What dental procedures are contraindicated in a patient with a history of hypertension (high blood pressure), hyperlipidemia (elevated lipids), and a recent transient ischemic attack (TIA), who is likely taking antihypertensive and lipid-lowering medications?

Dental Clearance for Patient with Recent TIA, Hypertension, and Hyperlipidemia

All listed dental procedures can be safely performed in this patient with controlled hypertension and a TIA that occurred several months ago, including procedures with local anesthesia containing epinephrine, nitrous oxide, and invasive surgery. 1, 2

Blood Pressure Control Requirements

The critical threshold for proceeding with dental treatment is systolic BP <180 mmHg and diastolic BP <110 mmHg. 1 If blood pressure exceeds these values, defer elective procedures until better control is achieved. 1

• Continue all antihypertensive medications on the day of dental procedures without interruption. 1
• Beta-blockers and clonidine must never be stopped abruptly due to life-threatening rebound hypertension risk. 1
• Measure blood pressure before each appointment to ensure adequate control. 3, 4

Specific Procedure Safety

Simple and Deep Cleaning (a)

Proceed without restrictions. 1 These non-invasive procedures carry minimal cardiovascular risk in patients with controlled hypertension and remote TIA history.

X-rays (b)

Proceed without restrictions. 2 Diagnostic imaging poses no cardiovascular contraindications.

Fillings, Crowns, Bridges (c)

Proceed with local anesthesia containing epinephrine. 1 Epinephrine-containing local anesthetics are safe in controlled hypertensive patients and do not cause significant hemodynamic complications. 1, 3

Surgery (Extraction, Implants, Grafting) (d)

Proceed if BP is controlled (<180/110 mmHg). 1 The patient's TIA occurred "a couple of months ago," which satisfies the timing requirements for elective procedures. 2

• Elective dental surgery should be avoided for 6 weeks after myocardial infarction, but TIA does not carry the same restriction. 2
• Use short appointments (less than one hour), preferably in the morning. 3
• Ensure adequate postoperative pain control, as pain increases sympathetic tone and blood pressure. 1

Root Canal Therapy (e)

Proceed with standard precautions. 2 Endodontic procedures are safe in patients with controlled cardiovascular disease.

Nitrous Oxide (f)

Nitrous oxide is safe and actually recommended for patients with cardiovascular disease, particularly those with ischemic heart disease. 3 It provides anxiolysis and reduces stress-related cardiovascular complications during dental procedures.

Local Anesthesia with Epinephrine (g)

Epinephrine-containing local anesthetics are safe and recommended. 1, 3 Effective local anesthesia is crucial to avoid undue stress during appointments, which poses greater cardiovascular risk than the epinephrine itself. 3

• Follow standard guidelines for epinephrine administration. 3
• Strictly avoid epinephrine-impregnated gingival displacement cord in patients with cardiovascular disease. 3

Critical Management Principles

Medication Continuation

• The patient is likely taking antihypertensive medications (ACE inhibitors, ARBs, beta-blockers, or thiazides) and statins for secondary stroke prevention. 5
• All cardiovascular medications should be continued without interruption. 1
• If the patient is on antiplatelet therapy (aspirin or other agents) for TIA, do not suspend it for common dental procedures. 2

Anxiety and Stress Management

• Consider premedication to alleviate anxiety. 3
• Nitrous oxide and oxygen intraoperatively is a reasonable strategy. 3
• Keep appointments short (less than one hour) and schedule in the morning when possible. 3

Monitoring During Procedures

• Monitor blood pressure during procedures if general anesthesia or sedation is used, as hypertensive patients may experience wider BP fluctuations. 1
• Have emergency medications available, including nitroglycerin if the patient has any history of angina. 3

Common Pitfalls to Avoid

• Never defer routine dental care indefinitely based solely on cardiovascular history if BP is controlled. 1, 2
• Never stop beta-blockers or clonidine abruptly before dental procedures. 1
• Never use epinephrine-impregnated gingival displacement cord in cardiovascular patients. 3
• Do not withhold epinephrine from local anesthetics out of excessive caution—the stress of inadequate anesthesia poses greater risk. 1, 3

Risk Factor Optimization

While providing clearance, reinforce that this patient requires ongoing management of cardiovascular risk factors:

• Blood pressure should be maintained <140/90 mmHg (or <130/80 mmHg given the TIA history). 5
• Statin therapy is recommended for most patients after atherothrombotic TIA. 5
• Antiplatelet therapy (aspirin or alternative) should be continued. 5

In summary, provide full clearance for all requested dental procedures with the stipulation that blood pressure must be <180/110 mmHg at the time of treatment, all cardiovascular medications should be continued, and standard cardiovascular precautions should be observed. 1, 2