By Joel M. Laudenbach, D.M.D.
Columbia University College of Dental Medicine

In April 2007, the American Heart Association (AHA) announced a new set of guidelines for dental patients with certain types of heart disease. The purpose of the guidelines is to help prevent infective endocarditis (IE). This heart infection is uncommon. But when it occurs, it is serious. It can be life threatening. Most people survive, but can develop serious health problems. These may include heart failure, blood clots or kidney problems.

This infection often begins in part of the heart that is damaged, diseased or repaired by surgery. Bacteria in the mouth may reach the heart by traveling through the bloodstream. Bacteria can enter the blood even through some everyday activities, the guidelines note. These include:

• Chewing food
• Brushing teeth
• Flossing
• Using a toothpick
• Using a water irrigation device

Having dental disease makes it easier for bacteria to enter the bloodstream through these activities. The theory is that bleeding gums provide the pathway. However, this is not proven.

Dental procedures also can create an opening for bacteria to enter the bloodstream. This is why the AHA and the American Dental Association advise certain groups of people to take antibiotics before dental procedures. These groups have the highest risk for serious health problems or death if they develop IE.

The 2007 guidelines explain that pre-treatment with antibiotics is reasonable for people with these conditions:

• Previous infective endocarditis (heart infection)
• Artificial heart valve or valve repair using artificial material
• Certain types of congenital heart disease (CHD). These types of disease are present at birth. They include:
  
  • Cyanotic heart disease that has not been repaired or was repaired incompletely. This includes people with shunts and conduits.
  • A heart defect that was completely repaired with a prosthetic material or device. In this case, antibiotics are advised only for the first six months after the procedure.
  • Any repaired heart defect that still has some defect at or next to the site of a prosthetic patch or device
• Valve disease that develops after a heart transplant

People in these groups should take antibiotics before certain kinds of dental appointments. These include any procedures that involve cutting or manipulating the gums or the area around a tooth root.

Usually the antibiotic given is 2 grams of amoxicillin. It is taken 30 to 60 minutes before the dental procedure. Some people are allergic to amoxicillin and other drugs related to penicillin. Other people cannot take pills. These patients can use other antibiotics.

Some kinds of dental procedures do not require pre-treatment. They include X-rays, injections into non-infected tissue, adjusting braces on teeth, and others.

The 2007 guidelines were written by a panel of experts. They updated a document from 1999. The older list recommended antibiotics before dental visits for more heart conditions than the new guidelines. The authors removed some conditions from the 1999 guidelines for multiple reasons. The changes were based on newer research.

The 2007 guidelines also explain that taking antibiotics for no good reason has risks as well. When antibiotics are taken too often, the bacteria can become resistant to the drugs. This makes them less effective. As a result, fewer antibiotics may be available to treat IE.

The guidelines also suggest that people get a dental exam before certain kinds of surgery. These include procedures to replace or repair a heart valve or congenital heart disease. In most cases, problems found in the dental exam could get treated before the heart surgery. This precaution could lead to fewer cases of IE.

Whether or not you have heart disease, your oral and medical health affect each other. Be sure to tell your dentist about your medical diseases, conditions and surgeries. Your dentist also needs to know what medicines you take.

Discuss any planned medical surgeries with your dentist, as well as your physician. Ask if there may be any problem or potential interaction with dental procedures. Your dentist and physician may need to discuss your medical history to ensure your safety.

Joel M. Laudenbach, D.M.D., is an assistant professor and director of Geriatric Dentistry at Columbia University College of Dental Medicine. He is an appointed attending dentist and dental director on the staff of New York-Presbyterian Hospital, and he maintains a private practice in oral medicine and geriatric dental medicine in Philadelphia.