The Association between Poor Oral Hygiene and Myocardial Infarction in 60 Years Old Woman

Muhammad Rifri Sjahrir 030.07. 171

Trisakti University Faculty of Medicine Jakarta 2011

Abstract
One of the most important risk factors for heart disease occurs in an area of the body that doesnt often be connected with cardiovascular health: the mouth. Yet, numerous studies have shown the correlation between poor oral health and heart disease. Both poor oral health and heart disease are common conditions in America. According to the American Heart Association, 36.3 percent (1 in 2.8) of deaths in 2004 were caused by cardiovascular disease. In elderly populations, poor dental health is also associated with all-cause mortality. Key Words: Oral Health, Acute Myocardial Infarction

Introduction
Both poor oral health and heart disease are common conditions in America. According to the American Heart Association, 36.3 percent (1 in 2.8) of deaths in 2004 were caused by cardiovascular disease.1 In elderly populations, poor dental health is also associated with allcause mortality.2 The National Health and Nutrition Examination Survey (NHANES) 1999-2002 investigated the oral health of the U.S. population. This study found that 41 percent of children aged 2-11, 50 percent of children aged 12 - 15 years, and 68 percent of adolescents aged 16 - 19 years had tooth decay in their primary teeth. Also, the prevalence of decay in adults showed that 87 percent of individuals ages 20-39 and 95 percent ages 40-59 had decay in the coronal surface of the permanent teeth. This study demonstrated another alarming fact: 25 percent of adults over age 60 had lost all of their teeth.3 Due to the prevalence of these conditions, the correlation between oral health and heart disease is significant as oral health may be a possible avenue of intervention to decrease cardiovascular mortality. (1)

CHAPTER I Poor Oral Hygiene Definition Of Poor Oral Hygiene

Poor oral hygiene is a condition where a person does not maintain the cleanliness of his mouth. These conditions may increase the risk of dental problems, especially the common dental caries and gingivitis, and bad breath.

Epidemiology of Poor Oral Hygiene

Epidemiological studies in the US and other developed countries have shown a decline in rates of edentulism in newer cohorts of elders. For example, findings of the NCHS survey of oral health in 1960-1962 revealed that 46% of Americans aged 65-74 were completely edentulous, compared with 32% in 1984-1986 and 24% in 1991-1992, according to the WHO/NIH International Collaborative Study II (ICSII). This large epidemiological study compared several countries regarding the oral health status and behaviors of their young, middle-aged and older populations. Trends in most countries demonstrated a reduction in tooth loss, especially among middle-aged populations, indicating greater need for restorative and periodontal care in future cohorts. Rates of periodontal disease were low in most countries, ranging from 3% in Germany to 5% in the US and 8% in Japan.

Physical Findings in Poor Oral Hygiene

Clinical examination revealed that 45.9% of the elderly patients had one or more oral mucosal lesions. Xerostomia (58.6%), coated-hairy tongue (54.1%) and halitosis (46.8%) were the most frequently encountered oral findings and mucosal lesions. As the most interesting finding discovered in elderly patients, macroglossia (30.6%) seems to depend on physical disability. Coated or hairy tongue was commonly related to poor oral hygiene. Halitosis and bruxism were commonly related to dentate patients. Increase in dental problems may have negative impacts on chewing, nutrition, aesthetics and phonation in elderly patients. It is particularly noteworthy that physical disability in elderly patients limits their ability to effectively follow oral hygiene procedures. (2)

Cause and Risk Factor of Poor Oral Hygiene

Poor oral health not regularly brushing or flossing is unlikely to be the primary cause of heart disease. But poor oral health combined with other risk factors may contribute to heart disease. Bacteria on teeth and gums could travel through the bloodstream and attach to fatty plaques in arteries (atherosclerosis), making the plaques become more swollen (inflamed). If one of the plaques bursts and causes a blood clot to form, it can caused a heart attack or stroke. It's possible that swelling in gums leads to swelling in other parts of the body, including the arteries. This swelling can also contribute to heart disease. (3)

Prevention of Poor Oral Hygiene

There are two main oral diseases: dental caries and periodontal diseases. Dental caries can be prevented by brushing and flossing regularly, using fluoride rinse, reducing carbohydrate intake along with simple sugars, reducing consumption of some fruits which are known to be acidic, and visiting dentist for two cleanings each year. While periodontal disease can be treated by scaling the roots to remove calculus and plaque below the gum line and reattaching gingival tissue to the surface of the tooth through surgery.(8)

CHAPTER II Myocardial Infraction Definition Of Myocardial Infraction

Myocardial infarction, commonly known as a heart attack, is the irreversible necrosis of heart muscle secondary to prolonged ischemia. This usually results from an imbalance in oxygen supply and demand, which is most often caused by plaque rupture with thrombus formation in a coronary vessel, resulting in an acute reduction of blood supply to a portion of the myocardium.

Epidemiology of Myocardial Infarction

Cardiovascular disease is the leading cause of morbidity and mortality among African American, Hispanic, and white populations in the United States. A male predominance in incidence exists up to approximately age 70 years, when the sexes converge to equal incidence. Premenopausal women appear to be somewhat protected from atherosclerosis, possibly owing to the effects of estrogen. The incidence increases with age indicated by the fact that most patients who develop an acute myocardial infarction are older than 60 years. Elderly people also tend to have higher rates of morbidity and mortality from their infarcts.

Physical Findings in Myocardial Infarction

Physical examination findings for myocardial infarction can vary. Low-grade fever may be present and hypotension or hypertension can be observed depending on the extent of the myocardial infarction. Fourth heart sound (S 4 ) may be heard in patients with ischemia. With ischemia, diastolic dysfunction is the first physiologically measurable effect and this can then cause a stiff ventricle and an audible S4. Dyskinetic cardiac bulge (in anterior wall myocardial infarction) can also occasionally be palpated. Systolic murmur can be heard if mitral regurgitation (MR) or ventricular septal defect (VSD) develops. Other findings include cool, clammy skin and diaphoresis. Signs of congestive heart failure (CHF) may also be found,

including third heart sound (S3) gallop, pulmonary rales, lower extremity edema, and elevated jugular venous pressure.

Causes and Risk Factors of Myocardial Infarction

The cause of myocardial infarction is either atherosclerotic or nonatherosclerotic. The former includes occlusive or partially occlusive thrombus formation. While the latter includes vasculitis, coronary emboli, congenital coronary anomalies, coronary trauma, coronary spasm, drug use (cocaine), heavy exertion, fever, hyperthyroidism, hypoxemia, and severe anemia. The risk factors are divided into three category: nonmodifiable, modifiable, and others. Nonmodifiable risk factors include age, sex, and family history of premature heart disease. Modifiable risk factors include smoking or other tobacco use, diabetes mellitus, hypertension, dyslipidemia, and obesity. Other risk factors include elevated homocysteine levels, male pattern baldness, sedentary lifestyle and/or lack of exercise, psychosocial stress, presence of peripheral vascular disease, and poor oral hygiene.

Treatment of Myocardial Infarction

Treatment is based on restoration of the balance between the oxygen supply and demand to prevent further ischemia, pain relief, and prevention and treatment of any complications that may arise. These can be fulfilled by using thrombolytic therapy, aspirin and/or antiplatelet therapy, heparin, nitrates, ace inhibitors, and beta-blockers. Surgical care such as percutaneous coronary intervention and emergent or urgent coronary artery graft bypass surgery can also be used. The latter is indicated in patients in

whom angioplasty fails and in patients who develop mechanical complications such as a VSD, LV, or papillary muscle rupture.

Prevention of Myocardial Infarction

Myocardial infarction can be prevented by refraining from smoking and maintaining appropriate blood pressure levels and a favourable balance of lipids. Following a myocardial infarction, further drug treatment should include aspirin, thrombolytic therapy (in acute myocardial infarction), beta-blockers, ACE inhibitors (in patients with a low ejection fraction) and perhaps anticoagulants.

CHAPTER III Association between Acute Myocardial Infarction and Oral Health
The mechanism by which oral health could influence the development of myocardial infarction remains unknown. Occlusive thrombus attached to atherosclerotic plaque caused by dental infection is the most common cause of acute myocardial infarction. Bacterial components affect endothelial integrity, metabolism of plasma lipoprotein, blood coagulation, and the function of platelets and their synthesis of prostaglandin, all of which are factors that influence the progression of atherosclerosis and the processes triggering myocardial infarction and sudden death in subjects with coronary disease. Many of these changes are mediated by the endotoxin associated with certain Gram negative bacteria, but other mechanisms must also play a part. On the other hand, little is known about the long term effects of chronic low grade bacterial infections, such as dental caries or periodontitis, on atherosclerosis and its complications. In the past 20 years researchers have investigated possible links between periodontal and vascular diseases. Although more research is needed to establish cause and effect, findings from numerous studies are compelling. Data from the First National Health and Nutrition Examination Survey (NHANES I) suggest that periodontal disease is a significant risk factor for stroke.(2) Grau and colleagues found that subjects with severe periodontal disease had a risk of stroke 4.3 times greater than that in control subjects.(3) And in a study of more than 4,000 subjects, severe periodontal disease was significantly related to hypertension and myocardial infarction.(4) Other research found a nearly six-fold increase in the risk of coronary heart disease in subjects with severe periodontal disease after controlling for age and smoking.(5) Further, periodontal disease has been shown to increase the risk of death from coronary heart disease. (6) The National Health and Nutrition Examination Survey (NHANES) 1999-2002 investigated the oral health of the U.S. population. This study found that 41 percent of children aged 2-11, 50 percent of children aged 1215 years, and 68 percent of adolescents aged 1619 years had tooth decay in their primary teeth. Also, the prevalence of decay in adults showed that 87 percent of individuals ages 20-39 and 95 percent ages 40-59 had decay in the coronal surface of the permanent teeth. This study demonstrated another alarming fact: 25 percent of adults over age 60 had lost all of their teeth.(7) Due to the prevalence of these conditions, the correlation between oral health and heart disease is

significant as oral health may be a possible avenue of intervention to decrease cardiovascular mortality. Some researchers have suggested that oral infections may produce inflammatory markers, which could contribute to the pathology of coronary heart disease (CHD). Studies indicate that serum inflammatory markers such as C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), and fibrinogen levels are significantly higher in individuals with CHD. CHD patients also have showed an increased prevalence of gingivitis and diseased supporting tissue, less natural teeth, and increased loss of all teeth compared to individuals without CHD. A study done in 2009 demonstrated that patients with AMI exhibited an unfavorable dental state of health. After statistical adjustment for age, gender, and smoking, they exhibited a significantly higher number of missing teeth, less teeth with root canal fillings, and a higher number of radiologic apical lesions compared with individuals without myocardial infarction. (8)

Conclusion
Cardiovascular diseases (CVD) are one of the main causes of death in the world, accounting for almost one third of all deaths world-wide. Cardiovascular diseases consist of heterogeneous groups of vascular diseases, with atherosclerotic vascular diseases being the commonest group. Although the risk factors of atherosclerotic vascular diseases include several risk factors such as abnormal lipids, hypertension, smoking and diabetes, a substantial proportion of cardiovascular events cannot be attributed to any of the risk factors. During the past three decades, oral epidemiologists have been actively testing the hypothesis that oral infections may be aetiological factors in atherosclerotic vascular diseases. Different explanatory variables such as periodontal pocket depth, clinical attachment loss or different indices have been used to measure the extent and/or severity of oral infection. Tooth loss, measured by number of teeth, has also been used as an explanatory variable, especially in situations where no other form of data is available. There is a strong connection between oral health and myocardial infarction, as shown by the results of researches above. Relying upon those facts, it is concluded that the prevalence of myocardial infarction can be reduced by paying a lot more attention and care to oral health.

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