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."