With continuing advances in medical diagnostics and therapeutics, dental patients are living longer lives; and with that comes the increased likelihood for these patients to present to the dental office with medical comorbidities such as hypertension. Hypertension is a chronic illness that affects over a billion people worldwide. Its absence of pain-producing symptoms often masks a more serious and potentially deadly underlying problem. Often, patients will see their dentist more regularly than their medical doctors, placing dentists on the frontline of hypertension screening and prevention. Possessing the ability to record regular blood pressure readings over time and referring the patient to a primary care medical doctor when indicated reinforces the dentist’s critical role as a member of the patient’s overall health care team. This chapter highlights risk factors that may predispose patients to acute hypertension and provides recommendations for management in the dental office. The chapter also discusses the identification and management of several potential complications of hypertension, including hypertensive urgency and emergency, as well as stroke. No matter what stage of training, dental practitioners should have a good working knowledge of the disease and be aware of current therapeutic options so they can feel comfortable in the dental management of patients with hypertension. Dentists should be able to assess the patient’s functional health status and baseline blood pressure, determine the urgency and invasiveness of the proposed dental procedure, and then make a decision on how best to manage the patient. The health and well-being of the patient must always come first.
Hypertension
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Approximately 75 million Americans suffer from hypertension (HTN).
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Studies have shown a consistent correlation between elevated blood pressure (BP) and cardiovascular disease (CVD).
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End organ damage and microalbuminuria often accompany heart failure and may portend future severe events.
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Primary, or essential, hypertension occurs in more than 90% of case with no identifiable causes.
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Secondary HTN occurs as an unwanted complication of other conditions such as obstructive sleep apnea, coarctation of the aorta, Cushing’s disease, renal artery stenosis, hyperaldosteronism, pheochromocytoma, and hyperthyroidism.
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In November 2017, the medical community published new BP targets and treatment recommendations.
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For years, HTN was classified as a BP reading of 140/90mm Hg or higher, but the updated guideline classifies HTN as a BP reading of 130/80mm Hg or higher.
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The updated guideline also provides new treatment recommendations which include corrections to lifestyle changes as well as BP-lowering medication regimens.
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Dentist practitioners should be well informed of these new guidelines because many dental patients will be reporting changes to their medical and medication histories.
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The 2017 Hypertension Guideline changes the definition of HTN, which now includes any systolic BP measurement of 130 mm Hg or higher or any diastolic BP measurement of 80 mm Hg or higher (▶ Table 12.1).
Pharmacologic Recommendations
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The updated guideline recommends BP-lowering medications for stage 1 HTN patients with clinical CVD, patients with 10-year risk of atherosclerotic CVD (ASCVD) of 10% or greater, or for those with stage 2 HTN.
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For stage 2, the recommendation is two BP-lowering medications in addition to healthy lifestyle changes, which amounts to a more aggressive treatment standard.
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The guideline also updates the recommendations for specific populations.
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For example, because more patients of African descent have been diagnosed with HTN than other groups, two or more anti-HTN medications are recommended to achieve a target of BP less than 130/80 mm Hg.
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Thiazide-type diuretics and/or calcium channel blockers are also indicated because of their increased efficacy in lowering BP alone or in multidrug regimens.
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Morbidity and mortality attributed to HTN are more common in adults of African and Hispanic descent compared to predominantly European populations.
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Monthly physician follow-up is recommended for adults with a novel or adjusted HTN drug regimen in order to gauge proper response until their BP is under control.
Emphasis on Cardiovascular Disease
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The updated guideline provides recommendations for patients with clinical CVD and makes new recommendations for using the ASCVD risk calculator:
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Use BP-lowering medication for primary prevention of CVD in adults with no history of CVD and an estimated 10-year ASCVD risk of less than 10% and a systolic BP of 140 mm Hg or greater or a diastolic BP of 90 mm Hg or greater.
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Use BP-lowering medications for secondary prevention of recurrent CVD events in patients with clinical CVD and an average systolic BP of 130 mm Hg or greater or a diastolic BP of 80 mm Hg or greater and for primary prevention in adults with an estimated 10-year ASCVD risk of 10% or greater with an average systolic BP of 130 mm Hg or greater or average diastolic BP of 80 mm Hg or greater.
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Hypertensive Urgency Versus Hypertensive Emergency
(▶ Table 12.2)
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Hypertensive urgency is associated with a severe BP elevation in an otherwise stable patient without acute or impending change in target organ function, i.e., no organ damage or dysfunction.
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Hypertensive emergency is a severe elevation in BP associated with evidence of new or worsening target organ damage.
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Target organ dysfunction includes encephalopathy, cerebrovascular accident (CVA), myocardial infarction, congestive heart failure, pulmonary edema, angina, dissecting aneurysm, and eclampsia.
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The therapy is to reduce the BP by no more than 25% over 30 to 60 minutes, and then to 160/100 in 2 to 6 hours.
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The goal is to return BP to a level where autoregulation restores normal perfusion pressures to vital organs and not necessarily to normal BP.
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