3: Patient with Hypertension

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).

Image described by caption and surrounding text.

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.

Source: www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/About‐High‐Blood‐Pressure_UCM_002050_Article.jsp#.V5V0RldVK0h.

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.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 3: Patient with Hypertension
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