HYPERTENSION IN EXODONTIA
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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
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Types
Hypertension
Essential
Secondary
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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
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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
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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
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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
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Micro aneurysm also occurs
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Heart High blood pressure
Left ventricular hypertrophy (atrial fibrillation)
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Left ventricular failure
Kidney ď Ž
Proteinuria
ď Ž
Progressive renal failure by damaging the renal vasculature
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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
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Investigations
For all patients
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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
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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
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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
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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
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Pre operative evaluation
Determine – – – –
Electrolyte Creatinine BUN Hypokalemia
Asses the complications – – – – –
Status of therapy Papilledema Retinal hemorrages Heart failure Cardiac enlarge maent
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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
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General anesthesia
Contraindications – Severe hypertension – Cardiac failure – Coronary / cerebral artery insufficiency – Renal insufficieny
Best treated under LA Diuretics should be stopped before surgery
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Conclusion
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References
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Thank you www.indiandentalacademy.com Leader in continuing dental education
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