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Hypertension

Many patients with hypertension have uncontrolled disease. Hence, it is known as the “silent killer” and it affects more than 1 billion people worldwide and is response for >7 million deaths annually. The most common way to evaluate blood pressure are office blood pressure measurement, home blood pressure measurement and ambulatory blood pressure measurement. Dentist will be measuring patient’s blood pressure with office blood pressure measurements.

1. Dentist’s role in hypertension

Multiple studies have shown that screening for hypertension in dental visits allows the identification of patients with previously undiagnosed hypertension, poorly controlled hypertension and patients at increased risk for cardiovascular events. Moreover, more frequent BP measurements are indicated for patients who are not compliant. However, the screening of hypertension in pediatric can be challenging due to common false positive results. In addition, white coat hypertensive phenomenon should be aware.

1.1  Blood pressure measurement

The American Heart Association recommends routine blood pressure screenings starting at 20 years old and at least twice a year if the blood pressure reading is <120/80mmHg. The current references for evaluation of hypertension is listed in Table 1.

Table 1 Classification of hypertension according to JNC6 and JNC7 Abbreviation: JNC 6, 6th joint national committee report; JNC7, 7th joint national committee report

2. Dental consideration

There is no demonstrated direct association between dental treatment and complications of hypertension. However, it is still important for the dental practitioners to understand the potential risks and complications that may occur to the hypertensive patients in dental settings. The primary concern in treating a hypertensive patient is a sudden elevation in BP during the course of treatment, which may lead to serious outcome such as stroke or MI. Such acute elevation can be the stimulation of endogenous catecholamines released during stress and anxiety or exogenous catecholamines in the form of vasoconstrictors in local anesthetic agent or in the gingival retraction cord.

2.1 Hypertensive drugs

Dental practitioners should be aware of the classes of antihypertensive medication and their side effects to the oral environment. The common antihypertensive drug classes, dental side effects and drug-drug interactions are included in Table 2. Common drug interaction encountered in dental practises include presence of epinephrine in local anesthetic agent, which may adversely react with beta-blockers. Sedatives has been used to manage patients with fear and anxiety. NSAIDs and antifungals are the common prescription for oral diseases and oral pain. Hence, the awareness of antihypertensive medication and their dental relevance is important for dental practitioners.

Furthermore, many antihypertensive medication tend to cause orthostatic hypotension. So, rapid changes in chair position during dental treatment should be avoided.

Table 2 Common antihypertensive drug classes, dental side effects and drug-drug interactions

2.2 Dental management and Follow-up Recommendation

The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly published a guidelines to estimate the risk for occurrence of stroke, MI, acute heart failure or sudden death as result of surgery. To determine the risk, three factors have to be evaluated:


 * 1) The risk imposed by the patient’s cardiovascular disease
 * 2) The risk imposed by the surgery or procedure
 * 3) The risk imposed by the functional reserve or capacity of the patient

The risk imposed by the patient’s cardiovascular disease has been classified into major, intermediate and minor categories. Uncontrolled BP (180/110 mmHg or greater) is classified under minor risk condition. However, ACC/AHA guidelines state that BP should be brought under control before any surgery. JNC 7 classification also recommends immediate refer the patients with BP 180/110 mmHg or higher.

Table 3 Dental Management and Follow-Up Recommendations Based on Blood Pressure

For the risk imposed by the surgery or procedure, head and neck surgery that include major oral and maxillofacial procedures and extensive periodontal procedures, is classified as intermediate risk. Minor oral and periodontal surgery and nonsurgical dental procedures are classified as low risk.

The factor imposed by the functional capacity of the patient is defined in metabolic equivalents (METs). Those who reports to be unable to climb a flight of stairs without chest pain, shortness of breath or fatigue are at increased risk during a procedure.

The decision should be done by determining if the hypertensive patient can be safely treated. Efforts should be made to reduce stress and anxiety associated with dental treatment. To manage stress, dental practitioners may:


 * 1) Avoid long or stressful appointments
 * 2) Set appointment short and in the morning
 * 3) Terminate and reschedule the appointment if patient becomes anxious or apprehensive
 * 4) Use of nitrous oxide plus oxygen for inhalation sedation

2.3 Bleeding

Elevated BP can result in excessive bleeding in surgical procedures but unlikely. Some hypertensive patients are prescribed with various anticoagulant medications for treatment. So, dental practitioners should follow the anticoagulant guideline.

2.4 Other dental recommendations

Adequate oxygen should be ensured to avoid postdiffusion hypoxia. When treating patient with stage 2 hypertension, it is advisable to leave the blood pressure cuff on the patient’s arm and check the pressure periodically. If BP rises above 179/109 mmHg is noted, terminate the procedure and refer the patient to his or her physician and reschedule the appointment. Figure 1 shows the dental management recommended for patient with hypertension.

3. Oral manifestations

There is no direct association between oral complications and hypertension.

The development of facial palsy has been reported in the patient with malignant hypertension. Dry mouth is reported due to antihypertensive drugs. Oral lesions with allergic and toxic reactions are noted with mercurial diuretics. ACEIs may cause angioedema, persistent coughing oral burning and neutropenia which resulting in delayed healing or gingival bleeding.

Lichenoid reactions have been reported with thiazides, methyldopa, propranolol, and labetalol. Lichenoid reactions share the clinical features with Oral Lichen Planus with presence of Wichkham’s striae. Table 4 shows the overview of investigations assessed in Lichenoid Reactions and Oral Lichen Planus. For drug induced lichnoid reaction, withdrawal and replacement may require medical consultation.

Table 4 Overview of investigations in Oral Lichen Planus and Lichenoid Reactions

Figure 2 Classical immunofluorescent presentation of oral lichenoid reaction

Extracted from ''Kamath, V., Setlur, K. and Yerlagudda, K. (2015). Oral lichenoid lesions - A review and update. Indian Journal of Dermatology, 60(1), p.102.''

Figure 3 Image of unilateral lichenoid reaction affecting the right cheek mucosa in a patient subjected to antihypertensive drug.

Extracted from ''DeRossi SS, Ciarrocca KN. Lichen planus, lichenoid drug reac- tions, and lichenoid mucositis. Dent Clin North Am. 2005;49:77-89.''

Calcium channel blockers may cause gingival overgrowth (Figure 4). Drug-induced gingival overgrowth or enlargement is abnormal growth of gingiva due to adverse reaction of the medication. Clinical manifestation of gingival enlargement appears within 1-3 months after initiation of treatment with the associated medications. As gingival enlargement develops, it might affect the normal oral hygiene practice and may interefere with masticatory functions. The severity of gingival enlargement in patients taking medications correlates well with poor plaque control.

Figure 4 Gingival hyperplasia in a patient taking a calcium channel blocker (Courtesy Dr. Terry Wright)

Extracted from ''Little, J. (2013). Little and Falace's dental management of the medically compromised patient. St. Louis, Mo: Elsevier, pp.166-168.''