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 Table of Contents  
Year : 2019  |  Volume : 11  |  Issue : 6  |  Page : 398-403

Effect of manual and air nonsurgical periodontal therapy on systolic and diastolic blood pressure

Department of Periodontal Dentistry, College of Dentistry, Mustansiriyah University, Baghdad, Iraq

Date of Web Publication26-Nov-2019

Correspondence Address:
Dr. Haider J Talib
Department of Periodontal Dentistry, College of Dentistry, Mustansiriyah University, Baghdad.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jioh.jioh_177_19

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Aims and Objectives: The blood pressure (BP) variability is a useful method to assess cardiac autonomic modulation in patients undergoing dental procedures because the knowledge of physiological conditions provides greater security to the professional as well as the possibility of a better plan treatment to patient benefit. The aim of our study was to study the association between BP and nonsurgical periodontal treatment. Materials and Methods: The research was carried out on 150 patients in Baghdad, all of them divided into two groups, first group: 75 patients, periodontal treatment for those groups was carried out by air scaling, second group: 75 patients, periodontal therapy for those groups was carried out by manual scaling. After the participants rested for ≥5min, we measured the systolic BP (SBP) and diastolic BP (DBP) three times (1–2min) in between for each participant in both groups by using mercury sphygmomanometer and bell stethoscope on the right arm of the patients while they were in sitting position. We used Community Periodontal Index for Treatment Need (CPITN) to determine the periodontal health status and the treatment needed for the study groups. Results: The results of this study revealed that the SBP and DBP mean values for the manual and air scaling groups had a significant increase after the scaling due to the pain and anxiety during therapy. The association between BP and CPITN was even stronger among participants with the time. Conclusion: This study showed that nonsurgical periodontal treatment led to elevated BP levels during therapy in correlation to the time and CPITN.

Keywords: Air scaling, Blood pressure, Diastolic blood pressure, Manual scaling, Systolic blood pressure

How to cite this article:
Mousa HA, Talib HJ, Mahmood AA. Effect of manual and air nonsurgical periodontal therapy on systolic and diastolic blood pressure. J Int Oral Health 2019;11:398-403

How to cite this URL:
Mousa HA, Talib HJ, Mahmood AA. Effect of manual and air nonsurgical periodontal therapy on systolic and diastolic blood pressure. J Int Oral Health [serial online] 2019 [cited 2023 Nov 30];11:398-403. Available from:

  Introduction Top

Psychosomatic changes can be stimulated by dental management and consequently can affect the treatment plan. Some extremely uncomfortable dental techniques can generate anxiety and substantial autonomic alterations.[1] A lot of patients have described dental therapy as stressful, which make them anxious. The patient acceptance to expose to some degree of discomfort during the treatment is the chief component that appears to impede with their behavior.[1],[2],[3] Hemodynamic changes during dental surgery have been investigated by numerous studies, and these studies gave the sympathetic effects, including the alterations in hypertension and tachycardia that arise from the pain and anxiety great attention.[4],[5],[6] On the contrary, the parasympathetic effects such as hypotension and hemodynamic variability in the patients were observed during dental treatment.[7]

Sympathetic tone can be increased by anxiety and pain. Some researchers have studied the effect local anesthesia can have on the sympathetic response, they have postulated that the elevation in heart rate and changes in blood pressure (BP) occurring during dental treatment are not related to the pharmacological effect, but the emotional stress causes the release of endogenous catecholamine.[6] Some scholars believe that the epinephrine in the local anesthetic solution is responsible for the cardiovascular response encountered during dental treatment.[7],[8] Alterations in adrenaline or noradrenaline levels in the plasma and urine as well as production of cortisol due to activation of the adrenal cortex have been documented; different dental treatments such as local anesthetic solution, drilling, filling, and teeth extraction cause substantial elevation in systolic blood pressure (SBP) and diastolic blood pressure (DBP) of the patients.[7] Elevation in SBP and DBP has been documented during restorative dental procedures that have been carried out without administration of local anesthetic solution or when the local anesthesia had no vasoconstrictor. Although another study suggests that elevated BP was responsible for the pain that the patients encountered as they reported no significant changes in BP during restorative treatment with local anesthesia.[4] During dental therapy, rise in BP could induce cardiovascular complications that the dentists should be aware of.[9],[10] A substantiated and effective treatment for periodontitis is nonsurgical periodontal therapy.[11] That includes mechanical scaling that perfumed without local anesthesia, so to create a local environment and microflora friendly with periodontal health by the elimination of plaque and calculus from tooth surfaces.[12] Periodontitis is commonly supposed to have some influence on general health as there is increasing evidence, which suggests that periodontitis has a possible risk factor for many systemic conditions, for example, cardiovascular disease.[13],[14] Since its chronic inflammation in nature connected with endothelial dysfunction and the systemic inflammatory markers.[15] Furthermore, the increased SBP and left ventricular mass in patients with hypertension have been associated with the severity of periodontitis.[16],[17] The commencement and advancement of hypertension can result from periodontitis-related systemic inflammation.[18]

Aims of study included the following:

  1. To find the relationship between BP and nonsurgical periodontal treatment and CPITN with time

  2. To overemphasize the importance of the routine measurement of BP in the dental office. BP measurement is an effective screening apparatus that can be alarm the patient, oral health professional, and physician to an unpredicted probable problem.

  Materials and Methods Top

The subjects consisted of 150 patients, subject’s collection was started on December 2016 to December 2017, from the Department of Periodontics, at the teaching hospital, College of Dentistry, Mustansiriyah University, Baghdad, Iraq. The subjects were divided into two groups, first group consisted of 75 patients and periodontal treatment for this group was carried out by air scaling. Second group consisted of 75 patients and periodontal treatment for this group was carried out by manual scaling. The ethics committee of Mustansiriyah University, College of Dentistry, approved this study (Ref no.: MUCD/582/2016–17).

Inclusion criteria constituted the following:

  1. Patients greater than 18 years of age.

  2. Patients with chronic periodontitis in which Periodontal pocket depth was >4mm, have at least five teeth remaining.

Exclusion criteria included the following:

  1. Patients who have undergone periodontal treatment in the three-month period before the study.

  2. All patients without present or previous cardiovascular disease or any other systemic disease.

  3. Systemic problems such as hyperthyroidism, severe anemia, severe myasthenia, active hemorrhage, acute alcohol intoxication, and recent myocardial infarction.

Community Periodontal Index for Treatment Need (CPITN) was used for the evaluation of periodontal health status and the treatment need; before this study, all informed consents were obtained from all participants.

Randomization in our research was carried out by choosing experimental participants randomly; we used simple random sampling, where participants’ names were drawn randomly, where everyone had an even probability of being chosen, we used this method so that we could guard or avoid bias selection.

Sample size in our study was usually determined based on time and conveniences of collecting data.

To estimate the right cuff size, the arm length and circumference of the participants were first measured. Each participant was rested for ≥5min, after which in sitting position, using mercury sphygmomanometer and bell stethoscope on the right arm of the participant, the SBP and DBP measurements were registered three times with 1–2-min intervals. Measurements were rounded upward to the nearest 2mm Hg, recorded, and later averaged. If the average SBP was ≥140mm Hg or average DBP was ≥90mm Hg then BP was considered elevated.[19] Before and after finishing dental hygiene therapy, SBP and DBP were registered.

Statistical analysis: Statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS version 21, Chicago, Illinois, in press), and the statistical tests used were Levene’s test, independent two-sample t-test, paired t-test, one-way analysis of variance with Dunnett’s T3 post hoc test, and Pearson correlation; the level of significance was set at P ≤ 0.05.

Sample size calculation: Sample size was calculated by using G*Power software, version, with program written by Franz Faul, Universitat Kiel, Germany.

Effect size d = 0.50, α err prob = 0.05, power (I – β err prob) = 0.85.

  Results Top

Sample population consisted of 150 patients; all of them were divided into two groups, first group consisted of 75 patients, periodontal treatment for this group was performed by air scaling. Second group consisted of 75 patients, periodontal treatment for this group was performed by manual scaling. All groups were examined clinically, and the results were statistically analyzed. [Table 1] and [Table 2] show the mean value of SBP and DBP that was elevated in all air and manual scaling groups, respectively, mean values are expressed in the mean and standard deviation (SD); for comparisons among groups according to time, F test was used; the results showed that there were significant differences (S) among and within SBP groups and high significance differences (HS) among and within DBP groups. [Table 3] presents paired t-test of BP change between before and after scaling for each group according to different times, the results showed that there were HS differences at P ≤ 0.01. The t-test was performed for comparison between manual and air scaling for SBP and DBP within different times, the results showed that there was Non significance (NS) difference at P ≥ 0.05 [Table 4]. Correlations (r) of time with CPITN and BP within groups (air scaling and manual scaling) were strong and they showed HS differences at P ≤ 0.01, but the correlation of BP with CPITN was NS difference at P ≥ 0.05 [Table 5].
Table 1: Descriptive and statistical test of both systolic and diastolic blood pressure in air scaling groups at different times

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Table 2: Descriptive and statistical test of both systolic and diastolic blood pressure in manual scaling groups at different times

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Table 3: Descriptive and statistical paired t-test of blood pressure change among different groups and times

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Table 4: Descriptive and statistical t-test for comparison between manual and air scaling for (systolic and diastolic blood pressure) at different times

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Table 5: Correlation (r) of time with Community Periodontal Index for Treatment Need and blood pressure within groups

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  Discussion Top

Periodontal SRP is considered the initial and effective nonsurgical treatments of choice for periodontal disease.[20] Evidence suggests that the treatment results for periodontitis are similar for all instruments, which could be hand instrumentation or other mechanical instruments, such as sonic and ultrasonic scalers.[21],[22] Scaling is the procedure of eliminating biofilm and calculus from both above and below the gingival margin without removing any tooth structure.[23] Increased BP and heart rate can be triggered by dental treatment, can give rise to psychosomatic alterations, which can prompt hypertensive crisis, causing accidents of unexpected proportions, and compromising the function of vital organs.[25] If SRP was performed without anesthesia, pain and discomfort could be encountered as in our study and in the studies by McLeod[26] and Canakci and Canakci,[27] who discovered that pain during SRP was associated significantly with SBP and DBP, even though pain perception is variable and different among patients. Pihlstrom et al.[28] showed that merely 46% of the subjects had mild to moderate pain after SRP due to the use of local anesthesia, whereas a study by Steenberghe van et al.[29] estimated that 83% of the patients had no or mild pain after SRP under local anesthesia. Power instrumentation has the potential to make scaling less demanding and more time efficient, and it has less chance for repetitive stress injuries and less tissue trauma compared with manual instruments.[23] The cardiovascular alteration during debridement session can be different due to the material type and the insert shape of the machining instrument. Patients reported no significant changes in BP during debridement with a manual and air scaling as used in this study [Table 4] of both SBP and DBP. The substantial and strong association between CPITN and BP with the time was found among participants.[19] The increase of both SBP and DBP shows a linear relation with the length of the scaling due to increase in oxygen demand by the myocardium during debridement according to Brand et al.,[24] who suggested that reduction in the time of the scaling session and/or application of some pain control medication or anesthetic before debridement can reduce the increase in BP during scaling, especially for subgingival debridement as patients reported increased pain perception during subgingival debridement. It can be suggested that pain encountered during dental therapy is the chief stimulus for the endogenous adrenaline release and it has such a vital role in the cardiovascular responses.[7] This hypothesis has been supported by two case reports, in which, fast elevation in SBP and DBP was experienced during painful dental episodes.[30],[31]

Anxiety and fear are detected in dental work and during periodontitis treatment, besides pain.[32] The treatment results can be adversely affected by these particular parts and may lead to dental treatment anticipation.[33] There is a brutal cycle of dental fear and anxiety as the experience of dental anxiety and fear can lead to postponement and avoidance of dental visiting, bad oral health, and consequently higher treatment needs, and to visiting the dental setting for relieving pain rather than for a checkup.[34]

Periodontal SRP (could be hand instrumentation or other mechanical instruments, such as sonic and ultrasonic scalers) is considered the effective nonsurgical treatment for periodontal disease, this treatment may lead to increase in SBP and DBP, giving rise to psychosomatic alterations, which can prompt hypertensive crisis, causing accidents of unexpected proportions and compromising the function of vital organs.


We would like to thank Mustansiriyah University ( Baghdad, Iraq for its support in this work, because of their help in gathering patients and facilitang research.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]


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