Dental Work and Pericarditis


While having dental work done, you may be exposed to bacteria responsible for inflammation of the heart tissue. However, you could just as easily be introduced to the bacteria in your own home, thanks to vigorous brushing.
While having dental work done, you may be exposed to bacteria responsible for inflammation of the heart tissue. However, you could just as easily be introduced to the bacteria in your own home, thanks to vigorous brushing.
iStockphoto/Thinkstock

Pericarditis is an inflammation of the double-layered, sac-like membrane surrounding the heart called the pericardium. That's the quick description. The root of that inflammation, however, can be exceedingly difficult to diagnose -- and exceedingly complicated in its root cause. It can also be a very thorny ailment to treat.

The primary role of the pericardium is to act as an organic buffer for the heart. The double-layered sac contains a fluid that protects the heart and major blood vessels while reducing friction between the heart and adjoining organs in the chest cavity. Problems occur when that fluid become inflamed, or the amount of fluid swells to such dangerous levels (pericardial effusion) that the pericardium is no longer effective in providing that cushion. Repeated bouts of pericarditis can also thicken the membrane, resulting in a less-elastic sheath, which will adversely affect the heart's ability to pump normally.

The causes of pericarditis are legion, and many are never fully diagnosed. Many cases are rooted in viral, bacterial or fungal infection. However, other causes can include heart attack, kidney failure, tuberculosis, cancer treatment (a potential byproduct of radiation), traumatic chest injury, AIDS and other autoimmune diseases such as lupus. In some instances, certain medications can trigger a bout of pericarditis [source: Mayo Clinic].

Though the connection between dental work and pericarditis is difficult to trace, it is certainly plausible, especially in cases where an infection is determined to be the culprit. Though the overwhelming majority of dental procedures -- even the most invasive operations -- are performed without complication, they aren't immune to the potential of infection. As with any surgery, infection can set in during surgery, or post-op. Patients need to be vigilant of any discomfort they have post surgery and closely monitor those aches and pains.

Even the symptoms of pericarditis can be confusing and difficult to diagnose. Chief among symptoms is chest discomfort, ranging from a dull ache to a sharp pain, which can result from the pericardium membrane rubbing against the outer layer of the heart. Easily confused with angina -- a condition that results from inadequate blood flow to the heart but heals quickly with rest -- pericarditis is characterized by a more persistent chest pain.

Other symptoms can include any one (or a combination) of the following: spreading pain in the shoulder area, muscle aches, swelling in your extremities, low-grade fever, exhaustion and coughing [source: WebMD].

Evolving Standards of Dental Work

Like all fields of medicine, the dental profession continues to evolve over time as dentists and oral surgeons develop new techniques and learn more about how procedures impact the entire human organism. One such change was the decision to limit the use of antibiotics in conjunction with ordinary dental procedures.

"When I first started practicing 23 years ago, it was standard operating procedure for anybody who had a heart murmur to be premedicated with a does on antibiotics prior to dental treatment, " says Dr. Ray Orzechowski Jr., a dentist with offices in Concord, N.H. "There clearly had to be cases documented where patients underwent dental treatment, and as part of routine dental treatment there was a risk of bacteria being pushed into the bloodstream, resulting in bacteremia."

According to Orzechowski, most of the dental research focuses on endocarditis, or inflammation of the endocardium (the lining of the heart valves), but it is just as applicable to pericarditis. The concern was that patients with heart murmurs had faulty valves that weren't efficiently driving the blood supply through the heart.

"So the theory was, there's a potential amount of blood that's recirculating around that heart valve because it's not being pushed cleanly through, creating a little ebb tide around the heart valve," he says. "If you have bacteria in that blood stream as the result of dental treatment, it theoretically could attach to that heart valve, because it's not being pushed cleanly through, and then establish a potential infection."

Making things more complicated was the fact that the use of antibiotics was only required for specific heart ailments -- mitral valve prolapse with regurgitation -- but many patients didn't know which classification they had. So the dental community took a "better safe than sorry" approach.

"As is often the case in medicine, things aren't always black and white," says Orzechowski. "This happened to be a very large gray area as far as whether the research supported the use of antibiotics. But everyone wanted to cover their liability, so there was just this blanket accepted standard that anybody who had a history of a heart murmur was going to get a premedication."

The reasoning appeared sound. "That was the standard of care," he says. "We premedicated any patient with a heart murmur with an antibiotic ... then you would have antibiotic in your bloodstream while you were having the procedure done. That way, any bacteria that got into your blood stream, the antibiotic would take care of it. So there was never an opportunity for those bacteria to colonize on your heart and create a potential problem."

Time for Change

The standard of premedicating patients with a heart murmur with an antibiotic came under scrutiny when the medical community noted an increase in resistant strains of bacteria. A concern arose that low-dose antibiotic treatment could encourage these resistant strains. As a result of extensive research done jointly by the dental and medical professions, the standard of care changed dramatically.

"What they found was that there is no discernable link between the risk of developing endocarditis as a result of dental treatment," says Orzechowski. "So the policy was changed to reflect that. Now the only patients who receive an antibiotic prior to dental treatment is someone with an artificial heart valve, or anybody with a history of endocarditis."

Further, Orzechowski noted that the dental community realized that the bacteria responsible for inflammation of the heart tissue could easily have been introduced in a patient's home and not at the dental office.

"You could put bacteria into your blood stream through your gum tissue by brushing your teeth aggressively," he says. "Someone with bad gum disease, who has swollen, inflamed, bleeding gums, they may be creating a bacteremia every day."

The policy change was critical, says Orzechowski, because it protected dentists and oral surgeons on the legal front.

"The other component is the whole liability issue," he says. "As much as we all suspected that [premedication] really wasn't necessary, nobody in their right mind would take it on their own to stop prescribing an antibiotic if the standard of care is that you use an antibiotic. So, it takes the profession, and in this case a joint effort between the medical community and the dental community, to look at those things as objectively as possible. And then if they feel the policy needs to be changed, then they create a position statement that says that."

Acute vs. Chronic Pericarditis

Pericarditis cases fall into one of two large categories: acute and chronic. Acute pericarditis makes up the vast majority of reported cases, and usually lasts less than a few weeks. Chronic or recurrent pericarditis, on the other hand, usually lasts six months or longer [source. Mayo Clinic].

Pericarditis generally results from heart attacks, infections or immunological disorders. Chest trauma -- caused by an accident or injury, or an invasive cardiac procedure or resuscitation -- is also a potential cause. In rare instances, pericarditis can result from radiation treatment or in response to certain drugs, such as anticoagulants and penicillin [source: Czapsky]. In the case of a heart attack, a patient may suffer from a delayed onset of pericarditis, known as Dressler's syndrome, in which the body can mistakenly attack its own tissue [source: Mayo Clinic].

If you suspect you may be suffering from pericarditis, make an appointment to see your doctor immediately. Expect a battery of questions regarding your and your family's medical histories. They will likely listen to your heart and possibly order tests, including X-rays, CT scans, MRI, blood work or even an electrocardiogram (EKG).

There is a broad range of treatment for pericarditis. What your doctors recommend will depend on the severity of your condition, but the primary goal is to reduce inflammation and eradicate the any underlying infection. In most instances, if your doctors suspect a viral or bacterial infection, they will likely order a round of antibiotics, aspirin or non-steroidal anti-inflammatory medications.

If the symptoms persist for more than a week, your doctors may order an echocardiogram, which can not only determine the amount of fluid in the pericardium, but can also indicate whether the fluid is putting pressure on the heart -- a condition known as cardiac tamponade -- or if the tissue that makes up the pericardium is compromised and becoming stiff (a condition known as constrictive pericarditis) [source: WebMD].

In cases of persistent or chronic pericarditis that fail to respond to lower-dose medications, doctors may opt to treat with colchicine or powerful corticosteroids to reduce inflammation. If the excess fluid in the pericardium doesn't diminish with initial treatment, doctors may suggest a pericardiocentesis. Surgeons can relieve pressure on the patient's heart by using a sterile needle and tube to remove excess fluid from the pericardium via a needle and tube (similar to amniocentesis). Tests on the extracted fluid can also shed some light on the cause of the inflammation, which can be another diagnostic tool for the doctors.

In the vast majority of cases, the pericarditis will clear up within a week to 10 days. However, in the case of chronic or recurrent pericarditis, inflammation and the resulting symptoms can linger for weeks on end. Though rarer, chronic pericarditis can also be much more dangerous. Left untreated, pericarditis can lead to a host of more serious, and even potentially fatal, conditions.

Chronic pericarditis is often linked to any number of other ailments, including leukemia, tuberculosis, lupus, rheumatoid arthritis, kidney failure, rheumatic fever, malfunctioning thyroid and AIDS/HIV infection. This persistent swelling of the pericardial fluid (pericardial effusion) can rob the pericardial sheath of its elasticity, leading to severe cardiopulmonary problems.

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