Did the dentist almost kill my grandma?
April 16, 2007 1:52 AM   Subscribe

Dentist yanked grandma's ten remaining teeth; a few days later, massive heart attack. Connected? Inappropriate?

Thank goodness, my 90-year-old grandmother survived the major heart attack she suffered last weekend, while recovering from having all her remaining teeth (which she said felt loose, and which she wanted to "deal with" while she still has all her marbles) pulled and dentures made. Needless to say, I was not consulted before she embarked on this cockamamie scheme.

Because she has been in the hospital, she was not able to wear the dentures, and now when she tries they are quite uncomfortable, and she's worried the $7500 cost has been wasted and she will not be able to wear them at all.

Me, I am concerned that a dentist did this kind of major oral surgery on an elderly patient with a history of heart attack and stroke, rather than trying to save her natural teeth. There are studies showing links between oral bacteria and heart attack, but she was not warned of any risk--in fact, she felt bad for some time before asking grandpa to take her to the hospital.

Mefites with medical/dental experience, does this sound like she received inappropriate treatment? Does she have any recourse (complaint, new or adjusted set of dentures)? Should the family be furious?
posted by Scram to Health & Fitness (18 answers total) 1 user marked this as a favorite
I can't speak for the appropriateness of the treatment, but for dentures not to fit properly right away is quite common. It took my mother 6 months, nearly, to have her dentures fit *perfectly* after she had her top teeth out. Apparently, the gums need to "settle".
posted by Solomon at 2:01 AM on April 16, 2007

I am not a dentist, I never will be a dentist.

90 year old women have heart attacks. Certainly not all of them, but enough that it's never surprising to hear that a 90 year old woman had such an episode.

Please don't accuse your grandmother's dentist of causing her heart attack. Perhaps call him and ask that he sit down with you (with or without grandma, but if it's without, you'll need her to sign something giving you permission to know about her medical details. HIPAA) Ask the dentist how long she may need to wait for her gums to heal and fit properly into the denture. And remember, dentures can be relined (drastic) and adjusted (minor) to deal with the comfort issues of changing bone structure.

Good luck, and remember, grandma won't live forever, whether she sees the dentist or not, but even though she doesn't have any teeth, she does need to see the dentist. They still screen for oral cancer, and it's especially important to keep looking at that denture, checking for cracks, good fit, and making sure it isn't rubbing funny anywhere.
posted by bilabial at 4:14 AM on April 16, 2007

See a lawyer.
posted by ewkpates at 4:40 AM on April 16, 2007

As much as I'm sure you must be worried and upset with what happened, I think you might be going through a bit of post hoc, ergo propter hoc fallacious thinking. I'm not a doctor though, so there's an about 50% chance I'm full of shit (but I have pretty much a 50/50 chance on this, so it doesn't say much).

I really, really suggest going with your grandmother (if she's well enough, of course!) to get some second opinions (and maybe third opinions, too) from doctors/dentists, after you get as many facts from the original dentist as possible (including any waivers she signed). I suggest doing this in person so they can actually see your grandmother, and know her medical history, and make decisions that way (again, assuming she's well enough! her health is more important than... uh... I can't find a truly polite way to say 'potentially well-deserved righteous fury', but realize that I'm saying those words in the most respectful and understanding of tones, having sick grandparents myself).

I hope your grandma recuperates well!
posted by flibbertigibbet at 4:56 AM on April 16, 2007

I'm not a dentist, but my mother is a dental ceramist, this is not medical advice, etc., etc., etc..

However, it's not unusual for dentists to agree to remove remaining teeth so a patient can transition to dentures. There have to be appropriate conditions, of course- damaged teeth, painful teeth, or not very many teeth left, but they do it. I have a 22 year old cousin whose teeth were so rotted that the dentist pulled them all to give her dentures. A 90 year old woman without a full, remaining set of teeth and teeth that are loose and uncomfortable is a prime candidate. So it's not a cockamamie scheme, it's pretty common. It's very hard to chew with just a few, loose teeth. Your grandmother is likely to get better nutrition with dentures, just because she'll be able to eat a wider variety of foods again.

Secondly, the dentures are going to be uncomfortable for the first few months. First, the tissue is very swollen and tender from the pulling, and second, it's like any prosthetic device. If you put on new shoes, it takes a while to break them in. If you put in new dentures, it takes a while to break your mouth in. She has only wasted her money if she avoids wearing the dentures until they become comfortable.

Thirdly, while it's certainly in the realm of possibility that tiny bits of plaque and oral bacteria got loose in her system and sparked the heart attack, it's more likely that she's 90 years old and 90 year olds are prone to heart attacks. Generally, the greatest teeth-to-heart danger is with people who have pre-existing conditions. My daughter, with a ventricular murmur, takes a small course of antibiotics for dental work. I, with my perfectly normal heart, do not. Unless your grandmother has a history of cardiac issues, it's unlikely her dentist would have mentioned the possibility because it's so slim.

Now, however, she should wait at least six months before another dental visit, and yes, a woman with no teeth should still occasionally see a dentist. Bone can drift, her palate can change- she needs to be evaluated regularly to make sure her dentures still fit. I know you're upset; I certainly would be too, but sometimes, grandmothers just have heart attacks. Take care of her, be glad to have her, and try not to make her feel like she should be afraid of the dentist or the dentures. It was just a coincidence.
posted by headspace at 5:57 AM on April 16, 2007 [1 favorite]

Sorry about your grandmother. I hope her recovery goes well, that's her focus right now.
I'm a dental assistant, my employer/dentist specializes in prosthodontics. Which means we recommend tooth removal and replacement with dentures several times per month.
Having teeth removed is traumatic to the oral tissues, but with care is much better for the whole body, the teeth we have removed are decayed, infected,broken, loose.

Since our patient base happens to skew older, it *has* happened that serious health events occur after treatment. (Unfortunately, strokes/heart attacks/cancer diagnoses are more common at that age) We are consciencious about taking health histories and the oral surgeons we refer to are aware of the risks of the procedures. Many times we need to confer with their MD/Cardiologist before treatment. It may be that everything was done for your grandmother that could possibly have been, and it was coincidental.

As for the fit/discomfort with the new dentures(were there teeth removed both upper and lower with new upper/lower dentures?): Fresh extraction sites, especially multiple extractions, are tender for several days/weeks. The ridge changes shape daily, we see our patients at least once a week to refit the denture and take care of any rubbing spots. Patients often exfoliate pieces of bone, which can feel like splinters as they erupt from the gum tissue. If they are loose enough, we just pluck them out with tweezers.
Complete healing of the ridge, long after the "wounds" heal, takes place almost a year post-extraction. That is when the ridge is completely smooth and the shape/contour should be stable. Her dentist will probably give her temporary liners in the first year, and at some point, when he feels she is ready, do a laboratory liner which sets a permanent plastic denture base to the fit of her ridge.
posted by Jazz Hands at 6:13 AM on April 16, 2007

Here is the American Dental Association's statement on antibiotic prophylaxis for endocarditis. And this is the American Heart Association's set of guidelines.

The pdf in the first link is pretty extensive. Basically, if someone is at risk for bacterial infection of their heart valves (endocarditis) due to a dental procedure, they should be given preventative (prophylactic) antibiotics beforehand. I don't know if your grandmother fit the criteria, but I am guessing she does. If she fit the criteria, she should have been given antibiotics. That's the standard of care.

If she wasn't given antibiotics beforehand, and should have been, you have an excellent case and should see a lawyer.
posted by selfmedicating at 7:59 AM on April 16, 2007

A good explanation of endocarditis here.

Did her doctors at the hospital know she'd had a major dental procedure a few days before the heart attack? Don't assume they did, you'd be surprised how much falls through the cracks. There are ways to find out if it was endocarditis, and she may want to get copies of blood tests and echocardiographs that were done if she thinks the dentist was at fault.
posted by selfmedicating at 9:18 AM on April 16, 2007

Endocarditis is not a heart attack( and a heart attack is not a symptom of endocarditis), and why would you assume Grandma fit the criteria for prophylactic antibiotics? The original question doesn't mention any previous heart issues, and even a previous heart attack is not a qualifying condition for the premed.
posted by Jazz Hands at 9:40 AM on April 16, 2007

IANADentist, but IAADoctor, and while I frankly have no idea what is and isn't appropriate with respect to dental extraction, I can tell you that while anything's possible, it's near impossible to verify an association between a dental procedure and a heart attack several days later.

It's true that such dental procedures do put you at risk for endocarditis depending on the condition of your heart valves and any history of congenital heart disease. In select patients, antibiotic prophylaxis is recommended. As noted, endocarditis and heart attacks (myocardial infarction) are two distinct entities. However, in a fraction of patients with endocarditis, heart attacks are a theoretical possibility as infectious vegetations on a valve may potentially break off and circulate to a coronary artery, causing an occlusion. However you don't mention anything about endocarditis, and if this were going on, I would presume you would know about it. Endocarditis has a whole constellation of findings, and it sounds like your grandmother had more of your run of the mill heart attack.

Another possibility is that during such a procedure, catecholamine levels tend to be elevated and occasionally local anesthetics with vasoconstrictive properties are used. In someone with coronary artery disease, this combination could conceivably lead to either angina, or demand/supply-induced myocardial infarction. However one would imagine that such an event would be far more likely to happen during the procedure, and not several days later. Regardless, currently there are minimal recommendations regarding periprocedural risk stratification or so-called 'cardiac clearance' for dental procedures beyond endocarditis prophylaxis in the appropriate population. Many clinicians (though I'm not sure there are any confirmatory medical societal guidelines on this), recommend avoiding major dental procedures for at least 6 months following a heart attack, but it sounds like that wasn't the case for your grand mother.

I believe there is data correlating the long-term risk of heart disease to periodontal disease and bacterial flora, however this is epidemiologic data and also quite contentious. Regardless, this has virtually nothing to do with the risk of a complication following a dental procedure, which is the question you're asking.

For more information here's an article from the Journal of the American Dental Association regarding oral care for patient's with heart disease.
posted by drpynchon at 11:02 AM on April 16, 2007 [1 favorite]

why would you assume Grandma fit the criteria for prophylactic antibiotics?
Because the guidelines recommend antibiotics for a procedure where significant bleeding is likely, and I am guessing that having ten teeth extracted fits that criteria.

The original question doesn't mention any previous heart issues
Previous heart attack and stroke, 4th paragraph. But it's the risk of bleeding that made me say she probably fit the guidelines.

Endocarditis is not a heart attack( and a heart attack is not a symptom of endocarditis).
A dental procedure could lead to endocarditis and endocarditis could lead to a heart attack. That's one of the big reasons to premedicate.

I'm not saying the dentist necessarily acted inappropriately. We don't have enough information to say. But if it were my grandmother, I'd look into it. I'm not convinced the ER doctors would have looked really hard into the causes of a heart attack in a 90 yr old woman with a previous MI. It may just be that Scram is the only person who has connected the dots here.
posted by selfmedicating at 12:14 PM on April 16, 2007

Because the guidelines recommend antibiotics for a procedure where significant bleeding is likely, and I am guessing that having ten teeth extracted fits that criteria.

I think you have misunderstood those guidelines. Indeed dental procedures with significant bleeding (and in fact all extractions) are considered procedures in which prophylaxis is recommended, but only in select high- and moderate- risk patient populations. Those include patients with a prior history of:

*Prosthetic cardiac valves, including bioprosthetic and homograft valves
*Previous bacterial endocarditis
*Complex cyanotic congenital heart disease (eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot)
*Surgically constructed systemic pulmonary shunts or conduits
*Most other congenital cardiac malformations (other than above and below)
*Acquired valvar dysfunction (eg, rheumatic heart disease)
*Hypertrophic cardiomyopathy
*Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

I'm not convinced the ER doctors would have looked really hard into the causes of a heart attack in a 90 yr old woman with a previous MI.

Let me reiterate that if endocarditis were the cause of the problem here, it would be very unlikely that such a thing would be missed. Symptoms of a persistent blood infection that's bad enough to cause septic emboli aren't usually subtle, and you wouldn't have to look too hard to find out if someone has, say, a fever or is in septic shock for example.
posted by drpynchon at 12:33 PM on April 16, 2007

Sorry, missed the part where he mentioned the previous heart issues, still not the kind of heart issues which indicate premedication.
posted by Jazz Hands at 1:08 PM on April 16, 2007

Response by poster: Thanks so much to everyone for the helpful and informative responses. We have another crisis that has just hit the family, and it's a bad time for me to be asking questions about antibiotic Rx, what the ER knew and when, blood panels, etc., but I will follow up in the next few days. It's always so good to be able to reach out to this community when something big and baffling is in the room.
posted by Scram at 1:11 PM on April 16, 2007

Yikes, Scram, take care!
posted by Jazz Hands at 1:17 PM on April 16, 2007

Please keep us posted - I'll be thinking of you and your family.

Drpynchon and Jazz Hands gave us some great info. Especially Dr. P's point that a blood infection that could lead to a heart attack isn't subtle. The endocarditis theory could fit if she had a fever before going to the hospital. The reason I keep harping on about it is that I think we are too quick to brush off health problems in the elderly, because we just expect them to be in poor health. Scram, you rule for looking out for your grandmother. Please do follow up.
posted by selfmedicating at 6:00 PM on April 16, 2007

Response by poster: Thanks again, folks. I just got back from a couple days caregiving. Grandma is still in bed, but getting stronger every day. She still can't comfortably wear her teeth, but has been trying to get used to them and will see the dentist when she's feeling better.

She didn't remember if she had been prescribed anything pre-extraction, but I poked around and found a recent, only partially empty, antibiotic script from her dentist under her night table (4 pills left) and told her she was a very bad girl for not taking all her pills.

Maybe this had something to do with her heart attack, maybe not. The main thing is that the family has recognized that, as independent as our grandfolks have always been (and insisted on being), it's now time for them to have more help and daily supervision. For now, a family member is living with them; down the road that may become a paid in-home caregiver, or they may go into an assisted living community.
posted by Scram at 4:48 AM on April 20, 2007

Scram, you're lucky to be in a family that looks out for each other like this. So are your grandparents.

It sounds like your grandmother filled the prescription for antibiotics when she got it, then forgot to take them the day of the procedure. The standard is 2g of amoxicillin the day of, and the whole prescription may have been for 4 tablets, 500 mg each.

I'm kind of surprised the dentist didn't ask a 90 yr old patient if she'd remembered to take the antibiotics. I might point that out to him, politely but firmly, and get him to make sure that she is damn happy with those dentures. I mean, after all this, she deserves to be ecstatic about those dentures.
posted by selfmedicating at 6:43 PM on April 20, 2007

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