HEALTHCARE JOURNAL OF ARKANSAS I MAR / APR 2020 53 Niki Carter, DMD Dental Director Delta Dental of Arkansas Bone height around teeth is eventually re- duced, and teeth become loose as the sup- porting structures have been compromised. The early phases of destruction are often silent when patients are not aware of com- mon signs and symptoms. In uncontrolled or “active” periodontal disease, a bacteremia can exist 5 . The bacte- ria enter the bloodstream orally and travel to heart tissue. Researchers have found these bacteria and bacterial DNA in heart tissue, arteries, and atherosclerotic plaques 6 . Multiple oral bacteria such as Streptococcus mutans, Streptococcus sanguinis, Strepto- coccus viridans, A. actinomycetemcomitans, P. gin-givalis, and T. denticola have a predi- lection for heart tissue 7 . In 1945, studies con- cluded that IE could be treated with penicil- lin. Before antibiotic treatment, outcomes of the disease were very grave 8 . Subacute endocarditis (SBE) is a type of IE which accounts for 70 percent of cases. In 1951, the suggestion of using an antibiotic prophylactically in patients with damaged valves undergoing high-risk procedures was indicated. High-risk patients were those who had diseased or damaged heart valves 9 . SBE diagnosis during this time period had a high fatality rate. As time went on, these high-risk patients, or those with a history of SBE, were given a larger dose of antibiotic before an invasive dental procedure 10 . This premedication of antibiotic with varying dosages over time was the protocol for many years, until theAmerican Heart As- sociation guidelines were updated in 2007 11 . These guidelines currently address prophy- lactic use of antibiotics for patients with: • Prosthetic cardiac valves, including transcatheter-implanted • Prosthetic material used for cardiac valve repair, such as annulopplasty rings and chords • History of infective endocarditis • Cardiac transplant with valve regurgita- tion due to a structurally abnormal valve • Congenital heart disease • Unrepaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device Heart transplants and surgeries are of special concern. Bacteria with a predilection for heart tissue must be controlled by way of assuring the oral cavity is free of disease, and no oral infection is present 12 . In high-risk surgery of this nature, dental work should be completed, or teeth extracted if medically necessary, to ensure a healthy oral cavity. Often physicians require dental clearance from the patient’s dentist. This clearance is a written endorsement provided by the dentist that a patient’s oral health is optimal and free of disease or infection. Other heart conditions, such as stroke, cardiac valve disease, irregular heart rhythms, atrial fibrillation, and deep vein thrombosis can be a concern for needed dental treatment. This is due to the type of medications indicated. There are numerous medications patients take for preventing clots and thinning blood. Depending on the type and dosage of the class of these anti- coagulants, a patient might need to halt or titrate the concentration of the drug 13 . For instance, in a full mouth extraction case, excessive bleeding is a major concern for patients taking anticoagulants. The physi- cian and dentist must work collaboratively to plan for optimal treatment outcomes for the patient. The key takeaway is that oral health and heart health are intricately linked, and pa- tients must be educated on the ways in which taking care of teeth affects important body systems and overall health outcomes. As medical-dental integration progresses, this holistic approach to overall care will benefit patients and public health compre- hensively. It is important to acknowledge that oral health is essential to overall health, and all healthcare providers should recog- nize that patients are not healthy without good oral health. n REFERENCES 1 Davis R.C.,Hobbs F.D.,LipG.Y.,ABC of Heart Failure History and Epidemiology.BMJ vol.320 2000,Jan.1. 2 Ramin S.,History of Endocarditis.Hektoen Interna- tional.AJournal of Medical Humanities.2020,Jan.8. 3 Mathews M.J., Mathews E. H., Mathews G. E., Oral Health and Coronary Heart Disease.BMCOral Health 122 (2016). 4 CDC National Center for Health Statistics. Stats of the State of Arkansas. 2020,Jan. 21. 5 Science Daily. Live Oral Bacteria Found in Arterial Plaque. 2005, March 31. 6 Leishman S. J., Do H. L., Ford P. J., Cardiovascular Disease and the Role of Oral Bacteria.Journal of Oral Microbiology. Doi: 10.3402/jom.V2i0.5781. 7 Babu N. C., Gomes A. J., Systemic manifestations of oral diseases.Journal or Oral andMaxillofacial Pa- thology. 2011 May-Aug; 15(2): 144–147. 8 Grinberg M., Solimene M. C., Historical Aspects of Infective Endocarditis. 2020,Jan. 14. 9 Lockhart P.B.,BrennanM.T.,Thornhill M.,et al.Poor Oral Hygiene as a Risk Factor for Infective Endocar- ditis Related Bacteremia. J. Am Dent. Assjoc. 2009, Oct. 140(10): 1238-1244. 10 Pierce D., Calkins B. C., Thornton K., Infectious Endocarditis: Diagnosis and Treatment. Am. Fam Physician. 2012;85(10):981-986. 11 FouadA. F., Byrne B. E., KiogenesA. R., et al.Antibi- otic Prophylaxis 2017 Update.AAE Quick Reference Guide onAntibiotic Prophylaxis 2017 Update.pg 1-3. 12 Mustafa M., Rusmizan Y., Phanindranath M., et al. Oral Health and itsAssociation with Cardio-vascular Disease. IOSR Journal of Pharmacy, vo. 5, issue 2 (Feb 2015) pg 45-51. 13 Barzilai B.,Oral Health &Risk for CVDisease.Cleve- land Clinic. 2019, Dec. 30. Dr.Niki Carter,DMD, is Dental Director at Delta Dental of Arkansas. Dr. Carter earned a doctorate from the University of Louisville School of Dentistry in 1988. After completing a General Practice Residency in Louisville, Kentucky, she returned to Arkansas and established her private practice in general dentistry in 1989. After 25 years, she sold her practice to initi- ate the first General Practice Residency program at UAMS. Dr. Carter joined Delta Dental of Arkansas in 2019. Dr. Carter is a member of the American Dental As- sociation, and has held various leadership roles at local,state,and national levels, including president of Arkansas State DentalAssociation’s (ASDA) Central District Dental Society,ASDACentral District Execu- tive Council representative and ASDA New Dentist Chair of Arkansas.