Poor dental hygiene puts congenital heart disease patients at risk of further heart damage

Poor dental hygiene behaviours in patients with congenital heart disease are increasing their risk of endocarditis. Teens with congenital heart disease floss, brush and visit the dentist less than their peers. But they have healthier behaviours when it comes to alcohol, cigarettes and illicit drugs. Adults with single ventricle physiology (a type of congenital heart disease) also have poorer dental hygiene practices than their peers despite having better health behaviours overall.

The findings were presented in two studies at the 12th Annual Spring Meeting on Cardiovascular Nursing, 16-17 March, in Copenhagen, Denmark.

“Patients with congenital heart disease are diagnosed and receive their initial treatment in childhood but this does not mean that they are cured,” says the supervisor of both studies, Professor Philip Moons, professor in nursing science at the University of Leuven, Belgium, and guest professor at Copenhagen University Hospital, Denmark. “They remain vulnerable for developing complications – for instance we know that in patients with congenital heart disease, binge drinking can trigger life-threatening arrhythmias and good dental hygiene helps prevent endocarditis.”

For the first study (FPN 34) 1, lifestyle information was collected from 429 adolescents with congenital heart disease aged 14-19 years from the longitudinal study i-DETACH (Information technology Devices and Education programme for Transitioning Adolescents with Congenital Heart disease). Of these, 401 were matched with a control of the same age and gender without congenital heart disease. All participants completed a questionnaire, developed by the research group of Professor Moons, which measures the use of alcohol, cigarettes and illicit drugs, dental care and physical activity. These behaviours are particularly important to the health of patients with congenital heart disease.

Using results from the questionnaire, the researchers calculated risk scores for ‘substance use’ (binge drinking; smoking; illicit drug use) and ‘dental hygiene’ (no dental visits; not brushing; not flossing) ranging from 0-. An ‘overall health risk score’ (range 0) was calculated using the substance use risk score, dental hygiene risk score, and the absence of physical activity. The 3 risk scores were transformed to a scale ranging from 0 (no risk) to 100 (maximum risk). Scores were compared across different age groups.

In adolescents with congenital heart disease, substance use increased with age (p<0.001). Compared with matched controls, adolescents with congenital heart disease had significantly lower substance use (p<0.001) and health risk (p<0.001) scores, and significantly higher dental hygiene risk scores (p=0.04).

What is endocarditis?
Endocarditis is an infection of the heart’s valves or its inner lining (endocardium). It is most common in people who have a damaged, diseased, or artificial heart valve.

What increases the risk for endocarditis?
If you have a normal heart, you have a low risk for endocarditis. But if you have a problem with your heart that affects normal blood flow through the heart , it is more likely that bacteria or fungi will attach to heart tissue. This puts you at a higher risk for endocarditis.

You have a higher risk of endocarditis if you have:

- Had endocarditis in the past.
- Hemodialysis for kidney failure.
- Abnormal or damaged heart valves.
- An artificial heart valve.
- A congenital heart defect.
- Hypertrophic cardiomyopathy.
- Injected illegal drugs using dirty needles or without cleaning the skin.
- HIV.

Not all heart problems give you a higher risk of endocarditis. You do not have a higher risk if you have:

- Coronary artery bypass graft surgery (bypass surgery).
- Previous rheumatic fever without heart valve damage.
- A pacemaker or an implantable cardioverter-defibrillator (ICD).
- A heart attack without other complications.
- Mitral valve prolapse without mitral valve regurgitation or unusually thickened valve leaflets.
- A coronary artery stent.

The results reveal that health risk behaviours are prevalent in adolescents with congenital heart disease and they increase with age. They also show that in general, the health behaviour of adolescents with congenital heart disease is better than their peers except for dental hygiene.

Professor Moons says: “The fact that adolescents with congenital heart disease have better health behaviour overall than the general population is understandable given the amount of input they have had from healthcare professionals over their lives. But we need to do more to understand why their dental hygiene is not as good as expected.”

For the second study (FPN 158), the same questionnaire was used to collect lifestyle information from adults aged 16-48 years (average age 24 years) with a type of congenital heart disease called single ventricle physiology. “This is a very complex congenital heart condition and we know that these patients are more at risk for endocarditis and arrhythmias than the larger population of congenital heart disease patients,” says Professor Moons. “This means that their health behaviour is even more important.”

Several studies have shown that dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors. Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed. Current policies for prophylaxis should be reconsidered.


Infective endocarditis is uncommon but potentially fatal. Administration of antibiotic prophylaxis is conventional, but data supporting its effectiveness derive solely from anecdotal reports, studies of bacteremia after dental and other procedures, and animal models. The low incidence of disease has made randomized human trials of antibiotic effectiveness impractical.

Even if effective, antibiotic prophylaxis should be reserved for patients at increased risk, such as those with cardiac abnormalities who are undergoing dental procedures. However, controlled human studies of risk factors are lacking. Previous case series indicate that approximately 15% of patients with infective endocarditis caused by mouth organisms had undergone a recent dental procedure, but the comparable percentage from a general population is unknown. The single hospital-based case–control study did not find an elevated risk associated with dental therapy, except for a borderline increase with dental scaling.

We are unaware of controlled human studies that quantify the risk for infective endocarditis associated with cardiac valve abnormalities other than mitral valve prolapse. We therefore conducted a population-based case–control study to evaluate and quantify risk factors for infective endocarditis, especially those considered by the American Heart Association (AHA) to be indications for antibiotic prophylaxis.

Dental and Cardiac Risk Factors for Infective Endocarditis: A Population-Based, Case-Control Study
Brian L. Strom, MD, MPH; Elias Abrutyn, MD; Jesse A. Berlin, ScD; Judith L. Kinman, MA; Roy S. Feldman, DDS, DMSc; Paul D. Stolley, MD, MPH; Matthew E. Levison, MD; Oksana M. Korzeniowski, MD; and Donald Kaye, MD

A cross sectional, case control study was conducted in 59 patients who were matched on age and gender to 172 healthy controls.

In patients with single ventricle physiology, 85% drank alcohol; 26% were binge drinkers; 20% smoked cigarettes; 12% used cannabis over the past year; 20% had not visited the dentist during the last year; 46% were not flossing teeth; and 39% were not physically active.

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