A challenging case: Endocarditis in a Boston terrier - Veterinary Medicine
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A challenging case: Endocarditis in a Boston terrier
Was this dog's tooth root abscess the cause of its severe, progressive systemic illness?


The relationship between periodontal disease and endocarditis

Although a causal relationship between periodontal and cardiovascular disease has been difficult to establish in veterinary medicine, numerous human studies have found an association between these conditions.15,16 About 80% of all studies found a significant positive association between periodontal disease and cardiovascular disease in people.15 Inflammation and endothelial dysfunction are believed to play a major role in periodontal disease leading to cardiovascular disease, and one study did find a causal relationship between periodontal disease and endothelial dysfunction.15 Even the reduction of pathogen burden with antibiotic therapy once endothelial dysfunction has occurred does not seem to lower the risk of cardiovascular morbidity and mortality.15 However, the treatment of severe periodontitis is shown to reverse endothelial dysfunction.17 Thus, the recommendation in human medicine for minimizing the risk of periodontal disease leading to cardiovascular disease is to prevent endothelial dysfunction from occurring by optimizing oral health.

There is some evidence that canine periodontal disease can affect the cardiovascular system. Common bacterial species of the oral cavity, such as Streptococcus species and Staphylococcus species, have been isolated from the heart valves of dogs.13 One study found that the risk of endocarditis was about six times higher in dogs with severe periodontal disease than in those without evidence of periodontal disease or with mild periodontal disease. However, there were several limitations to this study, including an inability to standardize the accuracy of diagnosis of cardiovascular-related events.18

The most recent guidelines from the American Heart Association for the prevention of infective endocarditis have attributed the association of dental disease and endocarditis to randomly occurring bacteremia during routine daily activities, rather than from bacteremia caused by invasive oral procedures, including dental scaling and polishing.19 It is postulated that maintaining optimal oral health and hygiene will reduce the prevalence of bacteremia.19 The American Veterinary Dental Society recommends routine home care including brushing, professional oral health assessment, and appropriate periodontal treatment in our veterinary patients as well in order to reduce the bacterial load.20

We should not only inform owners of the many potential benefits of maintaining a pet's oral health but should also emphasize the potential for periodontal and endodontic disease to result in serious local and systemic disease. Client education is an important key to improving overall compliance in what is often viewed as an elective procedure.


Periodontal disease in veterinary patients is generally not considered life threatening. However, the case reported here demonstrates how severe periodontitis can affect the overall health of a patient, ultimately leading to significant morbidity and death. In this case, severe periodontal disease was the suspected source of bacteremia leading to endocarditis.

Although bacterial endocarditis does not have a high prevalence in veterinary patients, it is associated with a poor prognosis. Maintaining good oral health is an important proactive measure by which pet owners and veterinarians can attempt to reduce the impact that advanced periodontal disease may have on the systemic health of our patients.

Michelle Fulks, DVM
Cape Cod Veterinary Specialists
11 Bourne Bridge Approach
Buzzards Bay, MA 02532

Rebecca Quinn, DVM, DACVIM
Pamela J. Mouser, DVM, MS, DACVP
Curtis A. Stiles, DVM, DAVDC
Angell Animal Medical Center
350 South Huntington Ave.
Boston, MA 02130


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