Poor dental hygiene puts congenital heart disease patients at risk of further heart damage
David Cohen, M.D.·Published 16 March 2012·9 min read
Key points
Poor dental hygiene behaviours in patients with congenital heart disease are increasing their risk of endocarditis.
If you have a normal heart, you have a low risk for endocarditis.
Poor dental hygiene and periodontal or periapical infections may produce bacteremia even in the absence of dental procedures.
The Annual Spring Meeting on Cardiovascular Nursing is the yearly meeting of the Council on Cardiovascular Nursing and Allied Professions (CCNAP) of the European Society of Cardiology (ESC).
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.
Written and revised by
David Cohen, M.D.
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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.
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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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Compared to healthy controls, patients with single ventricle physiology had better health behaviours overall. But patients exercised less and their dental hygiene practices (mainly flossing) was poorer.
The only statistically significant differences between patients and controls were for binge drinking and physical activity. A significantly lower proportion of binge drinking was found in patients compared to controls (24% vs 41%). And patients exercised less than controls (61% vs 76%).
"Patients with complex conditions can have physical restrictions so the fact that they are less physically active is perhaps not surprising," says Professor Moons. "But the reasons behind the poorer dental hygiene practices of patients in both studies need to be investigated further."
Endocarditis is a life-threatening disease, although it is relatively uncommon. Substantial morbidity and mortality result from this infection, despite improvements in outcome due to advances in antimicrobial therapy and enhanced ability to diagnose and treat complications. Primary prevention of endocarditis whenever possible is therefore very important.
Endocarditis usually develops in individuals with underlying structural cardiac defects who develop bacteremia with organisms likely to cause endocarditis. Bacteremia may occur spontaneously or may complicate a focal infection (eg, urinary tract infection, pneumonia, or cellulitis). Some surgical and dental procedures and instrumentations involving mucosal surfaces or contaminated tissue cause transient bacteremia that rarely persists for more than 15 minutes. Blood-borne bacteria may lodge on damaged or abnormal heart valves or on the endocardium or the endothelium near anatomic defects, resulting in bacterial endocarditis or endarteritis. Although bacteremia is common following many invasive procedures, only certain bacteria commonly cause endocarditis. It is not always possible to predict which patients will develop this infection or which particular procedure will be responsible.
Dental and Oral Procedures
Poor dental hygiene and periodontal or periapical infections may produce bacteremia even in the absence of dental procedures. The incidence and magnitude of bacteremias of oral origin are directly proportional to the degree of oral inflammation and infection. Individuals who are at risk for developing bacterial endocarditis should establish and maintain the best possible oral health to reduce potential sources of bacterial seeding. Optimal oral health is maintained through regular professional care and the use of appropriate dental products such as manual and powered toothbrushes, dental floss, and other plaque-removal devices. Oral irrigator or air abrasive polishing devices used inappropriately or in patients with poor oral hygiene have been implicated in producing bacteremia, but the relationship to bacterial endocarditis is unknown. Home-use devices pose far less risk of bacteremia in a healthy mouth than does ongoing oral inflammation.
Antiseptic mouth rinses applied immediately prior to dental procedures may reduce the incidence or magnitude of bacteremia. Agents include chlorhexidine hydrochloride and povidone-iodine. Fifteen milliliters of chlorhexidine can be given to all at-risk patients via gentle oral rinsing for about 30 seconds prior to dental treatment; gingival irrigation is not recommended. Sustained or repeated frequent interval use is not indicated as this may result in the selection of resistant micro-organisms.
In the past, efforts to prevent endocarditis in patients with congenital heart disease focused on taking antibiotics one hour before a dental procedure. This prevented bacteria released into the blood from damaged gums travelling to the heart and causing an infection (endocarditis).
But researchers have since discovered that daily dental hygiene is more important for preventing endocarditis than antibiotics before a procedure. Professor Moons says: "This was a change in the American Heart Association 2007 guidelines but not all physicians have switched to that new paradigm. And of course if you switch to that paradigm you also need to educate patients in a systematic way, but a lot of centres are not doing that yet."
He adds: "Systematic structured patient education on the importance of dental hygiene is critical for preventing endocarditis in patients with congenital heart disease."
About the Annual Spring Meeting on Cardiovascular Nursing
The Annual Spring Meeting on Cardiovascular Nursing is the yearly meeting of the Council on Cardiovascular Nursing and Allied Professions (CCNAP) of the European Society of Cardiology (ESC). This year's meeting was organised jointly with the Professional Society for Cardiovascular and Thorax Surgery Nurses, based in Denmark.
About the Council on Cardiovascular Nursing and Allied Professions (CCNAP)
The CCNAP aims to promote excellence in Cardiovascular Nursing and Allied Professions through practice education and research. In addition to nurses, allied health professionals belonging to the CCNAP include physiotherapists, dieticians, psychologists, cath lab technicians, imaging and diagnostic technicians and therapists working in rehabilitation and prevention. The CCNAP is one of five Councils of the European Society of Cardiology.
About the European Society of Cardiology (ESC)
The European Society of Cardiology (ESC) represents 75,000 cardiology professionals across Europe and the Mediterranean. Its mission is to reduce the burden of cardiovascular disease in Europe.
References Potentially detrimental lifestyle behaviours in adolescents with congenital heart disease in the transition to adulthood.
Substance abuse, dental hygiene and physical activity in adult patients with single ventricle physiology
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ESC Press Office [email protected] 33-049-294-8627 European Society of Cardiology
The topic of dental health is not a popular one - many people give their teeth cursory attention and put off going to the dentist as long as they possibly can. However, these poor practices can spell major trouble for…
