This course was published in the March 2019 issue and expires March 2022. The author has no commercial conflicts of interest to disclose. This 2 credit hour self-study activity is electronically mediated.
After reading this course, the participant should be able to:
- Explain the benefits and challenges of routine screening for hypertension in dental settings, as well as some of the objections that have been raised.
- Discuss the prevalence of high blood pressure, classification levels under the recently updated guidelines, and the clinical team’s responsibilities during screening.
- List key results and lessons learned from Maryland’s “Hypertension Screening in the Dental Setting” pilot project.
Published in 2000, Oral Health in America: A Report of the Surgeon General was a significant milestone that made the much-needed connection between oral and systemic health.1 Standing on its own, the report cannot be expected to help patients fully understand the connection and act accordingly. For this to occur, a more comprehensive movement must take place within medicine and dentistry — one in which oral health professionals must play a leadership role. This begins with the willingness to embrace new, evidence-based models of care that foster an interdisciplinary approach to oral and overall health. It also requires acceptance of the role of health literacy, and need to educate patients about the value of connecting the dots between their dental and medical care. As one example of an integrated approach, this paper will examine the opportunity for simple screening in dental practice that can have a significant impact in reducing high blood pressure and other chronic diseases.
Indeed, a modest number of medical and dental practices around the country are working, often in partnership with public health organizations, to integrate preventive oral health services in medical settings and preventive health services in dental settings. However, clinical practice guidelines, consensus statements and the current literature include only 24 examples of the integration of oral health services into medical settings, and six instances of the integration of general health services into dental practices.2 This begs the question, why are there four times as many medical settings offering preventive oral health services as dental settings offering preventive general health services?
In 2016, the U.S. Centers for Disease Control and Prevention (CDC) issued a request for proposals designed to address this issue. The goals of this funding, known as “Models of Collaboration for State Chronic Disease and Oral Health Programs,” were to foster collaboration between state oral health and chronic disease management programs, and test innovative ways to incorporate oral health into management systems — such as those developed to manage diabetes, hypertension, obesity and tobacco use. Under the program, the Maryland Department of Health’s (MDH) Office of Oral Health received funding to develop, implement and evaluate a pilot program that integrated hypertension screening and referrals into the dental setting. This article will outline the results and lessons learned from those efforts.
This paper will also discuss the importance of the dental setting as an untapped chronic disease touchpoint, where screening for common diseases — such as hypertension, diabetes and obesity — can be implemented in order to identify and refer patients to medical practices or community services and programs. By embracing the dental setting as a screening touchpoint for high blood pressure and referring patients for appropriate care, oral health professionals can meaningfully contribute to the management of chronic diseases and promote overall health.
HYPERTENSION SCREENING AND THE DENTAL PROVIDER
Heart disease is the leading cause of death worldwide. About 610,000 people die of heart disease in the United States every year — that is one in every four deaths.3 High blood pressure is a major risk factor for heart disease. Hypertension affects 80 million adults over the age of 20 in the United States and approximately 1 billion people worldwide. The prevalence of hypertension continues to increase, and it is estimated that by 2025 there will be 1.56 billion people with diagnosed hypertension.4
According to recently updated hypertension guidelines,5 blood pressure classifications for adults include: Normal, Elevated, Hypertension Stage 1, Hypertension Stage 2 and Hypertensive Crisis. Normal ranges include readings less than 120/80 mm Hg. Elevated levels range from 120 to 129 mm Hg systolic and less than 80 mm Hg diastolic. It is important to start monitoring blood pressure at this level. Hypertension Stage 1 ranges from 130 to 139 mm Hg systolic or 80 to 89 mm Hg diastolic. Lifestyle changes, such as a strict diet regimen and regular exercise, are recommended. Some patients might also be prescribed medication to regulate their blood pressure. The Hypertension Stage 2 range is 140/90 mm Hg or higher. Providers will most likely advise both blood pressure medication and lifestyle changes for individuals in this category. The Hypertensive Crisis range is anything greater than 180/120 mm Hg, which requires immediate medical attention if blood pressure does not drop. Dental professionals should educate patients about the deleterious effects of uncontrolled and undetected hypertension.6
The significance of regular blood pressure monitoring in the dental office as an aspect of comprehensive health care lies within the professional responsibility of dentists, and should not be minimized. Oral health professionals not only have a responsibility to take every patient’s blood pressure, they must also make patients aware of the connection between oral and systemic health.
If screening shows an elevated blood pressure reading, the patient should be educated about the negative effects on the body, and counseled on the variety of health habits — such as maintaining an ideal weight, regular exercise and choosing a healthy diet — that can help manage it. When hypertension is detected, dental professionals have the responsibility to make a referral to a primary care physician for a follow-up appointment. This will demonstrate the dental team is concerned with more than the patient’s teeth, and will help the patient understand the critical relationship between oral and overall health.
As important as this process is, it can be challenging, especially within high-risk populations. One study found that in caring for 100 Medicare patients, the average primary care provider needed to coordinate care with 99 clinicians working across 53 practices.2 In a national assessment of communication between primary care providers and specialists, subjects were asked about sending basic patient information to each other. The survey shows that only 69.3% of primary care providers and 80.6% of specialists report this information “always” or “most of the time.”2 No national data on referral rates between primary care providers and dentists was found. Referrals to a primary care physician are a necessary expectation when hypertension is detected, thus it is important to be aware of — and address — the communication challenges that surround the dental-to-medical referral process.
As noted, communication between medical and dental providers can prove challenging, and one reason is that effective referral networks and easily shared electronic health records are relatively uncommon. When systems are not in place to facilitate referrals, it is the provider’s responsibility to develop professional relationships that will help clinicians track the health status of the patient throughout the referral process and course of treatment.
MARYLAND PILOT PROGRAM
In 2016, Maryland received the previously discussed CDC funding to create a two-year pilot program to provide hypertension and tobacco screening within select dental settings. Within the MDH, partner offices for this project were the Office of Oral Health, Center for Chronic Disease Prevention and Control, and the Center for Tobacco Prevention and Control. A key goal was to expand the integration of oral health and chronic disease public health programs to involve dental providers in chronic disease prevention activities. An additional aim was to identify and understand challenges and opportunities for future medical and dental integration. The program sought to engage dentists to provide screening for hypertension and tobacco use during routine visits, and, when necessary, refer patients with undiagnosed or uncontrolled high blood pressure to primary care providers for follow-up. Tobacco users who expressed a willingness to participate in tobacco cessation counseling were referred to the Maryland Tobacco Quitline.
To meet these program objectives, an advisory committee of dental and medical professionals, as well as representatives from academia and health-related industries, developed the framework and standards for hypertension and tobacco screening protocols and related equipment used in dental settings. The advisory committee also determined thresholds for dental professionals to follow when referring hypertensive patients to primary care providers for follow-up care.
The MDH collaborated with local health departments (LHDs) throughout the state to implement program activities. The LHDs engaged a diverse group of dental practices — including private offices, clinic settings and federally qualified health centers — to introduce hypertension and tobacco screening. The MDH provided digital blood pressure cuffs, skills training, data collection advisement, educational materials and follow-up protocols for dental teams to use when screening and referring patients to medical providers. For quality assurance, a “train the trainer” approach was utilized: The MDH provided training sessions to LHD staff responsible for the management and implementation of the hypertension screening program, who, in turn, trained clinical dental teams.
To ensure patients and providers were informed and motivated to take part in the initiative, a health literacy and social marketing campaign was created. The goal of the “Two Minutes With Your Dentist Can Save Your Life” campaign (Figure 1) was to help patients understand the connection between oral and overall health, as well as the importance of hypertension screening in dental settings. Implementation of the Maryland awareness campaign included dental office posters, patient postcards, prescription pads and various emedia outreach efforts, as well as community relations and advertising placement strategies. The advertising launch included a 30-second video that ran on cable TV, in movie theaters, and on gas station pump TV screens located in the areas where LHDs and dental practices were participating in the program.
RESULTS FROM THE FIELD
Planning and implementation of Maryland’s “Hypertension Screening in the Dental Setting” project took place from September 1, 2016 to August 31, 2018. The actual hypertension screening activities ran from May 1, 2017 to June 30, 2018. Results show a large increase in involvement in the program over a relatively short period, thanks to the collaborative efforts, provider training, dental practice process mapping, and the comprehensive social marketing/health literacy campaign.
During implementation of the program, the MDH partnered with 14 LHDs in Maryland that, in turn, recruited and trained 47 dental settings to take part. At these clinics, 36,996 patients received blood pressure screenings. Among these individuals, 2689 were referred to physicians for follow-up care when their blood pressure reading was 140/90 mm Hg or higher (Hypertension Stage 2). Of the total patients screened, 2855 identified themselves as tobacco users, of which 1302 were referred to the Maryland Tobacco Quitline for help with tobacco cessation.7 The social marketing campaign, “Two Minutes With Your Dentist Can Save Your Life,” created significant program awareness, generating more than 3.1 million viewer impressions within its target geography.
At the outset, multiple challenges emerged while recruiting practices. When approached about screening, dental providers expressed concern that implementation of routine hypertension screening would disrupt practice workflow and take time away from addressing oral health issues. Additionally, the lack of insurance reimbursement for hypertension screening was a concern for some.
Among oral health providers, perceptions of the value of hypertension screening were underscored in research that revealed the majority of dentists and dental hygienists were not monitoring blood pressure — despite inclusion of such training in their dental curriculum.8 The main reason noted in the study was clinicians’ perception that doing so would require additional appointment time. The authors recommended that dental and dental hygiene schools place higher priority on the importance of blood pressure screening in oral health settings.
Another challenge that persisted throughout the program was a low referral rate from dental clinics to medical practices. Furthermore, dental providers were often unable to follow up on referrals to primary care providers. Similarly, medical offices were often unable to connect with dental providers to confirm that patients had been seen for follow-up. Feedback from oral health professionals about the referral process suggested that inadequate communication between dental and medical practices was common, and the lack of a shareable electronic health records contributed to communication issues.
In practice, dental settings that received guidance and support from the MDH and LHDs incorporated hypertension screening into their workflows with little disruption. This highlights the importance of proper guidance and support for program integration. Moreover, once dental teams were able to identify patients with undiagnosed and elevated blood pressure and refer them for follow-up care, they began to view hypertension screening as a vital service. This perception eased dental providers’ initial reservations regarding the lack of time or financial reimbursement for hypertension screening and potential workflow disruptions.
When developing medical/dental collaboration programs, it is recommended an emphasis be placed on creating strong referral networks between medical and dental providers prior to implementation. In addition to strengthening communication channels, emphasizing shared goals can lead to an increase in bidirectional referrals between medical and dental teams.
Ultimately, the most important lesson learned from this collaborative pilot program is that a strong bidirectional referral system is needed to facilitate medical/dental collaboration. This will ensure patients receive the medical attention required, and that open communication exists between medical and dental providers. Toward these goals, a case management system should be considered to encourage communication (which, by extension, will help patients better navigate treatment). Another lesson from the pilot program is that easily shareable electronic health records — and/or the creation of a standalone electronic health referral application — will facilitate referrals and treatment tracking, improve practice protocols, and increase the overall success of screening in the dental setting.
Integration between oral and primary health care is key to screening and early interventions that will help improve overall patient health. The CDC’s “Models of Collaboration for State Chronic Disease and Oral Health Programs” have demonstrated that dental providers can play a significant role in patients’ overall health. Another CDC grantee, the Minnesota Department of Health, conducted a pilot medical/dental integration project that developed a bidirectional referral system for hypertension and periodontal disease. Their results showed that approximately one-third of patients screened for hypertension had high blood pressure. Without this medical/dental integration, these cases simply would have been missed opportunities to curb disease and save lives.
As further evidence of the power of interdisciplinary care, researchers with the Center for Integration of Primary Care and Oral Health, a collaboration between federal agencies and universities, note the bidirectional link between diabetes and periodontal disease and its impact on glycemic control. Given this connection, they suggest dental practitioners can play a key role in helping to identify and treat chronic comorbid conditions.9
Clearly, these and other grant opportunities signal recognition and support for the integration of oral and medical care as a means to reduce illness and improve public health. These benefits have fiscal ramifications, too, as a study by the American Dental Association Health Policy Resources Center notes that screening for high blood pressure, diabetes and high cholesterol in dental settings could save the health care system up to $102.6 million annually.10
Along with numerous health care, public health, professional and advocacy groups calling for increased integration of medicine and dentistry, these developments and findings have created a groundswell of momentum for collaborative practice. Such integration is seen as a way to contain costs, ensure quality care and improve health outcomes.
Maryland’s “Hypertension Screening in the Dental Setting” pilot is only one example of the many programs that are demonstrating the significant impact dental professionals can have in reducing hypertension and other chronic diseases. Going forward, it is hoped the profession will embrace the dental setting as a chronic disease touchpoint with the potential to transform health outcomes for all Americans.
- U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Available at: https:/ / profiles.nlm.nih.gov/ ps/ access/ NNBBJV.pdf. Accessed January 28, 2019.
- Atchison KA, Rozier G, Weintraub JA. Integration of Oral Health and Primary Care: Communication, Coordination and Referral. Available at: https:/ / nam.edu/ integration-of-oral-health-and-primary-care-communication-coordination-and-referral/ . Accessed January 28, 2019.
- U.S. Centers for Disease Control and Prevention. Heart Disease Facts. Available at: https:/ / www.cdc.gov/ heartdisease/ facts.htm. Accessed January 28, 2019.
- Chockalingam A, Campbell NR, Fodor JG. Worldwide epidemic of hypertension. Can J Cardiol. 2006;22:553–555.
- American College of Cardiology. New ACC/ AHA High Blood Pressure Guidelines Lower Definition of Hypertension. Available at: acc.org/ latest-in-cardiology/ articles/ 2017/ 11/ 08/ 11/ 47/ mon-5pm-bp-guideline-aha-2017. Accessed January 28, 2019.
- American Heart Association. 2017 Hypertension Clinical Guidelines. Available at: https://professional.heart. org/professional/ScienceNews/UCM_496965_2017-Hypertension-Clinical-Guidelines.jsp?UTM_source=Postcard&utm_medium=Print&utm_campaign=Hypertension. Accessed January 28, 2019.
- Maryland Department of Health. Models of Collaboration for State Chronic Disease and Oral Health Programs in Maryland. Available at: https:/ / phpa.health.maryland.gov/ oralhealth/ Documents/ HypertensionFinalReport.pdf. Accessed January 28, 2019.
- Hughes CT, Thompson AL, Browning WD. Blood Pressure Screening Practices of a Group of Dental Hygienists: A Pilot Study. Available at: https:/ / pdfs.semanticscholar.org/ 7b08/ 969a130a0339c4c9ae7c88e2df0ebc153374.pdf. Accessed January 28, 2019.
- Center for the Integration of Primary Care and Oral Health, Harvard Medical School. Available at: https:/ / primarycare.hms.harvard.edu/ rospod/ ros-drs-christine-riedy-tien-jiang-from-the-center-for-integration-of-pcare-oral-health-cipcoh/ . Accessed January 28, 2019.
- Burger D. New Guideline on Hypertension Lowers Threshold. Available at: http:/ / www.ada.org/ en/ publications/ ada-news/ 2017-archive/ november/ new-guideline-on-hypertension-lowers-threshold. Accessed January 28, 2019.
Featured image by SUDOK1/ISTOCK/GETTY IMAGES PLUS
From Decisions in Dentistry. March 2019;5(3):36–39.