CADIOPATHY IN ODONTOSTOMATOLOGY

CADIOPATHY IN ODONTOSTOMATOLOGY

I. INTRODUCTION

The management of a patient suffering from heart disease warns the odontostomatologist, for the prevention of 03 major risks envisaged:

→ The risk of infection;

→ The risk of hemorrhage;

→ The risk of syncope.

2. ANATOMICAL REMINDER

The heart is a hollow muscle called the myocardium , which divides into four chambers: two atria and two ventricles .

The right chambers are separated from the left chambers by the interatrial and interventricular septa , so that the heart appears to consist of two independent halves: the right heart and the left heart .

• The wall: formed of three layers: the pericardium, the myocardium, the endocardium.
• The right heart: is formed by an atrium and a ventricle separated by the tricuspid apparatus . The right atrium receives the superior and inferior vena cavae and the coronary sinus. The right ventricle is separated from the pulmonary artery by the sigmoid valves.
• The left heart: the atrium and ventricle are separated by the mitral apparatus . The left atrium receives the pulmonary veins through its four angles.

The left ventricle is a cone whose base is occupied behind by the mitral orifice, in front by the aortic orifice.

Figure 1 : Anatomies of the Heart

3. RISK OF INFECTION
4. Infective endocarditis

It is the fixation and multiplication of an infectious agent at the level of the internal tunic of the heart; the germ coming from a variable entry point is carried to the heart by the blood.

Most often occurs on a previously injured endocardium.

2. Pathogenesis

Mucosal or cutaneous breach The germs graft onto the endocardium

The platelets sit on the lesion

Fibrin deposits form, creating vegetations of varying size and dimensions.

3. Bacteriology

The main germs involved are:

• Hemolytic streptococci and enterococci (60%).
• Staphylococci (25%).
• Gram-negative bacilli.
• Rarely yeasts.

4. Entrance doors

The incidence of bacteremia is estimated during dental care between:

• 18 – 85% for dental extractions.
• 60 – 90% for periodontal surgery.
• 7 – 82% for descaling.

5. Diagnosis
   • Clinical signs:
   • Infectious syndrome.
   • Presence of a breath.
   • Other signs: purpura, hematuria.
   • Additional examinations: FNS, VS >100.
   • Blood cultures.
6. Classification of heart disease according to Oslerian risk

Table I: Classification of heart disease according to the risk of infective endocarditis (IE)

High-risk heart disease	High-risk heart disease
Prosthetic valves Cyanotic congenital heart disease History of infective endocarditis	Valvulopathies Non-cyanotic congenital heart diseases Hypertrophic obstructive heart diseases

7. How to prevent an IE
   • Removal of all intra-oral infectious foci.
   • Need for preventive antibiotic therapy for all oral procedures likely to induce bacteremia.
   • Oral hygiene.
8. Practical methods of prevention

Concerning oral and dental procedures:

• In high-risk patients: treatment must be radical: Dental extraction under antibiotic prophylaxis according to the protocol described in Table II.
• In patients at risk:

Root canal treatments can be undertaken under ATB, under 04 conditions :

1. Strict asepsis (dam).
2. The entire endodontium is easily accessible.
3. No apical overhang of the dough
4. That the root canal treatment is carried out in a single session .

• Procedures that do not pose a risk of infective endocarditis, for example: taking impressions, dentin treatment (non-bloody procedures), must be performed without any special precautions in at-risk and high-risk patients.

9. Regarding antibiotic prophylaxis :

Table II: Antibiotic prophylaxis of IE during dental care and procedures involving the upper respiratory tract “outpatient care”

	Product	Dosage and route of administration (single dose 1/2 hour before)
No allergy to β-lactams	Amoxicillin	Adult: 2g orally Child: 75 mg/kg orally
β-lactam allergy	Pristinamycin or Clindamycin	Adult: 1g orally Child: 25 mg/kg orally
		Adult: 600mg orally Child: 15 mg/kg orally

• 2021 Antibiotic Prophylaxis Update

According to the American Heart Association.

The first drug of choice in case of penicillin allergy is azithromycin and not clindamycin: 500mg before tooth extraction .

• Special cases

→ Patient with acute rheumatic fever (ARF):

Antibiotic prophylaxis with Clindamycin or Pristinamycin (possibility of resistance).

→ If the treatment requires several appointments:

Perform as many acts as possible in each session, otherwise they should be spaced at least a week apart.

4. HEMORRHAGIC RISK

In dental medicine, practitioners are increasingly confronted with patients undergoing anticoagulant and antiplatelet treatments: Drugs that hinder hemostasis; Hemorrhagic accidents dominate the complications linked to their use.

1. Patients on anticoagulants
   1. Classification of anticoagulants

• Anti-vitamin K.
• Heparins.

The aim of anticoagulant treatment is to achieve hypocoagulability which may be:

• For preventive purposes: in subjects at risk of thromboembolic disease;
• For curative purposes: to limit the spread of an already established thrombosis.

1. Anti vitamin K
   • Among AVKs, only acecoumarol – Sintrom® is currently marketed and prescribed in Algeria.
   • AVK treatment is monitored by the Quick time expressed as INR (International Normalized Ratio).
   • The therapeutic zone is between 2 and 4.5 or a TP between 25 and 35. (Note that a normal INR = 1).

INR = ( patient TQ ) x Isi

TQ witness

• ISI=International Sensitivity Index. (Correction coefficient)
• INR therapeutic areas:

These therapeutic zones were established taking into account the thrombotic risk and the desired hypocoagulability:

→ Zone 1: “moderate anticoagulation” the INR must be between 2 and 3.

→ Zone 2: “high anticoagulation” the INR must be between 3 and 4.5.

*Please note that:

→ An insufficient dose of AVK is useless and exposes you to the risk of thrombosis;

→ An excessive dose of AVK exposes you to the risk of hemorrhage.

2. Heparins

• Heparins are indicated when other AVKs prove ineffective or when they are contraindicated or as a relay.
  • Their action: opposes the transformation of fibrinogen into fibrin.
  • Effectiveness time: immediate action, within the first 5 minutes.

2. How to prevent the risk of bleeding in oral surgery in a patient taking AVK:

-Assessment of the risk of hemorrhage, course of action depending on the type of procedure to be performed.

Procedure without hemorrhagic risk ° Conservative care ° Supragingival prosthetic care ° Para-apical, intra-ligamentous or intra-septal anesthesia.	Action to be taken No specific measures other than taking into account the possible risk of infection (prevention of endocarditis)
Procedure with moderate hemorrhagic risk ° Avulsion in localized sector ° Single implant ° Surfacing	Procedure °Local intra-alveolar compression with hemostatic material.°Sutures° Tranexamic acid (compression or passive rinsing)°Biological glue recommended if the INR is greater than 3
Procedures with high hemorrhagic risk ° Avulsion of more than three teeth ° Avulsion in different quadrants ° Periodontal surgery ° Disinclusion with surgical-endodontic traction ° Avulsion of temporary teeth ° Avulsion of teeth with weakened periodontium ° Avulsion in an inflammatory zone ° Avulsion of impacted teeth ° Multiple implants ° Cystic enucleations and apical surgery ° Biopsy	Action to be taken If the INR is less than or equal to 3: °Local intra-alveolar compression with hemostatic material.°Sutures.°Biological glue recommended.°Tranexamic acid (compression or passive rinsing) If the INR is greater than 3: °Management in a hospital environment°Local intra-alveolar compression with hemostatic material.°Sutures.°Systematic biological glue.°Tranexamic acid (compression or passive rinsing)
Contraindicated procedures °Free gingival graft°Contraindicated procedures according to the consensus conference on the prevention of infectious endocarditis if these measures are required.°All procedures presenting a risk of hemorrhage in cases where the technical platform available to the practitioner is insufficient.

2. Patient on antiplatelet drugs

Antiplatelet agents (APA): SFMBCB 2018 Recommendations.

• APAs are used to prevent or limit arterial thrombosis that complicates atherosclerosis
• They are administered orally and are often prescribed as part of long-term treatment.
• APAs are substances that inhibit primary hemostasis: They prevent platelets from adhering to vessel walls and oppose their aggregation; they directly interfere with dental care or surgical intervention.
• All antiplatelet drugs present a risk of bleeding.
• Only Aspirin®, Catalgine®, Aspégic®, Plavix® and Persantine® are available in Algeria.

1. Conditions for caring for patients under AAP:

– Stopping AAP treatment :

Even for a short time is responsible for an atherothrombotic event (acute coronary syndromes, strokes).

-Continuation of treatment with AAP :

During dental care or oral or periodontal surgery, it helps continue to prevent the risk of thromboembolism associated with cardiovascular disease.

In return, this therapeutic approach exposes to a perioperative hemorrhagic risk which is considered low and of good prognosis, when hemostasis measures are taken . (Therefore no treatment discontinuation in patients under AAP in the event of dental extraction).

3. Patient care on AAP or AVK during dental care or oral surgery

→ The medico-legal aspect:

• Informed consent from the patient must be obtained.
• The patient’s file must be regularly updated (recent shuttle sheet less than 6 months old).
• Biological tests are kept as well as copies of prescriptions.
• A panoramic pre-operative X-ray is essential.
• Each intervention gives rise to an operational report including the products used.

→ The patient assessment aims to:

• To research and identify factors likely to increase bleeding;
• To assess medical risk;
• To assess the patient’s degree of autonomy and cooperation.
• Patient on AVK: Prescription of a 24-hour INR between 2 and 4.5.
• Patient on AAP: Prescribing a bleeding time (BT) preoperatively is unnecessary. The assessment of bleeding risk is essentially based on medical history and clinical examination.
• It is best to schedule the procedure in the morning, at the beginning of the week, in order to control any post-operative bleeding and keep the patient until the bleeding stops.
• The patient must be accompanied, live less than an hour from the hospital, be able to follow medical prescriptions and have sufficient understanding of what is being proposed.
• If these criteria are not met, the procedure will be performed during hospitalization.

→ Anesthesia:

• Continuing treatment with AVK or AAP does not contraindicate:
• Performing local anesthesia (LA): It can be done para-apically or intraligamentously.
• In the absence of contraindications, local anesthesia should contain a vasoconstrictor.
• A slow injection helps limit tissue trauma.
• Locoregional anesthesia of the dental nerve is not recommended in order to prevent the risk of pharyngeal hematoma.

→ The surgical phase must be atraumatic

• The bony septa must be regularized as well as the mucous edges.
• Granulomas or cysts must be curetted completely.

→ Surgical hemostasis:

* Immediate or extrinsic compression :

• Initial compression of the site using a compress will be systematically carried out post-operatively until the hemorrhagic oozing has disappeared, it will be supplemented by intrinsic compression.
  • Intrinsic compression :
• A local resorbable hemostatic agent must be put in place, this can be native collagen (pangen, hemocollagen, biocollagen, etc.) or oxidized cellulose derivatives represented by

Surgicel®. It has the advantage of promoting clot formation. This will be followed by mucosal closure, which will be as watertight as possible.

• Sutures :

Wounds must be sutured: (The sutures can be absorbable or not (silk, polyamide, polypropylene) with separate single stitches. Overlock stitches should be avoided, as the risk of bleeding is greater if the stitches come loose.

• In case of persistent postoperative bleeding:

It is recommended to perform postoperative local compression using a compress soaked in tranexamic acid for at least 10 minutes.

* Surgical glues

• As indicated: A biological glue will be used in addition to the local hemostatic agent and sutures.

* gutters : prepared extemporaneously with a heavy silicone (OPTOSIL)

→ Postoperative monitoring:

• Written postoperative advice and instructions on how to handle postoperative bleeding are recommended.
• It is mandatory knowing that the 3 days following the surgical procedure represent the postoperative period which carries the greatest risk of bleeding: the patient must be warned of this and the slightest persistent bleeding must lead them to consult.
• Post-operative phase: clear instructions must be given to the patient:

• Protect the clot for the first 3 hours by staying calm.
• An ice pack: applied immediately after surgery (D1): (Apply the ice pack for 10 minutes per hour for 3 hours following surgery.)
• Do not rinse your mouth for the first 24 hours.
• Do not disturb the clot by sucking movements.
• Do not smoke or drink alcohol: alcohol and tobacco should be avoided due to the delay in healing they can cause.
• Do not eat or drink too hot food for the first few days: Soft or even liquid food that is rather cold: necessary for about a week.
• If bleeding resumes, local compression using a compress soaked in tranexamic acid for at least 10 minutes should be applied.

• A follow-up consultation in 24-48 hours or a simple telephone contact is recommended to check that post-operative advice is being followed correctly.
• Bleeding complications in the event of continued treatment with AVK or APA are rare and often have a good prognosis; curative treatment of a bleeding complication is based on surgical resumption of hemostasis.
• The removal of the gutter can be carried out as soon as the progress of healing has been clinically observed.

→ Post-operative drug prescriptions:

• Pain control will be achieved by using paracetamol as a first-line treatment;
• Opioid derivatives may be prescribed;
• Acetyl salicylic acid is contraindicated;
• Nonsteroidal anti-inflammatory drugs should not be used for pain relief;
• If an anti-inflammatory prescription is necessary:

short-term corticosteroids: in the absence of contraindications, should be preferred to NSAIDs

: (Solupred 20 mg, 1 mg/Kg for 03 days.)

• Prescribing antibiotic prophylaxis for the prevention of infective endocarditis does not interact with hemostasis;
• Antibiotics may be prescribed post-surgically: in certain cases: risk of infection, significant surgical trauma, lack of hygiene, immunosuppression, certain metabolic conditions, etc.
• Metronidazole interacts with AVKs and should be avoided.

5. SYNCOPAL RISK

Syncope is defined as a total loss of consciousness due to a lack of cerebral irrigation; it is linked to cerebral anoxia which is secondary to cardiac inhibition.

1. Mechanisms

Syncope can result from:

• Either, from a sudden insufficiency of cardiac output.
• Or, a vasovagal reflex: Violent pain, stress, can cause excitation of the fibers of the vagus nerve which would be responsible for syncope in patients with particular heart diseases.

2. Clinical signs

Among these signs:

• Complete loss of consciousness.
• Sudden intense pallor with cyanosis of the face;
• Slowing or even cardiac arrest, no pulse, inaudible heart sounds, uncontrollable blood pressure.
• Stop movements.
• Bilateral mydriasis.

3. Heart disease with a risk of syncope

Certain cardiovascular conditions can expose the patient to simple lipothymic discomfort, but also to the risk of syncopal symptoms:

• Rhythm disorders.
• Heart diseases that impair left ventricular ejection: Aortic stenosis, obstructive cardiomyopathy of the left ventricle.
• Heart disease obstructing the mitral orifice.
• Wearers of valve prostheses.
• Coronary ischemic heart disease: Angina attack, myocardial infarction.

4. Prevention of cardio-respiratory ailments
   1. Preventive behaviors
      • Place the patient in a position of maximum relaxation;
      • Psychological preparation of the patient: In a calm environment. Inform the patient, through a simplified explanation of the care that must be provided;

• The anamnesis:
  • Collect information from the patient regarding their pathological and medication history;
  • Contact the attending physician who must specify the pathology, quantify the risks and the treatments undergone or in progress (shuttle sheet);
• Pick up in the morning, after a good night’s sleep;
• Sessions as short as possible;
• Check your blood pressure;
• Limit factors that contribute to discomfort during treatment: Fasting; a belt and a tight collar can exert pressure on the carotid sinus, thus hindering breathing

;

• Abrupt standing up can lead to orthostatic hypotension during treatment with hypotensive drugs.

2. Premedication

Anxiety experienced during dental care sometimes requires premedication.

• Prescription of pain relief medication: to promote sedation of pain even before it appears:

Paracetamol® 500mg, taken as 2 tablets on the morning of the dental procedure. This prescription can be continued for 2 to 3 days after the procedure, depending on the case.

• Prescription of sedative medication: to limit stress, anxiety and possible vagal discomfort:
• Hydroxyzine: Atarax®
• Atarax® 25mg tablets: Adults: 1 to 2 tablets the day before and in the morning.
• Atarax® syrup 200mg/100ml: Child: 1 to 2 teaspoons (10 to 20mg) the day before and in the morning;

3. Anesthesia
   • The anesthetic product must be lukewarm;
   • Choosing the injection site: Avoid areas that are too vascularized. Endovascular injection increases the risk of product toxicity;
   • Slow administration (1ml/minute) and in a fractional manner limits the speed of penetration and tissue diffusion of the product, the pain will be reduced; on the other hand this allows the harmful effects of the injection to be monitored;

• The presence of a vasoconstrictor allows local anesthesia to counteract the massive release of endogenous catecholamines that takes place in any poorly anesthetized patient;
• The dose of adrenaline should be limited to 0.04 mg , knowing that one cartridge of anesthetic containing adrenaline at a concentration of 1/200,000 contains 0.01 mg of adrenaline. (do not exceed 4 cartridges)
• Contraindications of vasoconstrictors:

The use of vasoconstrictors is strictly contraindicated in certain clinical situations considered unstable. These pathologies include:

• Unstable angina;
• Recent myocardial infarction (A minimum period of 3 to 6 months must be observed before dental treatment).
• Coronary artery bypass surgery (Vasoconstrictors are contraindicated in the first 3 months following coronary artery bypass surgery).
• Poorly controlled heart failure.

5. What to do when you faint
   • Stop all treatment;
   • Immediately lay the patient down in a downward position, head low, clothes open;
   • With the subject lying down, feel the pulse, note the diastolic and systolic pressure and check the respiratory movements; if these 3 elements are almost normal, the discomfort is not serious. Otherwise:
   • Start artificial ventilation;
   • Immediately initiate external cardiac massage;
   • Call a medical team.

CONCLUSION

Interdisciplinary cooperation between cardiologists and dentists is essential, and when treatment is implemented methodically and rigorously, the dentist can therefore avoid complications with a dire prognosis .

CADIOPATHY IN ODONTOSTOMATOLOGY

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Dental veneers camouflage imperfections such as stains or spaces.
Misaligned teeth can cause digestive problems.
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Decayed baby teeth can affect the health of permanent teeth.
A soft-bristled toothbrush protects enamel and sensitive gums.
 

CADIOPATHY IN ODONTOSTOMATOLOGY