What are the guidelines for tooth extraction in a patient with hypertension?

Guidelines for Tooth Extraction in Hypertensive Patients

For patients with hypertension, tooth extraction can proceed safely if blood pressure is below 180/110 mmHg, while patients with blood pressure ≥180/110 mmHg should have their hypertension controlled before undergoing dental procedures. 1

Blood Pressure Assessment Before Dental Procedures

• Blood pressure should be measured in a relaxed environment using validated equipment with the patient seated and arm supported for at least one minute before the initial reading 1
• If the first measurement is ≥140/90 mmHg, blood pressure should be measured twice more, with each reading at least one minute apart; the lower of the last two readings is recorded as the blood pressure 1
• For patients with vascular or renal disease, measure blood pressure in both arms and use the arm with the higher reading if the difference is >20 mmHg 1

Classification of Hypertension and Dental Management

Safe for Immediate Dental Treatment:

• Blood pressure <140/90 mmHg (normotensive) 1
• Blood pressure 140-179/90-109 mmHg (Stage 1-2 hypertension) - can proceed with dental treatment, but the patient's primary care physician should be informed 1

Requires Medical Intervention Before Dental Treatment:

• Blood pressure ≥180/110 mmHg (Stage 3-4 hypertension) - refer back to primary care for blood pressure management before proceeding with elective dental procedures 1

Local Anesthetic Considerations

• Local anesthetics containing epinephrine can be safely used in patients with controlled hypertension 1, 2, 3
• A systematic review concluded that the use of epinephrine in local anesthetic solutions had minimal effect on blood pressure in hypertensive patients 1
• For patients with controlled hypertension (≤154/99 mmHg), one cartridge of local anesthetic with epinephrine can be used safely 3
• Articaine 4% with epinephrine 1:200,000 has been shown to have less effect on systolic blood pressure compared to lidocaine 2% with epinephrine 1:80,000 and is considered safer for hypertensive patients 4

Perioperative Management

• Patients with controlled hypertension should maintain their antihypertensive medications until the time of the dental procedure 1
• Blood pressure should be monitored closely if general anesthesia is administered to hypertensive patients due to potential wide fluctuations in blood pressure 1
• The highest alterations in blood pressure and pulse rate typically occur during tooth extraction rather than during administration of local anesthesia 2, 5

Special Considerations

• Calcium channel blockers and other vasodilators may cause gingival hypertrophy, which should be noted during dental examination 1
• Avoid rapid changes in patient position to prevent orthostatic hypotension, especially in patients taking antihypertensive medications 1
• For patients with uncontrolled hypertension requiring urgent dental treatment, consultation with the patient's physician is recommended 1

Postoperative Care

• Monitor blood pressure after the procedure, especially in patients with known hypertension 2
• Ensure adequate pain management as pain can increase blood pressure in the postoperative period 1
• Schedule follow-up appointments during morning hours when stress levels are typically lower 5

Common Pitfalls to Avoid

• Do not withhold epinephrine-containing local anesthetics based solely on a history of hypertension; evidence shows they can be used safely in patients with controlled hypertension 1, 2, 3
• Avoid intravascular injection of local anesthetics by using proper aspiration technique before injection 2
• Do not proceed with elective dental procedures in patients with blood pressure readings ≥180/110 mmHg due to increased risk of perioperative complications 1, 6