Cardiovascular Disease in Dental Care III Flashcards
Infective endocarditis assumptions
- Dental treatment has long been implicated as a significant cause of infective endocarditis
- The vast majority of patients with infective endocarditis have not had a dental procedure within ____ before the onset of symptoms
- In patients with a predisposing cardiovascular disorder, infective endocarditis most often was caused by bacteremia that resulted from a ____
- Thus taking antibiotics before these dental procedures, infective endocarditis could be ____
- For 50 years, the American Heart Association has published 10 sets of recommendations for antibiotic prophylaxis for dental patients at risk for acquiring infective endocarditis
2 weeks
dental procedure
prevented
Principles behind recommendations
• American Heart Association guidelines:
1. Infective endocarditis is an uncommon, but life-threatening disease, and ____ is preferable to treatment of established infection
2. Certain underlying ____ conditions predispose to infective endocarditis
3. Bacteremia with organisms known to cause infective endocarditis occurs commonly in association with invasive ____, gastrointestinal, or ____ tract procedures
4. Antimicrobial prophylaxis was proven to be effective for prevention of experimental infective endocarditis in ____
5. Antibiotic prophylaxis was thought to be effective in humans for prevention of infective endocarditis associated with dental, gastrointestinal, genitourinary tract procedures
prevention cardiac dental genitourinary animals
Questioning the validity of assumptions
• Bacteremia can result from many normal ____ such as toothbrushing or flossing; using toothpicks or water picks, and chewing
• The average person living in the U.S. makes fewer than ____ dental visits per year, so the frequency and exposure to bacteremia is likely greater through ____
• The frequency and cumulative duration of exposure to bacteremia from routine daily events over 1 year are likely much higher than those resulting from single dental procedures
• It seems inconsistent to recommend antibiotic prophylaxis for patients undergoing ____ but not for engaging in routine daily activities
daily activities
2
routine daily activities
dental procedures
• Shows reported frequency of bacteremia in dental procedures, and in contrast to normal toothbrushing and flossing
◦ In some ____ the frequency of bacteremia is just as high as some dental procedures
routine dental activities
Magnitude of bacteremia
• The collective published data suggest that the majority of dental office visits result in some degree of ____
• Assumption made that the magnitude of bacteremia resulting from dental procedures is more likely to cause infective endocarditis than magnitude resulting from ____, for example
• The infective dose required to cause infective endocarditis in humans is ____
• The number of microorganisms in the blood after a dental procedure or associated with daily activities are both ____
• No data shows that the incidence, magnitude, or duration of bacteremia from any ____ increases the risk of infective endocarditis
bacteremia chewing unknown low dental procedures
Assumption of antibiotic efficacy
• The assumption is that antibiotics given to at-risk patients before a dental procedure will prevent or reduce bacteremia that can lead to infective endocarditis
• Studies suggest that ____ therapy has a statistically significant impact on reducing the incidence, nature, and duration of bacteria associated with dental procedures, but does not eliminate ____
• Moreover, data do not show that such a reduction caused by antibiotic therapy reduces the risk or prevents ____
amoxicillin
bacteremia
infective endocarditis
- Study investigated the efficacy of antibiotic prophylaxis for preventing infective endocarditis in dental patients with native or prosthetic cardiac valves (van der Meer)
- Investigators concluded that dental or other procedures probably caused only a ____ of cases of infective endocarditis and that prophylaxis would prevent only a ____ of cases even if it were 100% effective
- Authors also performed a 2-year case control study, and found that among patients for whom prophylaxis was recommended, ____ of 20 cases of infective endocarditis occurred despite receiving antibiotic prophylaxis
- Concluded that antibiotic prophylaxis was not ____
small number
small number
5
effective
Current thinking
• The American Heart Association has concluded that
• of the total number of cases of infective endocarditis that occur annually, it is likely that an exceedingly ____ of these cases are caused by bacteremia-producing dental procedure.
• Only an extremely small number of cases of infective endocarditis might be prevented by ____, even if it were 100% effective.
• The vast majority of cases of infective endocarditis caused by oral microflora most likely results from random bacteremias caused by ____, and not from a single dental procedure
• The guidelines are quite different today from what they were 50 years ago
small number
antibiotic prophylaxis
routine daily activities
Cardiac conditions where prophy is recommended
- ____
- previous infective endocarditis
- CHD
– only these conditions: ____, including those with palliative shunts and conduits)
____ with prosthetic material or device by surgery or catheter intervention during the first ____ months after the procedure
repaired CHD with ____ at the site or adjacent to the site of a prosthetic patch or prosthetic device, which inhibits endotheliaization - cardiac transplant recipients who develop ____
prosthetic cardiac valve unrepaired cyanotic CHD completely repaired CHD 6 residual defects cardiac valvulopathy
Dental procedures
• Antibiotic prophylaxis is recommended only for patients with conditions as highest risk who undergo any dental procedure that involves the manipulation of ____ or the ____ of a tooth and for those procedures that perforate the ____
• This recommendation does not include routine ____ injection through non-infected tissue, taking of dental ____, placement of removable ____ appliances, adjustment of ____ appliances, or the shedding of ____ teeth and bleed from trauma to the ____
gingival tissues periapical region oral mucosa local anesthetic radiographs prosthodontic/orthodontic orthodontic deciduous lips or mucosa
Regimen
• Antibiotic prophylaxis should be administered in a single dose ___ minutes before the procedure
• If the antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to ___ hours after the procedure
• As for oral antimicrobial mouth rinses (chlorhexidine), the collective evidence suggests that there is no clear ___ associated with their use
30-60
2
benefit
• Shows the standard dosages: ◦ ___ grams for adults
◦ Modified for ____
• IV is not encountered in regular dental office
• If allergic to amoxicillin you can use ____ or clindamycin to avoid allergic reactions
2
children
azithromycin
Special situations
• Patients already taking antibiotics (penicillin or amoxicillin) for an infection or for long-term secondary prevention of ____ the presence of bacteria responsible for infective endocarditis relatively ____ to penicillin or amoxicillin is likely
• Clindamycin, azithromycin, or ____ should be selected for prophylaxis if treatment is necessary
• A 2 gram dose of amoxicillin should be acceptable for at least ____ hours, but if a procedure lasts longer than 6 hours, administering an additional ____ grams may be indicated
rheumatic fever resistant clarithromycin 6 2
Non valvular devices
• American Heart Association concluded that no convincing evidence suggests that microorganisms associated with dental procedures cause infections of ____ at any time after implantation
• Does not recommend routine antibiotic prophylaxis for patients with any of these devices who undergo dental procedures
• However, antibiotic prophylaxis is recommended for selected patients with these devices if
1. Undergoing incision and drainage of ____
2. Patients with residual valve ____ after device placement for attempted closure of leaks associated with ____, atrial septal defect, or ____
non valvular vascular devices infected tissue leak patent ductus arteriosus ventricular septal defect
- These do not need prophylaxis prior to dental treatments, only in the aforementioned exemptions
- ____ devices, in general, do not need prophylaxis
non-valvular
Talking to the dental patient
• Patients who used to take antibiotics prior to dental procedures who are now being advised against it might have a few questions
- Talking points
- Infective endocarditis is much more likely to result from frequent exposure to random bacteremias associated with ____ than from bacteremias caused by a dental, gastrointestinal tract, or genitourinary tract procedure
- The ____ of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy
- Maintenance of optimal health and ____ may reduce the incidence of bacteremia from daily activities and is more important than ____ for a dental procedure to reduce the risk of infective endocarditis
daily activities
risk
hygiene
prophylactic antibiotics
Risk factors
• There has been an overemphasis on antibiotic prophylaxis and under- emphasis on maintenance of good oral hygiene and access to routine dental care which are likely more important in reducing lifetime risk of infective endocarditis than the administration of antibiotic prophylaxis for a dental procedure
- Risk factors for infective endocarditis
- Age > ____ years
- ____
- ____ drug use
- Poor ____ or dental infection
60
male
injection
dentition
- More than half of all infective endocarditis cases in the US and Europe occur in patients over the age of 60; older adults are more likely to develop ____ and to require valve replacement, both of which are associated with an increased risk of ____
- Men predominate in most case series of infective endocarditis; male to female ratios range from 3:2 to 9:1
- Risk factors related to injection drug use include bloodstream seeding with ____, oral flora, and/or organisms contaminating the drug or materials used for injection. In addition, some illicit drugs may induce ____ predisposing to subsequent infection
- Poor dentition or dental infection is presumed to be risk factors for infective endocarditis due to ____
degenerative valve disease infective endocarditis skin flora valvular endothelial damage oral flora
Clinicopathologic case
• 53 year old female patient presents to oral diagnosis and emergency for admissions. Her chief complaint is “I want my teeth fixed.” On reviewing her health history you note that the patient has a pacemaker. Further questioning reveals that patient has a history of atrial septal defect that resolved shortly after birth.
• Atrial septal defect is a ____
• [someone answers question, cannot hear it]
◦ Patient has a pacemaker, that is a ____ device, so that doesn’t need prophylaxis
◦ But what about her presentation would have to change in order for you to decide she needs prophylaxis?
‣ If she presented complaining about tooth pain and an ____, then that would change your approach (incision and drainage of a site)
◦ What about atrial septal defect?
‣ A ____ is not on the list of exceptions; doesn’t need
prophylaxis
• What if she told you that a long time ago she had IE (25 years ago), would she need to be
prophylaxis?
◦ She has a ____ - she would be a candidate
◦ Recommendation for dosage: amoxicillin, 2 grams, and tell her to take it one hour
before the procedure; she can also take it after the procedure if she forgot it at home
CHD non-valvular abscess resolved atrial septal defect history
Hypertension
• Joint National Committee guidelines encourage the participation of all health care professionals in the detection of hypertension and the surveillance of treatment compliance
• Dental health professionals can play a significant role in the ____ and control of hypertension and may be the first to detect a patient with an elevation in blood pressure or with symptoms of hypertensive disease
• ____ is a valuable service because patients who are receiving treatment for hypertension may fail to achieve adequate control because of poor compliance
detection
monitoring
Dental management
• The primary concern in dental management of a patient with hypertension is that during the course of treatment, a sudden, acute elevation in blood pressure might occur, potentially leading to a serious outcome such as a ____ or myocardial infarction
• Such acute elevations may result from responses to ____ and anxiety, from epinephrine in the form of vasoconstriction in local anesthetics, or from the ____
• Two questions to consider before dental treatment is provided for a patient with hypertension
1. What are the associated ____ of treatment in this patient?
2. What level of ____ is treatment unsafe for the patient?
stroke stress gingival retraction cord risk BP
History
• History is crucial to the discovery of cardiac and/or comorbid diseases that would place the patient in a high surgical risk category
• Evaluate the cardiovascular system within the framework of the patient’s overall health; associated conditions may complicate cardiac management
- Pulmonary disease
- ____, hypercapnia, acidosis and increased work of breathing can lead to further deterioration of an already compromised cardiopulmonary system
- Diabetes mellitus
- ____ and myocardial ischemia are more likely in patients with diabetes mellitus
- Renal impairment
- ____ (high levels of urea) is commonly associated with cardiac disease and is associated with an increased risk of cardiovascular events
- Hematologic disorders
- ____ imposes a stress on the cardiovascular system that may exacerbate myocardial ischemia and aggravate heart failure
- Conditions that increase ____ may increase the risk of thromboembolism or hemorrhage
hypoxemia CAD azotemia anemia hypercoagulability
Guidelines
• The American Heart Association and the American College of Cardiology have published practice guidelines for the perioperative evaluation of patients with cardiovascular disease for whom noncardiac surgery of various types is planned
• The guidelines provide a framework to estimate the risk for occurrence of a stroke, myocardial infarction, acute heart failure, or sudden death as a result of surgery
• Oral and maxillofacial surgery ____ surgery
• These guidelines can also be applied to nonsurgical dental treatment
• Determination of risk includes the evaluation of:
- Risk imposed by the patient’s ____ disease
- Risk imposed by the____ or procedure
- Risk imposed by the functional reserve or ____ of the patient
noncardiac
cardiovascular
surgery
capacity
Risk from cardiovascular disease
• Risk imposed by the presence of a specific cardiovascular condition or disease is stratified into ____, intermediate, and minor risk categories
• Uncontrolled blood pressure is defined as ____ mmHg or greater, and is classified as a ____r risk condition
• Guidelines include a statement that blood pressure should be brought under ____ before any surgery is performed
• Recommends immediate referral for patients with blood pressure of 180/110 mmHg or higher depending on the presence or absence of symptoms
• Major risk factors?
major
180/110
minor
control
• Major risk factors:
◦ Any history of acute/recent ____
◦ Decompensated heart failure
◦ Significant ____ and valvular disease
• Intermediate risk factors:
◦ ____
◦ Diabetes
◦ ____
• Minor risk factors:
◦ Uncontrolled systemic ____
◦ Abnormal ____
• Taking these into consideration, can predict which of these patients will be in a higher risk during a non-cardiac surgical procedure
heart attack arrhythmias ischemic heart disease renal insufficiency hypertension EKG
Revised cardiac risk index
• Widely used risk calculator that includes six ____ predictors of complications:
• High ____ type of surgery, history of ____, history of ____, history of ____, preoperative treatment with ____, and preoperative serum creatinine concentration greater than ____ mg/dL
• Cardiac complication rates rise with an increasing number of these risk factors
• Patients are stratified into low, intermediate, or high cardiovascular risk on the basis of having 0, 1 or 2, or ____ or more factors included in the revised cardiac risk index, respectively
• The revised cardiac risk index has become the ____ tool for assessing the probability of perioperative cardiac risk in a given individual
independent risk ischemic heart disease congestive heart failure cerebrovascular disease insulin 2.0 3 standard
Risk from type of surgery or procedure
• Risk imposed by the type of surgery or procedure is stratified into high (>____% risk), intermediate (<5% risk) and low (
5 1 vascular blood loss intermediate low low
• Chart stratifying the different types of surgeries
◦ Most dental procedures are in the ____ category
◦ Implants in the ____ may increase the risk of complications
◦ Craniofacial reconstruction pushes the risk even higher
• [Question - cannot hear]
◦ Retraction cords are pre-soaked in ____
◦ Can get cords without epinephrine, but the epinephrine is ultimately the issue
low
lower anterior arch
epinephrine
Risk based on patient fitness
• Determination of the ability of patient to perform physical activities (____)
• The ability to perform common daily tasks can be expressed in ____ which quantify the body’s use of oxygen
• A MET is a unit of ____ consumption;1 MET = ____ mL of oxygen perk gof body weight per minute at rest
• It has been shown that risk for occurrence of a serious perioperative cardiovascular event increases in patients who are unable to meet a ____-MET demand during normal daily activity
• Daily activities requiring 4 METs include level ____ at 4 miles/hour or climbing a flight of ____
• Thus a patient who reports an inability to walk up a flight of stairs without shortness of breath, fatigue, or chest pain may be at increased risk for medical complications during ____ treatment, especially when such limitation is combined with other risk factors and the patient is under stress
functional capacity metabolic equivalents of tasks (METs) oxygen 3.5 4 walking stairs dental
Uncontrolled blood pressure
• Patients with uncontrolled blood pressure associated with symptoms such as headache, shortness of breath, or chest pain should be referred to a ____ for immediate evaluation
• Additional sign: Changes in ____, nausea (vomiting), muscle weakness, slurred speech
• For patients found to have asymptomatic blood pressure of 180/110 mmHg or greater, elective dental care should be ____, and a physician referral for evaluation and treatment within ____ week is indicated
• In patients with uncontrolled hypertension, certain problems such as pain, infection, or bleeding may necessitate ____ dental treatment
• Management in consultation with physician or referral to ____
physician vision deferred 1 urgent hospital dentistry
Orthostatic hypotension
• Decrease in systolic blood pressure of at least ____ mmHg or diastolic blood pressure of ____ mm Hg within ____ minutes of standing
• A person with orthostatic hypotension may experience ____ or syncope
• Avoid orthostatic hypotension by having patients sit ____ for a few minutes before standing from dental chair
20 10 3 light-headedness upright
Stress management
• Important for patients with hypertension to lessen the changes of endogenous release of ____, and the dentist should make every effort to reduce as much as possible the stress and anxiety associated with dental treatment
• ____ appointments seem best tolerated; if the patient becomes anxious or apprehensive during the visit, the appointment may be terminated and rescheduled for another day
catecholamines
short morning
Pharmacology
• Critical factor in providing an anxiety-free situation is the ____ established among the dentist, the office staff, and the patient
• Patients should be encouraged to express and discuss their ____, concerns, and questions about the dental treatment
• Anxiety can be reduced for many patients by oral premedication with a short-acting benzodiazepine such as ____, taken ____ hour before the start of the dental appointment
• ____ can be potentiated by the actions of anxiolytic and sedative drugs
• ____ for inhalation sedation is an excellent intraoperative anxiolytic for use in patients with hypertension
relationship fears triazolam 1 orthostatic hypotension nitrous oxide plus oxygen
Use of vasoconstrictors
• Profound local anesthesia is critical for pain and anxiety control, and is especially important for patients with hypertension
• Vasoconstrictors are used in combination with local anesthetics such as lidocaine during dental procedures to increase the ____ and effective of anesthesia, delays systemic absorption, and provides ____ during surgery
• Common question is if the use of local anesthetics with vasoconstrictor in a patient with hypertension could result in a potentially serious spike in blood pressure
duration
hemostasis
- The cardiovascular response to conventional doses of injected epinephrine, both in patients who are healthy and in those with hypertension, usually is of little ____ importance.
- Existing evidence indicates that the use of modest doses (____ cartridges of 2% lidocaine with 1:100,000 epinephrine) carries little clinical risk in patients with hypertension
- Use of more than this amount at one time may be tolerated but with increasing risk for adverse ____ change
clinical
one or two
hemodynamic
Contraindications
• ____ should be avoided in patients with hypertensions however because of its comparative excessive ____ stimulation
• The use of epinephrine generally is not advised in patients with uncontrolled hypertension; elective dental care should be ____
• A reasonable conclusion from the evidence is that the ____ of epinephrine outweigh the increased risks, so long as modest doses (e.g. 1 or 2 carpules) are used at one time and care is taken to avoid inadvertent intravascular injections.
levonordefrin
alpha1
deferred
benefits
Gingival retraction cords
• ____ is present in higher dosages in the epinephrine- impregnated gingival retraction cords used when taking an impression for a crown
• The amount of epinephrine in one retraction cord may be equivalent to ____ standard cartridges, and therefore has a higher theoretical risk of adverse cardiovascular events
• Using retraction cords that do not contain epinephrine should be considered for ____ patients
• One study reported that ____ (Visine), oxymetazoline (Afrin), and ____ (Neo-Synephrine) may be used to soak the cord, providing hemostatic effects similar to those obtained with epinephrine but with minimal cardiovascular effects. (Bowles et al. 1991)
epinephrine 12 high-risk tetrahydrozoline phenylephrine
Drug interactions
• The concern for use of nonselective beta-adrenergic blocking agents (e.g. propanolol) is that the normal compensatory vasodilatation of skeletal muscle vasculature mediated by ____ receptors is inhibited by these drugs
• The injection of epinephrine or levonordefrin may result in uncompensated peripheral vasoconstriction because of unopposed stimulation of ____ receptors
• Potential significant elevation in ____ and compensatory bradycardia
- The effect appears to be ____t, with the majority of adverse outcomes resulting when more than ____ carpules of local anesthetic with epinephrine were used
- Adverse interactions were less likely to occur in patients who take ____ beta-blockers and when ____ carpules or less are used (Hersh and Giannakopoulos 2010)
b2 alpha1 BP dose dependent 2 cardioselective less than 2
- Beta-blockers are generally not recommended as ____ therapy
- Nonselective
- ____, timolol, ____, sotalol (*ocular hypertension)
- Cardioselective
- ____, bisoprolol, ____, metoprolol, ____
- 1 to 2 carpules containing 1:100,000 epinephrine can be used safely even in patients taking ____ beta blocking agents
- ____ should be avoided
- ____ should be avoided
first-line propanolol levobunolol atenolol esmolol nebivolol nonselective levonordefrin gingival retraction cords
- Erythromycin and clarithromycin can exacerbate the hypotensive effect of ____ blockers and result in acute kidney injury (Gandhi et al. 2013)
- Calcium channel blockers are metabolized the cytochrome ____ and these antibiotics inhibit the metabolic activity
- Anxiolytics and sedative may be used for patients who take antihypertensive medications, with a reduced ____ especially in older adults
- The efficacy of antihypertensive drugs may be decreased by the prolonged use of ____
- The use of NSAIDs for a few ____ is of little clinical importance (Oates et al. 1988)
calcium channel P450 3A4 dosage NSAIDs days
• Orthostatic hypotension can be caused by antihypertensive medications that affect the autonomic nervous system (____), medications that cause vasodilation (____, hydralazine, calcium-channel blockers), and those that cause volume depletion (____)
clonidine and beta-blockers
terazosin
diuretics
Oral manifestations
• ____ and dental caries are the most commonly reported side effects of antihypertensives, such as ____, thiazide diuretics, ____, and clonidine
• Gingival hyperplasia seen most commonly in ____
• Risk factors seem to be increased plaque related gingival inflammation and the use of other drugs that cause ____ (i.e. cyclosporine, phenytoin)
- Dysgeusia (taste alteration) has been reported in the use of antihypertensive medications such as ____, acetazolamide, ____, and ACE inhibitors
- Lichenoid reactions have been reported in patients taking antihypertensive such as ____, thiazides, ____, captopril, ____
xerostomia ACE inhibitors loop diuretics calcium channel blockers gingival hyperplasia
beta blockers diltiazem beta blockers furosemide methyldopa
• Gingival hyperplasia
◦ Medications and poor ____
◦ Treatment: good ____, and in severe situations you will have removal of ____
◦ The tissue under biopsy doesn’t show anything ____
hygiene
cleaning
tissue
suspicious
• Lichenoid
◦ Looks like ____ on the mucosal tissues
◦ On buccal mucosa you have a lace-like manifestation of inflamed tissue
◦ Most likely it’s an ____ reaction of mucosal tissues of mouth
‣ Not on an ____ sense, but something about the medication seems to be driving this hyperactive inflammatory effect in mucosal tissues that manifests with this appearance
• Lichenoid lesions are a large category that can have ____ induced, ____ induced and an actual disease called ____
◦ By calling something lichenoid, you’re referring to something that has this spiderweb like manifestation
webbing allergic anaphylactic medication dental metal lichen planus
• List of adverse events that associate with antihypertensives
◦ Other than gingival hyperplasia and OH; ____ and ____ can see under other medications
‣ Helpful to look through the medications they’re taking, and it may help give you one
explanation why they have dry mouth/weird taste
dysgeusia
xerostomia
