Transcript DENTAL MANAGEMENT OF HYPERTENSION

DENTAL MANAGEMENT
OF HYPERTENSION
DENTAL MANAGEMENT
OF HYPERTENSION
Hypertension

Definition
A statement that a given arterial pressure
is above normal requires a knowledge of
the range of normality
Blood pressure
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
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
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
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
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 + 90 mmHg.
(อรสา ไวคกุล และคณะ พ.ศ..2537)
Classification of blood pressure
in adults (JNC v,1993)
Category
Normal BP
Systolic
pressure
< 130
Diastolic
pressure
< 85
High normal BP
130-139
85-89
Stage I
140-159
90-99
Stage II
160-179
100-109
Stage III
180-209
110-119
Stage IV
≥ 210
≥ 120
Hypertension
Classification of blood pressure
in adults (JNC VII,2003)
Category
Normal BP
Systolic
pressure
< 120
Diastolic
pressure
<80
Prehypertension
120-139
80-89
Stage I
140-159
90-99
Stage II
≥160
≥100
Hypertension
Essential Hypertension
Benign or Idiopathic Hypertension
 No recognizable cause can be found
 Associate with

 Genetic
 Age>50
 Obesity
 Sex
ชาย>หญิง
 emotion
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)
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
White- coat hypertension

Temporary rise in blood pressure in
doctor’s office
Sign and symptom

Symptom
 Suboccipital
 Ringing
headaches
ear
 Blurred vision
 Fatigability and loss of energy
 Angina pectoris
 Palpitation , nausea , vomiting
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
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
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

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 )
Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP >140-160 / 90-95
BP >160-200 / 95-115
Medical referral
BP >200 / >115
Technique for recording
the blood pressure
1.
Seat and relax the patient.
2.
Place sphygmomanometer cuff on right
upper arm with about 3 cm of skin visible at
the antecubital fossa.
Palpate radial pulse.
3.
4.
Inflate cuff to about 200 to 250 mmHg, or
until the radial pulse is no longer palpable.
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.
Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP >140-160 / 90-95
BP >160-200 / 95-115
Medical referral
BP >200 / >115
Unknown case

Mild hypertension

Blood pressure 140-160 / 90-95 mmHg.
 Recheck
blood pressure after 5 to 10 min.
 Routine dental management
 Stress reduction protocol
 Consider sedation (Tranquilizers, sedative,
hypnotic drug)
Unknown case

Moderate hypertension

Blood pressure 160-200 / 95-115 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
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
Dental management of hypertension
patient
Measured BP
Unknown case
Known case
BP >140-160 / 90-95
BP >160-200 / 95-115
Medical referral
BP >200 / >115
Known case


Blood pressure must be >130/ >90
mmHg.
Management
1.
2.
3.
4.
5.
Timing of dental appointments
Anxiety control
Orthostatic hypotension
Anesthesia
Other dental concerns
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
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
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 10-15
mmHg. (after 10 min)
Anesthesia

Local anesthesia

General anesthesia
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.
Local anesthesia

Data in regard to epinephrinecontaining 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
Local anesthesia

The use of epinephrine- containing
anesthetics in patients with
uncontrolled hypertension, and
elective dental procedures are
contraindicated
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)
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)
Local anesthesia
Use of aspirating syringes
 Avoid
: Intravenous , Intrarterial ,
intrabony and intraligamentary
injection

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.

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
Other dental concerns
Bleeding disorder in patient taking
aspirin
 Bacterial endocarditic

Antihypertensive drugs

Classification of drug
1.
2.
3.
4.
5.
6.
7.
8.
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
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
Diuretics

Side effects:

xerostomia

orthostatic hypotension

increased thirst

polyuria

dizziness

fatigue, weakness
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
Diuretics


Loop diuretics
Side effects:
 xerostomia
 lichenoid drug reaction
 orthostatic hypotension
 increased thirst
 neutropenia
 leukopenia
 anemia
 renal failure
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
Diuretics
Potassium-sparing agent
 Side effects:


xerostomia

lichenoid drug reaction

increase thirst

gingival bleeding (spironolactone)
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
Diuretics
Carbonic anhydrase inhibitors
 Side effects









orthostatic hypotension
xerostomia
sore throat
nasal stuffiness
asthma
drowsiness
depression
fluid retention
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
NONSELECTIVE ALPHA- AND
BETA- ADRENERGIC BLOCKERS

Side effects:

xerostomia

taste changes

orthostatic hypotension

bronchospasm

nausea, Gl upset

nervousness

anxiety, depression

parasthesia
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

BETA-ADRENERGIC BLOCKERS

Side effects

orthostatic hypotension

xerostomia

sore throat

nasal stuffiness

asthma

drowsiness

depression

fluid retention
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
CENTRAL-ACTING
ADNERNERGIC INHIBITORS

Side effects:

xerostomia

taste changes

salivary pain or swelling

palpitation

ECG abnormalities

insomnia

anxiety

drowsiness
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
PERIPHERAL-ACTING
ADRENERGIC INHIBITORS

Side effects:

xerostomia

orthostatic hypotension

bleeding

thrombocytopenia purpura

drowsiness, fatigue, weakness
VASODILATORS
 hydralazine
(Apresoline)
 minoxidil (Loniten)

direct relaxation (vasodilation) of
arteriolar smooth muscle

decrease blood pressure by decreasing
peripheral vascular resistance
VASODILATORS

Side effects:

nasal congestion

lupus-like syndromes

leukopenia
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

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
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
Slow Channel Calcium-Entry
Blocking Agents

Side effects:

gingival hyperplasia

xerostomia

orthostatic hypotension

light-headedness, nausea

edema

flushing, skin reactions

congestive heart failure
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
REFERENCES
ประไพ ศิวโมกษธรรม ,โรคทางระบบ ปั ญหาและการจัดการทางทัน
ตกรรม 1 , พิมพ์ ครัง้ ที่ 4 , ภาควิชาทันตวิทยา-พยาธิวิทยาช่ องปาก
คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ , พ.ศ. 2539
 อรสา ไวคกุล และคณะ, การวางแผนการรั กษาทางทันตกรรมใน
ผู้ป่วยที่มีโรคทางระบบ , พิมพ์ ครัง้ ที่ 1 , Text & Journal Publication
Co.,Ltd, พ.ศ. 2537
 เอกสารประกอบการสอน วิชา ศัลยศาสตร์ ช่องปาก 1 , ภาควิชาศัล
ศาสตร์ ช่องปาก คณะทันตแพทยศาสตร์ มหาวิทยาลัยเชียงใหม่ ,พ.ศ.
2545
 เอกสารประกอบการสอนกระบวนวิชา 320351 เภสัชวิทยา สาหรั บ
นักศึกษาทันตแพทย์ เล่ ม 1 , ภาควิชาเภสัชวิทยา คณะแพทยศาสตร์
มหาวิทยาลัยเชียงใหม่ , พ.ศ. 2546

REFERENCES
www.dent.ucla.edu/pic/members/hyperten
sion/
 www.thefreedictionary.com/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
