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Milieu in Dental Schools and Practice |
Ms. Kellogg is a dental student and Dr. Gobetti is Professor and Director, Undergraduate Oral Medicine and Diagnosis, Department of Oral Medicine, Pathology, and Oncology—both at the University of Michigan School of Dentistry, Department of Oral Medicine, Oncology, and Pathology. Direct correspondence and requests for reprints to Ms. Sara Kellogg, University of Michigan School of Dentistry, 1011 N. University Avenue, Room #G018, Ann Arbor, MI 48109-1070; 734-476-6705 phone; 734-764-2469 fax; skellog{at}umich.edu.
Key words: hypertension, diagnosis, patient care
Submitted for publication 11/12/03; accepted 06/24/04
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Abstract |
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180/ 110 as defined by the JNC VI report have now been combined.2 The report states that systolic blood pressure of more than 140 mm Hg is a much more important cardiovascular disease risk factor than diastolic blood pressure in persons fifty years and above. The JNC VII also made available antihypertensive medications and therapeutic guidelines that are more concise and useful for clinicians. The JNC VII is presented in two separate publications: a succinct, practical, user-friendly guide and a more comprehensive report that provides further justification for the newly implemented guidelines.
It should be noted that, during the summer of 2002 when this study was conducted, the JNC VI guidelines were still operative and stage I hypertension was defined as a systolic of above 140 mm Hg and/or a diastolic blood pressure of above 90 mm Hg. Thus, in this study we will refer to hypertension in terms of the older guidelines taken from the sixth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Table 1
presents the JNC VI blood pressure classification used in this study.
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Based on the findings and recommendations of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure, it should be recommended that dentists and student dentists take blood pressure readings on all patients before providing dental care. In addition, routine blood pressure determination in the dental office offers an excellent public health service to screen for hypertension. Dentists have the unique opportunity to play a more active role in the detection of hypertension. Most patients visit their dentists when they perceive themselves as healthy, but see their physicians only when they are sick. This behavior gives dental clinicians an opportunity to screen for underlying medical conditions such as hypertension of which the patient may have been previously unaware.6
For this project, we hypothesized that dentists and student dentists treat a significant number of hypertensive patients annually. Additionally, it was believed that a large number of these hypertensive patients were unaware of their condition. Using a patient pool taken from a U.S. dental school over a one year span, the number of hypertensive patients treated in a dental school was determined. We then analyzed characteristics of this discovered hypertensive population and compared it to national data and trends.
The American Dental Association (ADA) is a contributing member of the coordinating committee of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure and the National High Blood Pressure Education Program. The ADA supports dental professionals’ establishing a patient’s average blood pressure and screening for hypertension.2 However, designated blood pressure guidelines for the dental schools and private practices are still lacking. This research was conducted in anticipation of creating a national awareness of the prevalence of hypertension in the patient population, so that appropriate steps may be taken to improve current diagnosis, treatment, and management of hypertensive dental patients.
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Methods |
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Five hundred "useable" records were obtained by examining 976 randomly selected records meeting the following criteria: completed patient medical, dental, and clinical history forms, lists of medications used, and recorded systolic and diastolic blood pressures. Factors examined within these elements included a demographic profile, hypertension history, JNC blood pressure classification, treatment of hypertension, other medications used, and tobacco and alcohol use. The correlation among age, gender, ethnicity, and medical treatment was also examined as it relates to hypertension. The average age of the overall sample of 500 patients was 36.5 years. Fifty-seven percent of the total patient population was female; 43 percent were male. Of the total sample population examined, 352 patients’ ethnicities were not documented in their charts. Of those documented, ninety-seven were Caucasian, twenty-six were African American, five were Hispanic, eight were Asian, two were Native American, and ten patient’s ethnicities were documented as "other."
The collected data was sorted into hypertensive patients or non-hypertensive subgroups. Within both groups, blood pressure readings, age, sex, ethnicity, and tobacco and alcohol use were recorded and evaluated. However, more detailed record evaluation was conducted with the hypertensive group (see Table 2). Data collected within the hypertensive subgroup additionally included JNC classification, prior diagnosis of hypertension, number of years with hypertension, treatment of hypertension, number and frequency of anti-hypertensive medications taken by patient, other medical treatments patient is/was undergoing, other diseases, and other prescription medications being taken. Hypertension classification taken from the JNC VI national report ranged from JNC hypertension stages I (systolic 140 to 159 or diastolic 90 to 99), to JNC hypertension stage III, "hypertensive crisis" stage (systolic 180, diastolic 110). JNC classifications were taken from the Archives of Internal Medicine, 1997, volume 157 (see Table 1
).2 It should be noted that when protocol was followed, the last recorded, same day blood pressure (second, third, or fourth readings) was the value used in this study in order to most accurately report JNC class and eliminate initial high blood pressures associated with dental anxiety.
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Results |
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). Of the 500 patients, 285 (57 percent) were female, and 215 (43 percent) were male. Seventy-four or 46.3 percent of the 160 hypertensive patients in this study were male, and eighty-six or 53.8 percent were female (see Figure 2). Fourteen, or 8.8 percent, of the hypertensive patients had blood pressures in a dangerous range and had to be immediately sent for medical consult.
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). Seven patients or 4.4 percent of the hypertensive population were previously diagnosed as suffering from hypertension, but exhibited blood pressure readings below JNC hypertension stage I levels. All but one of these patients were being treated with anti-hypertension medication. Sixteen patients (10 percent) whose medical history forms indicated they had hypertension apparently never had their blood pressures measured before, during, or after their dental appointment. As a result, it was not possible to determine their JNC classification.
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shows the breakdown of the dental school population in terms of age classification. Forty-six of the patients, or 9 percent, were between the ages of fourteen and nineteen; of these, 13 percent (six people) were hypertensive. One hundred-sixty-three patients, or 33 percent, were between the ages of twenty and twenty-nine; of these, 17.2 percent (twenty-eight) were hypertensive. One hundred-eleven patients, or 22 percent, were between the ages of thirty and thirty-nine; of these, 32.4 percent (thirty-six) were hypertensive. Seventy-five patients of the total patient pool of 500, or 15 percent, were between the ages of forty and forty-nine; of these, 25.3 percent (nineteen) were hypertensive. Fifty-three patients, or 11 percent, were between the ages of fifty and fifty-nine; of these, 64.2 percent (thirty-four) were hypertensive. Twenty patients, or 4 percent, were between the ages of sixty and sixty-nine; of these, 75 percent (fifteen) were hypertensive. Seventeen patients, or 3 percent, were between the ages of seventy and seventy-nine; of these, 58.8 percent (ten) were hypertensive. Ten patients of the total patient pool, or 2 percent, were between the ages of eighty and eighty-nine; all ten of these patients (100 percent) were afflicted with hypertension. Five patients, or 1 percent, were between the ages of ninety and ninety-nine; of these, 40 percent (two) were hypertensive.
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illustrates the frequencies of antihypertensive medications taken by hypertensive patients in the dental school’s patient pool. It was found that twenty-six, or 39.4 percent of the hypertensive patients being treated for hypertension used ACE-Inhibitors, 30.3 percent (twenty patients) used a form of Beta-Blockers, 33.3 percent (twenty-two) used diuretics, 6.1 percent (four) used Alpha-Blockers, 27.3 percent (eighteen) used Ca+ Channel Blockers, 4.5 percent (three) were taking an Angiotension II Antagonist, and two patients were taking the centrally acting drug, Clonidine. Thirteen percent of the patients being treated for hypertension were taking two or more antihypertension medications.
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It should be noted that had the JNC VII instead of the JNC VI report been used to analyze the results of this study, the population of hypertensive patients would have been even larger, because patients falling into the pre-hypertensive category (120-139/80-89) would also have had to be considered.
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Discussion |
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It was found that 32 percent of the examined population treated at the University of Michigan School of Dentistry were hypertensive. This number is alarming, but even more so given that 49 percent of the examined hypertensive patient pool were unaware of their condition. In fourteen patients, blood pressure levels were so high, reaching JNC VI stage III classification, that patients had to be sent immediately for medical attention. The dental school recognized and referred almost half of the hypertensive patients for diagnosis and treatment.
Until recently, studies examining the prevalence of hypertension within a dental school patient population were very limited. However, in 2001, at the University of Mississippi School of Dentistry a similar study was undertaken in an attempt to identify the relative size of the hypertensive population treated at the dental school. Patient records were reviewed over a four-year span. Criteria included diagnosis of hypertension by a physician or presentation with a systolic reading of greater than 140 mm Hg and/or a diastolic reading of greater than 90 mm Hg. The prevalence of diagnosed hypertension in the study population was 16.6 percent. When the population exhibiting elevated blood pressure without a previous diagnosis was included, the prevalence of hypertension rose to 27.9 percent.7 Thus, in similar examinations of hypertension in patient populations, both studies found that greater than 25 percent of patients treated at a U.S. dental school were hypertensive.
Based on the JNC VI report, the American Dental Association supports that blood pressure readings should be taken at every dental appointment; thus, the ADA position stands as a rule of thumb for practicing dentists. However, recommendations are not definitively stated as guidelines, so consequently they are not routinely followed in a dental practice and the quality of hypertension care remains suboptimal.3
The prevalence of hypertensive patients seen at the dental school is also overlooked. The number of charts that did not meet the study criteria indicates that student dentists at time neglected to take patients’ blood pressure. Nine hundred seventy-six patient charts were examined in order to obtain 500 that met the designated criteria. Thus, 476 charts failed to meet the criteria. Many of those 476 charts had to be discarded from the study because they did not contain any notation about blood pressure reading in the designated clinical examination form. Even more disconcertingly, students did not correlate patients’ medical health histories to rule out the possibility of hypertension, and sometimes high blood pressures (JNC II, JNC III) were ignored. Blood pressure readings were not taken for sixteen patients who had medical history forms indicating that they had a history of hypertension.
Hypertensive patients’ health is jeopardized each time they are treated without thorough examination of their backgrounds, medical histories, medical treatments, and current blood pressures. Furthermore, if routine blood pressures are not taken, opportunities to screen for hypertension are lost. Dental care in hypertensive patients can be complicated, since any procedure causing stress is likely to increase an already elevated blood pressure and can result in acute complications such as a cardiac arrest or a cerebrovascular accident, retinal insufficiency, or combination of these.6 Chronic complications of hypertension, especially impaired renal function, can affect dental management. With such a high occurrence of hypertensive patients receiving treatment, it is of utmost importance to screen for hypertension at initial appointments and monitor at subsequent visits.
With the exception of a slight drop in the total percentages of hypertensive patients in their forties and seventies, the general prevalence of hypertension increased incrementally with age. In this study’s population, the age group of fourteen to nineteen years had a 13 percent prevalence of hypertension; those twenty to twenty-nine years had a 17.2 percent prevalence rate; those thirty to thirty-nine years had a 32.4 percent prevalence rate; those forty to forty-nine years had a 25.3 percent prevalence rate; those fifty to fifty-nine years had a 64.2 percent prevalence rate; those sixty to sixty-nine years had a 75 percent prevalence rate; those seventy to seventy-nine years had a 58.8 percent prevalence rate; and those eighty to eighty-nine years had a 100 percent prevalence rate. The age group of ninety to ninety-nine years presented a 40 percent prevalence rate; however, only five persons were in this age group (see Table 3). The demonstration of this population’s general rise in hypertension with increasing age is consistent with the national trend as reported by both the American Heart Association and the American Society of Hypertension.4
There is also a gender difference regarding the prevalence of hypertension. In younger people, hypertension is more common among men than women. With increasing age, however, more women than men are afflicted with it. These trends correlate with the examined hypertensive population as seen in Figure 5. In this study, the prevalence of hypertension in males is more frequent in their twenties and thirties, and the occurrence of hypertension in females steadily increased with age, surpassing males after age forty (the only exception being a sharp increase in hypertension found in males in their seventies).
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Dentists should further be aware of the importance of anxiety control of their (medicated and nonmedicated) hypertensive patients. Anxiety and psychosocial stressors have been linked to elevated blood pressure in susceptible patients. Practitioners may find it beneficial to premedicate with an anxiolytic agent the evening before the morning of a dental appointment when treating the anxious, hypertensive population. Nitrous oxide and afternoon appointments are also popular options for these patients. Dentists need to be aware of the orthostatic hypotensive-causing effects of antihypertensive medications affecting the sympathetic output or peripheral vasodilatory actions, such as -2-adrenergic agonists and -1-adrenergic antagonists.9 Patients using these types of antihypertensive medications should avoid rapid postural changes. Dental professionals should have little difficulty in treating patients with well-controlled hypertension and rarely have to make adjustments from normal patient care protocols. 9 Table 4 displays the types and frequencies of medications taken by hypertensive patients in the examined patient population.
Tobacco was also recorded for both normotensive and hypertensive patients in this study. Though not significant, the incidence of tobacco use was higher in hypertensive patients than normotensive patients (58.1 percent versus 56.6 percent). Tobacco use is a major contributor to hypertension and can increase the severity of hypertension.3
It should be noted that the data was collected at random from an allotted one-year span of time and the data was of a limited sample size and taken from patients’ charts who reside primarily in Ann Arbor, Michigan, and surrounding midwestern areas. Although efforts were made to demonstrate that findings of the study were representative of national findings, assessments may not necessarily apply to the other demographic areas of the United States.
Based on the evidence presented in this study, dentists should place an emphasis on the detection and referral of patients suffering from high blood pressure.5 It is important that blood pressure readings be taken before each initial and recall dental appointments. Patients with hypertension, cardiovascular disease, and endocrine disease will need their blood pressures taken at each dental appointment. Guidelines for U.S. dental schools and practitioners should be established in accordance with the findings of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure.2 The goal of this study was to create an awareness of the current problems in the diagnosis and treatment of hypertensive patients in the dental community, so that steps can be taken towards improving current conditions.
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Acknowledgments |
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REFERENCES |
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This article has been cited by other articles:
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  H.F. Al-Bayaty, P.R. Murti, R.S. Naidu, R. Matthews, and D. Simeon Medical Problems Among Dental Patients at the School of Dentistry, The University of the West Indies J Dent Educ., December 1, 2009; 73(12): 1408 - 1414. [Abstract] [Full Text] [PDF]
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 N. D. Robb and J. Leitch Physical evaluation of the dental patient Medical Emergencies in Dentistry, January 1, 2006; 1(1): med-9780198529316-div1-02 - med-9780198529316-div1-02. [Full Text]
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N. D. Robb and J. Leitch Chapter 2 Risk assessment Medical Emergencies in Dentistry, January 1, 2006; 1(1): med-9780198529316-chapter - med-9780198529316-chapter. [Full Text]
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M. A. Pyle and S. Kellogg Hypertension in a dental school patient population. J Dent Educ., March 1, 2005; 69(3): 320 - 321. [Full Text] [PDF]
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