Ann Thorac Surg 1997;63:402-404
© 1997 The Society of Thoracic Surgeons
Original Article: Cardiovascular
Oral Disease Burden in Patients Undergoing Prosthetic Heart Valve Implantation
Geza T. Terezhalmy, DDS,
Tala J. Safadi, DDS,
David L. Longworth, MD,
Derek D. Muehrcke, MD
Section of Oral Medicine, Department of Dentistry, Department of Infectious Disease, and Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, Cleveland, Ohio
Accepted for publication August 10, 1996.
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Abstract
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Background. Valvular heart disease predisposing to endocarditis and requiring prosthetic valve implantation is common among the elderly. Spontaneous bacteremias associated with acute or chronic oral/odontogenic infections may represent a far greater cumulative risk for the development of endocarditis than do occasional health care procedures administered in a professional setting.
Methods. To determine the oral disease burden in patients undergoing mechanical or bioprosthetic heart valve implantation, we performed a comprehensive clinical and radiographic regional examination on 156 consecutive patients, with emphasis on identifying acute and chronic oral/odontogenic infections and conditions.
Results. The mean number of remaining teeth in the cohort was 19.32; of these, 1.07 were carious, involving a mean number of 2.51 tooth surfaces. In addition, 15.38% of the patients had evidence of acute or chronic periapical abscesses, and 43.6% of the patients had moderate to advanced periodontitis.
Conclusions. In view of the substantial morbidity and mortality associated with prosthetic valve endocarditis and based upon the high incidence of dental disease identified in patients undergoing valvular operations, routine preoperative dental assessment should be deemed a "medical necessity" by third-party payors. Appropriate therapeutic intervention should be initiated whenever possible before valve implantation.
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Introduction
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The relation between certain health care procedures and transient bacteremias has been examined extensively. Endocarditis appears to follow bacteremias. Individuals who have prosthetic heart valves are at higher risk for endocarditis, which may be associated with substantial morbidity and mortality. However, only a small percentage of all cases of endocarditis appear to arise from bacteremia-prone procedures, and the administration of appropriate antibacterial prophylaxis is not always protective. Consequently, alternative approaches to prevention must be investigated. Valvular heart disease predisposing to endocarditis and necessitating prosthetic valve implantation is common among the elderly [1]. Similarly, the most recent national survey conducted by the National Institute of Dental Research [2] (1985 to 1986) concluded that seniors share a disproportionate percentage of the oral disease burden among United States adults. The prolific resident and transient oral flora is an important source of spontaneous bacteremias associated with acute or chronic oral/odontogenic infections. These infections may represent a far greater cumulative risk for the development of endocarditis than do occasional health care procedures administered in a professional setting. The purpose of this investigation was to determine the oral disease burden in patients undergoing mechanical or bioprosthetic heart valve implantation. When it was indicated, appropriate therapeutic intervention was implemented before prosthetic heart valve implantation.
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Material and Methods
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Patients with valvular heart disease requiring mechanical or bioprosthetic valve implantation in 1993 were included in this study. All patients were direct referrals to the Section of Oral Medicine, Department of Dentistry, from the Department of Thoracic and Cardiovascular Surgery, The Cleveland Clinic Foundation, as part of standard preoperative interdisciplinary assessment of such patients. A comprehensive clinical and radiographic regional examination was performed, with particular emphasis on identifying acute and chronic oral/odontogenic conditions, such as infected or nonrestorable teeth, periapical pathosis, and moderate to advanced periodontal disease, which may contribute to early or late prosthetic valve endocarditis. Regional radiographic examination included a panoramic and selected periapical views to help assess the extent of caries activity and periapical and periodontal disease patterns.
Determination of the periodontal status of the patients was based on the American Dental Association classification: type I, gingival disease-inflammation of the gingiva, characterized by changes in color, gingival form, position, surface appearance, and presence of bleeding or exudate; type II, early periodontitis-progression of the gingival inflammation into the deeper periodontal structures and alveolar bone crest, with slight loss of connective tissue attachment and alveolar bone; type III, moderate periodontitis-increased destruction of the periodontal structures and noticeable loss of bone support, possibly accompanied by an increase in tooth mobility or by furcation involvement in multi-rooted teeth; and type IV, advanced periodontitis-major loss of alveolar bone support, usually accompanied by increased tooth mobility and by furcation involvement in multi-rooted teeth.
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Results
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We reviewed the clinical and radiographic data from 156 consecutive patients with valvular disease requiring mechanical or bioprosthetic heart valve implantation. There were 59 women (37.8%) and 97 men (62.2%) in the cohort, with a mean age of 62.8 years (median, 66 years; range, 26 to 87 years). All patients required aortic valve, mitral valve, or multiple valve replacement. The mean number of teeth per patient was 19.32. The mean number of decayed teeth was 1.07, and the mean number of decayed tooth surfaces was 2.51. Radiographic findings revealed at least one periapical abscess associated with decayed or restored teeth in 15.38% (24/156) of the patients. In addition, 30.76% of the patients had evidence of past root canal treatment, involving a total of 113 teeth. Seven patients (4.5%) presented with type I, 78 patients (50.0%) with type II, 42 patients (26.9%) with type III, and 26 patients (16.7%) with type IV periodontitis.
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Comment
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The relation between certain health care procedures and transient bacteremias has been examined extensively [3–11]. The frequency of such bacteremias is reported as highest for oral health care procedures, intermediate for those procedures related to the genitourinary tract, and low for procedures involving the gastrointestinal tract [10, 12–14]. The relative frequency of endocarditis associated with these bacteremia-prone procedures also follows the same order [10, 15–17]. Procedure-related bacteremias are short lived. The frequency of positive blood cultures is highest in the first 30 seconds after tooth extractions [11], and most episodes of bacteremia associated with oral health care procedures last less than 10 minutes [4, 10, 11]. In animals, bacterial seeding of the endocardium can occur within minutes after the introduction of bacteria into the bloodstream [18, 19].
This observation is consistent with the rapid onset of symptoms when endocarditis follows a bacteremia-prone procedure [17, 20]. Some patients may have symptoms within 24 to 48 hours, with a median incubation period of 7 to 14 days. When the incubation period is longer than 14 days, the suspected bacteremia-prone procedure is probably not the cause of the endocarditis [17, 21, 22]. Consequently, evidence that a particular bacteremia-prone procedure caused a specific case of endocarditis is, at best, circumstantial, and causation based on a temporal relation seems to account for only 4% to 19% of all cases of endocarditis [5–8, 10, 17, 22–26].
Acute oral infection has been implicated in the pathogenesis of a minority of cases of early prosthetic valve endocarditis. Acute and chronic oral infections and bacteremia-prone oral health care procedures may contribute to the development of late prosthetic valve endocarditis in a larger number of cases. The incidence of spontaneous bacteremias associated with acute or chronic oral/odontogenic infections is unknown. However, spontaneous bacteremias have been reported, indicating that the prolific resident and transient oral flora often enters the bloodstream [4, 9–11]. These transient episodes of bacteremia probably present a greater cumulative risk of endocarditis to patients with predisposing heart disease than do occasional oral health care procedures administered in a professional setting.
Data on the frequency of bacteremias after selected oral health care procedures have been reported [10, 12–14]. The incidence of bacteremia after tooth extraction was reported to be 60% (range, 18% to 85%), and bacteremia was more predictable in patients who underwent multiple extractions or who had associated periodontal disease [4–8]. In this study, the average number of missing teeth per patient was 12.67; very conservatively, this suggests one bacteremia-prone procedure (extraction) every 4 years. The incidence of bacteremia after periodontal operations was reported to be 88% (range, 60% to 90%) [12]. Although we did not analyze the incidence of past periodontal procedures, the number of such procedures performed on patients is even smaller than the number of extractions. Bacteremia after brushing teeth and irrigation has a reported incidence of 40% (range, 7% to 50%) [12]. Considering that this activity is repeated by the average patient at least once daily, the cumulative risk of endocarditis associated with routine oral home care in patients with predisposing heart disease likely overshadows the risk associated with occasional oral health care procedures in a professional setting.
Although we made no attempt to determine whether the oral disease burden in patients undergoing prosthetic heart valve implantation was higher than in any other cohort, the frequency of such disease in our study group was substantial. The incidence of acute and chronic oral/odontogenic infections was sufficiently high to mandate a comprehensive clinical and radiographic examination preoperatively, with implementation of appropriate therapeutic intervention (if possible, before valve operations) whenever such high-risk patients were identified. In view of the substantial morbidity and mortality associated with prosthetic valve endocarditis, such a multidisciplinary approach is an essential component of preoperative assessment in patients undergoing valve operations. A routine preoperative dental examination should be deemed "medically necessary" by third-party payors. The purpose of this examination is not only to initiate diagnostic/therapeutic services for care of the teeth or of structures directly supporting the teeth, but also to identify and treat potential sources of oral/odontogenic infection, which would pose an increased risk for the development of prosthetic valve endocarditis postoperatively. Although our data do not prove that therapeutic intervention preoperatively will reduce the long-term risk of prosthetic valve endocarditis, we expect that this may well be the case. Thus, a randomized study is required for long-term assessment to compare the incidence of endocarditis between patients who are screened and treated preoperatively and those who are not.
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Footnotes
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Address reprint requests to Dr Terezhalmy, Section of Oral Medicine/A70, Department of Dentistry, The Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH 44195.
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References
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Abstract
Introduction
