Hello Riverflume,
Mitral valve prolapse is an interesting condition, affecting
about 2% of all Americans. This valve, named after a bishop?s mitered
hat, is composed of two triangular shaped membranes, attached to
cords, attached to muscles. A prolapsed valve indicates that these two
triangular shaped membranes are a little flaccid, or droopy, and do
not close properly. This allows some blood to leak from the ventricle
back into the atrium.
According to the site below, the risk of MVP (Mitral valve prolapse)
patients contracting bacterial endocarditis is 4 in one million,
without the use of prophylactic antibiotics. With antibiotics, the
risk is lowered to 1.8 per million.
?Mortality/Morbidity: The overall mortality rate for endocarditis is
approximately 25%. Left-sided endocarditis, however, has a mortality
rate of approximately 50%. Improved general health care, improved
dental care, early treatment, and antibiotic prophylaxis have
decreased mortality rates. Mortality is mostly due to secondary
congestive heart failure (CHF).?
http://www.emedicine.com/ped/topic2511.htm
?Endocarditis occurs when bacteria grow on the edges of a heart defect
or on the surface of an abnormal valve after the bacteria enter the
blood stream, most commonly from dental procedures but also from
procedures involving the gastrointestinal or urinary tract. Once the
bacteria infect the inner surfaceof the heart, they continue to grow
producing large particles called vegetation that may then break off
and travel to the lungs, brain, kidneys andskin. The continuing
infection may also seriously damage the heart valve on which the
vegetations have grown.?
http://www.csun.edu/~hcmth011/chaser/article2.html
?Though mitral valve prolapse was first identified as an anatomical
abnormality of the heart, it's not simply a heart disease in the
conventional sense. Cardiologists are beginning to look at this not as
a single variation of heart anatomy, but as a whole spectrum of
abnormalities, many benign and harmless, but some troubling.
Curiously, most of the abnormalities seem related to an underlying
instability of the autonomic nervous system. This is the part of our
nervous system that regulates the internal, visceral functions of the
body?such as blood pressure, heart rate, sweating, body temperature,
gastrointestinal activity, and emptying of the urinary bladder.
People with mitral valve prolapse seem somehow to be wired
differently. Their autonomic response can be much more volatile and
unstable, as if set on hair-trigger, so that normal stresses and
surprises set off an exaggerated response, flooding their systems with
stress hormones called the catecholamines. In fact, there may not be a
specific stressor?autonomic fluxes may occur unpredictably like
internal weather changes. In some ways this could be defined as a
catecholamine disorder. The principal catecholamines are epinephrine
and adrenaline. People with mitral valve prolapse are intermittently
and unpredictably awash in their own catecholamines. This leaves them
alternately innervated and exhausted?"wired but tired" is a common
feeling.?
?Why the concern? Some heart murmurs and valve implants are associated
with some increased risk of a bacterial infection of the heart, called
endocarditis. It's a devastating disease that before the antibiotic
era usually led to death, and even now normally requires a six week
course of very powerful intravenous antibiotics.
The fact is that there is a very, very slight statistical increase of
rates of endocarditis in people with mitral valve prolapse. It's
barely statistically significant, something like four cases per one
million dental procedures, but it's enough to scare the whole medical
and legal system into decreeing that everyone with the condition needs
prophylactic antibiotics in a variety of situations. So these people
tend to get bombarded with antibiotics. As a result, they often have
some of the predictable side effects, including disruption of the
intestinal flora, Candida infection. And ultimately the antibiotic
overuse will aid the spread of antibiotic-resistant bacteria.?
The author of this article, Dr. Ronald Hoffman,Medical Director of the
Hoffman Center in New York City, believes routine use of antibiotics
in mitral valce prolapse patients is unnecessary. He feels antibiotics
are only necessary where there is a regurgitation of blood through the
heart.
?Recent studies confirm that antibiotic treatment for mitral valve
prolapse patients is neither cost-effective nor useful. One suggests
that the risk of endocarditis is lowered from 4 in one million to 1.8
in one million, which is about equivalent to the risk of a fatal
penicillin reaction to the antibiotic. The studies agree that
antibiotic treatment should be limited to those with murmurs.? This
article goes on to suggest various alternative therapies such as
cognitive and nutritional therapy.
http://www.consciouschoice.com/1995-98/cc093/hmd093.html
?Bacteremia may occur spontaneously or may complicate a focal
infection (eg, urinary tract infection, pneumonia, or cellulitis).
Some surgical and dental procedures and instrumentations involving
mucosal surfaces or contaminated tissue cause transient bacteremia
that rarely persists for more than 15 minutes. Blood-borne bacteria
may lodge on damaged or abnormal heart valves or on the endocardium or
the endothelium near anatomic defects, resulting in bacterial
endocarditis or endarteritis. Although bacteremia is common following
many invasive procedures, only certain bacteria commonly cause
endocarditis. It is not always possible to predict which patients will
develop this infection or which particular procedure will be
responsible.?
?There are currently no randomized and carefully controlled human
trials in patients with underlying structural heart disease to
definitively establish that antibiotic prophylaxis provides protection
against development of endocarditis during bacteremia-inducing
procedures. Further, most cases of endocarditis are not attributable
to an invasive procedure. The following recommendations reflect
analyses of relevant literature regarding procedure-related
endocarditis, including in vitro susceptibility data of pathogens
causing endocarditis, results of prophylactic studies in experimental
animal models of endocarditis, and retrospective analyses of human
endocarditis cases in terms of antibiotic prophylaxis usage patterns
and apparent prophylaxis failures.
The incidence of endocarditis following most procedures in patients
with underlying cardiac disease is low. A reasonable approach for
endocarditis prophylaxis should consider the following: the degree to
which the patient?s underlying condition creates a risk of
endocarditis; the apparent risk of bacteremia with the procedure (as
defined in these recommendations); the potential adverse reactions of
the prophylactic antimicrobial agent to be used; and the cost-benefit
aspects of the recommended prophylactic regimen. Failure to consider
all of these factors may lead to overuse of antimicrobial agents,
excessive cost, and risk of adverse drug reactions.?
?Poor dental hygiene and periodontal or periapical infections may
produce bacteremia even in the absence of dental procedures. The
incidence and magnitude of bacteremias of oral origin are directly
proportional to the degree of oral inflammation and infection.24 25
Individuals who are at risk for developing bacterial endocarditis
should establish and maintain the best possible oral health to reduce
potential sources of bacterial seeding. Optimal oral health is
maintained through regular professional care24 26 27 and the use of
appropriate dental products such as manual and powered toothbrushes,
dental floss, and other plaque-removal devices. Oral irrigator or air
abrasive polishing devices used inappropriately or in patients with
poor oral hygiene have been implicated in producing bacteremia, but
the relationship to bacterial endocarditis is unknown.24 28 29 30 31
Home-use devices pose far less risk of bacteremia in a healthy mouth
than does ongoing oral inflammation.24 28 29 30 31
Antiseptic mouth rinses applied immediately prior to dental procedures
may reduce the incidence or magnitude of bacteremia.24 Agents include
chlorhexidine hydrochloride and povidone-iodine. Fifteen milliliters
of chlorhexidine can be given to all at-risk patients via gentle oral
rinsing for about 30 seconds prior to dental treatment; gingival
irrigation is not recommended. Sustained or repeated frequent interval
use is not indicated as this may result in the selection of resistant
micro-organisms.24?
http://circ.ahajournals.org/cgi/content/full/96/1/358
The American Heart Association recommends the following, and agrees
with mitral valve prolapse patients taking prophylactic antibiotics:
Several heart problems require you and your dentist to take special
precautions. Ask your physician for a Bacterial Endocarditis Wallet
Card. These cards are also available from your nearest American Heart
Association office.
These recommendations are especially important for people with
·prosthetic heart valves
·a previous history of endocarditis
·congenital and acquired heart defects such as
o most congenital cardiac malformations
o damaged heart valves
o hypertrophic cardiomyopathy (hi"per-TRO'fik kar"de-o-mi-OP'ah-the)
(Note: If you previously took the diet drug "fen/phen," see the "
Dietary / Weight-Loss Supplements" section of this guide.)
http://www.americanheart.org/presenter.jhtml?identifier=4548
The Cleveland Clinic follows the AHA guidelines above.
?Erythromycin is no longer recommended for penicillin-allergic
patients due to gastrointestinal adverse effects and the complicated
pharmacokinetics of its various formulations.1-2 Oral amoxicillin
remains the mainstay of dental prophylaxis. For penicillin-allergic
patients, alternatives are clindamycin, azithromycin, or
clarithromycin, with cefadroxil or cephalexin also possible for
patients who have not had immediate-type hypersensitivity reactions
(urticaria, angioedema, or anaphylaxis) to penicillin. The guidelines
also include recommendations for patients unable to take oral
medications.1-2 Although not required by the guidelines, some
clinicians prefer intravenous prophylaxis for high-risk patients,
especially those with histories of recurrent endocarditis or prior
prosthetic valve endocarditis.?
?Since endocarditis is a relatively uncommon condition, and many
episodes of endocarditis are not linked to procedures, such a study
would require a huge sample size of patients and is unlikely ever to
take place. What has been studied is which cardiac conditions most
commonly give rise to endocarditis, and the risk of bacteremia after
various procedures. Given the limitations of the available data, the
current guidelines should be viewed as the minimum recommendations for
prophylaxis. It is important that the guidelines incorporate latitude
for clinician preference for more aggressive prophylaxis for certain
high-risk patients. Consultation with an infectious disease specialist
can be helpful in such cases.?
?The American Heart Association recommendations for prevention of
bacterial endocarditis are the most widely followed guidelines in the
United States. Some exceptionally high-risk patients may warrant more
aggressive prophylaxis.?
http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/prophylaxis/prophylaxis.htm
The Medical College of Wisconsin concurs:
?If you have prolapse and a murmur, your heart valves are at a greater
risk of being infected. This is the reason for antibiotics before
dental work, because with cleaning and other procedures, bacteria from
the mouth can be temporarily introduced into the bloodstream.?
http://healthlink.mcw.edu/article/949097222.html
FamilyDoc.org also concurs:
?Although BE can occur in anyone, people with a heart valve problem,
an artificial valve or a heart defect are at greatest risk. Having a
heart murmur sometimes increases the chances of getting BE. Your
doctor can usually determine whether you have a type of heart murmur
that increases your risk of BE.?
?Dental work (including professional teeth cleaning) and some medical
procedures (such as colonoscopy, cysoscopy and sigmoidoscopy) increase
the risk of bacteria entering the bloodstream. If you have an abnormal
heart valve or another heart defect, you are at risk of BE any time
bacteria gets into your bloodstream.?
?If you have a heart defect or valve problem, make sure your doctor or
dentist knows about it. If you have your teeth cleaned or have
another one of the procedures mentioned above, you need to take
antibiotics. The antibiotics can help keep bacteria from surviving in
your bloodstream.
BE can't always be prevented, because doctors don't always know when
bacteria might get into your bloodstream. That's why you need to keep
a close eye on your health if you have a heart defect or a valve
problem.?
http://familydoctor.org/557.xml
This study, at New York Hospital-Cornell Medical Center, New York ,
concluded that prophylactic treatment, with erythromycin was both cost
effective and beneficial to MVP (Mitral valve prolapse) patients.
?Sensitivity analyses suggested that erythromycin prophylaxis might be
cost-saving under some scenarios, whereas intravenous ampicillin use
might cause net loss of life. Thus, prevention with oral antibiotics
of the cumulative morbidity and incremental health care costs due to
IE in MVP patients is reasonably cost-effective for MVP patients with
mitral murmurs?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=7977041&dopt=Citation
?Antimicrobial prophylaxis of bacterial endocarditis is widely
recommended for patients with mitral valve prolapse who undergo
procedures that may cause bacteremia. The benefits and risks of this
practice have been analyzed on the basis of published data and
response to a questionnaire survey of leading authorities on bacterial
endocarditis. Among 10 million patients with mitral valve prolapse
undergoing a dental procedure, an estimated 47 nonfatal cases and two
fatal cases of bacterial endocarditis would occur if no prophylaxis
were given, five cases of bacterial endocarditis and 175 deaths due to
drug reactions would occur if all patients were given prophylaxis with
a penicillin, and 12 nonfatal cases and one fatal case of bacterial
endocarditis would be expected if a policy of prophylaxis with
erythromycin were adopted.?
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=6711576&dopt=Citation
?Who is at risk?
Endocarditis rarely occurs in people with normal hearts. However, if
you have certain preexisting heart conditions, you're at risk when a
bacteremia occurs. Some of these conditions include having...
·an artificial (prosthetic) heart valve
·a history of previous endocarditis
·heart valves damaged (scarred) by conditions such as rheumatic fever
·congenital heart or heart valve defects
·hypertrophic cardiomyopathy (hi"per-TRO'fik kar"de-o-mi-OP'ah-the)?
Procedures with the greatest risk:
·professional teeth cleaning
·tonsillectomy or adenoidectomy
·examination of the respiratory passageways with an instrument known
as a rigid bronchoscope
·certain types of surgery on the respiratory passageways, the
gastrointestinal tract or the urinary tract
·gallbladder or prostate surgery
?If you've been told you have a congenital heart defect, a heart
murmur, mitral valve prolapse or other heart valve problems, ask your
doctor if you're at increased risk for bacterial endocarditis. If so,
be sure to tell your dentist and other physicians who may be treating
you.?
http://www.americanheart.org/presenter.jhtml?identifier=4436
?The risk of endocarditis is increased in persons with certain cardiac
disorders, particularly valvular heart disease. Transient bacteremia
may result in bacterial seeding of a previously abnormal endovascular
surface, such as a heart valve, resulting in the formation of a
vegetation. Although most cases of endocarditis are not attributable
to medical procedures, antibiotic prophylaxis for endocarditis has
focused on the risks associated with transient bacteremias during
dental, respiratory, gastrointestinal, or genitourinary
procedures.1-4?
?The organisms most likely to cause endocarditis after dental and
upper respiratory procedures are alpha-hemolytic streptococci of the
viridans group.?
http://www.clevelandclinicmeded.com/diseasemanagement/infectiousdisease/prophylaxis/prophylaxis.htm
?... it is important to understand the benefits of antibiotic
prophylaxis, though there is evidence that clinicians often either do
not know enough about its proper role, or are unmotivated to follow
its procedure. In a 1992 survey of Israeli dentists, only 58% used an
acceptable regimen of prophylaxis prior to dental work.(2)
Furthermore, while these practitioners were aware of the appropriate
antibiotic, only about 50% of the respondents had basic knowledge of
the proper timing of administration. About 29% knew the cardiac
conditions that constituted a high-risk patient for whom prophylaxis
is recommended (Table 1), while 64% were aware of those dental
procedures that required prophylaxis (Table 2).?
?Experimental models have allowed better definition of the most
important sites of antibiotic action. Findings indicate that their
principal prophylactic effect is to suppress bacterial growth on the
valvular thrombus, allowing the host's defenses to take over.
Antiinfective agents given within two hours following a procedure will
successfully block infection.?
http://www.tufts.edu/med/apua/Newsletter/17_2a.html
?In the US: Presently, the incidence of endocarditis is approximately
1 case per 1000 hospital admissions. This incidence has remained
essentially unchanged over the past 40 years; however, the
distribution of etiologies has shifted. Rheumatic fever, which was
once a common entity, is now a rare cause of endocarditis. In
contrast, the advent of more sophisticated cardiac procedures and
earlier intervention has led to an increase in the incidence of
endocarditis in the child with congenital heart disease. Preexisting
cardiac abnormalities are found in approximately 75% of children with
bacterial endocarditis.?
· ?The prognosis of bacterial endocarditis varies by the etiologic
agent. Infection by a penicillin-sensitive Streptococcus, diagnosed
early, has a cure rate of almost 100%. However, because many
infections are diagnosed late or are due to resistant organisms, the
average mortality rate is approximately 25%.?
http://www.emedicine.com/ped/topic2511.htm
?For the past 40 years, anecdotal information has suggested a link
between dental procedures and the onset of endocarditis, a potentially
deadly inflammation of the heart's lining and/or valves caused by
bacterial infection. As a result, professional guidelines issued
jointly by the American Heart Association (AHA) and the American
Dental Association (ADA) have recommended the administration of
prophylactic antibiotics to dental patients deemed at-risk for the
development of endocarditis -- i.e., those with known heart valvular
problems, including mitral valve prolapse and heart murmurs.?
http://www.uphs.upenn.edu/news/News_Releases/nov98/strom.shtml
?Dental hygienists are reminded that they are responsible for the
treatment they render. If the dental hygienist does not believe that
it is in the best interest of the client to proceed with treatment,
they must not do so. It is both unethical and illegal for the dentist
to insist that treatment be performed by the dental hygienist when
there are doubts as to the medical condition of the client. To provide
maximum protection against sub-acute bacterial endocarditis,
prophylactic antibiotics must be administered a minimum of one hour
prior to the commencement of any procedure that might induce bleeding.
The dental hygienist should always ask if the client has taken the
medication and document that fact.
The CDHO takes the position that dental hygienists are responsible for
informing the client of the possible consequences of treatment that
may occur if the prophylactic antibiotics have not been taken within
the specified time period. If, following a detailed explanation of the
risks and benefits of prophylactic coverage to the client and if the
dental hygienist is confident that the client understands the
ramifications, then the dental hygienist may choose to proceed or not
to proceed based on whether or not the risks out weigh the benefits.
Documentation of all of the facts is essential. As a precaution, every
client who requires prophylactic antibiotics should have a physician?s
letter in his/her file.?
You?ll notice on Table 1, that antibiotics are not recommended any longer.
http://www.cdho.org/Recommend.pdf
Additional Information:
http://www.pjonline.com/pdf/cpd/pj_20030419_oralcare2.pdf
As with many things medical, it is easy to find literature supporting
both sides of an issue. For the best answer, discuss this dilemma with
your doctor. S/he can decide if your condition warrants antibiotics.
Your general health, you immune system status, your age, and your
medical history all come into play, and some people are more prone to
infection than others. Taking antibiotics can carry some risk as well,
but seemingly far less than risking endocarditis. If you have taken
antibiotics with no ill effects before dental procedures in the past,
you should not expect to have any adverse effects the next time. Your
doctor should be able to help you decide whether or not to continue
taking prophylactic antibiotics. Anecdotally, it seems a good idea to
me, and in fact, I do take antibiotics before dental procedures, as I
am prone to infection. Please consult with your physician before
making a decision.
If any part of my answer is unclear, please do not rate this answer
until you are satisfied. Simply request an Answer Clarification, and I
will be happy to assist you further, if possible.
Sincerely, Crabcakes
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Mitral valve prolapse + dental procedures
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