Have you fallen out of the habit since dental hygiene school? Here are some life-saving reasons for resuming blood pressure assessments
By Linda Lawson, RDH, BS
It is a typical scene in almost every dental hygiene clinic. Students rush to greet and seat their patients. Medical histories are reviewed, and vital signs are taken and recorded. Dental hygiene students frantically wave to signal the supervising dentist that their patients are ready to be cleared so that preventive and therapeutic services can begin.
We were all taught the importance of assessing blood pressure before we even dared put a scaler in our patients' mouths. Why is it that there have been countless times over the course of my career that new patients were shocked when I asked them to extend their arms so I could take their blood pressure? Surprised looks were then followed with questions such as "Why is this necessary?" or "I've been going to the dentist every six months since I was a child and have never had my blood pressure taken in a dental office."
Blood pressure measures the force on the arterial walls as the heart pumps blood throughout the body. Normal blood pressure is essential for life. Oxygen or nutrients could not be delivered through the vessels and into the tissues and organs without the pressure to drive the blood through the circulatory system. In addition, blood pressure aids in distributing white blood cells throughout the body so they can protect the body against illness and disease.
A person's blood pressure rises when the heart beats and drops as the heart relaxes between beats. Optimal blood pressure is less than 120 systolic and less than 80 diastolic. It is worth noting that blood pressure readings will vary throughout the day, especially during periods of exercise, high stress, postural changes, or sleep. According to the American Heart Association, roughly one in three adults in the United States has high blood pressure.1 In most instances, the lower your blood pressure reading is, the better off you are.
Although we are well aware that normal blood pressure is important to a person's health, there are far too many dental professionals who have fallen out of practice in taking their patients' vitals before beginning treatment. As licensed health-care professionals, it is the standard of care for dental hygienists to assess and record blood pressure on all of their patients. The reading must then be discussed with the patient as a means of helping him take charge of his overall health. Listed below are 10 reasons why dental hygienists must take blood pressure on each patient at every visit.
Reason No. 1
Dental visits provide the perfect opportunity to screen for hypertension
By and large, dental patients who are not being treated by their primary care physician for a systemic disease will typically view themselves as being "healthy." These same patients typically see their dental hygienist two to four times per year for routine preventive care yet may only visit their physician every few years.
Dental hygienists are in a unique position to assess blood pressure and increase our patients' awareness about the risks associated with untreated hypertension due to the sheer number of times we see an individual patient on an annual basis. When we inform an unknowing patient that he or she has undetected, uncontrolled hypertension, the dental visit then serves as an entry point for the person to take charge of his or her overall health.
Reason No. 2
Detecting hypertension in early stages can limit damage to the body
High blood pressure is classically called the "silent killer" because the condition will often lack warning signs. Generally speaking, most individuals will not feel like they have high blood pressure until it is significantly high and at dangerous levels.
When it is finally detected, consistent elevated blood pressure may have already caused serious damage to the heart, blood vessels, kidneys, eyes, and more. When hypertension is discovered early at a routine dental appointment, patients can be referred to their physician to have it treated and controlled before serious damage to the body occurs.
Reason No. 3
Screening can help avert a hypertensive crisis
Last year, a longtime patient of mine came in for her preventive appointment and exam. It had been over three years since her last prophylaxis. The receptionist gave her a new medical form to fill out, and she reported no medical problems/issues. This particular patient was a nurse working in a hospital setting. She admitted that she had not had her blood pressure taken since her last dental visit.
When I measured her blood pressure, the reading was alarmingly high. I waited several minutes and assessed it two additional times. Two of the readings fell within the ASA III range on the American Society of Anesthesiologists Classification System where the systolic reading fell between 160-199 and the diastolic reading fell between 95-114. The third reading was 201/118, ASA IV on the classification system.2
I asked my longtime patient how she was currently feeling. She responded by saying that she had a mild headache, but otherwise felt fine. While she was still in my operatory chair, I advised her to call her physician for an immediate medical consultation.
My patient rescheduled her appointment a few months later when her blood pressure was under better control. When she arrived at her appointment, I was greeted with a tight hug and a wide smile. She then told me that her doctor said that she should thank her hygienist for saving her life. That moment was one of the highlights of my long career as a dental hygienist. Assessing my patient's blood pressure on the day of her appointment may have averted her from having a blood pressure emergency such as a stroke, heart attack, or aneurysm.
Reason No. 4
Routine screenings can shine a spotlight on the negative effects associated with white-coat syndrome
For certain patients, the stress and anxiety associated with a dental visit is enough to increase their blood pressure, resulting in higher numbers than if it had been assessed in a more relaxed environment. This common medical condition-called white-coat hypertension or white-coat syndrome-is important for dental professionals to recognize for several reasons.
First, carotid atherosclerosis is considerably greater in patients with white-coat hypertension when compared to those without hypertension, as demonstrated in 10 separate studies.3 Therefore, it can be concluded that white-coat hypertension is a risk factor for heart attack, heart failure, and stroke. Second, high blood pressure associated with white-coat syndrome has been linked to target organ damage through its effect on the left ventricle. Finally, white-coat hypertension can progress to sustained hypertension over time. Consequently, alerting patients about the presence of white-coat hypertension can act as a tool in helping them take charge of their cardiovascular health.3
Reason No. 5
Measuring blood pressure can reduce adverse pregnancy outcomes
In the past, it was not uncommon for women to avoid going to the dentist when they were pregnant for fear that undergoing dental procedures was unsafe. In recent years, however, there is an improved public awareness about the importance of preventive dental care and biannual exams. Given this information, dental hygienists are much more likely to have multiple pregnant patients in their practices at any given time.
Performing routine blood pressure screenings in the dental setting can alert expecting mothers of the presence of preeclampsia, a fairly common, yet serious condition that occurs during pregnancy and in the postpartum period. Preeclampsia progresses rapidly and the etiology is unknown. The main symptoms include high blood pressure and protein in the urine during pregnancy and in the immediate postpartum period.
Preeclampsia generally occurs during the second or third trimesters; however, the disorder can occur earlier than 20 weeks gestation in rare cases. Worldwide, preeclampsia and other hypertensive disorders of pregnancy are a principal cause of maternal and fetal morbidly and mortality. By conventional estimates, these conditions are responsible for 76,000 maternal and 500,000 infant deaths annually.4
Reason No. 6
Diabetes is the other "silent killer"
Screening for hypertension during routine preventive dental appointments is imperative because elevated blood pressure is often indicative of another serious medical condition that commonly occurs without symptoms and remains undiagnosed during its earliest stages-type II diabetes mellitus. Moreover, high blood pressure is reported in over 66% of people with type 2 diabetes, and its progression coincides with the progression of hyperglycemia.5
According to the U.S. Preventive Services Task Force (USPSTF), asymptomatic adult patients with persistent high blood pressure greater than 135/80 mm Hg should be tested for diabetes regardless of whether or not symptoms are present.6 Detecting diabetes early can mean avoiding much more dangerous symptoms later. Therefore, the dental hygienist who detects consistent blood pressure readings of higher than 135/80 should refer the patient to his or her physician to be evaluated for both hypertension and diabetes.
Reason No. 7
Blood pressure readings are required in order to choose the appropriate local anesthetic for dental injections
For patients with a blood pressure reading in excess of 200 mm Hg systolic or 115 mm Hg diastolic, the recommendation is that local anesthetics with epinephrine should always be avoided. What is more, Malamed advises a maximum dose of 0.04 mg of epinephrine for patients with a cardiac history. This equates to roughly 2 cartridges of an anesthetic containing a 1:100,000 concentration of epinephrine or 4 cartridges of 1:200,000 concentration of epinephrine.7
Reason No. 8
We unfortunately live in a litigious society
It is not uncommon for local anesthetic injections to be discounted as a professional liability risk because of their common occurrence and general safety. Although not a considerable source of professional liability claims, adverse events do occur in reaction to local anesthetic injections, sometimes with grave consequences.
The hygienist who measures blood pressure prior to administering a local anesthetic is provided with useful information as to whether or not the patient is considered at risk for a medical emergency. Thus, identifying at-risk patients is especially important when deciding on whether or not to choose a local anesthetic with an added vasoconstrictor when administering a local anesthetic injection.
Although it is true that some medical emergencies cannot be prevented, an emergency resulting from the administration of a local anesthetic with epinephrine on a cardiac patient would be difficult to defend in a court of law if a baseline blood pressure reading was not taken prior to giving the injection.
Reason No. 9
An elevated blood pressure reading may signal the need that stress reduction protocols be enacted
For many patients, a simple trip to their dental office can initiate a fight or flight response which is often characterized by an increase in blood pressure and heart rate. Elevated blood pressure readings can signal the dental hygienist that stress reduction tactics should be implemented to ease the patient.
Dental hygienists should specifically incorporate relaxation and distraction methods into the treatment plan of an anxious hypertensive patient to minimize patient discomfort and reduce the overall risk to the patient. For patients with an elevated blood pressure that is a result of dental anxiety, controlled breathing techniques, listening to relaxing music, and/or administering nitrous oxide may all be helpful.
Reason No. 10
Taking blood pressure is an easy action we can all take each day to advance our profession
The unfortunate truth is that the public has an exceedingly varied, and often very distorted, image of dental hygienists and our profession as a whole. Case in point, my 27-year-old cousin/physician assistant recently sent me a post that was on her friend's Facebook page. The post was designed to look like a dictionary entry and read "Dental hygienist: /den tal hi jen ist/ noun 1. Hot girl who cleans teeth and tells you to floss more." Although the post was meant to be funny, I believe that it does bear some truth regarding how the public perceives our profession.
When the segment on "The Bachelor" marginalized our profession by alluding that dental hygiene is a "fake profession" that doesn't require a college degree, hundreds of rants on various social media platforms followed voicing the views of frustrated dental hygienists everywhere. Like many others, my initial thoughts were laced with anger when my profession was called a "fake job." When my feelings of irritation began to settle, however, I reflected on the following questions.
- Why do the media portray the dental hygienist as the "hot girl who cleans teeth and tells you to floss more"?
- Why does the public think that our sole job is to "clean teeth"?
- Why do so many dentists believe that their hygienists are already "overpaid" and therefore do not deserve the benefits (sick days, vacation pay, cost of living raises, retirement benefits, etc.) allotted to other professionals?
- Why do dental assistants deem that they can just as easily do our jobs?
- Why do front desk staff cram patients into our schedules with the notion that it's okay if we rush through an appointment?
While there are many answers to all of these questions, the short answer to all of them is the same-we allow it. To take it a step further, we have all contributed to these misconceptions at one point or another.
Every time a dental hygienist neglects to take his or her patient's blood pressure or fails to do a screening for oral and skin abnormalities (SOSA), he or she contributes to the public's misconception that we are not health-care professionals. When a hygienist's only advice to his or her patient with a cavity is to "floss more," she contributes to the idea that anyone can do our job. Each time a hygienist reviews a medical history without having a real conversation with his or her patient, the hygienist contributes to the notion that we are "overpaid, pretty, tooth-cleaners." Finally, every time a hygienist rushes through an appointment without taking the time to explain the oral-systemic link, he or she fuels the premise that what we do is unimportant.
And it comes down to that. It is essential to help people understand who dental hygienists are and what dental hygienists do. In two words, we are "prevention specialists." Since there is no clear-cut boundary between the oral cavity and the rest of the body, strictly focusing on oral health would too narrowly define the role of the dental hygienist in comprehensive prevention and health promotion.
The task to educate the public on the role of the dental hygienist as a primary health-care provider while simultaneously awakening all dentists to view us as colleagues who offer a different level of professional expertise is a tremendous task. While the ultimate goal is to change legislation to support dental hygiene practice, taking blood pressure on every patient at every visit is something we all can do to bring more respect to our profession today.
Author disclosure: Some of the positions discussed under "Reason No. 10" are echoed in Shirley Gutkowski's interview with Lory Laughter in the May 2016 Crosslink Radio podcast titled, "How are dental hygienists seen by the public?" RDH
Linda Lawson, RDH, BS, is based in New York and has more than 17 years of experience in the dental profession. She received her associate's degree in 1999 from New York City College of Technology. In 2014, she attained her bachelor of science in dental hygiene from Farmingdale State College and was subsequently inducted into the Sigma Phi Alpha Dental Hygiene Society. In addition to clinical practice, Linda has worked as an adjunct dental assistant instructor and is currently a professional educator on behalf of Waterpik Inc. Linda is thrilled to be on the National Cancer Network (NCN) Visionary Team where she works to raise awareness to prevent late-stage diagnosis of all cancers. Linda can be reached at [email protected]. For those who wish to learn more about the NCN's vision or programs, please contact Linda at [email protected].
References
1. Understanding blood pressure readings. (August 2014). American Heart Association http://www.heart.org/HEARTORG/Conditions/HighBloodPressure/AboutHighBloodPressure/Understanding-Blood-Pressure-Readings_UCM_301764_Article.jspNo. .WAj_wsdiZlk
2. Nunn P. Medical emergencies in the oral health care setting. J Dent Hyg. 2000; 74(2): 136-151.
3. Cobos B, Haskard-Zolnierek K, Howard K. (2015). White coat hypertension: improving the patient-health care practitioner relationship. Psychol Res Behav Manag. 2015; 8: 133-141.
4. About Preeclampsia. (July 2010). Preeclampsia Foundation.
5. Ferrannini E, Cushman WC. (2012 Aug 11). Diabetes and hypertension: the bad companions. Lancet;380(9841):601-10. doi: 10.1016/S0140-6736(12)60987-8.
6. Final Update Summary: Diabetes Mellitus (Type 2) in Adults: Screening. U.S. Preventive Services Task Force. July 2015.
7. What dose of epinephrine contained in local anesthesia can be safely administered to a patient with underlying cardiac disease during a dental procedure? (2010). J Can Dent Assoc;76: a36
