60

HYPERTENSION PROFILE IN AN ADULT

DENTAL POPULATION
Tarek L. Al-Khateeb* B.D.S., M.D.S., Ph.D.
Mohammed A. Mahmoud B.D.S., M.Sc, Ph.D.

The
objective
of
the
present
study
was
to
determine
the
frequency
and
d i s t r i b u t i o n of h y p e r t e n s i o n in an a d u l t p o p u l a t i o n of d e n t a l p a t i e n t s
(>18
years).
The
study
was
conducted
on
1320
patients
(624
males
and
696
females).
The
frequency
of
hypertension
was
determined
through
history
taking,
and by measuring the
blood
p ress u re
values
of
every
patient.
Blood
pressure
values
and
hypertension
frequencies
were
analyzed as r e l a t e d to the age a nd s e x of the total p o p u l a t i o n s t u d i e d .
The
results
showed
a
hypertension
frequency
of
26.4%.
Males
showed
more
frequent
hypertension
(30.8%)
compared
to
females
(22.4%).
Of
the
recognized
hypertensive
patients,
59.2%
were
either
unaware
or
uncontrolled hypertensive patients.
Blood p r e s s u r e v a l u e s and
frequency
of h y p e r t e n s i o n i n c r e a s e d w i t h age. In older i n d i v i d u a l s (55
years
or
more),
hypertension
frequency
markedly
increased
to
58.6%
in
males,
and
to
60.6%
in
females.
The
findings
were
compared
to
those
reported
in
other
populations,
and
the
dental
implications
were
discussed.

Introduction
R e c e i v e d 25 10.97, R e v i s e d 24 12.97, Accepted
08.02 98
" A s s o c i a t e P r o f e s s o r , C h a i r m a n of the Oral and
Ma xillofacia l Surgery Department,
Vice Dean, F a c u l t y of D e n t i s t r y , King Abdul-Aziz
University
' A s s i s t a n t P r o f e s s o r , Oral M e d i c i n e , F a c u l t y of
D e n t i s t r y , King Abdul-Aziz U n i v e r s i t y
A d d r e s s r e p r i n t r e q u e s t s to: Dr T a r e k Al K h a t e e b ,
PO Box 51372, Jeddah 21543, S a u d i A r a b i a

The

potential
risk
associated
with
dental
treatment
of
patients
with
hypertension
has
been
well
documented.
Variable
increases
and f l u c t u a t i o n s in blood p r e s s u r e

THE SAUDI DENTAL JOURNAL, VOLUME 10, NUMBER 2, MAY - AUGUST 1998

61

HYPERTENSION IN ADULT DENTAL POPULATION

values,
as
well
as
adverse
hemodynamic
and
cardiovascular
changes
have
been
recognized
du ri ng
dental
treatment
of
hypertensive
p a ti e n t s. "
In
a d d i t i o n , the identified a d v e r s e
m e t a b o l i c effects and i n t e r a c t i o n s
of
antihypertensive
medications
r e p r e s e n t a n o t h e r p o t e n t i a l risk
further
complicating
dental
treatment. D e sp i te the identified
risk, evaluation of dental patients
r e g a r d i n g t h e i r blood p r e s s u r e
s t a t u s is not always as thorough as
it should be; and adverse reactions
have been reported as a result of
dental
treatments
conducted
without
being
aware
of
the
potential medical ri sk s. '
Recent
data
have
shown
increased
frequencies
of
hypertension among th ose s e e k i n g
dental treatment.
Moreover, it
has been estimated that over 50%
of hypertensive patients are either
i n a d e q u a t e l y controlled or t o t a l l y
unaware of t h e i r blood pressure
status.
This
unawareness
was
reported in a dental population, as
well as in a general population.
These
recognized
high
frequencies
of hypertensive patients, and the
high percentage of unaware and
uncontrolled c a s e s represent a
dental management challenge that
needs
to
be
further
addressed.
More s t u d i e s need to be conducted
on the profile of hypertension in
other dental populations; and, the
role
of
the
dentists
in
the
i d e n t i f i c a t i o n and management of
hypertensive p a t i e n t s needs to be
further emphasized.
The
objective
of
the
present
study
was
to
determine
the
frequency
and
distribution
of
hypertension
in
an
adult
population
of dental
p a ti e n t s
THE SAUDI DENTAL JOURNAL VOLUME 10. NUMBER 2, MAY - AUGUST 1998

among
the
Faculty
of
King A b d u l - A z i z University.

Dentistry,

Materials and Methods

A total of 1,320 adult patients
(>18 years of age) were randomly
s e l e c t e d to p a r t i c i p a t e in the
present study. The p a ti e n t s were
selected from those who attended
the screening clinic, F a c u l ty of
Dentistry,
King
Abdul-Aziz
U ni ve rsi ty, between 1995 and 1996.
The patients' age ranged between
18 and 76 years, and the average
age was 37.2 13.9 years. These
were 47.3% male (mean age 38.6
14.4
years),
and
52.7%
female
p a ti en ts (mean age 36 13.6 years).
The
blood
pressure
of
every
p a t i e n t was e v a l u a t e d by two
methods. First,
by responses on
direct
questioning
regarding
previous
blood
pressure
measurements,
previous
diagnosis
of hypertension, and current i n t a k e
of
antihypertensive
m e di c a t i o n s .
Second, by m e a s u r i n g the blood
pressure, applying the a u s c u l t a t i o n
method.
Blood
p r essu r e
measurements
were performed by one and the
same examiner. For every pa tien t,
blood pressure was t a k e n
twice.
One measurement was taken at the
beginning of the screening session,
after
the p a t i e n t
was s e a t e d
comfortably for five m i n u t e s ; the
other measurement was taken at
the end of the same screening
s e s s i o n . The lower of the two
blood pressure measurements was
recorded as the patient's true blood
pressure
to
avoid
over-estimation
of hypertension frequency in the
population studied. A patient was
categorized as hypertensive based

AL KHATEEB AND MAHMOUD

on e i t h e r a p o s i t i v e h i s t o r y of
diagnosed
hypertension,
or
a
measured blood pressure value 140 mm Hg Systolic, and = 90 mm
Hg, D i a s to l i c , or = 140 / 90 mm
Hg-

medication. Of those pa ti e n ts, 117

(45.2%)
were
inadequately
controlled
based
on
hypertension
threshold >. 140/90 mm Hg, >_ 140
mm Hg S y s t o l i c , or >_ 90 mm Hg
diastolic.

P a t i e n t s were divided into five

age groups (Table 1). Descriptive
s t a t i s t i c s were used to summarize
the collected data; blood pressure
values
and
hypertension
frequencies
were analyzed as
related to the age and sex of the
population studied.

Table I shows the mean s y s t o l i c

and diastolic blood pressure v a l u e s ,
as
well
as
the
frequencies
of
hypertension
in
different
age
groups.
The
v al ue s,

relationships of s y s t o l i c
diastolic
values,
and

Table I. Blood pressure v a l u e s and hypertension frequencies in different age g r o u p s .

Groups
(Age in y e a r s )

Group 1 (18 - 24)

Group II (25 - 34)
Group III (35 - 44)
Group IV (45 - 54)
Group V (55 or more)

Number of
Patients

339
303
264
228
186

Results
The prevalence of hypertension
in the studied population of dental
p a t i e n t s was 26.4%. The frequency
of hypertension in males (30.8%)
was greater than that in females
(22.4%).
Of the recognized
hypertensive p a ti e n t s, 259 (74.4%)
gave
a
positive
history
of
previously
diagnosed
hypertension,
and 89 (25.6%) were unaware of
their blood pressure s t a t u s , but
their
measured
blood
p r e s su r e
v a l u e s were = 140 mm Hg s y s t ol i c ,
= 90 mm Hg d i a s t o l i c , or = 140/90
mm
Hg.
Patients
with
previously
diagnosed hypertension were all on
a n t i h y p e r t e n s i v e m e d i c a ti on s but
with
variable
c o m pl ia nc e s
to

Systolic
blood
pressure
(mm Hg)
X SD

Diastolic
blood
pressure
(mm Hg)
X SD

Hypertension
frequency

116.3 1 1 . 3
117.1 13.3
122.4 15.1
130.2 20.7
135.6 21.8

74.4 8.5
76.4 9.7
79.5 10.2
83.5 9.9
84.8 10.6

5.3%
13.9%
22.7%
51.3%
59.7%

(%)

hypertension frequencies to the age

and sex of the population studied
are shown in Fig. (1) to Fig. (3).
Systolic
and
diastolic
blood
p r e s su r e
values,
as
well
as
hypertension
frequencies
i n c rea se d
with age. A dramatic increase in
the frequency of hypertension was
noted in older age groups (groups
IV and V, Table 1).
In younger age groups (< 55
years),
males
showed
higher
s y s t o l i c and d i a s t o l i c p r e s su r e
values,
and
more
frequent
hypertension compared to females.
In
older
patients
(55
years
or
more),
however,
systolic
and
dia stolic blood pressure v a l u e s in
females were closer to th ose in
males;
and
the
frequency
of
hypertension in female, s l i g h t l y

THE SAUDI DENTAL JOURNAL VOLUME 10, NUMBER 2, MAY - AUGUST 1998

63

HYPERTENSION IN ADULT DENTAL POPULATION

exceeded
that
(Figs. 1 - 3).

in

male

patient;

Discussion

The
potential
risk
associated
with
dental
treatment
of
hypertensive
patients
has
been
largely
related
to
the
adverse
hemodynamic
and
cardiovascular
changes
recognized
during
stressful
dental
procedures.3'4'2
On
the
other
hand,
significant
blood
pressure
increases
and
variable
fluctuations
have
been
also
recognized in a s s o c i a t i o n
with nonstressful
dental
procedures,
suggesting
a
potential
risk
r e g a r d l e s s of the
dental
procedure. 1 3 ' 1 5
The
need
for
a
routine
sc r een i n g
for
hypertension
has
been
stressed
in
order
to
prevent
unexpected
complications
and
systemic
exacerbations
during
dental treatm ent. 1 3 ' 4
In
the
present
study,
screening
of
an
adult
dental
population
revealed
a
hypertension
frequency
of
26.4%.
This
recognized
frequency
is
comparable
to
those
recently
recognized
in
other
dental
populations
(24%,
28%),89
further
supporting
an
increased
prevalence
of
hypertension
among
dental
patients.
Over the last two
decades,
advances
in
diagnosing
and
treating
hypertension
have
resulted
in
a
major
decli n e
in
cardiovascular
and
stroke
mortalities
and
enabled
hypertensive p a t i e n t s
to live longer
and
more
productive
lives."'6
This
might have changed the assembly of
dental
populations
to
i n cl u d e
higher
percentage
of
those
patients
with h y p e r t e n s i o n , hence, the

THE SAUDI DENTAL JOURNAL VOLUME 10, NUMBER 2, MAY - AUGUST 1998

AL KHATEEB AND MAHMOUD

64

controlle d c a s e s .
Data in the l i t e r a t u r e i n d i c a t e s a
higher
prevalence
of
hypertension
in males compared to f e m a l e s , but,
with
comparable
hypertension
frequencies
between
males
and
fe7
males
in
older
age
gr o up s.'
The
results
of this study are consistent
with
these
data.
In
younger
age
groups (<45),
males
showed higher
blood
pressure
values
and
more
frequent
hypertension
than
females,
which
contributed
to
the
hi ghe r
overall
hypertension
frequency
in
males
compared
to
females in the total p a t i e n t s studi ed.
In
older
patients,
however,
blood
p r e s s u r e v a l u e s of f e m a l e s were
clo ser to t h o s e of males, and the
frequency
of
hypertension
in
females
slightly
exceeded
that
in
males.

recognized high f r e q u e n c i e s .
Collectively,
unaware
and
uncontrolled
patients
represented
59.2%
of
the
total
hypertensive
patients
recognized
in
the
present
s t u d y . This is c o n s i s t e n t with the
recent
data
indicating
that
over
50% of the hypertensive p a t i e n t s in
general
population,
as
well
as
in
dental
populations8
are
either
unaware
or
uncontrolled.
Accordingly, i n sp i te of the increased public
awareness
of
hypertension,
and
the
rapidly
growing
array
of
antihypertensive
medications,
unaware
and uncontrolled
cases
still represent
major
proportions
of
hypertensive
patients.
This
observation
further
emphasizes
that
dentists
sho uld be aware of the blood pressure s t a t u s
of t h e i r p a t i e n t s in
order
to
avoid
the
complications
and i n t e r a c t i o n s a n t i c i p a t e d during
treatment of asymptomatic or un-

Both blood p r e s s u r e v a l u e s , and

hypertension
frequency
increased
with
age.
In
older
patients
(55
years or more), the h i g h e s t
blood
pressure
values
were
recognized,
and
the
frequency
of
hypertension
markedly
increased
to
59.7%.
This
is c o n s i s t e n t with the s t u d i e s i d e n t i fying
hypertension
as
the
most
common systemic d i s e a se in elderly
18
dental
patients,
and
in
older
19
populations
in
general.
Thus,
older i n d i v i d u a l s are at a markedly
greater
risk
of
dental
treatment.
Efforts towards e v a l u a t i o n
of t h e i r
blood pressure are even more important
than
in
younger
i n di v i duals.
In conclusion, the r e s u l t s of the
present study i n d i c a t e
that an increasing
number
of
hypertensive
patients
are
seeking
dental
treatment.
The
recognized
higher
frequency
of
hypertension
in
older
p a t i e n t s , and the high percents of
unaware and u n c o n t r o l l e d c a s e s

THE SAUDI DENTAL JOURNAL VOLUME 10, NUMBER 2, MAY - AUGUST 1998

65

HYPERTENSION IN ADULT DENTAL POPULATION

suggest
an
increased
risk.
Performing dental procedures on t h o s e patients
could
bring
about
serious
complications,
and
acute
exacerbat i o n s of t h e i r s y s t e m i c c o n d i ti o n s .
C o n s e q u e n t l y , it is the r e s p o n s i b i l ity of the d e n t i s t to i d e n t i f y t h o s e
p a t i e n t s at risk, e v a l u a t e the a s s o c i ated risk, and be aware of the side
effects and i n t e r a c t i o n s of the relevant
antihypertensive
medications.
Furthermore, it is e s s e n t i a l that the
d e n t i s t sho uld be prepared to apply
preventive
and
stress
r educti o n
measures,
as well as to manage
unexpected
hypertensive
emergencies.

Surg Oral Med Oral Pathol

Radiol Endo 80: 145-52, 1995.

5.

Cowper
TR
and
Terezhalmy
GT.
Pharmacotherapy
for
hypertension.
Dent
Clin
North
Am
40:585-610, 1996.

6.

Massalha R, Valdman S, F a r k a s h
P, M e r k i n L, and H e r i s h a n u Y.
Fatal
intracerebral
hemorrhage
dur i n g dental treatment. Isr J Med
Sci 32: 774-6, 1996.

7.

Kr e p l e r
K,
Wedrich
A,
and
Schranz
R.
I n tr ao ccu lar
hemorrhage associated with d e n t a l implant s u r g e r y .
Am J Ophthalmol
122:745-6, 1996.

8.

Bandl E, Boda K and Sonkodi S.

Hypertension scr e e n i n g in a dental surgery : a H u n g a r i a n s t u d y . J
Hum Hypertens 4 : 253-7, 1990.

9.

Seedat YK, Mayet FG, L a t i f f GH,

and
Joubert
G.
Study
of
risk
factors l e a d i n g to coronary h e a r t
d i s e a s e in urban South Africa. J
Hum Hypertens 7:529-32, 1993.

References

1.

2.

3.

4.

Meiller
TF,
Overholser
CD,
Kutcher MJ, and Bennett R. Blood
pressure f l u c t u a t i o n s in hypertensive p a t i e n t s during oral surgery.
J Oral M a x i l l o f a c Surg 41 : 715-8,
1983.

Hirota Y, Sugiyama K, Joh S, and

Kiyomitsu
Y.
An
echocardiog r a p h y study of p a ti en t s with card i o v a s c u l a r d i s e a s e s during dental treatment using local anesthesia.
J
Oral
Maxillofac
Surg
44:116-21, 1986.

Hasse AL, Heng MK and Garrett

NR. Blood pressure and el ectr o c a r d i o g r a p h i c response to dental
treatment with use of local anest h e s i a . JADA 113:639-42. 1986.

Campell RL and Langston WG. A

comparison
of
cardiac
ratepressure
product
and
pressurerate q u o t i e n t in h e a l t h y and medically compromised p a t i e n t s . Oral

THE SAUDI DENTAL JOURNAL, VOLUME 10, NUMBER 2, MAY - AUGUST 1998

Oral

10. Thorn TJ et al. Trends in blood

pressure control and m o r t a l i t y . In
Izzo JL, and Black HR (eds). Hypertension primer. Dallas, American Heart A s s o c i a t i o n , pp. 207,
1993.

11. The Fifth Report of the J o i n t National

Committee on D e t e c t i o n ,
E v a l u a t i o n and Treatment of High
Blood
Pressure
(JNCV).
Arch
Intern Med 153:154-183, 1993.

12. Meyer
F.
Haemodynamic
changes
under emotional stress f o l l o w i n g a

66

AL KHATEEB AND MAHMOUD

minor surgical procedure under local a n a e s t h e s i a . Int J Oral Maxillofac Surg 16:688-94, 1987.

13 Gortzak RA, Abraham-lnpijn L, and

O o s ti n g
J. Blood pressure response to dental check-up: a continuous non-invasive registration.
Gen Dent 39: 339-42, 1991.

14. Gortzak
RA,
Oosting
J,
and
Abraham-lnpijn L. Blood pressure
r e s p o n s e to routine r e s to r a ti v e
dental treatment with and without
local a n e s th e s i a . Oral Surg Oral
Med Oral Pathol 73:677-81, 1992.

15. Brand HS, Gortzak RA, PalmerBouva CC, Abraham RE, and Abraham InpijnL.Ca rdi ova sc ula r and
neuroendocrine
responses
during
acute stress induced by different
types of dental treatment. Int Dent
J 45: 45-8, 1995.

1 6 . T a n a k a H, Date C, Chen H.
Nakayama
T,
Yokoyama
T,
et
al. A brief review of e pi d e m i ol og i cal studies on ischemic heart disease in Japan. J Epidemiol 6 (3
suppl): S49-59, 1996.

17. Drizd T, et al. Blood pressure

levels in persons 18-74 years of
age in 1976-80, and tr e n ds in
blood pressure from 1960 to 1980
in the United States. Vital Health
Stat 234:1, 1986.

18. Umina M and Nagao M. Systemic

diseases in elderly dental patients.
Int Dent J 43:213-8, 1993.

19. Kannel WB. Prevalence, incidence

and hazards of hypertension in the
elderly. Am Heart J 112:1362-3,
1986.

THE SAUDI DENTAL JOURNAL. VOLUME 10, NUMBER 2, MAY - AUGUST 1998