Dental Managment , infective endocarditis , rheumatic fever

DENTALMANAGEMENTOF THE MEDICALLYCOMPROMISED PATIENT

Mosul university- College of dentistry-oral & maxillofacial surgery department
Dr.Ziad H. Delemi B.D.S, F.I.B.M.S (M.F.)
Infective Endocarditis & Rheumatic Fever & Rheumatic Heart Disease &Murmurs

Mosul university- College of dentistry-oral & maxillofacial surgery department

 is a life-threatening microbial infection of the heart valves or endocardium. it is more common in certain patients with congenital or acquired cardiac or vascular defects. Often caused by bacteria (Streptococcus viridans, faecalis, bovis, Staphylococcus aureus),or fungi (Candida albican) or other microorganisms like ( Coxilla, Klymedia). male to female ratio (2:1) mean age 30 to 50 years.
Infective Endocarditis:

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology & complications:
Bacterimia :Bacteria found in tooth plaque(mainly Streptococcus viridans) are the source of the inflammation of the heart . When gums bleed( by dental procedure), the bacteria enter the bloodstream and potentially infect the inner lining of the heart and its valves.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology & complications:
1- Cardiac lesions: accumulation of fibrin & platelets & other blood products & bacteria over the damaged valves often mitral valve this form vegetation.

Mosul university- College of dentistry-oral & maxillofacial surgery department

2- Embolic lesions: vegetation is friable & easily detached then fragmentation & emboli formation, 3-General lesions: splenomegaly, clubbing of fingers, arthritis, cardiac failure, liver disease, anemia. Complications include reinfection, congestive heart failure, renal disease, cerebrovascular accident, arrhythmia , heart block, abscesses in the heart that are very hard to treat, death.
Pathophysiology & complications:

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & Symptoms of Infective Endocarditis:
Signs: petechial haemorrhages on skin & mucous membrane Osler`s nodes (reaction to endotoxins) Clubbing of fingers Murmur Anemic pallor Janeway lesions Linear hemorrhage (nails) Retinal hemorrhage
Symptoms:(primary) Weakness Weight loss Fever, chills night sweats Arthralgia Myalgia (secondary to septic emboli) Paralysis Chest pain Bone pain Blindness Haematuria stroke

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & Symptoms of Infective Endocarditis:
petechia

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & Symptoms of Infective Endocarditis:
Clubbing of fingers



Mosul university- College of dentistry-oral & maxillofacial surgery department
Investigations & diagnosis:
blood culture (+ve) Complete blood picture (leukocytosis) & ESR ( ) General urine examination ECG changes Echocardiogram (+ve )
Medical treatment:
Early treatment Culture & sensitivity tests Use bactericidal agents I.V route administration Adequate dosage antibiotic Continue treatment long enough

Mosul university- College of dentistry-oral & maxillofacial surgery department

Dental management:
the goal is to prevent endocarditis that occurs in susceptible dental patients during dental procedure that causes injury to the soft tissue or bone resulting in bleeding & transient bacterimia results in endocarditis so those patients need antibiotic prophylaxis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Endocarditis Prophylactic Regimens for Dental & Oral Procedures
Standard general prophylaxis
Amoxicillin Adults: 2 g Children: 50 mg per kg  Taken orally one hour before the procedure
Cont.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Patient is unable to take oral medications
Ampicillin Adults: 2 g Children: 50 mg per kg  Given IM or IV within 30 minutes before the procedure
Cont.


Mosul university- College of dentistry-oral & maxillofacial surgery department
Patient is allergic to penicillin
Cont.
Azithromycin or clarithromycin (Klaribac) Adults: 500 mg Children: 15 mg per kg  Taken orally one hour before the procedure

Mosul university- College of dentistry-oral & maxillofacial surgery department

Cont.
Clindamycin Adults: 600 mg Children: 20 mg per kg  Taken orally one hour before the procedure Cefadroxil or cephalexin ( Keflex) Adults: 2 g Children: 50 mg per kg  Taken orally one hour before the procedure
Patient is allergic to penicillin

Mosul university- College of dentistry-oral & maxillofacial surgery department

Patient is allergic to penicillin and is unable to take oral medication
Clindamycin Adults: 600 mg Children: 20 mg per kg  Given IV within 30 minutes before the procedure Cefazolin Adults: 1 g Children: 50 mg per kg  Given IM or IV within 30 minutes before the procedure
Cont.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Patient should receive prophylactic antibiotic :
Artificial heart valves. Mitral valve prolapse with valvular regurgitation and/or thickened leaflets valves. Previous endocarditis. Surgically constructed systemic pulmonary shunt . Congenital heart defects. Acquired heart valve disease (rheumatic heart disease). Hypertrophic cardiomyopathy. Cardiac transplantation recipients with cardiac valvular disease


Mosul university- College of dentistry-oral & maxillofacial surgery department
Antibiotic prophylaxis is recommended for the dental procedures like:
Tooth extraction Implant placement Reimplantation of natural teeth Periodontal procedures Endodontic surgery Initial placement of orthodontic bands Intraligamentary local anesthetic injections Professional cleaning of teeth or implants if bleeding is anticipated Incision and drainage of infected oral tissues Biopsy taking

Mosul university- College of dentistry-oral & maxillofacial surgery department

Antibiotics are NOT recommended for following procedures:
Taking x-rays. Taking oral impressions. Fluoride treatments . Restorative dentistry. Placement of a rubber dam . Orthodontic appliance adjustment . Placement of removable orthodontic/prosthodontic appliances. Shedding of primary (baby) teeth. Postoperative suture removal. Intracanal endodontic treatment. Local anesthetic injections (specifically nonintraligamentary) .

Mosul university- College of dentistry-oral & maxillofacial surgery department

Rheumatic fever
Rheumatic fever is an immunologically mediated acute inflammatory disorder, which occurs in some individuals as a complication to group A beta hemolytic streptococcal pharyngeal infection. Multisystem disease affecting the heart, joints, brain, cutaneous and subcutaneous tissues There is no direct invasion to the tissue by the microorganism but its an autoimmune disease that involves Ag-Ab interaction. It must be pharyngeal infection not skin infection. Rheumatic fever cause permanent damage to the heart but not to the joint(only arthritis)

Mosul university- College of dentistry-oral & maxillofacial surgery department

Pathophysiology
Body produce antibodies against streptococci antigens , 1-These antibodies cross react with human tissues because of the antigenic similarity between streptococcal components and human connective tissues (molecular mimicry)[there is certain amino acid sequence that is similar between group A Strep. and human tissue] 2-Immunologically mediated inflammation & damage (autoimmune) to human tissues which have antigenic similarity with streptococcal components- like heart, joint, brain, connective tissues.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Because of the similarity between hyaluronic acid in group A Strep. capsule and in the connective tissue of the joints, Antibody produced against group A Strep. capsule will start to attack the joints and causes arthritis. M-protein in group A Strep. cell wall and the myocardium are similar, thus Antibody produced against group A Strep. cell wall will attack heart and will cause carditis and so forth.


Pathophysiology

Mosul university- College of dentistry-oral & maxillofacial surgery department

Mosul university- College of dentistry-oral & maxillofacial surgery department

Rheumatic fever-diagnosis
Major manifestations Carditis Polyarthritis Chorea Subcutaneous nodules Erythema marginatum
Subcutaneous nodule

Mosul university- College of dentistry-oral & maxillofacial surgery department

Minor manifestations Clinical findings- Arthralgia(joint pain without swelling ) Fever Laboratory findings- Elevated acute phase reactants raised ESR (erythrocyte sedimentation rate) raised CRP (C-reactive protein) Prolonged P-R interval (ECG)
Rheumatic fever-diagnosis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Rheumatic fever-diagnosis
Jones criteria for initial attack of rheumatic fever Evidence of preceding streptococcal infection + 2 major manifestations or one major manifestation and 2 minor manifestations indicates a high probability of acute rheumatic fever


Mosul university- College of dentistry-oral & maxillofacial surgery department

1-CARDITIS(pancarditis)- all 3 layers are involvedClinical evidence :Murmur(mitral or aortic regurgitation-endocardium involved)Heart failureCardiac enlargement(myocardium involvement)Pericardial rub or effusion(pericardium involvement)Investigations for evidence of carditisChest x-ray – cardiomegaly, pulmonary venous congestionECG- heart block, T wave changes, low voltage QRSEchocardiogram Signs & Symptoms of Rheumatic fever:
Cont.

Mosul university- College of dentistry-oral & maxillofacial surgery department

2-Arthritis Polyarthritis, migratory, large joints, no residual deformity, rapid response to aspirin. 3-Chorea Spasmodic, unintentional, jerky choreiform movements, speech affected, late manifestation. 4-Subcutaneous nodule Painless, hard nodules beneath skin, over bony prominence. 5-Erythema marginatum(rash) Erythematous, ring or crescent shaped, transient patches over trunk and limbs

Mosul university- College of dentistry-oral & maxillofacial surgery department

Bed rest 2-6 weeks(till inflammation subsided)Supportive therapy- treatment of heart failureAnti-streptococcal therapy- Benzathine penicillin(long acting) 1.2 million units once(IM injection) or oral penicillin 10 days, if allergic to penicillin erythromycin 10 days(antibiotic is given even if throat culture is negative)Anti-inflammatory agents-Aspirin 100 mg/kg per day for arthritis and in the absence of carditis- for 4-6 weeks to be tapered offCorticosteroids in presence of carditis – 1-2 mg/kg per day – for 4-6 weeks to be tapered off Medical treatment:

Mosul university- College of dentistry-oral & maxillofacial surgery department

Secondary prevention – prevention of recurrent attacksBenzathine penicillin G 1.2 million units IM every 4 weeksOr Penicillin V 250 mg twice daily orallyOr Sulfadiazine 1 g daily orallyIf allergic to both – Erythromycin 250 mg twice daily orally General WHO guidelines recommend that: If no carditis has developed, prophylaxis should be continued for 5 years after an acute attack or until the age of 18 years (whichever is longer). In cases of mild or healed carditis, treatment should continue for 10 years past the last attack or until age 25 years (whichever is longer). In cases of more severe carditis or valve surgery, treatment should be lifelong.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Treatment plane modifications
No contraindication to dental procedure in patient with rheumatic heart disease Carry out as much treatment as possible Allow at least 1week to elapse before starting new coverage If multiple coverage periods are needed alternate antibiotic used Lengthen coverage period in presence of sutures or area slow to heal


Mosul university- College of dentistry-oral & maxillofacial surgery department
Rheumatic Heart Disease
is the most serious manifestation of acute rheumatic fever and is the end result of carditis, which affects 30% to 45% of patients with acute rheumatic fever. Damage to the cardiac valves (usually mitral or aortic) may be chronic and progressive and can lead to congestive heart failure and death, Myocarditis is characterized by infiltration of mononuclear cells, vasculitis, and degenerative changes of the insterstitial connective tissue. The pathognomonic lesion is the Aschoff body in the proliferative stage, which is present in 30% to 40% of biopsy samples from patients with acute rheumatic fever.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Signs & Symptoms of Rheumatic heart disease:
Exertinal dyspnea Angina pectoris Congestive heart failure Epistaxis Blood in sputum Murmur ECG changes cardiomegaly

Mosul university- College of dentistry-oral & maxillofacial surgery department

Diagnosis of rheumatic heart disease:
1. History a. Not always clear. b. Erythematous rash with pharyngitis 2. Murmurs or other findings: a. Mitral Stenosis most common b. Aortic stenosis 3. Carditis with Polyarthritis 4. Complete blood count - WBC may be quite high; anemia often present 5. Elevated ESR, C-reactive protein 6. High Anti-Streptolysin O Titer (ASO) or hyaloronidase

Mosul university- College of dentistry-oral & maxillofacial surgery department

Treatment 1 Benzathine penicillin IM Aspirin to control fever Steroids in severe acute disease 4. Prophylaxis: Monthly IM inj. of benzathine penicillin(>5 years) 5. Alternative prophylaxis: Penicillin V 250mg P.O. twice a day or Erythromycin 250mg P.O. twice a day. 6. All patients at risk for progressive valve damage should receive antibiotic prophylaxis

Mosul university- College of dentistry-oral & maxillofacial surgery department

Notes:
If rheumatic heart disease is present the patient is susceptible to infective endocarditis following dental procedures that cause transient bacterimia so prophylaxis antibiotic is needed, but if rheumatic heart disease is not present in patient with history of rheumatic fever prophylaxis antibiotic is not needed


Mosul university- College of dentistry-oral & maxillofacial surgery department
Murmur
Is a soft sound hear by the stethoscope caused by turbulence in the circulation through the valves & champers of the heart which occurs due to increased flow rate, change in viscosity, narrow or dilated valves, or valve leaflets. There are 2 types: 1- Innocent (functional): occur in childhood development & in pregnancy, not need prophylactic antibiotic. 2- organic (pathologic): caused by abnormality in the heart , they require prophylactic antibiotic.

Mosul university- College of dentistry-oral & maxillofacial surgery department

Home work
Normal values: Bleeding time Prothrombine time Clotting time Partial thromboplastin time INR Blood sugar (random, fasting) , Hb A1c Serum alkaline phosphatase Serum calcium(total) Serum cholesterol LDL, HDL serum creatinine (male, female), S. Urea, S.Uric acid Serum iron Hemoglobin (male, female), PCV, RBC count WBCs count differential Platelets count Bilirubin direct , indirect