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91]

Original Article

Dentists’ Knowledge and Behavior toward Managing Hypertensive

Patients
DF Bogari

Department of Endodontics, Objectives: Dental office is an ideal screening place to identify undiagnosed/

Abstract
Faculty of Dentistry, King
Abdulaziz University, Jeddah,
uncontrolled patients with hypertension. The aim of this study was to assess the
Saudi Arabia 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.

Date of Acceptance: Keywords: Behavior, dentists, health knowledge, hypertension, public heath,
21-Nov-2018 Saudi Arabia

Introduction are in an important position to help with screening,

D entists 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.[1‑6] 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
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]
Address for correspondence: Dr. DF Bogari,
Faculty of Dentistry, King Abdulaziz University, Jeddah,
Saudi Arabia.
E‑mail: dfbogari@kau.edu.sa

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toward managing hypertensive patients. Niger J Clin Pract 2019;22:154-61.

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Bogari: Dentists' management of hypertensive patients

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
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
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 1a].
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

a b

c d
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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Bogari: Dentists' management of hypertensive patients

to be statistically significant between male and female 54.3% of respondents would measure BP and then
dentists [Table 3; P < 0.05]. Regarding the behavior of decide whether to perform the dental treatment if their
dentists toward using and obtaining a sphygmomanometer patients noted they were taking medications but not
for their dental clinic, 62.4% responded that they did taking them regularly. However, 42.9% of respondents
have a sphygmomanometer in their clinic [Figure 1b]. would prefer not to see such patients and would refer
However, only 13.3% measured the BP of all their patients them to a physician [Figure 4a]. The latter group was
before performing treatment, and the majority (63.3%)
did so only if the patient noted a BP problem [Figure 1c]. Table 1: Characteristics of the 210 study sample
Interestingly, 63.8% of respondents believed it was Demographics Count %
important to measure the BP of their patients in the clinic Total 210 100.0
before performing treatment [Figure 1d]. Regarding Gender Male 79 37.6
dentists’ knowledge of hypertension and its relationship Female 131 62.4
with medical and dental parameters, 79.5% believed Place of work Government hospital 72 34.3
that working with patients with high BP was associated King Abdulaziz Dental Faculty 1 0.5
with a risk of complications [Figure 2a]. Most of the Primary healthcare center 2 1.0
Private practice 38 18.1
participants believed that patients with high BP could
University hospital 74 35.2
suffer from heart diseases (92.4%) and other medical
Masters’ student 2 1.0
diseases (86.2%); 5.2% and 11.0% answered do not On international scholarship 1 0.5
know, respectively [Figure 2b and c; Table 3; P < 0.05]. Graduated 2 1.0
Dentists also believed that patients with high BP could Still studying 1 0.5
suffer from dental problems (67.6%); however, 19.0% Trainee 1 0.5
said they did not know [Figure 3a]. In addition, the Unemployed 16 7.6
majority of respondents believed that patients with high Position Consultant 36 17.1
BP could suffer from dental complications during or Specialist 9 4.3
after dental treatment (85.2%) and that BP medications General dentist 122 58.1
can cause oral side effects (71.4%) [Figure 3b and c]. Student in postgraduate program 36 17.1
Regarding the management of hypertensive patients, Others 7 3.3

a b c
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

a b c
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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Bogari: Dentists' management of hypertensive patients

a b c
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

Table 2: The survey questions and responses percentages

Variables Count %
Total 210 100.0
Do you have a sphygmomanometer in Yes 131 62.4
your dental clinic? No 79 37.6
Do you review the medical history of Yes 166 79.0
your patients routinely? No 44 21.0
How often do you see patients who <25% 130 61.9
mention they have BP issues? About 50% 61 29.0
About 75% 11 5.2
More than 75% 8 3.8
How often do you check the BP of On every patient 28 13.3
your patients before treatment? Only when the patient mentions he has BP issues 133 63.3
Rarely 40 19.0
Never 9 4.3
Even if you do not measure the BP Yes 134 63.8
for your patients, do you think it is Only in special cases if the patient mentioned a BP problem 72 34.3
important to do so? No 4 1.9
Do you believe working on a patient Yes 167 79.5
with high BP in your practice may Rarely 31 14.8
cause risk of complications? No 12 5.7
If the patient mentioned that he has Make sure to measure the BP before the treatment and then decide if I 114 54.3
high BP and he does not take his will treat the patient
medication regularly, thus, his BP is I do not believe that would be an issue, I will still work on the 6 2.8
not controlled, what would you do? patient
I will not work on the patient and I would refer him/her to a 90 42.9
physician
Do you believe that patients with high Yes 142 67.6
BP can suffer from dental problems? No 28 13.3
I don’t know 40 19.0
Do you believe that patients with high Yes 194 92.4
BP can suffer from heart diseases? No 5 2.4
I don’t know 11 5.2
Do you know if patients with high Yes 181 86.2
BP can suffer from other medical No 6 2.9
diseases? I don’t know 23 11.0
Do you know if patients with high BP Yes 179 85.2
can suffer some dental complications No 13 6.2
during or after dental treatment? I don’t know 18 8.6
Total 210 100.0

Contd...

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Bogari: Dentists' management of hypertensive patients

Table 2: Contd...
Variables Count %
Do you know if patients taking BP Yes 150 71.4
medications can suffer from oral side No 19 9.0
effects? I don’t know 41 19.5
How would you manage a patient I will defer the treatment to another day 36 17.1
with a BP reading of 180/100 mmHg? If patient is not in pain and don’t need dental ER treatment, I will not 164 78.1
treat but will refer him to see a physician urgently
Treat him/her as a normal patient 10 4.8
For hypertensive patients, what kind I will refer the patient to a consultant as I won’t feel comfortable 11 5.2
of local anesthetic do you usually working on an hypertensive patient
prefer to use? Local anesthetic with epinephrine, but limit the number of carpules to 85 40.5
be used
Local anesthetic with no epinephrine to prevent the increase of BP 114 54.3
during treatment
BP=Blood pressure

Table 3: Summary of all significant P

Variables Gender Position
How often do you see patients who mention 0.013a 0.735
they have BP issues? Males are more prevalent in seeing patients
with BP issues, more than 75%, than females
If the patient mentioned that he has high BP 0.039a 0.668
and he does not take his medication regularly, Females prefer to not work with the patient
thus, his BP is not controlled, what would you and ask to see a physician first than males
do?
Do you know if patients with high BP can suffer 0.790 0.027a
from other medical diseases? Majority of the general
dentists believe this statement
Do you know if patients taking BP medications 0.002a 0.683
can suffer from oral side effects? Females are more prevalent believing this
statement compared with males
a
Significant using Chi‑square test at <0.05 level. BP=Blood pressure

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 4b]. 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 4c]. 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.
Discussion
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.[13‑15]
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

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Bogari: Dentists' management of hypertensive patients
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
Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 2  ¦  February 2019
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.[37‑40] 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
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
159
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Bogari: Dentists' management of hypertensive patients
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
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
Nil.
Conflicts of interest
There are no conflicts of interest.
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Nigerian Journal of Clinical Practice  ¦  Volume 22  ¦  Issue 2  ¦  February 2019 161