How to manage a patient with hypertension undergoing tooth extraction?

Management of Hypertensive Patients Undergoing Tooth Extraction

Blood Pressure Thresholds for Proceeding with Extraction

Elective tooth extraction should be postponed if blood pressure is ≥180/110 mmHg until adequate control is achieved, while patients with controlled or mild-to-moderate hypertension (BP <180/110 mmHg) can safely undergo the procedure. 1

• For patients with BP 160-179/100-109 mmHg, confirm blood pressure with repeated measurements before proceeding with elective extraction 1
• Patients with controlled hypertension (BP <180/110 mmHg) can undergo routine dental procedures without delay 1
• Blood pressure should be measured in a relaxed, temperate environment with the patient seated and arm supported for at least one minute before the initial reading 2
• If the first measurement is ≥140/90 mmHg, take two additional readings at least one minute apart and record the lower of the last two readings 2

Medication Management

Patients should continue their antihypertensive medications on the day of the procedure, as abrupt withdrawal can cause rebound hypertension, particularly with beta-blockers and clonidine. 1

• Maintain all antihypertensive medications until the time of the procedure 2
• Resume oral antihypertensive therapy as soon as possible after extraction 1
• Adequate potassium supplementation should be provided if needed to correct hypokalemia well in advance of the procedure 2

Local Anesthetic Selection and Safety

Epinephrine-containing local anesthetics can be used safely in patients with controlled hypertension (BP <180/110 mmHg), though the concentration and technique matter. 1

• Lidocaine 2% with epinephrine 1:80,000 or articaine 4% with epinephrine 1:100,000 or 1:200,000 are appropriate choices for controlled hypertensive patients 3, 4, 5
• Articaine 4% with epinephrine 1:200,000 produces significantly less systolic blood pressure elevation than lidocaine 2% with epinephrine 1:80,000 and may be the safest option 5
• Norepinephrine-containing local anesthetics (1:20,000-1:30,000) are contraindicated in hypertensive patients due to excessive blood pressure elevation. 6
• All precautions must be taken to prevent inadvertent intravascular injection, as this is the primary risk factor for adverse hemodynamic events 3

Hemodynamic Monitoring During the Procedure

Blood pressure should be monitored before anesthesia, just before extraction, and in the immediate post-extraction period, as the highest blood pressure elevations typically occur during the actual extraction rather than from the anesthetic itself. 3, 4

• The stress of tooth extraction itself causes greater hemodynamic changes than the epinephrine in local anesthetics 3, 7
• Hypertension is common in the immediate post-procedure period due to pain and increased sympathetic tone 1
• Continuous BP monitoring is essential during emergency procedures in hypertensive patients 1

Common Pitfalls to Avoid

• Do not use high concentrations of norepinephrine (1:20,000) as this causes the most remarkable blood pressure elevation and heart rate changes 6
• Avoid postponing elective procedures unnecessarily in patients with BP <180/110 mmHg who are on stable antihypertensive therapy 1
• Do not abruptly discontinue antihypertensive medications perioperatively, particularly beta-blockers and clonidine 1
• Ensure proper aspiration technique before injecting local anesthetic to prevent intravascular administration 3
• Address pain and anxiety adequately, as these contribute more to blood pressure elevation than the vasoconstrictor in the anesthetic 2, 3