Have you ever sought physician evaluation for a patient with a hypertensive crisis reading instead of placating their firm belief that it was just white coat hypertension? If so, good for you. Whether a patient’s blood pressure is only high at the office or not, hypertension is cause for concern. Assessing blood pressure and discussing the significance of white coat conditions is a benevolent demonstration of what could be a life-saving intervention for your patients.
Breaking down white coat hypertension
“It’s just white coat-itis!” Like a broken record, right? “But my coat’s black!”—the perfect icebreaker for the hypertension conversation. Ask your patient why they think their blood pressure is high at the dentist. I’ll point out to patients that if it’s a stress response, you’d have to wonder what it is like in other stressful situations they frequently encounter and what that instability looks like to their cardiovascular health. Follow up by asking where else they screen their blood pressure. Sometimes, the answer is nowhere. Then, how do you know it’s only high here?
Is heart rate a clue in hypertension?
How does the patient’s pulse look? Bradley Bale, MD, agrees with my assumption that seeing a significantly elevated reading accompanied by a normal pulse in true white coat hypertension can be unusual because isolated hypertension triggered by stressors tends to promote a tachycardiac response (personal communication, December 27, 2024). Pointing this out can foster interest in the idea that this truly is more serious than just nerves. Some, however, will remain unconvinced.
Okay, so you’re just nervous to be here
Let’s say the blood pressure is only high at the dentist. White coat hypertension is not a benign condition. Uncontrolled, persistent, isolated instances of hypertension can be more dangerous than hypertension that is diagnosed and treated.
Amy Doneen, DNP, emphasizes that roughly 40%–50% of people with white coat hypertension will progress to sustained hypertension (personal communication, January 3, 2025). Many won’t seek intervention in time. Studies have found a higher incidence of cardiovascular morbidity and mortality in patients with white coat hypertension versus those observed with normal readings in and out of the office.1 These patients are twice as likely to die from heart disease than those on antihypertensives or with healthy blood pressure, and three times as likely to suffer a future heart attack, making in-office screenings imperative.
What’s the pulse on blood pressure checks in your office?
Suppose you’re not taking blood pressure on your patients yet—all aboard. Many people see the dentist more than the doctor, allowing us to be the first line of defense in screening this essential vital sign for what we know as the silent killer. The number one reason why cardiovascular-related deaths are so prevalent in the United States is due to the lack of early detection and treatment. Most patients want to chalk hypertension up to nerves or the reading being “wrong,” and this is where an office in sync with how they address blood pressure can help. Ban “It’s just a little high, probably because you’re here,” from your office scripts. Hypertension, which begins as “a little high,” is the number one risk factor for stroke and affects many other conditions, such as atrial fibrillation, kidney disease, heart failure, and Alzheimer’s.
“But I feel fine”
Ascribing high values to dental anxiety is medical negligence. Only blood pressure that is under 120/80 mmHg is normal, no matter how your patient feels. Hypertension is often asymptomatic, so many people don’t realize they have it. More serious symptoms of hypertension are often only felt during a cardiac event. The American Heart Association (table 1) currently defines hypertension as a systolic of at least 130 or a diastolic of at least 80, accommodating the white coat effect.2 In most adults, the systolic reading in a medical setting can increase by approximately 10 points compared to at-home readings and is normal within 10 minutes. Many perceive higher values as white coat hypertension. Elevated numbers reflect actual internal happenings—the damage of blood vessels—increasing the risk of heart attack and stroke and should be evaluated. Values above 160/100 mmHg may require medication initiation or adjustment, and you may choose to postpone dental care involving local anesthesia.
Going the distance in diagnosing
Twenty-four-hour ambulatory monitoring is the gold standard in determining if one has isolated or chronic hypertension; however, accessibility to this service is currently limited in health care (personal communication, December 27, 2024). Instead, efficient at-home monitoring is paramount, followed by a physician’s visit, blood work, and referral to a specialist if indicated. Give patients a copy of their office readings with the current AHA guidelines and show them how to correctly use a validated device* at home. A wrist cuff may be beneficial in some circumstances if placed precisely on the radial artery and held at heart level.3 Patients will collect as much data as possible and review it with their physician.
Ideally, physicians will do a thorough cardiac workup relying on scientific evidence versus mere expert opinion, or standard and sometimes unreliable testing such as the treadmill stress test.
Many noninvasive tests can save a patient’s life, including genetic testing to discover genetic markers, the highly accurate two-hour oral glucose tolerance test (OGTT) to screen for diabetes, and various ultrasounds and scans that uncover undetected red flags. A vital assessment is determining arterial obstruction, including percentages below the 70% rule—the number at which cardiologists will intervene with surgery—since most heart attacks occur in less severely blocked areas perilously deemed “fine.” Modifying lifestyle habits—such as sedentariness and diet and addressing risk factors such as obesity, smoking, and alcohol intake—will be crucial, a step that hygienists are well trained for via motivational interviewing.
Hygienists make the impact
Hygienists are well informed of all associative risks of hypertension and have the time with their patients to educate them on the relationship between cardiac and oral health. For example, patients with periodontal disease have double to triple the risk of a heart attack or stroke, even higher for those who smoke or have diabetes—an excellent fact to share with patients who don’t understand why we take their blood pressure. Beat the Heart Attack Gene reviewed a long-term study in seniors that found the risk of death increased by 20%–25% in those who didn’t brush at night, 30% in those who never flossed, and 50% in those who went a year without seeing a dentist, suggesting the necessity of good oral hygiene. A second study showed an alarming percentage of oral pathogens in arterial blood clot samples from at-risk patients, suggesting that oral infections related to decay or periodontal disease trigger 50% of heart attacks.4
Furthermore, patients with periodontal disease and hypertension have a significantly greater risk of developing Alzheimer’s, as discussed in Healthy Heart, Healthy Brain, a book that elaborates on the significance of the relationship between dental health and hypertension.5 Evaluating blood pressure is one way we prioritize our passion for the oral-systemic link, taken so seriously that I may require a doctor’s note to schedule another visit. “For a cleaning?” Yes.
The collaboration between hygienist and allied provider
A diligent physician is your next valuable relationship in getting your patient healthier. It’s heart-wrenching when you win the battle to get your patients to be proactive, just for their physician to tell them, “You were at the dentist; it’s just white coat hypertension.” It’s okay to disagree. You’re still essential in advocating for your patients’ health and safety.
Dr. Alexandra Ward, MD, FACC, a cardiologist specializing in women’s heart health, reiterates, “If a patient’s blood pressure is elevated at a medical visit, it is elevated many other times throughout their days, weeks, and months. Hygienists, empower your patient to continue at-home monitoring and be persistent in conversations with their primary care physician about how they can mitigate their risk for heart attack and stroke” (personal communication, January 17, 2025).
Align with organizations such as the National Network of Healthcare Hygienists, which gives hygienists access to become more integrated into the medical side of patient care. Collaborative efforts can bridge communication gaps between hygienists and allied providers.
Is your heart in it?
It’s challenging when patients are emotionally charged, dismissive, or defensive about their health, and it’s easy to give up and end the conversation about hypertension there. Still, I urge you to stay headstrong to be heartstrong. While it would be easier (and keep us on time), there are risks in observing a significant reading and saying, “Oh, it’s just a little high.” With compassion and understanding, we can mitigate these risks by sharing that we are treating not just a mouth, but a whole person—a person we care about. Hygienists will intervene and save lives, with any color of coat on.
* Validated BP cuffs for home monitoring include: Microlife 3BTO-A, Microlife WatchBP Home, Omron HEM 705 CP, Omron M7, Omron MIT, Andon iHealth Track, Omron HEM-9210T, Omron BP760N, Omron BP765. List supplied by Alexandra Ward, MD, FACC.
Editor's note: This article appeared in the March 2025 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.
References
- Mancia G, Bombelli M, Brambilla G, et al. Long-term prognostic value of white coat hypertension: an insight from diagnostic use of both ambulatory and home blood pressure. Hypertension. 2013;62(1):168-174. doi:10.1161/HYPERTENSIONAHA.111.00690
- High blood pressure. American Heart Association. 2020. https://www.heart.org/en/health-topics/high-blood-pressure
- Muntner P, Shimbo D, Carey RM, et al. Measurement of blood pressure in humans: a scientific statement from the American Heart Association. Hypertension. 2019;73(5):e35-366. doi:10.1161/HYP.0000000000000087
- Bale B, Doneen A. Beat the Heart Attack Gene. Turner Publishing Company; 2014:49.
- Bale B. Healthy Heart, Healthy Brain: The Personalized Path to Protect Your Memory, Prevent Heart Attacks and Strokes, and Avoid Chronic Illness. Little, Brown Spark; 2022:285.
