Exploring the relationship between dental anxiety and blood pressure in urgent dental care patients: an observational study 

Exploring the relationship between dental anxiety and blood pressure in urgent dental care patients: an observational study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Exploring the relationship between dental anxiety and blood pressure in urgent dental care patients: an observational study Debora Pallos, Luciano Miziara, Larissa Cavalcante, Najila Rocha, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4207277/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background: Dental anxiety is frequently observed in dental clinics, and when an increase in blood pressure (BP) values is detected, it can be classified as a type of white coat hypertension (WCH). The goal of this study was to monitor blood pressure before and after emergency dental treatments in a university dental clinic and to discuss the importance of approaching these patients considering their BP values and dental anxiety. Methods: This cross-sectional observational research randomly included patients in the dental waiting room of an urgent care clinic. A mercury sphygmomanometer was used by two calibrated researchers to assess the study participants before (T1) and after (T2) the emergency dental consultation. The variation in BP measurement was statistically compared with the Visual Analogue Scale (VAS), dental history, high blood pressure (HBP), and other comorbidities. Results: Among all participants (n = 75), the mean age was 45.5 ± 12.7 years old, 66.7% of patients were female, 78.7% had pain before dental care, VAS scale (5.2 ± 3.5), and used painkillers, and 44.4% reported dental anxiety. HBP was detected in 60% of patients (>130 mmHg), 53.3% of patients had a family history of HBP, 28.9% were diagnosed with AH, and among these, 50% were regularly using antihypertensive medication. The average systolic BP (SBP) was 131.9 and the diastolic BP (DBP) was 90.4 mm/hg, and in terms of evolution, the variation was 3.7 to 1.7, respectively. Conclusions: This study showed that BP monitoring at the dental clinic is recommended, and most patients presented HBP before the consultation, but these parameters were not considered decisive for canceling the dental urgent care. White coat hypertension Dental anxiety High Blood Pressure Dental emergency care Background High blood pressure (HBP) is a multifactorial disease characterized by sustained elevation of blood pressure (BP) systolic levels ≥ 139 and/or diastolic ≥ 39 mmHg, measured correctly at least on two separate occasions but confirmed after 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). 1 The BP may vary according to interactions between neurohumoral factors; the known risk factors for HBP are age, sex, ethnicity, overweight and obese salt intake, alcohol intake, sedentary lifestyle, socioeconomic and genetic, behavioral, and environmental factors. 1,2 According to the American College of Cardiology/American Heart Association (ACC/AHA), white-coat hypertension (WCH) is defined as the value referring to the differences between the BP measurement at the office and the mean of ABPM while awake or HBPM (≥ 130/80 mmHg). The WCH is considered significant when this variance is 20 and 10 mmHg above the threshold in systolic and diastolic pressures, respectively. 2-4 According to current research, WCH occurs in 15 to 40% of instances, and those who display WCH may have an increased risk of acquiring cardiovascular diseases in the long run, but this relationship is still uncertain. 3-6 This study aimed to measure the variation in BP of patients before and after stressful emergency dental procedures in an emergency dental clinic. Methods In this cross-sectional observational study, patients seen at the dental clinic of a Brazilian university were evaluated. After a brief explanation of the study, all patients had read and signed an informed consent form developed for the study (University of Santo Amaro IRB number: 68033517.2.0000.0081). This study included adults with known or unknown HBP status. All individuals in this study were randomly included and approached in the waiting room at the emergency dental service of a school of dentistry. Two calibrated researchers evaluated the participants of the study using a mercury sphygmomanometer before (T1) and after (T2) the emergency dental appointment. Also, the participants answered a questionnaire designed for this study, which included the visual analog pain scale (VAS), whose values ranged from 0 (no pain) to 10 (severe pain). Once the patient was comfortably seated, some questions were asked during the interview, such as: Do you drink coffee or another stimulating drink? Are you a smoker? Did you exercise before the consultation? Did you use any medication or illicit drugs before the consultation? Have you emptied your bladder? The BP values used were those recommended by the American Heart Association. 1 The results were described using means, standard deviations, and other summary measures for the BP values and their evolution. To assess whether there was a significant evolution and whether the evolutions were different, the non-parametric Wilcoxon test was used. For the evaluation of the correlations between the evolutions and the continuous measures, we used Pearson's linear correlation index. The JMP® Pro software version 13 (SAS Institute Inc., Cary, NC, USA), 1989–2019, was used for the analysis (significance level of 0.05, 95% confidence). Results The study included 75 adult patients over 18 years old who were evaluated in the waiting room of the emergency dental clinic of the university. Among all the participants (n = 75), 66.7% (n = 50) were female, and 33.3% (n = 25) were male. The mean age was 45.5 ± 12.7 years, ranging from 21 to 70 years. The emergency treatment consisted primarily of the treatment of oral and dental infections in 82.6% of the patients. The patients were divided into two groups: the first presenting with elevated BP values (>130 x 90 mm/hg) and the second group presenting normal BP levels. Among the participants, 60% presented HBP and 40% had normal values. The demographic data is shown in Table 1. Regarding the questions before BP measurement, eight patients smoked cigarettes and three practiced exercises. Among these, five participants who smoked before consultation presented BP values above 130 x 90 mmHg. Information associated with pain revealed that 78.7% (n = 57) presented pain with a VAS of 5.2 ± 3.5, 42.6% (n = 32) used analgesics, and 38.6% (n = 29) had dental anxiety. Data on blood pressure showed that 52% (n = 39) of patients had a family history of HBP, 18.6% (n = 14) had already been diagnosed with HBP, 14.6% (n = 11) were taking antihypertensive drugs, and 96% (n = 72) had never had their blood pressure tested before dental treatment. The mean BP was 133 x 90 mm/hg. Among the interviewed patients, 16% (n = 12) were sent to the doctor for hypertension (>180 x 110 mmHg). To assess whether there was a notable change in systolic and diastolic values at T1 and T2, we used the non-parametric Wilcoxon test, considering a p-value > 0.05. The systolic changes ranged from -30 mmHg to 80 mmHg in T1 and T2, with a p-value (0.0555) near significance. The diastolic changes ranged from 20 mmHg to 90 mmHg (p-value: 0.5480). There was an increment in the systolic BP in 36.0% of the patients, 21.3% presented a BP reduction, and 42.7% were within normal values. Whereas diastolic changes were present in 29.3% of patients, 25.3% BP reduction in T2, and 45.3% within normal values. Table 2 exhibits the differences seen after two BP measurements. All 45 patients who had an altered BP with values greater than 180 x 110 mm/hg even after the intervention or who presented with hypertensive crisis-related symptoms such as headache, dizziness, or altered vision were immediately referred to emergency care. Discussion Hypertension is an insidious disease associated with increased cardiovascular risk and mortality. HBP can lead to sudden death, stroke, acute myocardial infarction, heart failure, peripheral arterial disease, and fatal and non-fatal chronic kidney disease. Therefore, this condition can be considered one of the biggest public health problems in the world. 1 Patients at risk for HBP require specific dental care, considering that almost half of the hypertensive patients can be asymptomatic and unaware of the diagnosis. Dental management must include a comprehensive clinical examination, medical history, and BP monitoring prior to dental procedures. 7 Since HBP can be considered one of Brazil's significant public health problems, affecting more than 20% of the population, high BP values are constantly detected in the dental clinic during physical examination. Due to the large circulation of people and trained personnel, the dental clinic is a favorable setting for BP screening. Although studies monitoring BP levels in a dental environment are widely discussed in the literature, there is no consensus regarding the perfect timing to treat these patients. 8 Most people with hypertension have an uncontrolled condition. The dentist appointment provides a unique chance to evaluate patients for undiagnosed and uncontrolled hypertension, which could contribute to improved monitoring and treatment. Given a shortage of controlled randomized clinical trials, it is widely suggested that elective dental treatments be avoided in individuals with BP >180/110 mmHg. 10 The purpose of this study was to determine the average blood pressure of patients before they received urgent dental treatment. In all, 75 patients from the clinic's emergency dental service were examined; 38.6% of participants were apprehensive about receiving dental treatment. Stress and panic might result in high blood pressure or even an unknown WCH detection. Although the link between WCH and long-term cardiac events is still debated, there is emerging evidence that these early indicators might lead to a masked hypertension diagnosis. 8-9 WCH can directly affect hemodynamics, resulting in dramatic changes in blood pressure, heart rate, and myocardial oxygen demand. This anxiety can be prevented by scheduling visits in the morning, conducting brief appointments, regulating pain, and lowering stress, which often require anxiolytic medication prescriptions. 10,11 The stress reaction is significantly greater in patients who are hypertensive than in normotensive individuals, and in our study, we found that participants with a confirmed medical diagnosis of hypertension maintained high blood pressure levels before and after an emergency dental consultation. In these circumstances, management should involve efficient anesthetic techniques and the prescription of analgesics; otherwise, these procedures might raise blood pressure. 10,11 However, unnecessary dental appointment cancellations due to patients presenting higher BP values are frequent, even with no clinical signs of hypertensive crises. This mostly occurs due to the lack of knowledge of professionals about WCH or the management of hypertensive patients. Moreover, there is no scientific evidence that shows the advantage of postponing dental treatment in these cases. 11 Pain and oral infections of odontogenic origin will naturally lead to high BP values due to endogenous catecholamine release, a process that will not be interrupted if there is no dental intervention. 10 In our study, only twelve patients presenting with minor symptoms were referred for medical follow-up due to sustained increased values even after urgent dental care (>180 x 110 mmHg). Conclusion These results demonstrate that although there is a tendency for patients to present high BP values before emergency dental treatments, pain and infection must be treated accordingly. The healthcare professional must be able to identify these alterations and correctly refer the patients to medical treatment. Declarations Ethics approval and consent to participate Consent for publication This study was approved by the local ethics committee (IRB number: 68033517.2.0000.0081). All patients had read and signed the informed consent. Availability of data and materials After publication, all data and materials will be available at: https://repositorio.usp.br/ Acknowledgments: We would like to express our gratitude to Marcus Vinicius Castro, the biostatistician professional, for his valuable contribution to this research. Competing interests All authors declare that there are no competing interests. Funding This work was supported by The São Paulo Research Foundation. [grant numbers: 2018/02568-8 and 2020/15533-8 Authors' contributions DP: Elaboration and manuscript writing; Conceived and designed the analysis; LM: manuscript writing EP: Clinical evaluation and data collection LC: Clinical evaluation and data collection NR: Clinical evaluation and data collection FM: Study supervision; manuscript writing; conceived the study. References World Health Organization. (2023). Hypertension. Available on URL: https://www.who.int/news-room/fact-sheets/detail/hypertension Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018;138(17):e426-e83 Mancia G, Grassi G, 2016. The Heterogeneous Nature of White-Coat Hypertension. J Am Coll Cardiol. 2016 Nov 8;68(19):2044-2046. doi: 10.1016/j.jacc.2016.08.043 Nuredini G, Saunders A, Rajkumar C, Okorie M. Current status of white coat hypertension: where are we? Ther Adv Cardiovasc Dis. 2020 Jan-Dec;14:1753944720931637. doi: 10.1177/1753944720931637. Filippone EJ, Foy AJ, Naccarelli GV.Controversies in Hypertension III: Dipping, Nocturnal Hypertension, and the Morning Surge.Am J Med. 2023 Jul;136(7):629-637. doi: 10.1016/j.amjmed.2023.02.018. Epub 2023 Mar 7. Andersson H, Hedström L, Bergh H (2021) White coat hypertension detected during opportunistic blood pressure screening in a dental healthcare setting, Scandinavian Journal of Primary Health Care, 39:3, 348-354. Stergiou GS, Parati G. Diagnosis and management of white coat hypertension. Hypertension. 2018;72(2):232-233. Rao SS, Ramana Reddy KV, Nath P, Bindra S, Jadaun G. Is screening in dental office an effective method of detecting undiagnosed hypertension? Indian J Dent Res. 2018 Jul-Aug;29(4):534-539. Barroso et al. 7a Diretriz Brasileira de Hipertensão Arterial. Arq Bras Cardiol. 2021; 116(3):516-658. Yarows SA, Vornovitsky O, Eber RM, Bisognano JD, Basile J. Canceling dental procedures due to elevated blood pressure: Is it appropriate? J Am Dent Assoc 2020:S0002-8177(19)30906-7 Southerland JH, Gill DG, Gangula PR, et al. Dental management in patients with hypertension: challenges and solutions. Clin Cosmet Investig Dent 2016;8:111-20 Tables Table 1. Demographic and medical data of the two groups: altered and normal BP measurements. BP Characteristics Altered* Normal p-value Pain Yes 36 (80.0%) 21 (70.0%) 0.4100 No 9 (20.0%) 9 (30.0%) Dental Anxiety Yes 20 (44.4%) 9 (30.0%) 0.2352 No 25 (55.6%) 21 (70.0%) Hypertension Yes 13 (28.9%) 1 (3.3%) 0.0057 No 32 (71.1%) 29 (96.7%) Family history Yes 24 (53.3%) 15 (50.0%) 0.8169 No 21 (46.7%) 15 (50.0%) Gastritis Yes 2 (4.4%) 6 (20.0%) 0.0534 No 43 (95.6%) 24 (80.0%) Diabetes Yes 5 (11.1%) 1 (3.3%) 0.3920 No 40 (88.9%) 29 (96.7%) Smoking Yes 8 (17.8%) 6 (20.0%) 1.0000 No 37 (82.2%) 24 (80.0%) Alcoholism Yes 12 (26.7%) 7 (23.3%) 0.7929 No 33 (73.3%) 23 (76.7%) Regular physical activity Yes 12 (26.7%) 3 (10.0%) 0.1389 No 33 (73.3%) 27 (90.0%) Weight gain* Yes 0 (0.0%) 1 (3.3%) 0.4000 No 45 (100.0%) 29 (96.7%) *In the past six months Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4207277","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":288984209,"identity":"bf8dc1fa-9ec7-4acb-825f-b58018052e39","order_by":0,"name":"Debora Pallos","email":"","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Debora","middleName":"","lastName":"Pallos","suffix":""},{"id":288984210,"identity":"4e715726-2221-418e-a823-52dc97533953","order_by":1,"name":"Luciano Miziara","email":"","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Luciano","middleName":"","lastName":"Miziara","suffix":""},{"id":288984211,"identity":"75544744-cb03-451d-a813-2a876fe1aff4","order_by":2,"name":"Larissa Cavalcante","email":"","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Larissa","middleName":"","lastName":"Cavalcante","suffix":""},{"id":288984212,"identity":"ca6f3b76-0a54-40c0-939d-7fba52e87105","order_by":3,"name":"Najila Rocha","email":"","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Najila","middleName":"","lastName":"Rocha","suffix":""},{"id":288984213,"identity":"acd078cb-36de-49e6-83b5-4fbada3d5079","order_by":4,"name":"Jose Eduardo Pereira","email":"","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":false,"prefix":"","firstName":"Jose","middleName":"Eduardo","lastName":"Pereira","suffix":""},{"id":288984214,"identity":"f08bf527-f699-41a2-881b-72f596ff4f35","order_by":5,"name":"Fabiana Martins","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA5klEQVRIie3PsQrCMBCA4ROhLkE3SWnxGU4cXERfpVLQRfeMkUJcfB5dI655AEGXInTqoIs4CHqVCoIQOzrkh9IU8uUaAJfrD2tIqOkIgAHUNX136KlJK2G0ryQevaBXkZRLLMmPWHundaoGYX9prichEPCQJOebjQSTSI/VhIVmvukaQ+S4Vf7KQkbBDHVkdozDfO0v1B1wP1bF1SxTXuTBeCvPiGBBksv9JxGacT7z3kQG9il0l0jERLJ+VxpkPv1YEFpJvE1vOBzxVpylUmCnuZ+eLrmFfOa9zqi4+YO4XC6X66snCVxNZdQpSeQAAAAASUVORK5CYII=","orcid":"","institution":"Universidade de Santo Amaro","correspondingAuthor":true,"prefix":"","firstName":"Fabiana","middleName":"","lastName":"Martins","suffix":""}],"badges":[],"createdAt":"2024-04-02 14:09:27","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4207277/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4207277/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":71334642,"identity":"5f7d8580-1eb3-4469-8b3e-205b942f8621","added_by":"auto","created_at":"2024-12-13 12:17:31","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":328524,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4207277/v1/11fdda01-df18-4e70-ada8-00b5bf534c19.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Exploring the relationship between dental anxiety and blood pressure in urgent dental care patients: an observational study ","fulltext":[{"header":"Background","content":"\u003cp\u003eHigh blood pressure (HBP) is a multifactorial disease characterized by sustained elevation of blood pressure (BP) systolic levels \u0026ge; 139 and/or diastolic \u0026ge; 39 mmHg, measured correctly at least on two separate occasions but confirmed after 24-hour ambulatory blood pressure monitoring (ABPM) and home blood pressure monitoring (HBPM). \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe BP may vary according to interactions between neurohumoral factors; the known risk factors for HBP are age, sex, ethnicity, overweight and obese salt intake, alcohol intake, sedentary lifestyle, socioeconomic and genetic, behavioral, and environmental factors. \u003csup\u003e1,2\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAccording to the American College of Cardiology/American Heart Association (ACC/AHA), white-coat hypertension (WCH) is defined as the value referring to the differences between the BP measurement at the office and the mean of ABPM while awake or HBPM (\u0026ge; 130/80 mmHg). The WCH is considered significant when this variance is 20 and 10 mmHg above the threshold in systolic and diastolic pressures, respectively. \u003csup\u003e2-4\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eAccording to current research, WCH occurs in 15 to 40% of instances, and those who display WCH may have an increased risk of acquiring cardiovascular diseases in the long run, but this relationship is still uncertain. \u003csup\u003e3-6\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThis study aimed to measure the variation in BP of patients before and after stressful emergency dental procedures in an emergency dental clinic.\u003c/p\u003e\n"},{"header":"Methods","content":"\u003cp\u003eIn this cross-sectional observational study, patients seen at the dental clinic of a Brazilian university were evaluated. After a brief explanation of the study, all patients had read and signed an informed consent form developed for the study (University of Santo Amaro IRB number: 68033517.2.0000.0081).\u003c/p\u003e\n\u003cp\u003eThis study included adults with known or unknown HBP status. All individuals in this study were randomly included and approached in the waiting room at the emergency dental service of a school of dentistry.\u003c/p\u003e\n\u003cp\u003eTwo calibrated researchers evaluated the participants of the study using a mercury sphygmomanometer before (T1) and after (T2) the emergency dental appointment. Also, the participants answered a questionnaire designed for this study, which included the visual analog pain scale (VAS), whose values ranged from 0 (no pain) to 10 (severe pain). \u0026nbsp; \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOnce the patient was comfortably seated, some questions were asked during the interview, such as: Do you drink coffee or another stimulating drink? Are you a smoker? Did you exercise before the consultation? Did you use any medication or illicit drugs before the consultation? Have you emptied your bladder? The BP values used were those recommended by the American Heart Association. \u003csup\u003e1\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe results were described using means, standard deviations, and other summary measures for the BP values and their evolution.\u003c/p\u003e\n\u003cp\u003eTo assess whether there was a significant evolution and whether the evolutions were different, the non-parametric Wilcoxon test was used. For the evaluation of the correlations between the evolutions and the continuous measures, we used Pearson\u0026apos;s linear correlation index. The JMP\u0026reg; Pro software version 13 (SAS Institute Inc., Cary, NC, USA), 1989\u0026ndash;2019, was used for the analysis (significance level of 0.05, 95% confidence).\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe study included 75 adult patients over 18 years old who were evaluated in the waiting room of the emergency dental clinic of the university.\u003c/p\u003e\n\u003cp\u003eAmong all the participants (n = 75), 66.7% (n = 50) were female, and 33.3% (n = 25) were male. The mean age was 45.5 \u0026plusmn; 12.7 years, ranging from 21 to 70 years. The emergency treatment consisted primarily of the treatment of oral and dental infections in 82.6% of the patients.\u003c/p\u003e\n\u003cp\u003eThe patients were divided into two groups: the first presenting with elevated BP values (\u0026gt;130 x 90 mm/hg) and the second group presenting normal BP levels. \u0026nbsp;Among the participants, 60% presented HBP and 40% had normal values. The demographic data is shown in Table 1.\u003c/p\u003e\n\u003cp\u003eRegarding the questions before BP measurement, eight patients smoked cigarettes and three practiced exercises. Among these, five participants who smoked before consultation presented BP values above 130 x 90 mmHg.\u003c/p\u003e\n\u003cp\u003eInformation associated with pain revealed that 78.7% (n = 57) presented pain with a VAS of 5.2 \u0026plusmn; 3.5, 42.6% (n = 32) used analgesics, and 38.6% (n = 29) had dental anxiety. Data on blood pressure showed that 52% (n = 39) of patients had a family history of HBP, 18.6% (n = 14) had already been diagnosed with HBP, 14.6% (n = 11) were taking antihypertensive drugs, and 96% (n = 72) had never had their blood pressure tested before dental treatment. The mean BP was 133 x 90 mm/hg. Among the interviewed patients, 16% (n = 12) were sent to the doctor for hypertension (\u0026gt;180 x 110 mmHg).\u003c/p\u003e\n\u003cp\u003eTo assess whether there was a notable change in systolic and diastolic values at T1 and T2, we used the non-parametric Wilcoxon test, considering a p-value \u0026gt; 0.05.\u003c/p\u003e\n\u003cp\u003eThe systolic changes ranged from -30 mmHg to 80 mmHg in T1 and T2, with a p-value (0.0555) near significance. The diastolic changes ranged from 20 mmHg to 90 mmHg (p-value: 0.5480).\u003c/p\u003e\n\u003cp\u003eThere was an increment in the systolic BP in 36.0% of the patients, 21.3% presented a BP reduction, and 42.7% were within normal values. Whereas diastolic changes were present in 29.3% of patients, 25.3% BP reduction in T2, and 45.3% within normal values. Table 2 exhibits the differences seen after two\u0026nbsp;BP measurements.\u003c/p\u003e\n\u003cp\u003eAll 45 patients who had an altered BP with values greater than 180 x 110 mm/hg even after the intervention or who presented with hypertensive crisis-related symptoms such as headache, dizziness, or altered vision were immediately referred to emergency care.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eHypertension is an insidious disease associated with increased cardiovascular risk and mortality. HBP can lead to sudden death, stroke, acute myocardial infarction, heart failure, peripheral arterial disease, and fatal and non-fatal chronic kidney disease. Therefore, this condition can be considered one of the biggest public health problems in the world. \u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;Patients at risk for HBP require specific dental care, considering that almost half of the hypertensive patients can be asymptomatic and unaware of the diagnosis. Dental management must include a comprehensive clinical examination, medical history, and BP monitoring prior to dental procedures. \u003csup\u003e7\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eSince HBP can be considered one of Brazil\u0026apos;s significant public health problems, affecting more than 20% of the population, high BP values are constantly detected in the dental clinic during physical examination. Due to the large circulation of people and trained personnel, the dental clinic is a favorable setting for BP screening. Although studies monitoring BP levels in a dental environment are widely discussed in the literature, there is no consensus regarding the perfect timing to treat these patients. \u003csup\u003e8\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; Most people with hypertension have an uncontrolled condition. The dentist appointment provides a unique chance to evaluate patients for undiagnosed and uncontrolled hypertension, which could contribute to improved monitoring and treatment. Given a shortage of controlled randomized clinical trials, it is widely suggested that elective dental treatments be avoided in individuals with BP \u0026gt;180/110 mmHg. \u003csup\u003e10\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe purpose of this study was to determine the average blood pressure of patients before they received urgent dental treatment. In all, 75 patients from the clinic\u0026apos;s emergency dental service were examined; 38.6% of participants were apprehensive about receiving dental treatment. Stress and panic might result in high blood pressure or even an unknown WCH detection.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAlthough the link between WCH and long-term cardiac events is still debated, there is emerging evidence that these early indicators might lead to a masked hypertension diagnosis. \u003csup\u003e8-9\u003c/sup\u003e \u0026nbsp;\u003c/p\u003e\n\u003cp\u003eWCH can directly affect hemodynamics, resulting in dramatic changes in blood pressure, heart rate, and myocardial oxygen demand. This anxiety can be prevented by scheduling visits in the morning, conducting brief appointments, regulating pain, and lowering stress, which often require anxiolytic medication prescriptions. \u003csup\u003e10,11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eThe stress reaction is significantly greater in patients who are hypertensive than in normotensive individuals, and in our study, we found that participants with a confirmed medical diagnosis of hypertension maintained high blood pressure levels before and after an emergency dental consultation. In these circumstances, management should involve efficient anesthetic techniques and the prescription of analgesics; otherwise, these procedures might raise blood pressure. \u003csup\u003e10,11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003eHowever, unnecessary dental appointment cancellations due to patients presenting higher BP values are frequent, even with no clinical signs of hypertensive crises. This mostly occurs due to the lack of knowledge of professionals about WCH or the management of hypertensive patients. Moreover, there is no scientific evidence that shows the advantage of postponing dental treatment in these cases.\u003csup\u003e11\u003c/sup\u003e\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;\u0026nbsp;Pain and oral infections of odontogenic origin will naturally lead to high BP values due to endogenous catecholamine release, a process that will not be interrupted if there is no dental intervention.\u003csup\u003e10\u003c/sup\u003e In our study, only twelve patients presenting with minor symptoms were referred for medical follow-up due to sustained increased values even after urgent dental care (\u0026gt;180 x 110 mmHg).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThese results demonstrate that although there is a tendency for patients to present high BP values before emergency dental treatments, pain and infection must be treated accordingly. The healthcare professional must be able to identify these alterations and correctly refer the patients to medical treatment.\u003c/p\u003e\n"},{"header":"Declarations","content":"\u003cp\u003eEthics approval and consent to participate\u003c/p\u003e\n\u003cp\u003eConsent for publication\u003c/p\u003e\n\u003cp\u003eThis study was approved by the local ethics committee\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e(IRB number: 68033517.2.0000.0081). All patients had read and signed the informed consent.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Availability of data and materials\u003c/p\u003e\n\u003cp\u003eAfter publication, all data and materials will be available at: https://repositorio.usp.br/\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003cstrong\u003eAcknowledgments:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to express our gratitude to Marcus Vinicius Castro, \u0026nbsp;the biostatistician professional, \u0026nbsp;for his valuable contribution to this research.\u003c/p\u003e\n\u003cp\u003eCompeting interests\u003c/p\u003e\n\u003cp\u003eAll authors declare that there are no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Funding\u003c/p\u003e\n\u003cp\u003eThis work was supported by The S\u0026atilde;o Paulo Research Foundation. [grant numbers: 2018/02568-8 and 2020/15533-8\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eDP: Elaboration and manuscript writing;\u0026nbsp;Conceived and designed the analysis;\u003c/p\u003e\n\u003cp\u003eLM: manuscript writing\u003c/p\u003e\n\u003cp\u003eEP: Clinical evaluation and data collection\u003c/p\u003e\n\u003cp\u003eLC: Clinical evaluation and data collection\u003c/p\u003e\n\u003cp\u003eNR: Clinical evaluation and data collection\u003c/p\u003e\n\u003cp\u003eFM: Study supervision; manuscript writing; conceived the study.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWorld Health Organization. (2023). Hypertension. Available on URL: https://www.who.int/news-room/fact-sheets/detail/hypertension \u003c/li\u003e\n\u003cli\u003eWhelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2018;138(17):e426-e83\u003c/li\u003e\n\u003cli\u003eMancia G, Grassi G, 2016. The Heterogeneous Nature of White-Coat Hypertension. J Am Coll Cardiol. 2016 Nov 8;68(19):2044-2046. doi: 10.1016/j.jacc.2016.08.043\u003c/li\u003e\n\u003cli\u003eNuredini G, Saunders A, Rajkumar C, Okorie M. Current status of white coat hypertension: where are we? Ther Adv Cardiovasc Dis. 2020 Jan-Dec;14:1753944720931637. doi: 10.1177/1753944720931637.\u003c/li\u003e\n\u003cli\u003eFilippone EJ, Foy AJ, Naccarelli GV.Controversies in Hypertension III: Dipping, Nocturnal Hypertension, and the Morning Surge.Am J Med. 2023 Jul;136(7):629-637. doi: 10.1016/j.amjmed.2023.02.018. Epub 2023 Mar 7.\u003c/li\u003e\n\u003cli\u003eAndersson H, Hedstr\u0026ouml;m L, Bergh H (2021) White coat hypertension detected during opportunistic blood pressure screening in a dental healthcare setting, Scandinavian Journal of Primary Health Care, 39:3, 348-354. \u003c/li\u003e\n\u003cli\u003eStergiou GS, Parati G. Diagnosis and management of white coat hypertension. Hypertension. 2018;72(2):232-233.\u003c/li\u003e\n\u003cli\u003eRao SS, Ramana Reddy KV, Nath P, Bindra S, Jadaun G. Is screening in dental office an effective method of detecting undiagnosed hypertension? Indian J Dent Res. 2018 Jul-Aug;29(4):534-539.\u003c/li\u003e\n\u003cli\u003eBarroso et al. 7a Diretriz Brasileira de Hipertens\u0026atilde;o Arterial. Arq Bras Cardiol. 2021; 116(3):516-658. \u003c/li\u003e\n\u003cli\u003eYarows SA, Vornovitsky O, Eber RM, Bisognano JD, Basile J. Canceling dental procedures due to elevated blood pressure: Is it appropriate? J Am Dent Assoc 2020:S0002-8177(19)30906-7\u003c/li\u003e\n\u003cli\u003eSoutherland JH, Gill DG, Gangula PR, et al. Dental management in patients with hypertension: challenges and solutions. Clin Cosmet Investig Dent 2016;8:111-20\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003e\u003cstrong\u003eTable 1. Demographic and medical data of the two groups: altered and normal BP measurements.\u0026nbsp;\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"537\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"42.193308550185876%\" colspan=\"2\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eBP\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eAltered*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003eNormal\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003ep-value\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003ePain\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e36 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.4100\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eDental Anxiety\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e20 (44.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e9 (30.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.2352\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e25 (55.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 (70.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eHypertension\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e13 (28.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.0057\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e32 (71.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eFamily history\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (53.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e15 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.8169\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e21 (46.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e15 (50.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eGastritis\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e2 (4.4%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e6 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.0534\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e43 (95.6%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eDiabetes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e5 (11.1%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.3920\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e40 (88.9%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eSmoking\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e8 (17.8%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e6 (20.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e1.0000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e37 (82.2%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e24 (80.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eAlcoholism\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e12 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e7 (23.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.7929\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e33 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e23 (76.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"top\"\u003e\n \u003cp\u003eRegular physical activity\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e12 (26.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e3 (10.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.1389\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e33 (73.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e27 (90.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003eWeight gain*\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e0 (0.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e1 (3.3%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e0.4000\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd width=\"31.598513011152416%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"10.594795539033457%\" valign=\"bottom\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"26.20817843866171%\" valign=\"bottom\"\u003e\n \u003cp\u003e45 (100.0%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.985130111524164%\" valign=\"bottom\"\u003e\n \u003cp\u003e29 (96.7%)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd width=\"15.613382899628252%\" valign=\"bottom\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u0026nbsp;*In the past six months\u003c/p\u003e\n\u003cp\u003e\u003cimg src=\"data:image/png;base64,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\"\u003e\u003c/p\u003e\n"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"White coat hypertension, Dental anxiety, High Blood Pressure, Dental emergency care","lastPublishedDoi":"10.21203/rs.3.rs-4207277/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4207277/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: Dental anxiety is frequently observed in dental clinics, and when an increase in blood pressure (BP) values is detected, it can be classified as a type of white coat hypertension (WCH). The goal of this study was to monitor blood pressure before and after emergency dental treatments in a university dental clinic and to discuss the importance of approaching these patients considering their BP values and dental anxiety.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eMethods: This cross-sectional observational research randomly included patients in the dental waiting room of an urgent care clinic. A mercury sphygmomanometer was used by two calibrated researchers to assess the study participants before (T1) and after (T2) the emergency dental consultation. The variation in BP measurement was statistically compared with the Visual Analogue Scale (VAS), dental history, high blood pressure (HBP), and other comorbidities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eResults: Among all participants (n = 75), the mean age was 45.5 ± 12.7 years old, 66.7% of patients were female, 78.7% had pain before dental care, VAS scale (5.2 ± 3.5), and used painkillers, and 44.4% reported dental anxiety. HBP was detected in 60% of patients (\u0026gt;130 mmHg), 53.3% of patients had a family history of HBP, 28.9% were diagnosed with AH, and among these, 50% were regularly using antihypertensive medication. The average systolic BP (SBP) was 131.9 and the diastolic BP (DBP) was 90.4 mm/hg, and in terms of evolution, the variation was 3.7 to 1.7, respectively.\u003c/p\u003e\n\u003cp\u003eConclusions: This study showed that BP monitoring at the dental clinic is recommended, and most patients presented HBP before the consultation, but these parameters were not considered decisive for canceling the dental urgent care.\u003c/p\u003e","manuscriptTitle":"Exploring the relationship between dental anxiety and blood pressure in urgent dental care patients: an observational study ","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-04-11 12:39:52","doi":"10.21203/rs.3.rs-4207277/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b4ea94e3-1f0d-45a0-9932-59f1274d36b4","owner":[],"postedDate":"April 11th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-12-13T12:09:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-04-11 12:39:52","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4207277","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4207277","identity":"rs-4207277","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}