Endocarditis

Question 1

what is infective endocarditis

Answer 1

infection of the endocardium

usually at the valves

Question 2

how does infective endocarditis occur

Answer 2

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

Question 3

what organism in the mouth causes endocarditis

Answer 3

viridans group streptococci

Question 4

what is rheumatic fever

Answer 4

an immunological reaction to a bacterial infection

Question 5

what patients with rheumatic fever actually need prophylaxis

Answer 5

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

usually this was mitral valve disease

Question 6

explain what is in the cycle of infective endocarditis

Answer 6

• 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

Question 7

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

Answer 7

○ 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

Question 8

how do most endocarditis patients present

Answer 8

Many patients tend to have a mild flu like symptoms

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

Question 9

what are splinter haemorrhages

Answer 9

little emboli underneath the nail beds

Question 10

what can the onset between dental procedures and infective endocarditis be

Answer 10

up to 6 weeks

Question 11

what is bacteraemia

Answer 11

presence of bacteria in the blood

Question 12

what is the effect of infective endocarditis

Answer 12

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

Question 13

how can at risk patients be identified

Answer 13

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

Question 14

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

Answer 14

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

Question 15

what does the BSAC 2006 guidelines suggest for antibiotic prophylaxis

Answer 15

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

Question 16

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

Answer 16

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

Question 17

according to BSAC 2006 guidelines which dental procedures are a risk

Answer 17

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

Question 18

what do the NICE guidelines state with regards to antibiotic prophylaxis

Answer 18

• 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

Question 19

what is a problem with the NICE guidelines

Answer 19

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

Question 20

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

Answer 20

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

Question 21

what was added to the

NICE guidelines in 2016 and what affect did this have

Answer 21

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

Question 22

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

Answer 22

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

Question 23

what does Montgomery require with regards to prophylaxis

Answer 23

○ 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

Question 24

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

Answer 24

• 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

Question 25

what is the most useful way to reduce the endocarditis risk

Answer 25

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

Question 26

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

Answer 26

• 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

Question 27

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

Answer 27

• 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

Question 28

is antibiotic prophylaxis routinely recommended for people undergoing dental procedures

Answer 28

no

Question 29

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

Answer 29

○ Acquired valvular heart disease with stenosis or regurgitation ○ Hypertrophic cardiomyopathy ○ Previous infective endocarditis ○ Structural congenital heart disease ○ Valve replacement

Question 30

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

Answer 30

○ 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

Question 31

what is defined as routine management

Answer 31

where invasive dental treatment is provided without antibiotic prophylaxis

Question 32

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

Answer 32

○ 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

Question 33

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

Answer 33

investigated and treated promptly to reduce risk of endocarditis developing

Question 34

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

Answer 34

invasive dental procedures only

Question 35

what is included in invasive dental procedures

Answer 35

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

Question 36

what is included in non-invasive dental procedures

Answer 36

○ 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