April 4th, 2017

Of Little Hearts and Little Teeth

Emily F. Moore, RN, MSN, CPNP-PC, CCRN practices pediatric cardiovascular care across the Pacific Northwest.

Recently, I had to cancel a child’s heart surgery because she had multiple cavities. I recall spending close to an hour explaining the surgical process and obtaining a complete history and physical only to then discover obvious caries on multiple teeth during an oral exam.

Turning to the parents, I asked when their daughter had last seen a dentist, not shocked to hear, “Never.” I remember the look of defeat on their faces when I told them she would have to see a dentist before undergoing surgery. Traumatized by this news, the parents told me they hadn’t seen a dentist because their child had heart disease and it wasn’t a priority. Imagine their surprise when this seemingly small detail caused their daughter’s needed surgery to be canceled.

Although my world of cardiology and the world of dentistry don’t collide every day, when they do, it usually has a big impact on me and my patients. Despite the infrequency of these moments, they remind me of the importance of dental health care beyond good hygiene.

Children are recommended to have their first dental visit by age 1. The earlier that dental health is established as routine primary care, the earlier it becomes habit. Though professional care is necessary for maintaining oral health, sadly, a recent statistic I saw indicates that 25 percent of poor children have not seen a dentist before kindergarten.

In my experience, most of my patients lack the understanding of the importance of a healthy mouth and its relationship to overall health. As a provider, I see this as an obstacle that shouldn’t exist.

So, some things I am doing include educating my patients about the importance of brushing and flossing, and avoiding soda and other foods with excess sugar. Also stressing the importance of seeing a dentist every six months, or at least when possible. In addition, I have begun to educate parents of small children to be more involved in the act of teeth brushing, as the average toddler does not have the dexterity to properly brush his or her teeth.

In our current political climate, I do not foresee access to dental care improving. I am not a dentist and certainly do not claim to be an expert in dental hygiene. However, as a provider, the duty to give patients appropriate anticipatory guidance regarding a healthy mouth is something I take seriously.

With regard to my preoperative cardiac surgery patients, our coordinators advise parents that their child needs to see a dentist prior to surgery. And since the above incident, I make sure that dental care is one of the first history and physical questions I ask when entering a patient’s room. Talking about oral health and the need for a dentist isn’t always easy; however, it is devastating to have to tell a parent that their child cannot undergo open heart surgery until a cavity is treated. And preventing that seems well worth it.

 

References on Children’s Oral Health

http://www2.aap.org/commpeds/dochs/oralhealth/index.html

https://www.nidcr.nih.gov/DataStatistics/SurgeonGeneral/Documents/hck1ocv.@www.surgeon.fullrpt.pdf

 

Register Now for more NEJM Journal Watch Content

8 Responses to “Of Little Hearts and Little Teeth”

  1. Ruth McDonald says:

    Thank you Emily for sharing this important information. Well done!

  2. Elizabeth A. Smith MN, FNP-BC says:

    Many of my adult patients were born outside the US & have had little to no dental care. Asking about their last dental visit is my standard practice for routine health exams. Fortunately there is a dental school in our area that will treat these folks on a sliding scale, as most of them don’t have dental insurance and county resurces are woefully inadequate. It’s a tough problem for those of s in primary care.

    • Emily Moore says:

      What a wonderful program. Thanks for sharing Elizabeth.
      I agree refugees have very little dental treatment prior to coming to the United States, making their care much more complex.

  3. alexandra godfrey says:

    Hi Emily – thank you for your post.

    As a professional, I agree with you. A lot more attention needs to be paid to dental health in children. In the ER, I see the outcomes of poor dental care. I see young children with bottles of juice hanging from their mouths and teenagers with next to no teeth. Drinking 4 liters of mountain dew a day is not uncommon. It represents a significant disease burden.

    On a personal note, I have had first hand experience of the importance of good dental hygiene in the setting of kids’ heart health. My son was born with a complex congenital heart defect and has needed 4 open heart surgeries. We have kept up his teeth but this hasn’t been easy. Here’s some reasons:

    1) Some dentists will not see a child with heart problem. We had a dentist refuse to see my son when he was 20 months. He was turned away and we were advised to see a pediatric dentist,. We had to call around to find one comforable to take him on and then we were out of network. Time and money.

    2) The dentists will not see your child unless you have documentation from pediatric cardiology. This needs to come directly from ped cardiology. This takes time, effort and focus.

    3) Many dentists won’t call in the pre-med. Nor will the pcp, This has to done by cardiology.

    4) There’s confusion about who does and does not need the pre-med -still.

    5) We were advised after surgery no 3 and n 4 that our son should not see a dentist for at least 6 months unless it was an emergency. I can see how this could cause confusion and result in kids dropping out of care.

    We also have to manage coumadin. The combination of complex heart issues and coumadin in a kid needing abx prophylaxis is quite a lot to manage.

    I think there needs to be a lot more education available to both parents and the medical professionals. Clinicans need to ask about whether a child has a dentist, if they need documentation of cardio clearance, and to talk how these things need to be managed safely. Risks, benefits, med dosing, abx, coumadin.

    We have navigated these issues but dental visits remain stressful. I know you were speaking more broadly about kids dental health (and not kids with CHDs) and I agree it is a topic that needs more attention. I wanted to highlight though some of the barriers to care kids with chronic health issues, especially heart issues face when trying to take care of their teeth. Kids with cardiac issues incite fear in medical providers, including dentists -as a parent you end up making lots of calls, paying more, and having to get so many ducks in a row just for a simple cleaning.

    I assume the surgery was non-emergent 🙂 My son had a terrible ear infection the day before his last open heart but a wonderful ENT fixed that with abx powder and a hefty dose of abx. We couldn’t delay surgery.

    Thank you for your thoughtful post.

    • Emily Moore says:

      Alexandra,
      First, I am sorry to hear your son has CHD and has undergone multiple surgeries.
      I agree with everything you say.
      I was indeed speaking to a broader population but admit dental care for those with complex cardiac disease is tricky. Especially with the guidelines on who requires prophylaxis changing so frequently. Myself and the group of APP’s I work with have been very proactive educating cardiologists on dental screening and the need to interface with dentists.
      As for urgency and day of findings, yes, this was a non-urgent case. However, we have a dentist on site for those needing immediate cardiac surgery, forunately.

  4. William H. Hite, Jr., D.D.S. says:

    Dear Emily and Concerned Parents,

    As a now retired career general dentist I understand the hesitancy of dentists not seeing a CHD pediatric patient for certain dental procedures, but not for a valuable initial complete oral exam including radiographs. It was drilled, no pun intended, into our heads to do a complete medical history and know that the standard of care has been to pre-medicate certain patient’s with prosthetic implantation and disease before certain procedures. In these cases it is the responsibility of the patient and the cardiac physician to provide to the dentist an accurate diagnosis and prescribe the antibiotic regimen for invasive dental procedures in writing. Often dentists are presented with scant information at the time of the patient appoint which then as you know results in delays, lost productive time and possibly liability risks for the practitioner.

    People, not just little people, who have certain CHD are recommended to be prophylactically covered with antibiotic including dental prophylaxis, beginning before procedures that introduce small amounts and sometimes large amounts of bacteria into the blood stream that could result in the patient suffering from bacterial endocarditis.

    Unfortunately, today a few general dentists shy away from these situations and refer to a pediatric dental specialist as a responsible solution. Education for everyone is critically important.

    Thank you for recognizing this complex issue that has only been treated here superficially.

    Sincerely,

    William H. Hite Jr., D.D.S.

  5. GIANMARCO RUFFATTI BATLLE says:

    Is the reason por denying the surgery is the risk of the child developing endocarditis? If so why is there a strong link between oral/tooth lesions,infections and procedures with endocarditis? Why cant the bacteria just as easily infect the heart through a skin lesion?

  6. Dr Eleni says:

    According to the medical experts, there is a link between periodontal disease and heart disease. Because of that, dentists are taking extra steps to teach patients about importance of preserving healthy gums not just for good dental health, but as well to promote the overall health.

NP/PA Bloggers

NP/PA Bloggers

Elizabeth Donahue, RN, MSN, NP‑C
Alexandra Godfrey, BSc PT, MS PA‑C
Emily F. Moore, RN, MSN, CPNP‑PC, CCRN
Harrison Reed, PA‑C

Advanced practice clinicians treating patients in a variety of settings and specialties

Learn more about In Practice: Reflections from NPs and PAs.