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INDIAN DENTAL ACADEMY Leader in continuing dental education

CONTENTS          

Definition Types Causes Signs Target organ diseases Investigation General Management Dental aspect of hypertension Conclusion References

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





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Idiopathic 40-60% is genetic factor  High salt intake  Heavy consumption of alcohol  Obesity  Lack of exercise  Impaired intrauterine growth  Stress 

Secondary Alcohol  Pregnancy  Renal disease 

– Renal artery disease – Pyelonephritis – Glomerulonephritis – Polycystic disease – Post trasnplant 

Coarctation of aorta

Secondary causes contd. 

Endocrine disease – – – – –

Pheochromocytoma Cushings syndrome Acromegaly Thyrotoxicosis Hyperaldosteronism

Cerebral disease

– Cerebral oedema (stroke, head injuries & tumours)

Drugs – – –

Oral contraceptives Streroids NSAIDS

Signs Paroxysmal headache  Palpitation  Sweating  Breathlessness  Angina 

Target organ disease Blood vessels

Central nervous system Retina Heart Kidneys Malignant or accelerated phase hypertension

Blood vessels

Larger arteries

Smaller arteries

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

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

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 hypertension is controlled

Retina ď Ž

Central retinal vein thrombosis occurs

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Micro aneurysm also occurs

Heart High blood pressure

Left ventricular hypertrophy (atrial fibrillation)

Left ventricular failure

Kidney ď Ž


ď Ž

Progressive renal failure by damaging the renal vasculature

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


For all patients

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 

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


Non-drug therapy

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 

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

Vasodilators Prazosin (0.5-20mg/day)  Indoranmin (20-100mg/day)  Hydralazine (25-100mg/day)  Minxidil (10-50mg/day)  Adverse effects 

– Headache – Hypertrichosis – oedema

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

Calcium channel blockers – Nifidipine (30-90mg/day) – Verapamil (240mg/day) 

Oral effects – Gingival hyperplasia – Salivation

Adverse effects – Headache and flushing – Swollen legs

Dental aspects ď Ž

Pre operative evaluation

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Management guidelines

Pre operative evaluation 

Determine – – – –

Electrolyte Creatinine BUN Hypokalemia

Asses the complications – – – – –

Status of therapy Papilledema Retinal hemorrages Heart failure Cardiac enlarge maent

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

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

General anesthesia 

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

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

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