Dental management of hypertensive patient

Oral surgery lecture 1

Dental management of hypertensive patient
Hypertension is a sustained elevation in the arterial blood pressure. The normal adult blood pressure is <120/<80 mmHg and pre-hypertension within 120-139 (SBP) and (DBP) 80-89 mm Hg. Reading within 140/90 mmHg or greater is considered within abnormal range. There are two types of hypertension either primary which is of unknown origin and comprises 95% of hypertension cases; and secondary hypertension which is associated with other systemic condition such as chronic renal diseases or endocrine tumors like pheochromocytoma. White coat hypertension is another type of hypertension associated with fear and anxiety of doctors white coat.
Hypertension with other risk factors such as hypercholestremia and smoking might cause cardiovascular complications such as myocardial infarction and angina pectoris. Prolonged elevation in the arterial blood pressure affecting vital organs such as eyes, kidneys , brain and heart and causes blindness, renal damage, cerebrovascular accident (CVA) and ischemic heart disease.
Dentist may play an important role in detecting patient with hypertension from signs and symptoms and monitoring patient blood pressure. Hypertensive patient may develop some complications during tooth extraction or other surgical operations such as local bleeding, angina pectoris, myocardiac infarction, CVA..etc. These complications could be associated with stress and anxiety of dental procedures or use of vasoconstrictor in the local anesthesia or drug interaction or as a result of side effect of certain anti-hypertensive drugs. The most common drugs that might be interacted with anti-hypertensive agents include conscious sedations used in dental practice, non-steroidal ant-inflammatory drugs and anti-fungal drugs.
Signs and symptoms of hypertension:
Occipital headache, weakness, dizziness ringers in ears and retinal hemorrhage. However, sometimes there is no obvious signs and symptoms and the case can be detected through reading arterial blood pressure using stethoscope and sphygmomanometer.
Medical management of hypertensive patient is the responsibility of physician and there are many drugs can be used for lowering blood pressure such angiotensin-converting enzyme inhibitors, calcium channels blockers ,beta-blockers, Diuretics…etc. A combination of these drugs could be prescribed in the treatment of certain situation. It is important to be familiar with anti-hypertension drugs as some of these drugs cause orthostatic hypotension and gag reflex which could be triggered during dentist work.


Dental management:
- The diagnosed patient can be detected through history taking, patient s medications and signs and symptoms. However, the blood pressure of any patient of 40 years old or above should be checked during dental appointment. Patient with elevated blood pressure (>140/ >90 mm Hg) should be referred to physician for medical management. Blood pressure reading should be checked at least twice before starting dental procedure.
- Patients with uncontrolled blood pressure 180-110 mm Hg or more cannot be treated.
- Ask about medications and be familiar with these drugs.
- Establish an honest relationship with patient.
- Short, morning and non-stressful appointment might be helpful to reduce medical complications.
- An anti-anxiety protocol can be used to reduce stress and anxiety of dental procedure. Benzodiazepam as 2-5 mg can be used at bed time one day before and 1 hour before surgical operation. Nitrous oxide sedation can be used as anxiolytic agent.
- Use plain (without vasoconstrictor) anesthesia or anesthesia with low adrenaline concentration (1:100:000) and 2% lidocain in one to two cartridges. Local anesthesia containing felypressin which is non-catecholamine also can be used.
- Avoid using gingival retraction cord containing vasoconstrictor.
- Change dental chair position gradually to prevent development of orthostatic hypotension.
- Avoid stimulating gag reflex during dental procedure.