Our Role in the Diagnosis of Hypertension – What Has Changed with the Pandemic?

As dental care professionals, we are all familiar with measuring our patients’ blood pressure. Since the beginning of the COVID-19 pandemic, there have been several changes in our health care system, some of which have led to the question: is it time we make changes to the frequency of blood pressure measurements in the dental office?

The pandemic has impacted all our lives in ways we could not have anticipated. It has impacted our personal and professional interactions. As dental professionals, we have adapted to a new way of practicing with several layers of protection while still providing care for our patients. It is amazing how adaptable we are as human beings. The gowning and doffing that felt so foreign to us two years ago is now just a routine part of our day.

Our healthcare system has had to adapt. Although we have returned to caring for our patients in person as our profession requires it, many of our physician colleagues continue to assess and treat their patients via telehealth consultations. This provides a unique challenge for us as dental care professionals. In the past, we often depended on the assessment of primary care physicians to assess hypertension in our mutual patients. However, it is important to recognize that if patients are not being assessed in person, a physical exam is not being performed, and vital signs are not being measured.

In 2015, my colleague, Dr. Soheil Khojasteh, wrote an article in this journal addressing the importance of blood pressure measurement in the dental office. He recommended that dentists should consider taking blood pressure measurements at every new patient exam, before surgery, and before every appointment for patients with known cardiovascular disease.¹

In 2022, seven years later, we may be the only primary health care professionals that our patients see in person on a regular basis, and for that reason, I believe it behoves us to take a blood pressure measurement for every patient at their first consultation, at every recall appointment, and regularly for patients with cardiovascular disease.

Truly, this is not a new recommendation. The American Dental Association (ADA) in 2007 recommended that, since hypertension is an extremely common medical condition, dental care professionals should be involved in the detection and management of hypertension. The ADA recommended that blood pressure should be measured for every new patient, at each recall appointment, and throughout appointments for cardiovascular patients where complex procedures are being performed.²

Hypertension is a significant risk factor for several serious comorbidities such as congestive heart failure, renal failure, ischemic heart disease (angina and myocardial infarction), and blindness. It is a key risk factor for coronary artery disease which accounts for 35-45% of annual cardiovascular morbidity and mortality in Canada.³

What is the best way to measure blood pressure? Automated blood pressure measurement at the level of the arm is typically most accurate.1 It is best to have the patient in the seated position with feet flat on the floor and their arm at the level of the heart. Measurements should be taken after the patient has been resting for five minutes to avoid an elevated measurement as a result of exertion.²

Measurements should be interpreted according to the latest guidelines on hypertension. The American College of Cardiology (ACC) and American Heart Association (AHA) updated their guidelines on categories of hypertension in 2017.² An elevated blood pressure is now considered to be a systolic blood pressure > 120 mmHg. A measurement reading greater than 130 mmHg is considered Stage 1 hypertension, and a reading of greater than 140 mmHg is considered stage 2 hypertension. Diastolic values are considered normal when they are below 80 mmHg. A measurement greater than 80 mmHg is considered Stage 1 hypertension and a diastolic measure of greater than 90 mmHg is considered Stage 2 hypertension. These are much tighter targets for hypertension control compared to past guidelines where 140/90 was considered Stage 1 hypertension.²

If a measurement is elevated, the next step is to determine whether it is acutely elevated or chronically elevated. Acute elevation in blood pressure can be caused by stress, anxiety, fear, or recent exertion. A stress reduction protocol should be employed before further blood pressure measurements are taken. This should include care and attention to voice tone while communicating with your patient, turning down operatory lighting, playing calming music, and encouraging breathing exercises. There are many apps that are readily available on your smartphone that can provide direction for using breathing exercises, such as the Calm app. If the blood pressure measurement decreases after this protocol, you can conclude that it was acutely elevated, and that it is safe to proceed with elective treatment.

However, if elevated measurements are sustained, the findings and measures you employed to reduce blood pressure readings should be documented and communicated to the patient’s primary care physician. In my opinion, it is important to communicate findings in black and white (by fax or email). This is important from a medicolegal perspective, and it generally will generate greater attention from our physician colleagues. It is important for us as dental healthcare professionals to take on a role of advocacy and to aid our physician colleagues in the detection of hypertension in this unprecedented time when they may not be able to assess it themselves.

Ultimately, we should be playing a greater role in our patient’s overall healthcare since we have the privilege of in-person assessments. Early detection and treatment of hypertension can prevent progression of the disease and damage to vital organs. This, in turn, means fewer emergency room visits and hospital admissions for myocardial infarctions, congestive heart failure, strokes, and acute renal failure caused by uncontrolled hypertension. By aiding in the diagnosis of hypertension, we can help to reduce stress on our healthcare system.

We have all had to come together as a community to take care of and protect one another in the past two years. It can be challenging when patients are not assessed in person by their primary care physicians, and ultimately, things can and will be missed. Routine blood pressure measurement in the dental office should be a routine part of care for our patients, and they allow us to further contribute to the health of our community.

Oral Health welcomes this original article.

References

Khojasteh, S. (2015). The use of automated office blood pressure devices in the dental practice. Oral Health, February 1, 2015. https://www.oralhealthgroup.com/features/the-use-of-automated-office-blood-pressure-devices-in-the-dental-practice/. Accessed December 22, 2021.
Herman K J L, and Prisant L M (2004). New national guidelines on hypertension: A summary for dentistry. The Journal of the American Dental Association (1939), 135(5), 576–84; quiz 653–4.
Lapointe H J, Armstrong J E, and Larocque, B. (1998). Clinical criteria for the use of a decision-making framework for the medically compromised patient: hypertension and diabetes mellitus. Journal of the Canadian Dental Association, 64(10), 704-9.
Greenberg BL, Glick M, Goodchild J, Duda PW, Conte NR, Conte M. Screening for cardiovascular risk factors in a dental setting. The Journal of the American Dental Association. 2007 Jun;138(6): 798-804. doi: 10.14219/jada.archive.2007.0268. Erratum in: J Am Dent Assoc. 2007 Jul;138(7): 945. PMID: 17545269.

About the Author

Alia El-Mowafy is a board certified Dental Anaesthesiologist. She practices in the GTA providing anaesthesia predominantly for specialists. She practices various anesthesia techniques and serves all patient demographics. She particularly enjoys the challenge and reward of treating pediatric patients. She also teaches at the Faculty of Dentistry, University of Toronto acting as a clinical instructor to graduate residents in the Dental Anaesthesia program. In her spare time, Alia loves to travel and cook.