fabricated with flexible
material.

13. Prolonged presence of xerostomia is conducive to greater carious activity and is therefore
extremely hostile to the margins of cast metal or ceramic restorations.
14. Usually implant procedures are longer and they induce more stress and anxiety to the
patient. The best way to effectively reduce pain and anxiety without aggravating the heart
with a combination of medications is to deliver an adequate dosage of numbing agents
spread out over more injections over a greater length of time. The best way to limit the
stress on the heart is to get the patient through the procedure quickly and allow them to
begin to relax sooner.

CONCLUSION

1. While providing prosthodontic care to the patients with hypertension,

understanding the disease, its treatment and its impact on the patient’s ability to
undergo and respond to dental care is mandatory.
2. It is highly recommended to choose dental treatment alternatives as conservative
and as minimally invasive as possible to reduce the risks along the entire dental
treatment.
3. With an increase in awareness of the availability of various prosthodontic
treatments, the number of patients seeking consultation has tremendously
increased.
4. Hypertensive patients no longer form a negligible portion of the consultation.
When equipped with thorough knowledge about hypertension, the drug
interactions, the expected complications, the probable causes of treatment failure
and the mandatory precautions to be taken during such treatment,
prosthodontists can hope for better results.
5. Cautious approach and appropriate precautions when taken by the
prosthodontists in hypertensive patients can go a long way in providing quality
dental care.
 REFERENCES

1) DAVIDSON Principal & practice of Medicine.

2) Essential of MEDICAL PHYSIOLOGY
- K SEMBULINGAM
- PREMA SEMBULINGAM
3) Textbook of ORAL AND MAXILLOFACIAL SURGERY
- NEELIMA ANIL MALIK
4) MEDICAL EMERGENCIES IN THE DENTAL OFFICE
- STANLEY F . MALAMED
5) Review Article
Hypertensive Patients and Their Management in Dentistry
SandaMihaela Popescu,1 Monica Scrieciu,1 Veronica Mercuu,1
Mihaela tuculina,2 and Ionela Dascslu2

6) Hypertension and Prosthodontic Care Dr. Ganaraj Shettya*, Dr. Kiran Kumar S.b

7) International Journal of Clinical Preventive Dentistry Volume 8, Number 1, March 2012

Management of Hypertensive Elderly in Clinical Dentistry
Patcharaphol Samnieng1, Kantapong Ploydanai2