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Invasive Dental Procedures: Primum non nocere Arnold Seto, MD,
MPAAssistant Professor, CardiologyUC-Irvine and Long Beach VA
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GoalsMedical risk assessment for dental procedures
New Guidelines on Antibiotic prophylaxis for infective
endocarditis
Evidence
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Can we provide dental treatment to the patient without
endangering their (or our) health and well being? Is the benefit of
having dental treatment worth the risk to the patient?
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What do you do in the course of providing dental care that can
affect the health and well being of a patient?Instill fearInflict
painInject local anesthetic solutionsInject potent
vasoconstrictorsCause bleedingControl body position
Expose to radiationExpose to dental materialsPrescribe
medicationsAlter oral functionCause inflammation
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Most Common Medical Emergencies in Dental Practice (4000
dentists over 10 years)Syncope 15,407Mild Allergic Reaction
2,583Angina Pectoris 2,552Postural Hypotension 2,475Seizures
2,195Asthmatic Attack 1,392
Hyperventilation 1,326Epinephrine Reaction 913Insulin Shock
890Cardiac Arrest 331Anaphylaxis 304Myocardial Infarction 289
Many of these events are preventable, or at least the chancesof
them occurring can be reduced
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Risk of Vascular Events
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Risk Factors for the Occurrence of Adverse EventsDependent upon
4 factors:The medical condition of the patient (diagnosis,
severity, stability, control)The nature of the dental procedure
(invasiveness, length of procedure, blood loss, type of anesthesia,
use of vasoconstrictor)The cardiopulmonary reserve which is the
ability to respond to physical/emotional challenges (METs; oxygen
utilization); can the patient climb a flight of stairs without
chest pain or shortness of breath = 4 METsThe emotional stability
of the patient (fear, anxiety)
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Risk AssessmentMedical Condition? Severity Stability Control
Functional Capacity? METs
Emotional Status? Fear Anxiety
Dental Procedure? Invasiveness Length of procedure Blood Loss
Vasoconstrictor use
Decreased RiskIncreased Risk
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Risk AssessmentMedical Condition? Recent heart attack Labile
Hypertension
Dental Procedure? Full mouth extraction
Functional Capacity? Climbing a flight of stairs causes chest
pain and shortness of breath
Emotional Status? Afraid of the dentist
Increased Risk
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Risk AssessmentMedical Condition? Stable Angina
Dental Procedure? Exam and x-rays
Functional Capacity? Can climb a flight of stairs
Emotional Status? Doesnt like dentists
Decreased Risk
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Risk Assessment?Can we provide routine dental treatment to this
patient without endangering their (or our) health and well
being?Yes. No problems are anticipated, and treatment can be
delivered in the usual manner. (Benefit >> Risk)Yes, but
potential problems may be anticipated, and modifications in the
delivery of treatment are necessary. (Benefit > Risk)No.
Potential problems exist that are serious enough to make it
inadvisable to provide elective dental treatment. (Risk >
Benefit)
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Risk vs BenefitYou may not be able to completely eliminate the
risk of an adverse event occurring during dental treatment or as a
result of dental treatment, however, our goal is to reduce that
risk as much as possibleThe issue then becomes whether the
remaining risk is acceptable and that having the dental treatment
is of more benefit than not having it
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Biggest risk? Delaying needed dental carePeriodontal disease is
a chronic gram-negative infection, affecting up to 75% of
adultsPeriodontal disease is associated with markers of chronic
inflammation like CRPChronic inflammation has been associated with
progression of coronary artery disease, which is itself an
inflammatory statePeriodontal treatment reduces markers of
inflammationCollected studies suggest an 24-35% increased risk of
CAD in patients with periodontal disease
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CV risk in Periodontal PatientsHumphrey, J. Gen Int Med 23 (12):
2079-86
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Effect of periodontal treatmenton vascular endothelium
Flow-Mediated Dilatation during the 6-Month Study PeriodTonetti MS
et al. N Engl J Med 2007;356:911-920
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Circulating Biomarkers in the Two Groups during the 6-Month
Study PeriodTonetti MS et al. N Engl J Med
2007;356:911-920Intensive periodontal treatment resulted in acute,
short-term systemic inflammation and endothelial
dysfunctionHowever, 6 months after therapy, the benefits in oral
health were associated with improvement in endothelial function
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Periodontal disease and medical riskIn general, most periodontal
procedures are low risk and likely have CV benefits.
Only patients at highest risk of medical instability require
delay of care and medical evaluationUnstable anginaUncontrolled
hypertensionDecompensated congestive heart failure
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Management of antiplatelet agents during dental
proceduresAspirin should generally be continued for all coronary
artery disease patientsClopidogrel (Plavix) should be continued for
up to 1 year after myocardial infarction and stenting, to minimize
the risk of stent thrombosis
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Subacute stent thrombosis
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Management of anticoagulantsWarfarin (Coumadin) can usually be
stopped for 5-7 days preoperatively, and restartedMost patients
Atrial fibrillation, stroke, history of deep venous thrombosisOther
patients at higher risk recent DVT/PE, artificial heart valves
require close monitoring and possibly bridging therapy with
heparin. CONSULT.Dabigatran (Pradaxa) new oral anticoagulant
replacing warfarin. Can be stopped just 1 day prior to procedure,
and restarted thereafter
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Dental management of hypertension
Identify patients with hypertension both diagnosed or
undiagnosed.Medical history include diagnosis of it, how it is
being treated, identification of antihypertension drugs, compliance
of the patient, the presence of the symptoms associated with
hypertension and stability of the disease.Blood pressure
measurement should be routinely performed for all new patient and
recall appointmentsStress and anxiety management which increase
BP(relationship among dentists, patient & office staff and
longer stressful appointment are best avoided and short morning
appointment are recommended) .
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Management of antihypertensivesMost should generally be
continued to minimize hypertensive reactions to Clonidine is
especially prone to withdrawal hypertension and should be
continuedAbort the procedure if BP > 180/110
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Highest Risk PatientsRecent myocardial infarction (<
3months)Active unstable anginaDecompensated congestive heart
failureRecommendations:Avoid elective careIf treatment is necessary
, consult with physician and limit treatment to pain relief,
treatment of acute infection, or control bleedingConsider including
the following:Prophylactic nitroglycerinPlacement of intravenous
lineSedationOxygenContinuous electrocardiodiographic
monitoringPulse oximeterFrequent monitoring of BPCautious use of
epinephrine in local anesthetic.
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Other risk reduction measures(Intermediate risk patients)Morning
appointmentShort appointmentComfortable chair positionPretreatment
vital signsNitroglycerin readily available Stress-reduction
measuresGood communicationOral sedation(e.g triazolam 0.125-0.25mg
on the night before & 1hr before appointmentIntraoperative
N2O/O2 Excellent local anesthesiaLimit use of vasoconstrictor
(max.0.038mg epinephrine)Avoidance of epinephrine-impregnated
retraction cordAdequate postoperative pain control
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Bacterial EndocarditisA microbial infection of the endothelial
lining of the heart; most commonly occurring as a vegetation on the
valve leaflets
- Mortality Rates100% fatal if not treatedWith antibiotic
treatment, fatality rate:NVE (native valve)Streptococcus
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Endocarditis description
At any rate, at approximately one-quarter to twelve that night,
I remember distinctly getting up from my chair and from the table,
where my books lay, and taking off my suit coat. No sooner had I
removed the left arm of my coat, than there was on the ventral
aspect of my left wrist a sight which I shall never forget until I
die. There greeted my eyes about fifteen or twenty bright red,
slightly raised, hemorrhagic spots about 1 millimeter in diameter
which did not fade on pressure and which stood defiant as if they
were challenging the very gods of Olympus. ... I took one glance at
the pretty little collection of spots and turned to my
sister-in-law, who was standing nearby, and calmly said: I shall be
dead within six months.
- Alfred Reinhardt, Harvard Medical Student, 1931
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Pathogenesis of BEAnatomic/physiologic predisposition
(endothelial damage)Non-bacterial thrombotic
endocarditis(NBTE)Bacteremia (source??)Bacterial colonization of
vegetationAdditional deposition and growth of thrombusEmbolization
and bacteremia
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PathogenesisMandell
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Board Review QuestionWhich organism is the most commonly cause
of endocarditis in periodontal disease patients?
A) Strep viridansB) Staph aureusC) Candida albicansD) Coagulase
negative staphE) Enterococcus
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Diagnosis
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Modified Duke Criteria
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Modified Duke Criteria
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Oslers NodeTender subcutaneous nodulesPulps of digits or thenar
eminence
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Janeway LesionsNontenderHemorrhagicPalms and
solesErythematous
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Splinter HemorrhageFinger and toenailsNonspecificLinear and
redBrown after 2-3 d
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Roth Spots
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Valve Surgery
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Prophylaxis for IE: First origins1943, Northrup and Crowley
postulated that most IE were caused by dental extractions and that
Abx would prevent IE.Identified 20% of patients with IE had
preceding dental proceduresGave sulfa to separate cohort receiving
dental extractions and found that all patients had sterile blood
cultures.Concluded that Abx prevent IE and should be given.AHA
issued first recommendations in 1955Northrup, Crowley. J Oral
Surgery 1943; 1:19-29
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Circulation, published online April 19, 2007
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GuidelinesAmerican Heart AssociationCommittee on Rheumatic
Fever, Endocarditis, and Kawasaki DiseaseCouncil on Cardiovascular
disease in the YoungCouncil on Clinical CardiologyCouncil on
Cardiovascular Surgery and AnesthesiaQuality of Care and Outcomes
Research Working GrpEndorsed by:American Dental
AssociationInfectious Diseases Society of AmericaPediatric
Infectious Diseases Society
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Previous Guidelines1960 emphasized PCN resistance, suggested
chloramphenicol for PCN allergic patients1965 First guideline
dedicated solely on prophylaxis, recognized enterococci after GI,
GU procedures as a risk1972 Joined by ADA, emphasized importance of
good oral hygiene1977 introduced high vs. low risk groups1984
simplified antibiotic regimens1990 complete list of procedures and
cardiac conditions made, with statement that these serve as a
guideline and not as established standard of care1997
high/moderate/low risk groups made, acknowledgement that most cases
of IE are not due to a procedure
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Previous Guidelines
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Durack NEJM 1995; 332(1): 38-44
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Estimated risk of IE per procedure1 case of IE per 14 million
dental proceduresMVP: 1:1.1 million proceduresCongenital Heart
Disease: 1:475,000Rheumatic Heart Disease: 1:142,000Prosthetic
Valve: 1:114,000Previous IE: 1:95,000Guidelines
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Prophylaxis in 1997Recommended for:High Risk: previous IE,
prosthetic heart valve, cyanotic congenital heart diseaseModerate
Risk:Hypertrophic cardiomyopathyAcquired valvular diseaseMitral
valve prolapse with regurgitationOther congenital anomaliesNot
recommended for:Isolated ASD, MVP without regurg, previous CABG,
previous pacemaker, surgically repaired ASD/VSD/PDA
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Rationale in 19971. IE is an uncommon but life threatening
disease, and prevention is preferable to treatment2. Certain
underlying cardiac conditions predispose to IE3. Bacteremia with
organisms known to cause IE occors commonly in association with
invasive dental, GI, GU procedures4. Antimicrobial prophylaxis was
proven to be effective for prevention of experimental IE in
animals5. Antimicrobial prophylaxis was thought to be effective in
prevention of IE in humans
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Summary of Changesonly an extremely small number of cases of
infective endocarditis might be prevented by antibiotic prophylaxis
for dental procedures even if such therapy was 100% effective.
Infective endocarditis prophylaxis for dental procedures should
be recommended only for patients with underlying cardiac conditions
associated with the highest risk of adverse outcome from infective
endocarditis.
Prophylaxis is not recommended based solely on an increased
lifetime risk of acquisition of infective endocarditis.
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Change in approachAntibiotic prophylaxis is now recommended only
for those patients with the highest risk of adverse outcome from
IE, not just those with highest lifetime risk of IEProphylaxis for
dental procedures even for these highest risk patients is
reasonable but with poor evidence (Class IIb, LOE B)
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Treatment
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Rationale for Revision
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Additional ReasonsOver years, guidelines became complicatedPoor
recollection of guidelines by practitionersPoor compliance amongst
patients and dentists Ambiguities and inconsistencies were subject
to wide interpretations in malpractice casesPrevious guidelines not
evidence basedDesire to stimulate research on IE prophylaxis
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Nonadherence to prophylaxis70% of 455 Dutch patients recalled
being warned to take IE prophylaxis, but only 22% reported actually
taking them.Prophylaxis was given to young patients 4x more than
older patients.Surgeons are twice as likely to recommend
prophylaxis for patients with pacemakers than cardiologists.As
summarized in Durack NEJM 1995; 332(1): 38-44
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Quiz Question:According to the 1997 AHA Guidelines on
endocarditis prophylaxis, which of the following conditions require
antibiotic prophylaxis?
Mitral valve prolapse Previous CABG with tricuspid annuloplasty
ringPrevious pacemakerSecundum atrial septal defectMild aortic
regurgitationMild mitral regurgitationMild aortic stenosisAortic
sclerosis without stenosis
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Mitral valve prolapse Previous CABG with tricuspid annuloplasty
ringPrevious pacemakerSecundum atrial septal defectMild aortic
regurgitationMild mitral regurgitationMild aortic stenosisAortic
sclerosis
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Seto, Am J Med, 2001; 111:657-660
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Scope of patientsHow many adults over age 60 would be eligible
for IE prophylaxis based on prevalence of cardiac conditions and
1997 guidelines?
A) 2%B) 6% C) 10%D) 24%E) 50%
Croft Am J Card 2004; 94:386-89
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Croft Am J Card 2004; 94:386-89
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Croft Am J Card 2004; 94:386-89
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40% of cases of IE occurs in patients without previously
identified risk factors.
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Bacteremia and Dental ProceduresLancet 1935
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BacteremiaWidely studiedFrequency/intensity related toDensity of
floraDegree of inflammationDegree of infectionMagnitude of tissue
traumaPeak 10 minutes after tooth extraction, drops off between
10-30 minutesDurack NEJM 1995; 332(1): 38-44
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Guntheroth. Am J Card 1984;54:797-801
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Chewing?60 normal healthy patientsSupervised brushing for 2
minutesChewing gum for 10 minutesScaling/Root planingNone were
culture positive before4/20 with periodontal disease had bacteremia
from chewing gum, 1/20 after brushingScaling caused bacteremia in
2/20 healthy patients, 4/20 gingivitis patients, 15/20 periodontal
disease patients
Forner. J Clin Periodontology 2006; 33:401-407
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Bacteremia in Dental ProceduresRoberts, Pediatric Cardiology
1997; 18:24-27735 pediatric patients with blood cultures drawn 30
seconds after procedure.Cardiac patients received antibiotic
prophylaxis.
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Cumulative Risk:Total duration of bactermiaGuntheroth. Am J Card
1984;54:797-801Almost 1000x more risk in the month of extraction to
daily activities than from extraction.
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BacteremiaDental procedures: 104 CFU/mlRoutine daily activities:
sameExperimental IE in animal studies: 106-108
Cumulative risk from daily activities:Risk from brushing teeth
over 1 year may be 154,000 times greater than single extraction.
Risk from all daily activities may be 5.6 million:1
Roberts Pediatric Cardiology 1999. 20: 317-325
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Cumulative riskRoberts. Pediatric Cardiology.
1999;20:317-325
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BacteremiaIn patients with underlying cardiac conditions,
lifelong antibiotic therapy is not recommended to prevent IE that
might result from bacteremias associated with routine daily
activities.The focus on the frequency of bacteremia have resulted
in an overemphasis on antibiotic prophylaxis and an underemphasis
on maintanence of good oral hygiene; which is likely more important
in reducing the lifetime risk of IE than the administration of
antibiotic prophylaxis for a dental procedure.
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Do Abx Reduce Bacteremia?Reductions on variety of microbes and
duration of positivity demonstrated in some studies, not in
othersNot 100% effective in preventing bacteremiaProbably 75%
effective at best
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Does Prophylaxis Work in Humans?No prospective, randomized,
placebo controlled studies in patientsRetrospective and prospective
case-cohort trials limited by:1) Low incidence of IE2) Large
variety of underlying conditions3) Large variety of dental
procedures/states
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Dutch Case-control studyNationwide case control study in
Netherlands14.5 million patients screened over 2 years.All patients
in country with suspected IE reported to author.438 patients with
IE over 2 years, 48 included (had surgical/dental procedure within
6 months)Only 18 patients had IE within 30 daysCompared with 200
patients with same cardiac diagnosis, similar procedureVan der
Meer. Lancet 1992; 339:135-139
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Dutch Case-control studyOnly 1:6 in both groups had IE
prophylaxisOnly 12.7% of patients with IE had procedure within 30
days Possible 49% risk reduction with Abx, but not significant
(11-229%)At best, full compliance with prophylaxis might
prevent:17.1% of 275 patients with an incubation of 180 daysAt most
23 /275 (8.4%) if 30 days.Might prevent 5.3% of all cases with
endocarditis.
Van der Meer. Lancet 1992; 339:135-139
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Summary: Case Control TrialsPossible benefit for prophylaxis
cannot be excludedYale and French studies suggest possible
statistically significant benefitSmall numbers, 12 week
association, recall bias a problemDutch study had non-significant
differenceProphylaxis for IE is inconsistently prescribedInfective
endocarditis is not consistently associated with a dental
procedure
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French study1 year epidemiological study of IE in an area of 16
million peopleEstimates of predisposing cardiac conditions (PCC), #
of dental procedures, whether antibiotics were given obtained from
survey of 2805 peopleResults extrapolated to country populationPCCs
restricted. Highest-risk only in French recommendations 2002
(prosthetic valve, previous endocarditis) Heart 2005 91:715-8
Duval. Clin Infect Dis. 2006;42:e102-e107
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French study: ConclusionsEstimated Risk of IE:1:46,000 for
unprotected procedures1:10,700 for prosthetic valves1:54,300 for
native valves1:150,000 for protected proceduresEven if antibiotics
were 66% effective, large number needed to treat, even for high
risk patients isolated using French standardsDuval. Clin Infect
Dis. 2006;42:e102-e107
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Decision AnalysisMarkov multiple states modelTake estimates of
benefit, cost, complications, incidence from literature and
calculate likelihood of possible options
Agha. Medical Decision Making 2005;25:308
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Decision Analysis ResultsIf 10 million patients underwent
prophylaxis with amoxicillin19 cases of IE preventedNet loss of 181
lives due to anaphylaxisIf 10 million patients underwent
prophylaxis with clarithromycin119 cases of IE prevented, 19 deaths
preventedIncremental cost effectiveness of $88,007/QALYValve
replacement/previous IE patients had much better CE ratio of
$14,000-38,000If true incidence of cases of IE due to dental
procedures were less than 17% used in model, cost would
increase.Agha. Medical Decision Making 2005;25:308
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Future DirectionsDue to the low rate of endocarditis,An
adequately powered RCT would require 6,000 60,000 patients over 2
years, and screening of many more patients than this.A prospective
cohort study would require 18,000 patients over 10 yearsOnly
possible in countries with large organized health systems with
centralized records, and including every patient in that system
Cochrane Review 2004
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Future DirectionsLarge case-control trial would be more
feasibleSelecting appropriate matched controls for cases would be
requiredCochrane Review 2004
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Medical MalpracticeFour criteria must be metDuty was owed to
patientDuty was breached failure to conform to standard of
careBreach caused an injury and was proximate cause of the
injuryDamages occurred
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Recent malpractice casesFailure to diagnose endocarditis:Shea v
Dr. F. Mohebban 1999, Minella v. Dr. E AntelisSettled for $1.2
million, $1.95 million after MD failed to order blood CxFailure to
prescribe prophylaxis and failure to diagnoseMullen v Zylstra MD,
Pederson MD, Maynard DDS 199128 yo man with abnormal bicuspid
AVAfter tooth loosened by trauma, DDS attempted to reinsert. No abx
given despite history of bicuspid AV.Weeks later, tooth was grossly
infected, constitutional symptoms of endocarditis. MD failed to
listen to heart or order blood cx, diagnosis delayed, AVR
required.$3 million finding against MD. DDS settled for
$25,000MoreLaw database
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Other CasesFailure to ask?Bacon v Kentopp DDS, 2000,
NebraskaPatient required AVR and MVR after dental induced
endocarditis. Filed against DDS for failure to ask whether she had
heart problems, claimed that Abx would have been prescribed and
would have prevented endocarditisDefendant (DDS) won verdict.
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Treatment
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Dental procedures and IE prophylaxis: RecommendedDental
extractionsPeriodontal proceduresDental implants and reimplantation
of avulsed teethEndodontic proceuresSubgingival placement of
antibiotic fibers and stripsInitial placement of orthodontic bands
(not brackets)Intraligamentary local anesthetic
injectionsProphylactic cleaning
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Dental procedures and IE prophylaxis: Not recommendedRestorative
dentistryNon-intraligamentary local anesthetic injectionsTaking
oral impressionsFluoride treatmentsOral radiographsOrthodontic
appliance adjustmentShedding primary teeth
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Discussion?
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Criteria for effective prophylaxisIs the disease preventable?Is
it worth preventing?Can patients at risk be identified?Is
prophylaxis clinically effective?Is prophylaxis safe and well
tolerated?Can prophylaxis be delivered consistently and easily?Is
prophylaxis cost effective?
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Prophylaxis in 1997Dental: Any procedure that might induce
bleedingAmoxicillin 2gm PO, 1 hour preprocedureGIERCP, stricture
dilatation, varices, surgeryGUCystoscopy, prostate surgery,
ureteral stentPulmonaryT&A, rigid bronchoscopyRx:
Ampicillin/Gentamicin for non dental procedures.
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Unfortunately this table does not match the text of the van de
Meer article!
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Do Abx Reduce Bacteremia?Animal studies in the 1970s used
rabbits, valve damage from catheter, and large inoculum (108
CFU/ml) S. viridans to generate IE.Vancomycin and PCN uniformly
effective in preventing IE.Single dose Abx failed when even larger
doses of inoculum used.
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Do Abx Reduce Bacteremia in Humans?Lockhart. Circulation 2004;
109:2878-2884RCT of 100 children in dental OR given amoxicillin
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Do Abx Reduce Bacteremia?Erythromycin 1.5 gm oral before tooth
extraction.Randomized double blind trialS. viridans recovered
in:6/40 (15%) treated patients18/42 (43%) control patientsShanson.
J Antimicrob Chemo 1985; 15:83-90
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Do Abx Reduce Bacteremia?39 patients randomized to cefaclor or
placebo prior to extractionS. viridans recovered from 79% in
treated group50% in placebo group60 patients randomized to PCN,
amoxicillin, placebo in another study95%, 90%, 85% positive blood
culturesHall. Eur J Clin Microbiol Infectious Dis
1995;15:646-649Hall Clin Infect Dis 1993; 188-94
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Do Abx Reduce Bacteremia?Reductions on variety of microbes and
duration of positivity demonstrated in some studies, not in
othersNot 100% effective in preventing bacteremiaProbably 75%
effective at best
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Yale-New HavenCase-control trial, 2 hospitals34 patients with IE
between 1980-1986 with oral flora and cardiac lesion8/34 (23%) of
patients had dental procedure within 12 weeksControls matched for
same lesion, same procedure
Imperiale. Am J Med 1990; 88: 131-136
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Yale-New HavenImperiale. Am J Med 1990; 88: 131-136
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Lacassin studyCase control trial18.5 million population in 1
year, 1990-1Endocarditis, excluding IVDU, Q-fever171 cases, matched
to control by age, sex, cardiac conditionQuestionnaire to recollect
procedures
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
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Lacassin studyLacassin Eur Heart Journal 1995; 16(12)
1968-74
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Lacassin studyDental procedures as a whole were not associated
with increased risk, although scaling and root canal had trend
(P=0.065)In multivariate analysis, only skin wounds and other
infections increased overall risk of endocarditis. But when
selecting only S. viridans endocarditis, scaling was a significant
risk independent of other factors (but data not shown)Tooth
extraction was notSkin and other infections were significantly more
prevalent in case group (19% vs 5%)
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
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Lacassin studyLacassin Eur Heart Journal 1995; 16(12)
1968-74
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RejectedBoth these positive studies rejected from an analysis by
Cochrane Database as potentially being seriously biased.Prolonged
duration (12 weeks) considered too long by Cochrane committeeRecall
bias a concernOther limitations:ConfoundersAssociation without
causationOliver. Cochrane Database 2004.
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Philadelphia ProjectCase-control study: 8 counties around
Philadelphia and Delaware, 54 hospitals273 cases with community
acquired, non IVDU endocarditisControls were matched only to age,
sexNo association found with dental care, frequency of tooth
brushing, use of irrigators, denturesVery few patients in either
group received Abx prophylaxis (2.2% case, 0.7% controls)Case
patients were more likely to have cardiac lesions, be on VA or
Medicaid insurance
Strom Ann Int Med 1998; 129(10) 761-769, Circulation 2000;
102:2842-2848
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Strom Ann Int Med 1998; 129(10) 761-769, Circulation 2000;
102:2842-2848Case patients with IE no more likely to have received
dental procedure (OR 0.8 CI 0.4-1.5)
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Philadelphia ProjectStrom Circulation 2000; 102:2842-2848
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French EstimateDuval. Clin Infect Dis. 2006;42:e102-e107
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French EstimateDuval. Clin Infect Dis. 2006;42:e102-e107
The published AHA guidelines do not specifically define acquired
valvular dysfunction, so we applied the following DHHS criteria for
significant valvular abnormalities[4]: patients with moderate or
greater mitral regurgitation, tricuspid regurgitation, or pulmonary
regurgitation qualified for IE prophylaxis. Patients with mild or
greater aortic regurgitation qualified. Additionally, mild mitral
regurgitation with a thickened or redundant mitral valve as well as
mitral valve prolapse with any degree of mitral regurgitation
qualified for prophylaxis. [6] Also, any valvular stenosis of mild
or greater degree qualified.