HYPERTENSION IN EXODONTIA
www.indiandentalacademy.com
INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com
www.indiandentalacademy.com
CONTENTS
Definition Types Causes Signs Target organ diseases Investigation General Management Dental aspect of hypertension Conclusion References www.indiandentalacademy.com
ď Ž
Increase in blood pressure
ď Ž
It is a traitor opposed to a specific disease and represent a quantitative rather than a qualitative deviation from the norm, hence any definition is arbitrary
www.indiandentalacademy.com
Types
Hypertension
Essential
Secondary
www.indiandentalacademy.com
White collar
Causes
Idiopathic
Secondary www.indiandentalacademy.com
Idiopathic 40-60% is genetic factor High salt intake Heavy consumption of alcohol Obesity Lack of exercise Impaired intrauterine growth Stress
www.indiandentalacademy.com
Secondary Alcohol Pregnancy Renal disease
– Renal artery disease – Pyelonephritis – Glomerulonephritis – Polycystic disease – Post trasnplant
Coarctation of aorta www.indiandentalacademy.com
Secondary causes contd.
Endocrine disease – – – – –
Pheochromocytoma Cushings syndrome Acromegaly Thyrotoxicosis Hyperaldosteronism
Cerebral disease
– Cerebral oedema (stroke, head injuries & tumours)
Drugs – – –
Oral contraceptives Streroids NSAIDS www.indiandentalacademy.com
Signs Paroxysmal headache Palpitation Sweating Breathlessness Angina
www.indiandentalacademy.com
Target organ disease Blood vessels
Central nervous system Retina Heart Kidneys Malignant or accelerated phase hypertension www.indiandentalacademy.com
Blood vessels
Larger arteries
Smaller arteries
www.indiandentalacademy.com
Larger arteries (Over 1mm in dia) ↓ Internal elastic lamina is thickened ↓ Smooth muscle hypertrophy ↓ Fibrous tissue is deposited ↓ Vessels dilate become tortous, walls become less compliant ↓ Aggravates hypertension by increasing peripheral vascular resistance ↓ Aortic aneurysm & dissection, coronary & cardiovascular disease, renal failure www.indiandentalacademy.com
Smaller arteries ↓ Hyaline arteriosclerosis in the wall ↓ Lumen narrows ↓ aneurysm develops ↓ Aggravates hypertension by increasing peripheral vascular resistance ↓ Aortic aneurysm & dissection, coronary & cardiovascular disease, renal failure www.indiandentalacademy.com
Central nervous system
Stroke due to cerebral hemorrhage or infarction
Carotid atheroma & transient cerebral ischemia attacks are common
Subarachnoid haemorrhage
Symptoms are – – – –
Disturbance of speech or vision Paraesthesia Disorientation Fits & loss of consiousness
Neurologial deficit is usually reversible if the www.indiandentalacademy.com hypertension is controlled
Retina ď Ž
Central retinal vein thrombosis occurs
ď Ž
Micro aneurysm also occurs
www.indiandentalacademy.com
Heart High blood pressure
Left ventricular hypertrophy (atrial fibrillation)
www.indiandentalacademy.com
Left ventricular failure
Kidney ď Ž
Proteinuria
ď Ž
Progressive renal failure by damaging the renal vasculature
www.indiandentalacademy.com
Malignant or accelerated phase hypertension This rare condition may complicate hypertension of etiology and is characterized by damage with necrosis in the walls of small arteries & arterioles ď Ž
www.indiandentalacademy.com
Investigations
For all patients
www.indiandentalacademy.com
Selected patients
Investigations for all patients Urine analysis for blood, protein and glucose Blood urea, electrolyte, and creatinine Blood glucose Serum total and high density lipoprotien 12 lead ECG
www.indiandentalacademy.com
Investigations for selected patients
Chest radiograph Ambulatory BP recording Echocardiogram Renal ultrasound Renal angiography Urinary catecholamines Urinary corstiol and dexamethasone supressing test Plasma renin activity and aldosterone www.indiandentalacademy.com
Management
Non-drug therapy
www.indiandentalacademy.com
Drug therapy
Non drug therapy Correct obesity Reducing alcohol intake Restricting salt intake Regular physical exercise Increasing consumption of fruits and vegetables Quitting smoking Eating oily fish
www.indiandentalacademy.com
Drug therapy
ß adrenoreceptor blockers – – – –
Possible oral effects – – –
Metaprolol (100-200mg/day) Bisoprolol (50-100mg/day) Atenolol(50-100mg/day) Labetalol (200-2.4g/day) Dry mouth Lichenoid reactions Paresthesia with labetalol
Other adverse effects – – – – –
Contraindicated in asthma Avoid in heart failure/block Muscle weakness Lassitude Disturbed sleep www.indiandentalacademy.com
Vasodilators Prazosin (0.5-20mg/day) Indoranmin (20-100mg/day) Hydralazine (25-100mg/day) Minxidil (10-50mg/day) Adverse effects
– Headache – Hypertrichosis – oedema www.indiandentalacademy.com
ACE inhibitors – – – –
Possible oral effects – – – –
Captopril (25-75 mg/BD) Enalapril (20mg/day) Ramipril (5-10 mgdaily) Lisinopril (10-20 mg /day) Sinusitis Lichenoid reaction Loss of taste Burning sensation
Adverse effects – – – –
Sudden fall in bp Impair renal function Cough Angioedema www.indiandentalacademy.com
Calcium channel blockers – Nifidipine (30-90mg/day) – Verapamil (240mg/day)
Oral effects – Gingival hyperplasia – Salivation
Adverse effects – Headache and flushing – Swollen legs www.indiandentalacademy.com
Dental aspects ď Ž
Pre operative evaluation
ď Ž
Management guidelines
www.indiandentalacademy.com
Pre operative evaluation
Determine – – – –
Electrolyte Creatinine BUN Hypokalemia
Asses the complications – – – – –
Status of therapy Papilledema Retinal hemorrages Heart failure Cardiac enlarge maent
www.indiandentalacademy.com
Management guidelines
Untreated mild or moderate hypertension – Diastolic- 90-110 mg hg – Bp should be monitored – Medication should be used pre and post operatively
Controlled hypertnsion – Therapy should be maintained untill the night before surgery – Medication to be known to anaesthesiologist – Potassium preoperative to be given www.indiandentalacademy.com
Moderate to severe hypertension – Diastolic greater than 110mm hg – Rapidly acting agents can be given – Emergency- nitriprusside or nitroglycerine – I.v methydopa or diazoxide – Oral prazosin or clonidine
www.indiandentalacademy.com
General anesthesia
Contraindications – Severe hypertension – Cardiac failure – Coronary / cerebral artery insufficiency – Renal insufficieny
Best treated under LA Diuretics should be stopped before surgery
www.indiandentalacademy.com
Thank you www.indiandentalacademy.com Leader in continuing dental education
www.indiandentalacademy.com