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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 described this technique in 1905

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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

• Lewington, Lancet 2002;360:1903-1913

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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

revascularization– 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 BPNormal <120 <80Prehypertension 120-139 80-89Stage 1 140-159 90-99Stage 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 ModificationsWeight loss if overweightAdopt 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 activityLimit 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

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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)acebutol (Sectral)atenolol (Tenormin)betaxolol (Kerlone)bisoprolol (Zebeta)metoprolol (Lopressor) metoprolol extended release (Toprol XL)

Non-Selective (β-1&2)cartelol (Cartrol)labetalol (Trandate)nadolol (Corgard)penbutolol (Levatol)pindolol (Visken)propanolol (Inderal)propanolol long-acting (Inderal LA)sotalol (Betapace)timolol (Blocadren)

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Combined Alpha-Beta Blockers

Carvedilol (Coreg)Labetalol (Normodyne; Trandate)

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ACE (angiotensin converting enzyme) Inhibitors

• Benazepril (Lotensin)• Captopril (Capoten)• Enalapril (Vasotec)• Fosinopril (Monopril)• Lisinopril (Zestril; Prinivil)

• Moexipril (Univasc)• Perindopril (Aceon)• Quinipril (Accupril)• Ramipril (Altace)• 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 BlockersAmlodipine (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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Treatment/Referral 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:

– Limit treatment to only that which is necessary

– Use stress reduction protocol

– Excellent anesthesia; use as small a dose as possible of vasoconstrictor

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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

• *Avoid the use of epinephrine impregnated

retraction cord

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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 epinephrine in local anesthetics was minimal”

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“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

Dry mouth

Lichenoid reactions (thiazides, beta blockers)

Gingival hyperplasia (Ca channel blockers)

Altered taste (beta blockers, ACE inhibitors, ARBs)

Lupus-like lesions (direct vasodilators)

Angioedema/cough (ACE inhibitors, ARBs)

Burning mouth (ACE inhibitors)