Download AUTHOR: Margaret J. Fehrenbach, RDH, MS AUDIENCE: Dentists

AUTHOR: Margaret J. Fehrenbach, RDH, MS
AUDIENCE: Dentists; Dental Hygienists; Dental Assistants
ABSTRACT: While high blood pressure is recognized as the “silent killer”
throughout the United States, it is rarely associated with any kind of
preventive measures within the dental office. As a considerable portion of
the general public attends regular dental appointments every year, it
should be more well-known that oral health professionals can play a vital
role in the detection and management of hypertension.
LEARNING OBJECTIVES:
1. Describe the vital signs of blood pressure and its normal values.
2. Recognize the reasons behind taking a patient's blood pressure.
3. Understand the basic medications that are often taken for hypertension, and the
complications they may cause in the oral cavity.
4. Review the stages of high blood pressure and what can cause it to elevate inside and
out of the dental office.
CATEGORY: Oral-Systemic
CE ACTIVITY: Online/Self-Instructional
NUMBER OF CREDITS: 2 CE Credits
COST: $20.00
EXPIRATION DATE: March 2015
SPONSORED BY:
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CONFLICT OF INTEREST: Margaret J. Fehrenbach, RDH, MS does not have a financial arrangement or
affiliation with any corporate organization offering financial support or grant monies for this continuing
dental education program, nor does she have a financial interest in any commercial product(s) or
service(s) she discusses in this program. The Richmond Institute for Continuing Dental Education is a division
of Young Innovations, Inc. It is dedicated to ensuring that its continuing dental education programs are
intended for the sole purpose of education and do not serve as an endorsement for any product(s) or
service(s), including those of the sponsoring company.
FEEDBACK AND QUESTIONS: After the course has been completed, an evaluation form will be emailed to
the user to provide valuable feedback on the information just presented. If you have additional
feedback, questions, or need technical assistance, please email [email protected].
SCORING: To earn credit for completing a course from The Richmond Institute for Continuing Dental
Education, participants must earn an overall score of 80 percent or above on the associated exam
before receiving a certificate that confirms CE accreditation. (*NOTE: There is no limit to the number of
times a participant may re-take the exam in order to obtain this passing score). All courses that are
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course on their own time and submit the accurate payment in order to earn CE credit.
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LIMITED KNOWLEDGE RISK: The information provided in this course may not be comprehensive enough for
implementation into professional dental practice. It is highly recommended that additional information be
attained once the course is completed to establish greater proficiency on the topic at hand.
The Richmond Institute for Continuing Dental Education
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INTRODUCTION
Blood pressure (BP) is the force of the blood against the walls
of arteries. BP is recorded in mm Hg (millimeters of mercury) as
two numbers: the systolic blood pressure (SBP) reading--highest
pressure when the heart contracts--and the diastolic blood
pressure (DBP) reading--lowest pressure just before the heart
contracts. The measurement is written with the systolic on top or
before and the diastolic on the bottom or after. For example, a
written BP measurement of 120/80 mm Hg is expressed verbally
as "120 over 80." which is considered normal.
A new category by the American Heart Association (AHA) has
recently been introduced (see table) when discussing BP. It is
called prehypertension, but was formally referred to as “high
normal” (between 120/80 mmHg and 139/89 mmHg).[1] It was changed to increase awareness that
lifestyle changes are needed to prevent more serious levels of BP. It is important to inform patients that
these changes can include weight loss, regular physical activity, avoiding a salty diet, stopping smoking,
and consuming no more than two alcoholic drinks a day, since all of these factors can increase
BP.[2] Prehypertension should serve as an early warning that the metabolic changes that could ultimately
lead to complications may well be underway.[3]
When BP stays elevated over time, it is called high blood pressure (HBP) or hypertension (HTN) (a level
of 140/90 mmHg or higher). About two-thirds of people over the age of 65 have HBP. This is especially
dangerous since it often has no warning signs or symptoms. The high blood pressure is often called
the “silent killer” since it can increase the risk for getting cardiovascular disease—the first leading cause
of death in the United States—kidney disease, as well as increasing the risk for having a cerebrovascular
accident or stroke, which are the third leading causes of death in the United States.[4]
It also makes the heart work harder and contributes to atherosclerosis (hardening of the arteries). There is
a doubling of risk for each 20-point rise in the systolic, or 10-point rise in the diastolic. It is not unusual for
older persons over the age of 50 to have an increased systolic reading, and have a normal diastolic,
increasing their related health risks.[5] For those under the age of 50, the opposite is true- the diastolic
reading can predict the patient’s health risks as well as the systolic. Regardless of race, age, or gender,
anyone can develop HBP; it is estimated that one in every three adults has HBP, or approximately 58
million Americans.[2]
Once it develops, it usually lasts a lifetime. High blood pressure can be prevented by changing one’s
lifestyle, and in some cases, taking prescribed medications. In the United States, only an estimated 70
percent of people with high blood pressure have been diagnosed. Of people with a diagnosis of high
blood pressure, about 84 percent receive treatment, and of the people receiving treatment, about 58
percent have adequately controlled blood pressure.[6]
RECORDING BP
In the patient record, it is important to have an accurate baseline
assessment of BP as measurements since even a few points off can
make a big difference. In addition, although there is a wider
acceptance on measuring BP outside the physician’s office to help
regulate this vital sign, calibration of the electronic home devices
needs to be performed periodically to the standard mercury meters.
Meter calibration is easily performed by having the patient bring it
to the next dental or medical appointment and comparing its
readings to the professional assessment.
There is great variability in many of these monitors and it is not
necessarily related to the cost of the meter. Physicians consider it
important to use a mercury meter as the standard, but there is no
comparable standard for dental offices. In the future, hybrid devices
using electronic transducers instead of mercury may prove to be a
valid option.
KEY CONSIDERATIONS

Use actual readings. There is a tendency to round off the readings; for example, 112 becomes 110;
166 may become 170. However, in recording a BP, a few millimeters may make the difference in a
patient’s diagnosis. Always record the reading to the nearest 2 mm Hg. Do not be biased; just because
a patient is normally around 126/82 (for example), do not prematurely assume the next reading will
fall near that range. Record each reading based on the observations at that time.

Position the patient properly. For baseline BP recordings, the relaxed patient should be seated with
back and arm supported. The patient should not be conversing or having his or her legs crossed. The
midpoint of the upper arm should be at the level of the heart; when the arm is below the heart level,
the reading will be too high. In fact, it has been reported that the reading can be as much as 8 mm
higher than normal when the patient’s arm is hanging at his or her side. The newer digital devices will
not even work unless the patient is positioned correctly; user manuals that came with the device need
to be consulted for more specific information.

Check equipment. Routinely inspect the office BP equipment. Repair, replace, and clean as necessary.
Consider using a cuff that has an imbedded antimicrobial agent to help prevent bacterial growth and
mildew. Studies show that BP cuffs can carry significant bacterial colonization, and can actually be a
source of transmission of infection.[7] Wipe the earpieces with 70 percent ethyl alcohol to avoid
transmission of ear infections without damaging the device.

If using a cuff, select the right size inflation system. This is the most common mistake according to
the AHA.[8] Choose the appropriate size cuff based on the circumference of the patient’s bare upper
arm. The bladder (inside the cuff) should encircle 80 percent of an adult’s arm, and 100 percent for a
child less than 13 years old. A cuff/bladder that is too narrow for the arm will result in a too high
reading. The dental office needs to have a full range of cuff sizes available to accommodate today’s
patient populations.[8]
TABLE 1: BLOOD PRESSURE LEVELS
USING A STANDARD ANEROID DEVICE:
Step 1: Position the patient's arm so the anticubital fold is level with the heart.
Support the patient's arm with an arm or a table or patient chair.
Step 2: Place the cuff over the patient’s bare skin. Center the bladder of the cuff
over the brachial artery, approximately 2 cm above the anticubital fold. Be sure the
index line falls between the size marks when applying the cuff.
Step 3: Position the patient's arm so it is slightly flexed at the elbow.
Step 4: Palpate the radial pulse and inflate the cuff until the pulse disappears. This
is a rough estimate of the systolic blood pressure.
Step 5: Place the stethoscope earpieces facing forward. Clip the dial on the top of
the device so it can be easily seen. Place the stethoscope over the brachial artery.
Step 6: Inflate the cuff to only 30 mm Hg above the estimated systolic pressure.
Step 7: Release the pressure slowly; at no greater than 5 mm
Hg per second.
Step 8: The level at which you consistently hear beats is a reading of the systolic
blood pressure (SBP).
Step 9: Continue to slowly lower the pressure as before until
the sounds muffle and disappear. This is a reading of the
diastolic blood pressure (DBP).
Step 10: Record the BP as systolic pressure reading over
diastolic pressure reading in the patient record ("120/80" for
example).
Retake BP: If the reading needs to be repeated, wait two to three minutes before re-inflating the cuff.
Using a Digital Device: First, put the cuff around the arm and turn on the power. The cuff will inflate by
itself with a push of a button on the automatic models. On the semiautomatic models, the cuff is inflated
by squeezing a rubber bulb. After the cuff is inflated, the automatic mechanism will slowly reduce the cuff
pressure. Look at the display window to see the reading. Press the exhaust button to release all of the air
from the cuff. If the reading needs to be repeated, wait two to three minutes before re-inflating the cuff.
BP CASE SCENARIOS

Normal BP to Prehypertension - With normal levels of BP, the patient should have his or her blood
pressure rechecked in two years. With prehypertension, treat the patient as usual; however, the dental
office may want to recommend that the patient check with a physician if it is slightly high, in order to
rule out any lifestyle factors that may increase the risk of cardiac problems over time.

Stage I HBP: Mild - Repeat BP in five minutes. Why? Maybe the patient was running or walking fast.
Also, certain patients can have a “white-coat” syndrome that occurs when healthcare professionals
take their BP. Both instances can cause a mild rise in BP. Studies show that using digital device and
having the patient sit alone in the dental chair can reduce these latter effects that may occur with the
clinician manually taking the BP.[8] The dental office should recommend that the patient see a
physician for follow-up, to rule out any other cardiac considerations, and to work on lifestyle changes.

Stage 2 HBP: Moderate - Repeat BP in five minutes. If the BP is still elevated after five minutes, find
out if the patient has ever been told that he or she has HBP. Ask if the patient was prescribed any
medication, and if the medication is currently being taken. The number one problem with patients with
HBP is that they forget to take their prescribed medications, especially if they are taking it daily for life.
If they do not take the medication, their BP will go up; since there are no symptoms, they will not know
if they are gradually increasing their blood pressure levels over time. If a patient has moderate HBP
after recording and re-recording the BP, contact patient’s physician to decide if the patient can be
seen for any elective care or only emergency care. In addition, the dental office will need to
recommend that the patient see his or her physician within one month for an evaluation. For this
patient, stress reduction protocol is very important during future dental appointments.

Stage 3 or 4 HBP: Severe to Very Severe - A patient with severe HBP needs to have their physician
contacted immediately so as to evaluate the patient before any dental care. The dental office should
also recommend that the patient see his or her physician within one week. If the patient has very
severe HBP, then there should be an immediate physician referral or emergency protocol may be
instituted depending on the patient’s medical status. Knowing when to not treat a patient is a very
important consideration.
HBP PRESCRIBED MEDICATIONS

Diuretics. These help to increase the kidneys' excretion of water and
sodium, and thus, are often called "water pills". Consequently, the
volume of blood the heart has to pump is reduced. It is the most
commonly prescribed initial medication for HBP.

ACE inhibitors. These work by blocking production of hormones
(angiotensin II), which cause vessels to narrow, causing HBP.

Alpha blockers. These work by dilating the arterioles. Muscle cells in the
arterial walls have alpha-receptors which, when stimulated, cause the
muscle to contract and, in turn, constrict the arteries. The artery walls are
caused to relax by blocking the effects of adrenaline, which can increase
BP.

Beta blockers. These help reduce the workload of the heart. Important beta-receptors are located in
both the heart and the kidneys. Beta-receptors stimulate the strength and speed of contraction in the
heart. In the kidney, beta-receptors stimulate the release of renin. By blocking stimulation of receptors,
beta-blockers can reduce the amount of blood being pumped by the heart.

Calcium channel blockers. These work by reducing the narrowing of vessels enabling blood to flow
more freely. The contraction of smooth muscle cells in the arterioles is related to the amount of
calcium inside the blood.
CONCLUSION
It is recommended that BP readings should be taken for all new patients and for recall patients on at least
an annual basis. Additionally, patients who have hypertension should have BP assessed at each visit in
which significant dental procedures are to be performed. It is felt that the dental office can play an
important role in the detection and management of hypertension because dental care is one of the few
healthcare services to which a considerable proportion of the general population comes for regular checkups.[10] In addition, an evidence-based comprehensive set of clinical guidelines for overall cardiovascular
risk are being considered and will be announced within the next few years.[11]
The newest studies are now looking to see if HBP is related to an increased risk of periodontal
disease.[12] Initial findings show that with the sign of 10 percent greater extent of gingival bleeding
usually associated with the presence of periodontal disease, the average SBP was higher by 0.5 mm Hg;
higher levels of subgingival periodontal bacteria have also been noted in patients with SBP.[13] These
associations may have important ramifications in the future for clinical dental practice.
REFERENCES
[1] American Heart Association, Blood pressure. Accessed September 30, 2011 at: http://
heart.org/HEARTORG/Conditions/HighBloodPressure/High-Blood-Pressure-ATH_UCM_002020_SubHomePage.jsp
[2] Health and Human Services, Lowering high blood pressure and cholesterol (2011). Accessed September 30, 2011 at
http://www.hhs.gov/news/healthbeat/2011/03/20110309a.html
[3] Chobanian AV, Bakris GL, Black HR, et al; Joint National Committee on Prevention, Detection, Evaluation, and
Treatment of High Blood Pressure. National Heart, Lung, and Blood Institute; National High Blood Pressure Education
Program Coordinating Committee. Seventh report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252.
[4] CDC, Blood pressure. Accessed September 30, 2011 at http://www.cdc.gov/bloodpressure/
[5] National Institute of Health, Blood pressure. Accessed on September 30, 2011
at http://hp2010.nhlbihin.net/nhbpep_slds/jnc/jncp1_7.htm
[6] Merck Home Health Handbook, Blood pressure. Accessed on September 30, 2011
at http://www.merckmanuals.com/home/heart_and_blood_vessel_disorders/high_blood_pressure/high_blood_pressure.ht
ml?qt=&sc=&alt=
[7] de Gialluly C, Morange V, de Gialluly E, Loulergue J, van der Mee N, Quentin R.Blood pressure cuff as a potential vector
of pathogenic microorganisms: a prospective study in a teaching hospital. Infection Control and Hospital
Epidemiology, 2006;27(9):940-3.
[8] American Dental Association. New national guidelines on hypertension: a summary for dentistry. Journal of the
American Dental Association, 2004; 135(5): 576-584. Accessed September 30, 2011
at http://jada.ada.org/content/135/5/576.full
[9] Andreadis EA, Angelopoulos ET, Agaliotis GD, Tsakanikas AP, Mousoulis GP. Why use automated office blood pressure
measurements in clinical practice? High Blood Pressure and Cardiovascular Prevention, 2011;18(3):89-91.
[10] Engström S, Berne C, Gahnberg L, Svärdsudd K. Efficacy of screening for high blood pressure in dental health
care. BMC Public Health, 2011; 11:194. Accessed September 30, 2011 at http://www.ncbi.nlm.nih.gov/pubmed/21450067
[11] National Heart, Lung, and Blood Institute, Cardiovascular Risk Reduction Guidelines in Adults: Cholesterol Guideline
Update (ATP IV) Hypertension Guideline Update (JNC 8) Obesity Guideline Update (Obesity 2) Integrated Cardiovascular
Risk Reduction Guideline. Accessed September 30, 2100
at http://www.nhlbi.nih.gov/guidelines/cvd_adult/background.htm#background
[12] Tsakos G, Sabbah W, Hingorani AD, Netuveli G, Donos N, Watt RG, D'Aiuto F.Is periodontal inflammation associated
with raised blood pressure? Evidence from a National US Survey. Journal of Hypertension, 2010;28(12):2386-93.
[13] Desvarieux M, Demmer RT, Jacobs DR Jr, Rundek T, Boden-Albala B, Sacco RL, Papapanou PN.Periodontal bacteria and
hypertension: the oral infections and vascular disease epidemiology study (INVEST). Journal of Hypertension,
2010;28(7):1413-21.
[14] Higashi, Yukihito; Goto, Chikara; Jitsuiki, Daisuke; Umemura, Takashi; Nishioka, Kenji; Hidaka, Takayuki; Takemoto,
Hiroaki; Nakamura, Shuji; Soga, Junko; Chayama, Kazuaki; Yoshizumi, Masao; Taguchi, Akira.Periodontal Infection Is
Associated With Endothelial Dysfunction in Healthy Subjects and Hypertensive Patients. Hypertension, 2008;51(2, Part
2):446-453. Accessed September 30, 2011 at http://hyper.ahajournals.org/content/51/2/446.full