PRESENTED BY-

GUIDED BY-

• Introduction

• History

• Definitions

• Measurement

• Normal Values

• Factors Determining BP

• Regulation of BP :

• Short term regulation

• Long term regulation

• Applied Physiology

• Hypertension

• Periodontal Implications

• Hypotension

• Conclusion

Riva- Rocci (1896) Present-day Technique

Simple palpation of the pulse Early Egyptians

Stephen Hales (1677-1761)

Now, in the 21st century BP is monitored continually by

sensors worn on the patient's thumb;

Inflatable cuffs coupled to a servomechanism which

maintains suitable cuff pressure.

Strain gauges, photocells and semiconductors are

coming into use in the recording of blood pressure.

Proc. roy. Soc. Med. Volume

70 November 1977

Blood pressure is defined as the force exerted by the blood on unit area of

vessel wall.

VENOUS PRESSURE

PERIPHERAL VENOUS

PRESSURE CAPILLARY PRESSURE

FEW MORE TERMS RELATED TO BP

Recumbent

mm

of

Hg

Indirect method

Auscultatory Palpatory Oscillatory

Arterial pressure fluctuates between

a systolic level of 120 mm Hg

and a diastolic level of 80 mm Hg,

Thus a BP of 120/80 is considered as normal.

Chronic or Prolonged Elevation → Chronic Hypertension

Secondary

Hypertension

Cardio-vascular shock or Spinal shock → BP falls

Essential

Hypertension

3. DRUG INDUCED

• Amount of blood ejected per ventricle per beat

depends on-

a) Cardiac inflow

b) Contractility of the heart

c) Heart rate

CARDIAC OUTPUT :

Heart rate

(within physiological limits)

Cardiac Output

(Minute Volume)α

BP = Cardiac output X Peripheral resistance.

Not applicable to Windkessel vessels

• Chiefly Arterioles & to a small extent Capillaries.

depends on

a) Viscosity

b) Velocity

c) Elasticity

d) Lumen of vessel

PERIPHERAL RESISTANCE

R = 8ηl/π r4 =ΔP/Q

R = Peripheral resistance l = Length of the blood vessel

r = Radius of blood vessel Q = Cardiac output

ΔP = Difference in pressure in the vessel η= dynamic fluid viscosity

Hagen-Poiseulle

law

The Baro-receptor mechanism

The Chemo-receptor mechanism

The CNS Ischemic mechanism

SHORT TERM REGULATION

BARORECEPTOR MECHANISM

CHEMORECEPTOR MECHANISM

THE CNS ISCHEMIC MECHANISM

• ↓ CEREBRAL Blood flow causes

• Failure of the slowly flowing blood to

Carry CO2 away from the

VASOMOTOR CENTER

• Stimulation of Vasomotor centre

Systemic Arterial Pressure RISE

• Above threshold level such that HEART can pump blood &

CEREBRAL blood flow RESTORED

LONG TERM REGULATION

Hypertension is a persistently raised BP resulting from increased peripheral arteriolar resistance (scully & cawson)

DEFINITION

CLASSIFICATION

-ACCORDING TO ETIOLOGY

• >95%

• Underlying cause not known

Primary Hypertension

• 5 % of pts

• Consequence of disease/ abnormality

• Sodium retention

• With or without vasoconstriction

Secondary Hypertension

CLASSIFICATION-BASED ON BP MEASUREMENTS

In 2003, the National Heart, Lung and Blood Institute issued revised

guidelines for evaluation and management of hypertension

Do’s Average

value of 3 recordings

3 different appointments

Do

n’ts Diagnose by

Single Recording.

DIAGNOSIS

The Higher value is considered for the

classification among Systolic & Diastolic.

Isolated Systolic Hypertension

OBJECTIVE OF INITIAL EVALUATION OF

NEWLY DIAGNOSED…

Obtain accurate and representative measurements

Identify contributory factors/underlyingcause

Quantify cardiovascularrisk

Any complications (target organ damage)

Choice of antihypertensive therapy.

CLINICAL FEATURES

IF UNDIAGNOSED…

RISK FACTORSN

on

-mo

dif

iab

le • Age

• Sex

• Genetics

• Ethnicity

Mo

dif

iab

le • Obesity

• Salt intake

• Saturated fats

• Dietary fibers

• Alcohol

• Physical activity

• Environmental stress

MANAGEMENT

Urinalysis for blood, protein,

& glucose

Blood urea, electrolytes# &

creatinineBlood glucose

Serum total and HDL

Cholesterol

12-lead ECG (LVH, CAD)

# Hypokalaemic alkalosis may indicate Primary

Aldosteronism but is usually due to diuretic therapy.

- INVESTIGATIONS FOR ALL HYPERTENSIVES

• Cardiomegaly, Heart failure

• Coarctation of aortaChest X-ray

• To assess ’white coat’ hypertension

Ambulatory BP recording

• Detect or quantify LVHEchocardiogram

• Detect possible renal disease

Renal ultrasound /Angiography

- INVESTIGATIONS FOR SELECTED

↓ Alcohol intake

Restricting Salt intake

Appropriate life-style

(Correcting Obesity)

Eating oily fish

Regular physical exercise

Quitting smoking

↑ Consumption

of fruit/ vegetables

- NON DRUG THERAPY

ANTIHYPERTENSIVE DRUGS

ANTIHYPERTENSIVE DRUGS

• Losartan (50-100 mg)

• Valsartan (40-160 mg)

• Blocks Angiotensin II type I

Angiotensin receptor blockers

• Amlodipine (5-10 mg)

• Nifedipine (30-90 mg)

• Side effects- flushing, palpitations, Gingival Enlargement

• Used Hypertension co-exists with angina

Calcium antagonists

• Vasodilators

• α- Blockers

• Prazosin

• Hydralazine

• Minoxidil

Other Drugs

TREATMENT MODIFICATIONS

Period

on

tal pro

ced

ure • Safe if

stress minimized

Patient on

medic

ation • Consult

Physician

Info

rm the

Ph

ysic

ian • Duty of

dentist

• Degree of stress

• Length of procedure

• Complexity of treatment

TREATMENT MODIFICATIONS

Risk of providing emergency dental care must out weigh risk of possible

hypertensive complication.#

TREATMENT CONSIDERATIONS

• Analgesics for pain

• Antibiotics for infection

• Surgical I & D

Do’s

• Treatment of HT pt not on medication

• LA with adrenalin >1:1,00,000 IU

Dont’s

Important to minimize pain → providing profound local anesthesia → avoiding

an increase in endogenous epinephrine secretion. (Mealy BL, 1996 & Muzyka

bc, Glick M, 1997)

SOME PHARMACOLOGICAL ASPECTS

Epinephrine- α & βadrenergic agonist

• ↑Heart rate by direct stimulation

• α -Vasoconstriction

• Β-Vaso dilatation

• Propanolol/ Nadolol+ LA with ADRENALIN = ↑ BP

WHY NOT ADRENALIN / EPINEPHRINE

WITH LA IN HYPERTENSIVES ???...

However, The benefits of the small doses of Epinephrine used in dentistry far

outweigh the potential for hemodynamic compromise!!!

BP increases around awakening

and peaks around mid morning

(Smolensky; 1996, Raab FJ et al; 1998)

HENCE, AFTERNOON DENTAL APPOINTMENTS MAY BE

PREFERRED

Postural hypotension is

very common!!

MINIMIZED BY SLOW POSITIONAL CHANGES

Strong positive association between

increased subgingival colonization by

A.a, P.g, T. forsythia and T. denticola

and prevalent Hypertension is seen

Nausea, sedation, oral

dryness, lichenoid reaction &

GINGIVAL OVERGROWTH

DESVARIEUX ET AL (2012)

ARTERIAL HYPERTENSION DOES NOT NORMALLY

PRECLUDE PERIODONTAL SURGERY. .(LINDHE)

ASSOCIATED WITH CERTAIN ANTIHYPERTENSIVE AGENTS

GINGIVAL OVERGROWTH &

ANTIHYPERTENSIVE AGENTS

Hypertensive pt

Calcium channel blockers

Nifedipine=44%

Diltiazem = 20%

Verapamil = 4%

Safe among other CCB

Other Anti-Hypertensives

No Gingival Overgrowth

Safe

•The dihydropyridine derivative, ISRADIPINE, can replace

Nifedipine in some cases and does not induce gingival

overgrowth.

A decrease in blood pressure below the normal value is termed as Hypotension

Acute Chronic

Systemic Causes

Serious Infections

Acute Hemorrhage

Vomiting

Diarrhea

Severe Burns

Anaphylactic shock

MI

Tachycardia

WeaknessLethargyEasy fatigabilityDizziness and fainting (erect posture)Interference with neural pathway

CLINICAL FEATURES

Dizziness Bradycardia Postural hypotension

Fainting

MANAGEMENT

Thorough Case history

High salt diet High fluid intake

Vaso-vagal shock-ATROPINE 0.6mg

iv

Hypertension is highly prevalent!!

Role of periodontist can be vital.

Hence, as periodontal surgeons we should

1. Record proper History

2. Consult the physician – Discuss

3. Minimize stress

4. Periodic recall and follow-up even can help in

hypertension monitoring.

CONCLUSION

1. Davidson’s Principles and Practice of Medicine, 18th Ed.

2. Concise Medical Physiology- Choudhuri, 2nd Ed.

3. Textbook of Medical Physiology – Guyton & Hall, 9th Ed.

4. Review of Medical Physiology – William F. Ganong, 20th Ed.

5. Carranza’s Clinical Periodontology, 10th Ed.

6. Journal of periodontol, 2002, 73: 954 – 68.

7. Clinical Periodontology and Implant dentistry – Jan Lindhe, 4th Ed.

8. Periodontics-Medicine, Surgery and Implants – Rose, Mealey, Genco & Cohen.

9. Harrison’s Principles of Internal Medicine, 16th Ed.

10. Vanderheyden et al. JADA 1989: 119; 407-412

11. Perio 2000: vol 23; 136 -141