Management of Controlled Hypertensive Patients Undergoing Dental Extraction and Filling
Patients with controlled hypertension can safely proceed with tooth extraction and filling while continuing their antihypertensive medications, and local anesthetics containing epinephrine can be used safely without significant hemodynamic complications. 1
Preoperative Blood Pressure Assessment
- Measure blood pressure before any dental procedure to confirm the hypertension remains controlled 2
- Proceed with dental treatment if systolic BP <180 mm Hg and diastolic BP <110 mm Hg 1
- Defer elective procedures if BP ≥180/110 mm Hg until better control is achieved, as this threshold is associated with increased perioperative cardiovascular complications 1
- For urgent dental needs with uncontrolled hypertension, coordinate with the patient's physician for rapid BP optimization before proceeding 1
Medication Management
Continue all antihypertensive medications on the day of the dental procedure 1
Key medication-specific considerations:
- Beta-blockers and clonidine must never be stopped abruptly due to risk of rebound hypertension, which can be life-threatening 1
- ACE inhibitors and ARBs may be considered for temporary discontinuation 24 hours before the procedure if the patient has risk factors for hypotension, though this is controversial and not mandatory for routine dental procedures 1
- Calcium channel blockers should be continued but note they may cause gingival hyperplasia, which can complicate periodontal procedures 1
Local Anesthetic Selection
Epinephrine-containing local anesthetics are safe and can be used in controlled hypertensive patients 1
- A systematic review concluded that epinephrine has minimal cardiovascular effects even in hypertensive patients during dental procedures 1
- Research demonstrates no statistically significant hemodynamic changes when using 2% lidocaine with 1:80,000 epinephrine in controlled hypertensive patients compared to plain lidocaine 3
- Studies show articaine with 0.012 mg epinephrine can be safely used in hypertensive patients with BP ≤154/99 mm Hg 4
- Use careful aspiration technique to prevent inadvertent intravascular injection, which is the primary safety concern 3
Intraoperative Monitoring
Monitor blood pressure during the procedure if general anesthesia or sedation is used, as hypertensive patients may experience wider BP fluctuations and risk of hypotension when receiving antihypertensive drugs 1
For routine local anesthesia procedures:
- The highest hemodynamic changes typically occur during the extraction itself, not from the anesthetic 3
- Anxiety and pain are major contributors to BP elevation during dental procedures 2
- Consider anxiety management techniques and adequate pain control to minimize sympathetic stimulation 1
Postoperative Management
- Resume or continue all antihypertensive medications immediately after the procedure 1
- Provide adequate postoperative pain control, as pain increases sympathetic tone and vascular resistance 1
- Standard post-extraction care applies; controlled hypertension does not require modification of routine postoperative instructions 3, 4
Critical Safety Thresholds
Do not proceed with elective dental surgery if:
- Systolic BP ≥180 mm Hg or diastolic BP ≥110 mm Hg 1
- The patient has stopped taking beta-blockers or clonidine within the past 48 hours (rebound hypertension risk) 1
- Signs of hypertensive emergency are present (acute end-organ damage) 5
Common Pitfalls to Avoid
- Never withhold epinephrine-containing anesthetics based solely on hypertension diagnosis when BP is controlled, as the evidence shows safety 1, 3
- Never advise patients to skip their morning antihypertensive medications before dental appointments 1
- Do not confuse controlled hypertension with hypertensive crisis (BP >180/120 mm Hg), which requires different management 5
- Recognize that the stress of dental procedures itself causes BP elevation independent of anesthetic choice 3, 4