Abstract
Objective
Children with cardiac defects should have good oral health, particularly prior to cardiac surgery to minimize risks of infective endocarditis. The aim of the study was to examine the oral health assessment practices of North American cardiologists.
Methods
Online surveys were e-mailed to 1409 cardiologists. Cardiologists without paediatric patients or practicing in centres without cardiac surgical care were excluded. Surveys addressed oral health assessment practices for paediatric cardiac patients, and perceptions of the impact of oral health on cardiac care.
Results
The centre response rate was 69%, individual response rate 20%. Most cardiologists (96%) reported oral health was assessed as part of cardiac care. The most common time for assessment was prior to cardiac surgery (44%), with a quarter assessing by age 1 (28%). While most oral assessments involved a dentist (59%), 17% of cardiologists performed the oral assessment without the aid of a dentist. Four-fifths of cardiologists (83%) reported cancellation of cardiac surgery due to oral disease. Cardiologists who deferred assessment until prior to surgery had the highest experience of cancellation (96%). Assessments were delayed despite the common belief (89%) that children on pre-surgical high-calorie diets are at increased risk of oral disease.
Conclusion
Assessments of oral health status were often deferred until immediately prior to cardiac surgery despite the cardiologist’s perception that children with cardiac defects were at increased risk of oral disease and prior experience of surgical cancellation due to oral disease. Paediatricians may need to facilitate early oral assessment for these children.
Keywords: Cardiology, Dental screening
While rare, the significant morbidity and mortality associated with infective endocarditis warrants strategies to prevent its development in susceptible children (1,2). Oral bacteria, particularly viridans streptococci, have been implicated in the pathogenesis of infective endocarditis (1,3). Guidelines for the prevention of infective endocarditis recommend patients at risk maintain good oral health and eliminate or reduce oral sources of infection prior to cardiac surgery (4,5). Despite the benefits of good oral health, children with cardiac conditions often have greater caries experience than healthy children and access to adequate dental care can be challenging for families (6,7).
Several key professional bodies, including the Canadian Paediatric Society, Canadian Dental Association, American Academy of Pediatrics and American Academy of Pediatric Dentistry, recommend children have a dental home established and dental examination within 6 months of the eruption of the first tooth or by age 1 (8–11). As paediatric cardiologists, paediatricians and primary care physicians provide care for children with congenital heart disease from infancy through childhood, the opportunity exists to facilitate early oral examination and optimize the child’s oral health.
While paediatricians in North America have been receptive to the inclusion of oral health as part of their practice, little is known about the practices paediatric cardiologists employ to ensure good oral health of their patients. Only two reports have been published about oral health screening practices or protocols of cardiac teams (12,13). A short communication by Olderog-Hermiston et al. reported that only 29% of North American paediatric cardiology department chairs provided oral health education or screening for their patients (12). Most (80%) American transplant teams surveyed by Guggenheimer et al. request assessment of oral health prior to cardiac transplant with postponement of transplant due to oral disease experienced by 38% of respondents (13).
Given the paucity of information regarding practices of oral health assessment of paediatric cardiac patients, the aim of this study was to investigate: 1) the current oral health assessment or screening practices of paediatric cardiologists within North America, 2) cardiologists’ experience of the impact of dental disease and poor oral health on the treatment of their patients and 3) cardiologists’ perceptions of the importance of oral health for their patients.
METHODS
Research ethics approval was obtained from the Research Ethics Board of The Hospital for Sick Children prior to commencement (REB:1000039504).
A total of 1399 paediatric cardiologists at 99 tertiary cardiology centres in North America were identified and invited to participate. Names and e-mail addresses of paediatric cardiologists at these facilities were obtained via direct contact with heads of cardiology departments or through publically available resources including the Canadian Association of Paediatric Cardiology, faculty websites and contact information displayed on the websites of cardiology departments where available.
Cardiologists were eligible for participation if they practiced paediatric cardiology/cardiac surgery, assessed patients on an ambulatory/outpatient basis and consented to participate. Participants were e-mailed a brief online survey with predominantly closed questions with open-ended options via SurveyMonkey (SurveyMonkey L.L.C., Palo Alto, California, USA). The survey addressed the practices of cardiologists with regard to oral health assessments of their patients, timing of assessments, health professional performing the assessment, information about oral health given to parents, risks for poor oral health for their patients and whether oral health had impacted their patient care including cancellation of surgery (Table 1).
Table 1.
Summary of questionnaire
| Questions |
|---|
| 1) At what stage do you assess for oral health of your patients? |
| 2) Who provides the oral health assessment of your patients? |
| 3) If a dentist/dental professional provides the oral health assessment, please indicate the type of professional and location |
| 4) If the cardiac team provides the oral health assessment, who performs the assessment and how is information disseminated to the family? |
| 5) Does a member of your cardiac team discuss the importance of oral health with the family of your patients? |
| 6) If oral health is discussed, which of the following topics are included in the discussion (choose all that apply): |
| • Dietary habits and dental disease |
| • When to start brushing a child’s teeth |
| • When a child should have their first dental visit |
| • The link between oral/dental disease and cardiac risk |
| 7) If diet is discussed, who delivers dietary counselling? |
| 8) How prevalent do you believe poor oral health is in your paediatric cardiac patients compared to the healthy paediatric population? |
| 9) Have any of your patients had their surgery postponed or cancelled due to dental infection, untreated dental caries or poor oral health? |
| 10) When would you advise the parents of your patients that a child should first see a dentist? |
| 11) Characterize the risk of poor oral health (dental caries) for patients with pre-surgical high-calorie diets or nutritional support |
Responses were de-identified, tabulated and analyzed using the Statistical Package for the Social Sciences, version 22.0 (SPSS Inc., Chicago, Illinois, USA). Descriptive statistics were used to summarize responses and chi-square analysis of the association between answers was undertaken to examine trends between practices and perceptions, with P <0.05 determined as the threshold for statistical significance. As not all questions required an answer, only completed survey responses for each question were analyzed. Qualitative answers from respondents were excluded from statistical analysis.
RESULTS
Participants
Paediatric cardiologists (n=1409) from 15 centres in Canada and 84 centres in the USA were invited to participate by e-mail. Surveys were unable to be delivered to the e-mail addresses of 101 cardiologists. Of the remaining 1298 paediatric cardiologists, 15 were ineligible due to retirement or exclusively adult practice and 2 declined to participate. Responses were received from paediatric cardiologists at 69% (68/99) of centres. A total of 259 (20%) paediatric cardiologists participated and provided completed surveys, with participation from 48% (40/93) of Canadian and 18% (219/1198) of American paediatric cardiologists.
Oral health assessments
Overall, 96% of participants reported they had arranged or recommended oral health assessments for their patients (Table 2). Timing for oral assessment ranged from within months of the child’s initial cardiac diagnosis or by 12 months of age (28%), prior to cardiac surgery (44%), at an older age when disease was evident or in response to parent/child complaint (20%), to rarely/never (8%). A similar proportion of cardiologists from the USA and Canada assessed oral health at an early stage (28% and 27%, respectively). Significantly more cardiologists in Canada assess oral health as part of pre-operative workup (68%) compared with their US colleagues (40%) with more US cardiologists reporting that they rarely/never assess oral health or delay assessment until disease was evident (P=0.003). Eighteen participants offered alternative timing for assessment including: assessment between 12 and 36 months, no formal oral assessment but a recommendation for regular dental care and a reliance on paediatrician to assess.
Table 2.
Distribution of oral health assessments by timing, country and health professional utilized*
| Earliest response of timing of oral health assessment | Canada, n=37 (%) | USA, n=201 (%) | Total, n=238 (%) | χ 2 (df) |
|---|---|---|---|---|
| After diagnosis/by age 1 | 10 (27.0) | 56 (27.9) | 66 (27.7) | 13.61 (3) |
| Prior to surgery | 25 (67.6) | 80 (39.8) | 105 (44.1) | P=0.003† |
| Disease evident/complaint | 1 (2.7) | 46 (22.9) | 47 (19.7) | |
| Rarely/never | 1 (2.7) | 19 (9.5) | 20 (8.4) | |
| Health professional assessing oral health | Canada, n=37 (%) | USA, n=199 (%) | Total, n=236 (%) | χ 2 (df) |
| Cardiac only | 3 (8.1) | 36 (18.1) | 39 (16.5) | 2.34 (3) |
| Dental only | 23 (62.2) | 115 (57.8) | 138 (58.5) | P=0.49 |
| Cardiac and dental | 9 (24.3) | 40 (20.1) | 49 (20.8) | |
| Other (paediatrician or primary health care provider) | 2 (5.4) | 8 (4.0) | 10 (4.2) | |
| Dental professional assessing oral health | Canada, n=25 (%) | USA, n=120 (%) | Total, n=145 (%) | χ 2 (df) |
| Paediatric dentist | 9 (36.0) | 94 (78.3) | 103 (71.0) | 18.02 (1) |
| Community-based | 2 (8.0) | 50 (41.7) | 52 (35.9) | P<0.001‡ |
| Hospital-based | 7 (28.0) | 44 (36.7) | 51 (35.2) | |
| General dentist | 16 (64.0) | 26 (21.7) | 42 (29.0) | 20.3 (3) |
| Community-based | 15 (60.0) | 23 (19.2) | 38 (26.2) | P<0.001§ |
| Hospital-based | 1 (4.0) | 3 (2.5) | 4 (2.8) |
*Incomplete responses excluded from analysis; †Significant at P <0.05 threshold; ‡Significant at P <0.05 threshold for analysis of dentist type only; §Significant at P <0.05 threshold for analysis of dentist type and location
More than half (59%) of the cardiologists relied on dental professionals to undertake the oral health assessment, 21% shared the responsibility between dental and cardiac teams and 21% did not utilize a dental professional but instead relied on members of the cardiac team. Ten cardiologists relied exclusively upon the patient’s paediatrician or primary care physician to be responsible for the oral health assessment. The most frequent dental professional utilized for oral health assessments by cardiologists were paediatric dentists, accounting for more that two-thirds (71%) of dental professionals.
An association between the timing of oral health assessment and type of clinician utilized was observed (Table 3). Cardiologists who assessed oral health early or prior to cardiac surgery reported significantly more involvement from the cardiac team in oral health assessments (48% to 49%), whereas cardiologists who assessed late or rarely/never almost exclusively relied on the dental team for assessment (P=0.03). Practice location of the cardiologist did not affect the choice of health practitioner utilized, but had a significant impact on the choice of dentist (P<0.001). American paediatric cardiologists utilized more paediatric dentists (P<0.001) than their Canadian colleagues in obtaining an oral health assessment.
Table 3.
Type of health professional utilized for oral assessment, perceptions, experiences and recommendations—distribution and association with timing of oral health assessments*
| Health professional assessing oral health | After diagnosis/by age 1, n=61 (%) | Prior to surgery, n=101 (%) | Disease evident/complaint, n=40 (%) | Rarely/never, n=4 (%) | Total, n=206 (%) | χ 2 (df) |
|---|---|---|---|---|---|---|
| Cardiac only | 10 (16.4) | 22 (21.0) | 4 (9.1) | 0 | 36 (17.5) | 13.84 (6) |
| Dental only | 32 (52.5) | 54 (51.4) | 32 (72.7) | 4 (100.0) | 122 (59.2) | P=0.03† |
| Cardiac and dental | 19 (31.1) | 25 (23.8) | 4 (9.1) | 0 | 48 (23.3) | |
| Perceptions and experiences | After diagnosis/by age 1, n=53 (%) | Prior to surgery, n=102 (%) | Disease evident/complaint, n=42 (%) | Rarely/never, n=19 (%) | Total, n=216 (%) | χ 2 (df) |
| Perception of prevalence vs. healthy | 12.03 (6) | |||||
| More prevalent | 16 (30.2) | 33 (32.3) | 13 (31.0) | 5 (26.3) | 67 (31.0) | P=0.06 |
| No difference | 32 (60.4) | 68 (66.7) | 29 (69.0) | 14 (73.7) | 143 (66.2) | |
| Less prevalent | 5 (9.4) | 1 (1.0) | 0 | 0 | 6 (2.8) | |
| Experienced cancellation of surgery | 23.62 (3) | |||||
| Surgery cancelled | 42 (79.2) | 96 (94.1) | 32 (76.2) | 10 (52.6) | 180 (83.3) | P<0.001† |
| No surgery cancelled | 11 (20.8) | 6 (5.9) | 10 (33.8) | 9 (47.4) | 36 (16.7) | |
| Risk of caries for children with congenital heart disease | 10.82 (3) | |||||
| Increased risk | 49 (92.5) | 91 (89.2) | 40 (95.2) | 13 (68.4) | 193 (89.4) | P=0.01† |
| No increased risk | 4 (7.5) | 11 (10.8) | 2 (4.8) | 6 (31.6) | 23 (10.6) | |
| Recommendation for first dental exam | After diagnosis/by age 1, n=51 (%) | Prior to surgery, n=101 (%) | Disease evident/complaint, n=40 (%) | Rarely/never, n=19 (%) | Total, n=211 (%) | χ 2 (df) |
| Current guidelines | 25 (49.0) | 32 (31.7) | 5 (12.5) | 2 (10.5) | 64 (30.3) | 22.23 (9) |
| Previous guidelines | 21 (41.2) | 48 (47.5) | 22 (55.0) | 9 (47.4) | 100 (47.4) | P<0.001† |
| Late | 3 (5.9) | 6 (5.9) | 2 (5.0) | 1 (5.3) | 12 (5.7) | |
| Rarely/never | 2 (3.9) | 15 (14.9) | 11 (27.5) | 7 (36.8) | 35 (16.6) |
*Incomplete responses excluded from analysis; †Significant at P <0.05 threshold.
Oral health education/advice
More than three-quarters of cardiologists (76%) reported that a member of their team discussed oral health and its importance with patients and families. The topic most frequently discussed was the link between oral and cardiac disease (92%). Other topics included age for first visit to the dentist (55%), dietary advice (44%) and oral hygiene instructions or the importance of tooth brushing (33%). Notably several cardiologists described specific information discussed with parents about risk factors and prevention of early childhood caries.
Cardiologists were asked about the age they would recommend a child have his/her first dental visit. The recommendations of less than one-third of cardiologists (30%) were aligned with the current recommendation that the first dental visit occur by age 1. Most cardiologists (47%) recommended a first examination by age 3, long after published recommendations.
Perceptions and experiences
Cardiologists’ perceptions about the risk for poor oral health in their patients and its impact on cardiac care were surveyed (Table 3). Most cardiologists believed that the prevalence of poor oral health was the same for their patients as for healthy children (69%). When asked to characterize the risk for dental caries for patients prescribed a high-calorie diet to prepare for cardiac surgery, the majority of cardiologists (89%) felt that their patients were at increased risk. Cancellation of cardiac surgery of their patients due to poor oral health was reported by 83% of cardiologists. There were no significant differences in the perceptions and experiences of cardiologists in Canada and USA.
Comparisons of perceptions, experiences and recommendations with oral health assessment practices
The timing of oral health assessments was compared with the experience of cancellation or postponement of surgery, recommendations of age for first dental examination, and perceptions of prevalence of poor oral health and risk for dental caries (Table 3). Cardiologists who believed their patients were at risk of poor oral health assessed oral status significantly earlier than cardiologists who did not perceive an increased risk (P=0.02). Surprisingly, cardiologists who rarely/never assessed for oral health reported the lowest experience of cancellation of cardiac surgery (53%), significantly less than those who referred prior to cardiac surgery (94%; P<0.001). Regardless of timing of assessment, practice location or recommendations for first visit, two-thirds of cardiologists believed the risk of poor oral health was not different for their patients than for healthy children (P>0.05).
The age at which cardiologists recommended a child have his/her first dental visit was compared with reported oral health assessment practices. Regardless of reported timing of oral health assessment more than two-fifths of cardiologists would recommend their patients have a dental examination by age 3. Of the remaining respondents, significantly more cardiologists who assess early would recommend a first examination aligned with current guidelines than those who recommend later (P<0.001).
DISCUSSION
Since the US Surgeon General’s statement on oral health there has been greater emphasis of the importance of oral health to general health (14). For children with cardiac conditions, poor oral health may predispose a child to infective endocarditis. It was therefore encouraging that almost all cardiologists who responded were cognizant of the importance of oral health to cardiac health of their patients, referring or assessing for oral health, and/or providing oral health information.
Most cardiologists deferred assessment until immediately before cardiac surgery with only slightly more than one-quarter of cardiologists assessing oral health at time consistent with the guidelines for first dental visit. Delaying oral health assessment until prior to cardiac surgery after age 1 means that opportunities for anticipatory guidance and implementation of preventive practices to promote good oral health are missed. Conversely, when single stage repair occurs prior to 6 months of age, before eruption of the primary dentition, oral health assessment may be overlooked. In the only published investigation of the oral health of children referred for assessment prior to cardiac surgery, 11.5% of surgical procedures over a 6-year period were postponed or cancelled due to the presence of untreated dental caries and dental abscesses (15).
The establishment of a dental home and first visit by age 1 has been demonstrated to have a positive effect on the caries experience of healthy children (16,17). If examination is deferred until age 3 (previous recommendation), the risk factors for early childhood caries are established and young children may present with advanced disease (10). By 3 to 4 years of age, a common time for single ventricle palliative surgery, children with congenital cardiac disease can present with dental caries that are already established and advanced (6,18,19). By age three, 17% of American children with cardiac defects already have dental caries requiring surgical intervention, affecting an average of three teeth (2.97 ± 2.06) (6). Despite the positive benefits of establishing a dental home by age 1, only 28% of cardiologists surveyed recommend a first dental visit consistent with current recommendations, almost half recommending a visit by age 3 and several unaware of the recommended age.
Our study is the first to reveal which health professionals are utilized in the assessment of oral health of patients of paediatric cardiologists. Most paediatric cardiologists relied upon a dentist for assessment with almost two-thirds of assessments undertaken by paediatric dentists. There were differences in the use of general versus paediatric dentists between the two countries. We suspect these differences may be attributable to the larger proportion of paediatric dentists in the workforce in the USA compared with Canada. Interestingly, one-fifth of paediatric cardiologists did not utilize a dental professional in their assessment. We did not investigate the reasons for utilizing specific health professionals; however, there are anecdotal reports of general dentists being reluctant to treat children with cardiac conditions (7,20,21). Physicians have demonstrated adequate ability to diagnose dental caries with high sensitivity and specificity for advanced disease but low sensitivity for early signs of dental caries (22). Providing cardiologists and cardiac nurses with training similar to paediatricians on the identification of dental disease may improve not only assessment of oral health but also oral health outcomes as parents elevate the importance of oral health when information is delivered by the cardiac team (23). Paediatricians may have an added role in facilitating early oral health assessment for children with cardiac conditions.
There were several conflicts between the cardiologists’ perceptions, experiences and their current assessment practices. Despite being cognizant of the importance of oral health, perceiving their patients to be at increased risk of poor oral health and having experienced cancellation or postponement of surgery, very few assessed oral health at an early stage or provided education other than information on the link between oral and cardiac health. Most perceived their patients to be at increased risk of dental caries if on prescribed high-calorie diets, however very few provided dietary advice. The lowest experience of cancellation of cardiac surgery was reported by cardiologists who rarely/never assessed oral health. This result may represent cardiologists who are unaware of which children have poor oral health whose cardiac health is at risk. It is also possible that these children’s dental needs were managed elsewhere without the cardiologist’s knowledge. Future research should investigate why to identify and address actual or perceived barriers and any potential shortfalls in knowledge to ultimately improve oral and cardiac health outcomes.
Our study had some limitations. The individual response rate was 20% despite multiple attempts at contact; however, we received responses from at least one cardiologist at 69% of the centres approached. While practices and opinions among cardiologists can vary, responses were received from multiple regions of North America. The only comparable study by Olderog-Hermiston had a response rate of 38%; however, only paediatric cardiology department chairs were interviewed (12). Ambiguity existed with potential timing of assessments ‘prior to cardiac surgery’ due to the heterogeneity in timing of surgical interventions or catheterizations. Not limiting the response to a specific age allowed investigation of patterns of practices related to oral assessments.
In conclusion, North American cardiologists are cognizant of the importance of oral health for the cardiac care of their patients assessing for oral health and providing parents with information on the importance of oral health. Despite being knowledgeable, perceiving their patients may be at increased risk of poor oral health and the common experience of cancellation or postponement of cardiac surgery, oral assessments are often deferred until prior to cardiac surgery. Early assessment provides the opportunity to maximize the oral health of the young paediatric cardiac patient and potentially reduce the incidence of cancellation of cardiac surgery. Given difficulty with access to care and delayed assessment by cardiologists, paediatricians and primary care physicians may need to facilitate early oral health assessment for children with cardiac conditions.
Acknowledgements
Ethics approval: The Hospital for Sick Children Research Ethics Board Approval: REB#1000039504. No funding was secured for this study. The authors have no financial relationships relevant to this article to disclose and conflicts of interest to disclose.
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