Dental hygiene critical for preventing endocarditis in patients with congenital heart disease

Poor dental hygiene behaviours in patients with congenital heart disease are increasing their risk of endocarditis. Teens with congenital heart disease floss, brush and visit the dentist less than their peers. But they have healthier behaviours when it comes to alcohol, cigarettes and illicit drugs. Adults with single ventricle physiology (a type of congenital heart disease) also have poorer dental hygiene practices than their peers despite having better health behaviours overall.

The findings were presented in two studies at the 12th Annual Spring Meeting on Cardiovascular Nursing, 16-17 March, in Copenhagen, Denmark.

"Patients with congenital heart disease are diagnosed and receive their initial treatment in childhood but this does not mean that they are cured," says the supervisor of both studies, Professor Philip Moons, professor in nursing science at the University of Leuven, Belgium, and guest professor at Copenhagen University Hospital, Denmark. "They remain vulnerable for developing complications - for instance we know that in patients with congenital heart disease, binge drinking can trigger life-threatening arrhythmias and good dental hygiene helps prevent endocarditis."

For the first study (FPN 34) 1, lifestyle information was collected from 429 adolescents with congenital heart disease aged 14-19 years from the longitudinal study i-DETACH (Information technology Devices and Education programme for Transitioning Adolescents with Congenital Heart disease). Of these, 401 were matched with a control of the same age and gender without congenital heart disease. All participants completed a questionnaire, developed by the research group of Professor Moons, which measures the use of alcohol, cigarettes and illicit drugs, dental care and physical activity. These behaviours are particularly important to the health of patients with congenital heart disease.

Using results from the questionnaire, the researchers calculated risk scores for 'substance use' (binge drinking; smoking; illicit drug use) and 'dental hygiene' (no dental visits; not brushing; not flossing) ranging from 0𔃁. An 'overall health risk score' (range 0𔃅) was calculated using the substance use risk score, dental hygiene risk score, and the absence of physical activity. The 3 risk scores were transformed to a scale ranging from 0 (no risk) to 100 (maximum risk). Scores were compared across different age groups.

In adolescents with congenital heart disease, substance use increased with age (p<0.001). Compared with matched controls, adolescents with congenital heart disease had significantly lower substance use (p<0.001) and health risk (p<0.001) scores, and significantly higher dental hygiene risk scores>

The results reveal that health risk behaviours are prevalent in adolescents with congenital heart disease and they increase with age. They also show that in general, the health behaviour of adolescents with congenital heart disease is better than their peers except for dental hygiene.

Professor Moons says: "The fact that adolescents with congenital heart disease have better health behaviour overall than the general population is understandable given the amount of input they have had from healthcare professionals over their lives. But we need to do more to understand why their dental hygiene is not as good as expected."

For the second study (FPN 158)-, the same questionnaire was used to collect lifestyle information from adults aged 16-48 years (average age 24 years) with a type of congenital heart disease called single ventricle physiology. "This is a very complex congenital heart condition and we know that these patients are more at risk for endocarditis and arrhythmias than the larger population of congenital heart disease patients," says Professor Moons. "This means that their health behaviour is even more important."

A cross sectional, case control study was conducted in 59 patients who were matched on age and gender to 172 healthy controls.

In patients with single ventricle physiology, 85% drank alcohol; 26% were binge drinkers; 20% smoked cigarettes; 12% used cannabis over the past year; 20% had not visited the dentist during the last year; 46% were not flossing teeth; and 39% were not physically active.

Compared to healthy controls, patients with single ventricle physiology had better health behaviours overall. But patients exercised less and their dental hygiene practices (mainly flossing) was poorer.

The only statistically significant differences between patients and controls were for binge drinking and physical activity. A significantly lower proportion of binge drinking was found in patients compared to controls (24% vs 41%). And patients exercised less than controls (61% vs 76%).

"Patients with complex conditions can have physical restrictions so the fact that they are less physically active is perhaps not surprising," says Professor Moons. "But the reasons behind the poorer dental hygiene practices of patients in both studies need to be investigated further."

In the past, efforts to prevent endocarditis in patients with congenital heart disease focused on taking antibiotics one hour before a dental procedure. This prevented bacteria released into the blood from damaged gums travelling to the heart and causing an infection (endocarditis).

But researchers have since discovered that daily dental hygiene is more important for preventing endocarditis than antibiotics before a procedure. Professor Moons says: "This was a change in the American Heart Association 2007 guidelines but not all physicians have switched to that new paradigm. And of course if you switch to that paradigm you also need to educate patients in a systematic way, but a lot of centres are not doing that yet."

He adds: "Systematic structured patient education on the importance of dental hygiene is critical for preventing endocarditis in patients with congenital heart disease."