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BDS2 - Cardiovascular > Endocarditis > Flashcards

Endocarditis Flashcards

1
Q

what is infective endocarditis

A

infection of the endocardium

usually at the valves

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2
Q

how does infective endocarditis occur

A

bacteria travelling through the blood stream can settle on small thrombi that are produced by eddy currents and this allows platelets to adhere to damaged endothelial surfaces and therefore allows infected vegetations to build up

= microbial colonisation of thrombi on endocardial surface abnormalities

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3
Q

what organism in the mouth causes endocarditis

A

viridans group streptococci

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4
Q

what is rheumatic fever

A

an immunological reaction to a bacterial infection

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5
Q

what patients with rheumatic fever actually need prophylaxis

A

patients who has heart valve damage due to rheumatic fever = rheumatic heart disease

usually this was mitral valve disease

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6
Q

explain what is in the cycle of infective endocarditis

A

• Surface abnormalities
○ Starting point
○ Usually the abnormalities occur on valves or sometimes on the endocardium itself

• Haemodynamic changes
○ Blood flowing in abnormal ways

• Turbulence which then causes

• Platelet / fibrin deposition on the tissues (thrombus)
○ This thrombosis becomes colonised by bacteria travelling through the blood stream leading to a

  • Vegetation
  • Microbial attachment and multiplication

• Enlargement of vegetation
○ Causes damage to the tissue
○ Bacteria then can spread to the endocardium

then back to surface abnormalities

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7
Q

what is in the physical findings for the diagnosis of infective endocarditis

A

○ Fever

○ Heart murmur

○ Embolic phenomena
§ Eg splenic or renal infarction
§ Cerebral emboli

○ Skin manifestations
§ Eg Osler nodes,
§ Splinter haemorrhages
§ Petechiae

○ Splenomegaly

○ Septic complications
§ Eg pneumonia
§ Meningitis

○ Mycotic (infective) aneurysm

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8
Q

how do most endocarditis patients present

A

Many patients tend to have a mild flu like symptoms

Only get diagnosed when they develop a significant heart murmur or splinter haemorrhages

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9
Q

what are splinter haemorrhages

A

little emboli underneath the nail beds

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10
Q

what can the onset between dental procedures and infective endocarditis be

A

up to 6 weeks

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11
Q

what is bacteraemia

A

presence of bacteria in the blood

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12
Q

what is the effect of infective endocarditis

A

Prolonged antibiotic treatment
○ 4+ weeks of bactericidal treatment
○ Often combinations of drugs

Cardiac valve damage
○ Valve dysfunction
○ Urgent valve replacement needed

Significant risk of death from disease or its complications

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13
Q

how can at risk patients be identified

A

From the medical history and Prominent identification in case record

nearly impossible for dentist to detect a first episode risk patient
most patients who develop endocarditis have no previous history of any cardiac problem

these patients probably have an undetected cardiac structure defect that has never previously caused any complications

a patient who has had an episode of endocarditis can be identified and are susceptible to develoing another episode

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14
Q

is avoiding risk procedures a good way to avoid endocarditis in high risk patients

A

no
this method largely involves removing all of the patient’s teeth so that they required no dental intervention and this did not prevent the patient from developing endocarditis

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15
Q

what does the BSAC 2006 guidelines suggest for antibiotic prophylaxis

A

that patients who need antibiotic prophylaxis were only those who were at high risk of developing endocarditis

○ This included patients who
§ previously had infective endocarditis,
§ patients with cardiac valve replacements and
§ patients who had some surgically constructed pulmonary shunts or congenital heart problems

And if these patients were to be treated with any dental procedure involving the dento-gingival junction this was considered high risk

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16
Q

according to BSAC 2006 guidelines which cardiac patients are NOT a risk

A
  • Coronary artery bypass grafting
  • Angioplasty and stent insertion
  • Hypokinetic cardiac muscle segment (following a MI)
  • Implanted pacemaker
  • Implanted defibrillator
17
Q

according to BSAC 2006 guidelines which dental procedures are a risk

A
  • Extractions
  • Periodontal therapy
  • Implants
  • Restorations if the gingival margin is involved or a matrix band is used
18
Q

what do the NICE guidelines state with regards to antibiotic prophylaxis

A

• No indication of antibiotic prophylaxis
§ No benefit from prophylaxis in terms of risk reduction from endocarditis
§ Possible harm from ADR (adverse drug reaction) from the use of antibiotics

19
Q

what is a problem with the NICE guidelines

A

although they found a lack of evidence this is not the same as finding evidence of no risk

there is evidence to prove that no antibioitic prophylaixs causes an increase in the number of patients developing endocarditis and as a result more patients die
this is compared to the risk of patients having an adverse reaction to antibiotics which is much lower and the death rate much lower as well

20
Q

what do the NICE guidelines suggest to do instead of focusing on antibiotic prophylaxis

A 
dental efforts should be concentrated on reducing risk by reducing size and frequency of bacteraemia 
○ Improve patient's OH efforts
○ Remove areas of dental sepsis
	§ Unrestorable teeth
	§ Teeth causing infection
○ Work at prevention of oral disease
	§ Diet
	§ Hygiene
	§ High F content toothpaste

patients develop bacteraemia every time they eat, chew and brush their teeth and therefore small bacteraemia are frequent and normal throughout the day
○ These can be reduced by following the advice above to ensure there are no areas of plaque trapping or bacterial colonisation to the best extent

• The small number of high bacteraemia producing procedures caused by dental care was not any relevance when compared to the regular bacteraemia caused by dental use in a normal daily function

21
Q

what was added to the

NICE guidelines in 2016 and what affect did this have

A

antibiotic prophylaxis against infective endocarditis is not recommended routinely

routinely = important
Allows for situations where clinical need would outweigh the guidance recommendation
Gives more flexibility

22
Q

what dental issues arises from the NICE guidelines and how have these been overcome

A

How do dentists determine which patients should be offered antibiotic prophylaxis?
NICE gives no recommendation on which dental procedures should be covered
NICE gives no advice on the prophylaxis regime to be used

SDCEP gives advice based on NICE guidelines specifically for dentists

23
Q

what does Montgomery require with regards to prophylaxis

A

○ Consequences of antibiotic prophylaxis must be discussed
○ Consequences of no antibiotic prophylaxis must be discussed
○ For cases who are high risk undergoing invasive dental procedures = Dento-gingival manipulation

Patients need to be given the opportunity to look at the evidence themselves and decide for themselves whether the risk of allergy to the antibiotic is worth reducing the risk of endocarditis depending on their risk category

24
Q

how should the decision on prophylaxis be made clear from the patient to the dentist

A

• Made by patient and their physician
• Communicated to dentist in writing
Only for procedures likely to produce a significant bacteraemia = manipulation of dento-gingival junction

25
Q

what is the most useful way to reduce the endocarditis risk

A

○ Attendance for oral care
○ Rapid management infection
○ Maximal OH and prevention
○ Avoid risk activity - piercings

26
Q

what is the drug regime for antibiotic prophylaxis when it is indicated

A

• Amoxycillin 3g oral 1 hour before procedure - even if used recently

If the patient is allergic to penicillin
• Clindamycin 1.5g
○ Only use this if there is an allergy
○ Higher ADA risk

27
Q

what is the dentist’s role with regards to high risk patients and prophylaxis

A

• The patient should be risk assessed by the dentist based upon the medical history then discussed with the patient’s physician to arrive at a conclusion which is appropriate for that individual patient

The dentist’s role is to liaise with them and provide prophylaxis when it is required for appropriate dental procedures

28
Q

is antibiotic prophylaxis routinely recommended for people undergoing dental procedures

A

no

29
Q

what patients are deemed to be at an increased risk of developing infective endocarditis

A

○ Acquired valvular heart disease with stenosis or regurgitation

○ Hypertrophic cardiomyopathy

○ Previous infective endocarditis

○ Structural congenital heart disease

○ Valve replacement

30
Q

what patients are included in the sub-group for which special consideration for non-routine management is required

A

○ Patients with an prosthetic valve

○ Patients with a previous episode of infective endocarditis

○ Patients with congenital heart disease

this should be assessed in consultation with the patient’s cardiology consultant, cardiac surgeon or local cardiology centre

31
Q

what is defined as routine management

A

where invasive dental treatment is provided without antibiotic prophylaxis

32
Q

what advice and information should be given to a high risk patient

A

○ Potential benefits and risks of antibiotic prophylaxis and an explanation of how ABP is not routinely recommended

○ The importance of maintaining good oral health

○ Symptoms that may indicate infective endocarditis and when to seek expert advice

○ The risk of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing

record this discussion in the notes

33
Q

how should episodes of dental infection in high risk patients be treated

A

investigated and treated promptly to reduce risk of endocarditis developing

34
Q

if patient has decided they want antibiotic prophylaxis when should it be given

A

invasive dental procedures only

35
Q

what is included in invasive dental procedures

A

involve manipulation of the dento-gingival junction, the peri-apical region or perforation of the oral mucosa (excluding LA injection in non-infected soft tissues)

○ Placement of matrix bands
○ Placement of sub-gingival rubber dam clamps
○ Sub-gingival restorations including fixed prosthodontics
○ Endodontic treatment before apical stop has been established
○ PMCs
○ Full periodontal examinations (including pocket charting in diseased tissues)
○ RSD / sub-gingival scaling
○ Incision and drainage of abscess
○ Dental extractions
○ Surgery involving elevation of muco-periosteal flap or muco-gingival area
○ Placement of dental implants including temporary anchorage devices, mini-implants
○ Uncovering implant sub-structures

In addition ABP is not recommended following exfoliation of primary teeth or trauma to the lips or oral mucosa

36
Q

what is included in non-invasive dental procedures

A

○ Infiltration or block LA injections in non-infected soft tissues
○ BPE screening
○ Supra-gingival scale and polish
○ Supra-gingival restorations
○ Supra-gingival orthodontic bands and separators
○ Removal of sutures
○ Radiographs
○ Placement or adjustment of orthodontic or RPD appliances

BDS2 - Cardiovascular (3 decks)

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