Marys Medicine

Efficacy of intravenous sedation and oral nifedipine in dental implant patients with preoperative hypertension - a retrospective study of 516 cases

Kimura et al. International Journal of Implant Dentistry (2015) 1:6 DOI 10.1186/s40729-015-0004-4 Efficacy of intravenous sedation and oralnifedipine in dental implant patients withpreoperative hypertension - a retrospective studyof 516 cases Motoshi Kimura1*, Yoshihiro Takasugi2, Shigeyoshi Hanano1, Katsuyuki Terabe3 and Yuko Kimura4 Background: To examine the effects of intravenous sedation and oral nifedipine on blood pressure and pulse rate inpatients with perioperative high blood pressure undergoing implant surgery, the clinical records of dental implantpatients managed by intravenous sedation at our outpatient dental offices were retrospectively evaluated.
Methods: A total of 516 clinical charts were evaluated. The subjects were divided into two groups: a normotensive groupwith no history of hypertension and a hypertensive group with a history of hypertension. The patients in the hypertensivegroup were further divided into two subgroups: with or without nifedipine administration before operation. Systolicblood pressure (SBP), diastolic blood pressure (DBP), pulse rate (PR), and rate pressure product (RPP) were assessed.
Results: In 30 patients (33%) of the hypertensive group, the high blood pressure on arrival obviously declined to aroundor less than 160 mmHg; in the remaining patients in the group who showed a mean SBP of 182.1 ± 13.8 mmHg onarrival, the blood pressure did not decrease after a 30-min rest. Oral nifedipine administered to the patients with sustainedhigh blood pressure decreased SBP to 144.7 ± 23.1 mmHg in 28.1 ± 9.3 min after administration, comparable to that inhypertensive patients without nifedipine.
Conclusions: For patients with stage 2 hypertension before operation, it may be difficult to maintain the recommendedblood pressure during surgery by only intravenous sedation; reduction of blood pressure by antihypertensive drugs maybe necessary.
Keywords: Oral surgery; Dental implant; Hemodynamics; Intravenous sedation; Nifedipine administration regular dental care, but those with stage 2 hypertension Osseointegrated dental implants were introduced in (≥160/≥100 mmHg) should receive noninvasive treatment Japan in 1983, and the procedures are now performed only and be referred to the physician for immediate very frequently. Dental implants are placed in a wide age follow-up . Normotensive individuals may develop signs range of patients, including elderly patients with hyper- of hypertensive encephalopathy at blood pressures as low tension. Patients with very high blood pressure are at as 160/100 mmHg, whereas chronically hypertensive pa- great risk for acute medical problems when undergoing tients can tolerate higher blood pressure and may not do stressful dental procedures, such as oral surgery, peri- so until the blood pressure rises to 220/110 mmHg or odontal surgery, and placement of dental implants [ above . Although no recommendation has been pre- Patients with normal blood pressure (<120/80 mmHg), sented on the optimal level of blood pressure to avoid prehypertension (120 to 139/80 to 89 mmHg), or stage I hypertensive complications during invasive dental treat- hypertension (140 to 159/90 to 99 mmHg) may receive ments, blood pressure in hypertensive patients should bemaintained below 160/100 mmHg.
* Correspondence: Pain, stress, or anxiety-related dental procedures can raise 1Hanano Dental Clinic, 4-2-3 Yamanoue, Hirakata, Osaka 573-0047, Japan blood pressure in both hypertensive and normotensive Full list of author information is available at the end of the article 2015 Takasugi et al.; licensee Springer. This is an open access article distributed under the terms of the Creative CommonsAttribution License which permits unrestricted use, distribution, and reproductionin any medium, provided the original work is properly credited.
Kimura et al. International Journal of Implant Dentistry (2015) 1:6 patients ]. We have employed intravenous sedation to BP-88, Omron Healthcare, Kyoto, Japan) was mounted, manage patients with hypertension as well as dental anxiety and blood pressure was measured at 2- to 5-min intervals.
and phobia. The oral antihypertensive agent nifedipine is In patients with a history of cardiovascular disease, ECG mainly administered to patients with high systolic blood was continuously monitored. Following confirmation of a pressure (SBP) ≥160 mmHg prior to implant placement.
definite decline of blood pressure or SBP <160 mmHg, To examine the effects of intravenous sedation and oral ni- infiltration anesthesia and/or conduction anesthesia was fedipine on blood pressure and pulse rate in patients with administered using 1 to 3 cartridges (1.8 to 5.4 ml) of 2% perioperative high blood pressure, the clinical records of lidocaine containing 1/80,000 epinephrine.
dental implant patients managed by intravenous sedation at Following confirmation of a sufficient anesthetic effect, our outpatient dental offices were retrospectively evaluated.
intravenous sedation with continuous infusion of propofol The purpose of this clinical study is to examine whether 1 to 2 mg/kg/h and midazolam 20 to 40 μg/kg bolus to- intravenous sedation and oral administration of nifedipine gether with inhalation of oxygen 3 L/min via nasal can- is efficient for the hemodynamic for the patient with hyper- nula was initiated. After confirming Verrill sign, implant tension. The authors expect that it is possible not only to surgery was initiated. During operation, the propofol dose obtain a hemodynamic blood stable but also to prevent the was adjusted to maintain the optimum conscious sedative medical sequelae by performing intravenous sedation and condition (level 2 on the Ramsay sedation scale) , and oral nifedipine for patients with hypertension.
local anesthesia was added when the patient complainedof pain. On completion of surgery, administration of oxy- gen and propofol were terminated and the patient was ob- A retrospective review of the clinical records was con- served for about 1 h, until normal cognitive and motor ducted for 336 patients who received dental implant- functions were restored.
related surgeries combined with intravenous sedation The subjects were divided into two groups: a normo- between January 2008 and February 2012 at our outpatient tensive group with no history of hypertension and a dental offices. Among the patients, 125 patients received hypertensive group with a history of hypertension. Thir- multiple surgeries during the observation period: 4 patients teen patients who had no history of hypertension were underwent surgery five times, 7 patients four times, 29 pa- included in the hypertensive group, since they indicated tients three times, 85 patients twice, and others once. The SBP ≥160 mmHg on arrival at the office and were later following surgical procedures were performed in a total of diagnosed with essential hypertension by cardiologists.
516 patients: dental implant placement (466 patients), Furthermore, the patients in the hypertensive group sinus lift surgery and dental implant (28 patients), socket were divided into two subgroups: with or without nifedi- lift and dental implant (10 patients), and guided bone re- generation and dental implant (12 patients).
From the clinical chart, data of SBP, DBP, PR, and per- We performed surgeries after medical consultation cutaneous oxygen saturation (SpO2) were sampled at the when patients had a history of hypertension or cardio- point of arrival to the office, prior to the initiation of vascular or cerebrovascular diseases. History of ischemic sedation, 30 min after the initiation of operation, and on heart disease, renal dysfunction, diabetes mellitus, cere- completion of operation. Furthermore, rate pressure bral infarction, or articular rheumatism was documented product (RPP: SBP × PR) was calculated.
in 17 patients in the hypertensive group and 16 patients There were two primary outcome measures: (1) inci- in the normotensive group. They were confirmed stable dence of improved hypertension following oral nifedipine and well controlled for implant surgery. For patients and (2) incidence of normal ranges of hemodynamic pa- who received therapeutic drugs, surgery was performed rameters during surgery. The secondary outcome variable following daily medication.
was incidence of hypertension related to perioperative The patients were allowed to have water or snacks until 2 h before the visit. On arrival at the office, systolicblood pressure (SBP), diastolic blood pressure (DBP), Statistical analysis and pulse rate (PR) were measured using an automatic In this study, we used data from all cases (516 cases) for blood pressure monitor with an oscillometric method (HEM-1010, Omron Healthcare, Kyoto, Japan). The ceph- Data were described as mean ± standard deviation. The alic vein was cannulated with a 22-G disposable intraven- unpaired t test was used to compare demographic variables ous catheter. Nifedipine capsule (10 mg) was orally between groups. Fisher's exact test was used to compare ra- administered to patients with sustained increases in tios of patients in hypertensive group between subgroups.
SBP ≥160 mmHg for 30 min from baseline measurement.
One-way analysis of variance (ANOVA) followed by Tukey's A noninvasive blood pressure monitoring system with elec- multiple comparison test was performed to examine the trocardiogram (ECG) monitor and pulse oximeter (Moneo change in the values of parameters. Repeated measures Kimura et al. International Journal of Implant Dentistry (2015) 1:6 ANOVA followed by Dunnett's multiple comparison test Although the mean SBP in the hypertensive group was was used to compare the values of parameters in groups at significantly higher than that in the normotensive group each time point. Statistical analysis was performed using during operation, SBP <160 mmHg was maintained in Prism 5 for Windows Ver. 5.01 (GraphPad Software Inc., San all patients except three in the hypertensive group (2.8%) Diego, CA, USA). The significance level was set at p < 0.05.
and one in the normotensive group (0.2%). The values ofDBP in patients in the hypertensive group were higherthan those in the normotensive group throughout the observation course, and changes in DBP in each group This study protocol was approved by the ethics committee were similar to those in SBP.
of Japanese Dental Society of Anesthesiology (No. 2015–4).
On arrival at the office, RPP ≥12,000 bpm × mmHg was found in 74 patients (70%) in the hypertensive group and 111 patients (27%) in the normotensive group. More than Patient demographics and clinical characteristics are sum- 90% of the patients with preoperative nifedipine showed marized in Table There were significant differences in high RPP on arrival at the office. Among patients with age (p < 0.0001) and duration of surgery (p = 0.025) be- high RPP, all patients in the normotensive group, 10% of tween normotensive and hypertensive groups. On arrival at the patients without nifedipine in the hypertensive group the office, values of all hemodynamic parameters, including and 35% of patients with nifedipine in the hypertensive SBP, DBP, PR, and RPP, were higher in the hypertensive group had RPP <12,000 bpm × mmHg until initiation of group than in the normotensive group (p < 0.0001).
intravenous sedation. The values of RPP during operation Tables and indicate incidences of patients with under intravenous sedation were maintained at a normal SBP ≥160 mmHg and RPP ≥12,000 bpm × mmHg, and range except in nine patients (8.5%) in the hypertensive perioperative hemodynamic changes, respectively. On ar- group and one patient (0.2%) in the normotensive group.
rival at the office, 66 patients (62%) in the hypertensive In patients with oral nifedipine in the hypertensive group and 41 patients (10%) in the normotensive group re- group, the PR value slightly increased prior to initiation vealed high SBP ≥160 mmHg. Thirty minutes later, SBP de- of intravenous sedation (p = 0.224) and then significantly clined to less than 160 mmHg in most of the patients in the decreased until completion of the operation (p < 0.001).
normotensive group. On the other hand, in 30 patients All patients stated a pleasant feeling and amnesia during (33%) in the hypertensive group, high blood pressure on ar- surgery. No complication occurred during surgery, and no rival obviously declined to around or less than 160 mmHg, cognitive and motor dysfunctions were observed 1 h after while in the remaining patients in the group who showed a surgery. The patients revealed SBP of >160 mmHg during mean SBP of 182.1 ± 13.8 mmHg on arrival, the blood pres- and at completion of operation showed maximum SBP of sure did not clearly decrease after 30 min of rest. Oral ni- 180 mmHg in the normotensive group, 190 mmHg on the fedipine administered to patients with sustained high hypertensive group without preoperative oral nifedipine, blood pressure decreased SBP to 144.7 ± 23.1 mmHg by and 180 mmHg in the hypertensive group with preopera- 28.1 ± 9.3 min after administration, which was similar to tive oral nifedipine. They did not complaint any symptom that in hypertensive patients without nifedipine.
such as headache, confusion, and chest pain. Upon leaving Table 1 Demographic and clinical characteristics Normotensive group Hypertensive group Number (male: female) Age (year mean ± SD) Values of circulation parameters on arrival at office RPP (bpm × mmHg) Preoperative oral nifedipine Duration of surgery (min) Duration of sedation (min) SBP, systolic blood pressure; DBP, diastolic blood pressure; PR, pulse rate; RPP. rate pressure product.
Kimura et al. International Journal of Implant Dentistry (2015) 1:6 Table 2 Incidence of high blood pressure and high rate pressure product SBP (>160 mmHg) RPP (>12,000 bpm × mmHg) Normotensive group (N = 410) On arrival at the office Prior to sedation Completion of operation Hypertensive group without preoperative oral nifedipine (N = 62) On arrival at the office Prior to sedation Completion of operation Hypertensive group with preoperative oral nifedipine (N = 44) On arrival at the office Prior to sedation Completion of operation *p <0.05, **p <0.01 vs normotensive group (Fisher's exact test). SBP, systolic blood pressure; RPP, rate pressure product.
the office, high SBP of the patients decreased to the level of oral nifedipine. Intravenous sedation after nifedipine on arrival without any antihypertensive treatment.
administration to hypertensive patients resulted in stablehemodynamics during implant surgery.
The Seventh Report of the Joint National Committee on In 44 (8.5%) of the 516 implant surgery cases, oral ni- Prevention, Detection, Evaluation, and Treatment of High fedipine had to be administered, since preoperative SBP Blood Pressure classified hypertensive patients into five was higher than 160 mmHg in these patients. Within categories based on systolic or diastolic blood pressure.
30 min of administration of nifedipine, SBP of hyperten- Patients with normal blood pressure (<120/80 mmHg), sive patients decreased to a similar range as that of prehypertension (120 to 139/80 to 89 mmHg), or stage I hypertensive patients who did not need administration hypertension (140 to 159/90 to 99 mmHg) can receive Table 3 Changes in values of hemodynamic parameters RPP (bpm × mmHg) Normotensive patients (N = 410) On arrival at the office Prior to sedation Completion of operation Hypertensive patients without preoperative oral nifedipine (N = 62) On arrival at the office Prior to sedation Completion of operation Hypertensive patients with preoperative oral nifedipine (N = 44) On arrival at the office Prior to sedation Completion of operation *p <0.01 vs value on arrival at the office (Dunnett's multiple comparison test). SBP, systolic blood pressure; DBP, diastolic blood pressure; PR, pulse rate; RPP, ratepressure product.
Kimura et al. International Journal of Implant Dentistry (2015) 1:6 regular dental care, though a stress reduction protocol is The overdose of vasoconstrictor that is added to the necessary for stage I hypertension [In accordance with local anesthetic in order to prolong the anesthetic effect the guidelines during oral surgery, the blood pressure of and hemostatic action may cause increased blood pres- hypertensive patients should be maintained at a normal or sure and arrhythmias. Elevation of blood pressure in prehypertension level. RPP is a reliable predictor of myo- hypertensive patients is greater than that in normoten- cardial oxygen consumption and RPP >12,000 bpm × sive patients during dental surgery Although there mmHg is associated with myocardial ischemia In is an increase in blood pressure and tachycardia when this study, although blood pressure was managed by a using three cartridges of local anesthetic containing epi- physician, hypertensive patients showed SBP >160 mmHg nephrine 1:10,000 (5.4 ml), there are no adverse symp- when they visited the dental office for dental implant toms in patients with normal blood pressure Little surgery, and 50% of hypertensive patients showed high recommended that the amount of local anesthetic solu- RPP after 30 min of rest. In patients presenting with tion administered should be less than two cartridges high blood pressure and high RPP, anxiety and fear must (3.6 ml) for patients with hypertension Nakamura be reduced by conscious sedation and antihypertensives et al. reported that patients with essential hypertension to prevent cardiovascular complications during dental who have been administered nifedipine can receive less implant surgery.
than 3.6 cartridges of local anesthetic containing epineph- Increases in SBP due to psychological stress are propor- rine 1:80,000 (6.4 ml) The administration of exogen- tional to age and baseline blood pressure . Intravenous ous epinephrine with local anesthesia produces the sedation stabilizes measurable changes in blood pressure highest plasma concentration in 3 to 6 min and lasts for and pulse rate due to fear and anxiety about dental treat- 20 min It has been reported that the anesthetic rate ment and has been used to manage patients with ischemic of 2% lidocaine containing 1:10,000 epinephrine is 47% heart disease and hypertension ]. In this study, the ef- 45 min after administration and 27% 60 min after admin- fect of intravenous sedation was as follows: SBP and RPP, istration []. During dental implant surgery which re- compared with those prior to intravenous sedation, were quires a relatively long duration and a wide field in decreased by 15% and 20% in patients with normal blood patients with hypertension, administration of conduction pressure, 15% and 25% in hypertensive patients without anesthesia including inferior alveolar block and posterior oral nifedipine, and 15% to 20% and 20% to 30% in hyper- superior alveolar nerve block is desirable. When the pa- tensive patients with administered nifedipine, respectively.
tient complains of pain, it is important to add local That is, SBP and myocardial oxygen consumption of pre- anesthesia while monitoring blood pressure to prevent in- hypertension and stage I hypertension can be reduced to creased blood pressure caused by pain.
the levels recommended for dental treatment before sur- Implant surgery is performed in patients with a wide gery by intravenous sedation.
age range, including elderly patients with hypertension.
For patients with stage 2 hypertension before operation, it Dentists or oral surgeons often encounter hypertensive is difficult to maintain the recommended blood pressure patients who are undiagnosed or noncompliant. Among during surgery using only intravenous sedation, and it is ne- Japanese over the age of 30, 60% of men and 44.6% of cessary to decrease blood pressure by antihypertensive women suffer from high blood pressure, and 33.8% of drugs. In this study, the blood pressure of patients with sus- men and 25.6% of women with a history of hypertension tained hypertension was reduced to stage I hypertension have not been managed medically [In this study, about 30 min after administration of oral nifedipine. On the though 13 of the patients did not have a history of hyper- other hand, the decrease in RPP after oral nifedipine admin- tension, they were diagnosed with essential hypertension istration was not less than 12,000 bpm × mmHg, which by a physician because they had high blood pressure be- could be due to the fact that an increase in pulse rate with fore surgery. Among patients with a history of high blood nifedipine by reflex tachycardia. Thereafter, blood pressure pressure, 31 patients (29%) showed high blood pressure and RPP during surgery under intravenous sedation has before surgery. Because there are many of dental patients remained at levels similar to those of hypertensive patients with undiagnosed or noncompliant hypertension, blood with well-controlled blood pressure. Maximum effect (21.4% pressure measurement before treatment, particularly inva- decreases in SBP) appears in 30 to 60 min and lasts about sive surgery, is indispensable.
3 h on oral administration of nifedipine The half-lives For dental implant surgery in hypertensive patients who of oral nifedipine, diltiazem and verapamil, and calcium an- are not adequately controlled, the application of intraven- tagonists are 0.2 to 1 h, 6 to 8 h, and 6 to 8 h, respectively ous sedation and preoperative antihypertensive medication Since oral nifedipine has the properties of fast onset would be useful in order to prevent perioperative hyper- (30 to 45 min) [and relatively short duration, it is suit- tension crisis including hypertension emergency with end- able for outpatient dental implant surgery and is useful in organ damage or hypertension urgency without end-organ perioperative management of patients with hypertension.
damage. Since sublingual administration of immediate- Kimura et al. International Journal of Implant Dentistry (2015) 1:6 release (IR) nifedipine may cause side effects such as sig- Vaughan CJ, Delanty N. Hypertensive emergencies. Lancet. 2000;356:411–7.
nificant decrease in blood pressure, reflex tachycardia, and Tsuchihashi T, Takata Y, Kurokawa H, Miura K, Maruoka Y, Kajiyama M, et al.
Blood pressure response during dental surgery. Hypertens Res.
acute myocardial infarction the sublingual adminis- tration of IR nifedipine to hypertension crisis has not been Ramsay MA, Savege TM, Simpson BR, Goodwin R. Controlled sedation with approved by the Food and Drug Administration (1985) alphaxalone-alphadolone. Br Med J. 1974;2:656–9.
Chobanian AV, Bakris GL, Black HR, Cushman WC, Green LA, Izzo Jr JL, et al.
and Japanese Society of Hypertension Guidelines for the The seventh report of the Joint National Committee on Prevention, Management of Hypertension (2000). Since we could man- Detection, Evaluation, and Treatment of High Blood Pressure: the JNC 7 age patients with high blood pressure without any cerebro- report. JAMA. 2003;289:2560–72.
Holm SW, Cunningham Jr LL, Bensadoun E, Madsen MJ. Hypertension: vascular complications by oral administration of nifedipine classification, pathophysiology, and management during outpatient under closely monitoring, it may be concluded that pre- sedation and local anesthesia. J Oral Maxillofac Surg. 2006;64:111–21.
operative administration of oral nifedipine to patients with Gobel FL, Norstrom LA, Nelson RR, Jorgensen CR, Wang Y. The rate-pressureproduct as an index of myocardial oxygen consumption during exercise in high blood pressure may be effective to prevent hypertensive patients with angina pectoris. Circulation. 1978;57:549–56.
crisis due to sudden rise in blood pressure during surgery.
White WB. Heart rate and the rate-pressure product as determinants of Further studies are necessary to evaluate the usefulness of cardiovascular risk in patients with hypertension. Am J Hypertens.
captopril, clonidine, and labetalol, which have been reported Urban MK, Gordon MA, Harris SN, O'Connor T, Barash PG. Intraoperative as alternatives to nifedipine in emergency hypertension hemodynamic changes are not good indicators of myocardial ischemia.
in patients with high blood pressure.
Anesth Analg. 1993;76:942–9.
Ichinohe T, Kaneko Y, Nakakuki T, Aida H, Abe H. Systemic management ofdental patients with cardiovascular disease. Anesth Prog. 1989;36:219–21.
Kuwajima I, Ueda K, Kamata C, Matsushita S, Kuramoto K, Murakami M, et al.
In this study, we showed that the stable hemodynamic A study on the effects of nifedipine in hypertensive crises and severehypertension. Jpn Heart J. 1978;19:455–67.
was obtained by performing intravenous sedation and oral Elliott WJ, Ram CV. Calcium channel blockers. J Clin Hypertens (Greenwich).
administration of nifedipine for patients with hyperten- sion. It is important not only to understand the systemic Cohan JA, Checcio LM. Nifedipine in the management of hypertensiveemergencies: report of two cases and review of the literature. Am J Emerg management of the patient but also to obtain stabled hemodynamic by performing intravenous sedation and Abraham-Inpijn L, Borgmeijer-Hoelen A, Gortzak RAT. Changes in blood oral administration of nifedipine for patients with hyper- pressure, heart rate, and electrocardiogram during dental treatment withuse of local anesthesia. J Am Dent Assoc. 1988;116:531–6.
tension in order to perform the implant surgery safely, Brand HS, Gortzak RA, Palmer-Bouva CC, Abraham RE, Abraham-Inpijn L.
and it could be possible to prevent the medical sequelae.
Cardiovascular and neuroendocrine responses during acute stress inducedby different types of dental treatment. Int Dent J. 1995;45:45–8.
Nakamura K, Shionoya Y, Furuya H. The effect of a sublingually administered SBP: Systolic blood pressure; DBP: Diastolic blood pressure; PR: Pulse rate; calcium antagonist, nifedipine, on the action of epinephrine in patients with RPP: Rate pressure product; ECG: Electrocardiogram; SpO essential hypertension. J Jpn Dent Soc Anesthesiol. 1987;15:244–53 oxygen saturation; ANOVA: Analysis of variance; IR: Immediate-release.
(In Japanese with English abstract).
Knoll-Köhler E, Knöller M, Brandt K, Becker J. Cardiohemodynamic andserum catecholamine response to surgical removal of impacted mandibular Competing interests third molars under local anesthesia: a randomized double-blind parallel Motoshi Kimura, Yoshihiro Takasugi, Shigeyoshi Hanano, Katsuyuki Terabe group and crossover study. J Oral Maxillofac Surg. 1991;49:957–62.
and Yuko Kimura declare that they have no competing interests.
Katz S, Drum M, Reader A, Nusstein J, Beck M. A prospective, randomized,double-blind comparison of 2% lidocaine with 1:100,000 epinephrine, 4% Authors' contributions prilocaine with 1:200,000 epinephrine, and 4% prilocaine for maxillary infiltrations.
YT and MK designed the study; MK, SH, and KT performed the surgeries; YT Anesth Prog. 2010;57:45–51.
performed the intravenous sedation. YT, MK, and YK collected and analyzed Ministry of Health, Labour and Welfare, Japan. National health and nutrition the data; MK wrote the manuscript. YT revised the manuscript. All authors survey Japan, 2012. (in Japanese) read and approved the final manuscript.
Grossman E, Messerli FH, Grodzicki T, Kowey P. Should a moratorium beplaced on sublingual nifedipine capsules given for hypertensive emergencies and pseudoemergencies? JAMA. 1996;276:1328–31.
Hanano Dental Clinic, 4-2-3 Yamanoue, Hirakata, Osaka 573-0047, Japan.
Thach AM, Schultz PJ. Nonemergent hypertension, new perspectives. Adv Department of Anesthesiology, Kinki University Faculty of Medicine, 377-2 Updat Cardiovasc Emerg. 1995;13:1009–23.
Ohno-Higashi, Osaka-Sayama, Osaka 589-8511, Japan. 3Terabe Dental Clinic, Murphy C. Hypertensive emergencies. Adv Updat Cardiovasc Emerg.
4-249 Sakae-cho, Tsu, Mie 514-0004, Japan. 4First Department of Internal Medicine, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka Hirschl M. Guidelines for the drug treatment of hypertensive crises. Drugs.
569-8686, Japan.
Received: 8 October 2014 Accepted: 14 January 2015 Little JW. The impact on dentistry of recent advances in the managementof hypertension. Oral Surg Oral Med Oral Pathol Oral Radiol Endod.
Aubertin MA. The hypertensive patient in dental practice: updatedrecommendations for classification, prevention, monitoring, and dentalmanagement. Gen Dent. 2004;52:544–52.


Obstetrics and GynecOlOGy Comparative Study of Sublingual versus Vaginal Misoprostol on Preoperative Cervical Priming in First Trimester Abortion Parneet Kaur*, Manjeet Kaur*, balwinder Kaur**, Manjit Kaur MOhi†; KhushPreet Kaur‡, Preeti jindal¶ AbstrActObjective: To compare the effect of sublingual versus vaginal misoprostol on preoperative cervical priming in first trimester

GET THE DETAILS Das englischsprachige Trip Dossier gehört zu Deinen wichtigsten Reiseunter lagen. Darin findest Du neben einem ausführlichen Reiseverlauf auch eine Vielzahl relevanter Informationen rund um diese Reise. Wir empfehlen Dir, das Trip Dossier bereits vor der Buchung zu lesen, damit Du genau weißt, was Dein Reiseerlebnis beinhaltet. Jungle Fever - Extension