Poor dental hygiene puts congenital heart disease patients at risk of further heart damage
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.”
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Notes to editor
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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