The Oral Health Status, Salivary Flow Rate and pH in Hypertensive

Patients Who Consume Antihypertensive Drugs in Puskesmas

Kasihan I Yogyakarta

Nurvita Risdiana

and Eka Nuraeni

School of Nursing, Faculty of Medicine and Health Sciences, Universitas Muhammadiyah Yogyakarta, Indonesia

Keywords: Hypertension, Oral health status, Salivary pH, Salivary flow rate

Abstract: Prolonged use of antihypertensive drugs causes side effects, especially in oral health status such as

glossodynia (burning sensation in the mouth), xerostomia (dry mouth), swollen salivary glands and pain,

changes in taste sensation, gingival overgrowth, changes in salivary pH, and decreased Salivary Flow Rate

(SFR). Decreases of SFR affect oral health in hypertensive patients who consume antihypertensive drugs

routinely. This research aims to determine the oral health status, SFR, and salivary pH in hypertensive patients

who consume antihypertensive drugs routinely. This was a quantitative research with a cross-sectional

approach. This study included 63 hypertensive patients in public primary care center (Puskesmas) Kasihan I

Yogyakarta who consume antihypertensive drugs routinely at least in the last three months. The data of oral

health status were collected using The Oral Health Assessment Tools (OHAT). Oral health status data include

SFR, and salivary pH. Univariate analysis using frequency distribution and percentage was conducted to

describe the oral health status. There is a change of oral health status in the majority of participants (77.5%)

with mean ± SD were 6.00 ± 1.33, low SFR (57.7%) with mean ± SD were 0.153 ± 0.047 and salivary pH

quite acidic (80.3%) with mean ± SD 6.188 ± 0.127. Most participants have a change of oral health status

(77.5%), low SFR (57.7%) and quite acidic salivary pH (80.3%)

1 INTRODUCTION

Oral health becomes the important determinant for

individual quality of life and affects the physical

appearance (Koistinen et al., 2020). Oral health is

influenced by several factors, one of them is high

blood pressure. High blood pressure is one of the

most common health conditions found both globally

and in Indonesia. Indonesian people. Nearly 30% of

adults in the world suffer from high blood pressure.

Approximately 31% population of America suffer

from high blood pressure and abouy 75 million adults

in America suffer from high blood pressure (Nimma

et al., 2016). Without massive preventive efforts,

about 26% of global population will suffer from high

blood pressure in 2025 (Bisnu et al., 2017). The

current prevalence of high blood pressure in

Indonesia is 34.1% and in Yogyakarta Special

Administrative Region, the prevelance is similar to

https://orcid.org/0000-0003-0684-0556

https://orcid.org/0000-0002-0711-1630

national prevalence aroun 34-35% in 2018 (Pengurus

Besar Persatuan Dokter Gigi Indonesia, 2018).

High blood pressure is treated using various

antihypertensive drugs. Several commonly used

antihypertensive drugs are diuretic drugs,

Angiotensin Converting Enzyme (ACE inhibitors)

such as captopril, and Calcium-Channel Blockers

(CCB) such as Amlodipin.

When consumed for a long time, antihypertensive

drugs can cause oral health disruption. The result of

the previous study shows that taking antihypertensive

drugs can cause dry mouth. The side effects of

consuming antihypertensive have been documented

which included bleeding and redness of the gingiva (

85.35%), hyposaliva (16.99%), and gingival swelling

(16.9%) (Mehta et al., 2014)(Kumar et al., 2012).

Another study also presents the side effects caused by

antihypertensive drugs which were glossodynia

(burning sensation in the mouth), xerostomia (dry

mouth), pain and oedema in salivary glands, change

Risdiana, N. and Nuraeni, E.

The Oral Health Status, Salivary Flow Rate and pH in Hypertensive Patients Who Consume Antihypertensive Drugs in Puskesmas Kasihan I Yogyakarta.

DOI: 10.5220/0010491302730277

In Proceedings of the 1st Jenderal Soedirman International Medical Conference in conjunction with the 5th Annual Scientiﬁc Meeting (Temilnas) Consortium of Biomedical Science Indonesia

(JIMC 2020), pages 273-277

ISBN: 978-989-758-499-2

273

in taste sensation, gingival overgrowth and decrease

in Salivary Flow Rate (SFR). Hypertensive patients

tend to have Autonomic Nervous System Imbalance

compare with no hypertensive which may affects the

saliva condition (Edwards et al., 2011).

The decrease in SFR caused by

pharmacodynamics drugs may cause a decrease in

heartbeat rate and myocardial contractility.

Therefore, the cardiac output will decrease and

followed by the decrease of plasma volume which

affect the saliva flow rate and the change in saliva pH

(Wotulo et al., 2018). The decrease of SFR can cause

the decrease of calcium secreted by saliva which lead

to demineralization and cause causes dental caries.

This will cause disruption in oral health and

significant loss of oral cavity health (R. M. Alamsyah,

2015). Other long-term impacts of using

antihypertensive drugs on oral health are toothpain

and the growth of cariogenic bacteria such as Candida

albicans, Lactobacillus, mutant Streptococcus will

increase which may cause infections and alter the

taste sensation (Rawung et al., 2017).

Based on the background illustrated above, this

study aimed to describe the oral health status, salivary

flow rate and pH of hypertensive patients who

consume antihypertensive drugs regu.

2 MATERIALS AND METHODS

The study was a quantitative descriptive research with

the cross-sectional approach to describe the oral

health status, the pH of the saliva and the saliva flow

rate in patients with high blood pressure who

consume antihypertensive drugs.

2.1 Participants

The research population were 250 hypertensive

patients of Public Primary Healthcare Center

(Puskesmas) Kasihan 1 Yogyakarta in 2019 who

consume anti-hypertensive drugs routinely. The

samples were 71 patients selected through purposive

sampling method based on Slovin formula.

The inclusion criteria were hypertension patients

who routinely consume antihypertensive drugs in the

last three months and agreed to participate in the

study. Patients who were smokers were excluded

from the sample as well as for those who did not

consume antihypertensive drugs routinely.

2.2 Data Collection

The oral health status was measured using The Oral

Health Assessment Tools (OHAT) (Maille et al.,

2019), while pH indicator, measuring glass and

stopwatch were used to saliva pH and saliva flow

rate

2.2.1 The Oral Health Assessment Tools

(OHAT)

Oral health status assessment includes several aspects

which were lips, tongue, gum and the tissue, saliva,

real teeth, false teeth, mouth hygiene, and pain in the

teeth(Maille et al., 2019). The score from assessment

using OHAT were classified into 0-3 for a healthy

category, 4-8 for changes category and 9-19 for

unhealthy category (Maille et al., 2019).

2.2.2 pH indicator, Measuring Glass and

Stopwatch

pH indicator used to measure the saliva acidity level.

The categories of saliva pH consist of very acid (red)

with pH <6, moderately acid (yellow) with pH 6.0-

6.5 and healthy saliva (green) with pH ≥ 6.75.

Measuring glass used to collect and measure the

volume of saliva at the same time the duration of

saliva collection was measured using stopwatch. The

saliva flow rate was calculated by dividing the

volume of collected saliva with the duration of

collection (ml/minute). The saliva flow rate

categorized into normal (0.3-3 ml/minute), low (0.1-

0.29 ml/minute), or very low (< 0.1 ml/minute).

Saliva flow rate measured using spitting method – in

which saliva spat, and it conducted for five minutes

and draining method – spitting method in which

saliva let to drop by itself (Yendri et al., 2018).

2.3 Data Analysis

To describe the data, univariate analysis was

conducted by presenting the data using frequency

distribution and percentage

3 RESULTS

The characteristics of participants were described in

table 1. Most respondents are elderly (63.4%) with

the mean ± SD of age is 60.76 ±3.06. Most

respondents are female (80.3%). Most of the

respondents have been suffering hypertension for 1-5

JIMC 2020 - 1’s t Jenderal Soedirman International Medical Conference (JIMC) in conjunction with the Annual Scientiﬁc Meeting

(Temilnas) Consortium of Biomedical Science Indonesia (KIBI )

274

years (69%) with the mean 2.08±1.26. The most

consumed antihypertensive drugs are amlodipine

which is consumed by 42 respondents (59.2%). All

respondents take drugs routinely (100%).

Table 1: The Characteristics of Participants.

Cate

Mean ± SD Percenta

Age

Late adulthood

(

n=4

)

43.00 ± 1.41 5.6

Early Senior

(

n=22

)

52.32 ± 2.19 31

Late Senior

(n=45)

60.76 ± 3.06 63.4

Gende

Female

(

n=57

)

- 80.3

Male

(

)

- 19.7

The duration of

hypertension

3-5 month

(

n=12

)

3.38 ± 7.18 16.9

5-11 month

(

n=6

)

6.67 ± 1.63 8.5

1-5

ears

(

n=49

)

2.08 ± 1.26 69

5-10 years (n=3) 9.00 ± 1.73 4.2

>10 years (n=1) 11.00 ± - 1.4

Antihypertension

drugs

Amlodipine

(

n=42

)

- 59.2

ril

(

n=29

)

- 40.8

Drugs adherence

Routine (n=71) 71 100

The oral health status of the participants is displayed

in table 2. Findings from this study showed that in the

majority of the respondents the oral health status was

in the category of “change” (78.9%, mean ±SD 5.64

±1,31), the salivary flow rate was in low category

(57.7%; mean ±SD of 0.302 ±0.007), and the pH of

saliva was in “moderate acid” (80.3%; mean ±SD of

6.188 ± 0.127).

4 DISCUSSION

Most respondents with high blood pressure were

elderly. Age is one of the factors which cannot be

modified. Age causes physiological changes human

body where blood pressure will increase as human

grows older. The increase of blood pressure is caused

by arterial wall thickening caused by collagen. which

piles up in the muscle layer. Therefore, as people

grow older, the arteries will be narrower and stiffer

(Amanda & Martini, 2018).

Table 2: Oral Health Status in Hypertensive patients who

consume Antihypertension drug.

Categor

Mean ± SD Pe

centage

Oral Health

Status

Health

(

n=13

)

2.54 ± 0.66 18.3

Change (n=56) 5.64± 1.31 78.9

Unhealthy (n=2) 9.33 ± 0.51 2.8

Salivary Flow

Rate

Normal (n=7) 0.302 ± 0.007 9.9

Low (n=41) 0.153 ± 0.047 57.7

Very Low

(n=23)

0.030 ± 0.015 32.4

H Saliva

Healthy (n=9) 6.833 ± 0.176 12.7

Moderate Acid

(n=57)

6.188 ± 0.127 80.3

Very Acid

(

n=5

)

5.700 ± 0.111 7.0

Besides age, gender is also one of the risk factors of

high blood pressure which cannot be changed. The

findings showed that the percentage of the female

who has hypertension is bigger than male. Women

tend to have high blood pressure when they reach an

elderly age. When younger, females still have high

level of estrogen, which has a role in increasing the

level of High-Density Lipoprotein (HDL) and has

protective effect on high blood pressure (Ramanto

Saputra et al., 2017). Menopausal women have a

higher risk in experiencing increase in blood pressure

compared to men because lower High-Density

Lipoprotein (HDL) and higher Low-Density

Lipoprotein (LDL) increase blood pressure

(Fernandez & Murillo, 2016). Low HDL is one of the

causes of arteriosclerosis in which the arteries are

shifted and causes high blood pressure in menopausal

women (Ramanto Saputra et al., 2017).

Most of the respondents has been suffering from

high blood pressure for 1-5 years. These respondents

have a long history of high blood pressure and

routinely have their health checked at Puskesmas

Kasihan 1 Bantul Yogyakarta, as well as routinely

consume antihypertensive drugs. However, many

respondents admit that they have not practised a

healthy lifestyle such as limiting salt intake so that the

blood pressure is not fully controlled although most

of them routinely consume antihypertensive drugs.

Most of the respondents consume amlodipine as the

antihypertensive drug. This may be caused by

complain from the patients that they do not respond

well to captopril and asked for the amlodipine instead.

Finding from the study showed that there are

changes in oral health status of the majority of

The Oral Health Status, Salivary Flow Rate and pH in Hypertensive Patients Who Consume Antihypertensive Drugs in Puskesmas Kasihan I

Yogyakarta

275

respondents. This likely due to the decrease of SFR

which lead to complaints by patients such as dry

mouth, chapped lips, and white layer of tongue,

although these conditions are not always noticed by

patients. This finding similar to previous study which

states that antihypertensive drugs often cause

xerostomia, dry mouth and changes in the taste

sensation (Villa et al., 2014).

This study showed that most of the hypertensive

patients had very low SFR. Antihypertensive drugs

both amlodipine and captopril inhibit the calcium ion

to enter the heart muscle cells and the smooth muscle

of blood vessels and cause muscle relaxation lead to

decreases in blood pressure. At the same time, both

drugs will suppress water secretion in the salivary

gland by closing channel Ca

so that Cl

the door is

closed, and it cannot come out through acinar cell

membranes. Thus, water cannot enter acinar lumen,

and hyposalivation will occur in which 99% of the

saliva is water. As a result, oral health is disrupted

(Asmi Usman & Hernawan, 2017).

Antihypertensive drugs can also decrease SFR

by depressing the autonomous nerves, which regulate

the salivary gland secretion. The decrease of SFR can

also be caused by the lack of natrium in the body. In

patients with high blood pressure, natrium intake is

limited to assist pharmacological therapy so that it

may contribute to the unavoidable decrease of SFR

(Zuliasih et al., 2015). This side effect usually takes

three months after routine consumption of

antihypertensive drugs (Wotulo et al., 2018)

In elderlies, salivary glands can experience

atrophic changes, therefore as people aged the

atrophic changes can decrease saliva production or

hyposalivation, and it can also change some

composition of saliva. The atrophic change will lead

to the reduction of parenchyma glands and replaced

by fat glands and connective tissue (Arsyad, 2017).

The research result indicates that most saliva pH

is in the category of very acid. Saliva pH can be

changes because of changes in circadian rhythm, age,

diet, and secretion rate stimulation (Haryani et al.,

2016)). In hypertensive patients, the consumption of

antihypertensive drugs will affect autonomous nerves

through parasympathetic nerves and decrease the

salivary flow rate. The low SFR causes

hyposalivation and increase the acidity of the saliva

(Nabilla et al., 2019).

5 CONCLUSIONS

Antihypertensive drugs have a contribution to change

the Oral Health Status, salivary flow rate and pH in

hypertensive patients. Need for further information in

the next about how to prevent the negative effect of

antihypertensive drugs

ACKNOWLEDGEMENTS

The authors thank the hypertensive patients in

Puskesmas Kasihan I for their participation in this

study and to all health workers in Puskesmas Kasihan

I Bantul Yogyakarta. Universitas Muhammadiyah

Yogyakarta provided funding for the research

funding with reference number 030/PEN-

LP3M/I/2020.

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