February 1, 2015
by Soheil Khojasteh, DDS
Blood pressure (BP) measurement can be a difficult and time-consuming task in the dental office. Many general practitioners avoid measuring their patients’ blood pressures, and some wonder, “Why should I even measure blood pressure in the office?” However, there are many reasons why dentists should be cognizant of their patients’ blood pressures. First and foremost, we should be informed about our patients’ medical history in order to be able to recognize and manage potential complications that may arise in the office. Considering the high prevalence of hypertension, it is certainly wise to take blood pressure measurements on the very first visit (new patient examination), and before surgical procedures, as these procedures may involve significant bleeding and induce anxiety. Furthermore, knowledge of our patients’ blood pressures allows us to be aware of which patients need to have limited epinephrine doses from local anesthetic. Patients with cardiovascular disease, including hypertension, are recommended to have no more than 0.04 mg of epinephrine administered to them during a dental appointment. This corresponds to approximately two standard 1.8 mL cartridges of local anesthetics containing 1:100,000 epinephrine, or four cartridges containing 1:200,000 epinephrine. As healthcare providers, we should also be involved in the overall healthcare of our patients by making referrals to their family physicians when very high blood pressures are noted during new patient examinations. This is especially true in our profession, as dental care is one of the few medical services that a considerable proportion of the general population attends for regular checkups, and hypertension is such a prevalent disease. So it is clear that dentists should certainly be measuring their patients’ blood pressures in the office. But is there any way we can make this time-consuming and complicated task easier and more efficient?
Most of us are aware of automatic blood pressure measurement devices, however, many people think these devices are inaccurate. These notions are based on the thought that the most accurate measurement of blood pressure is through manual sphygmomanometers. However, recent guidelines have made ambulatory blood pressure monitoring the gold standard for making a diagnosis of hypertension, and this method uses an automatic blood pressure measuring device. The type of blood pressure device used during this diagnostic test is different from most automated devices that are available for use in an office setting. But there are a number of automated devices that are available. Some of these devices can be placed on the upper arm (at the level of the brachial artery), whereas others can be placed on the wrist or finger. The devices that are placed on the wrist are not recommended, as the measurement will not be taken at the heart level and may be inaccurate. The devices that are placed on the finger are not recommended for the same reason, and there can also be vasoconstriction in the fingers, which may produce inaccurate BP readings. The automated devices that are placed on the upper arm are the best and most accurate to use. Canadian investigators, namely Dr. Martin G. Myers, conducted studies to test these automated devices to the gold standard devices used in diagnosing hypertension. Following such studies, it was concluded that automated blood pressure devices available for use in the office closely approximate the devices used to diagnose hypertension, and are therefore suitable for recording automated office blood pressure (AOBP) readings. In fact, 25 percent of general family medicine practices have incorporated these devices in their offices, and the Canadian Hypertension Education Program has claimed these AOBP devices can even be used to diagnose hypertension.
Time constraints are the main reason many dentists do not record their patients’ blood pressures in the office. However, now that it has been shown that accurate AOBP devices are available, this issue should no longer be a concern. These devices are extremely advantageous, as they do not require any specific training, BP measurements can be taken in an environment of any noise level, and these factors mean the dental assistant can measure a patient’s BP. Blood pressure measurements in the office no longer have to be difficult and time-consuming. Some dentists may find the following recommendations useful:
1. Dental assistant takes patient’s BP measurement in the dental chair before the dentist walks in, or in the waiting area before the patient enters the operatory room;
2. BP measurements can be taken before as part of the new patient examination;
3. BP measurements should be taken before any surgical procedure; and
4. BP measurements should be taken before all appointments for patients with known cardiovascular disease, such as hypertension.
There are a few AOBP devices available in Canada. The device used in the most recent study comparing AOBP measurements to ambulatory blood pressure monitoring (the gold standard for diagnosing hypertension) is the WatchBP Office (Microlife Corp., Heerbrugg, Switzerland). Another device that is available is the BpTRU device (BpTRU Medical Devices Inc., Coquitlam, British Columbia, Canada). General dentists who are not measuring their patients’ blood pressures are encouraged to purchase an AOBP device, as these accurate and convenient devices can add tremendously to the practice of general dentistry and patient care.OH
Soheil Khojasteh, DDS
MSc Candidate (Dental Anaesthesiology)
Disclaimer: The author bears no relation to any individual, corporation, or product mentioned in this article.
Davis, B. “What dose of epinephrine contained in local anaesthesia can be safely administered to a patient with underlying cardiac disease during a dental procedure?” J Can Dent Assoc. 2010;76:a36
Engstrom S, Bernce C, Gahnberg L, Svardsudd K. “Efficacy of Screening For High Blood Pressure in Dental Health Care.” BMC Public Health. 2011. Mar 30; 11:194.
Haas D. “An Update on Local Anesthetics in Dentistry.” Journal of the Canadian Dental Association. 2012. Oct. 68(9): 546-551.
Myers M, Godwin M. “Automated Office Blood Pressure.” Canadian Journal of Cardiology. 2012, 28: 341-346.
Myers M, Kaczorowski J, Dawes M, Godwin M. “Automated Office Blood Pressure Measurement in Primary Care.” Canadian Family Physician. 2014, 60:127- 132
Myers M, Valdivieso M. “Evaluation of an Automated Sphygmomanometer For Use in the Office Setting. Blood Pressure Monitoring. 2012, 17: 116-119
O’Brien E, Waeber B, Parati G, Staessen J, Myers M. “Blood Pressure Measuring Devices: Recommendations of the European Society of Hypertension. BMJ. 322: 531-536.
Pickering T, Hall J, Appel L, Falkner B, Graves J, Hill M, Jones D, Kurtz T, Sheps S, Roccella E. “Recommendations for Blood Pressure Measurement in Humans and Experimental Animals: Part 1.” Hypertension. 2005, 45: 142-161.
Umeizudike KA, Ayanbadejo PO, Umeizudike TI, Isiekwe GI, Savage KO. “Relevance of Routine Blood Pressure Assessment Among Dental Patients in Lagos, Nigeria.” J Contemp Dent Pract. 2013 Nov 1; 14(6): 1145-1150.