Hypertension & Renal

8/6/2019 Hypertension & Renal

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HYPERTENSION ANDHYPERTENSION AND

RENAL DISEASERENAL DISEASEText ReadingText Reading

Assignment:Assignment:

Essentials of OralEssentials of Oral

MedicineMedicine

Chapter 4Chapter 4 -- pp. 36pp. 36--

4141

Renal DiseasesRenal Diseases

and Hypertensionand Hypertension


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HYPERTENSION (HTN)HYPERTENSION (HTN)

Things to know / ask:Things to know / ask:

What is hypertension?What is hypertension?

How is it diagnosed?How is it diagnosed?

What are signs, symtoms and complications ofWhat are signs, symtoms and complications of

the disease?the disease?

How is the disease treated?How is the disease treated?

What areWhat are side effects of treatmentside effects of treatment??

What are the dental implications of HTN?What are the dental implications of HTN?

What is the relationship withWhat is the relationship with renal diseaserenal disease??

What are the dental implications of renalWhat are the dental implications of renal

disease?disease?


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What is Hypertension?What is Hypertension?

Pathologic Disregulation of Blood PressurePathologic Disregulation of Blood Pressure (Blood(Blood

Volume, Vasoconstriction, or Cardiac Output)Volume, Vasoconstriction, or Cardiac Output)

SustainedSustained

DamagingDamaging

> 140/90 mm Hg> 140/90 mm Hg

Primary (90%)Primary (90%) andand Secondary (10%)Secondary (10%) (Especially Renal(Especially Renal

Associated)Associated) TypesTypes

May Affect 20May Affect 20--40 % ofPopulation40 % ofPopulation

Definition DependentDefinition Dependent % Increases with Age% Increases with Age

More Common in Blacks and MenMore Common in Blacks and Men

Associated with Stress, Weight, Smoking, DiabetesAssociated with Stress, Weight, Smoking, Diabetes


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Blood PressureBlood Pressure

Determining F

actorsDe

termining F

actors

BPBP

Cardiac Output:Cardiac Output:

Stroke VolumeStroke Volume

Heart RateHeart Rate

Force of ContractionForce of Contraction

PeripheralPeripheral

Resistance **Resistance **

Blood Volume **Blood Volume **

DiureticsDiuretics

Beta BlockersBeta Blockers

Calcium ChannelCalcium Channel

BlockersBlockers

VasodilatorsVasodilators

ACE InhibitorsACE Inhibitors

ACE InhibitorsACE Inhibitors


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Types of HypertensionTypes of Hypertension

0

20

40

60

80

100

ssential

Sec

onda

ry

90%

10%RenalRenal

Ischemia ReninIschemia Renin

AdrenalAdrenal

CorticalCorticalCushings SyndromeCushings Syndrome

Aldosterone AdenomaAldosterone Adenoma

MedullaryMedullary

PheochromocytomaPheochromocytoma

PituitaryPituitary

ACTH AdenomaACTH Adenoma

Secondary HTN ClassificationSecondary HTN Classification

Malignant HypertensionMalignant Hypertension


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How is HypertensionHow is Hypertension

Dia

gnosed?Dia

gnosed? Medical DiagnosisMedical Diagnosis

BPBP =/>=/> 140140/90/90 (Systolic/(Systolic/DiastolicDiastolic))

Dental Screening / MonitoringDental Screening / Monitoring

ScreenScreen all Patients for Evidence of Diseaseall Patients for Evidence of Disease

ReferReferKnowns and Unknowns forKnowns and Unknowns for

pressures ofpressures of~~ 140/90140/90 or greateror greater( 2 successive( 2 successive

measurements)measurements)

MonitorMonitorKnown HTN Patients for ControlKnown HTN Patients for Control


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A Relatively RecentA Relatively Recent

Complete ClassificationComplete Classification

OptimalOptimal < 120< 120 < 80< 80

NormalNormal < 130< 130 < 85< 85

High NormalHigh Normal 130130--139139 8585--8989

HTNHTN -- Stage IStage I 140*140*--159159 90*90*--9999

HTNHTN -- Stage IIStage II 160*160*--179179 100*100*--109*109*

HNTHNT -- Stage IIIStage III 180*180*--209209 110110--119119

HTNHTN -- Stage IVStage IV =/> 210=/> 210 =/> 120=/> 120

SystolicSystolic DiastolicDiastolicCategoryCategory

* Routine Care OK but Refer for Diagnosis or Improved Managment* Routine Care OK but Refer for Diagnosis or Improved Managment

*** No* No ElectiveElective TreatmentTreatment withouwithout Medicalt Medical ConsultConsult andand ImprovedImproved BPBP


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WhatareWhatare SymptomsSymptoms andand

ComplicationsComplications of Untreated orof Untreated or

Undiagnosed Disease?Undiagnosed Disease? SymptomsSymptoms

Usually AsymptomaticUsually Asymptomatic (95%)(95%) Unless SevereUnless Severe

Severe:Severe: Dizzines, Ringing in Ears, Headaches, Fainting Spells,Dizzines, Ringing in Ears, Headaches, Fainting Spells,

Blurred Vision, Epistaxis (Bleeding Nose) or otherP

rolongedBlurred Vision, Epistaxis (Bleeding Nose) or otherP

rolongedBleedingBleeding

ComplicationsComplications -- Undiagnosed or UntreatedUndiagnosed or Untreated

Accelerated AtherosclerosisAccelerated Atherosclerosis

Increased Risk ofIncreased Risk ofMyocardial Infarction (M / Heart AttackI)Myocardial Infarction (M / Heart AttackI) andand

Cerobrovascular Accidents (CVA / Stroke)Cerobrovascular Accidents (CVA / Stroke) Congestive Heart Failure (CHF)Congestive Heart Failure (CHF)

Swollen AnklesSwollen Ankles

Shortness of BreathShortness of Breath

CoughCough

Small Risk of Eye and/or Renal DamageSmall Risk of Eye and/or Renal Damage


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How is the DiseaseHow is the Disease

Treated?Treated? Life Style ChangesLife Style Changes

Low Salt DietLow Salt Diet

Weight LossWeight Loss

Reduced StressReduced Stress

Smoking CessationSmoking Cessation

Medication !!!Medication !!!

DiureticsDiuretics (Decrease blood volume)(Decrease blood volume)

VasodilatorsVasodilators (Decrease peripheral resistance)(Decrease peripheral resistance)

Beta Blockers and Calcium Channel BlockersBeta Blockers and Calcium Channel Blockers (Decrease(DecreaseCardiac Output)Cardiac Output)

AAngiotensinngiotensin CConvertingonverting EEnzymenzyme (ACE)(ACE) InhibitorsInhibitors

(Decrease Angiotensin Formation: Decreased(Decrease Angiotensin Formation: Decreased

Vasoconstriction and Blood VolumeVasoconstriction and Blood Volume--AldosteroneAldosterone

associated sodium retention and blood volume)associated sodium retention and blood volume)


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Whatare Side Effects ofWhatare Side Effects of

Treat

ment

of HTNTreat

ment

of HTN?? ExamplesExamples -- SystemicSystemic

Postural Hypotension (Stand upPostural Hypotension (Stand up -- Fall Down)Fall Down)

ImpotenceImpotence

ExamplesExamples -- OralOral

Dry Mouth (Xerostomia)Dry Mouth (Xerostomia)

Gingival Hyperplasia (Calcium ChannelGingival Hyperplasia (Calcium Channel

BlockersBlockers -- NifedipineNifedipine))

Specific Medication DependentSpecific Medication Dependent -- AlwaysAlways

CheckCheck


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Questions to Ask in the Medical HistoryQuestions to Ask in the Medical History

How long diagnosed?How long diagnosed?

What medications taking? / Do you takeWhat medications taking? / Do you take

them? / Any recent changes?them? / Any recent changes?

Any side effects of medications?Any side effects of medications?

How well controlled?How well controlled?

What is normal with and withoutWhat is normal with and without

medication?medication? Any blood pressure related dentalAny blood pressure related dental

problems?problems?


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Things to Do in the Dental ChairThings to Do in the Dental Chair

Ask if patient took medication todayAsk if patient took medication today

Check blood pressure before startingCheck blood pressure before starting

appointmentappointment

Monitor Blood pressure during appointmentMonitor Blood pressure during appointment

Be judicious with vasoconstrictor in anestheticBe judicious with vasoconstrictor in anesthetic

-- Dont use retraction cord with epinephrineDont use retraction cord with epinephrine

Remain alert for medication side effects andRemain alert for medication side effects and

disease complicationsdisease complications


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Pertinent Aspects of MedicalPertinent Aspects of Medical

History Related to HTNHistory Related to HTN

II Have you ExperiencedII Have you Experienced (Symptoms)(Symptoms)??

Chest Pain(Angina)Chest Pain(Angina) -- AtherosclerosisAtherosclerosis

Swollen AnklesSwollen Ankles -- Long StandingLong Standing CHFCHF

Shortness of BreathShortness of Breath -- Long StandingLong Standing CHFCHF CoughCough -- Long StandingLong Standing CHFCHF

Bleeding ProblemsBleeding Problems -- Severe HTNSevere HTN

Dizziness, Ringing in Ears, Headaches, FaintingDizziness, Ringing in Ears, Headaches, Fainting

Spells, Blurred VisionSpells, Blurred Vision -- Severe HTNSevere HTN Excessive Thirst, Frequent Urination /Excessive Thirst, Frequent Urination / DiabetesDiabetes

MellitusMellitus related HTNrelated HTN -- ((AtherosclerosisAtherosclerosis and/orand/orRenalRenal

DiseaseDisease))


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III. Have you Had / Do you HaveIII. Have you Had / Do you Have

(Diseases)(Diseases)?? Heart Disease, Heart AttackHeart Disease, Heart Attack

Stroke, Hardening of the ArteriesStroke, Hardening of the Arteries

High Blood PressureHigh Blood Pressure Kidney DiseaseKidney Disease

Diabetes MellitusDiabetes Mellitus


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Are You Taking (Medications)?Are You Taking (Medications)?

Any Medications for Blood PressureAny Medications for Blood Pressure

ControlControl

Which Ones?Which Ones?

Check for any side effectsCheck for any side effects


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Management of HypertensiveManagement of Hypertensive

Pat

ient

sPat

ient

s 140/90 orLess140/90 orLess -- No Precautions NeededNo Precautions Needed

141/91141/91 -- 160/110160/110 -- Sedation? Or DelaySedation? Or Delay

> 161/111> 161/111 -- No Elective / Emergency onlyNo Elective / Emergency onlywith Med Consultwith Med Consult

Controlled HTN: LA Vasoconstrictor OK /Controlled HTN: LA Vasoconstrictor OK /

Avoid EpiAvoid Epi--Retraction CordRetraction Cord Undiagnosed Screening: Retake BP /Undiagnosed Screening: Retake BP /

Refer for DiagnosisRefer for Diagnosis


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What is Renal (Kidney)What is Renal (Kidney)

Disease?Disease? Inflammatory / Infectious Disease (Usually) that Damages Kidney andInflammatory / Infectious Disease (Usually) that Damages Kidney and

Alters Kidney FunctionAlters Kidney Function

GlomerulonephritisGlomerulonephritis:: Immunopathic Disease of GlomerulusImmunopathic Disease of Glomerulus (Many Sub(Many Sub--

Types)Types)

PyelonephritisPyelonephritis:: Infection of Connective Tissue and TubulesInfection of Connective Tissue and Tubules

May Require:May Require:

MedicationMedication

DialysisDialysis (End(End--StageStage -- Renal Failure) (300,000)Renal Failure) (300,000)

TransplantTransplant (End(End--StageStage -- Renal Failure) (30,000/yr)Renal Failure) (30,000/yr)

May interfere with:May interfere with:

Drug MetabolismDrug Metabolism

Infection Control and Wound HealingInfection Control and Wound Healing BleedingBleeding (Platelet Adhesion Inhibition)(Platelet Adhesion Inhibition)

Renal Failure May also be Associated with:Renal Failure May also be Associated with:

AnemiaAnemia (loss of erythropoietin)(loss of erythropoietin)

HTNHTN

Secondary HyperparathyroidismSecondary Hyperparathyroidism (loss of Ca++) **(loss of Ca++) **

Uremic Stomatitis ** or Oral CandidiasisUremic Stomatitis ** or Oral Candidiasis

KidneyKidneyDamageDamage

End Stage RenalEnd Stage Renal

Dialysis or TransplantDialysis or Transplant

Glomerulonephritis

Kidney Stones

Developmental

Malformations

Chemical Toxins

Pyelonephritis


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SecondarySecondary

Hyperparath

yroidism **Hyperparath

yroidism **

Decreased Serum CalciumDecreased Serum Calcium

Increased ParathormoneIncreased Parathormone

Calcium removed from boneCalcium removed from bone

Ground Glass Radiographic AppearanceGround Glass Radiographic Appearance

or Radiolucent lesions Filled with Giant Cellor Radiolucent lesions Filled with Giant CellGranulomaGranuloma

Loss ofLamina DuraLoss ofLamina Dura


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Uremic StomatitisUremic Stomatitis

Precedes Renal FailurePrecedes Renal Failure

Ammonia in SalivaAmmonia in Saliva

Oral UlcerationOral Ulceration

Dysgeusia (abnormal taste): metalicDysgeusia (abnormal taste): metalic

Increased SalivationIncreased Salivation


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The KidneyThe Kidney

GlomerulonephritisPyelonephritis


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GlomerulonephritisGlomerulonephritis

-- Immunopathic DiseaseImmunopathic Disease --

d d

Podocyte Epithelial Cells of Bowmans Capsule with foot processes

Endothelial Cells of Glomerular Capillaries

Antigen / Antibody Complexes Localized

orDeposited in Basement Membrane Area

Basement Membrane Area

Inflammatory Damage to Glomerulus


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What is Relationship ofWhat is Relationship of

Renal Disease to HTN?Renal Disease to HTN? Renal Disease may damage the kidney blood supply andRenal Disease may damage the kidney blood supply and

activate theactivate the RENINRENIN--ANGIOTENSINANGIOTENSIN system (Release ofsystem (Release of

ReninRenin with ultimate formation ofwith ultimate formation ofAngiotensin IIAngiotensin II which raiseswhich raises

BP via vasoconstriction and sodium retention)BP via vasoconstriction and sodium retention) -- A form ofA form ofsecondary hypertensionsecondary hypertension

HTN may damage the blood supply to the kidney (viaHTN may damage the blood supply to the kidney (via

accelerated atherosclerosis or arteriolosclerosis) andaccelerated atherosclerosis or arteriolosclerosis) and

further contribute to its own progressionfurther contribute to its own progression

Altered function may increase Na+ and fluid retention withAltered function may increase Na+ and fluid retention withincreased blood volume and pressureincreased blood volume and pressure


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ReninRenin -- AngiotensinAngiotensin

Juxtaglomerular

Cells

Glomerulus and Bowmans Capsule

Decreased BP

Renin Release

Formation ofAngiotensin

Increased Vasoconstriction

Increased Aldosterone

with Increased Na++ and

Fluid Retention


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Kidney Disease / EndKidney Disease / End--StageStage

Renal DiseaseRenal Disease

May Lead to or Cause:May Lead to or Cause:11.. Nephritic SyndromeNephritic Syndrome

Blood in Urine (Hematuria),Blood in Urine (Hematuria),

Nitrogen RetentionNitrogen Retention

(Azotemia) and decreased(Azotemia) and decreased

urine output (oliguria)urine output (oliguria)

22.. Nephrotic SyndromeNephrotic Syndrome

Proteinuria andProteinuria and

Hypoproteinemia withHypoproteinemia with

Edema (Tissue Swelling)Edema (Tissue Swelling)

33.. UremiaUremia

Decreased Filtration(GFR)Decreased Filtration(GFR)

and Toxic Elevated Bloodand Toxic Elevated Blood

Urea Nitrogen (BUN)Urea Nitrogen (BUN)

KidneyKidneyDamageDamage

End Stage RenalEnd Stage Renal

Dialysis or TransplantDialysis or Transplant

Glomerulonephritis

Kidney Stones

Developmental

Malformations

Chemical Toxins

Pyelonephritis


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Renal (Kidney) DiseaseRenal (Kidney) Disease

Questions to AskQuestions to Ask

What kind of kidney problem?What kind of kidney problem?

Does it interfere with everyday living?Does it interfere with everyday living? WhatWhat MedicationsMedications ??

Are you onAre you on DialysisDialysis??

Have you had a KidneyHave you had a Kidney TransplantTransplant??

Do you also haveDo you also have HTNHTN??


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Dental Management ofDental Management of

Patients with Renal DiseasePatients with Renal Disease

AvoidAvoid Renal Toxic DrugsRenal Toxic Drugs (Acetominophen)(Acetominophen)

Alter Dosage or Type ofAlter Dosage or Type ofRenal Excretable DrugsRenal Excretable Drugs

(Penicillin)(Penicillin) DayDay afterafterDialysisDialysis for Dental Appointmentsfor Dental Appointments

Best Mental Status and General HealthBest Mental Status and General Health

Anticoagulants(Post)Anticoagulants(Post) andand Decreased Platelete Function /Decreased Platelete Function /

AdhesionAdhesion (Pre)(Pre) May Interfere with HemostasisMay Interfere with Hemostasis

Increased Risk of Infection forIncreased Risk of Infection forTransplantTransplant

Patients (Patients (ImmunosuppressionImmunosuppression))


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HYPERTENSION / RENALHYPERTENSION / RENAL

Health History FindingsHealth History Findings

Go ToGo To

HealthHealth

HistoryHistory

HEA

TH HI TORYUn i

rsit

f t

P

cific Sc

l

f

ntistr

P

ti

nt N

: S

c. S

c. N

.:

irt

t

:

I.

IRC

EA

RO

RIATEANSWER (l

l

nk if

!

"

not!

nderst

nd q!

estion) :

#

. Yes No Is our$

ener

l

ealt

$

ood ?2. Yes No Has t

ere%

eena c

ange in our

ealt

& it

in t

e last ear?

'

. Yes No Have

ou % een os ( italizedor ada serious illness in t e last t ree

ears?If Y

)

S,&

?0

. Yes No Are ou%

eing treated%

a(

siciannow ? Forwhat?

ateof last

edical exam?

ateof last

ental exam 5. Yes No Have ouhad

(

roblems with(

riordental treatmen t?

1

. Yes No Are

ou in ( ainnow?

II. HAVEYOUEX

ERIENCED:7. Yes No Chest

(

ain (angi na)? #

8. Yes No Dizziness?8. Yes No Swollenankles? # 9. Yes No Ringing inears?9. Yes No Shortness ofbreath? 20. Yes No Headaches?

#

0. Yes No Recent weight loss, fever, night swea ts? 2#

. Yes No Fainting s(

ells?

# #

. Yes No Persistent cough, coughingupblood? 22. Yes No Blurredvision?

#

2. Yes No Bleedingproblems, bruisingeasil

? 2'

. Yes No Seizures?

#'

. Yes No Sinus problems? 20

. Yes No Excessive thirst? #

0

. Yes No Difficult

swallowing? 25. Yes No Frequent urination?

#

5. Yes No Diarrhea, constipation, blood in stools? 21

. Yes No Dr mou th? #

1

. Yes No Frequen t vom iting, nausea? 27. Yes No Jaundice?

#

7. Yes No Difficult

urinating, blood inurine? 28. Yes No Joint pain, stiffness?

III. DOYOUHAVEORHAVEYOUHAD:29. Yes No Heart disease?

0

0. Yes No AIDS

'

0. Yes No Heart attack, heart defects? 0

#

. Yes No Tumors, cancer?

'

#

. Yes No Heart murmurs? 0

2. Yes No Arthritis, rheumatism?

'

2. Yes No Rheumatic fever? 0 '

. Yes No Eyediseases?

' '

. Yes No Stroke, hardeningofarteries? 0 0

. Yes No Skindiseases?

' 0

. Yes No Highblood pressure? 0

5. Yes No Anem ia?

'

5. Yes No Asthma , TB, emphysema , other lungdiseases? 0 1

. Yes No VD (syph ilis orgonorrhea)?

' 1

. Yes No Hepatitis, other liverdisease? 0

7. Yes No Herpes?

'

7. Yes No Stomachproblems, ulcers? 0

8. Yes No Kidney, bladderdisease?

'

8. Yes No Allergies to: drug s, foods, med ications, latex? 0

9. Yes No Thyroid, adrenal disease?

'

9. Yes No Fam ilyhistoryofdiabetes, heart problems, tumors? 50. Yes No Diabetes?

IV. DO YOUHAVEORHAVEYOUHAD:5

#

. Yes No Psychiatric care? 51

. Yes No Hospitalization?52. Yes No Radiation treatments? 57. Yes No Blood transfusions?5

'

. Yes No Chemotherapy? 58. Yes No Surgeries?5

0

. Yes No Prosthetic heart valve? 59. Yes No Pacemaker?55. Yes No Artificial

2

oint? 1

0. Yes No Contact lenses?

V. AREYOUTAKING:

1

#

. Yes No Recreationa l drugs? 1 '

. Yes No Tobacco inany form?

1

2. Yes No Drugs, med ications, over-the-countermed icines1 0

. Yes No Alcohol?(includingAspirin), nat ural remedies?

Please list:

VI. WOMENON

Y:

1

5. Yes No Areyou or couldyou bepregnant ornursing? 1 1

. Yes No Takingbirth control pills?

VII. A

PATIENTS:

1

7. Yes No Doyou haveorhaveyou hadanyotherdiseases ormed ical problems N3

T listedon this form?If so, pleaseexp lain:

To the best of my k nowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my healthand/or medication.

Patients signature: Date:

RECA4 4

REVIEW:

5

. Patients signature Date:

2. Patients signa ture Date:

6

. Patients signature Date:

General Health

Signs & Symptoms

Specific Diseases

Types of Treatment

Medications


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HYPERTENSION / RENALHYPERTENSION / RENAL

UOP Protoc

ol

sUOP Protoc

ol

s

Go ToGo To

UOPUOP

ProtocolProtocol

University of the acific chool of Den tistry

rotocols for the

DENTAL MANAGEMENT OF MEDICALLYCOMPLEX PATIENTS

TOP IC PAG E

1. Bleeding Problems (including anticoagulants) 2

2. Cardiac Problems (heart murmurs, cardiac defects) 4

3. CardiovascularProblems (high blood pressure, arrhythmias) 8

4. Central Nervous System Problems (seizures, stroke) 12

5. Diabetes 15

6. Immunosuppression 17

7 . I n fe cti ou s D is ea se s (tu be rc ul os is , h ep ati ti s, H IV , h er pe s, f lu ) 1 9

8. Kidney Problems 24

9. LiverProblems 25

10. Pregnancy 27

11. Prosthetic Joints 29

7

rotocols compiled by:7

eter L. Jacobsen,7

h.D., D.D.8

Department of7

athology and Medicine

7

lease direct all comments, edits and suggestions to him at:

[email protected] or call (41 9 )@ A @

-66 B@

or fax (41 9 )@ A @

-66 9 4 or write to:Department of 7 athology and Medicine

UO 7 8

chool of DentistryA

19 9

Webster8

treet8

an C rancisco, CA@

411 9

See:See:

Questions to AskQuestions to Ask

Diagnostic TestsDiagnostic Tests

Dental ManagementDental Management

AlertsAlerts

(Complications)(Complications)


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THE ENDTHE END

Hypertension & Renal

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