In recent years, diseases of the gums and teeth have been implicated as risk factors for heart disease, particularly cardiovascular diseases such as atherosclerosis. Periodontal disease in particular appears to be linked to inflammatory diseases of the heart. However, study results are inconclusive, and more research is necessary to determine the exact relationship between heart disease and oral health.

Even so, proper dental care includes many heart-healthy recommendations, such as smoking cessation and a healthy diet. Good dental hygiene is vital to achieving and maintaining optimal general health.

Also, there is a potential link between some dental procedures and a rare infection of the heart lining called bacterial endocarditis. This disease occurs when bacteria from the mouth enter the bloodstream, sometimes as a result of dental procedures, and infect the heart valves. This disease occurs mainly in patients with pre-existing valvular heart disease or an artificial valve.

Because of the risk of heart valve infection, some heart patients may need to take preventive (prophylactic) antibiotics before and after having any dental work done. This preventive measure is particularly important for those patients with mechanical valves, complex congenital heart defects and repairs, or those who have previously experienced endocarditis.

A patient with a mechanical valve may be prescribed a higher dose of preventive oral antibiotics than the standard published oral antibiotic dosing schedule. In addition, some physicians may choose to administer the antibiotics intravenously, rather than orally, to achieve an even better antibiotic protection.In 2007, the American Heart Association (AHA) issued new recommendations on the use of antibiotics before dental procedures, reducing the intances when this preventative measure is recommended.

Dental professionals may recommend that people with heart-related conditions take special precautions to avoid the development of periodontal disease. For example, patients who take medication for either high blood pressure (hypertension) or epilepsy will need to monitor for drug-induced gingival overgrowth, a side effect that can contribute to periodontal disease. Also, people with diabetes will need to pay particular attention to controlling their blood sugar levels, cholesterol levels and triglyceride levels to reduce their increased risk of periodontal disease and heart disease.

Periodontal disease is a chronic bacterial infection of the gums. The beginning stage of the disease is known as gingivitis, which is a curable condition marked by inflammation and bleeding of the gums. The later, irreversible stage is known as periodontitis. Periodontitis involves loosening of the teeth and deterioration of the jaw bone beneath them. Advanced periodontal disease can lead to chewing problems, pain, tooth loss and, possibly, heart disease.

Research has suggested that people with periodontal disease may be at increased risk for developing heart disease. The American Academy of Periodontology reported that periodontal patients have nearly twice the risk of having a fatal heart attack than patients with healthy gums. However, other studies have contradicted this data, and research continues into the relationship between periodontal disease and cardiovascular disease, including stroke.

Currently, there are two leading theories that link periodontal disease with heart disease. The first holds that the periodontal bacteria from dental plaque can enter the bloodstream. This can occur through inflamed gums, the simple act of chewing, or through small cuts and tears made by dental procedures. Once in the bloodstream, bacteria can produce an enzyme that causes blood platelets to become sticky and form small blood clots. These blood clots may contribute to the development of “hardening of the arteries” (atherosclerosis).

The second theory holds that the presence of gum inflammation enhances overall inflammation throughout the body, which may cause further buildup of existing arterial plaque. Studies have shown that inflammation in the gums, such as found with periodontal disease, is connected to an increase in white blood cells, C-reactive protein and other markers for inflammation. This finding dovetails with recent research showing that atherosclerosis is also an inflammatory disease of the arterial walls. However, once again, there are many questions to answer before this theory is accepted as fact, and studies are ongoing.

Until a connection is either proven or refuted, the American Heart Association (AHA) recommends that people with heart disease take extra precautions regarding their dental health. Certain heart patients may need to take antibiotics before a dental procedure to help prevent infection of a deformed or diseased heart valve. These include patients with existing heart valve disease and congenital heart disease. In some cases, the risks involved with preventative antibiotics may outweigh the benefits. In 2007, the AHA issued new recommendations on the use of antibiotics before dental procedures, reducing the instances when this measure is recommended.

Recent research has also linked specific bacteria in periodontal pockets to acute coronary syndrome.  These bacteria infections may help explain the relationship between periodontal disease and heart problems. In addition, periodontal bacteria increase the body’s inflammatory response, which in turn elevates white blood cell counts and C-reactive protein levels. These two factors have been linked to heart disease in previous research studies.

The American Association Heart (AHA) cites several responsibilities for the general dental health of all heart patients:

People taking medication for high blood pressure (hypertension) or epilepsy are urged to watch for any signs of a side effect called drug-induced gingival overgrowth (DGO). DGO can cause an inflammation that contributes to gum disease and, perhaps, heart disease. Therefore, DGO and other side effects should always be discussed as soon as they are detected to determine an immediate course of action.

Individuals with diabetes also have a higher chance of periodontal disease. Diabetes can potentially damage the capacity of the blood vessels to transport blood to the body’s cells and organs. As a result, there may be decreased nourishment to the mouth and poorer removal of waste from the mouth. These two factors increase the risk of infection. People with diabetes are urged to control their blood sugar levels, as well as their cholesterol and triglyceride levels, to reduce their risk of periodontal disease. 

Smokers also face a higher risk for periodontal disease because nicotine constricts the blood vessels, reducing the amount of oxygen-rich blood that can reach the gums and teeth. 

Unless special precautions are taken, dental procedures to treat periodontal disease can cause additional problems for certain heart patients. The small cuts and tears that often occur during dental procedures give millions of bacteria direct entry into the bloodstream. In healthy people, this is usually harmless. Among people with compromised immune systems, however, this has been linked to bacterial endocarditis, a rare bacterial infection of the lining of a deformed valve.

Even minor procedures, such as a routine dental exam, may have this effect, as well as more invasive procedures such as:

In general, dental procedures that involve little or no surgical cutting, tearing and bleeding pose a much lower risk of bacteria-related complications. It is difficult to predict the amount of dental work that may cause bacteria to enter the bloodstream. However, preventative antibiotics are only recommended for certain people who have an increased risk of developing bacterial endocarditis. Accordingly, when antibiotics have been prescribed by your physician for dental work, they must be taken exactly as ordered and only when directed.

To reduce the risk of infection (e.g., bacterial endocarditis), certain heart patients are strictly advised to take antibiotics before any dental work. These heart patients include those who have the following:

Although many physicians and organizations recommend antibiotics for all of the above conditions, the American Heart Association notes some exceptions. These possible exceptions include patients with:

• Atrial septal defects with no other heart defects.
  
  
• Successfully repaired atrial septal defects.
  
  
• History of successful coronary artery bypass surgery.
  
  
• Mitral valve prolapse without leakage.
  
  
• Prior Kawasaki disease or rheumatic fever without heart valve damage.
  
  
• Implanted pacemakers and implantable cardioverter defibrillators that are successfully treating irregular heart rhythms (arrhythmias).

Aspirin is often taken to prevent the formation of blood clots, but some evidence has linked its daily use to complications such as bleeding during routine dental procedures (e.g., tooth removal). Some dentists recommend suspending aspirin therapy for several days to a week before elective surgery to reduce the risk of heavy bleeding, but recent advances in topical agents have made stopping aspirin less of a requirement. Patients should always consult their physician before beginning or suspending any aspirin therapy, even for a short time. Blood clots can seriously interfere with a coronary stent or even a person’s original coronary arteries if severe coronary atherosclerosis is present.

Smokers are not only more likely to develop diseases of the heart, lungs and blood vessels, but also of the mouth and gums. Smoking reduces the effectiveness of many periodontal procedures. Quitting smoking has been found to show immediate results and improvement not only in terms of preventing periodontal disease, but in the physical appearance of the mouth as well.

Researchers have found that the new panoramic dental x-rays now used by the majority of dentists may show early warning signs of a stroke. The x-rays appear to be able to detect calcium in the carotid arteries located in the neck, which are the main arteries that carry oxygen–rich blood to the brain. Calcium in the arteries is a sign that calcified plaque is present, which is an indicator of “hardening of the arteries” (atherosclerosis). When the carotid arteries are hardened and narrowed by calcified plaque, the risk of a stroke is greatly increased. People with carotid artery disease are also more likely to have coronary artery disease, as well. Therefore, early detection may lead to early treatment to prevent a stroke and/or a heart attack.

While these x-rays should not be viewed as diagnostic tools for non-dental conditions, they may work well as “warning signals” for heart attack and stroke. In fact, some researchers predict that in the future, patients may routinely learn about the health of their carotid arteries from their dentists, rather than their physician.

Preparing questions in advance can help patients to have more meaningful discussions with their physicians regarding their conditions. Patients may wish to ask their doctor the following questions related to dental care and heart disease:

1. Do I have any heart problems that raise the risk of complications from dental procedures?
   
   
2. What medical information is necessary to share with my dentist?
   
   
3. What steps can I take to avoid tooth and gum disease?
   
   
4. How often should I have my teeth cleaned by a dentist?
   
   
5. Do I need to take any preventative medications before having dental work done?
   
   
6. If so, what type of medications do I need to take?
   
   
7. Am I currently taking any medications that put me at increased risk for developing periodontal disease?
   
   
8. What can happen if I develop gum disease?
   
   
9. Does my diabetes put me at increased risk of developing a periodontal disease? How can I limit this risk?
   
   
10. How does smoking affect my risk of periodontal disease?
    
    
11. Should I change my aspirin regimen before visiting a dentist?
    
    
12. Should I have certain dental x-rays for cardiovascular preventive reasons?