Quality Resource Guide l Screening and Monitoring Blood Pressure in Dental Practice 3rd Edition 3 www.metdental.com detailed in the 2017 ACC/AHA/AAPA/ABC/ACPM/ AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: A Report of the American College of Cardiology/ American Heart Association Task Force on Clinical Practice Guidelines. 3 The oral healthcare provider’s role in measuring blood pressure The dentist is responsible for several management considerations associated with patient with HTN. These include: identification of those with undiagnosed disease (screening) with referral for appropriate medical assessment; detection and identification of irregularities and abnormalities associated with control of disease; support of lifestyle and compliance to assist medical management of disease; determination of need for stress/ anxiety reduction; identification of possible drug interactions, and; identification and management of adverse drug effects. Adults are generally more likely to have a dental appointment than they are to go to a physician’s office. This puts the oral health care provider in an ideal position to screen asymptomatic individuals for potential health issues. Screening tests are conducted to assess the risk of developing disease among individuals who present with no clinical signs or symptoms of disease. It is not the role of the dentist to diagnose systemic disease, but oral healthcare providers can screen for those at risk for the disease by putting together data from the screening tests with the medical history, symptoms and family history. If a dental patient is identified as high risk for HTN, he/ she should be referred to their physician for follow- up. Early identification of these individuals allows early diagnosis, initiation of intervention and/or treatment, and the potential for reduction in disease-specific morbidity and mortality. Abnormal BP detected in a patient receiving therapy may identify resistance to treatment, or low compliance. They should also be referred to their physician. Routine BP measurement is the recommendation of the American Dental Association and the National Heart, Blood and Lung Institute (NHLBI). Minimally, blood pressure measurements should be obtained on all new patients and at recall examinations. Individuals with a history of HTN who are either non- compliant with medications or poorly controlled, as well as those with comorbid conditions (for example stroke and/or cardiovascular disease) require more frequent monitoring. Measuring BP helps fosters a better patient-provider relationship in the dental office, with many informed patients now expecting providers to record BP during the course of their dental visit. How to measure blood pressure Because the new definition of HTN is lower (130/80), more people will be classified as having HTN. Therefore, it is imperative that measurements be performed properly. When BP is measured in the dental setting it reflects what is happening at one instance in time. There are many factors that may influence the blood pressure measurements. The dentist and/or any appropriately trained auxiliary in a dental office may measure BP and record this data. Patients should abstain from smoking, exercising and consuming caffeinated beverages for at least 30 minutes prior to taking the reading. Ideally, the BP is measured after the patient has rested comfortably for at least 5 minutes in a seated position with their feet on the floor. If measurements are obtained while a patient is seated in the dental chair, their legs should be uncrossed, and patients should not talk while measuring the BP. The patient’s arm should be abducted, slightly flexed, and supported by a smooth, firm surface. The brachial artery from which the blood pressure is to be recorded should be at a level with the heart. Arm level and degree of support/lack of support can significantly affect the measurements (see Table 3). For example, if the arm is unsupported, the BP may be elevated by 5-11 mm Hg due to added hydrostatic pressure induced by gravity. Table 3 - Factors that contribute to errors in blood pressure 4 Type Factor Systolic (mmHg) Diastolic (mmHg) Duration Patient Heavy physical exertion  18-20  7-9 1 hour Daily stress  10  15 Several minutes Distended bladder or bowel   Eating a big meal  20  20 Caffeine  10-14  10-14 Tobacco/nicotine  6-20 30 minutes Technique Arm height not at heart level  8  8 Arm not supported  6-10  5-11 Rapid cuff deflation  10  10 Cuff size too small  10  2-8 Cuff size too large  3