Dental Health, Heart Disease and Chemotherapy

My youngest sister was born with a heart defect. She had repeated visits to her physicians for monitoring and did well enough through high school and into early adulthood.”Her diagnosis was mitral valve prolapse, and the doctors thought that heart valve replacement would give her a better quality of life. My parents wrestled with the decision, but like most caring parents, had a hard time signing the consent form that had death as one of the possible complications of surgery.

When my sister turned sixteen and I opened my first dental office, she worked with me as a part-time dental assistant. When she turned eighteen, she was still being followed by the cardiologist at a local hospital and decided that she would not have surgery unless it were unavoidable.

At twenty-two, she was living at home and continuing her college education. On a day I will never forget, my receptionist told me my mom was on the phone.

“Bertrand, it’s your sister! Mom started.”

“What’s happening,” I queried.

“They’re working on her. The EMS.”

“Is she alright?”

“She’s gone, I can’t.”

“Where are they taking her?”

“Kings County Hospital.”

“Mom, I’ll meet you there.”

My mother’s voice was in a tone that I never heard before or since. It was sure the result was not going to be good. I rushed back and forth, told my receptionist to cancel all remaining appointments, and rushed to the hospital. My sister’s last sight was her body passing by on a gurney as one Emergency Medical Technician was performing chest compressions at the hospital.

Several days later, my Dad and I went to identify her body in the morgue. We held onto each other for support, and in silence, while being choked up, we wobbled to the car together. It was over for this young child, and it was uncertainty for the young two-year-old child she left behind.

We could not believe it. The death certificate stated as the cause of death “Floppy mitral valve.” My diagnosis was a functional heart murmur. My concern for patients with heart problems increased to the point where I took the American Heart Association courses and became Advanced Cardiac Life Support Certified.

There is a connection between the heart and the mouth, and anyone with a heart murmur or artificial joint knows that they may have to take antibiotics before dental treatment. Antibiotic prophylaxis is medication taken in high enough doses to treat bacteria from the mouth that gets into the bloodstream to prevent it from damaging the heart or artificial joints. The mouth, throat, and sinuses are places that are conducive to the breeding of viruses, bacteria, and fungus that can spread throughout your body if your immune system is compromised.

How Chemotherapy Affects Dental Health

Chemotherapy can compromise your immune system to the point where your remaining white blood cells are not enough to keep the body from coming down with a general infection. The general guidelines that your dental team gives you for taking care of your teeth and gums should be strictly followed to ensure that you will not suffer severe oral symptoms during chemotherapy.

Radiation treatments affect the body in many ways. The jaws’ bones are particularly susceptible to radiation because they compromise the blood flow in the bones. The salivary glands are adversely affected if they become exposed to radiation. The salivary glands are scarred and generally reduce their production of saliva, causing dry mouth. Saliva serves a protective and lubricating function in the mouth, but dry mouth leads to multiple oral problems, including increased cavities and gum ulcerations.

The worse condition that can occur after radiation treatment is osteoradionecrosis. Osteoradionecrosis is the breakdown of the bones that happens after radiation treatment and can be exacerbated by ongoing oral infections. Hospitals treating this condition use the hyperbaric chamber with pressurized oxygen treatments over several appointments. The remaining jawbone that survives after treatment presents significant problems for restoring teeth because it is hard to make a compromised jawbone’s satisfactory prosthesis.

My best advice is to take the prevention of gum disease and cavities seriously. Ensure your oral health is in the best shape before doing any elective surgery or before the need for chemotherapy or radiation treatment. So let us review the April 2007 recommendations by the American Heart Association.

American Heart Association Recommendations

Increased use of antibiotics also increases the risk of an allergic reaction to a specific antibiotic, which can be even more immediately life-threatening than bacteria in the bloodstream. Consult your physician if you are uncertain about needing antibiotics before dental treatment.

The following are basic guidelines for needing antibiotics before treatment.

Prosthetic cardiac valve

Previous bouts of infective endocarditis

Certain congenital diseases (Unrepaired cyanotic Cardiac Heart Defects (CHD ), first six months after prosthetic repair of CHD, repaired CHD with residual defects, palliative shunts, and conduits, etc.)

Cardiac transplant recipients who develop valvulitis

Mitral valve prolapse with associated defects that your physician thinks may put you at risk for endocarditis.

In addition to the above, specific cardiac surgical procedures may require that you wait six months before having a dental procedure, providing you do not have a life-threatening dental infection. If there is any uncertainty, the best option is to see your physician before visiting the dentist.

Poor Dental Health and Cardiovascular Diseases

Over the last few years, more scientific studies have supported the link between poor oral health and cardiovascular diseases. Current advances in DNA studies will allow doctors to predict the patients who are more at risk for diseases than others based on oral salivary or blood samples. Some dentists are using screening tests for C-Reactive proteins and early diabetic screening to see which patients may require close monitoring of their dental health.

Many studies have indicated the correlation between gum disease and cardiovascular disease. One in-office treatment for severe periodontal disease involves using an antibiotic delivered directly into the space between tooth and gum. The area is cleaned and irrigated, and an antibiotic is administered. You can discuss this method with your dentist and dental hygienist. We train our Registered Dental Hygienists (RDHs) to help the treatment in conjunction with the dentist’s diagnosis. We’ll repeat therapy in areas of your gums that are infected and, if necessary, refer you to a periodontist for further treatments.

Root Canals, Apicoectomies, and Extractions

At first glance, a tooth may seem like a piece of hard bone that chews food. However, if cut in a cross-section, a healthy tooth has a network of nerves, arteries, and veins that respond to stimuli from the outside and the inside. Repeated drilling or cavities on a tooth allow oral fluids, water, chemicals, and bacteria to find their way into channels called dentinal tubules, and they could eventually affect the nerve inside the tooth. Sometimes the effect will manifest years after the initial insult.

What is Pulpitis?

Pulpitis is the pulp’s inflammation (the inner part of the tooth-bearing the blood vessels and nerve). The condition of the pulp can be described using three words: reversible, irreversible, and necrotic. Reversible pulpitis refers to a fleeting and low-grade inflammation sometimes caused by stimulation or sensitivity of the tooth. Irreversible pulpitis means the nerve is damaged or infected to the point that the tooth will not recover unless pulpal treatment is performed. Necrotic pulp means damaged, infected pulpal tissue that may no longer be responsive to stimuli or is infected. For irreversible pulpitis and necrotic teeth, the treatment is to perform a root canal.

The Root Canal Process

The root canal process involves preparing the tooth with instruments a little deeper than a large filling to locate the pulp and identify the canals. Tools like files and reamers, driven by a motor or used by hand, can remove the pulpal tissues. Solutions that clean and disinfect are used to irrigate the canals as the residue is suctioned away. Diagnostic equipment and radiographs (X-rays) can determine the length of roots. Eventually, the canals can be dried and filled with root-canal cement along with a non-metallic filler if the clinician determines. Numerous materials can be used, and some can be partially removed after filling the root to make space for a cemented post to support filling material and a crown. New materials and instruments help make this treatment faster and easier for the patient.

Benefits of a Root Canal

Intentional root canals are beneficial in several cases. Sometimes the tooth is in a rotated position, and a cosmetic and functional solution would mean reducing the area of the tooth that sticks out from the ideal arch form. When removing the tooth structure leads to encroachment on the nerve, an intentional root canal will ensure that the patient will not have to suffer undue pain later. Clinical judgment is also used when we approach close enough to the nerve that putting in a filling may irritate the nerves and cause the patient undue suffering.

Some people think that root canal treatment should not be done because there are always residual bacteria in the complex network of a tooth’s nerves that can lead to future infection and immune response.

I say the sooner we intercept problems, the better the chances of having a good outcome.

Root canal (endodontic) therapy requires special skills and intimate knowledge of the structure of teeth. Most front teeth have one canal; other teeth may have two, three, four, or more. Some lower front teeth have complex canal systems that make it challenging to find and clean them adequately. Calcified canals result when the pulp chamber lays down calcium salts on the inside of the canal in response to an insult to protect itself.

Sometimes these canals are hard to find and may require multiple visits or referrals to a root canal specialist (endodontist).

Some studies indicate that root canal treatment can have a 93 percent success rate five years after the treatment was initiated. The other 7 percent of teeth may need to be retreated, extracted, or have an apicoectomy performed. An abscess at the root of a tooth with a root canal, a post placed, and then a crown may not lend itself readily to being retreated. However, we can lift the gums can off the bone and remove the abscess at the root. After removing the infected root tip, a filling is placed in the remaining root to seal it from being re-infected. This procedure is called an apicoectomy, where the apex is the end of the tooth’s root. When a root canal fails or a tooth fractures vertically or horizontally below the bone level, the best option is to take the tooth out, remove the infection, place a bone graft in the area, and then place and restore an implant at a later date.

Extractions of teeth with root canal treatments present some unique problems because the tooth is more brittle and may break easily. This problem is common when patients do not follow up after their root canal by having the tooth crowned. Once the brittle tooth breaks, the tooth needs to be extracted. Cavities can also destroy a root canal tooth if the patient does not discover it in time; cavities do not cause a root canal tooth to hurt, and patients who do not see their dentist often may miss the fact that a cavity was developing.