Issuu on Google+

HYPERTENSION IN EXODONTIA

www.indiandentalacademy.com


INDIAN DENTAL ACADEMY Leader in continuing dental education www.indiandentalacademy.com

www.indiandentalacademy.com


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

www.indiandentalacademy.com


Types

Hypertension

Essential

Secondary

www.indiandentalacademy.com

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 

www.indiandentalacademy.com


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 

www.indiandentalacademy.com


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

www.indiandentalacademy.com


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

ď Ž

Micro aneurysm also occurs

www.indiandentalacademy.com


Heart High blood pressure

Left ventricular hypertrophy (atrial fibrillation)

www.indiandentalacademy.com

Left ventricular failure


Kidney ď Ž

Proteinuria

ď Ž

Progressive renal failure by damaging the renal vasculature

www.indiandentalacademy.com


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

www.indiandentalacademy.com


Investigations

For all patients

www.indiandentalacademy.com

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 

www.indiandentalacademy.com


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

www.indiandentalacademy.com

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 

www.indiandentalacademy.com


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

www.indiandentalacademy.com


Pre operative evaluation 

Determine – – – –

Electrolyte Creatinine BUN Hypokalemia

Asses the complications – – – – –

Status of therapy Papilledema Retinal hemorrages Heart failure Cardiac enlarge maent

www.indiandentalacademy.com


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

www.indiandentalacademy.com


General anesthesia 

Contraindications – Severe hypertension – Cardiac failure – Coronary / cerebral artery insufficiency – Renal insufficieny

Best treated under LA  Diuretics should be stopped before surgery 

www.indiandentalacademy.com


Thank you www.indiandentalacademy.com Leader in continuing dental education

www.indiandentalacademy.com


Hyper tension/ dental implant courses by Indian dental academy