Original article

Oral lesions in hypertensive patients attending a South

Western Nigerian Tertiary Hospital
Oyetola Elijah Olufemi*, Ibitoye K S, Owotade F J, Fatusi O A, Adesina O M
Email: phemyhoye12@yahoo.com

Abstract
Background: Hypertensive patients often suffer from oral conditions because of their ailment or its treatment.
Several Caucasian studies have reported oral lesions among hypertensives but there is paucity of data among
Africans. Materials and Methods: The study population was a random sample of hypertensive patients
attending the cardiovascular clinic of the Obafemi Awolowo University Teaching Hospital Complex (OAUTHC)
and healthy volunteers. Each subject was interviewed and examined. Diagnosis of oral lesions was made based
on clinical grounds alone. The results were analysed with STATA statistical software version 11. Results: In
the study, 200 subjects comprising 100 hypertensive respondents (mean age 52.3 years Standard Deviation
SD 12.) and 100 healthy volunteers (mean age 50.9 years SD=1.4) participated. The difference in age was not
statistically significant, p=0.77. The mean systolic and diastolic blood pressures of hypertensive respondents
were 131.4mmHg (SD=14.4) and 81.9mmHg (SD=10.2) respectively while that of the controls were significantly
lower. There were 71 (71%) hypertensive subjects and 27 (27%) of controls had oral lesions, p<0.001. Among
the hypertensive respondents, gingival swelling was the commonest oral lesion (42, 42%), followed by varicose
vein (28, 28%), halitosis (24, 24%), xerostomia (23, 23%), and Temporo Mandibulat Joint (TMJ) pain (21, 21%).
The subjects with oral lesions had a significant association with increased body weight, high blood pressure,
and a long duration of hypertension. The oral lesions were more frequent among hypertensive respondents on
combination of amlodipine and enalapril (42%) and when compared to those on the other drug combinations the
difference was statistical significant p=0.002. Conclusion: Several oral lesions are associated with hypertension
and therapy with combination of amlodipine and enalapril may predispose to gingival enlargement. Appropriate
attention to oral hygiene in hypertensive respondents is recommended.
Key words: Hypertension, gingival swelling, amlodipine, enalapril

Introduction elevated blood pressure of >140mmHg systolic

Hypertension is one of the serious public health
problems worldwide.1, 2 The burden of the disease
reflects in its strong association with cardiovascular
morbidity and mortality which is the leading cause
of death worldwide. Hypertension is a sustained
Oyetola Elijah Olufemi
Department of Preventive and Community Dentistry,
Obafemi Awolowo University, Ile Ife, Nigeria
blood pressure and >90mmHg diastolic blood
pressure based on the evidence from randomized
control trials that the subjects with these blood
pressure measurements would benefit from
the treatments that will achieve blood pressure
Fatusi O A
Department of Oral and Maxillofacial Surgery and Oral
Pathology, Obafemi Awolowo University, Ile Ife, Nigeria

Ibitoye K S Adesina O M
Department of Preventive and Community Dentistry, Obafemi Department of Oral and Maxillofacial Surgery and Oral
Awolowo University, Ile Ife, Nigeria Pathology, Obafemi Awolowo University, Ile Ife, Nigeria

Owotade F J * Corresponding Author

Department of Oral and Maxillofacial Surgery and Oral
Pathology, Obafemi Awolowo University, Ile Ife, Nigeria.

How to cite this article: Oyetola Elijah Olufemi, Ibitoye K S, Owotade F J, Fatusi O A, Adesina O M. (2016). Oral lesions in
hypertensive patients attending a South Western Nigerian Tertiary Hospital. MJDS, 1(2), 1-8.

Manipal Journal of Dental Sciences | October 2016 | Volume 1 | Issue 2 1

 Olufemi E O, et al: Oral lesions in hypertensive patients attending a South Western Nigerian Tertiary Hospital
reduction.3 Prevalence of hypertension varies
around the world with the lowest prevalence in the
rural Indian men (3.4%) and the highest prevalence
of 72.5% in Polish women.4 A recent Nigerian study
reported 28% prevalence with an alarming rate of
lack of awareness among the population.2 There
are varying reports on the gender distribution of
hypertension, while Ninios et al5 reported a female
predilection in a Greek population, a Nigerian study
found 55% male predilection.6 Generally, about one-
quarter of world adult population have a clinical
hypertension but 70% is aware of their status and
less than 20% achieve control.7 The situation is
worse in the developing world where the scenario
is complicated with lack of public awareness,
ignorance, and poverty.2, 7
Attention on the oral aspects of hypertension has
been grossly lacking. A long term treatment protocol
and serious widespread complications associated
with hypertension are among the possible reasons
for the oral manifestations in hypertensive patients
and hence the need for dentists’ interventions in
the management of hypertensive patients.8 The
presence of co-morbid conditions as reflected in the
aetiopathogenesis of secondary hypertension may
also play some roles in oral manifestations.9 Some
of the common causes of secondary hypertension
such as chronic kidney diseases, neoplasm, diabetes
mellitus, and thyrotoxicosis are associated with the
established oral signs.10 The studies show that when
the associated oral lesions in systemic diseases are
not well managed, the quality of life and response to
treatment of the underlying systemic illness in such
individuals is often grossly impaired.11, 12
The documented oral lesions in hypertensive
respondents include gingival swelling,9,13–15
periodontitis,9,13 xerostomia, taste impairment,
sublingual varicosity (16%),16 burning sensations,
hyposalivation,17 increased oral microbiota17 and
apical periodontitis affecting endodontically treated
teeth18 in 43% of hypertensive patients. In addition,
Janket et al19 studied cardiovascular patients with
missing teeth, they found a better survival rate
among those who had prosthesis (removable partial
denture (RPD) fabricated to replace their missing
teeth when compared to those whose missing
2 Manipal Journal of Dental Sciences | October 2016 | Volume 1 | Issue 2
teeth were not treated. In addition, Segura-Egua
et al`8 found a higher prevalence of periodontitis
in hypertensive patients (75%) when compared
with the control (61%) but the differences were not
statistically significant.
A few studies have investigated the oral health status
of hypertensive patients and none was done on any
African population where the burden of hypertension
is on a continual rise.2 More so, none of the studies
specifically addressed the predictors of oral lesion
in this group of patients. The present study is
therefore designed to determine the pattern of
presentation of common oral lesion in hypertensive
patients in an African population. We hope that the
findings from the study provide information that
would encourage/enhance a better participation of
dentists in the management of hypertensive patients
with a view to improving their holistic care.
Methodology
Study design: Case control study
Study location
Obafemi Awolowo University Teaching Hospitals’
Complex (OAUTHC), Ile Ife, Nigeria. The institution
is a major referral centre in the Southwestern region
of Nigeria, providing tertiary medical and dental
health services for the people in the region. It is
also a teaching hospital for the training of doctors,
nurses, medical laboratory scientists, and medical
health record officers.
Selection of Subjects
Hypertensive respondents (cases) were selected
from the pool of hypertensive patients attending the
cardiovascular clinics of the OAUTHC while the
controls were consecutive healthy volunteers who
presented for dental check up in the dental clinic. A
simple random sampling method was used for the
selection of the hypertensive respondents.
The inclusion criteria for the cases include a
confirmed diagnosis of hypertension and adult
above 18 years. For the controls, absence of history
suggestive of systemic disease, normal blood
pressure, and adult above 18 years constituted the
inclusion criteria.
 Olufemi E O, et al: Oral lesions in hypertensive patients attending a South Western Nigerian Tertiary Hospital

Selection of Sample size Oral mucosa assessment and diagnosis was made
Gingival swelling, a frequent oral finding in based on clinical findings alone and was based on
hypertensive patients, was used to estimate the the WHO Guide to Epidemiology and Diagnosis of
sample size. Oyetola et al20 had earlier reported a Oral Mucosal Diseases.21
2% prevalence of gingival swelling among healthy
adults while Kumar et al9 reported a prevalence Statistical analysis
of 16.9% among hypertensive patients. With a Data analysis was done using a STATA 11 statistical
statistical significance (Alpha) set at 5% and power software (Statacorp, College Station, Texas). The
of 90%, the 100 subjects were required in each statistical significance was inferred at p<0.05 and
group using STATA 11 as the statistical software the confidence interval was set at 95% for all the
for calculating the sample size. analysis.
Collection of Data Results
Collection of data was done using a structured
In the study, 200 subjects comprising 100
questionnaire designed to have three sections. The
hypertensive patients and 100 healthy volunteers
first section (Section A), collected information on
participated.
the bio-data, weight, and blood pressure of the
subjects. Also included in the section, the history of Socio-demographic factors and presence of oral
their medical conditions such as when the diagnosis lesions among subjects
of hypertension was made and the progress in Among the study participants, 111(55.5%) were
the relief of associated symptoms following the males while 89 (44.5%) were females. The mean age
treatment. Body weight was measured using a (SD) of all the participants was 52.2 (0.94) years.
standard weighing scale (Hansen, England). The
The difference in the mean age of the hypertensive
subjects were asked to stand on the weighing
respondents and the controls was not statistically
balance without their shoes and jackets and the
significant, p=0.462 (Table 1). Oral lesions were
measurements were taken in the nearest 0.1kg.
Blood pressure was taken with sphygmomanometer seen in about half (102, 51%) of all the participants.
with the patients in the sitting position. The lesions were most frequent within the
41-50-year-age group. About three-quarter (71%)
Section B collected information on the presence of hypertensive cases had oral lesions while only
of oral symptom(s) noticed after the diagnosis 27 subjects (27%) of the healthy controls had oral
of hypertension. Questions asked in this session lesion. The difference was statistically significant,
include: “Do you feel oral dryness or any gum/tooth p<0.001.
pain?”, “Do you think you have mouth odour?”, “Do
you feel burning sensation in your mouth?”, “Do you Table 1: Socio-demographic factors and the presence of oral
lesions among the subjects
feel a change in your taste perception?”
Characteristics All subjects Hypertensive C o n t r o l s p value
n=200 Cases n=100 n=100
Section C recorded the findings of extra oral and
Sex
intra oral examination. Male (%) 111(55.5) 60(60) 51(51) 0.255
Female 89(44.5) 40(40) 49(49)
An Oral Medicine specialist did oral examination
in the dental clinic. Each subject, after a successful
recruitment was asked to supply necessary Mean Age 51.6(0.9) 52.3(1.2) 50.9(1.4) 0.462
(SD)
information on the questionnaire. Thereafter they
Age group
were asked to go inside a consulting room to meet a <20 2 0 2 0.066
dentist for the oral examination on the dental chair. 21-30 8(4) 1(1) 7(7)
31-40 32 16 16
The examiner was blinded against the category of 41-50 56 33 23
the subjects (hypertensive or not) before the oral 51-60 52 22 30
examination. >60 50 28 22

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 Olufemi E O, et al: Oral lesions in hypertensive patients attending a South Western Nigerian Tertiary Hospital

Characteristics All subjects Hypertensive C o n t r o l s p value Characteristics All subject Hypertensives C o n t ro l s p value
n=200 Cases n=100 n=100 n=200 n=100 n=100
Mean weight 66.7(0.8) 67.13(1.1) 66.3(1.1) 0.6983 Taste
(SD) impairment 27(13.5) 23(23) 4(4) <0.001*
Oral lesion Present 173(86.5) 77(77) 96(96)
Present 102(51) 71(71) 27(27) 0.001* Absent
Absent 98(49) 29(29) 73(73) Fischer’s exact, * stands for statistically significant
Fischer’s exact, * stands for statistically significant
Percentage distribution of Oral lesion and
Oral lesions among the subjects duration of hypertension
Gingival swelling was the most frequent oral lesion, There were more subjects with oral lesions
seen in 42% of hypertensives and 6% of the controls, compared with those without oral lesion at all times
significantly higher among the hypertensives, irrespective of the duration of hypertension. Oral
p<0.001. Other lesions that were significantly lesions were present in all (100%) subjects who had
higher among the hypertensives include sublingual been diagnosed with hypertension for more than 26
varicosity, halitosis, gum bleeding, xerostomia, weeks. The difference in the duration of hypertension
taste impairment, TMJ pain/discomfort, lichenoid with an occurrence of oral lesion was, however, not
reaction, and facial paralysis (Table 2). statistically significant, p=0.306, Fischer’s exact test
(Figure 1).
Table 2: Oral lesions among the subjects
Characteristics All subject Hypertensives C o n t ro l s p value Figure 1: Percentage distribution of Oral lesion and duration of
n=200 n=100 n=100 hypertension
Gingival
swelling 48(24) 42(42) 6(6)
Present 152(76) 58(58) 94(94)
Absent
Halitosis
Present 27(13.5) 24(24) 3(3) <0.001*
Absent 173(86.5) 76(76) 97(97)
Xerostomia
Present 26(13) 23(23) 3(3) <0.001*
Absent 174(87) 77(77) 97(97)
TMJ pain
Present 27(13) 24(24) 3(3) <0.001*
absent 173(86.5) 76(76) 97(97)
Gingivitis
Present 19(9.5) 15(15) 4(4) 0.007* Association of mean values of weight, duration
Absent 181(90.5) 85(88) 96(96)
of hypertension, blood pressure of subjects, and
Gum
bleeding 14(7) 11(11) 3(3) 0.024* oral lesions
Present 186(93) 89(89) 97(97)
Absent
The average weight of the subjects with oral lesions
Lichen was significantly lower compared to those without
Planus 15(7.5) 12(12) 3(3) 0.014* oral lesions p=0.026 while the mean diastolic
Present 185(92.5) 88(88) 97(97)
Absent blood pressure of the subjects with oral lesion was
Facial significantly higher compared to those without
Paralysis 9(4.5) 8(8) 0(0) 0.017*
Present 191(95.5) 92(92) 100)
oral lesion, p<0.05. Although the duration of
Absent hypertension and the systolic blood pressure of the
Sublingual subjects with oral lesion were higher than in those
varicose 31(15.5) 28(28) 3(3) <0.001*
Present 169(84.5) 72(72) 97(97) without lesions, the difference was not statistically
Absent
significant p=0.131 and 0.115 respectively (Table 3).

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 Olufemi E O, et al: Oral lesions in hypertensive patients attending a South Western Nigerian Tertiary Hospital

Table 3: Relationship of mean values of weight, duration of This study showed the prevalence of oral lesions in
hypertension, blood pressure, and oral lesions
hypertensives to be 71%. This value is significantly
Characteristics Oral lesion present Oral lesion p value greater than the prevalence of oral lesions in healthy
[Mean(SD)] absent
[Mean (SD)] controls as reported by Oyetola et al20 who reported
Weight (Kg) 67.6(1.0) 63.0(2.6) 0.026* 15% prevalence among the healthy individual in
Duration of 11.2(1.0) 9.2(1.0) 0.131
a similar study. This finding is in agreement with
hy p e r te n si o n the previous reports that show a significantly high
(weeks) prevalence of potential oral manifestations in
Systolic blood 132.5(1.2) 128.6(2.7) 0.115 hypertensive patients with the recorded prevalence
pressure
from 20% to 83%.9, 13, `16, 19 However, while some
Diastolic blood 84.4(1.2) 75.7(1.15) <0.001*
pressure reports confirmed a positive association between
T-test * statistically significant
the presence of oral lichenoid reaction in the oral
cavity of diabetic and hypertensive patients referred
Relationship between the antihypertensive drug to as Grinspan’s syndrome,23, 24 others found no
and the oral lesion significant association between these systemic
Oral lesions were more frequent among the subjects diseases and oral lichenoid reaction.25, 26 Oral lesions
on amlodipine and lisinopril combination therapy. in hypertensive are largely due the effects of the
The patients on amlodipine alone have 20% chance long use of antihypertensive drugs, associated
of developing oral lesion (Figure 2). stress of hypertension and effects/complications
of hypertension such as vasculopathy on the oral
Figure 2: Drug and Oral lesion
tissues.

The commonest oral finding in the present study is

Discussion
Due to increasing prevalence of hypertension
worldwide, a significant proportion of hypertensive
patients will be presenting for dental treatments.1, 2,
22
To worsen the scenario, the studies have shown
that about two-third of the people with clinical
hypertension are undiagnosed or not properly
managed as recommended by Joint National
Committee,7, 22 these are the patients that dentists
would be confronted with as they come for dental
treatment. Unfortunately, attention on oral aspects
of hypertension has suffered serious neglect over
the years despite good oral health care improves the
quality of life of patients.17, 19
gingival swelling, found in 42% of subjects. Gingival
swelling is a common presentation in hypertensive
patients with a prevalence of 25-83% reported in the
literature.9, 14, 15 Our study showed that patients on
combination therapy of amlodipine and lisinopril are
more vulnerable compared with those on amlodipine
alone. Livada et al27 described the pathogenesis of
calcium channel blocker induced gingival swellings
as due to its action on the gingival fibroblasts. The
net action of the drug leads to reduced cell Ca2+
influx into the cell and this results in the reduction
of folic acid production, thus, limiting the production
of the active collagenase. The reduced rate of
collagen degradation results in the accumulation
of collagen and metalloproteinase, which leads to
gingival swelling.
Sublingual varicose vein was present in 28% of
hypertensive subjects in the present study and is
significantly higher when compared to the findings
of Oyetola et al20 who found no case of sublingual
varicosity in the healthy adult patients. Several
studies have associated sublingual varicosity with
hypertension/cardiovascular disease.16,28 Many
studies attribute sublingual varicose to old age29,30

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 Olufemi E O, et al: Oral lesions in hypertensive patients attending a South Western Nigerian Tertiary Hospital
but in the present study, majority of the subjects
were middle aged (mean age of the subjects is
52.5 years). Findings from our study is therefore
not in support of age as an associating factor in
the pathogenesis of the sublingual varicosity in
hypertensive patients. Hypertension is associated
with vasculopathy especially when it is long standing
and poorly managed a situation that is common in
our environment.31, 32 The vasculopathy associated
with hypertension may therefore be responsible for
the sublingual varicose seen in the hypertensive
patients.
Xerostomia is present in 23% of the subjects in the
present study, which is higher than the prevalence
in a healthy population, which is about 1%.20 This
finding is consistent with that of Kumar et al
who reported the prevalence of xerostomia in
hypertensive patient as 17.0% in a clinical study.9
Xerostomia in hypertensives is essentially due to the
effects of medications.
Similar to earlier studies,20, 33 our findings also
showed that the patients who presented late for
treatment of their systemic diseases have more
associated oral complications/lesions. The present
study also showed a significantly higher body weight
among patients with oral lesions when compared to
those without oral lesions. This is in agreement with
the earlier studies that showed more complications
in hypertensive patients with higher body weight/
obese.34,35 Increased body weight is associated with
excess fat accumulation and glucose intolerance,
which tends to cause immunosuppression resulting
in oral complications and other systemic problems.34
This study, consistent with earlier studies,9, 36 showed
a higher prevalence of oral lesions/complications
among the subjects as the duration of hypertension
increases. Severity of systemic complications and
adverse effects of failed attempts at treatments
that is often associated with late presentation may
contribute to the oral complications.
Despite the continual rise in the prevalence of
hypertension especially in African population, oral
aspect of the management has been neglected
for so long. Gingival swelling, xerostomia, taste
impairment, facial paralysis, and halitosis, which
6 Manipal Journal of Dental Sciences | October 2016 | Volume 1 | Issue 2
are found in hypertensive subjects in this study, are
associated with the reduced quality of life in the
affected patients. Considering the enormous impact
of oral lesions in hypertensive patients, it is thus
vital for a comprehensive dental evaluation and
treatments for hypertensive patients.
Conclusion
The prevalence of oral lesions among the
hypertensive patients in this study is 71% and this
value is significantly higher that value for the healthy
controls (15%) reported by Oyetola et al20. The most
common oral lesion among hypertensive patients
was gingival swelling, seen in 43(43%) subjects.
Other lesions seen include taste impairment, TMJ
pain, facial paralysis, and halitosis.
High diastolic blood pressure (DBP) (mean DBP
84.4mmHg), increased body weight (mean 67.7kg),
duration of hypertension (mean 11.2 weeks) and
the use of combination therapy of amlodipine
and lisinopril in the treatment of underlying
hypertension were associated with the oral lesions
in the hypertensive patients in the study population.
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