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Role of screening for hypertension in patient management
C L IN IC A L
REPORT
Role of screening for hypertension in patient management George Wessberg, DDS, Honolulu
There are estimated to be more than 23 million Americans with high blood pressure. Many of these persons are unaware of their disease; those who are treated lead normal lives only with pharmacotherapeutic assistance. By screening for hypertension, by understanding the disease, by being knowledge able of the therapeutic agents used, and by realizing the amount of stress the patient will satisfactorily tolerate, the dentist can properly manage the hyper tensive patient.
T he need for routine screening for hypertensive disease in dental practice has been well docu m en ted .1-5 O nce hypertension has been diag nosed, the m edical treatm ent o f the disease is relatively sim ple.6"8 M ore im portantly, recent studies have shown that early detection and effec tive antihypertensive therapy can reduce m orbid ity and m ortality considerably.911 G o vernm ent agencies estim ate that there are m ore than 23 million A m ericans12 w ho have hypertension. In spite o f the ease o f detection and treatm ent, only half o f these individuals have had their disease properly diagnosed and m erely 25% o f them are receiving adequate th era p y .13 W hen left undetected o r uncontrolled, hyper tensive disease is a pow erful and com m on con tributor to the prem ature degeneration o f its target organs: the brain, the heart, the kidneys, and the e y e s.14 H ypertension also accelerates the devel opm ent o f coronary and cerebral artherosclero sis.15 U ntil preventive m ethods to elim inate hyper tension are developed, these facts should stim u late all health professionals to routinely screen patients for signs o f hypertensive disease. 1040 ■ JADA, Vol. 96, June 1978
Evaluation Thorough evaluation o f the p atien t’s condition should precede all dental therapy. T he m easure m ent o f arterial blood pressure is an im portant aspect o f this evaluation. T he Inter-Society C om m ission for H e art D isease R esources and o th ers16' 18 have proposed the following guidelines that indicate incipient hypertension for specific age groups: younger than 15 years, 120/80 mm Hg; 15 to 40 years, 140/90 mm H g; and older than 40 years, 160/95 mm H g. Early detection o f hypertension is stressed b e cause adequate control depends on early trea t m ent, before the disease affects the target o r g an s.11 ■ M edical history: T he dentist should have the p atien t’s m edical history available to ensure p roper m anagem ent. F acto rs predisposing to hypertension include a family history o f heart trouble, chronic anxiety, obesity, cigarette sm ok ing, excessive sodium intake, and the taking of oral co n tracep tiv es.19-20 Sym ptom s th at m ay be associated with hyper tension in any o f its stages are suboccipital head aches, failing vision, tinnitis, peripheral pares thesia, angina pectoris, congestive heart failure, and renal failure.21 T he patient should be questioned directly about current antihypertensive m edications so that these agents m ay be review ed and listed in the chart with notations of significant interactions and side effects o f d ru g s.1 ■ P hysical exam ination: A ccuracy in m easuring
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blood pressure is dependent on proper cuff size and placem ent o f the cuff over the brachial artery. T he m easurem ent is m ost valid when it is rec orded after the patient has reclined in the dental chair for at least five m inutes. G ifford21 suggests that values associated with the appearance and disappearance o f K o ro tk o ff s sounds are the sys tolic and the diastolic blood pressures, respec tively. T he M anual o f M edical T herapeutics22 proposes the relationship betw een these arterial blood pressure readings and the various stages of circulatory tension as — H ypotension: less than 80/40 mm Hg — N orm otension: 80 to 139/40 to 89 mm Hg — Mild hypertension: 140 to 164/90 to 114 mm Hg — M oderate hypertension: 165 to 189/115 to 129 mm Hg — Severe hypertension: greater than 190/130 mm Hg. F o r arterial blood pressure to be considered hypertensive, the reading m ust be duplicated on two of three successive appointm ents on different days. Physicians supplem ent m easurem ent of blood pressure with exam ination o f the optic fun dus. T he appearance of the retina is a m ore im por tant index o f the severity of hypertension than the blood pressure m easurem ent.21 T he ability of the dentist to provide safe, ap propriate dental care depends on understanding the p atien t’s physical problem s, the m edications that he is receiving, and his ability to tolerate stress.23
Classification T he degrees o f hypertension have been pre sented. Each form o f the disease may progress from a mild to a severe stage. T he two basic forms o f hypertensive disease are prim ary and secon dary. W hen left untreated, either may progress to a third or malignant form. In approxim ately 85% o f patients with hyper tension, no specific cause can be established.15 T he forerunner o f sustained, essential prim ary hypertension is a transient form term ed liable hypertension. Its onset com m only occurs be tween the ages o f 25 and 55 years. A diagnosis of essential hypertension is established only after a thorough search for a specific cause is unsuccess ful. M ost physiologists agree that high blood pres sure occurs when there is increased resistance in
REPORT
peripheral circulation resulting from increased tone in the arterioles and precapillary sphincters. Physiologists do not agree, how ever, on the cause o f the disease. T here are three favored th eo rie s.19 One is that transient episodes o f em otional stress with resultant sym pathetic stim ulation tend to es tablish an elevated blood pressure as “ norm al” by m ediation of the central nervous system .22 A nother shows that increased levels o f cadmium in the blood serum o f rats increases the arterial blood pressure. A third suggests that a num ber of factors may cause hypertension with various in fluences at different stages o f the disease. Scientists have only been able to diagnose spe cific causes in 15% o f patients with hypertension. T he cause of the elevated blood pressure may lie within one of the m ajor body system s: ren al,15 cardiovascular,19 endocrine,19,24 or neurologi cal.24 H ypertensive crisis is characterized by severe progressive changes in the brain, heart, kidneys, and eyes o f individuals with a sudden or sustained rise in arterial blood pressure to levels greater than 190 mm Hg systolic or 130 mm Hg diastolic, or b o th .15 T his phenom enon is term ed malignant because it causes w idespread arteriolar necrosis and hyperplasia o f the intima o f the interlobular vessels of the kidney, which in turn cause is chem ic atrophy o f the n ep h ro n .15 W ithout treat m ent, there is rapidly progressive renal failure, left ventricular failure, and encephalopathy. M or tality approaches 80% in the first year and 100% in the second y ear.24
Antihypertensive therapy Basic therapy for essential hypertension begins with diet control. T he diet is modified to restrict calories and sodium. T his alone has brought some
THE AUTHOR Dr. Wessberg was a resident in general practice in the depart ment of dentistry at The Queen's Medical Center in H onolulu. He is currently a research fellow at the Center fo r C orrection of Dentofacial Deform ities, John Peter S m ith Hospital, 1500 S Main St, Ft. W orth, Tex 76104. WESSBERG
Wessberg: ROLE OF SCREENING FOR HYPERTENSION . 1041
C L IN IC A L
REPORT
reduction in blood pressure in a third o f the p a tie n ts.19 W hen diet control is not effective, a vari ety o f pharm acologic agents is used to indi vidualize treatm ent. T he pharm acologic m anagem ent of hyperten sion is im portant for the dentist to understand. A gents com m only used orally are diuretics, v as odilators, sym patholytics, and sedatives. Thiazide diuretics probably reduce the blood pressure by prom oting the excretion o f sodium. T his decreases the volum e o f plasm a and extracel lular fluid. T h ese drugs are the preferred tre a t m ent o f mild hypertension and are able to control it in a third o f the p atien ts.19 Exam ples include thiazide, chlorothiazide, furosem ide, and spiro nolactone. W hen diuretics are com bined with potent nondiuretics, the reduction in fluid vol ume perm its low er doses o f the more potent drug. B ecause they prom ote the excretion o f potassium as well as sodium , supplem ental p o tas sium chloride is often necessary to prevent hypokalem ia. H ydralazine reduces peripheral resistance by dilating the renal and splanchnic vessels.22 Prazocin H C L decreases sm ooth m uscle tone in p e ripheral vessels.24 B oth agents are used for mild to m oderate hypertension. A fter thiazide diuretics, the sym pathetic in hibiting agents are the m ost com m only used. E xam ples are neurotransm itter depletors (reserpine), false neuro transm itters (m ethyldopa), selective inhibitors (guanethidine sulfate, pentolinium, clonidine hydrochloride), and receptor blockers (propranolol hydrochloride, phenoxybenzam ine hydrochloride).19,21,25
M anagem ent H ealthy persons w ho have a transient elevation in blood pressure because o f anxiety at the first ap pointm ent and are norm otensive at subsequent appointm ents require no special consideration. H ow ever, patients who have sustained elevations in blood pressure or are currently receiving anti hypertensive m edications m ust be treated accord ingly. W hen evaluating the condition of a hyperten sive individual, it is wise to postpone elective dental treatm ent until an attending physician can be consulted about the p atien t’s ability to tolerate the stress o f dental surgery. M inimizing stress during the dental appoint m ent m ay be the m ost im portant aspect of therapy 1042 ■ JADA, Vol. 96, June 1978
for the hypertensive patient. Sym ptom s o f dis tress will be evident by changes in skin color (pale and m oist), am ounts o f hem orrhage (increases with elevation in blood pressure), and discom fort (lack o f cooperation). T he pulse can be m onitored at several accessible locations (tem poral, labial, carotid, o r radial). T he pulse will indicate heart rate (fast or slow), rhythm (regular or irregular), and cardiac output (weak or strong). T he opera tive procedure should be stopped if the patient has becom e distressed. H e should be reassured and his condition should be m onitored until it is stable; the patient then can be dism issed with som eone to assist him. B ecause o f the constant hazard of postural hypotension, the patient should never be left unattended. F uture appointm ents m ay re quire the use o f additional agents in com bination with local anesthetics to control the pain and anx iety associated with a dental procedure. A dequate local anesthesia is param ount in the efforts to reduce operative stress. T he cat echolam ine response associated with pain may elevate the blood pressure significantly. P o st operative analgesics m ust be prescribed accord ingly and with attention to drug interactions. The use o f potent vasopressors in the anesthetic solu tion is not recom m ended.26 Several barbiturates, narcotics, and antianxiety agents are available to aid in the m anagem ent of preoperative stress. T he hazard o f potentiation with some antihypertensive agents m ust be con sidered. N itrous oxide-oxygen analgesia may be very effective in selected patients w hen used in con junction with adequate regional analgesia. T he am ount o f nitrous oxide used should be in direct correlation with the patient’s psychological con dition; if the condition is poor, the indication for using nitrous oxide is less as it is a weak form of sedation. Total regulation o f the p atien t’s level o f seda tion is best achieved by using a com bination of depressant drugs and intravenous techniques. Again, adequate regional analgesia m ust not be ignored. Solutions given intravenously should be low in sodium , and the am ount o f fluid infused should be minimized. H ypertensive patients who cannot be managed properly in the dental office should be sedated in the hospital operating room to ensure that adequate care will be available if a hypertensive em ergency arises. M ost patients receiving antihypertensive m edi cation, who are otherw ise healthy individuals, are suitable candidates for general anesthesia. H y p o
C L IN IC A L
tension is o f prim ary concern in these patien ts.27 T he heart o f the hypertensive individual, espe cially one with coronary arteriosclerosis, is over w orked. W hen sudden depression o f the central nervous system occurs, there is rapid peripheral vasodilation leading to a trem endous decrease in cardiac o u tp u t.27 This reduced blood flow is con ducive to th e form ation o f throm bi that m ay cause cerebral, retinal, renal, o r coronary ischem ia.28 W hen used w isely, there are several com bina tions of anesthetics, analgesics, and sedatives available to the dental profession to aid in the m anagem ent o f the hypertensive patient. T he dentist should recognize the disease and plan the p roper m anagem ent.
Hypertensive em ergencies T he prevention, recognition, and treatm ent o f em ergencies in the dental office have been p re sented by F reem an and o th ers.29 T he m anage m ent o f hypertensive em ergencies has also been presented by D h ar and F reed m an .28 P ostural hypotension is com m on to antihyper tensive drug therapy. Sym ptom s sim ilar to those associated w ith syncope, a decrease in arterial blood pressu re, and peripheral cyanosis indicate a hypotensive episode. T he sudden rise o f the diastolic blood pressure to levels greater than 130 mm H g is indicative o f a hypertensive crisis. W hen sustained at this level, it m ay precipitate acute congestive heart failure, cardiac arrhythm ias, m yocardial infarction, ca r diac arrest, or cerebrovascular accident. Em ergency situations in dental practice are sel dom fatal, b u t can be life threatening if im properly m anaged. P ro p er planning and prevention will elim inate m ost o f these situations. W hen they do arise, a calm approach with proper attention to the p atien t’s airw ay and cardiopulm onary system will be sufficient in m ost instances.
Report of case In A ugust 1976, an elderly Filipino m an appeared in the Q ueen Em m a D ental Clinic for exam ina tion. A fter he was exam ined, this reasonably healthy 66-year-old m an (100 lb and 5 ft 2 in tall) w as referred to a physician for the evaluation o f apparent mild hypertension. Oral and radiographic exam inations show ed extensive dental
REPORT
caries and advanced periodontal disease indicat ing the need for preprosthetic surgery. T h e attending physician determ ined that the blood pressure was 165/95 mm H g and recom m ended that no antihypertensive therapy be given. T he p atien t’s heart and lungs w ere satisfac tory for the planned oral surgery. In D ecem ber, the patient was adm itted to T he Q ueen’s M edical C en ter for com plete odontectom y, alveoplasty, and frenectom y with a blood pressure o f 160/90 mm Hg. R outine laboratory findings show ed that the electrolyte levels and results o f the SMA-12 were within satisfactory limits. T he electrocardiogram w as norm al. T he night before surgery, the patient w as given 30 mg flurazepam hydrochloride orally to help him sleep. T he next m orning, an intravenous line was started and 5% dextrose in w ater was in fused. Preoperative m edications o f m eperidine hydrochloride, 50 mg; hydroxyzine hydrochlor ide, 50 mg; and atropine, 0.4 mg, w ere given in tram uscularly an hour before the scheduled surgery. In the operating room the preanesthetic blood pressure, in a supine position, was 160/85 mm Hg. G eneral anesthesia was induced w ith thiopental sodium , 200 mg, and succinylcholine chloride, 60 mg, in an intravenous bolus. A dequate nasoendotracheal intubation was accom plished, and the anesthesia was m aintained with enflurane, nitrous oxide, and oxygen. A 2% solution o f lidocaine hydrochloride containing epinephrine (1:100,000) was infiltrated in the appropriate areas o f surgery. T he blood pressure during the 90-m inute proce dure was m aintained at 130/80 mm Hg. A fter surgery, recovery w as induced, extubation was accom plished in the operating room , and the pa tient was transferred to the recovery room in satisfactory condition. T otal fluid intake by this time was 250 ml. T hirty m inutes postoperatively, the patient began to show signs o f distress; oral hem orrhage was increasing and a large hem atom a w as forming in the region o f the maxillary labial frenectom y. T he p atien t’s blood pressure had risen to 180/110 mm H g and his pulse rate was 80 and regular; no pain w as reported. T he intravenous infusion was slowed to 30 m l/hr and the patient w as reassured and encouraged to urinate. D uring the next 30 m inutes, a total o f 300 ml o f urine w as passed, yet the blood pressure rose to 200/120 mm H g w ith the pulse rate and respiration satisfactory. T he p atien t’s physician was called, and he re c om m ended the im m ediate adm inistration o f 10 mg Wessberg: ROLE OF SCREENING FOR HYPERTENSION ■ 1043
C L IN IC A L
REPORT
o f hydralazine in a slow intravenous infusion. T he blood pressure was m onitored closely and d e creased steadily to 120/80 mm H g within five m in utes. T h e infusion was run rapidly to prevent re flex hypotension. T he blood pressure stabilized at 100/70 mm H g and slowly returned to 120/80 mm H g. T h e infusion was slowed to 60 ml/hr and the vital signs w ere checked every five m inutes. A total o f 850 ml o f urine was passed. An hour after the hypertensive episode, the blood pressure was stable at 145/85 mm H g, and the patient was returned to the w ard for postsurgical care. H e w as discharged tw o days later in satisfactory condition. T he patient had a norm al and com plete recovery.
Sum m ary D etectio n o f hypertension and m onitoring of the 23 million hypertensive A m ericans should be of concern to all health professionals. Early detec tion and diagnosis and adequate therapy, as p re scribed by a physician, can prevent the prem ature degeneration o f hypertension’s target organs. T h e dentist in particular is responsible for the safe, appropriate m anagem ent o f the hyperten sive individual during the stress o f dental trea t m ent. A prim ary m easure to prevent em ergencies in dental offices in these patients is the perfor m ance o f a thorough pretreatm ent evaluation. M any persons with controlled hypertension are able to lead norm al lives with pharm acotherapeutic assistance. By understanding the p atien t’s pathological condition, by being know ledgeable o f the therapeutic agents used, and by realizing the am ount of stress th at the patient will tolerate satisfactorily, the dentist can properly m anage the hypertensive patient. The author acknowledges the assistance of Drs. Bell, Tiner, and Scheerer of The Queens Medical Center in Honolulu. 1. Little, J., and Jakobsen, J. Management of the hypertensive patient in dental office. J Oral Med 29:13 Jan-March 1974. 2. Abbey, L.M. Screening for hypertension in the dental office. JADA 88:563 March 1974.
1044 ■ JADA, Vol. 96, June 1978
3. Berman, C.L.; Guarino, M.A.; and Giovannoli.S.M. High blood pressure detection by dentists. JADA 87:359 Aug 1973. 4. Genest, J., and others. Screening programs for hypertension. Can Med Assoc J 111:147 Ju ly 20, 1974. 5. Moyer, J.H. Nation’s attention focused on hypertension. Pa Med 76:34 May 1973. 6. Finnerty, F.A., Jr. Hypertension: new techniques for patient compliance. In The hypertension handbook. West Point, Pa, Merck, Sharp, and Dohme, 1974. 7. Moser, M. Office management of hypertension. Am Fam Physician 10:153 Sept 1974. 8. Hickler, R.B. The office management of hypertension. Angiology 26:42 Jan 1975. 9. Veterans Administration Cooperative Study Group on Antihy pertensive Agents. Effects of treatment on morbidity in hyperten sion. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 213:1143 Aug 17, 1970. 10. Freis, E.D. The clinical spectrum of essential hypertension. Arch Intern Med 133:982 June 1974. 11. Groover, M.E., Jr.; Simpson, W.E.; and Fulghum, J.E. The early detection and treatment of hypertension. Angiology 26:15 Jan 1975. 12. Department of Health, Education, and Welfare. Blood pres sure of adults by race and area, by age and sex. US 1960-62 NHS Series II no. 4 and 5, 1964. 13. Caleel, G.T. Hypertension: diagnosis and management guidelines. J Am Osteopath Assoc 74:814 May 1975. 14. Kannel, W.B. Role of blood pressure in cardiovascular dis ease: the Framingham study. Angiology 26:1 Jan 1975. 15. Krupp, M.A., and Chatton, M.J. Current medical diagnosis and treatment. Los Altos, Lange, 1974. 16. Report of Inter-Society Commission for Heart Disease Re sources. Guidelines for the detection, diagnosis, and management of hypertension populations. Circulation 44:A263, 1971 (Rev, Aug 1972). 17. Kilcoyne, M.M.; Richter, R.W.; and Alsup, P.A. Adolescent hypertension. Detection and prevalence. Circulation 50:758 Oct 1974. 18. Lieberman, E. Essential hypertension in children and youth: a pediatric perspective. Pediatr 85:1 July 1974. 19. Hypertension. Heart Information Center, National Institute of Health no. 1714, June 1975. 20. Seltzer, C.C. Effect of smoking on blood pressure. Am Heart J 87:558 May 1974. 21. Gifford, R.W., Jr. Hypertension: current views on diagnostic evaluation. In The hypertension handbook. West Point, Pa, Merck, Sharp, and Dohme, 1974. 22. Boedeker, E.C., and Dauber, J.H. Manual of medical therapeutics, ed 21. Boston, Little-Brown, 1974, p 147. 23. Hussar, D.A. Interactions involving drugs used in dental practice. JADA 87:349 Aug 1973. 24. Spivak, J.L., and Barnes, H.V. Manual of clinical problems in internal medicine. Boston, Little-Brown, 1974. 25. Baker, C.E. (ed.). Physician’s desk reference, ed 32. Oradell, NJ, Medical Economics, Inc., 1978. 26. Bennett, C.R. Conscious-sedation in dental practice. St. Louis, C. V. Mosby Co., 1974. 27. Churchill-Davidson, H.C., and Wylie, W.D. A practice of anaesthesia, ed 3. Chicago, Lloyd-Luke, 1972. 28. Dhar, S.K., and Freedman, P. Clinical management of hyper tensive emergencies. Heart Lung 5:571 July-Aug 1976. 29. Freeman, N.S., and others. Office emergencies: an outline of causes, symptoms, and treatment. JADA 94:91 Jan 1977.
REPORT
Role of screening for hypertension in patient management George Wessberg, DDS, Honolulu
There are estimated to be more than 23 million Americans with high blood pressure. Many of these persons are unaware of their disease; those who are treated lead normal lives only with pharmacotherapeutic assistance. By screening for hypertension, by understanding the disease, by being knowledge able of the therapeutic agents used, and by realizing the amount of stress the patient will satisfactorily tolerate, the dentist can properly manage the hyper tensive patient.
T he need for routine screening for hypertensive disease in dental practice has been well docu m en ted .1-5 O nce hypertension has been diag nosed, the m edical treatm ent o f the disease is relatively sim ple.6"8 M ore im portantly, recent studies have shown that early detection and effec tive antihypertensive therapy can reduce m orbid ity and m ortality considerably.911 G o vernm ent agencies estim ate that there are m ore than 23 million A m ericans12 w ho have hypertension. In spite o f the ease o f detection and treatm ent, only half o f these individuals have had their disease properly diagnosed and m erely 25% o f them are receiving adequate th era p y .13 W hen left undetected o r uncontrolled, hyper tensive disease is a pow erful and com m on con tributor to the prem ature degeneration o f its target organs: the brain, the heart, the kidneys, and the e y e s.14 H ypertension also accelerates the devel opm ent o f coronary and cerebral artherosclero sis.15 U ntil preventive m ethods to elim inate hyper tension are developed, these facts should stim u late all health professionals to routinely screen patients for signs o f hypertensive disease. 1040 ■ JADA, Vol. 96, June 1978
Evaluation Thorough evaluation o f the p atien t’s condition should precede all dental therapy. T he m easure m ent o f arterial blood pressure is an im portant aspect o f this evaluation. T he Inter-Society C om m ission for H e art D isease R esources and o th ers16' 18 have proposed the following guidelines that indicate incipient hypertension for specific age groups: younger than 15 years, 120/80 mm Hg; 15 to 40 years, 140/90 mm H g; and older than 40 years, 160/95 mm H g. Early detection o f hypertension is stressed b e cause adequate control depends on early trea t m ent, before the disease affects the target o r g an s.11 ■ M edical history: T he dentist should have the p atien t’s m edical history available to ensure p roper m anagem ent. F acto rs predisposing to hypertension include a family history o f heart trouble, chronic anxiety, obesity, cigarette sm ok ing, excessive sodium intake, and the taking of oral co n tracep tiv es.19-20 Sym ptom s th at m ay be associated with hyper tension in any o f its stages are suboccipital head aches, failing vision, tinnitis, peripheral pares thesia, angina pectoris, congestive heart failure, and renal failure.21 T he patient should be questioned directly about current antihypertensive m edications so that these agents m ay be review ed and listed in the chart with notations of significant interactions and side effects o f d ru g s.1 ■ P hysical exam ination: A ccuracy in m easuring
C L IN IC A L
blood pressure is dependent on proper cuff size and placem ent o f the cuff over the brachial artery. T he m easurem ent is m ost valid when it is rec orded after the patient has reclined in the dental chair for at least five m inutes. G ifford21 suggests that values associated with the appearance and disappearance o f K o ro tk o ff s sounds are the sys tolic and the diastolic blood pressures, respec tively. T he M anual o f M edical T herapeutics22 proposes the relationship betw een these arterial blood pressure readings and the various stages of circulatory tension as — H ypotension: less than 80/40 mm Hg — N orm otension: 80 to 139/40 to 89 mm Hg — Mild hypertension: 140 to 164/90 to 114 mm Hg — M oderate hypertension: 165 to 189/115 to 129 mm Hg — Severe hypertension: greater than 190/130 mm Hg. F o r arterial blood pressure to be considered hypertensive, the reading m ust be duplicated on two of three successive appointm ents on different days. Physicians supplem ent m easurem ent of blood pressure with exam ination o f the optic fun dus. T he appearance of the retina is a m ore im por tant index o f the severity of hypertension than the blood pressure m easurem ent.21 T he ability of the dentist to provide safe, ap propriate dental care depends on understanding the p atien t’s physical problem s, the m edications that he is receiving, and his ability to tolerate stress.23
Classification T he degrees o f hypertension have been pre sented. Each form o f the disease may progress from a mild to a severe stage. T he two basic forms o f hypertensive disease are prim ary and secon dary. W hen left untreated, either may progress to a third or malignant form. In approxim ately 85% o f patients with hyper tension, no specific cause can be established.15 T he forerunner o f sustained, essential prim ary hypertension is a transient form term ed liable hypertension. Its onset com m only occurs be tween the ages o f 25 and 55 years. A diagnosis of essential hypertension is established only after a thorough search for a specific cause is unsuccess ful. M ost physiologists agree that high blood pres sure occurs when there is increased resistance in
REPORT
peripheral circulation resulting from increased tone in the arterioles and precapillary sphincters. Physiologists do not agree, how ever, on the cause o f the disease. T here are three favored th eo rie s.19 One is that transient episodes o f em otional stress with resultant sym pathetic stim ulation tend to es tablish an elevated blood pressure as “ norm al” by m ediation of the central nervous system .22 A nother shows that increased levels o f cadmium in the blood serum o f rats increases the arterial blood pressure. A third suggests that a num ber of factors may cause hypertension with various in fluences at different stages o f the disease. Scientists have only been able to diagnose spe cific causes in 15% o f patients with hypertension. T he cause of the elevated blood pressure may lie within one of the m ajor body system s: ren al,15 cardiovascular,19 endocrine,19,24 or neurologi cal.24 H ypertensive crisis is characterized by severe progressive changes in the brain, heart, kidneys, and eyes o f individuals with a sudden or sustained rise in arterial blood pressure to levels greater than 190 mm Hg systolic or 130 mm Hg diastolic, or b o th .15 T his phenom enon is term ed malignant because it causes w idespread arteriolar necrosis and hyperplasia o f the intima o f the interlobular vessels of the kidney, which in turn cause is chem ic atrophy o f the n ep h ro n .15 W ithout treat m ent, there is rapidly progressive renal failure, left ventricular failure, and encephalopathy. M or tality approaches 80% in the first year and 100% in the second y ear.24
Antihypertensive therapy Basic therapy for essential hypertension begins with diet control. T he diet is modified to restrict calories and sodium. T his alone has brought some
THE AUTHOR Dr. Wessberg was a resident in general practice in the depart ment of dentistry at The Queen's Medical Center in H onolulu. He is currently a research fellow at the Center fo r C orrection of Dentofacial Deform ities, John Peter S m ith Hospital, 1500 S Main St, Ft. W orth, Tex 76104. WESSBERG
Wessberg: ROLE OF SCREENING FOR HYPERTENSION . 1041
C L IN IC A L
REPORT
reduction in blood pressure in a third o f the p a tie n ts.19 W hen diet control is not effective, a vari ety o f pharm acologic agents is used to indi vidualize treatm ent. T he pharm acologic m anagem ent of hyperten sion is im portant for the dentist to understand. A gents com m only used orally are diuretics, v as odilators, sym patholytics, and sedatives. Thiazide diuretics probably reduce the blood pressure by prom oting the excretion o f sodium. T his decreases the volum e o f plasm a and extracel lular fluid. T h ese drugs are the preferred tre a t m ent o f mild hypertension and are able to control it in a third o f the p atien ts.19 Exam ples include thiazide, chlorothiazide, furosem ide, and spiro nolactone. W hen diuretics are com bined with potent nondiuretics, the reduction in fluid vol ume perm its low er doses o f the more potent drug. B ecause they prom ote the excretion o f potassium as well as sodium , supplem ental p o tas sium chloride is often necessary to prevent hypokalem ia. H ydralazine reduces peripheral resistance by dilating the renal and splanchnic vessels.22 Prazocin H C L decreases sm ooth m uscle tone in p e ripheral vessels.24 B oth agents are used for mild to m oderate hypertension. A fter thiazide diuretics, the sym pathetic in hibiting agents are the m ost com m only used. E xam ples are neurotransm itter depletors (reserpine), false neuro transm itters (m ethyldopa), selective inhibitors (guanethidine sulfate, pentolinium, clonidine hydrochloride), and receptor blockers (propranolol hydrochloride, phenoxybenzam ine hydrochloride).19,21,25
M anagem ent H ealthy persons w ho have a transient elevation in blood pressure because o f anxiety at the first ap pointm ent and are norm otensive at subsequent appointm ents require no special consideration. H ow ever, patients who have sustained elevations in blood pressure or are currently receiving anti hypertensive m edications m ust be treated accord ingly. W hen evaluating the condition of a hyperten sive individual, it is wise to postpone elective dental treatm ent until an attending physician can be consulted about the p atien t’s ability to tolerate the stress o f dental surgery. M inimizing stress during the dental appoint m ent m ay be the m ost im portant aspect of therapy 1042 ■ JADA, Vol. 96, June 1978
for the hypertensive patient. Sym ptom s o f dis tress will be evident by changes in skin color (pale and m oist), am ounts o f hem orrhage (increases with elevation in blood pressure), and discom fort (lack o f cooperation). T he pulse can be m onitored at several accessible locations (tem poral, labial, carotid, o r radial). T he pulse will indicate heart rate (fast or slow), rhythm (regular or irregular), and cardiac output (weak or strong). T he opera tive procedure should be stopped if the patient has becom e distressed. H e should be reassured and his condition should be m onitored until it is stable; the patient then can be dism issed with som eone to assist him. B ecause o f the constant hazard of postural hypotension, the patient should never be left unattended. F uture appointm ents m ay re quire the use o f additional agents in com bination with local anesthetics to control the pain and anx iety associated with a dental procedure. A dequate local anesthesia is param ount in the efforts to reduce operative stress. T he cat echolam ine response associated with pain may elevate the blood pressure significantly. P o st operative analgesics m ust be prescribed accord ingly and with attention to drug interactions. The use o f potent vasopressors in the anesthetic solu tion is not recom m ended.26 Several barbiturates, narcotics, and antianxiety agents are available to aid in the m anagem ent of preoperative stress. T he hazard o f potentiation with some antihypertensive agents m ust be con sidered. N itrous oxide-oxygen analgesia may be very effective in selected patients w hen used in con junction with adequate regional analgesia. T he am ount o f nitrous oxide used should be in direct correlation with the patient’s psychological con dition; if the condition is poor, the indication for using nitrous oxide is less as it is a weak form of sedation. Total regulation o f the p atien t’s level o f seda tion is best achieved by using a com bination of depressant drugs and intravenous techniques. Again, adequate regional analgesia m ust not be ignored. Solutions given intravenously should be low in sodium , and the am ount o f fluid infused should be minimized. H ypertensive patients who cannot be managed properly in the dental office should be sedated in the hospital operating room to ensure that adequate care will be available if a hypertensive em ergency arises. M ost patients receiving antihypertensive m edi cation, who are otherw ise healthy individuals, are suitable candidates for general anesthesia. H y p o
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tension is o f prim ary concern in these patien ts.27 T he heart o f the hypertensive individual, espe cially one with coronary arteriosclerosis, is over w orked. W hen sudden depression o f the central nervous system occurs, there is rapid peripheral vasodilation leading to a trem endous decrease in cardiac o u tp u t.27 This reduced blood flow is con ducive to th e form ation o f throm bi that m ay cause cerebral, retinal, renal, o r coronary ischem ia.28 W hen used w isely, there are several com bina tions of anesthetics, analgesics, and sedatives available to the dental profession to aid in the m anagem ent o f the hypertensive patient. T he dentist should recognize the disease and plan the p roper m anagem ent.
Hypertensive em ergencies T he prevention, recognition, and treatm ent o f em ergencies in the dental office have been p re sented by F reem an and o th ers.29 T he m anage m ent o f hypertensive em ergencies has also been presented by D h ar and F reed m an .28 P ostural hypotension is com m on to antihyper tensive drug therapy. Sym ptom s sim ilar to those associated w ith syncope, a decrease in arterial blood pressu re, and peripheral cyanosis indicate a hypotensive episode. T he sudden rise o f the diastolic blood pressure to levels greater than 130 mm H g is indicative o f a hypertensive crisis. W hen sustained at this level, it m ay precipitate acute congestive heart failure, cardiac arrhythm ias, m yocardial infarction, ca r diac arrest, or cerebrovascular accident. Em ergency situations in dental practice are sel dom fatal, b u t can be life threatening if im properly m anaged. P ro p er planning and prevention will elim inate m ost o f these situations. W hen they do arise, a calm approach with proper attention to the p atien t’s airw ay and cardiopulm onary system will be sufficient in m ost instances.
Report of case In A ugust 1976, an elderly Filipino m an appeared in the Q ueen Em m a D ental Clinic for exam ina tion. A fter he was exam ined, this reasonably healthy 66-year-old m an (100 lb and 5 ft 2 in tall) w as referred to a physician for the evaluation o f apparent mild hypertension. Oral and radiographic exam inations show ed extensive dental
REPORT
caries and advanced periodontal disease indicat ing the need for preprosthetic surgery. T h e attending physician determ ined that the blood pressure was 165/95 mm H g and recom m ended that no antihypertensive therapy be given. T he p atien t’s heart and lungs w ere satisfac tory for the planned oral surgery. In D ecem ber, the patient was adm itted to T he Q ueen’s M edical C en ter for com plete odontectom y, alveoplasty, and frenectom y with a blood pressure o f 160/90 mm Hg. R outine laboratory findings show ed that the electrolyte levels and results o f the SMA-12 were within satisfactory limits. T he electrocardiogram w as norm al. T he night before surgery, the patient w as given 30 mg flurazepam hydrochloride orally to help him sleep. T he next m orning, an intravenous line was started and 5% dextrose in w ater was in fused. Preoperative m edications o f m eperidine hydrochloride, 50 mg; hydroxyzine hydrochlor ide, 50 mg; and atropine, 0.4 mg, w ere given in tram uscularly an hour before the scheduled surgery. In the operating room the preanesthetic blood pressure, in a supine position, was 160/85 mm Hg. G eneral anesthesia was induced w ith thiopental sodium , 200 mg, and succinylcholine chloride, 60 mg, in an intravenous bolus. A dequate nasoendotracheal intubation was accom plished, and the anesthesia was m aintained with enflurane, nitrous oxide, and oxygen. A 2% solution o f lidocaine hydrochloride containing epinephrine (1:100,000) was infiltrated in the appropriate areas o f surgery. T he blood pressure during the 90-m inute proce dure was m aintained at 130/80 mm Hg. A fter surgery, recovery w as induced, extubation was accom plished in the operating room , and the pa tient was transferred to the recovery room in satisfactory condition. T otal fluid intake by this time was 250 ml. T hirty m inutes postoperatively, the patient began to show signs o f distress; oral hem orrhage was increasing and a large hem atom a w as forming in the region o f the maxillary labial frenectom y. T he p atien t’s blood pressure had risen to 180/110 mm H g and his pulse rate was 80 and regular; no pain w as reported. T he intravenous infusion was slowed to 30 m l/hr and the patient w as reassured and encouraged to urinate. D uring the next 30 m inutes, a total o f 300 ml o f urine w as passed, yet the blood pressure rose to 200/120 mm H g w ith the pulse rate and respiration satisfactory. T he p atien t’s physician was called, and he re c om m ended the im m ediate adm inistration o f 10 mg Wessberg: ROLE OF SCREENING FOR HYPERTENSION ■ 1043
C L IN IC A L
REPORT
o f hydralazine in a slow intravenous infusion. T he blood pressure was m onitored closely and d e creased steadily to 120/80 mm H g within five m in utes. T h e infusion was run rapidly to prevent re flex hypotension. T he blood pressure stabilized at 100/70 mm H g and slowly returned to 120/80 mm H g. T h e infusion was slowed to 60 ml/hr and the vital signs w ere checked every five m inutes. A total o f 850 ml o f urine was passed. An hour after the hypertensive episode, the blood pressure was stable at 145/85 mm H g, and the patient was returned to the w ard for postsurgical care. H e w as discharged tw o days later in satisfactory condition. T he patient had a norm al and com plete recovery.
Sum m ary D etectio n o f hypertension and m onitoring of the 23 million hypertensive A m ericans should be of concern to all health professionals. Early detec tion and diagnosis and adequate therapy, as p re scribed by a physician, can prevent the prem ature degeneration o f hypertension’s target organs. T h e dentist in particular is responsible for the safe, appropriate m anagem ent o f the hyperten sive individual during the stress o f dental trea t m ent. A prim ary m easure to prevent em ergencies in dental offices in these patients is the perfor m ance o f a thorough pretreatm ent evaluation. M any persons with controlled hypertension are able to lead norm al lives with pharm acotherapeutic assistance. By understanding the p atien t’s pathological condition, by being know ledgeable o f the therapeutic agents used, and by realizing the am ount of stress th at the patient will tolerate satisfactorily, the dentist can properly m anage the hypertensive patient. The author acknowledges the assistance of Drs. Bell, Tiner, and Scheerer of The Queens Medical Center in Honolulu. 1. Little, J., and Jakobsen, J. Management of the hypertensive patient in dental office. J Oral Med 29:13 Jan-March 1974. 2. Abbey, L.M. Screening for hypertension in the dental office. JADA 88:563 March 1974.
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3. Berman, C.L.; Guarino, M.A.; and Giovannoli.S.M. High blood pressure detection by dentists. JADA 87:359 Aug 1973. 4. Genest, J., and others. Screening programs for hypertension. Can Med Assoc J 111:147 Ju ly 20, 1974. 5. Moyer, J.H. Nation’s attention focused on hypertension. Pa Med 76:34 May 1973. 6. Finnerty, F.A., Jr. Hypertension: new techniques for patient compliance. In The hypertension handbook. West Point, Pa, Merck, Sharp, and Dohme, 1974. 7. Moser, M. Office management of hypertension. Am Fam Physician 10:153 Sept 1974. 8. Hickler, R.B. The office management of hypertension. Angiology 26:42 Jan 1975. 9. Veterans Administration Cooperative Study Group on Antihy pertensive Agents. Effects of treatment on morbidity in hyperten sion. Results in patients with diastolic blood pressure averaging 90 through 114 mm Hg. JAMA 213:1143 Aug 17, 1970. 10. Freis, E.D. The clinical spectrum of essential hypertension. Arch Intern Med 133:982 June 1974. 11. Groover, M.E., Jr.; Simpson, W.E.; and Fulghum, J.E. The early detection and treatment of hypertension. Angiology 26:15 Jan 1975. 12. Department of Health, Education, and Welfare. Blood pres sure of adults by race and area, by age and sex. US 1960-62 NHS Series II no. 4 and 5, 1964. 13. Caleel, G.T. Hypertension: diagnosis and management guidelines. J Am Osteopath Assoc 74:814 May 1975. 14. Kannel, W.B. Role of blood pressure in cardiovascular dis ease: the Framingham study. Angiology 26:1 Jan 1975. 15. Krupp, M.A., and Chatton, M.J. Current medical diagnosis and treatment. Los Altos, Lange, 1974. 16. Report of Inter-Society Commission for Heart Disease Re sources. Guidelines for the detection, diagnosis, and management of hypertension populations. Circulation 44:A263, 1971 (Rev, Aug 1972). 17. Kilcoyne, M.M.; Richter, R.W.; and Alsup, P.A. Adolescent hypertension. Detection and prevalence. Circulation 50:758 Oct 1974. 18. Lieberman, E. Essential hypertension in children and youth: a pediatric perspective. Pediatr 85:1 July 1974. 19. Hypertension. Heart Information Center, National Institute of Health no. 1714, June 1975. 20. Seltzer, C.C. Effect of smoking on blood pressure. Am Heart J 87:558 May 1974. 21. Gifford, R.W., Jr. Hypertension: current views on diagnostic evaluation. In The hypertension handbook. West Point, Pa, Merck, Sharp, and Dohme, 1974. 22. Boedeker, E.C., and Dauber, J.H. Manual of medical therapeutics, ed 21. Boston, Little-Brown, 1974, p 147. 23. Hussar, D.A. Interactions involving drugs used in dental practice. JADA 87:349 Aug 1973. 24. Spivak, J.L., and Barnes, H.V. Manual of clinical problems in internal medicine. Boston, Little-Brown, 1974. 25. Baker, C.E. (ed.). Physician’s desk reference, ed 32. Oradell, NJ, Medical Economics, Inc., 1978. 26. Bennett, C.R. Conscious-sedation in dental practice. St. Louis, C. V. Mosby Co., 1974. 27. Churchill-Davidson, H.C., and Wylie, W.D. A practice of anaesthesia, ed 3. Chicago, Lloyd-Luke, 1972. 28. Dhar, S.K., and Freedman, P. Clinical management of hyper tensive emergencies. Heart Lung 5:571 July-Aug 1976. 29. Freeman, N.S., and others. Office emergencies: an outline of causes, symptoms, and treatment. JADA 94:91 Jan 1977.