27 minute read
Hypertension Screening in the Dental Setting: A Pilot Program to Enhance Chronic Disease Management Through Medical-Dental Integration
John Welby, MS, is the director of health literacy and social marketing for the Maryland Office of Oral Health at the Maryland Department of Health. He obtained his master’s in communication from Clarion University and has developed and produced social and behavior change campaigns for some of the nation’s most respected health care organizations. Conflict of Interest Disclosure: None reported.
Debony Hughes, DDS, is the director of the Office of Oral Health at the Maryland Department of Health. She received her DDS degree and certificate in advanced general dentistry from the Howard University College of Dentistry and is a fellow in the American College of Dentists and the International College of Dentists. Dr. Hughes serves on several boards and has provided testimony for oral health legislation to the Maryland Legislature and the United States Senate. Conflict of Interest Disclosure: None reported.
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Kristi Pier, MHS, MCHES, is the director of the Center for Chronic Disease Prevention and Control at the Maryland Department of Health. She holds a Master of Health Science degree from the Johns Hopkins University Bloomberg School of Public Health and is a Master Certified Health Education Specialist. Ms. Pier is a member of the National Association of Chronic Disease Directors Board. Conflict of Interest Disclosure: None reported.
ABSTRACT: As health care providers and public health professionals peel back the barriers preventing medical/dental collaboration, the benefits of these partnerships have become clear. Even so, the potential for dental and medical professionals working together to prevent and treat disease has yet to be fully realized. Put simply, there is more work to do and much more to learn. The Maryland Hypertension Screening in the Dental Setting pilot offers a glimpse into the benefits that can be achieved when dental professionals explore new models of care. Because of the impact of programs like the Maryland pilot and others that work to foster medical/dental collaboration, patients are beginning to see life-changing and sometimes even life-saving results.
Keywords: Collaboration, hypertension, high blood pressure, dental care, chronic disease, medical/ dental collaboration, oral and overall health, dentist, primary care provider, communication
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Since the publication of “Oral Health in America: A Report of the Surgeon General” in 2000, there has been a steady increase in investigating and promoting the connection between oral health and overall health. [1] Public health organizations throughout the nation have recognized and increasingly called for the integration of oral and overall health. Medical and dental practices have begun to collaborate, often in federally qualified health center (FQHC) settings or in partnership with public health organizations to investigate the benefits of integrating preventive oral health services in medical settings and preventive health services in dental settings. In 2016, the publication of “The Oral Health Strategic Framework” by the U.S. Department of Health and Human Services elevated the importance of medical-dental integration even more by listing five overarching goals to be considered when strategically working to improve oral health. Number one on the list is to integrate oral health and primary health care. [2]
Recognizing this movement within public health, the Centers for Disease Control and Prevention (CDC) issued a request for proposals in 2016 entitled Models of Collaboration for State Chronic Disease and Oral Health Programs. This funding opportunity was designed to integrate medical and dental care by fostering collaboration between state oral health and chronic disease programs and to test innovative approaches of incorporating oral health into chronic disease management systems, such as those developed to manage diabetes, hypertension, obesity and tobacco usage. The Maryland Department of Health (MDH) Office of Oral Health (OOH) received this funding to develop, implement and evaluate a pilot program that integrated hypertension screening and referrals into the daily workflow of select dental settings.
This paper addresses the importance of hypertension screening within the dental setting and outlines the development, implementation, results and lessons learned from the Maryland Hypertension Screening in the Dental Setting pilot program funded by the CDC. This program recognizes that dentists are trained in dental school to take a patient’s blood pressure and views the dental setting as a place where hypertension screening should readily occur. It also acknowledges that screening for common chronic diseases such as hypertension, diabetes, obesity and tobacco usage can be instituted within the dental setting to identify and refer patients to appropriate diagnostic and treatment services. Moreover, it calls on state oral health and chronic disease programs to seek partnerships that will identify and build programs that can screen for chronic disease in the dental setting and refer dental patients to medical providers for appropriate follow-up services. By doing so, state oral health and chronic disease programs can play a key role in operationalizing medical/dental integration throughout the nation and can significantly contribute to the management of chronic disease, thereby not only improving oral health but also overall health.
Hypertension Screening and the Dental Provider
Heart disease is the leading cause of death worldwide. In the United States, more than 650,000 people die of heart disease every year: 1 in every 4 deaths. [3] Heart disease is the leading cause of death for both men and women and people of most racial and ethnic groups. [3]
Coronary artery disease, the most common type of heart disease, occurs when a build-up of plaque accumulating within the arteries restricts blood flow to the heart. [3] Coronary artery disease is a major cause of heart attacks. [3] Every year more than 800,000 Americans have a heart attack: approximately one every 40 seconds. One of every five heart attacks occur without the individual being aware of the conditions that led to the attack. [3]
When the heart beats, it creates pressure that pushes blood through a network of blood vessels, which include arteries, veins and capillaries. [4] High blood pressure (HBP or hypertension) is when the force of your blood pushing against the walls of your blood vessels is consistently too high. [4]
High blood pressure or hypertension is a major risk factor for heart disease and can lead to heart attack, stroke, heart failure and premature death. [5] Known as a silent killer, hypertension can commonly present itself without symptoms; consequently, many people with hypertension do not know they have the disease. [5] It is therefore important that blood pressure is monitored regularly. [5]
The primary way that high blood pressure causes harm is by increasing the workload of the heart and blood vessels — making them work harder and less efficiently. [4] Over time, the force and friction of high blood pressure damages the delicate tissues inside the arteries. In turn, LDL (bad) cholesterol forms plaque along tiny tears in the artery walls, signifying the start of atherosclerosis. [4] The more the plaque and damage increase, the narrower (smaller) the insides of the arteries become — raising blood pressure and starting a vicious circle that further harms arteries, the heart and the rest of the body. [4]
Hypertension affects more than 1 billion people worldwide. [6] Nearly half of U.S. adults have hypertension and only about 1 in 4 of those individuals have their blood pressure under control. [7] As the prevalence of hypertension continues to increase, it is estimated that more than 1.5 billion people will be diagnosed with hypertension by 2025. [8] This estimate becomes even more alarming when we consider that millions of people with hypertension remain undiagnosed. The potential benefits of spreading the word about the prevalence and impact of hypertension and educating the public about the importance of working with their health care provider to detect hypertension are significant and may save countless lives. [9]
A blood pressure reading is given in millimeters of mercury (mm Hg) and has two numbers. The first, or upper, number measures the pressure in the arteries when the heart beats (systolic pressure). [10] The second, or lower, number measures the pressure in the arteries between beats (diastolic pressure). [10] According to the hypertension guidelines published by the American Heart Association, the ranges of blood pressure measurement include normal, elevated, hypertension stage 1, hypertension stage 2 and hypertensive crisis. Normal blood pressure reading ranges include readings less than 120/80 mm Hg. [11] Elevated blood pressure readings range from 120–129 systolic and less than 80 mm Hg diastolic. [11] It is important to start regular monitoring of blood pressure at this level. Hypertension stage 1 ranges from 130–139 systolic or 80–89 mm Hg diastolic. Lifestyle changes such as a strict diet regimen and regular exercise are recommended at this stage. Some patients might also be prescribed medications to regulate their blood pressure. The hypertension stage 2 range is at 140/90 mm Hg or greater. Providers will most likely advise blood pressure medications and lifestyle changes for this category. The hypertensive crisis range is anything greater than 180/120 mm Hg which requires immediate medical attention. [11]
The significance of regular blood pressure measurement in the dental office as a component of comprehensive health care is within the professional responsibility of dentists and cannot be minimized. Dental professionals not only have the responsibility to take every patient’s blood pressure, they must also make sure to follow up with appropriate education and/or referrals to medical care when appropriate. Measurement of blood pressure in the dental setting is also important, as many clinical decisions occur within the dental setting, such as the choice of an appropriate anesthetic and whether to perform certain invasive procedures that require knowledge of a patient’s blood pressure measurement. Also, taking a patient’s blood pressure is an opportunity to make patients aware of the connection between oral and overall health.
Once an elevated blood pressure has been detected, the patient should be educated about its negative impact on the body as well as counseled on the health habits that can help control hypertension, such as maintaining a healthy weight, regular exercise and choosing a healthy diet, so that these habits can be incorporated into their lifestyle to help manage the condition. The dental professional has the responsibility to make the appropriate referral to the patient’s primary care physician for follow-up when hypertension is suspected due to elevated blood pressure readings. This referral to the primary care provider is not only essential, it will also demonstrate to the patient that the dentist is concerned with more than the patient’s oral health and will help the patient understand the important relationship between oral and overall health. One strategy in “The Surgeon General’s Call to Action to Control Hypertension” is to optimize patient care by promoting team-based care. [7] Although including dental providers as part of multidisciplinary team-based care is often overlooked, it holds great promise for enhancing the collaboration needed to ensure that appropriate referrals to primary care physicians for hypertension or other chronic diseases are made.
As important as this process is, it can be difficult to ensure appropriate followup due to the lack of communication infrastructure between dental and medical facilities, entrenched systemwide practice patterns within these settings and the challenges of working with highrisk populations. In fact, communication within the medical system itself is not without its own challenges. One study found in caring for 100 Medicare patients, the average primary care provider will need to coordinate care with 99 other providers working across 53 practices. [12] Additionally, a national survey of communication between primary care providers and specialists found 69% of primary care providers reported sending basic patient information to specialists either “always” or “most of the time.” [13] Nonetheless, according to a research brief published by the Health Policy Institute of the American Dental Association, physicians report being dissatisfied with current referral systems to dentists. [14] Physicians reported that an inadequate dental referral system exists and the creation of an electronic medical record or method that enhanced communication and referrals between doctors and dentists was necessary. They also called for an increase in promoting dental education among physicians. They felt that these changes would benefit both providers and patients by improving care as well as increasing referrals, collaboration and satisfaction among physicians and dentists. [14]
Referrals to a primary care physician are a necessary expectation when hypertension is suspected due to elevated blood pressure readings; therefore, it is important to be aware of and address the communication challenges that surround the dental-to-medical referral process. Communication between medical and dental providers is difficult. Shared electronic health records between medical and dental providers do not always provide the needed information that either medical- or dental-specific systems offer. When systems are not in place to facilitate communication and complete the referral process, it is the responsibility of individual providers to investigate alternatives, build professional relationships and develop and implement demonstration projects that will create effective linkages between primary care teams and dentists in private practices so the accurate health status of the patient is maintained throughout the referral process and course of treatment. [13]
The Maryland Pilot
In 2016, the MDH was awarded the CDC “Models of Collaboration for State Chronic Disease and Oral Health Programs” grant funding to create a two-year pilot program to provide hypertension and tobacco screening within select dental settings in Maryland. Partner offices within MDH for this project were the OOH, the Center for Chronic Disease Prevention and Control (CCDPC) and the Center for Tobacco Prevention and Control. The goal of the pilot was to enhance and expand the integration of oral health and chronic disease public health programs to involve dental providers in chronic disease prevention activities and to identify and understand challenges and opportunities for future medical and dental integration. The program sought to engage dentists in Maryland to provide hypertension and tobacco screenings during routine dental visits and to refer patients with undiagnosed or uncontrolled hypertension to primary care providers for follow-up evaluation when necessary. Tobacco users who expressed a willingness to participate in tobacco cessation counseling were referred to the Maryland Tobacco Quitline.
To accomplish program objectives, the MDH formed an advisory committee of dental and medical professionals as well as representatives from academia and health-related industries. Together, they developed the framework and standards for the implementation of hypertension and tobacco screening protocols as well as identified the appropriate equipment used for hypertension screening during routine dental visits. The advisory committee also determined thresholds for dental professionals to follow when referring hypertensive patients to primary care providers for follow-up medical care. Initially, patients were referred to primary care providers when a blood pressure measurement of 140/90 mm Hg or greater was obtained. In 2017, as the pilot was being implemented, the American Heart Association and the American College of Cardiology issued new blood pressure guidelines based on updated medical research and accumulated evidence. The Maryland hypertension screening in the dental setting pilot program adopted the new guidelines. The new referral measurement at which dental providers referred their patients was updated to 120 mm Hg to 129 mm Hg systolic and less than 80 mm Hg diastolic.
Implementation
The MDH collaborated with 14 local health departments (LHDs) throughout the state to implement pilot program activities that took place from Sept. 1, 2016, to Aug. 31, 2018. The LHD model had been previously utilized in MDH chronic disease management programs to establish referral systems with provider practices for evidence-based programs to prevent and manage diabetes and hypertension. The 14 LHDs engaged 47 dental practices to participate in the pilot program and introduce hypertension and tobacco screenings into their clinical practice. The dental practices recruited were intentionally diverse and included private practices, clinic settings and FQHCs located near the LHD sites. The MDH provided digital blood pressure cuffs, clinical protocols, skills training, data collection advisement, customized education materials and follow-up procedures for dental providers to use when screening and referring patients to the appropriate primary care provider. For quality assurance, a “train-the-trainer” approach was utilized to implement the pilot at the dental practice sites. Training components included:
■ Workflow process mapping, which allowed for visualization of the workflow within the dental practice that facilitates improvements and ensures an efficient and sustainable implementation of screenings for hypertension within dental practices.
■ Learning about the hypertension screening process, which entailed a review of the hypertension screening guidelines adopted by the advisory panel as well as standards and the procedures for taking accurate blood pressure measurements using the selected blood pressure monitoring equipment.
■ Data collection methods, which included discussions regarding the proper methods of collecting and recording data, specific instructions on how to collect data from the participating dental practices so LHDs could accurately complete the reporting template that would be submitted to the OOH on a quarterly basis.
■ Dental referrals to primary care providers, which was comprised of a review of best practices when making referrals from dental providers to primary care providers by using a standardized medical-dental referral form created for this initiative.
To ensure both dental patients and providers were informed and motivated to take part in the initiative, a health literacy/social marketing campaign was created entitled “[2] Minutes With Your Dentist Can Save Your Life.” The goal of the campaign was to help patients understand the connection between oral and overall health and recognize the importance of hypertension screenings in the dental setting and its relationship to helping prevent heart disease. Implementation of the campaign included dental office posters, patient postcards, prescription pads, a website, television, Facebook and internet advertising and a media and community relations strategy (FIGURE 1). The advertising launch included a 30-second television ad that also ran in movie theaters and on gas station pump TV screens located in areas approximate to participating LHD communities and dental practices as well as on targeted cable TV stations.
Data Collection
During the train-the-trainer sessions, LHDs were instructed on how to train participating dental practices, FQHCs and dental clinics in data collection using an Excel spreadsheet created by the OOH and CCDPH for data collection purposes. The LHDs then trained participating dental practices using the Excel spreadsheet. As participating dental practices initiated hypertension screenings, data from patient encounters were collected using the data tracking Excel document and reported to LHDs. LHDs then compiled the data from the participating dental practices and reported them to OOH and CCDPH on a quarterly basis. Data included the number of patients seen, clinical visits, patients offered screening for hypertension, patients who received screening, patients referred to their PCP for high blood pressure (> = 140/90) and confirmed referral visits to primary care. Data were also collected on patients who identified as a “current smoker” and the number of “current smokers” who were referred to the Maryland Tobacco Quitline. Demographic data were also collected, including age, gender, race and county of residence.
Dental patients were referred to primary care providers if the patients’ blood pressure reading was (> = 140/90). A medical/dental referral form was created by OOH and the Center for Chronic Disease Prevention and Control for this purpose (FIGURE 2). This form was completed by the dental practice and faxed to a medical practice where the patient would undergo further evaluation and receive follow-up care if necessary. After follow-up, the medical practice would complete the appropriate portion of the medical/dental referral form and fax it back to the dental practice, thus closing the referral feedback loop. In addition, patients who were identified as tobacco users interested in quitting were referred to the Maryland Tobacco Quitline using the quitline’s fax-to-assist referral form.
Results
Hypertension screening activities were monitored from April 1, 2017, to June 30, 2018. During this time, 47 dental practices were recruited, trained and conducted blood pressure screenings with 36,996 patients; of those patients, 2,689 (7.2%) were referred to primary care providers for follow-up evaluation because their blood pressure reading met or exceeded the predetermined threshold criteria (FIGURE 3). Of the total patients screened for hypertension, 2,855 identified themselves as tobacco users; of those identified as tobacco users, 1,302 were referred to the Maryland Tobacco Quitline for tobacco cessation support. The social marketing campaign “[2] Minutes With Your Dentist Can Save Your Life” was conducted through this time period and created significant program awareness, generating more than 3.1 million viewer impressions in the target audience.
Challenges
Multiple challenges emerged at the outset of the program while recruiting dental practices. Dental providers expressed a concern that the implementation of regular hypertension screening would be challenging and time-consuming. This feeling was common despite the recognition by the American Dental Association (ADA) that hypertension is one of the most common and deadly cardiovascular conditions in the U.S. and that blood pressure management is considered an important screening vital sign at dental visits. [15] Dentists and dental hygienists are trained to take a patient’s blood pressure as part of the patient’s medical history, which is considered standard practice. Nonetheless, dentists felt that adding hypertension screening to the practice workflow would take time away from staff who were needed to complete the scheduled dental procedures for patients. This is consistent with findings from another study conducted with 100 dental hygienists where the majority indicated they were not conducting blood pressure screenings during appointments, even though their training emphasized doing so, because of insufficient time and the minimal value given to the procedure by their employers. [16] Additionally, the lack of insurance reimbursements for hypertension screenings caused concern for some providers. Dental providers stated the time needed to screen each patient would add up to a considerable amount of time that could be used to address oral health concerns. In a study conducted in Georgia to understand whether dental providers were monitoring blood pressure, the study revealed the majority of the dentists or dental hygienists were not monitoring blood pressure despite inclusion of it in their dental curriculum. [16] The main reason stated was their perception that doing so would increase the amount of time it would take for them to finish the appointment. The study recommended that dental curricula in colleges and universities prioritize the importance of blood pressure screening for all patients.
Another challenge was a low rate of referrals from dental practices to medical practices. Dental practices were asked to create partnerships with medical practices in their community to establish a feedback mechanism for patient referrals and follow-up. Only 43% of dental practices were able to establish this feedback loop. Some cited lack of medical practices in the dental practice area as others indicated that potential referral sites were unable to take on new patients. FQHCs were generally more successful in this endeavor than private dental practices, as medical and dental services were often provided within the same facility. A method that proved useful in creating feedback loops within private practices was to have a dedicated member of the dental team follow up with the medical practice on a regular basis after the referral was made.
This hurdle persisted throughout the pilot even though a review of best practices for referrals from dental providers to primary care providers and a standardized dental-medical referral form was created for and provided to participating dental practices in the initial training sessions. Furthermore, dental providers were often unable to complete follow-up on referrals they made to primary care providers, and primary care providers were unwilling, unable or simple too busy to connect with dental providers to confirm their patients had been seen for medical follow-up. The feedback from dental providers as to why this referral process was not seamless indicated that inadequate communication channels between dental and medical practices were common and that the lack of a shared electronic health record was considered to be the main obstacle contributing to this lack of communication.
Lessons Learned
Dental practices that received guidance and support from the MDH and LHDs incorporated hypertension screenings into their workflow with little disruption. This observation highlights the importance of proper guidance and support for maximum program integration. Moreover, once dental providers were able to detect patients with undiagnosed or elevated blood pressures in their patient population and were able to refer them to primary care physicians for follow-up care, they began to view hypertension screenings as a vital service for their patients. This new perspective eased dental providers’ concerns regarding the lack of time and financial reimbursement as well as the potential workflow disruptions they initially felt hypertension screening would cause. Even so, only 43% of dentists were able to generate a bidirectional referral process with primary care providers.
Clearly, the most important lesson learned from the Models of Collaboration for State Chronic Disease and Oral Health Programs initiative was that improved communication between medical and dental providers is necessary and holds tremendous promise for improved health outcomes in the identification and management of hypertension. This pilot showed that a strong bidirectional referral system that is integrated into existing health records and medical-dental referral systems is needed to help facilitate the communication and collaboration necessary to screen for and help manage chronic disease within the dental setting.
Recommendations
In developing medical-dental collaboration programs, a greater focus should be on creating and building a strong referral network among medical and dental providers prior to program implementation. In addition, increasing communication between dental and medical providers and emphasizing the importance of shared program goals before program implementation can lead to an increase in bidirectional referrals between medical and dental providers.
It is also recommended that both medical and dental practices explore opportunities to integrate existing health records into electronic referral systems. Such systems will ensure patients receive the proper follow-up, diagnosis and treatment when presenting with hypertension during routine dental visits. A case management system should be considered to help with communication between medical and dental professionals, which can also help patients understand and navigate their treatment. In addition to improving and integrating existing electronic health referral systems, the creation of a standalone electronic application, designed to help facilitate referrals between medical and dental providers, should be researched and potentially developed to improve communication between medical and dental providers and increase the rate of successful referrals that occur between them.
The experience of collaboration between staff at the state’s OOH and CCDPH throughout this pilot was an invigorating, organic process that systematically grew into the development and implementation of the pilot. Each team member brought their own excitement and expertise to the project, and as a result, the project and team members benefited greatly. The level of engagement, trust and teamwork that occurred cannot be overstated. Therefore, it is strongly recommended that oral health programs consider building collaborative relationships with state chronic disease programs. These collaborative relationships centered on addressing shared oral health and chronic disease interests can not only help to potentially reduce common chronic diseases, but can also stimulate the workplace, inspire staff and provide a clear window into fostering and operationalizing medical/dental integration.
Lifesaving Outcomes
In several cases, patients in the pilot who were found to have hypertension reported lifesaving and life-changing results after leaving the dental office. This occurred in a few patients who chose to visit hospital emergency departments after their screening. In one instance, a 41-year-old male whose blood pressure reading was 140/101 mm Hg reported that upon leaving the dental office he immediately visited the closest emergency department. There he was diagnosed with an untreated heart condition and was briefly hospitalized, treated and released. In another case, an individual with hypertension who presented to an emergency department after screening in the dental setting was diagnosed with a heart condition requiring surgery. This patient recounted how he was immediately transferred to a second hospital where the successful surgery took place. In both cases, the patients are now doing well and credit the dental professionals who took the time to take their blood pressure during their dental visit for saving their lives.
Conclusion
Integration between oral health care and primary health care is a key factor to improving overall health as well as reducing mortality. The CDC Models of Collaboration for State Chronic Disease and Oral Health Programs grant program has clearly demonstrated how dental providers can play a significant role in the overall health of their patients. Another CDC grantee, the Minnesota Department of Health, conducted a pilot medical-dental integration bidirectional referral system for both blood pressure and periodontal disease. Their project results showed that approximately onethird of people screened for hypertension had high blood pressure. Without collaboration between state oral health and chronic disease programs and the subsequent medical-dental integration that occurred, these cases simply would have been missed opportunities to curb disease and potentially save lives. [17] In a recent podcast, Drs. Riedy and Jiang of the Center for Integrating Primary Care and Oral Health funded by the Health Resources and Services Administration (HRSA) at the Harvard School of Dental Medicine highlight the dental practice as playing a key role in helping to identify and treat chronic comorbid conditions, citing the bidirectional link between diabetes and periodontal disease and its impact on glycemic control. [18]
The CDC and HRSA through grant opportunities have signaled their recognition and support of the integration of oral health and chronic disease programs as a pathway to improve overall health and reduce illness. These grant programs, if continued, will hopefully allow state health departments across the country to create models of integrated care. In a 2014 study published by the ADA Health Policy Research Center, screening for high blood pressure, diabetes and high cholesterol in the dental office could save the health care system up to $102.6 million each year. [19] These recent developments and findings, along with the many health care, public health, professional and advocacy groups calling for increased integration of medicine and dentistry, have created a ground swell of momentum that can increase collaboration as a way to ensure access to quality health care, decreased costs and improved health outcomes throughout the nation.
The Maryland Hypertension Screening in the Dental Setting pilot program is only one example of the many programs demonstrating the significant impact dental professionals can have on the reduction of hypertension and other chronic diseases. In the Maryland pilot, 47 dental practices screened 36,996 patients for hypertension and referred 2,689 to primary care physicians for further evaluation and/or treatment in just more than one year. These numbers indicate the positive impact of chronic disease screening in the dental setting and the potential for nationwide incorporation of hypertension screening in dental practices to help the fight to reduce heart disease.
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14. Miloro MB, Vujicic M. Physicians dissatisfied with current referral process to dentists. Health Policy Institute Research Brief. American Dental Association. www.ada.org/~/media/ ada/science%20and%20research/hpi/files/hpibrief_0316_5. pdf.
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16. Hughes CT, Thompson AL, Browning WD. Blood pressure screening practices of a group of dental hygienists: A pilot study. J Dent Hyg Fall 2004;78(4):11. Epub 2004 Oct 1.
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18. Center for the Integration of Primary Care and Oral Health, audio blog interview. www.listennotes.com/podcasts/rosreview-of/ros-drs-christine-riedy-tien-Sw3UoeA0G1P.
19. Burger D. New Guideline on Hypertension Lowers Threshold. American Dental Association. New guideline on hypertension lowers threshold. www.ada.org/en/publications/ ada-news/2017-archive/november/new-guideline-onhypertension-lowers-threshold.
NOTE: To find more information on Maryland’s Hypertension Screening in the Dental Setting pilot program, visit: Maryland Department of Health. Models of Collaboration for State Chronic Disease and Oral Health Programs in Maryland. phpa.health.maryland.gov/oralhealth/Documents/ HypertensionFinalReport.pdf.
THE CORRESPONDING AUTHOR, John Welby, MS, can be reached at john.welby@maryland.gov.
