Dental Management

Considerations for the

Patient with High Blood
Pressure
Donald Falace, DMD
Professor and Division Chief
Oral Diagnosis and Oral Medicine
University of Kentucky College of Dentistry

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

Korotkoff sounds: First appearance of

sounds is the systolic pressure; the
complete disappearance of sounds is the
diastolic pressure.

The Seventh Report of the Joint

National Committee on
Prevention, Detection, Evaluation,
and Treatment of High Blood
Pressure
The JNC 7 Report
Hypertension. 2003;42:1206-1252 (Complete
version)
JAMA. 2003;289:2560-2572 (Express version)
From the National Heart, Lung, and Blood Institute

Epidemiology
More than 65 million Americans have HBP
30% are unaware of their disease
40% are not being treated
60% of those being treated are not adequately
controlled
Prevalence increases with age; >half of people
over age 65 have HBP
Systoloic pressure rises throughout life; diastolic
pressure levels off or falls after age 50
The higher the BP, the greater the risk of stroke,
MI, heart failure, and kidney disease

Morbidity and Mortality

Associated with HBP
5888 adults, >65 years, recruited in 198990 from 4 medical centers; followed for
average of 6.7 years

SBP, DBP, and pulse pressure were all

strongly and directly related to the risk of
coronary and cerebrovascular events
Effects are linear (graph)
Arch Int Med. 2001; 161:1183-1192

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

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

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

Hypertension is an insidious disease

and may remain completely
asymptomatic for many years
Measurement of blood pressure is the
only means of detection

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

Classification of High Blood

Pressure: JNC 7
BP Classification

Systolic BP

Normal
Prehypertension
Stage 1
Stage 2

<120
120-139
140-159
>160

Diastolic BP
<80
80-89
90-99
>100

Based on 2 or more properly measured seated BP

readings on each of 2 or more office visits

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

Lifestyle Modifications
Weight loss if overweight
Adopt 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 activity
Limit alcohol intake (< 1-2 drinks/day)
Stop smoking

Oral Antihypertensive Drugs

Decision to prescribe depends upon:
Degree of BP elevation
Presence of target organ damage
Presence of cardiovascular disease
Risk factors

Diuretics
Thiazides (Diuril,
hydrochlorthiazide, HCTZ)
Loop Diuretics (Lasix)
K-Sparing Diuretics (Midamor,
Dyrenium)
Combination (Aldactazide, Dyazide)

Beta Blockers
Cardioselective (-1)

Non-Selective (-1&2)

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

cartelol (Cartrol)
labetalol (Trandate)
nadolol (Corgard)
penbutolol (Levatol)
pindolol (Visken)
propanolol (Inderal)
propanolol long-acting
(Inderal LA)
sotalol (Betapace)
timolol (Blocadren)

Combined Alpha-Beta Blockers

Carvedilol (Coreg)
Labetalol (Normodyne; Trandate)

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)

Angiotensin Receptor Blockers (ARBs)

Candesartan (Atacand)
Eprosartan (Teveten)
Irbesartan (Avapro)
Losartan (Cozaar)
Olmesartan (Benicar)
Telmisartan (Micardis)
Valsartan (Diovan)

Calcium Channel Blockers

Amlodipine (Norvasc)
Bepridil (Bepadin; Vascor)
Diltiazem (Cardizem)
Felodipine (Plendil)
Isradipine (DyanCirc)
Nicardipine (Cardene)
Nifedipine (Procardia)
Nimodipine (Nimotop)
Verapamil (Calan; Isoptin)

Alpha-1 Blockers
Doxazosin (Cardura)
Prazosin (Minipress)
Terazosin (Hytrin)

Central Alpha-2 Agonists and

Other Centrally Acting Drugs

Clonidine (Catapres)
Clonidine patch (Catapres-TTS)
Methyldopa (Aldomet)
Reserpine (generic)
Guanfacine (Tenex)

Direct Vasodilators
Hydralazine (Apresoline)
Minoxidil (Loniten)

Medication Compliance
(What happens when you prescribe medication?)

1/3 take their medication

1/3 take their medication sometimes
1/3 dont take their medication at all

Blood Pressure Measurement

When:
All new patients
At recall
appointments

Why?
Identification of
undiagnosed
hypertension
Monitoring for
control/compliance in
known hypertensives

Risk Assessment
At what level of blood pressure is it
unsafe to treat a patient?
How much of a risk is there if I treat a
patient with an elevated blood pressure?
How much of a risk is there if I use
epinephrine in a patient with high blood
pressure?

Risk Guidelines For

Performing Non-cardiac
Surgery
American Heart Association and American
College of Cardiology
Eagle, KA, et al: Guidelines for perioperative cardiovascular
evaluation for noncardiac surgery. J Am Coll Cardiol 27(4):910948, 1996
(www.americanheart.com)

Clinical Predictors:
Minor Risk

Advanced age
Abnormal ECG ( LVH, LBBB, ST-T abnormalities)
Heart rhythm other than sinus (e.g. atrial fibrillation)
Low functional capacity ( e.g. inability to climb one
flight of stairs with a bag of groceries)
History of stroke
Uncontrolled systemic hypertension (BP>180/110);
should be treated prior to elective procedures

Surgical/Procedures Risk
Stratification: Low Risk (<1%)

Endoscopic procedures
Superficial procedures*
Cataract surgery
Breast surgery
*(Minor oral surgery, minor perio surgery and
all non-surgical dental procedures would be
included in this category)

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

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

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

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

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

Potential Adverse Drug

Interactions with Epinephrine:
Non-selective beta blockers
(Epinephrine may be used cautiously, if needed, in
modest amounts [.018-.036 mg])

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

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)