GETTING TO THE HEART OF THE MATTER- ORAL HEALTH & HYPERTENSION GUIDANCE TO HELP SAVE LIVES

July 17, 2020

BACKGROUND

The purpose of this assessment was to:

Assess screening procedures for hypertension and diabetes by oral health professionals.

Assess the knowledge of oral health professionals to facilitate referrals for diagnosis and care for hypertension and diabetes.

Quantify the referrals for high blood pressure readings and elevated blood glucose levels by oral health professionals.

Determine if oral health professionals perform any follow up after making referrals for patients with high blood pressure readings and elevated blood glucose levels.

REPORT: WWW.MICHIGAN.GOV/ORALHEALTH

RECOMMENDATIONS/NEXT STEPS

State of Michigan guidelines for screening for hypertension (and diabetes) in dental settings

Referral guidelines and materials can be created for dental and medical providers to use when referring for medical or dental care

Chairside reference cards can be developed for oral health professionals advising on when to refer a patient for care

Education opportunities can be created to educate oral health professionals on proper screening methods for hypertension (and diabetes)

Pilot interventions could be developed between oral health practices and primary care sites to incorporate best practices and successful methods of referral to increase the number of Michigan residents that are screened and referred

Connections with oral health practices to community resources for people with hypertension (and diabetes) could be encouraged

Content:

WHY SHOULD OHPS TAKE BPS??

• Screening for Hypertension in the Dental Setting

• Equipment and Methods for Taking Blood Pressures

• Checklist for Accurate Measurements

Content:

HYPERTENSIVE PATIENTS AND DENTAL PROCEDURES

REFERRAL PROCEDURES AND FOLLOW-UP

WRITTEN POLICY/PROTOCOLS FOR DENTAL STAFF

APPENDICES

www.michigan.gov/oralhealth

Guidance Document

Susan Deming, RDH, RDA, BSMDHHS Oral Healthdemings@Michigan.gov

Hypertension Screening: Dr. Lisa Knowles

Why Dental Professionals?Case Study: 42 year-old, presumed healthy male, with nothing marked on his health history form. Came into my practice with a cracked tooth. He had been to the endodontist, had RCT and now needed a core and a crown. Actual Health Hx: Highly Stressed, Nail Biter, No physical in past several years. No PCP. Married, father of two daughters. BP: 210/110. Recent headaches.

Research shows that dental visits may be the only routine care that a patient receives. Dental professionals are trusted resources and patients often welcome their advice when it comes to their overall health.

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association. 16

Opportunity to Make An Overall Health Impact

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Educational Moments Add Value

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

• Be More Valuable to Your Patients

• Help Them Understand Your Depth of Knowledge

• Make the Oral and Systemic RE-Connection For Your Patients

• Save A Life or Prevent A Lifelong Disability from Stroke

How To Use The Screening Guidance PDF

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Key Points

1. Screening begins at age 182. New Thoughts on White Coat Hypertension3. Area on Equipment and Methods for Taking Blood Pressures

(excellent training guide for new employees)4. Post the Step By Step Guidelines In Your Offices5. Post the BP Screening Algorithm (More from Dr. Levy on this next)

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Post Easy 7 Step Guide

Dr. Lisa Knowles

Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

My Time Is Up!Thank you

A Deeper Dive Into the MDHHS HTN Oral Health Professional Screening

Guideline

Phillip D. Levy, MD, MPH, FACEP, FAHA, FACCProfessor and Associate Chair for Research

Department of Emergency Medicine

Assistant Vice President for Translational Science and Clinical Research Innovation

Wayne State University

Chief Innovation Officer

Wayne State University Physician Group

SBP/DBP ≥130/80 mm Hg or Self-Reported Antihypertensive

Medication†

SBP/DBP ≥140/90 mm Hg or Self-Reported Antihypertensive Medication‡

Overall, crude 46% 32%Men

(n=4717)Women

(n=4906)Men

(n=4717)Women

(n=4906)Overall, age-sex adjusted 48% 43% 31% 32%

Age group, y20–44 30% 19% 11% 10%45–54 50% 44% 33% 27%55–64 70% 63% 53% 52%65–74 77% 75% 64% 63%75+ 79% 85% 71% 78%

Race-ethnicity§

Non-Hispanic White 47% 41% 31% 30%Non-Hispanic Black 59% 56% 42% 46%Non-Hispanic Asian 45% 36% 29% 27%

Hispanic 44% 42% 27% 32%

Hypertension is Common..

Muntner et al. Circulation 2017;137:109-18.

Muntner et al. Circulation 2017;137:109-18.

Yet Poorly Controlled

NCHS, Health, United States, 2017, Figure 10. Data from the National Health and Nutrition Examination Survey.

Hardy et al. J Am Heart Assoc. 2015;4:e002276 doi: 10.1161/JAHA.115.002276.

Population Level BP Reduction of 2 mm Hg

Driven By The Motor City...

Age-adjusted mortality rates per 100,000 for ten leading causes of death, Detroit, Michigan, and United States, 2014

Olsen et al. Lancet 2016;388:2665-2712.

SBP >180 mm Hg and/or DBP >120 mm Hg

Target organ damage new/progressive/worsening

Reduce SBP to <140 mm Hg during first h* and to <120 mm Hg

in aortic dissection†(Class I)

Yes

Yes

Reduce BP by max 25% over first h†, then to 160/100–110 mm Hg over next 2–6 h,

then to normal over next 24–48 h(Class I)

No

Markedly elevated BP

Reinstitute/intensify oral antihypertensive drug therapy

and arrange follow-up

Hypertensive emergency

Admit to ICU(Class I)

No

Conditions:• Aortic dissection • Severe preeclampsia or eclampsia • Pheochromocytoma crisis

Whelton et al. J Am Coll Cardiol. 2018;71:e127-e248.

Miller et al. Am J Hypertens 2020 [epub ahead of print].

Janke et al. J Am Heart Assoc. 2016;5:e004511 doi/10.1161/JAHA.116.004511

Janke et al. J Am Heart Assoc. 2016;5:e004511 doi/10.1161/JAHA.116.004511

Table: End Organ Damage Among ED Visits for Hypertensive Emergency # % (95% CI) Papilledema/Retinal Hemorrhage 189 0.13% (0.09% to 0.18%) Heart Failure 84,244 59.02% (57.74% to 60.31%) Myocardial Infarction 15,737 11.03% (10.29% to 11.76%) Dissection of Major Vessel 20,936 14.67% (14.05% to 15.29%) Intracranial Hemorrhage 8,624 6.04% (5.36% to 6.73%) Other Cerebrovascular Disease 39,642 27.77% (26.80% to 28.75%) Ruptured Aneurysm 4,744 3.32% (3.03% to 3.62%) Total Hypertensive Emergencies 142,731

Janke et al. J Am Heart Assoc. 2016;5:e004511 doi/10.1161/JAHA.116.004511

Levy et al. Am J Emerg Med 2015;33:1219-24.

Masood et al. Ann Emerg Med 2016;68:258-67.

Masood et al. Ann Emerg Med 2016;68:258-67.

Patel et al. JAMA Intern Med. 2016; 176::981-8.

Patel et al. JAMA Intern Med. 2016; 176::981-8.

Wolf et al. Ann Emerg Med. 2013;62:59-68.

Baumann et al. Am J Hypertension 2009;22:604-10.

McNaughton and Levy. Curr Hypertens Rep 2016;18:88.

plevy@med.wayne.edu