DEPARTMENT OF PERIODONTOLOGY

NEW HORIZON DENTAL COLLEGE AND RESEARCH INSTITUTE

SEMINAR ON BLOOD PRESSURE

GUIDED BY- PRESENTED BY-

Dr.P.V Sunil Reddy (Professor & Hod) Palak Sharma

Dr.Shailendra S.Chaturvedi (Reader) PG Student

Dr.Pramod V.(Reader)

Dr.Hiroj Bagde(Reader)

Dr.Abhilasha Singh
 CONTENTS-

INTRODUCTION
TYPES OF BLOOD PRESSURE
VARIATIONS
DETERMINANTS OF BLOOD PRESSURE
REGULATION OF BLOOD PRESSURE
NERVOUS MECHANISM
RENAL MECHANISM
HORMONAL MECHANISM
LOCAL MECHANISM
MEASUREMENT OF BLOOD PRESSURE
APPLIED PHYSIOLOGY
CONCLUSION
REFERENCES
 INTRODUCTION

Arterial blood pressure is defined as the lateral pressure exerted by the column of blood on the
wall of arteries. The pressure is exerted when the blood flows through the arteries

TYPES OF BLOOD PRESSURE-

SYSTOLIC BLOOD PRESSURE

DIASTOLIC BLOOD PRESSURE
PULSE PRESSURE
MEAN ARTERIAL BLOOD PRESSURE

SYSTOLIC BLOOD PRESSURE

It is defined as the total pressure exerted in the arteries during the systole of the heart.
Normal systolic pressure
120mm of Hg

Range- 110-140 mm of Hg
 DIASTOLIC BLOOD PRESSURE
It is defined as the minimum pressure exerted on the arteries during diastole of the heart.

Normal rate-80 mm of Hg
RANGE- 60-80 mm of Hg

PULSE PRESSURE
• It is the difference between systolic and diastolic pressure.
• Normal rate- 40 mm of Hg

MEAN ARTERIAL PRESSURE

 • It is the average pressure existing in the arteries.
rd.
• It is the diastolic pressure + 1/3 the pulse pressure

i.e. (80+13=93mm of Hg)

VARIATIONS
PHYSIOLOGICAL VARIATIONS-

• Age
• Sex
• Body built
• Diurnal variation
• After meals
• During sleep
• Emotional conditions
• After exercise

PATHOLOGICAL VARIATIONS-

HYPERTENSION

HYPOTENSION
 DETERMINANTS OF ARTERIAL BLOOD PRESSURE

• CENTRAL FACTORS
• CARDIAC OUTPUT
• HEART RATE
• PERIPHERAL FACTORS
• PERIPHERAL RESISTANCE
• BLOOD VOLUME
• VENOUS RETURN
• ELASTICITY OF BLOOD VESSELS
• VELOCITY OF BLOOD FLOW
• DIAMETER OF BLOOD VESSELS
• VISCOSITY OF BLOOD

REGULATION OF BLOOD PRESSURE

 NERVOUS MECHANISM FOR REGULATION OF BLOOD PRESSURE
The nervous mechanism operates through the vasomotor system
VASOMOTOR SYSTEM INCLUDES-
Vasomotor center
Vasoconstrictor fibres
Vasodilator fibres

VASOMOTOR CENTRE-
• It consists of 3 parts-
• Vasoconstrictor area
• Vasodilator area
• Sensory area
It sends impulses to the blood vessels through vasoconstrictor sympathetic fibres which lead to
rise in blood pressure.

VASODILATOR AREA-
• It is also called the depressor area and it suppresses the vasomotor centre thus causing
vasodilation and fall in blood pressure.

SENSORY AREA-

• It receives impulses from the baroreceptors and controls the vasodilator and
vasoconstrictor areas.

VASOCONSTRICTOR FIBRES-

They are a part of sympathetic div of autotnomic nervous system. They release noradrenaline and
cause vasoconstriction.

Noradrenaline acts through the alpha receptors on smooth muscle of blood vessel.

VASODILATOR FIBRES-
• They are of 3 types-
• Parasympathetic vasodilator fibres
• Sympathetic vasodilator fibres
 • Antidromic vasodilator fibres
BARORECPTOR MECHANISM

It sends impulses to the blood vessels through vasoconstrictor sympathetic fibres which lead to
rise in blood pressure.

VASODILATOR AREA-
• It is also called the depressor area and it suppresses the vasomotor centre thus causing
vasodilation and fall in blood pressure.

SENSORY AREA-
It receives impulses from the baroreceptors and controls the vasodilator and vasoconstrictor areas.

RENAL MECHANISM
 RENIN ANGIOTENSION SYSTEM

LOCAL FACTORS

LOCAL VASOCONSTRICORS-
Endothelins(ET1,ET2,ET3)
LOCAL VASODILATORS-

Metabolic origin(CO2,Lactate,H2 ions adenosine)

Endothelial origin(NO)

HORMONAL MECHANISM-
Hormones which increase blood pressure-

Adrenaline, noradrenaline, thyroxine, aldosterone, vasopressin, angiotensin, serotonin

Hormones which decrease blood pressure-

Bradykinin, histamin, acetylcholine, Vasoactive intestinal polypeptide, atrial natiuretic peptide,

brain natriuretic peptide, c-type natriuretic peptide.

MEASUREMENT OF BLOOD PRESSUE

DIRECT METHOD

Used in animals

INDIRECT METHOD

Apparatus-
SPHYGMOMANOMETER
STETHOSCOPE
PRINCIPLE

When external pressure is applied over the artery, the blood flow through it is obstructed.
And, the pressure required to cause occlusion of blood flow indicates the pressure inside
the vessels.

PROCEDURE

PALPATORY METHOD
AUSCULTATORY METHOD
OSCILLATORY METHOD

PALPATORY METHOD-
 • Feel the radial pulse
• Increase the pressure in the cuff by inflating air in it.
• The mercury column shows the pressure.
• After the radial pulse disappears the pressure is increased by 20 mm HG.
• Then the pressure in the cuff is released slowly, bywatching the mercury column and
feeling the pulse.
• Pressure is noted when the pulse reappears.

AUSCULTATORY METHOD

FIRST PHASE- While decreasing the pressure from the arm cuff, the occlusion of the artery is
relieved and when the blood starts flowing through the artery , the first sound appears suddenly
when the pressure is reduced to 120mm Hg.

This indicates the SYSTOLIC SOUND.

SECOND PHASE-

Following the clear and taping sound, a murmuring sound is heard when the pressure is reduced
further by about 15 mm Hg.

• After the murmuring sound a very clear and louder sound is heard. It is of gong type. It is
heard while reducing the pressure by another 15 mm of Hg.
 FOURTH PHASE-
rd
• After the 3 sound , a mild and muffled sound is heard when the pressure is decreased
further by 5 mm Hg. This indicates DIASTOLIC SOUND.

OSCILLATORY METHOD
SYSTOLIC PRESSURE-

When the pressure in the arm cuff is increased above systolic pressure the artery gets occluded,
and the mercury column remain static. When the pressure is released , oscillations occur at the
top of the mercury denoting the systolic pressure. While deflating further the amplitude and
duration of oscillations are increased denoting the systolic pressure

DIASTOLIC PRESSUE-

When the cuff pressure is reduced further the amplitude and duration of oscillation is reduced
denoting the diastolic pressure.

APPLIED PHYSIOLOGY
• HYPERTENSION-
 Hypertension is defined as the persistent high blood pressure. Clinically when the blood
pressure is elevated above 150mm of Hg and diastolic is above 90 mm of Hg it is
considered as hypertension.

CLASSIFICATION

ETIOLOGIC CLASSIFICATION

ESSENTIAL HYPERTENSION
Genetic factor
Racial and environmental factor

Risk Factors

SECONDARY HYPERTENSION
i) Renal-
Reno vascular
Renal parenchymal disease
ii) Endocrine-
Adrenocortical hyper function
Hyperparathyroidism
Oral contraceptives
iii) Coarctation of aorta
iv) Neurogenic

EFFECTS OF HYPERTENSION
 KIDNEY (NEPHROSCLEROSIS)

Reduction In size and weight

Hyalinisation and sclerosis of arteries
Intimal thickening
Fibrosis of parenchyma

HEART
(HYPERTENSIVE HEART DISEASE)
Increased weight and size of heart.
Hypertrophy of left ventricle.
Myocardial fibrosis and oedema.

EYES
(HYPERTENSSIVE RETINOPATHY)
Arteriolar narrowing
Cotton wool spots in the superficial layer
Atriovenous nicking
Leakage of lipid and fluid in the macula

NERVOUS SYSTEM
(INTRACRANIAL HAEMORRHAGE)
Dark mass of blood clot replacing the parenchyma after few months it may resolve into an
apopletic cyst containing yellow fluid.

MANAGEMENT
In 2003, the National Heart, Lung and Blood Institute issued revised guidelines for evaluation
and management of hypertension. The seventh report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC-7) guidelines
simplified the classification of blood pressure

Periodontal procedures should not be performed until accurate BP measurements and histories
have been taken to identify those patients with significant hypertensive disease. The time of day
also should be recorded since BP varies significantly throughout the day. outlines appropriate
medical referral or consultation and dental treatment modifications, depending on the patient's
stage of hypertension.

If a patient is currently receiving antihypertensive therapy, consultation with the physician may
be warranted regarding the current medical status, medications, periodontal treatment plan, and
patient management. Many physicians are not knowledgeable about the nature of specific
periodontal procedures. The dentist must inform the physician regarding the estimated degree of
stress, length of the procedures, and complexity of the individualized treatment plan. Morning
dental appointments were once suggested for hypertensive patients. However, recent evidence
indicates that BP generally increases around awakening and peaks at midmorning. Lower BP
levels occur in the afternoon; therefore afternoon dental appointments may be preferred.
No routine periodontal treatment should be given to a patient who is hypertensive and not under
medical management. For patients with systolic BP greater than 180 mm Hg or diastolic BP
greater than 110 mm Hg, treatment should be limited to emergency care until hypertension is
controlled. Analgesics are prescribed for pain and antibiotics for infection. Acute infections may
require surgical incision and drainage, although the surgical field should be limited because
excessive bleeding may be seen with elevated BP.

When treating hypertensive patients, the clinician should not use a local anesthetic containing an
epinephrine concentration greater than 1 : 100,000 nor should a vasopressor be used to control
local bleeding. Local anesthesia without epinephrine may be used for short procedures (<30
minutes). In a patient with hypertensive disease, however, it is important to minimize pain by
providing profound local anesthesia to avoid an increase in endogenous epinephrine secretion
The benefits of the small doses of epinephrine used in dentistry far outweigh the potential for
hemodynamic compromise. The smallest possible dose of epinephrine should be used, and
aspiration before injection of local anesthetics is critical. Intraligamentary injection is generally
contraindicated because hemodynamic changes are similar to intravascular injection. If the
hypertensive patient exhibits anxiety, use of conscious sedation in conjunction with periodontal
procedures may be warranted

Beta-adrenergic receptor antagonists, or β-blockers, are typically used to treat hypertension . β-

blockers are either cardioselective, blocking only β-1 cardiac receptors (β1 receptors), or
nonselective, blocking both β-1 cardiac receptors and β-2 peripheral receptors (β2 receptors).
Epinephrine, an α-adrenergic and β-adrenergic agonist, produces an increase in heart rate
through direct stimulation of cardiac β-1 receptors. Epinephrine also stimulates α-adrenergic
receptors, producing vasoconstriction of arteries, as well as β-2 receptors, causing vasodilation of
skeletal muscle arterioles. Administration of local anesthetics containing epinephrine to patients
taking nonselective β-blockers (e.g., propranolol, nadolol) may cause elevated BP.[119]
Epinephrine-induced α-adrenergic stimulation results in vasoconstriction and increased BP.
Because the patient's nonselective medication has blocked the β-2 receptors, epinephrine will not
stimulate the normal compensatory β-2 receptor–induced vasodilation.
increased BP, followed by reflex bradycardia mediated by the vagus nerve and carotid
baroreceptors. The end result is a patient with severe hypertension and bradycardia, resulting in a
dangerous decrease in vascular perfusion and possible death. Because of this potential
complication, epinephrine-containing local anesthetics should be used cautiously and only in
very small amounts in patients taking nonselective β-blockers, with careful monitoring of vital
signs
 HYPERTENSION AND PERIODONTOGY

• Ahn et al conducted a study in 2015 and concluded that Hypertension showed a

significant positive association with periodontitis
• Peres et al in 2012 stated that tooth loss is associated with increased levels of SBP in
adult population of Brazil.

HYPOTENSION

• Definition-
Hypotension is the low blood pressure. When the systolic pressure is less than 90 mm of
Hg, it is considered as hypotension.
• TYPES-
Primary
Secondary
 GUIDELINES FOR THE DENTAL PRACTIONER

Reduction of stress and anxiety:

While managing a hypertensive patient in the dental office, the dentist must take efforts to per-
form the dental procedures with optimum pain control, reduced stress and anxiety. Effective
control of operative and postoperative pain after surgical, periodontal, or other dental procedures
is one of the most important things the dentist can do to minimize blood pressure elevation in the
patient with hypertension

Precautions before administration of local anesthesia:

Admininistration of dental local anesthesia with epinephrine in these patients is considered risky
because of the beta-1 effects of epinephrine on the heart, and of the beta-2 effect on skeletal
muscle blood vessels - which might result in increased blood pressure and pulse rate. Literature
reveals that the use of dental local anesthesia containing epinephrine in hypertensive patients -
two 1.8 ml cartridges of lignocaine containing 1:100,000 epinephrine (0.036 mg) -assures a safe
control in patients with hypertension and stage 1 hypertension (HTN-1) (BP 159/99)
Researchers evoke that in stage 2 hyper- tension (HTN-2) patients (BP > 160/100mmHg), the
local anesthesia containing epinephrine can be administered with appropriate precautions and
care.

Life Style Modifications

Life style modifications do actively influence the treatment of hypertension. These modifications
include increased physical activity, reduced salt intake to less than 6 g per day, and limited
alcohol intake.
 CONCLUSION

Cardiovascular diseases (CVD) are the leading cause of death, accounting for approximately
30% of all deaths worldwide. High blood pressure is the main risk factor for CVD and stroke;
studies have suggested that high blood pressure also marks for oral inflammation, periodontal
diseases and tooth loss. Hence its early detection is critical in prevention of such diseases.
 REFERENCES

• Peres MA, Tsakos G, Barbato PR, Silva DAS, Peres KG. Tooth loss is associated with
increased blood pressure in adults – a multidisciplinary population-based study. J
ClinPeriodontol 2012; doi: 10.1111/j.1600-051X.2012.01916.x.
• Ahn Y-B, Shin M-S, Byun J-S, Kim H-D. The association of hypertension with
periodontitis is highlighted in female adults: results from the Fourth Korea National
Health and Nutrition Examination Survey. J ClinPeriodontol 2015; 42: 998–1005. doi:
10.1111/jcpe.12471.
• S.K, Essentials of medical physiology, jaypee publications, fifth edition, cardiovascular
system, pg 581-592
th
• Mohan .H, Essentials of pathology for dental students, jaypee publications, 4 edition,
Systemic hypertension, pg 488-496