FACT SHEET: Hypertension in Children & Adolescents (also known as “high blood pressure” or “high BP”)
Note: This fact sheet focuses on hypertension in persons aged less than 18 years. For hypertension in adults (i.e., persons aged 18 years and above), please refer to Hypertension in Adults Fact Sheet.
Is the initiation of non-invasive dental hygiene procedures* contra-indicated?
- No, unless blood pressure is greatly elevated1 or a hypertensive crisis is suspected. Warning symptoms/signs of a hypertensive crisis in children and adolescents, in the context of markedly elevated blood pressure, include: severe headache, blurred vision, seizures, nausea/vomiting, chest pain, shortness of breath, nosebleeds, and heart palpitations (i.e., fast, pounding, or fluttering heartbeat). Hypertensive crisis is a medical emergency, and emergency protocol should be activated. For practical purposes for informing self-initiation decision-making for patients/clients aged less than 18 years, the dental hygienist can use actual or suspected stage 2 hypertension (i.e., BP > 95th percentile plus 12 mm Hg) as a basis for not initiating non-invasive and invasive dental hygiene procedures.
Is medical consult advised?
- Yes, if blood pressure approaches or exceeds the 95th percentile for children of the same sex, age, and height, as determined through the use of normative tables/calculators. For children less than 6 years of age, normative tables/calculators should always be used, whereas simplified thresholds may alternatively be used for older children and adolescents, as described immediately below.
- Yes, if blood pressure approaches or exceeds the following simplified hypertension diagnostic thresholds2:
- if SBP > 120 mm Hg or DBP is > 80 mm Hg in children 6-11 years of age;
- if SBP > 130 mm Hg or DBP > 85 mm Hg in children/adolescents 12-17 years of age.
- Yes, if BP is at or exceeds the values in Table 4’s simplified table for initial blood pressure screening.
- Prompt medical referral3 should be made for evaluation and therapy if the child/adolescent’s BP is at stage 2 level (i.e., BP > 95th percentile plus 12 mm Hg).
Is the initiation of invasive dental hygiene procedures contra-indicated?**
Is medical consult advised?
- See above.
Is medical clearance required?
Is antibiotic prophylaxis required?
Is postponing treatment advised?
- No, unless hypertensive crisis is suspected or BP is stage 2 or there are other concerns that invasive procedures may significantly elevate patient/client blood pressure (e.g., missed anti-hypertensive medications), which should prompt medical consultation prior to the performing of invasive procedures. Dental hygiene procedures should be deferred for any child who is suspected to have stage 2 hypertension, which necessitates prompt medical referral.
- Asymptomatic paediatric patients/clients with elevated BP less than stage 2 (particularly those without other cardiovascular risk factors) can likely receive any indicated dental hygiene treatment; however, children/adolescents with elevated blood pressures should be encouraged to see their physician for investigation and optimal management.
Oral management implications
- The auscultatory method of office blood pressure measurement is currently preferred for children over automated methods. (See Table 1 below for the standard approach to BP measurement in children.) BP can be measured with a mercury or aneroid sphygmomanometer.4 Because BP varies with sex, age, and height, BP values should be compared with norms for sex, age, and height (see Table 2 below).
- While regular measurement of BP by physicians for children ≥ 3 years of age is recommended by various authorities (and particularly for those considered at particular risk of hypertension5 aged 3+ to 5 years), routine measurement of BP by dental hygienists in young children in the oral care setting may not always be practical. Where it is feasible and appropriate to measure blood pressure (as in older children and adolescents, particularly in those with risk factors), tables and/or calculators (see weblinks immediately below Table 2 plus Table 3) can guide screening for hypertension (i.e., BP beyond the 95th percentile for sex, age, and height).
- Simplified diagnostic thresholds (see Table 3 below) can be used (in addition to, or as an alternative to, normative tables/calculators) for children/adolescents aged 6-17 years of age. These simplified thresholds are as follows: children can be diagnosed as hypertensive if SBP or DBP is > 120/80 mm Hg in children 6-11 years of age, or greater than 130/85 mm Hg in children 12-17 years of age. (For children aged 1-6 years of age, normative tables/calculators should be used.)
- Table 4 (below) may be used for simplified BP screening to inform referral for medical evaluation.
- The primary concern in dental hygiene management of a patient/client with hypertension is that during the course of treatment a sudden, acute elevation of blood pressure might occur, potentially leading to a serious outcome, such as stroke or seizure. Emotional stress and pain stimulate the sympathetic nervous system, which can result in elevated blood pressure. The two important questions to be answered before dental hygiene treatment are: 1/ what are the associated risks of treatment in this patient/client; and 2/ at what level of blood pressure is treatment unsafe for the patient/client.
- The procedural risk associated with an adverse cardiovascular outcome from both non-invasive and invasive dental hygiene procedures is very low. Markedly elevated blood pressure should be brought under control before elective procedures or surgery are performed.
- Appointments should be scheduled at a time of day when the paediatric patient/client is rested and most likely to cooperate. Stress management in a paediatric context is important to decrease the chances of endogenous release of catecholamines that might increase blood pressure.
- Stress management is important to decrease the chances of endogenous release of catecholamines that might increase blood pressure.
- Orthostatic hypotension (i.e., low blood pressure when standing erect) can result from drugs (e.g., angiotensin converting enzyme inhibitors, angiotensin II receptor blockers, and direct vasodilators) used to treat hypertension. Dental hygienists can minimize patient/client light-headedness or fainting by avoiding rapid chair position changes.
- Beta-blockers can result in dizziness, bronchospasm, and masking of hypoglycemia; the dental hygienist should be alert to these possible drug side effects.
- Dental hygienists should educate patients/clients (and/or parents/guardians, depending on age of the patient/client) when abnormal vital signs (including blood pressure) are present, and recommend medical referral when appropriate. They should encourage compliance with physician’s recommended hypertension management plan, including prescription medications.
- Dental hygienists should counsel patients/clients who smoke (particularly those who are hypertensive) to stop smoking and refer them to cessation supports in their local communities (e.g., public health unit, smokers’ help line, etc.). In Ontario, the Canadian Cancer Society offers a free, confidential Smokers’ Helpline for smokers via Telehealth Ontario at 1-866-797-0000 or 1-877-513-5333; Smokers’ Helpline Online is available at www.smokershelpline.ca.
- None are specific to hypertension, but the contributory factor smoking has well-known oral manifestations. The development of facial palsy has been described in the occasional patient/client with very severe hypertension. Excessive bleeding after surgical procedures or trauma has been uncommonly reported in patients/clients with severe hypertension.
- Side-effects of anti-hypertensive medications include:
- chronic cough (e.g., angiotensin converting enzyme inhibitors — ACEIs, as well as direct renin inhibitors);
- taste changes (e.g., ACEIs, beta blockers, alpha-adrenergic blockers, and calcium channel blockers — CCBs);
- loss of taste (e.g., ACEIs and angiotensin II receptor blockers — ARBs);
- angioedema of lips, face, tongue (ACEIs and ARBs);
- upper respiratory tract infections (e.g., ARBs);
- gingival hyperplasia/overgrowth (e.g., CCBs);
- dry mouth (e.g., thiazide diuretics and alpha-adrenergic blockers);
- lichenoid reactions6 (e.g., thiazide diuretics and beta blockers);
- lupus-like oral and skin lesions (e.g., direct vasodilators); and
- parotid pain (e.g., central alpha-adrenergic — alpha 2 — agonists).
Related signs and symptoms
- Hypertension (high blood pressure) in children is generally defined as blood pressure that is at or above the 95th percentile for children of the same sex, age, and height, which can be ascertained through the use of normative tables/calculators. (Refer to Tables 2 and 3 and their associated weblinks below.) However, simplified diagnostic thresholds can be additionally or alternatively used to diagnose hypertension in children/adolescents aged 6-17 years. These simplified thresholds are as follows: children can be diagnosed as hypertensive if SBP or DBP is > 120/80 mm Hg in children 6-11 years of age, or greater than 130/85 mm Hg in children 12-17 years of age. For children less than 6 years of age, normative tables/calculators should be used. For persons aged 18 years of age and older, adult diagnostic thresholds apply.
- Normal blood pressure rises as a child ages.
- Hypertension affects 1% to 2% of children/adolescents in Canada, with higher rates amongst those who are overweight or have obesity. High BP is more frequent in boys than girls.
- The younger a child is, the more likely it is that hypertension is caused by an identifiable underlying cause; i.e., secondary hypertension. Older children (i.e., age 6 years and over) and adolescents, similar to adults, are more likely to have primary hypertension (also known as “essential” or “idiopathic” hypertension; i.e., with blood pressure with no specific identifiable cause). Primary hypertension now accounts for most cases of childhood hypertension.
- Risk factors for primary hypertension in children/adolescents include: being overweight or having obesity; having a family history of high blood pressure; having type 2 diabetes or high fasting blood glucose level; having high cholesterol; eating too much salt; smoking or being exposed to second-hand smoke; being sedentary; being male; and being Black or Hispanic.
- Causes of secondary hypertension include: chronic kidney disease; polycystic kidney disease; renal artery stenosis; certain cardiovascular problems (such as coarctation of the aorta7); certain adrenal gland disorders (such as Cushing syndrome, hyperaldosteronism, and pheochromocytoma); obstructive sleep apnea; certain medications and licit drugs (such as stimulants used to treat attention deficit hyperactivity disorder [ADHD], steroids, non-steroidal anti-inflammatory drugs [NSAIDs], and caffeine); and some illicit drugs (such as cocaine and methamphetamine).
- High BP in childhood is linked to high BP in adulthood, and hypertension is a risk factor for myocardial infarction, stroke, heart failure, and chronic kidney disease.
- While hypertension doesn’t usually cause overt signs/symptoms (at least until associated morbidities manifest themselves), signs/symptoms of a hypertensive crisis (i.e., high blood pressure emergency) in children include: severe headache, blurred vision, seizure, vomiting, chest pain, shortness of breath, nosebleeds, and heart palpitations (i.e., fast, pounding, or fluttering heartbeat).
- Dental hygienists are most likely to encounter hypertensive paediatric patients/clients taking angiotensin converting enzyme inhibitors (ACEIs, such as ramipril); angiotensin II receptor blockers (ARBs, such as losartan); and various long-acting calcium channel blockers (CCBs, such as felodipine, diltiazem, and verapamil). Less frequently used are thiazide diuretics (e.g., hydrochlorothiazide), beta-blockers (e.g., metoprolol), and direct vasodilators (e.g., hydralazine).
The tables and information that follow are intended only as guides to help inform decision-making. The dental hygienist must also consider the current clinical status of the patient/client in the office. Patients/clients with high blood pressure who have signs/symptoms such as severe headache, blurred vision, shortness of breath, nosebleeds, nausea/vomiting, chest pain, or seizures, should be referred to a physician for immediate evaluation. Furthermore, the dental hygienist should compare current BP reading with previous readings. A person who typically has low or normal blood pressure who now has unexpectedly elevated blood pressure may be more worrisome in the short-term than a person who habitually has high blood pressure.
The dental hygienist should consider the individual circumstances of each paediatric patient/client. Specific procedures (be they non-invasive or invasive) should be avoided if the dental hygienist believes they could cause stress/anxiety resulting in a sudden, acute elevation in blood pressure. This individual consideration of stress/anxiety is particularly important for patients/clients with pre-existing high blood pressure. If in doubt, the dental hygienist should defer the procedure(s) pending medical evaluation.
Table 1: Standard approach for BP measurement in children
Adapted from: Hypertension Canada’s 2020 Comprehensive Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children
Table 2: Determining normative data for blood pressure values in children
Adapted from: 1/ Hypertension Canada’s 2020 Comprehensive Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children. 2/ Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017 Sep;140(3):e20171904. doi: 10.1542/peds.2017-1904. Epub 2017 Aug 21.
Weblink to Blood Pressure Tables for determination of normative data for blood pressure values in children/adolescents: https://pediatrics.aappublications.org/content/140/3/e20171904 (Refer to article’s Table 4 for BP Levels for Boys by Age and Height Percentile; Refer to article’s Table 5 for BP Levels for Girls by Age and Height Percentile)
Weblink to Calculator for determination of normative data for blood pressure values in children/adolescents: https://www.bcm.edu/bodycomplab/BPappZjs/BPvAgeAPPz.html. (Note: While this calculator can be used to determine percentiles for SBP and DBP by sex/age/height, the included American definitions of elevated blood pressure and hypertension differ somewhat from Hypertension Canada’s 2020 guidelines.)
Table 3: Criteria for Diagnosis of Hypertension in Children and Adolescents
Adapted from: Hypertension Canada’s 2020 Comprehensive Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children
Table 4: Simplified Table for Screening Blood Pressure Values Requiring Further Medical Evaluation
Note: This simplified table for initial blood pressure (BP) screening is based on the 90th percentile BP for sex and age for children at the 5th percentile of height. It should not be used to diagnose elevated BP or hypertension by itself, because SBP and DBP cut-offs in complete BP tables may be as much as 9mm Hg higher depending on a child’s age and height.
Adapted from: 1/ Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020. 2/ Flynn JT, Kaelber DC, Baker-Smith CM, et al. Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017 Sep;140(3):e20171904. doi: 10.1542/peds.2017-1904. Epub 2017 Aug 21.
References and sources of more detailed information
- College of Dental Hygienists of Ontario
https://cdho.org/factsheets/hypertension-in-adults/ (Hypertension in Adults)
- Li P, Rowan-Legg A, Kwok B, Bayoum I, Arulthas S, Tedone E, Leduc D, Rourke J, Rourke L. 2020 edition of the Rourke Baby Record: What is new in preventive care of children up to 5 years of age. Canadian Family Physician. 2021 Jul;67(7):488-498. DOI:10.46747/cfp.6707488 https://www.cfp.ca/content/67/7/488.full
- Rourke Baby Record https://www.rourkebabyrecord.ca/Default.asp
- Flynn JT, Kaelber DC, Baker-Smith CM, Blowey D, Carroll AE, Daniels SR, de Ferranti SD, Dionne JM, Falkner B, Flinn SK, Gidding SS, Goodwin C, Leu MG, Powers ME, Rea C, Samuels J, Simasek M, Thaker VV, Urbina EM; Clinical Practice Guideline for Screening and Management of High Blood Pressure in Children and Adolescents. Pediatrics. 2017 Sep;140(3):e20171904. doi: 10.1542/peds.2017-1904. Epub 2017 Aug 21. Erratum in: Pediatrics. 2017 Nov 30;: Erratum in: Pediatrics. 2018 Sep;142(3): PMID: 28827377.
- Riley M, Hernandez A, Kuznia A. High Blood Pressure in Children and Adolescents. Am Fam Physician. 2018 Oct 15;98(8):486-494. https://www.aafp.org/afp/2018/1015/p486.html
- National High Blood Pressure Education Program Working Group on High Blood Pressure in Children and Adolescents. The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. Pediatrics. 2004 Aug;114(Supplement 2):555-576. https://pediatrics.aappublications.org/content/114/Supplement_2/555.long
- Hypertension Canada https://guidelines.hypertension.ca
- Hypertension Canada’s 2020 Comprehensive Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children
https://www.onlinecjc.ca/article/S0828-282X(20)30191-4/fulltext#secsectitle1260 (Special Populations 2. Hypertension and Pediatrics)
- Hypertension Canada’s 2018 Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children https://www.onlinecjc.ca/article/S0828-282X(18)30183-1/fulltext
- Hypertension Canada’s 2017 Guidelines for Diagnosis, Assessment, Prevention, and Treatment of Pediatric Hypertension
https://www.onlinecjc.ca/cms/10.1016/j.cjca.2017.03.007/attachment/6c701aae-1b6d-41fa-b7d9-cdbdda056b8f/mmc1.pdf (Supplemental Tables, including S1 — Grading Scheme for Recommendations; S2 — Standard approach for BP measurement in children; S3 — Determining normative data for BP values in children; S4 — History and Physical Examination; S5 — Suggested to classify BP in children)
- HealthLinkBC https://www.healthlinkbc.ca/health-topics/high-blood-pressure-children (High Blood Pressure in Children)
- Centers for Disease Control and Prevention
https://www.cdc.gov/growthcharts/ (2000 CDC Growth Charts, National Center for Health Statistics)
https://wwwn.cdc.gov/nchs/nhanes/1999-2000/BPX.htm (1999-2000 BP Data, National Health and Nutrition Examination Survey)
https://www.cdc.gov/ncbddd/heartdefects/coarctationofaorta.html (Congenital Heart Defects)
- Children’s Nutrition Research Center, Baylor College of Medicine
https://www.bcm.edu/bodycomplab/BPappZjs/BPvAgeAPPz.html (Age-based Pediatric Blood Pressure Reference Charts and Pediatric BP Calculator)
- Mayo Clinic
- Bowen DM (ed.) and Pieren JA (ed.). Darby and Walsh Dental Hygiene: Theory and Practice (5th edition). St. Louis: Elsevier; 2020.
- Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier Mosby; 2018.
- Pickett FA and Gurenlian JR. Preventing Medical Emergencies: Use of the Medical History in Dental Practice (3rd edition). Baltimore: Wolters Kluwer Health, 2015.
2 The simplified childhood hypertension diagnostic thresholds are defined in Hypertension Canada’s 2020 Comprehensive Guidelines for Diagnosis, Risk Assessment, Prevention, and Treatment of Hypertension in Adults and Children (Special Populations 2. Hypertension and Pediatrics). This relatively new Canadian option of using a simplified threshold approach for children/adolescents aged 6 years to 17 years differs from the continued promulgation of the normative table/calculator approach for all children/adolescents by some American authorities (and also differs from older Canadian guidelines).
3 Some authorities define “prompt” in this context as “within one week.”
4 If an oscillometric device is used, abnormal oscillometric values should be confirmed with auscultation.
5 Risk factors include obesity, sleep-disordered breathing, prematurity, low birth weight, kidney disease, diabetes, congenital heart disease, or taking medications that increase blood pressure.
6 Lichenoid drug reactions/eruptions are also known as drug-induced lichen planus.
7 Coarctation of the aorta is a birth defect in which part of the aorta is narrower than usual. Most commonly, this narrowing occurs just after arteries branch off to deliver blood to the head and upper extremities.
8 Oscillometric determination of blood pressure entails use of an automated device that measures mean arterial pressure. Systolic and diastolic blood pressure are then calculated via an algorithm.
* Includes oral hygiene instruction, fitting a mouth guard, taking an impression, etc.
** Ontario Regulation 501/07 made under the Dental Hygiene Act, 1991. Invasive dental hygiene procedures are scaling teeth and root planing, including curetting surrounding tissue.