History
First task of the dentist is to take proper history of the patient and identify patients with hypertension, both diagnosed and undiagnosed. A proper medical history, including the diagnosis of hypertension, how it is being treated, identification of antihypertensive drugs, compliance of the patient, the presence of symptoms associated with hypertension, and the level of stability of the disease should be obtained. Sometimes, the patient may not reveal to the dentist that he has been diagnosed as hypertensive. In such situations, the dentist should identify the problem by extracting from the patient, regarding the medicinal prescriptions.
Examination
All the new patients should be routinely examined for blood pressure by using a sphygmomanometer. However, strict indications for blood pressure measurement are patients who are not compliant with treatment, who are poorly controlled, or who have comorbid conditions like heart failure, previous myocardial infarction, or stroke. On examination when it is diagnosed that the patients who are undergoing treatment for hypertension but are still seen to have blood pressure above normal are most often inadequately treated. Such patients should be encouraged to return to their physician. Also, the patient who does not give history of hypertension but, on examination exhibits high blood pressure, should be informed about elevated blood pressure and referred to the physician. Dentist should not make a diagnosis of hypertension.
Stage 1 hypertension – Systolic blood pressure – 140 to 159mmHg
Diastolic blood pressure – 90 to 99mmHg
Stage 2 hypertension – Systolic blood pressure >160mmHg
Diastolic blood pressure >100mmHg
When a patient with upper level stage 2 blood pressure is being given any kind of dental treatment, it is advisable to leave the blood pressure cuff on the patient’s arm and periodically keep checking the blood pressure during the treatment. If blood pressure rises above 179/110mmHg, the appointment should be terminated and the patient rescheduled.
The primary concern to the dentist while providing dental treatment for a patient with hypertension is that during the course of treatment, the patient might experience an acute elevation in blood pressure that could lead to a serious outcome such as a stroke or myocardial infarction.
The acute elevation in blood pressure could result from following reasons-
• The release of endogenous catecholamines in response to stress and anxiety.
• From injection of exogenous catecholamines in the form of vasoconstrictors.
• From absorption of a vasoconstrictor from the gingival retraction cord.
Other concerns to the dentist in regards to hypertensive patients are-
• Potential drug interactions between the patient’s antihypertensive medications and the drugs prescribed.
• Oral adverse effects that might be caused by antihypertensive medications.
Dental Management Recommendations for patients with hypertension-
• Patients with blood pressure less than 180/110mmHg can be treated for any necessary dental treatment, both surgical and non-surgical, with very little risk of an adverse outcome.
• For patients found to have asymptomatic blood pressure >180/110mmHg (uncontrolled hypertension), elective dental care should be deferred and the patient referred to a physician as soon as possible for evaluation and treatment.
• Patients with elevated blood pressure with symptoms such as headache, shortness of breath, chest pain, nosebleeds, or severe anxiety (severs anxiety) may require more urgent medical attention.
• At times, in patients with uncontrolled or severe hypertension, the need for urgent dental treatment as in case of pain, infection or bleeding may necessitate dental treatment. In such cases the dentist should manage the patients in consultation with physician and measures such as intra-operative blood pressure monitoring, ECG monitoring, establishment of an IV-line and sedation may be used.
Once, after the decision that the hypertensive patient can be safely treated, a management plan should be developed as follows-
• The dentist should make every effort to reduce as much as possible the stress and anxiety associated with dental treatment.
• Dentists should establish a good rapport with the patient. This will encourage the patient to express and discuss their fears, concerns and questions about dental treatment with the dentist.
• Long and stressful appointments should be avoided. Short morning appointments seem to be best tolerated.
• If the patient becomes anxious or apprehensive during the appointment, the appointment may be terminated and rescheduled for another day.
• In order to reduce anxiety in patients, oral premedication can be considered. A short acting benzodiazepine such as triazolam can be prescribed. An effective approach is to prescribe a dose at bedtime the night before and another dose 1 hour before the dental appointment.
• Some antihypertensive agents (which the patient may be put on) tend to produce orthostatic hypertension. Thus sudden changes in chair position during dental treatment should be avoided. When treatment has concluded for that appointment, the dental chair should be returned slowly to an upright position. After patients have had time to adjust to the change in posture, they should be physically supported while slowly getting out of the chair and should have obtained good balance and stability. If they complain of dizziness or lightheadedness, they should sit back down until they recover equilibrium.
• Profound local anesthesia is very important so as to control pain and anxiety in patients with hypertension or other cardiovascular disease to decrease the endogenous catecholamine release.
• Epinephrine in local anesthetic should be used cautiously in patients who are taking non-selective beta blockers or peripheral adrenergic antagonists.
• Always avoid the use of epinephrine impregnated gingival retraction cord in hypertensive patients, because these cords contain highly concentrated epinephrine, which can be quickly absorbed through the gingival sulcular tissues, resulting in tachycardia and elevated blood pressure.
Oral Manifestations in hypertensive patients
• Patients with malignant hypertension have been reported to occasionally develop facial palsy.
• Patients with severe hypertension tend to bleed excessively after surgical procedures or trauma.
• Patients who take antihypertensive drugs, especially diuretics, may report dry mouth.
• Mercurial diuretics may cause oral lesions.
• Lichenoid reactions have been reported with thiazides, methyl-dopa, propranolol, and labetolol.
• ACE-inhibitors may cause neutropenia, resulting in delayed healing or gingival bleeding.
• Non allergic angioedema may be caused by ACE-inhibitors.
• All calcium channel blockers may cause gingival hyperplasia.
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