Richard H. Nagelberg, DDS
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A patient presented to my office on July 22, 2010, indicating the need for dental clearance prior to cardiac surgery. Esther has been a patient for many years. She is 63 years old, partially edentulous, restored with upper and lower removable partial dentures. She was previously made aware of the presence of periodontal disease but did not present for evaluation and treatment planning.
Esther said her surgery would involve replacement of the mitral valve and repair of the aortic valve, both of which would be completed during one procedure. Prior to the surgery, the cardiologist needed documentation stating that there are no identifiable sources of infection in the oral cavity.
This is not an unusual request of dental providers prior to a variety of surgeries. It is, however, a big responsibility, especially when a life-threatening procedure is involved. Open heart surgery certainly falls in this category. Periodontal evaluation revealed case type 4 periodontal disease in the upper right, upper left, and lower left quadrants. Tooth No. 14 was missing and No. 16 was tilted mesially, creating a biofilm and food trap.
Additionally, the partial denture framework and clasps increased biofilm accumulation. The perio diagnosis and case typing indicated the disease severity, but did not shed light on the cause, namely the specific periodontal pathogens responsible. Salivary diagnostic bacterial DNA testing was performed using OralDNA® Labs, MyPerioPath® test. Test results revealed high levels of six pathogens including three high risk species: P. gingivalis, T. forsythia, and T. denticola.
The number and virulence of the causative bacteria presented a significant treatment challenge. Esther was given a copy of the DNA test results, along with a letter to her cardiologist. Several days later, the cardiologist called to discuss the results of the DNA test and its significance.
The large number of pathogens and the inclusion of three highly virulent species of bacteria were pointed out. I indicated that the only way I could qualitatively and quantitatively determine bacteria level reduction was to provide periodontal treatment and re-test the bacterial levels, a process that would take approximately seven weeks.
Esther’s cardiologist said the open heart surgery could be postponed for that period of time, and he would not proceed until the oral infection and high bacterial counts were controlled. He concluded the call by stating that he would schedule the surgery when dental clearance was provided.
Nonsurgical periodontal therapy was provided in one visit. Treatment consisted of scaling and root planing, subgingival irrigation with 10% povidone iodine, placement of locally applied antibiotics (Arestin®, minocycline hydrochloride microspheres 1 mg) in all perio pockets, and prescription antibiotics: amoxicillin 500 mg three times per day for eight days, and metronidazole 500 mg two times per day for eight days.
Perhaps most importantly, the patient was given extensive home-care instructions. The Philips Sonicare FlexCare toothbrush was recommended along with a variety of interdental brushes, floss, tongue cleaner, and Listerine mouthwash, all with the intention of sanitizing the mouth on a daily basis.
Sufficient instructions were provided for Esther to demonstrate proficiency with each of the home-care items. The patient’s home care up to that point had been less than ideal. Esther understood the consequences of achieving less than ideal perio treatment and biofilm control results on her heart surgery, namely the increased risk of post-op complications.
Reevaluation four weeks following perio treatment revealed significant clinical improvement with a reduction in all clinical parameters. Bacterial DNA was re-tested five weeks later using the same OralDNA Labs® test. Post-op test results revealed a significant reduction in five of the six perio pathogens to low levels.
Only T. forsythia remained slightly above threshold. The reduction of approximately 85% of the bacterial species, combined with the considerable clinical improvement and home-care efficacy, was sufficient to recommend proceeding with the heart surgery.
As a clinician charged with the responsibility of certifying the oral condition of a patient undergoing open heart surgery, having a written, quantifiable DNA analysis of the bacterial levels in the patient’s mouth was critically important. Without the bacterial tests, certifying Esther’s dental clearance for surgery would have been an educated guess at best. Co-management of Esther’s health certainly enhanced the likelihood of a successful outcome, and that is what it is all about.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 28 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. In-office consultations are available. Contact him at [email protected].
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