DEPARTMENT OF ORAL AND

MAXILLOFACIAL SURGERY HYPERTENSION

BYASHOK KUMAR AFINAL YEAR BDS

CONTENTS :• DEFINITION• TYPES OF HYPERTENSION • ETIOLOGY• GRADING OF BLOOD PRESSURE• CLINICAL FEAUTURE• COMPLICATION• INVESTICATION• TREATMENT• HYPERTENSION MANAGEMENT IN DENTISTRY

HYPERTENSIONDEFINITION : Hypertension is a condition in which arterial blood pressure is chronically elevated.

High blood pressure said to be present if it is persistently at or above 140/90 mm Hg.

TYPES OF HYPERTENSION :

1)Primary hypertension or essential hypertension.

2)Secondary hypertension.

PRIMARY HYPERTENSION Condition of elevated blood pressure with no underlying cause. 1)Benign hypertension.

2)Malignant hypertension.

Environmental Factor : 1) High salt intake 2) Heavy consumption of alcohol 3) Obesity 4) Lack of exercise 5) Impaired intrauterine growth 6) Stress

SECONDARY HYPERTENSION Condition of elevated blood pressure with some specific underlying cause. CAUSES: 1) Alcohol 2) Obesity 3) Increased intra cranial pressure 4) Toxaemia of pregnancy

5) RENAL DISORDER a) Renal vascular disease b) Glomerulonephritis c) Polycystic kidney disease 6) ENDOCRINE DISORDER a) Pheochromocytoma b) Cushing syndrome c) Hyperaldosteronism 7) CARDIOVASCULAR DISORDER a) Coarctation of aorta b) Atherosclerosis

8) DRUGS a) Oral contraceptive b) Corticosteroids c) sympathomimetic drugs

REGULATION OF BLOOD PRESSURE NERVOUS RENAL HORMONAL LOCAL

By vasomotor By regulation By Hormones By local center & of ECF volume causing vasoconstrictor Impulse from & Renin - Angiotensin vasoconstriction & periphery mechanism & vasodilators vasodilatation

Normal BP value is 120/80 mm HgGRADE SYSTOLIC BP ( in mm Hg) DAISTOLIC BP ( in mm Hg)

Grade 1 (Mild Hypertension) 140 - 159 90 - 99

Grade 2 (Moderate Hypertension) 160 - 179 100 - 109

Grade 3 (Severe Hypertension) > 180 >110

White coat hypertension

Transient Increase in blood pressure in normal individual when blood pressure is recorded in a physician consultation room or in hospital

CLINICAL FEATURES : 1) Severe Head ache 2) Dizziness 3) Palpitation 4) Sweating 5) Blurred vision 6) Loud aortic heart sound

COMPLICATION CNS - Transient ischaemic attacks - Strokes - Hypertensive encephalopathy OPTHALMIC - Hypertensive retinopathy CVS - Left ventricular failure - coronary artery disease

RENAL - Protenuria - progressive renal failure MALIGNANT HYPERTENSION - Elevated blood pressure with end organ damage such us retinopathy , renal dysfunction and left ventricular failure may occur, if left untreated death occurs within months.

INVESTIGATION 1) Urinalysis for glucose, blood , protein 2) Blood urea , Blood glucose level 3) Serum total & HDL cholesterol level 4) ECG 5) Echocardiogram 6) Chest X-ray 7) Renal Ultrasonography

TREATMENT NON DRUG THERAPHY LIFE STYLE MODFICATION -Relief of stress -Salt restriction -Weight reduction -Reduced Alcohol intake -Stop smoking -Regular physical exercise

DRUG THERAPHY : THIAZIDE & OTHER DIURETICS -Hydrochlorothiazide , Cyclopenthiazide -Furosemide , bumetanide ACE INHIBITOR -Enalapril , ramipril , lisinoprilANGIOTENSIN RECEPTOR BLOCKER -Valsartan , LosartanCALCIUM CHANNEL BLOCKER -Amlodipine , nifedipine , verapamil

BETA BLOCKER -Proponalal , atenolol , metoprolal MIXED ALPHA & BETA BLOCKER -Labetalol , Carvedilol OTHER DRUGS -Prazosin , terazosin , -hydralazine , sodium nitroprusside

HYPERTENSIVE CRISESHYPERTENSIVE EMERGENCIES High BP associated with target organ damage. Requires treatment in ICU with constant monitoring of BPHYPERTENSIVE URGENCIES High BP but no organ damage. Treatment : -Sodium nitroprusside -Nifedipine -Nitroglycerin -Hydralazine -Labetolol

HYPERTENSION MANAGEMENT IN

DENTISTRY

GUIDELINES FOR BLOOD PRESSURE (ADULT)BLOOD PRESSURE (in mm Hg)

ASA CLASSIFICATION

DENTAL THERAPY CONSIDERATION

<140 & <90 I

1) Routine dental management.2) Recheck in 6 months.

140-159 & 90-94 II

1) Recheck BP prior to dental treatment for three consecutive appointments; if all exceed these guidelines , medical consultation is indicated.

2) Routine dental management.3) Stress reduction protocol as indicated.

BLOOD PRESSURE ( in mm Hg)

ASA CLASSIFICATION

DENTAL THERAPY CONSIDERATION

160-199 &/or 95-114 III

1)Recheck blood pressure in 5 minutes.2)If still elevated ,medical consultation before dental therapy.3)Routine dental therapy.4)Stress reduction protocol.

>200 &/or >115 IV

1)Recheck blood pressure in 5 minutes.2)Immediate medical consultation if still elevated.3)No dental therapy, routine or emergency , until elevated BP corrected.4)Emergency dental therapy with drugs5)Refer to hospital if immediate dental therapy indicated.

PRE OPERATIVE MEDICATION & MANAGEMENT

• Patient BP should be monitored & controlled within normal.• To antihypertensive patient morning dose of medication

prior to surgery must be given.

INTRA AND POST OPERATIVE MANAGEMANT

1) Blood pressure should be monitored continuously. 2) Patient cardiac status also monitored. 3) Antihypertensive must be continued. 4) If the procedure is performed under local anesthesia , the local anesthetic without adrenaline is to be used.

REFERANCE 1) DAVIDSON Principal & practice of Medicine. 2) Essential of MEDICAL PHYSIOLOGY - K SEMBULINGAM - PREMA SEMBULINGAM 3) Textbook of ORAL AND MAXILLOFACIAL SURGERY - NEELIMA ANIL MALIK 4) MEDICAL EMERGENCIES IN THE DENTAL OFFICE - STANLEY F . MALAMED

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