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Year : 2019  |  Volume : 22  |  Issue : 2  |  Page : 154-161

Dentists' knowledge and behavior toward managing hypertensive patients

Department of Endodontics, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia

Date of Acceptance21-Nov-2018
Date of Web Publication7-Feb-2019

Correspondence Address:
D F Bogari
Faculty of Dentistry, King Abdulaziz University, Jeddah
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/njcp.njcp_493_18

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Objectives: Dental office is an ideal screening place to identify undiagnosed/uncontrolled patients with hypertension. The aim of this study was to assess the knowledge and behavior of dentists toward performing proper management of hypertensive patients in Saudi Arabia. Materials and Methods: A close-ended e-questionnaire was created and sent to dentists of all levels (n = 710) in Saudi Arabia. The questionnaire included questions that assessed attitudes and behavior toward using a sphygmomanometer in dental clinics and assessed dentists' knowledge and behavior toward proper management of patients with hypertension. Results: About 62.4% of dentists had a sphygmomanometer in their clinic. Around 79.5% believe that working on patients with high blood pressure (BP) is associated with a risk of complications. However, only 13.3% of them measure the BP of all patients prior to treatment, and 63.3% would do so only if the patient noted a problem. About 54.3% of the respondents prefer using local anesthetics without epinephrine, and they would prefer to refer those patients to dental consultants for treatment. If a patient's BP was 180/100 mmHg, 78.1% of dentists would urgently refer that patient to his or her physician and would not perform a routine elective dental treatment. Conclusion: There is a lack of knowledge and behavior toward proper management of patients with hypertension in our dental sociality. Broadening the breath of dentists' responsibilities to include screening and working together with physicians will help improve the community dental and general health of visiting patients and should be the goal of all dentists.

Keywords: Behavior, dentists, health knowledge, hypertension, public heath, Saudi Arabia

How to cite this article:
Bogari D F. Dentists' knowledge and behavior toward managing hypertensive patients. Niger J Clin Pract 2019;22:154-61

How to cite this URL:
Bogari D F. Dentists' knowledge and behavior toward managing hypertensive patients. Niger J Clin Pract [serial online] 2019 [cited 2022 Aug 14];22:154-61. Available from:

   Introduction Top

Dentists can play a crucial role in maintaining the general health of their patients not only by performing quality dentistry work but also by screening patients for life-threatening diseases such as head and neck cancer and hypertension. Unfortunately, there is a lack of awareness of this important matter worldwide.[1],[2],[3],[4],[5],[6] Hypertension is the primary risk factor for several systemic diseases including stroke and cardiovascular disease.[7],[8] In a meta-analysis study, it was estimated that an increase of 20 mmHg in systolic blood pressure (BP) and 10 mmHg in diastolic BP was each associated with a twofold increase in death from heart disease, vascular diseases, or stroke.[9] Therefore, dentists are in an important position to help with screening, diagnosing, and following up with physicians when needed to provide their patients with the highest overall standard of care. In a previous study conducted by our group, 63% of the cohort was found to be hypertensive, regardless of the degree of hypertension. Roughly half of the screened patients were unaware of this important health issue. When they were referred to physicians, some underwent medical treatment and some had to follow preventive measures and change their lifestyles.[4] Similarly, other studies also reported that 50% or more of hypertensive patients are unaware of their medical issue.[6],[10],[11] Therefore, educating dental students before graduation and dentists at all levels will help us raise our standards of care and contribute to decreasing the burden of this silentkiller disease. The aim of this study was to assess the knowledge and behavior of dentists toward performing proper management of patients with hypertension in Saudi Arabia. The results obtained from this study will help evaluate where we stand in terms of promoting a better healthcare system, which can be enriched starting in dental clinics.

   Materials and Methods Top

The e-questionnaire protocol

A close-ended e-questionnaire was created and sent to dentists of all levels (n = 710) using well-known dental social media groups in Saudi Arabia. The e-questionnaire stem contained the title and the purpose of the research project. All the participants confirmed that they answered the questions to the best of their knowledge and according to their daily dental management. In addition, they agreed to us using the provided information for research and educational purposes. The questionnaire included questions that assessed attitudes and behaviors toward having and using a sphygmomanometer in dental clinics and assessed knowledge and behavior toward the management of patients with BP problems within dental practices.

Statistical methodology

This study was analyzed using IBM SPSS version 23. Simple descriptive statistics were used to define the characteristics of the study variables by counting and calculating percentages for the categorical variables. To establish a relationship between categorical variables, we used Chi-square test, where a P value less than 0.05 was taken to indicate statistical significance. All the significant variables are listed in the tabulated representations.

Human subjects' statement

The e-questionnaire constituted written consent that was obtained from all participants. The e-questionnaire was approved by the research ethical committee review board of King Abdulaziz University, Faculty of Dentistry (KAUFD). This project was approved by the committee and was in full accordance with the Declaration of Helsinki, World Medical Association.

   Results Top

The response rate was 30.0%. Of those, 37.6% were males and 62.4% were females. About 34.3% were from governmental hospitals, 35.2% were from university hospitals, and 18.1% were from private practices. About 58.1% of the participants were general dentists. The characteristics of all 210 participants are presented in [Table 1]. The majority of dentists (79.0%) review the medical history of all their patients before treatment, whereas 21.0% would not do so routinely [Figure 1]a. About 61.9% reported that fewer than 25.0% of their patients mentioned BP issues, 29.0% reported that roughly 50.0% of their patients mentioned BP issues, and 9.1% reported that roughly 75% or more of their patients mentioned BP issues [Table 2]. The last group was found to be statistically significant between male and female dentists [Table 3]; P < 0.05]. Regarding the behavior of dentists toward using and obtaining a sphygmomanometer for their dental clinic, 62.4% responded that they did have a sphygmomanometer in their clinic [Figure 1]b. However, only 13.3% measured the BP of all their patients before performing treatment, and the majority (63.3%) did so only if the patient noted a BP problem [Figure 1]c. Interestingly, 63.8% of respondents believed it was important to measure the BP of their patients in the clinic before performing treatment [Figure 1]d. Regarding dentists' knowledge of hypertension and its relationship with medical and dental parameters, 79.5% believed that working with patients with high BP was associated with a risk of complications [Figure 2]a. Most of the participants believed that patients with high BP could suffer from heart diseases (92.4%) and other medical diseases (86.2%); 5.2% and 11.0% answered do not know, respectively [Figure 2]b and [Figure 2]c; [Table 3]; P < 0.05]. Dentists also believed that patients with high BP could suffer from dental problems (67.6%); however, 19.0% said they did not know [Figure 3]a. In addition, the majority of respondents believed that patients with high BP could suffer from dental complications during or after dental treatment (85.2%) and that BP medications can cause oral side effects (71.4%) [Figure 3]b and [Figure 3]c. Regarding the management of hypertensive patients, 54.3% of respondents would measure BP and then decide whether to perform the dental treatment if their patients noted they were taking medications but not taking them regularly. However, 42.9% of respondents would prefer not to see such patients and would refer them to a physician [Figure 4]a. The latter group was found to be statistically significant between male and female dentists [Table 3]; P < 0.05]. If a patient's BP was 180/100 mmHg, most of the dentists (78.1%) would urgently refer that patient to his or her physician and would not perform a routine elective dental treatment [Figure 4]b. When it comes to using local anesthetic for dental treatment, 54.3% of the respondents preferred using local anesthetic with no epinephrine compared with 40.5% of respondents who would still use a local anesthetic with epinephrine but would limit the number of carpules [Figure 4]c. The survey questions and summary of all the parentages are listed in [Table 2]. A summary of the significant P values is given in [Table 3].
Table 1: Characteristics of the 210 study sample

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Figure 1: Dentists' attitude and behaviors toward obtaining medical history and blood pressure measurement prior to treating patients. (a) Medical history. (b) The presence of a sphygmomanometer in the dental clinic. (c) How often the sphygmomanometer is used. (d) Dentists' beliefs about measuring blood pressure

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Table 2: The survey questions and responses percentages

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Table 3: Summary of all significant P

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Figure 2: Dentists' knowledge about hypertension and its relation to medical conditions. (a) Beliefs about risks of complications. (b) Association with heart disease. (c) Association with other medical conditions

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Figure 3: Dentists' knowledge about hypertension and its relation to dentistry. (a) Incidence of dental problems. (b) Complications during or after dental treatment. (c) Drugs associated with oral side effects

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Figure 4: Dentists' management of patients with blood pressure problems in dental clinics. (a) Management of uncontrolled blood pressure. (b) Management of patients with a blood pressure reading of 180/100 mmHg. (c) Preference of using local anesthetic with/without epinephrine

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   Discussion Top

Prevention is the key for maintaining a better life, decreasing burdens on healthcare services, and improving the quality provided by our healthcare providers.[12] This aim requires a significant amount of understanding and teamwork to raise patient awareness of screening for important diseases and provide health benefits. Achieving these goals also includes closing the gap between dentists and physicians to ensure that all healthcare providers work together. Increasing awareness and educational levels in our society will help ensure the control of noncommunicable diseases and their risk factors. Therefore, broadening the breath of dentists' responsibilities to participate in screening for such diseases and improving the general health of visiting patients must be the goal of all dentists. This work will ensure a better life for our patients, and thus, a healthy mouth means a healthy life.[13],[14],[15] Therefore, the aim of this study was to assess the knowledge and behavior of dentists toward performing proper management of patients with hypertension in Saudi Arabia. Our results showed that 79% of the participating dentists did review their patients' medical histories before performing dental treatment; however, we expected that this should be done by all dentists with no exception. Reviewing patient's medical history can guide the dentist to reach the proper diagnosis, particularly in complicated cases such as cases associated with referred pain [16],[17] or systemic diseases.[18],[19] In addition, reviewing medical history can prevent unexpected complications during and after dental procedures, such as fainting and excessive bleeding.[20],[21] In our cohort, about 38% of dentists noted patients with BP issues at least 50% of the time. If dentists never ask about their patients' medical history or assess their BP before treatment, how can they deal with any unexpected complications? Several studies had investigated the prevalence of hypertension in dental clinic. An average of 50% of the identified patients were unaware of their disease.[5],[6],[11] Therefore, our finding that only 13.3% of our participants measure BP in all patients is alarming. If 63% of our participants believe that it is important to measure the BP of their patients prior to treatment, then there is no excuse for not doing so. The majority of our participants believe that working with patients with high BP carries some risk of complications during or after dental treatment and that these patients may suffer from heart diseases and other medical conditions. In addition, they also believe that BP medications can cause dental side effects. Indeed, studies have shown that BP medications have oral side effects and can interact with commonly used dental drugs such as epinephrine and nonsteroidal anti-inflammatory drugs.[22] Moreover, dentists should be aware of the potential risks of treating these patients and should be prepared and know how to manage them during and after dental treatment. If management was to be a problem, then the patient should be referred to an expert consultant dentist.[23],[24] It has been found that diabetes and hypertension can be associated with decreased retention of teeth after nonsurgical root canal treatments.[25],[26] Therefore, dentists should be aware of these facts when talking about success rates and treatment outcomes. In addition, hypertension was found to be responsible for about 50% of deaths in cases of heart diseases and strokes.[27] Therefore, when treating those patients, special treatment modifications maybe needed to decrease the risk of complications.[24] In our study, 42.9% of the participating dentists preferred not to work on hypertensive patients who were not taking their medications regularly. In addition, most of the dentists preferred using local anesthetic with no epinephrine. If they measured their patient's BP and found it to be 180/100 mmHg before treatment, they would not treat the patient and instead send him or her to a physician. Dentists taking responsibility for treating such patients should be trained and feel confident treating patients with BP issues, and they should know when and how to treat versus when to stop and refer.[28],[29] The use of epinephrine in hypertensive patients is an area of controversy. This is because of the possible interaction of epinephrine with some hypertensive treatment medications such as β-blockers,[23],[24] and the possibility of the sudden increase in BP as an effect of epinephrine administration.[30] This interaction can be based on several factors such as the dose of epinephrine given, the medical condition of the patient, and the anxiety state of the patient during treatment.[31] The increase in BP after local administration of anesthesia with epinephrine seems to be transient and subsides 5–15 min after injection.[30] In terms of the marginal increase in BP, it seems to be clinically insignificant even for patients with cardiovascular problems (not including cardiac transplant recipients).[32],[33] Indeed, the majority of the studies still support the use of local anesthetic with epinephrine such as 2% lidocaine with 1:100,000 epinephrine (one to two carpules; containing 0.018–0.036 mg epinephrine) depending on BP status and the underlying medical conditions; BP should be closely monitored if needed.[33],[34] The insignificant clinical increase in BP is permissible given the benefits gained from administration (e.g., better control of pain and bleeding and more efficient and prolonged anesthesia during dental procedures).[22] In addition, ensuing to always inspirate, giving slow injections, and increasing the time between injections help decrease the side effects of local anesthetic and achieve more confirmable and effective anesthesia.[35],[36] The accepted BP cut-off for performing dental treatment has been reported to be 180/110 mmHg.[37],[38],[39],[40] Therefore, patients with BP lower than this reading can be treated by an expert dentist but caution should be taken. However, in such cases, elective treatments should be deferred and the patient should receive an urgent medical consultation to overcome unwanted heath and dental complications.[22],[24]

   Conclusion Top

There is a lack of knowledge and behavior that is appropriated when managing patients with hypertension in our dental community. Dentists seem to believe that measuring BP in dental clinics is important, but they still do not do so. In addition, they seem to be hesitant to treat patients with hypertension. Thus, increasing the knowledge and awareness of dentists about this important matter and implementing new guidelines and principles to broaden the breath of dentists' responsibilities, to include screening and working together with physicians, is critical. Doing so will help improve the general health of our patients, which should be the goal of all dentists. Higher levels of health will, in turn, ensure better and longer lives for our patients.

   Acknowledgment Top

This project was funded by the Deanship of Scientific Research (DSR) King Abdulaziz University, Jeddah, Saudi Arabia, under grant no. G-718-165-38. The author acknowledges and thanks DSR for technical and financial support. The author also thanks Kalvin Balucanag and his team for helping with the data tabulation and analysis. The author also thanks Dr. Majdi Munshi, Dr. Faris Aljuaid, Dr. Nouran Alzebiani, Dr. Rowaina Mansouri, Dr. Faisal Alghamdi, and Dr. Maha Bamhisoun for their help in gathering the data. Finally, the author also thanks Dr. Turki Alhazzazi for his help in reviewing the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

  [Table 1], [Table 2], [Table 3]


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