CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
336
AFRICA
Oral health of patients with severe rheumatic heart
disease
BREMINAND MAHARAJ, AHMED C VAYEJ
Abstract
In order to determine whether adequate attention is paid
to the maintenance of good oral health in patients at risk
of developing infective endocarditis, we studied 44 black
patients with severe rheumatic heart disease before they had
cardiac surgery. Plaque and gingival index scores were calcu-
lated and panoramic radiographs were done in all patients.
There were 17 males and 27 females (mean age: 30.6 years).
The plaque and gingival index scores were classified as
poor in 31.8 and 54.6% of patients, respectively. Panoramic
radiographic findings included caries in 56.8% of patients,
peri-apical pathology in 18.1% and retained roots in 22.7%
of patients. This study demonstrates that inadequate atten-
tion is paid to the maintenance of good oral health in patients
with severe rheumatic heart disease. The oral and dental care
of patients at risk of developing infective endocarditis needs
to be improved.
Keywords:
oral health, rheumatic heart disease, periodontal
health
Submitted 30/11/11, accepted 8/2/12
Cardiovasc J Afr
2012;
23
: 336–339
DOI: 10.5830/CVJA-2012-009
There are many case reports of the failure of antibiotic
prophylaxis to prevent infective endocarditis.
1
Wahl suggested,
however, that ‘failures of prophylaxis’ were actually successful,
and that patients had developed endocarditis before or after the
dental procedure because of poor oral hygiene.
2
Individuals who
have poor oral health are at high risk of developing spontaneous
bacteraemia.
3
The literature indicates that most cases of infective endocarditis
are not related to procedures.
4,5
Eykyn stated that it is becoming
increasingly clear that poor dental hygiene rather than dental
procedures are responsible for most, if not all, cases of viridans
streptococcal endocarditis.
6
In the study by Pogrel and Welsby,
oral sepsis was associated with infective endocarditis in 12% of
cases.
7
Guntheroth pointed out that bacteraemia was found in
11% of patients with oral sepsis and no intervention.
8
A number of authors have stressed proper oral hygiene as a
far more important preventative measure than chemoprophylaxis
against infective endocarditis.
2,3,8-11
In his review of the medical
and dental literature on the prevention of infective endocarditis,
Barco stated: ‘Finally, and most importantly, dental and
periodontal health is the best long-term prevention of infection
from the oral cavity for such patients at risk of infective
endocarditis’.
12
Most national guidelines on infective endocarditis prophylaxis
stress the maintenance of optimum oral health. The 1997
recommendations of the American Heart Association stated that
individuals who are at risk of developing infective endocarditis
should establish and maintain the best possible oral health
to reduce potential sources of bacterial seeding. They also
stated that optimal oral health is maintained through regular
professional care.
13
The Endocarditis Working Party of the British Society
for Antimicrobial Chemotherapy has emphasised the need
for regular dental attendance for the management of dental
health in patients susceptible to infective endocarditis.
14,15
More
recent guidelines have stressed the importance of this aspect of
prophylaxis.
16,17
The aim of this study was to determine by clinical and
radiological examination whether adequate attention is paid to
the maintenance of good oral health in black patients who are at
risk of developing infective endocarditis.
Methods
Black patients who had been evaluated by a cardiologist at the
cardiac unit at the Wentworth Hospital, Durban, and assessed
as having severe rheumatic heart disease requiring valvular
surgery, were studied. Patients were examined during the week
preceding their cardiac surgery in the cardio-thoracic unit of this
hospital after informed consent had been obtained. The study
was approved by the Ethics committee of the Nelson R Mandela
School of Medicine, University of Natal, Durban.
For each patient, the age, gender and nature of the valvular
abnormality were recorded. Plaque and gingival index scores
were calculated after careful clinical examination, and rotational
panoramic radiographs were done in all patients.
18-20
Each
radiograph was examined without magnification using a standard
viewing box in a horizontal position. Two observers examined
all radiographs; differences in interpretation were resolved by
consensus.
Recording sheets were compiled and the presence of the
following lesions was recorded: caries, missing teeth, impacted
teeth, hypercementosis, peri-apical radiolucencies, attrition,
fractured teeth, unerupted teeth, and retained roots. Definitions
used for all the radiographic lesions are listed in Table 1.
Results
A total of 44 black patients with severe rheumatic heart
disease were studied. There were 17 males and 27 females,
with ages ranging from 13 to 50 years (mean age: 30.6 years).
Department of Therapeutics and Medicines Management,
University of KwaZulu-Natal, Durban, South Africa
BREMINAND MAHARAJ, MB ChB, FCP (SA), MD, PhD, FRCP
(London),
Programme: Oral Health, Department of Health, KwaZulu-
Natal, Durban, South Africa
AHMED C VAYEJ, BDS
