Undiagnosed Diabetes and Hypertension in Patients at a Private Dental Clinic in Saudi Arabia

Abstract

bjective: The aim of this study was to determine the prevalence of un-

diagnosed diabetes mellitus (DM) and undiagnosed hypertension in a private dental clinic in Saudi Arabia.

Mohammed A. Al-Harbi, BDS Resident Dentist Faculty of Dentistry, King Abdulaziz University Jeddah, Saudi Arabia E-mail: alharbi.mohammed@hotmail.com

Basel M. Abozor, BDS Endodontic Resident Faculty of Oral and Dental Medicine Cairo University Cairo, Egypt E-mail: drbasel1@yahoo.com

Mohammad S. AlZahrani, BDS, MSD, PhD Associate Professor and Head, Division of Periodontics Faculty of Dentistry, King Abdulaziz University Jeddah, Saudi Arabia E-mail: msalzahrani@kau.edu.sa

ethods: A total of 98 consecutive patients provided information about sociodemographics, history of DM and hypertension, and the use of antidiabetic and antihypertensive medications. Random blood glucose (RBG) levels were measured using a glucometer. Patients with RBG 200 mg/dL were classified as having DM. Two blood pressure (BP) measurements were taken by a nurse; the average measurement was used to determine hypertension classification. Patients with BP 140/90 mm Hg were classified as hypertensive. Results: Approximately 12% and 14% of the total sample of patients had diabetes and hypertension, respectively; of these, 4% had both conditions. The prevalence of undiagnosed DM and undiagnosed hypertension was 3% and 8%, respectively. Among subjects 35 years of age, 27% and 25% had DM and hypertension, respectively, whereas the prevalence of undiagnosed DM and undiagnosed hypertension was 6% and 11%, respectively, in this age group. Conclusion: The prevalence of undiagnosed DM and undiagnosed hypertension among our subjects is high, especially among the older age group. Oral health professionals are advised to use the opportunity presented at routine dental visits to review and ensure optimum overall patient health through proper screening, diagnosis, and referral.

Introduction
Diabetes mellitus (DM) and hypertension are chronic diseases that are becoming increasingly common global health problems that require lifelong management to decrease morbidity and mortality because of their associated complications.
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Table 1 Characteristics of Study Subjects

Variable Gender Education Male Female Illiterate Completed elementary school Completed intermediate school Completed secondary school Completed more than secondary school Saudi Arabian Non-Saudi Arabian

Number of patients 62 36 14 13 18 29 24 44 54

Percentage 63.3 36.7 14.3 13.2 18.4 29.6 24.5 44.9 54.1

strated that untreated hypertension was responsible for about 28% of incident strokes, one of the leading causes of death worldwide.14 Thus, increasing the detection and improving the management of hypertension might prevent a considerable proportion of the incident strokes.14 Among patients presenting for dental treatment in Saudi Arabia, limited data exists on the prevalence of undiagnosed diabetes and hypertension15; therefore, the goal of this study was to assess the prevalence of undiagnosed DM and undiagnosed hypertension in a sample of dental patients.

Nationality

Methods
This cross-sectional study was conducted at a private dental clinic in the western region of the Kingdom of Saudi Arabia, from which 98 consecutive patients were selected. Information about sociodemographics, history of DM and hypertension, and the use of antidiabetic and antihypertensive medication were obtained from the participants. Random blood glucose (RBG) levels were measured using a glucometer. Patients with RBG 200 mg/dL were classified as having DM. In addition, 2 BP measurements were taken, 5 minutes apart on the right and left arms, by a nurse using an electric sphygmomanometer (HEM-775; Omron Healthcare Inc). The average measurement from the 2 readings was used in the present study. Criteria from The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High BP were used for the BP classification.16 Patients with BP 140 mm Hg systolic and/or 90 mm Hg diastolic were classified as hypertensive. Data were analyzed using the Statistical Package for Social Sciences, version 16 (SPSS Inc). Means and frequency distributions were calculated for continuous and categorical variables, respectively.

DM is a disease in which the body either does not produce or respond to insulin. It is considered to be a common cause of death, and its prevalence has increased globally.1,2 More than 240 million people worldwide have DM, and it is predicted that this number will double or triple within the next 10 years.3,4 In Saudi Arabia, 23.7% of individuals 30 to 70 years of age have DM.5 Complications of DM include: 1) diabetic ketoacidosis, caused by sustained high blood sugar; 2) nephropathy (diabetic patients are 25 times more likely to develop endstage renal disease than nondiabetics)6; 3) neuropathy or damaged peripheral nerves; 4) delayed wound healing and high susceptibility to infection; and 5) increased susceptibility to periodontal infection. Globally, approximately 26% of the adult population has hypertension.7 The prevalence of hypertension in the Saudi Arabian population is approximately 25%.8,9 Many people are unaware that they have hypertension. According to studies conducted in US and Japanese dental schools, approximately 49% and 20%, respectively, of individuals with high blood pressure (BP) were not aware of their condition prior to their dental visit.10, 11 Complications of hypertension can include hardening and thickening of the arteries (atherosclerosis), which may lead to a heart attack, cerebrovascular events (stroke), aneurysm, and renal diseases.12 A recent study demonstrated that about 16% of the new cases of end-stage renal diseases in Australia were because of hypertension.13 Moreover, it has been demon-

Results
Males comprised 63.3% of the total sample, and approximately 45% of the total sample was Saudi Arabian (Table 1). The mean age of the study sample was 32 years, and approximately 40% of the sample was 35 years of age or older. A history of DM and hypertension was reported by approximately 15.6% and 10.4%, respectively, of the total sample. The mean RBG level was 133.2 mg/dL.

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Table 2 Table 2 Variable

Prevalence of DM, Undiagnosed DM, and Uncontrolled DM Categorized by Demographic Factors Percentage of total sample 15.6% 11.7% 2.6% 9.1% <35 years 2.3% 0% 0% 0% Age 35 years 33.3% 27.3% 6.2% 21.1% Gender Male Female 16% 14.8% 12% 11.2% 4% 0% 8% 7.1% Nationality Saudi Non-Saudi 17.1% 14.3% 17.1% 7.1% 5.7% 0% 11% 11.4%

History of diabetes RBG mg/dL 200 Undiagnosed DM* Uncontrolled DM

DM, diabetes mellitus; RBG, random blood glucose. *Patients with no history of DM whose RBG is 200 mg/dL. Patients with history of DM whose RBG is 200 mg/dL.

Table 3 Table 2 Variable

Prevalence of Hypertension, Undiagnosed Hypertension, and Uncontrolled Hypertension Categorized by Demographic Factors Age <35 years 2% 6.7% 6.8% 0% 35 years 24.3% 25% 11.1% 13.9% Gender Male Female 9.8% 11.4% 13.1% 14.3% 10% 5.7% 3.3% 8.6% Nationality Saudi Non-Saudi 13.6% 7.7% 14% 13.2% 9.3% 7.7% 4.7% 5.8%

Percentage of total sample History of hypertension 10.4% Hypertensive* 13.5% Undiagnosed hypertension 8.4% Uncontrolled hypertension 5.3%

*Patients with BP 140/90 mm Hg. Patients with no history of hypertension whose BP was 140/90 mm Hg. Patients with history of hypertension whose BP was 140/90 mm Hg.

Mean systolic and diastolic BP was 112.6 mm Hg and 77.3 mm Hg, respectively. The prevalence of subjects in our sample with undiagnosed DM and undiagnosed hypertension was 2.6% and 8.4%, whereas the prevalence of uncontrolled DM and hypertension was 9.1% and 5.3%, respectively. Undiagnosed and uncontrolled diabetes and hypertension were significantly more common among older than among younger individuals. As shown in Tables 2 and 3, men had a higher prevalence of undiagnosed DM and hypertension (4% and 10%, respectively) than did women (0% and 5.7%). However, women demonstrated a higher prevalence of uncontrolled diabetes and hypertension (11% and 8.6%, respectively) compared with men (8% and 3.3%).

Discussion
Many people have diabetes or hypertension but are not aware of their condition, usually because they either do not have serious symptoms or they have mild symptoms that have been treated without an appropriate diagnosis.

This is also true with hypertension, which typically has no symptoms. People usually discover they have these diseases at a later stage, when more severe complications begin to develop. In the present study, about 18% of the sample had a history of diabetes or a high blood glucose level on the day of the examination. Among subjects 35 years of age or older, 39% had a high blood glucose level or had reported a history of diabetes. This is higher than the 24% reported by Al-Nozha and colleagues5 for a similar age group. This difference could be because of the different techniques used to assess the blood glucose level in the 2 studies. In the present study, RBG level was used, whereas fasting plasma glucose was used in the Al-Nozha, et al. study. In the present study, approximately 22% of the subjects with high blood glucose were not aware of their condition prior to their dental visit. This is slightly lower than that reported by Al-Nozha, et al.5, which was approximately 28%. This difference may be because of increased healthcare awareness in patients attending private clinics

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in comparison to those from urban and rural areas who were involved in the Al-Nozha et al. study. Approximately 19% of the participants in the present study had hypertension or had reported a history of hypertension. This finding is slightly lower than that reported in a recent survey conducted in Saudi Arabia in which 24% of the study population had elevated BP.8

Many people have diabetes or hypertension but are not aware of their condition, usually because they either do not have serious symptoms or they have mild symptoms that have been treated without an appropriate diagnosis.
In the present cross-sectional survey, more than 62% of the subjects with high BP were not aware of their condition before their dental visit. This result is consistent with a recent report on a sample of female dental school patients in Saudi Arabia, but higher than that reported in dental patients in the United States and in Japan.10, 11, 15 It is important to remember that being in a dental clinic induces anxiety and may lead to a temporary increase in BP.17,18 In addition, a diagnosis of hypertension cannot be made based on 1 random reading during 1 visit. Generally an average of multiple readings during 2 or more visits is required to establish a diagnosis of hypertension. The involvement of all healthcare providers in diagnosing hypertension and diabetes is highly encouraged. Furthermore, all healthcare providers, including oral health professionals, need to encourage their patients with diabetes and hypertension to comply with prescribed treatment. The roles of oral health professionals in the diagnosis and management of diabetes and hypertension is important, as they can be the first to detect such diseases or their complications.11

among the older age group. Oral health professionals are advised to use routine dental visits to review and ensure optimum overall patient health through proper screening, diagnosis, and referral. Oral healthcare providers can be the first to diagnose these diseases and should therefore be knowledgeable about diabetes and hypertension. Routine screening tests for diabetes and hypertension performed in dental clinics can lower the chances of complications associated with these diseases during or after dental treatments.

References
1. Nathan DM, Cleary PA, Backlund JY, et al. Diabetes Control and Complications Trial/Epidemiology of Diabetes Interventions and Complications (DCCT/EDIC) Study Research Group. Intensive diabetes treatment and cardiovascular disease in patients with type 1 diabetes. N Engl J Med. 2005;22;353:2643-2645. 2. Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management. Quintessence Int. 2005;36:779-795. 3. Geiss LS, Pan L, Cadwell B, et al. Changes in incidence of diabetes in U.S. adults, 1997-2003. Am J Prev Med. 2006; 30:371-377. 4. American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care. 2006;29(suppl 1): S43-S438. 5. Al-Nozha MM, Al-Maatouq MA, Al-Mazrou YY, et al. Diabetes mellitus in Saudi Arabia. Saudi Med J. 2004;25:16031610. 6. Nathan DM. Complications of diabetes. In: Kahn HS, ed. Joslins Diabetes Mellitus. 14th ed. Philadephia, PA: Lippincot, Williams and Wilkins; 2005:1808. 7. Kearney PM, Whelton M, Reynolds K, et al. Global burden of hypertension: analysis of worldwide data. Lancet. 2005;365:217-223. 8. Al-Nozha MM, Osman AK. The prevalence of hypertension in different geographical regions of Saudi Arabia. Ann Saudi Med. 1998;18:401-407. 9. Ibrahim NK, Hijazi NA, Al-Bar AA. Prevalence and determinants of prehypertension and hypertension among preparatory and secondary school teachers in Jeddah. J Egypt Public Health Assoc. 2008;83:183-203.

Conclusion
The prevalence of undiagnosed DM and undiagnosed hypertension is high in the present sample, especially

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10. Kellogg SD, Gobetti JP. Hypertension in a dental school patient population. J Dent Educ. 2004;6:956-964. 11.Miyawaki T, Nishimura F, Kohjitani A, et al. Prevalence of blood pressure levels and hypertension-related diseases in Japanese dental patients. Community Dent Health. 2004;21:134-137. 12. Chobanian AV, Bakris GL, Black HR, et al. The seventh report of the Joint National committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure: The JNC 7 report. JAMA. 2003;289:2560-2572. 13. Australian Institute of Health and Welfare 2004. Australias Health 2004. Canberra: Australian Institute of Health and Welfare. 14. Klungel OH, Stricker BH, Paes AH, et al. Excess stroke among hypertensive men and women attributable to undertreatment of hypertension. Stroke. 1999;30(7):1312-1318. 15. AL-Zahrani MS. Prehypertension and undiagnosed hypertension in a sample of dental school female patients. Int J Dent Hygiene. 2010 (in press). 16. Chobanian AV, Bakris GL, Black HR, et al. Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Hypertension. 2003;42:1206-1252. 17. Brand HS, Abraham-Inpijn L. Cardiovascular responses induced by dental treatment. Eur J Oral Sci. 1996;104:245252. 18. Brand HS, Gortzak RA, Palmer-Bouva CC, et al. Cardiovascular and neuroendocrine responses during acute stress induced by different types of dental treatment. Int Dent J. 1995;45:45-48.

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