This document outlines the parameters that guide decisions relative to the care of patients who present with elevated blood pressure. The American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines for blood pressure targets and treatment recommendations were updated as of November 2017:
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Table 1
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Current Values [mm Hg]
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Prior Values [mm Hg]
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Hypotension
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<90 / < 60
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N/A
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Normal
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< 120 / < 80
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< 120 / < 80
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Elevated
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120 – 129 / < 80
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120 – 139 / 80 - 89
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Stage 1 Hypertension
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130 – 139 or
80 – 89
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140 – 159 / 90 – 99
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Stage 2 Hypertension
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> 140 or
> 90
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> 160 / >100
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Hypertensive Urgency*
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> 180 * or
> 120*
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> 210 / >120
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*Non-compliant w/ therapy or intensify anti-HTN Rx therapy; treat anxiety prn.
GUIDELINES:
All BP measurements and vital signs taken must be recorded in the patient’s electronic health record (EHR) immediately Students are required to measure vital signs at each appointment.
• Blood pressure should be measured using a sphygmomanometer and stethoscope or calibrated stand (oscillometric) monitor. Other calibrated oscillometric (electronic) BP measuring devices may be used except for wrist cuffs.
• Support the arm and make sure the BP cuff is at heart level and the patient is sitting upright with both feet on the floor.
• If elevated, have patient sit quietly for 5 minutes then remeasure. Consider measuring in both arms and record the higher reading.
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Utilize appropriate stress management protocols. In patients with hypertension who are anxious or fearful, consider use of intraoperative inhalation sedation with nitrous oxide / oxygen.
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Additional appointment management protocols. Avoid rapid position changes to minimize the risk of orthostatic hypotension. For patients with BP measurements greater than 140 / 90, periodic monitoring of BP during treatment, and at the conclusion of the appointment, is advisable.
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Capacity to tolerate care; Hypotensive. Patients with BP measurements below 90/60 should be questioned to determine if treatment may continue. Have or do they:
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Do you faint, have vertigo, or have blurry vision?
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Do you fall?
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Have you started a new blood pressure medication or any new medication?
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Have you taken any non-prescribed medications or street drugs?
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Have you been diagnosed with renal disease?
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Have you been diagnosed with congestive heart failure or irregular heartbeat?
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Do you have a well-balanced diet including water intake?
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Is this a normal blood pressure reading for you?
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Capacity to tolerate care; Hypertensive. Patients with BP measurements 160 / 100 may receive any necessary dental treatment. For those presenting with BP > 160 / 100, elective dental treatment may be deferred until the BP is brought under better control as confirmed by receipt of a medical clearance from the patient’s primary care physician, internist, or cardiologist. If urgent or emergency dental treatment is determined to be required, proceed with limited and conservative treatment procedures as possible to address the chief complaint and/or relieve acute pain unless the BP is confirmed to be > 180 / 110. At this point, no treatment of any type should be performed without a physician consultation.
NOTE: Superficial surgical procedures, including minor oral and periodontal surgery and non-surgical dental procedures, are classified as low risk. Therefore, it appears that the risk associated with most general, outpatient dental procedures is very low.
TREATMENT CONSIDERATIONS:
Table 2 CURRENT Values [mm Hg] Dental Management
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Hypotension
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<90 / <60
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Observe for possible syncope or lightheadedness. Interview the patient to determine the need for medical consultation. No contraindications to dental treatment are available.
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Normal
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< 120 / < 80
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No contraindications to dental treatment.
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Elevated
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120 – 129 / < 80
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Stage 1 Hypertension
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130 – 139 or
80 – 89
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Stage 2 Hypertension
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140 – 159 or
90 – 99
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*Upper-level Stage 2 Hypertension*
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160 – 179 or
100 - 109
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*Defer ELECTIVE treatment and refer to physician promptly for evaluation. OR intraoperative monitoring of BP and refer to physician for evaluation
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Hypertensive Urgency
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> 180 * or > 110*
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Defer ALL treatment and refer to physician immediately for evaluation.
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*Abnormal pressures should be confirmed by the attending faculty before termination of the appointment. Document in the patient’s chart the cuff placement (ex: right arm), patient position (ex: sitting), interval between readings, and method/s of measurement (ex: stand monitor).
*For borderline values, use professional judgment while taking into consideration patient specific factors such as age and co-morbidities as well as the planned treatment procedures.
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Follow-up considerations: Encourage healthy lifestyle changes, Rx compliance, and self-monitoring when discussing a patient’s level of BP control. Physician follow-up intervals will vary based on the stage of HTN, type of medication(s), level of BP control, and 10-year cardiovascular disease risk assessment.
REFERENCES:
1. Little, JW, Miller, C, Rhodus, NL. Little & Falace’s Dental Management of the Medically Compromised Patient, 9th Edition, 2018
