Dianne Glasscoe Watterson, MBA, RDH
When is it appropriate to dismiss a patient from an appointment?
In my office, we take our patients’ vital signs annually (or more often if needed). Recently, I had a patient with a blood pressure of 166/109. So, the dentist told me to hook the patient up to a portable machine that monitored the blood pressure during treatment.
I was nervous the whole time and felt that the patient should have been rescheduled and instructed to see her physician immediately. The patient was given the blood pressure printout of her readings for the 45 minutes of treatment to show her physician.
Now that this scary situation is behind me, I want to tell the doctor that I will never do this again, as I feel like he was putting the patient at risk by having me treat her. What are the maximum blood pressure readings that would cause you to protest providing care, even if continuous monitoring takes place? Thank you.
Thank you for writing. This is a subject that is sure to come up more frequently as the population ages, since increased age equals greater likelihood blood pressure levels will increase.
Your post brings up several questions. You do not mention the patient’s age or if there is any history of high blood pressure. Was this a patient of record, or was this a first-visit patient? I would also like to have known if the blood pressure stayed high during your treatment or if it came down after the patient had a few minutes to relax. Did the patient have other mitigating factors, such as smoking, diabetes, a history of cardiovascular problems, or chronic kidney disease? Is the patient overweight or obese? Finally, was the patient taking any medications, especially high blood pressure medications?
It would have been entirely appropriate and advisable to call this patient’s physician and inquire about what the patient’s last recorded blood pressure was and when it was taken. “I have our mutual patient, ABC, in my chair today, and when I took her blood pressure, it was high. I’m calling to find out what her last recorded blood pressure was in your office.” This information would have been helpful in making the decision to dismiss the patient or proceed with needed care. Is the elevated blood pressure something new, or it is this the norm for this patient?
The thing to remember is that some people have high blood pressure all of the time, even on medications. It would be wrong to deny treatment for such people, as we know that good preventive care is an integral part of good overall health.
Some people come to their appointments in a rush or right after something has upset them, and this could cause a temporary rise in blood pressure. We used to see this frequently when I taught, as our clinic patients had to walk quite a distance to get to our building. When a patient presented with elevated blood pressure, I always had my students wait five minutes and retake the blood pressure. In our school clinic, anything that exceeded 140/90 required a medical clearance. We had a good number of senior citizens who came regularly, and we allowed our students to treat people with hypertension if the patient presented a medical clearance from their physician. We never had an untoward episode during my tenure.
In the past, many clinicians felt that 160/100 was the upper limit of “safe” to treat, but that rule does not apply universally. I think it is entirely safe to treat some people when their blood pressure is higher than the “norm.”
It just depends on the patient’s age and history. My husband died at age 50 of a sudden massive myocardial infarction, and he never had high blood pressure, nor did he have any of the mitigating factors related to his general health. In fact, he was the picture of health. The only risk factor he had was that he had been a former smoker, although he had not smoked in more than 15 years.
In 2017, the American College of Cardiology and American Heart Association published new blood pressure guidelines. (The previous guidelines were published in 2003.) “The new ACC/AHA guidelines were developed with nine other health professional organizations and were written by a panel of 21 scientists and health experts who reviewed more than 900 published studies.”
According to the ACC website, the new guidelines “lower the definition of high blood pressure to account for complications that can occur at lower numbers and to allow for earlier intervention. The new definition will result in nearly half of the US adult population (46%) having high blood pressure, with the greatest impact expected among younger people. Additionally, the prevalence of high blood pressure is expected to triple among men under age 45, and double among women under 45,” the guideline authors note.
While this may not seem like good news, the new guidelines will create more awareness of blood pressure issues, leading to lifestyle and/or dietary changes and possible medication intervention when appropriate.
“You’ve already doubled your risk of cardiovascular complications compared to those with a normal level of blood pressure,” said Paul K. Whelton, MB, MD, MSc, FACC, lead author of the guidelines. “We want to be straight with people. If you already have a doubling of risk, you need to know about it. It doesn’t mean you need medication, but it’s a yellow light that you need to be lowering your blood pressure, mainly with nondrug approaches.”
You can view the guidelines by googling “2017 blood pressure guidelines.”
Blood pressure categories in the new guideline are:
Normal: Less than 120/80 mm Hg;
Elevated: Systolic 120–129 and diastolic less than 80;
Stage 1: Systolic 130–139 or diastolic between 80-89;
Stage 2: Systolic at least 140 or diastolic at least 90 mm Hg;
Hypertensive crisis: Systolic over 180 and/or diastolic over 120, with patients needing prompt changes in medication if there are no other indications of problems, or immediate hospitalization if there are signs of organ damage.
The new guidelines eliminate the category of prehypertension, categorizing patients as having either Elevated (120–129 and less than 80) or Stage I hypertension (130–139 or 80–89). “While previous guidelines classified 140/90 mm Hg as Stage 1 hypertension, this level is classified as Stage 2 hypertension under the new guidelines.”
I applaud you for being diligent with blood pressure screenings. If a patient in our chair has blood pressure issues, we need to know it, and we always need to be as prepared as we can be for an emergency if it should occur. Just remember—an emergency can happen any time, even with “normal” blood pressure.
To my readers: if you send me a question and I use it in a future column, I will send you a complimentary copy of my newest book, Real World Dental Hygiene – Where the Rubber Cup Meets the Road.
All the best,
DIANNE GLASSCOE WATTERSON,MBA, RDH, is an award-winning author, speaker, and consultant. She has published hundreds of articles, numerous textbook chapters, and three books. Her new DVD on instrument sharpening is now available on her website at wattersonspeaks.com under the Products tab. Visit her website for information about upcoming speaking engagements. Dianne may be contacted at (336) 472-3515 or by email at [email protected].
Proceed with appointment?
The following guidelines* should be followed when determining whether to proceed with a dental appointment. These guidelines are also intended to inform the patient of concerns regarding evident hypertension when vitals are taken at the start of the visit.
Normal: Systolic <120 and Diastolic <80
Elevated: Systolic 120–129 and Diastolic <80
1. No contraindications to elective dental treatment, but inform the patient.
Stage 1 HTN: Systolic 130–139 or Diastolic 80–89
1. Retake and confirm blood pressure.
2. Proceed with elective dental treatment.
3. Monitor blood pressure during the appointment.
Stage 2 HTN: Systolic 140+ or Diastolic 90+
1. Retake and confirm blood pressure.
2. Monitor blood pressure during the appointment.
3. Refer patient to his or her physician for medical evaluation.
Systolic 180+ and/or Diastolic 120+
1. Retake and confirm blood pressure with an alternate device, such as a mercury manometer–type sphygmomanometer.
2. If the blood pressure is unchanged, consider immediate referral of the patient to a physician or emergency room for evaluation.
3. No treatment of any type should be undertaken.
4. Medical consult should be required prior to any dental treatment.
*Based on 2017 AHA reporting of updated BP guidelines