|Year : 2020 | Volume
| Issue : 4 | Page : 349-354
Assessing the correlation between sublingual varices and hypertension among the adults of Satara district, Maharashtra: An observational study
KM Shivakumar1, Vaishali Raje2, Vidya Kadashetti3
1 Department of Public Health Dentistry, Faculty of Dental Sciences, Karad, Maharashtra, India
2 Department of Preventive and Social Medicine, Krishna Institute of Medical Sciences, Karad, Maharashtra, India
3 Department of Oral Pathology and Microbiology, Faculty of Dental Sciences, Krishna Institute of Medical Sciences “Deemed to be University”, Karad, Maharashtra, India
|Date of Submission||28-Nov-2019|
|Date of Decision||15-Jan-2020|
|Date of Acceptance||15-Jan-2020|
|Date of Web Publication||20-Aug-2020|
Dr. K M Shivakumar
Department of Public Health Dentistry, Faculty of Dental Sciences, Krishna Institute of Medical Sciences “Deemed to be University”, Malkapur, Karad, Maharashtra.
Source of Support: None, Conflict of Interest: None
Aim: In most of the times, sublingual varices (SLV) are noticed during aging process, cardiovascular disease, and smoking. The aim of this study was to find the relation of SLV and the presence of hypertension. Materials and Methods: A total of 215 dental patients were enrolled for the study, of which 14 were dropped, and the status of tongue and blood pressure of a total of 201 study subjects was recorded. The patients with an average blood pressure (at home) of ≥85 mm Hg (diastolic) and ≥135 mm Hg (systolic) were reported to the hospital, where three hypertension measurements were recorded with an interval of 1 week. Student t test and Pearson chi-square test were used for the analysis. Results: An association was found between hypertension and SLV (odds ratio = 2.16, P < 0.001). The systolic blood pressure was found to be 121.2 mm Hg and 138.1 mm Hg in subjects with grade 0 and grade 1 SLV, respectively (P < 0.001). The mean diastolic blood pressure was found to be 81.2 mm Hg and 85.2 mm Hg in patients with grade 0 and grade 1 SLV, respectively (P < 0.05). Conclusion: An association was observed between SLV and hypertension. Examination of lateral borders of tongue can be performed easily, and causes no harm to the patients, and can be considered as an important diagnosis method for the dentists to take an active role in preventive and primary health care.
Keywords: Blood Pressure, Hypertension, Preventive Health Care, Sublingual Varices
|How to cite this article:|
Shivakumar K M, Raje V, Kadashetti V. Assessing the correlation between sublingual varices and hypertension among the adults of Satara district, Maharashtra: An observational study. J Int Oral Health 2020;12:349-54
|How to cite this URL:|
Shivakumar K M, Raje V, Kadashetti V. Assessing the correlation between sublingual varices and hypertension among the adults of Satara district, Maharashtra: An observational study. J Int Oral Health [serial online] 2020 [cited 2022 Oct 3];12:349-54. Available from: https://www.jioh.org/text.asp?2020/12/4/349/292758
| Introduction|| |
Sublingual varices (SLV) are tortuous dilated veins seen along the floor of mouth, and tongue’s ventral surface, which mostly become more prominent as the age progresses., Sometimes, these SLV may be noticed by dentists during routine examinations or by patients themselves. These SLV are main veins, which run from tip of tongue to backward, and they are differentiated for malignant melanomas at the floor of the mouth. Many reasons have been put forward concerning the etiopathogenesis of SLV; the aging process, which includes the changes in the walls of the veins and tissues of the connective origin, is commonly noted with the increased incidence of SLV. Very Few literature is available regarding the correlation between Cardiovascular disease and hypertension. The small veins, which are dilated under the lateral walls of tongue, are the characteristic features of SLV. There is a well-established evidence that the pathogenesis may be because of a weakening of the venous wall and change in the connective tissue or as a result of the degeneration of elastic fibers related to the aging process.,,,
The hypertension and cardiovascular diseases are the preliminary risk factors for disease burden in the world, and they can cause damage to the organs, may be in presymptomatic phase, which may lead to myocardial infarctions and stroke. Hence, it is important to find out and treat blood pressure and cardiovascular diseases at the earliest. Globally, structured screening for hypertension among healthy individuals is not existent. However, hypertension is generally noticed when people are looking for health care for any other reason. Most of the population visit dentists as and when it is required for the dental problems.
The dentists may find a condition, which contains varicosities, called benign venous lesion. These are found in different areas of the oral cavity, that is, in lateral borders of tongue, mucosal areas of lower lip, and buccal side. Detailed phenomenon of SLV is poorly established and it can be considered for age correlation, smoking, varicose veins affecting the leg, and cardiovascular disease.,,, The connection between blood pressure and SLV has not been established properly. Hence, this study aimed to investigate the relation between SLV and the presence of hypertension in the study subjects.
| Materials and Methods|| |
Setting and design
This observational study was conducted between June 2016 and May 2017, at Krishna Hospital, Karad, Maharashtra, India. A pilot study was conducted on patients attending the hospital. On the basis of the results of the pilot study, the sample size calculation was carried out by using the following formula (Z: Standard Variate at 95% Confidence level = 2; p: prevalence = 5; q: 100 – 5 = 95; d: allowable error = 10 % of ‘p’):
The sample size was found to be 195, and additional sample (10%) was considered due to the variation in the prevalence with age and geographical area, which gives rise to 214.5, and the sample size was rounded to 215. All the study subjects gave the informed consent in both verbal as well as written information, which was obtained to conduct the examination. The participants who were accepted to participate, provided with the written consent. The patients older than 40 years of age were asked to participate in this study. The patients with atrial fibrillation, pregnancy, renal disease, and any severe medical conditions were excluded from this study. A total of 215 patients were asked to participate in this study after the sample size calculations and 14 patients were dropped out of the study and the remaining 201 participants underwent complete study protocol.
The study participants were interviewed medically and were assessed clinically for the absence or presence of SLV. These study participants answered a questionnaire, which contained the sociodemographic information and actual health status (atrial fibrillation, myocardial infarction, smoking, hypertension, stroke, ischemic heart disease, and any other lower limb varices).
The medical history of the patients was blind-folded for the examiner. The examiner was requested to note the movement of the tongue bilateral as well as upward and to examine the lateral borders and ventral surface of tongue and floor of mouth. On the basis of previously mentioned criteria, the SLV are divided into two grades: grade 0 for SLV, which were absent during examination and/or only very few visible, and grade 1 for SLV, which were present in a severe form of medium in nature [Figure 1] and [Figure 2].
The patients were also examined if study subjects had no history or diagnosis of hypertension, and were measured for an average systolic blood pressure of ≥140 mm Hg, and the average diastolic blood pressure was ≥90 mm Hg.
The Statistical Package for Social Sciences software (version 21.0; SPSS, Chicago, Illinois) was used for the analysis. Analytical and descriptive statistics assessed all variables. Student t test and Pearson chi-square test were applied.
| Results|| |
The mean age of 52.3 ± 11.5 years was observed among 201 study subjects. Gender distribution was 121 males and 80 females. The presence of SLV among males and females was 25.6% and 42.5%, respectively, and for >50 years age-group, 32.6% of patients had SLV when compared to 31.8% in<50 years age-group. The presence of SLV was found to be 63.1% in those who smoke for >15 years in their lifetime when compared to 36.6% for those with <15 years of smoking duration. We found that 60% of patients with SLV alone were found in patients with hypertension of the total study population. Statistically significant difference was observed among age-groups, smoking habits, duration of smoking, and presence or absence of any medical history [Table 1].
|Table 1: The study population and incidence of sublingual varices in relation to gender, age-group, smoking, and medical history|
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Mean systolic blood pressure during the inclusion in the clinic was found to be 121.2 mm Hg (standard deviation [SD], 15.1) and 138.1 mm Hg (SD, 18.6) in the group with grade 0 SLV and the group with grade 1 SLV, respectively [Figure 3] (P < 0.05). Mean diastolic blood pressure was found to be 81.2 mm Hg (SD 10.2) and 85.2 mm Hg (SD 12.5) in the group with no or few SLV with grade 0 and grade 1 SLV group, respectively [Figure 4] (P < 0.05).
|Figure 3: Mean systolic blood pressure with 95% confidence intervals in patients with grade 0 (n = 112) and grade 1 (n = 89) sublingual varices|
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|Figure 4: Mean diastolic blood pressure with 95% confidence intervals in patients with grade 0 (n = 112) and grade 1 (n = 89) sublingual varices|
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The distribution of the study subjects and its relation to smoking habits, cardiovascular disease, and presence of SLV are shown in [Table 2]. Among 60- to 69-year-old study participants, 76.3% were found to have SLV, followed by 30.5% among 50- to 59-year-old age-group and 25% among ≥70-year-old age-group. Overall 32.3% of the study participants had SLV in the study population.
|Table 2: Distribution of the study participants and its relation to smoking habits, cardiovascular disease, and sublingual varices|
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[Table 3] showed the risk factors and its influence on SLV by logistic regression analysis (n = 201) for the study participants. A significant difference was observed among all the parameters such as age, gender, smoking and its duration, and the presence or absence of medical history.
|Table 3: The risk factors and its influence on sublingual varices by logistic regression analysis (n = 201) among participants|
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The prevalence or absence of SLV with grade 0 and grade 1 was 37.3% (75/201) in the study population, with 19.1% (grade 1) in those subjects having normal blood pressure and 86.6% (grade 1) in those diagnosed with hypertension (P < 0.05, S) [Table 4]. These SLV showed an indication of hypertension in subgroup of smokers and showed specificity of 0.3 and sensitivity of 0.59, a negative predictive value of 0.19, and a positive predictive value of 0.63.
|Table 4: Distribution of sublingual varices in hypertensive and normotensive patients (n = 201)|
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| Discussion|| |
A definite association between smoking and SLV with hypertension and age was found in our study. The prevalence of SLV increased with hypertension stage, and it confirms the association to raised blood pressure. Earlier, no relation was detected between SLV and hypertension. Various studies were conducted to assess the stage of SLV with histopathology,,, pathology investigations, and the relation with cardiovascular disease.,,
A study conducted by Bhaskar could not find the relation between hypertension and SLV. In a study, which included 281 adults, a strong association was found between the SLV and cardiovascular disease. Also there is a substantial amount of evidence that the blood pressure is related to the loss of teeth, and a strong correlation is noticed in females aged ≥60 years in all gender and age-groups., It is also noticed that the predisposing factors for SLV are found to be long-standing cough, cardiopulmonary diseases, venous insufficiency, chronic vitamin C deficiency, portal hypertension, diabetes mellitus, and denture wearing. Cardiovascular diseases are most commonly seen in patients with hypertension, and it is one of the important risk factors., Hypertension (74%) was diagnosed in majority of cases with cardiovascular disorders; however, they were self-reported and not verified with the recordings of the blood pressure.,,,
In this study, patients with hypertension had a higher percentage of SLV and hence can be diagnosed at the clinics. This difference may be due to increased blood pressure acquired at the hospital as a result of the hospital setup and patients load attending the hospital. Probable explanations to the connection between SLV and blood pressure could include a divergent opinions in available literature, and may be due to hemodynamic effect.
The drawback of the study lies in accurately detecting the SLV. The implications of SLV act as the indicator of risk for blood pressure is the possible clinical condition.,
In every visit to the different hospital including dental clinics by examining the lateral borders of the tongue for the presence or absence of SLV can indirectly detect the presence or absence of hypertension and also causes no harm for the patient during routine examination. Depending on the results of this study, a patient older than 40 years with clinical SLV has a 51% risk of getting hypertension, and for a smoker, the risk may be increased to 65%. With the minor effort of the dental surgeon and less discomfort to the patients, it is possible to diagnose hypertension with highly positive predictive value.,
This study results found a positive correlation between SLV and hypertension in patients older than 40 years of age. With a high sensitivity and specificity, a positive predictive value as an indication of SLV is interesting and acts as an indicator remarkable in detecting the presence or absence of hypertension. Lateral borders of tongue can be examined easily by a dental surgeon, which felt no/less harm to patients, and every dental surgeon can take active participation in prevention of diseases.
We are very much thankful to Dr. N.D. Shashikiran, Dean, School of Dental Sciences & Directorate of Research Office, Krishna Institute of Medical Sciences Deemed to be University, Karad, Maharashtra for their constant support and guidance in completing research and writing the manuscript.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
All the authors has been involved in one or other work like designing the study, describing their intellectual content in the study, literature search, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review and act as guarantor for the study.
Ethical policy and Institutional Review board statement
Study approval has been granted that the proposed work is carried out in accordance with the ethical guidelines prescribed by Central Ethics Committee on Human Research (CECHR [KIMSDU/IEC/03/2015]).
Patient declaration of consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Data availability statement
The data set used in this study is available as repository in the department.
| References|| |
Al-Shayyab MH, Baqain ZH Sublingual varices in relation to smoking, cardiovascular diseases, denture wearing, and consuming vitamin rich foods. Saudi Med J 2015;36:310-5.
Hedström L, Albrektsson M, Bergh H Is there a connection between sublingual varices and hypertension? BMC Oral Health 2015;15:78.
Ettinger RL, Manderson RD A clinical study of sublingual varices. Oral Surg Oral Med Oral Pathol 1974;38:540-5.
Jassar P, Jaramillo M, Nunez DA Base of tongue varices associated with portal hypertension. Postgrad Med J 2000;76:576-7.
Rappaport I, Shiffman MA The significance of oral angiomas. Oral Surg Oral Med Oral Pathol 1964;17:263-70.
Kocsard E, Ofner F, D’Abrera VS The histopathology of caviar tongue. Ageing changes of the undersurface of the tongue. Dermatologica 1970;140:318-22.
Southam JC, Ettinger RL A histological study of sublingual varices. Oral Surg Oral Med Oral Pathol 1974;38:879-86.
Lim SS, Vos T, Flaxman AD, Danaei G, Shibuya K, Adair-Rohani H, et al
. A comparative risk assessment of burden of disease and injury attributable to 67 risk factors and risk factor clusters in 21 regions, 1990–2010: A systematic analysis for the Global Burden of Disease Study 2010. Lancet 2012;380:2224-60.
Lazos JP, Piemonte ED, Panico RL Oral varix: A review. Gerodontology 2015;32:82-9.
Kleinman HZ Lingual varicosities. Oral Surg Oral Med Oral Pathol 1967;23:546-8.
Hedström L, Bergh H Sublingual varices in relation to smoking and cardiovascular diseases. Br J Oral Maxillofac Surg 2010;48:136-8.
Pickering TG, Miller NH, Ogedegbe G, Krakoff LR, Artinian NT, Goff D; American Heart Association; American Society of Hypertension; Preventive Cardiovascular Nurses Association. Call to action on use and reimbursement for home blood pressure monitoring: Executive summary: A joint scientific statement from the American Heart Association, American Society of Hypertension, and Preventive Cardiovascular Nurses Association. Hypertension 2008;52:1-9.
Belghazi J, El Feghali RN, Moussalem T, Rejdych M, Asmar RG Validation of four automatic devices for self-measurement of blood pressure according to the International Protocol of the European Society of Hypertension. Vasc Health Risk Manag 2007;3:389-400.
Bhaskar SN Oral lesions in the aged population. A survey of 785 cases. Geriatrics 1968;23:137-49.
Shin HS Association between the number of teeth and hypertension in a study based on 13,561 participants. J Periodontol 2018;89:397-406.
Akkaya N, Ölmez D, Özkan G Evaluation of the factors associated with sublingual varices: A descriptive clinical study. Folia Morphol (Warsz) 2019;78:325-30.
Da D, Wang F, Zhang H, Zeng X, Jiang Y, Zhao Q, et al
; Shanghai Aging Study. Association between tooth loss and hypertension among older Chinese adults: A community-based study. BMC Oral Health 2019;19:277.
Chen WW, Gao RL, Liu LS, Zhu ML, Wang W, Wang YJ, et al
. China cardiovascular diseases report 2015: A summary. J Geriatr Cardiol 2017;14:1-10.
Parati G, Stergiou GS, Asmar R, Bilo G, de Leeuw P, Imai Y, et al
; ESH Working Group on Blood Pressure Monitoring. European Society of Hypertension guidelines for blood pressure monitoring at home: A summary report of the second international consensus conference on home blood pressure monitoring. J Hypertens 2008;26:1505-26.
Mancia G, De Backer G, Dominiczak A, Cifkova R, Fagard R, Germano G, et al
; Management of Arterial Hypertension of the European Society of Hypertension; European Society of Cardiology. 2007 guidelines for the management of arterial hypertension: The task force for the management of arterial hypertension of the European Society of Hypertension (ESH) and of the European Society of Cardiology (ESC). J Hypertens 2007;25: 1105-87.
SBU-Swedish Council on Health Technology Assessment. Moderately Elevated Blood Pressure: A systematic Literature Review. Stockholm, Sweden: SBU; 2004.
The microcirculation and the lymphatic system: capillary fluid exchange ,interstitial fluid, and lymph flow. Local and humoral control of blood flowby the tissues. Guyton AC, Hall JE, editors. Textbook of medical physiology.11th ed. New York: WB Saunders. 2003.
Guyton AC, Hall JE Local and humoral control of blood flow by tissues. In: Textbook of Medical Physiology. 11th ed. New York: WB Saunders; 2003.
Altman DG Some common problems in medical research. In: Altman DG, editor. Practical Statistics for Medical Research. 1st ed. London: Chapman and Hall; 1991. p. 396-439.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]