2023+意大利实践指南：高血压和牙周炎.pdf

Vol.:(0123456789)High Blood Pressure&Cardiovascular Prevention https:/doi.org/10.1007/s40292-022-00553-2CLINICAL GUIDELINES ANDPRACTICE RECOMMENDATIONSPractical Guidelines forPatients withHypertension andPeriodontitisDavidePietropaoli1,2 FrancescoCairo3 FilippoCitterio4 FrancescoDAiuto5 ClaudioFerri6 GuidoGrassi7,8 LucaLandi9 ClaudioLetizia10 StefanoMasi11,12 MariaLorenzaMuiesan13,14 GuerinoPaolantoni15 NicolaMarcoSforza16,17 RitaDelPinto2,6 the Italian working group on Hypertension and Periodontitis(Hy-Per Group)Received:31 October 2022/Accepted:12 November 2022 The Author(s)2023AbstractArterial hypertension(AH)and periodontitis are among the most common non-communicable chronic diseases worldwide.Besides sharing common risk factors,an increasing body of evidence supports an independent association between the two conditions,with low-grade systemic inflammation acting as the plausible biological link with increased cardiovascular risk.In 2021,the Italian Society of Arterial Hypertension(SIIA)and the Italian Society of Periodontology and Implantology(SIdP)have joined forces and published a joint report on the relationships between AH and periodontitis,reviewing the existing scientific evidence and underlining the need to increase awareness of the strong connection between the two con-ditions and promote treatment strategies for the control of gums inflammation in patients with AH.The current document extends the previous joint report,providing clinical practical guidelines aimed to support clinicians in the management of patients who suffer from or are at risk of being affected by both conditions.These recommendations are based on careful consideration of the available evidence as well as of the current guidelines on the management of periodontitis and AH and are supported by SIIA and SIdP.Keywords Hypertension Periodontitis Practice guidelines1 IntroductionArterial hypertension(AH)and periodontitis are among the most common chronic diseases in the world,and they can significantly affect peoples health and well-being 1.AH is the most relevant risk factor for cardiovascular diseases,which are still the main cause of death in the world and affects about 1 in 3 Italians,half of whom are unaware.Simi-larly,periodontitis,a chronic non-communicable disease of the supporting tissues of the teeth,affects up to 50%of the worlds population,with about 3 millions Italians suffering from severe forms and running an imminent risk of tooth loss 2.In 2021,the Italian Society of Arterial Hypertension(SIIA)and the Italian Society of Periodontology and Implan-tology(SIdP)have joined forces and published a Joint report on the relationships between AH and periodontitis,review-ing the existing scientific evidence and underlining the need to promote strategies that aim to control gums inflammation in the management of patients suffering from AH 3.The current document extends the previous joint report,providing clinical practical guidelines aimed to support cli-nicians in the management of patients affected or at risk of being affected by both conditions.These recommendations are based on careful consideration of the available evidence as well as of the current guidelines on the management of hypertension and periodontitis and are supported by SIIA and SIdP.*Claudio Ferri claudio.ferriunivaq.it*Luca Landi Extended author information available on the last page of the article D.Pietropaoli et al.Practical Recommendations 1.Measuring blood pressure and diagnosis of AH 2.Diagnosis of gingivitis/periodontitis 3.Assessing common risk factors 4.Identifying patients with gingivitis/periodontitis at risk for AH 5.Identifying patients with AH at risk of gingivitis/periodontitis 6.Patient information to increase the level of aware-ness 7.Identifying whom to refer patients at risk 8.Step 1,2 and 3 of periodontal therapy 9.Follow-up and supportive care 10.Integrated care pathways 11.Recommendations for healthcare providers 12.Essential bibliography1.Measuring blood pressure and diagnosis of AHA correct blood pressure(BP)measure is crucial to reach an accurate diagnosis of AH,define the severity of the condi-tion,prescribe appropriate treatments,and plan the patients follow-up.The most widely used method to screen for AH is based on the measure of BP values in a health care setting(by a physician,a nurse,a pharmacist,or a dentist),referred to as Office Blood Pressure Monitoring(OBPM)4.A single BP recording is insufficient to reach a final diagnosis of AH,which instead should be made after repeated BP measure-ments 4.These might be acquired:(a)in the same health care setting of the screening visit,if there is the experience in measuring BP or(b)through an ambulatory BP monitoring(ABPM),which records the BP values over 24 h(a minimum of 70%usable BP recordings are required for a valid ABPM measurement session)or(c)through home BP monitoring(HBPM),which repre-sents the average of all BP readings performed with a semiautomatic,validated BP monitor,for at least 3 days(and preferably for 67 consecutive days)before each clinical visit.When the HBPM is used to confirm the diagnosis of AH,patients should be instructed to acquire at least two BP measurements 12 min apart for each recording,and record-ings should be performed in the morning and the evening 4.The method used to confirm the diagnosis of AH should take into account the availability of ABPM devices,the indi-viduals ability to acquire accurate BP values at home,the suspect of secondary forms of AH(i.e.obstructive sleep apnea syndrome)and the severity of BP elevation recorded during the first screening.Independently of the method used to confirm the diag-nosis of AH,all individuals with elevated BP values at a first screening should receive adequate training on the most appropriate method to measure BP at home.1.1 BP measurements should be acquired in a quiet environ-ment after 5 minutes of resting in a seated position.1.2 Acquisitions should be carried out under conditions of mental and physical well-being,as measurements taken in the presence of symptoms(pain,anxiety,stress)are generally associated with increased BP values that do not represent the real BP control of the patient.1.3 Measurements should be taken with a bladder cuff placed around the upper arm at the level of the heart.The cuff size should be appropriate for the size of the patients arm(obese individuals should use larger cuff sizes to avoid overestimation of BP values).1.4 The acquisition of the first measurement should be fol-lowed by a second and third measurement,spaced at least 23 min apart.1.5 A progressive decrease of BP in repeated measurements is often observed in individuals with a white coat effect or an alert reaction to BP measurement.In these cases,the patients final BP value should be considered asthe average of at least 2 BP measurements taken consecu-tively and for which the difference in systolic BP should be 3 mm are defined as pockets,which in gen-eral present subgingival bacterial colonization and benefit from scaling,with CAL gain and PD reduction after treat-ment.REC is the distance between the CEJ and the gingival margin.BOP assessment consists of the recording of the presence of bleeding at a specific site after gentle probing with the periodontal probe.BOP is strictly correlated with the presence of inflammation in the periodontal tissues.Full-mouth assessment at 4-to 6-sites per tooth is required.2.1 A patient with at least 10%of the sites with BOP is diagnosed with gingivitis.Gingivitis is then classified as localized(10%BOP 30%)or generalized(30%).This classification applies both to patients with intact periodontium and patients with a reduced periodontium(i.e.CAL loss).2.2 The diagnosis of periodontitis is established if a patient presents with:(a)Interdental CAL loss at2 non-adjacent teeth,or(b)Buccal or lingual CAL loss 3mm with pocket-ing3mm detectable at2 teeth.2.3 It is important to exclude cases in which CAL loss is caused by other factors than periodontitis,such as trau-matic REC,vertical root fractures,subgingival restora-tions or decay,impaction of third molars,or an endodon-tic lesion draining through the marginal periodontium.2.4 The severity and the risk of progression of periodontitis are further classified according to stage and grade.Diag-nostic process includes:a detailed medical and dental history and periodontal and intra-oral radiologic exami-nations.2.5 Stage(IIV)defines the severity of periodontitis and the complexity of treatment and depends on different parameters,including CAL,PD,radiologic bone loss,tooth loss,furcation involvement and impairment of masticatory function.2.6 Grade(A to C)identifies the risk of progression of peri-odontitis and depends on previous evidence of progres-sion and on local and systemic risk factors.2.7 Extent is then classified as localized(30%of teeth involved),generalized,or molar/incisor pattern.Take home messages Dental professionals should check patients periodontal conditions during routine dental visits.Clinical and radiographic assessments are required to diagnose gingi-vitis and periodontitis.Staging and grading are useful tools to determine the severity of the disease and the complexity of treatment.3.Assessing common risk factorsEvidence indicates that an independent association exists between periodontitis and AH,with common genetic denominators involving genes entailed in the immune function 7.In parallel,these conditions share common unmodifiable and modifiable risk factors,such as older age,male sex,smoking habits,sedentary life-style,overweight/obesity,low socioeconomic status,and D.Pietropaoli et al.poor education,which concur,through intertwined mecha-nisms,to determine the clinical phenotype.Therefore,when collecting medical history,attention should be paid to the burden represented by the exposure to such contributors,and the patient should be advised regarding the most updated approaches to the management of modifiable traits and how to persist over time in healthy lifestyle modifications.Even within the time constraints of clinical practice,very brief advice is encouraged,as recommended by cardiovascular prevention guidelines 8.3.1 Patients with periodontitis and with AH should be screened for concomitant and shared modifiable cardio-vascular risk factors.3.2 Patients with periodontitis and with AH should be advised that they should actively manage all their car-diovascular risk factors for an effective reduction of their lifetime risk of related diseases.3.3 Smoker individuals with AH and/or with periodonti-tis should be identified(“ASK”),advised on the best method of quitting(“ADVISE”),and offered help in their quitting attempts(“ACT”)at every visit.3.4 Overweight and obese individuals with AH and/or with periodontitis should be informed of the BP benefit and the cardiovascular risk reduction associated with los-ing weight,and recommendations to adhere to healthy diet and engage in physical exercise should be given and reiterated over time.3.5 According to guidelines,adults of all ages should be encouraged to stay active as their abilities and health condition allow,to increase their physical activity if sedentary,and,in the absence of specific limitations,to engage in at least 150-300 minutes of moderate-intensity exercise on a weekly basis,or in 75-150 minutes a week of vigorous-intensity aerobic exercise,or an equivalent combination thereof 8.3.6 Individuals with AH and/or with periodontitis who also present with lipid and/or glucose metabolism disorders should be informed of the importance to control these concomitant risk factors to achieve a better control of their BP,improve periodontal outcomes,and reduce their lifetime cardiovascular risk.Take home messages Routine assessment and management of modifiable cardiovascular risk factors according to guidelines should be undertaken in indi-viduals with periodontitis and in those with AH.4.Identifying patient with gingivitis/periodontitis at risk for AHAn increased risk of incident AH exists in the pres-ence of periodontal diseases 9.Notably,observational evidence indicates an increased risk of uncontrolled AH in adults receiving antihypertensive treatment who also suffer from periodontitis 10.In parallel,home and pro-fessional oral care are associated with improved BP pro-file 1113.For the multimodal connections between periodontal diseases and cardiovascular health status,in the light of thepotential implications in terms of lifetime risk of cardi-ovascular diseases,early identification of individuals with gingivitis and periodontitis who are at risk of developing AH is desirable.4.1 In patients with gingivitis/periodontitis,periodontal inflammation increases the risk of developing AH and might affect the achievement of adequate BP control during antihypertensive treatment.4.2 Patients with gingivitis/periodontitis should regularly check their BP values.4.3 In patients with gingivitis/periodontitis,family and per-sonal history of risk factors and conditions that increase their risk for developing AH should be investigated:4.3.1 Enquire on family history of AH,cardio-vascular diseases,or renal disease,which,if present,poses an increased risk of developing AH;4.3.2 Inform of the lifestyle factors that have a detrimental impact on cardiovascular health and increase the risk of AH,including sedentary habits,excessive body weight,high-salt diet,low vegetables consumption,smoking,alcohol use,recreational drug use,and poor sleep.Take home messages In individuals with gingivitis/periodontitis:identify those with risk factors for developing AHinvite to regular BP checks also outside the health care setting.Practical Guidelines for Patients with Hypertension and Periodontitis5.Identifying patients with AH at risk of gingivitis/peri-odontitisWith the genetic component playing a role in the life-time risk of periodontitis and AH,and in the light of the susceptibility of both conditions to common risk factors,it is important to identify individuals diagnosed with AH who might be at increased risk of periodontitis.Interestingly,a high-salt diet,which is a common environmental trigger for AH,was demonstrated to impair antibacterial response and to favor tissue inflammation 14,15,both of which can have potential relevance for the risk and severity of periodontitis.Also,since the presence of gingival bleeding was found to increase the risk of high/uncontrolled BP,especially when occurring on top of an already established chronic periodon-tal disease 16,it is important that individuals with AH are made aware of the importance of a healthy periodontium.5.1 Individuals with AH should be asked information on their family history of periodontal diseases.5.2 Exposure to common risk factors should be investigated.5.3 Individuals with AH and poor home oral hygiene prac-tices(e.g.toothbrushing 2times/day)should be identi-fied.5.4 Individuals with AH should be asked if they have expe-rienced bleeding