Case 3
Patient with Hypertension
Medical History
His medical history is positive for hypertension diagnosed three years ago. He blames it on gaining weight after quitting smoking five years before. He sees his doctor four times a year. The physician prescribed medications that he confessed taking sometimes and forgetting sometimes. He denies any other medical issue. His blood pressure today was 165/95 and 170/93. He claims he rushed to the appointment that he did not take his medications. His medications are amlodipine (Norvasc) and hydrochlorothiazide and a daily multivitamin.
Dental History
He manually brushes at least once a day, in the morning, does not use any interdental cleaning device, but uses an alcohol containing mouthwash twice a day. He is concerned that brushing aggravates the bleeding.
Social History
He smoked more than a pack a day for 40 years. He drinks alcohol socially.
Dental Examination
The intra‐ and extraoral soft tissue exam were unremarkable.
Little saliva is observed present but the patient does not report dry mouth.
All teeth were present besides #17. All posterior buccal surfaces had some degree of loss of attachment. Teeth #16 and #31 have visible caries. Plaque is present in 40% of posterior surfaces. There is 75% bleeding and probing, calculus is present on the lingual surfaces of lower anterior teeth and probing depths range 3–6 mm. Radiographic examination shows the presence of generalized mild to moderate bone loss, especially in the lower incisors (Figure 10.3.1).
Figure 10.3.1: Panoramic image of the patient.
Dental Considerations
The patient will require:
- Oral hygiene instructions to reduce plaque, bleeding on probing, and sensitivity
- Extraction of #16 and possibly #31 because of a poor prognosis
- Periodontal treatment to reduce plaque and calculus and reduce periodontal pockets.
Medical Considerations: Hypertension
Hypertension (HTN) is a very prevalent medical condition affecting one every three adults overall, although that prevalence increases drastically with age. Among the adults with HTN only about half are under control. Up to 95% of patients have what is known as primary or essential hypertension where there is no single identifiable cause.
The American Heart Association establishes the categories of blood pressure ranging from normal all the way to hypertensive crisis (Table 10.3.1). Uncontrolled HTN can lead to myocardial infarction, stroke, renal failure, and death. It is also known as “the silent killer” because for most patients it has no symptoms.
Table 10.3.1: Blood pressure categories defined by the American Heart Association.
| What is the AHA recommendation for healthy blood pressure? This blood pressure chart reflects categories defined by the American Heart Association. |
|||
| Blood Pressure Category | Systolic mmHg (upper#) |
Diastolic mmHg (lower #) | |
| Normal | less than 120 | and | less than 80 |
| Prehypertenslon | 120–139 | or | 80–89 |
| High Blood Pressure (Hypertension) Stage 1 | 140–159 | or | 90–99 |
| High Blood Pressure (Hypertension) Stage 2 | 160 or higher | or | 100 or higher |
| Hypertensive Crisis (Emergency cere needed) | Higher than 180 | or | Higher than 110 |
Accurate measurement of the blood pressure is vital during dental evaluation and during follow up. Blood pressure should be taken following recommendations from the American Heart Association as follows:
- Patients should be seated with back supported and arm bared and supported
- Patients should refrain from smoking or ingesting caffeine for 30 minutes before measurement
- Measurement should be done after at least five minutes of rest
- Appropriate cuff size and calibrated equipment should be used
- Systolic and diastolic values should be recorded
- Additional readings are recommended if >140/90
There are special considerations that need to be taken during dental treatment depending on blood pressure values (Table 10.3.2).
Table 10.3.2: Special considerations during dental treatment regarding blood pressure values.
| BP values | Treatment Recommendations |
| <120 or < 80 | All dental treatment |
| >120/80 but <140/90 | All dental treatment. Monitor BP. May include some modifications (e.g., limit vasoconstrictor) |
| >140/90 but <165/95 without target organ disease (e.g. kidney) | Recommend following up with primary care provider. Most dental treatment is safe. Monitor BP and limit epinephrine |
| >160/100 but <180/110 | Medical Consultation before elective treatment. Palliative care of pain and infections |
For values above 180/110 they require immediate referral to the primary care provider or the ER.
Medical Considerations: Medications
Multiple pharmacological options are available for the treatment of hypertension with different mechanism of action. Patients can be treated with single agents but, in many cases, they require more than one drug (polypharmacy).
Providers need to become familiar with each medication including learning about side effects and potential interactions that may affect treatment or require modifications to the dental treatment.
A summary of relevant adverse effects and interactions from high blood pressure medications related to dental treatment are present in Table 10.3.3.
Table 10.3.3: Side effects and interactions of high blood pressure medications.
| Classes of Blood Pressure Medications | Examples of Relevant Side Effects and Interactions |
| Diuretics | Orthostatic hypotension NSAIDs may diminish the therapeutic effect of these drugs |
| Beta‐blockers | Limit vasoconstrictor use with noncardioselective beta‐blockers (e.g., propranolol, naldolol, pindolol, penbutolol, sotalol, timolol) NSAIDs may diminish the therapeutic effect of these drugs |
| ACE inhibitors | Orthostatic hypotension Dry cough |
| Angiotensin II receptor blockers | Orthostatic hypotension NSAIDs may diminish the therapeutic effect of these drugs and affect kidney function Systemic antifungals may decrease drug metabolism |
| Calcium channel blockers | May cause gingival overgrowth Systemic antifungals may decrease drug metabolism Macrolide antibiotics may decrease drug metabolism |
| Alpha blockers | Orthostatic hypotension Dry mouth |
| Alpha‐2 receptor agonist | Orthostatic hypotension Dry mouth Sore tongue |
| Combined alpha and beta‐blockers | Orthostatic hypotension NSAIDs may diminish the therapeutic effect of these drugs |
| Central agonists | Orthostatic hypotension Dry mouth |
| Peripheral adrenergic inhibitors | Orthostatic hypotension Dry mouth Caution w/vasoconstrictor |
| Vasodilators | Orthostatic hypotension NSAIDs may diminish the therapeutic effect of these drugs |
Specific Considerations
It is important before treatment plan to first identify all the medical issues and conditions that may require management and plan appropriately.
VIDEdental - Online dental courses
