HYPERTENSION

Bold/ underline = IMPORTANT; gray = extra explanation

Definition:
 Chronic elevation in blood pressure >140/90mmHg. in separate readings

 High blood pressure (hypertension) is a major cause of premature vascular

disease i.e atherosclerosis, leading to cerebrovascular events, ischemic heart

disease i.e reduced blood supply and peripheral vascular disease.
Epidemiology: commonality
 The prevalence of hypertension may be 30–45% of the general population.

 The prevalence increasing with age to 70% in the seventh decade

 Due to loss of bv elasticity

Etiology: cause
 A- Essential (primary) B-secondary

 A-Essential (primary): In more than 95 % of cases, an underlying

cause cannot be found i.e. idiopathic
Kidney, in addition to liver, regulates blood pressure by the renin
angiotensin system

Pathogenesis:
It is not clearly understood. Proposed mechanisms include:
1- Excess renal sodium retention when it’s supposed to excrete sodium
2- Over activity of the sympathetic nervous system causes vasoconstriction
3- Renin angiotensin excess disorder in its own system
4-Hyperinsulinemia as part of metabolic syndrome:
 hyperinsulinemia, glucose intolerance,

 reduced levels of HDL cholesterol, hypertriglyceridemia and

 central obesity‫رش‬:‫( ك‬all of which are related to insulin resistance).

5- Alterations in vascular endothelium resulting in reduction of vasodilators or increase in

vasoconstrictors
Factors contributing to the development of Essential
Hypertension(risk factors):
B- Secondary hypertension:
In about 5% of cases an underlying cause can be found:
 1-Renal
:
i. It accounts for 80% of the cases of secondary hypertension.
ii.Parenchymal its own ct. renal diseases like chronic glomerulonephritis, diabetic
nephropathy , adult polycystic disease, chronic tubulointerstitial nephritis inf and
renovascular
2- diseases like renal artery stenosis (simple ttt of stent)
Endocrinal
Hypo or hyperthyroidism, Cushing syndrome i.e. moon face; hypercortisone, primary
aldosteronism i.e. Na retention and K excretion, pheochromocytoma adrenal medulla
hyperactivity, hyperparathyroidism, and acromegaly gigantism; lower jaw protrusion.
3-Drugs and toxins


 glucocorticoids, oral contraceptives, cocaine, cyclosporine, erythropoietin

4-Pregnancy
4-Pregnancy
-Induced hypertension
Preeclampsia until giving
birth.
5-Vascular coarctation
5-Vascular coarctation
of of
aorta, vasculitis
aorta, vasculitis
Diagnosis:

Category Systolic BP(mmHg) Diastolic BP(mmHg)

BP
Optimal < 120 <85
Normal < 130 85
High normal 130–139 85–89
 

Hypertension
Grade 1 (mild) 140–159 90–99
Grade 2 (moderate) 160–179 100–109
Grade 3 (severe ) ≥ 180 ≥ 110
 

Isolated systolic hypertension (aortic regurge)

Grade 1 140–159 < 90
Grade 2 ≥ 160 < 90
 
Postural Hypotension
Symptoms:
 Usually none, occasionally headache (occipital, blurred vision,

dizziness and epistaxis; nosebleed ).

 A history of over-the-counter medication use, current and previous

unsuccessful antihypertensive medication trials.
 A history of cardiovascular risk factors e.g hypercholesterolemia,
diabetes mellitus,
 tobacco use and family history of premature cardiovascular disease.
Symptoms specific of secondary hypertension:

New onset hypertension below age of 30 (renal artery stenosis; primary)

or above 50 years (valve regurge).
 Weakness, polyuria and muscle cramps caused by hypokalemia in =

primary hyperaldosteronism.
 Weight gain and emotional liability (euphoric-depressed mix)

=Cushing's syndrome
 Headaches, palpitations and sweating in = pheochromocytoma.

 Systemic vasculitis
Symptoms of complications:

In chronic or severe hypertension:

 symptoms of congestive heart failure,

 coronary artery disease,

 cerebrovascular disease and

 chronic kidney injury (uremia).

Signs:
1 - High blood BP reading:
 It should be measured in the sitting or the supine position with the arm supported

after 5 minutes resting

 Standing BP should be measured in the elderly and those suffering from positional

hypotension (diabetics and patients on anti-hypertensive medications) to exclude

orthostatic hypotension.
 "White coat hypertension": apparent hypertension in the clinic, with a normal BP

when recorded by automated devices in the patient's own home.‫مترعبمنا@@لدكتور ب@@@س‬

 Ambulatory BP over 24 hours is helpful in patients with labile BP, symptomatic

hypotension and those with "white coat hypertension"

2- Signs of secondary hypertension
 Radio-femoral delay (coarctation of the aorta)

 Enlarged kidneys (polycystic kidney disease)

 Abdominal bruits noisy sound (renal artery stenosis)

 Moon face and trunkal obesity (Cushing syndrome)

3- Signs of other cardiovascular risk factors:

 Abdominal obesity (metabolic syndrome)

 Endonxanthomas (hyperlipidemia) lipid on eye

4- Signs of end organ damage and complications
 Eye: Retinopathy

 Cardiac: Left ventricular enlargement or failure.

 Peripheral vascular disease: weak or absent peripheral pulsations.

 Carotid vascular disease: (carotid bruit).

 CNS: Cerebrovascular disease (stroke).

:Complications of hypertension
Skipped!
 Blood vessels:
Wide spread atheroma formation leading to coronary and or cerebrovascular disease,
particularly if other risk factors (e.g. smoking, dyslipidemia, diabetes) are present.
 Central nervous system:

 Stroke (due to hemorrhage or thrombosis and transient ischemic attacks (TIAs) are

more common in hypertensive patients

 Subarachnoid hemorrhage

 Hypertensive encephalopathy: a condition of high blood pressure and neurologic

symptoms, usually reversible if hypertension is controlled.

 Symptoms include disturbances of speech and vision, disorientation, fits and loss of

consciousness. Papilledema is common

Skipped!
 Retina:
-Changes are associated with hypertension include retinal ischemia or infarction
and also central retinal vein thrombosis.
 Heart:

- Higher incidence of coronary artery disease

- Left ventricular
- failure Left ventricular hypertrophy
 Kidneys:

- Long standing hypertension may lead to proteinuria and renal failure due to
damage of renal vasculature
Investigations
All hypertensives:
 Urine: for blood, protein and glucose check for renal impairment

 Blood urea and serum creatinine:. If elevated, more specific renal

investigations are as creatinine clearance

 Electrolytes: (hypokalemia may occur in primary hyperaldosteronism or

more commonly due to diuretic therapy)

 Blood glucose, lipid profile: (total and high density lipoprotein cholesterol).

 ECG: Left ventricular hypertrophy (LVH) & coronary artery disease (CAD)
In selected cases:
Imaging
 - Chest xray: (cardiomegaly, heart failure, coarctation).
 - Ambulatory BP monitoring: (borderline or white coat hypertension).
 - Echocardiography: left ventricular hypertrophy (LVH).
 - Abdominal ultrasound: (possible renal disease).
 - Renal angiography, MR & CT angiography, renal arterial duplex (renal artery
stenosis).
Laboratory:
 - urinary catecholamines e.g free metanephrins (pheochromocytoma).
 - Urinary cortisol and Dexamethasone suppression test: (Cushing's syndrome).
 - Plasma renin and aldosterone (primary aldosteronism).
 - Sensitive thyroid-stimulating hormone level (TSH)
Treatment:
Treatment goal Bp <140/90 for most patients.
 Treatment of hypertension includes:
A-Non-pharmacologic therapy (Life style interventions):
 Smoking cessation: smoking accounts for 30% of all cardiovascular deaths. It decreases the risk

to never smoked at 2 years

 Weight reduction:

 Diet: low salt :< 6gm/d, adequate potassium: increase fruit and vegetable consumption, adequate

calcium, low saturated fat diet.

 Exercise: moderate exercise 30-40 minutes most days of the week.

 No alcohol consumption

B-Pharmacologic therapy (antihypertensive medications):

 Aim: to reduce the risk of complications.
Classes of drugs; different causes
l- Angiotensin converting enzyme inhibitors (ACE inhibitors):
 Mechanism: They block the conversion of angiotensin I to angiotensin II, which is a potent
vasoconstrictor.
 They block the degradation of bradykinin, a potent vasodilator. Side effect: cough
2-Angiotensin receptor blockers (ARBs): Selective block of the receptors of angiotensin II
3-Calcium channel blockers:
 Mechanism: Arteriolar dilatation, some also reduce the force of cardiac contraction.
4-Thiazide diuretics
5-Alpha adrenergic blockers:
 Block the post synaptical-receptors with resulting vasodilatation.
6-Beta blockers: attenuate the effects of the sympathetic nervous and renin-angiotensin
systems.
Dental management of hypertensive patients:

The sequential treatment plan for hypertensive patients generally starts

with:
 *consulting the physician regarding the current medical status,

medication, and patient management during periodontal therapy.

 *Dentist must inform the physician regarding the estimated degree

of stress, length of procedures, and complexity of the

individualized treatment plan i.e. Local anesthesia
 Initial evaluation of each patient with hypertension should include
detailed family history of cardiovascular disease, history of
hypertension, medications, duration and antihypertensive treatment
history, severity of disease, and its complications.
 *Before starting dental treatment, dentist has to assess the presence of
hypertension and accordingly the treatment changes needed.
 *Patients with hypertension are at increased risk of developing adverse
effects in a dental office.
 Therefore, measuring blood pressure (BP) will be done in the dental
office to every new patient for each visit.
 In patients with chronic systemic diseases, BP measurement will be
carried out during more complicated dental interventions as oral
surgical procedures, restorative treatment complicated with longer
sessions, placing dental implants, and periodontal surgery.
 *Routine measurement of BP may reduce the risk of cardiovascular
events and acute complications during dental treatment, especially
when conscious sedation or general anesthesia is required
 Whenever a dentist meets a patient with hypertensive crisis, the
dental procedure should be postponed and the patient should be
immediately sent to a hospital
Oral Manifestations Caused by the Adverse Effects of Antihypertensive
Drugs

Xerostomia

*Many anti hypertensives medications like ACEIs, thiazide diuretics, loop

diuretics, and clonidine are associated with xerostomia Its likelihood increases
with the number of concomitant medications.

Xerostomia has many consequences, like decay, difficulty in chewing,

swallowing, and speaking, candidiasis, and oral burning syndrome.

Sometimes the feeling is transient and salivary function is adjusted by the patient
itself.

*There are situations when is required to change the antihypertensive medication.

It is often necessary to treat xerostomia directly with parasympathomimetic

agents such as pilocarpine or cevimeline.
 Other recommendations include frequent sipping of water, sugarless
candies, coffee consumption reduction, and avoiding alcohol
containing mouthwashes.
 *To reduce the risk of caries topical applications of fluoride,
particularly in the form of gels with high concentrations applied by
brush are recommended.
Gingival Hyperplasia

It can be caused by calcium channel

blockers,. The majority of cases are
associated with nifedipine.
The effect could be dose related.
Gingival hyperplasia is manifested by
pain, gingival bleeding, and difficulty in
mastication.
A good oral hygiene greatly reduces its
incidence.
By changing antihypertensive
medication hyperplasia can be reversed .
Lichenoid Reaction

Many antihypertensives (thiazide diuretics,

methyldopa, propranolol, captopril, furosemide,
spironolactone, and labetalol) are associated with
oral lichenoid reactions . Clinical forms differ
greatly from lichen planus itself.

*The easiest way to treat it is to change

antihypertensive medication, and lichenoid
reactions are resolving after discontinuation of
the responsible drug.

*If medication could not be changed, lichenoid

reactions are treated with topical corticosteroids
Other Undesirable Effects
 ACE inhibitors are associated with cough and loss of taste (ageusia)

or taste alteration (dysgeusia).

 Dysgeusia has also been reported with other antihypertensives use,

like β-blockers, acetazolamide, and diltiazem.

 It has been postulated that dysgeusia may result through a mechanism

affecting salivary handling of metal ions such as magnesium

 6. Drug Interactions between Anti hypertensives and Drugs Used in
Dentistry

Most antihypertensive drugs have drug interactions with LA (local

anesthetic) and analgesics.
 *Interaction of LA with nonselective beta-blockers may increase LA

toxicity .
 The cardiovascular effects of epinephrine used during dental procedures

may be potentiated by the use of nonselective b-blockers (propranolol and

nadolol).
 *so decreasing the dose and increasing the time interval between

epinephrine injections
 Long-term use of NSAIDs may antagonize the antihypertensive effect of
diuretics, beta-blockers, alpha blockers, vasodilators, ACE inhibitors .
 *Short-term administration has, however, a clinically meaningful effect.
 *Other pain relievers such as paracetamol can be used to avoid this side
effect.
 *Dental treatment in hypertensive patients necessitates special attention,
because any stressful procedure may increase blood pressure and trigger
acute complications such as cardiac arrest or stroke.
 Control of pain and anxiety is very important in patients with
high medical risk.
 *Patients with cardiovascular disease have a high risk of
complications due to endogenous catecholamines (adrenaline and
noradrenaline) released from pain and stress. These catecholamines
may increase dramatically BP and cardiac output.
 *This effect is reduced by controlling dental pain. Local anesthetics
with epinephrine produce a longer and more effective anesthesia than
simple LA, thus avoiding an exaggerated response to stress .
Avoid sudden death of LA misuse
 LA with vasoconstrictor should be avoided or used in low doses in patients taking nonselective
beta-blockers or in patients with uncontrolled hypertension.
 *The maximum recommended dose of epinephrine in a patient with cardiac risk is 0.04 mg,
which is equal to that containing about two cartridges of LA with 1 : 100000 epinephrine or 4
cartridges with 1 : 200000 epinephrine .
 *In patients with severe disease it may be useful to measure BP and heart rate after anesthetic
injection. Slow administration can prevent undesirable reactions.
 *Other contraindications to vasoconstrictor LA include severe uncontrolled hypertension,
refractory arrhythmias, myocardial infarction or stroke by age less than 6 months, unstable
angina, coronary artery bypass graft under 3 months, congestive heart failure, and untreated
hyperthyroidism .
 * The use of epinephrine for gingival eviction in patients with cardiovascular disease is
contraindicated .