HYPERTENSION AND

RENAL DISEASE
Text Reading
Assignment:
Essentials of Oral
Medicine
Chapter 4 - pp. 36-
41
“Renal Diseases
and Hypertension”
 HYPERTENSION (HTN)
• Things to know / ask:
– What is hypertension?
– How is it diagnosed?
– What are signs, symtoms and complications of
the disease?
– How is the disease treated?
– What are side effects of treatment?
– What are the dental implications of HTN?
– What is the relationship with renal disease?
– What are the dental implications of renal
disease?
 What is Hypertension?
• Pathologic “Disregulation” of Blood Pressure (Blood
Volume, Vasoconstriction, or Cardiac Output)
– Sustained
– Damaging
– > 140/90 mm Hg
• Primary (90%) and Secondary (10%) (Especially Renal
Associated) Types
• May Affect 20-40 % of Population
– Definition Dependent
– % Increases with Age
– More Common in Blacks and Men
– Associated with Stress, Weight, Smoking, Diabetes
 Blood Pressure
Determining Factors
Cardiac Output:
Peripheral
Stroke Volume
Resistance **
Heart Rate
Vasodilators
Force of Contraction
ACE Inhibitors
Beta Blockers
Calcium Channel
BP
Blockers

Blood Volume **
Diuretics ACE Inhibitors
 Types of Hypertension
100
90%
80

60 Essential

40 Secondary

Secondary HTN Classification

20
Renal
10%
Ischemia Renin
0
Adrenal
Cortical
Cushing’s Syndrome
Aldosterone Adenoma
Medullary
Pheochromocytoma
Malignant Hypertension Pituitary
ACTH Adenoma
 How is Hypertension
Diagnosed?
• Medical Diagnosis
– BP =/> 140/90 (Systolic/Diastolic)
• Dental Screening / Monitoring
– Screen all Patients for Evidence of Disease
– Refer “Knowns” and “Unknowns” for
pressures of ~ 140/90 or greater ( 2 successive
measurements)
– Monitor Known HTN Patients for Control
 A “Relatively Recent”
Complete Classification
Category Systolic Diastolic
• Optimal < 120 < 80
• Normal < 130 < 85
• High Normal 130-139 85-89
• HTN - Stage I 140*-159 90*-99
• HTN - Stage II 160*-179 100*-109*
• HNT - Stage III 180*-209 110-119
• HTN - Stage IV =/> 210 =/> 120
* Routine Care OK but Refer for Diagnosis or Improved Managment

** No Elective Treatment without Medical Consult and Improved BP

 What are Symptoms and
Complications of Untreated or
Undiagnosed Disease?
• Symptoms
– Usually Asymptomatic (95%) Unless Severe
– Severe: Dizzines, Ringing in Ears, Headaches, Fainting Spells,
Blurred Vision, Epistaxis (Bleeding Nose) or other Prolonged
Bleeding
• Complications - Undiagnosed or Untreated
– Accelerated Atherosclerosis
• Increased Risk of Myocardial Infarction (M / Heart AttackI) and
Cerobrovascular Accidents (CVA / Stroke)
– Congestive Heart Failure (CHF)
• Swollen Ankles
• Shortness of Breath
• Cough
– Small Risk of Eye and/or Renal Damage
 How is the Disease
Treated?
• Life Style Changes
– Low Salt Diet
– Weight Loss
– Reduced Stress
– Smoking Cessation
• Medication !!!
– Diuretics (Decrease blood volume)
– Vasodilators (Decrease peripheral resistance)
– Beta Blockers and Calcium Channel Blockers (Decrease
Cardiac Output)
– Angiotensin Converting Enzyme (ACE) Inhibitors
(Decrease Angiotensin Formation: Decreased
Vasoconstriction and Blood Volume-Aldosterone
associated sodium retention and blood volume)
What are Side Effects of
Treatment of HTN?
• Examples - Systemic
– Postural Hypotension (Stand up - Fall Down)
– Impotence
• Examples - Oral
– Dry Mouth (Xerostomia)
– Gingival Hyperplasia (Calcium Channel
Blockers - Nifedipine)
• Specific Medication Dependent - Always
Check
Questions to Ask in the Medical History

• How long diagnosed?

• What medications taking? / Do you take
them? / Any recent changes?
• Any side effects of medications?
• How well controlled?
• What is “normal” with and without
medication?
• Any blood pressure related dental
problems?
Things to Do in the Dental Chair
• Ask if patient took medication today
• Check blood pressure before starting
appointment
• Monitor Blood pressure during appointment
• Be judicious with vasoconstrictor in anesthetic
- Don’t use retraction cord with epinephrine
• Remain alert for medication side effects and
disease complications
Pertinent Aspects of Medical
History Related to HTN
• II Have you Experienced (Symptoms)?
– Chest Pain(Angina) - Atherosclerosis
– Swollen Ankles - Long Standing CHF
– Shortness of Breath - Long Standing CHF
– Cough - Long Standing CHF
– Bleeding Problems - Severe HTN
– Dizziness, Ringing in Ears, Headaches, Fainting
Spells, Blurred Vision - Severe HTN
– Excessive Thirst, Frequent Urination / Diabetes
Mellitus related HTN - (Atherosclerosis and/or Renal
Disease)
Pertinent Aspects of Medical
History Related to HTN

• III. Have you Had / Do you Have

(Diseases)?
– Heart Disease, Heart Attack
– Stroke, Hardening of the Arteries
– High Blood Pressure
– Kidney Disease
– Diabetes Mellitus
Pertinent Aspects of Medical
History Related to HTN
• Are You Taking (Medications)?
– Any Medications for Blood Pressure
Control
• Which Ones?
• Check for any side effects
Management of Hypertensive
Patients
• 140/90 or Less - No Precautions Needed
• 141/91 - 160/110 - Sedation? Or Delay
• > 161/111 - No Elective / Emergency only
with Med Consult
• Controlled HTN: LA Vasoconstrictor OK /
Avoid Epi-Retraction Cord
• Undiagnosed Screening: Retake BP /
Refer for Diagnosis
 What is Renal (Kidney)
Disease?
• Inflammatory / Infectious Disease (Usually) that Damages Kidney and
Alters Kidney Function
– Glomerulonephritis: Immunopathic Disease of Glomerulus (Many Sub-
Types)
– Pyelonephritis: Infection of Connective Tissue and Tubules
• May Require: Pyelonephritis Glomerulonephritis
– Medication
– Dialysis (End-Stage - Renal Failure) (300,000)
– Transplant (End-Stage - Renal Failure) (30,000/yr)
• May interfere with:
– Drug Metabolism
Chemical Toxins
Kidney
– Infection Control and Wound Healing Damage
– Bleeding (Platelet Adhesion Inhibition) End Stage Renal
• Renal Failure May also be Associated with: Dialysis or Transplant
– Anemia (loss of erythropoietin)
– HTN
– Secondary Hyperparathyroidism (loss of Ca++) ** Developmental
– Uremic Stomatitis ** or Oral Candidiasis Kidney Stones Malformations
 Secondary
Hyperparathyroidism **

• Decreased Serum Calcium

• Increased Parathormone
– Calcium removed from bone
• Ground Glass Radiographic Appearance
• or Radiolucent lesions Filled with Giant Cell
Granuloma
• Loss of Lamina Dura
 Uremic Stomatitis

• Precedes Renal Failure

• Ammonia in Saliva
• Oral Ulceration
• Dysgeusia (abnormal taste): metalic
• Increased Salivation
 The Kidney
Pyelonephritis Glomerulonephritis
 Glomerulonephritis
- Immunopathic Disease -

Podocyte Epithelial Cells of Bowman’s Capsule with “foot processes”

Basement Membrane Area

d d
Endothelial Cells of Glomerular Capillaries

Antigen / Antibody Complexes Localized

or Deposited in Basement Membrane Area

Inflammatory Damage to Glomerulus

 What is Relationship of
Renal Disease to HTN?
• Renal Disease may damage the kidney blood supply and
activate the RENIN-ANGIOTENSIN system (Release of
Renin with ultimate formation of Angiotensin II which raises
BP via vasoconstriction and sodium retention) - A form of
secondary hypertension
• HTN may damage the blood supply to the kidney (via
accelerated atherosclerosis or arteriolosclerosis) and
further contribute to its own progression
• Altered function may increase Na+ and fluid retention with
increased blood volume and pressure
 Renin - Angiotensin
Glomerulus and Bowman’s Capsule

Juxtaglomerular
Cells

Decreased BP
Renin Release

Formation of
Angiotensin

Increased Vasoconstriction
Increased Aldosterone
with Increased Na++ and
Fluid Retention
 Kidney Disease / End-Stage
Renal Disease
May Lead to or Cause:
1. Nephritic Syndrome
Blood in Urine (Hematuria),
Nitrogen Retention
(Azotemia) and decreased
Pyelonephritis Glomerulonephritis
urine output (oliguria)
2. Nephrotic Syndrome
Proteinuria and
Hypoproteinemia with
Edema (Tissue Swelling)
Kidney
Damage
3. Uremia End Stage Renal
Decreased Filtration(GFR) Dialysis or Transplant
and Toxic Elevated Blood
Urea Nitrogen (BUN) Chemical Toxins
Developmental
Kidney Stones Malformations
 Renal (Kidney) Disease
• Questions to Ask
– What kind of kidney problem?
– Does it interfere with everyday living?
– What Medications ?
– Are you on Dialysis?
– Have you had a Kidney Transplant?
– Do you also have HTN?
 Dental Management of
Patients with Renal Disease

• Avoid Renal Toxic Drugs (Acetominophen)

• Alter Dosage or Type of Renal Excretable Drugs
(Penicillin)
• Day after Dialysis for Dental Appointments
– Best Mental Status and General Health
– Anticoagulants(Post) and Decreased Platelete Function /
Adhesion (Pre) May Interfere with Hemostasis
• Increased Risk of Infection for Transplant
Patients (Immunosuppression)
HYPERTENSION / RENAL
Health History Findings HEALTH HISTORY
University of the Pacific School of Dentistry
Patient Name: Soc. Sec. No.:
Birth Date:
I. CIRCLE APPROPRIATE ANSWER (leave Blank if you do not understand question):
1. Yes No Is your general health good?
2. Yes No Has there been a change in your health within the last year?

General Health
3. Yes No Have you been hospitalized or had a serious illness in the last three years?
If YES, why?
4. Yes No Are you being treated by a physician now? For what?
Date of last medical exam? Date of last Dental exam
5. Yes No Have you had problems with prior dental treatment?
6. Yes No Are you in pain now?
II. HAVE YOU EXPERIENCED:
7. Yes No Chest pain (angina)? 18. Yes No Dizziness?
8. Yes No Swollen ankles? 19. Yes No Ringing in ears?
9. Yes No Shortness of breath? 20. Yes No Headaches?
10. Yes No Recent weight loss, fever, night sweats? 21. Yes No Fainting spells?

Signs & Symptoms

11. Yes No Persistent cough, coughing up blood? 22. Yes No Blurred vision?
12. Yes No Bleeding problems, bruising easily? 23. Yes No Seizures?
13. Yes No Sinus problems? 24. Yes No Excessive thirst?
14. Yes No Difficulty swallowing? 25. Yes No Frequent urination?
15. Yes No Diarrhea, constipation, blood in stools? 26. Yes No Dry mouth?
16. Yes No Frequent vomiting, nausea? 27. Yes No Jaundice?
17. Yes No Difficulty urinating, blood in urine? 28. Yes No Joint pain, stiffness?
III. DO YOU HAVE OR HAVE YOU HAD:
29. Yes No Heart disease? 40. Yes No AIDS
30. Yes No Heart attack, heart defects? 41. Yes No Tumors, cancer?
31. Yes No Heart murmurs? 42. Yes No Arthritis, rheumatism?

Specific Diseases
32. Yes No Rheumatic fever? 43. Yes No Eye diseases?
33. Yes No Stroke, hardening of arteries? 44. Yes No Skin diseases?
34. Yes No High blood pressure? 45. Yes No Anemia?
35. Yes No Asthma, TB, emphysema, other lung diseases? 46. Yes No VD (syphilis or gonorrhea)?
36. Yes No Hepatitis, other liver disease? 47. Yes No Herpes?
37. Yes No Stomach problems, ulcers? 48. Yes No Kidney, bladder disease?
38. Yes No Allergies to: drugs, foods, medications, latex? 49. Yes No Thyroid, adrenal disease?
39. Yes No Family history of diabetes, heart problems, tumors? 50. Yes No Diabetes?
IV. DO YOU HAVE OR HAVE YOU HAD:

Types of Treatment
51. Yes No Psychiatric care? 56. Yes No Hospitalization?
52. Yes No Radiation treatments? 57. Yes No Blood transfusions?
53. Yes No Chemotherapy? 58. Yes No Surgeries?
54. Yes No Prosthetic heart valve? 59. Yes No Pacemaker?
55. Yes No Artificial joint? 60. Yes No Contact lenses?
V. ARE YOU TAKING:
61. Yes No Recreational drugs? 63. Yes No Tobacco in any form?

Medications
62. Yes No Drugs, medications, over-the-counter medicines 64. Yes No Alcohol?
(including Aspirin), natural remedies?
Please list:

VI. WOMEN ONLY:

65. Yes No Are you or could you be pregnant or nursing? 66. Yes No Taking birth control pills?
VII. ALL PATIENTS:
67. Yes No Do you have or have you had any other diseases or medical problems NOT listed on this form?
If so, please explain:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health
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and/or medication.
Patient’s signature: Date:
Health
RECALL REVIEW:

1. Patient’s signature Date:

History
2. Patient’s signature Date:

3. Patient’s signature Date:

 HYPERTENSION / RENAL
UOP Protocols
University of the Pacific School of Dentistry

Protocols for the

• See: DENTAL MANAGEMENT OF MEDICALLY
– Questions to Ask COMPLEX PATIENTS

– Diagnostic Tests
– Dental Management TOPIC

1. Bleeding Problems (including anticoagulants)

PAGE

– Alerts 2. Cardiac Problems (heart murmurs, cardiac defects) 4

(Complications) 3. Cardiovascular Problems (high blood pressure, arrhythmias) 8

4. Central Nervous System Problems (seizures, stroke) 12

5. Diabetes 15

6. Immunosuppression 17

7. Infectious Diseases (tuberculosis, hepatitis, HIV, herpes, flu) 19

8. Kidney Problems 24

9. Liver Problems 25

10. Pregnancy 27

11. Prosthetic Joints 29

Protocols compiled by: Peter L. Jacobsen, Ph.D., D.D.S

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Department of Pathology and Medicine
UOP
Please direct all comments, edits and suggestions to him at:
pjacobse@uop.edu or call (415) 929-6609 or fax (415) 929-6654 or write to:
Department of Pathology and Medicine
Protocol
UOP School of Dentistry
2155 Webster Street
San Francisco, CA 94115
THE END