CARE FOR HEART PATIENTS
I/ INTRODUCTION
The management of cardiopathic patients requires the dental doctor to collaborate with the cardiologist and have a perfect knowledge of the precautions intended to prevent the three major risks that these patients may incur, which are:
– the risk of infection,
– the risk of hemorrhage,
– and the risk of syncope.
A/THE RISK OF INFECTION
It is represented by bacterial endocarditis. This is an inflammation of the endocardium by bacteremia mainly affecting the heart valves and most often of infectious origin.
- ANATOMY
Heart valves are flexible membranous structures separating the four cavities of the myocardium and allowing a smooth and “one-way” circulation of blood inside the heart. When germs pass into the bloodstream (bacteremia), they will be able to adhere and colonize the surface of the valvular structures participating in the formation of friable masses of a few millimeters or centimeters called vegetations. From these vegetations, the infection can spread to the entire valve, generating anatomical lesions that alter the functioning of the valves.
- SYMPTOMS: Auscultation, echocardiography and blood culture.
- CAUSES AND FACTORS: fibrosis- calcifications and lipid deposits
- TREATMENT: Selective antibiotic therapy and/or valvular surgery
- PORTAL OF ENTRY AND BACTEREMIA: The oral portal of entry is the most important.
- RESPONSIBLE BACTERIA : Streptococcus viridans and Staphylococcus aureus.
- BACTERIAMIA: perhaps:
– physiological: determined by a trivial act such as chewing or brushing
– pathological: determined by an invasive therapeutic act. - PATIENTS AT RISK OF BACTERIAL ENDOCARDITIS:
CARE FOR HEART PATIENTS
- CONDUCT TO BE ADOPTED WHEN WATCHING A PATIENT AT RISK OF INFECTIOUS BACTERIAL ENDOCARDITIS
Currently, it is considered that only patients at high risk of infective endocarditis should receive antibiotic prophylaxis.
- PREVENTION OF ENDOCARDITIS
DEFINITION OF ACTS
NON-INVASIVE PROCEDURES
- conservative care
- bloodless prosthetic care
- remove stitches
- fitting or adjustment of orthodontic appliance
- taking intraoral dental x-rays.
INVASIVE PROCEDURES
All acts involving manipulation:
- of the gum
- of the pulp or periapical region of the tooth
- or in case of breach of the oral mucosa
- NB: the installation of a dam is an invasive procedure
(apart from local or locoregional anesthetics).
- GENERAL PRECAUTIONS
- If in doubt about the nature of the patient’s heart disease, the patient should contact the treating physician.
- in patients at high risk of infective bacterial endocarditis:
- some invasive procedures are contraindicated
- any authorized invasive procedure requires antibiotic prophylaxis
- take into consideration patients who are also on anticoagulants and antiplatelet agents
- ANTIBIOPROPHYLAXIS PROTOCOL :
In the hour before an invasive procedure, the patient must take: orally:
2 g of amoxicillin in adults;
50 mg/kg of amoxicillin in children.
NB: if allergic to penicillins:
600 mg clindamycin in adults,
20 mg/kg of clindamycin in children from 6 years old.
- PRECAUTIONS REGARDING ANESTHESIA
Intraligamentous anesthesia is contraindicated in patients at high risk of infective endocarditis.
- PRECAUTIONS REGARDING COMMON PRESCRIPTIONS IN DENTISTRY :
- no special precautions but take into consideration the patient’s medications as well as other associated pathologies
CONTRAINDICATED PROCEDURES: IN PATIENTS AT HIGH RISK OF INFECTIOUS ENDOCARDITIS
- Intraligamentous anesthesia
- Endodontic treatment on tooth with non-vital pulp
- Endodontic retreatment.
- The laying of the dam
- Endodontic treatment on teeth with living pulp in several sessions.
- Root amputation
- Pre-orthodontic surgery of impacted or impacted teeth.
- Periapical surgery
- Periodontal surgery,
- Implant surgery
- Installation of filling materials
- Transplantation and reimplantation
B/HEMORRHAGIC RISK: This concerns patients taking anticoagulants and antiplatelet drugs.
- ANTIPLATELET AGENTS (APA)
- MODE OF ACTION: Antiplatelet agents cause primary hemostasis disturbance at the level of the 03 phases (adhesion, activation and aggregation)
- MAIN INDICATIONS: Prevention of atherothrombotic events
- THE MAIN FAMILIES
CARE FOR HEART PATIENTS
- ORAL REPERCUSSIONS: Hemorrhagic lesions of the mucous membranes
- GENERAL CARE AND PRECAUTIONS
- Contact with the attending physician
- AAP treatment should not be modified or stopped regardless of planned oral care.
- Even if the risk of bleeding is increased, no biological test can assess it.
- The assessment of bleeding risk is based on:
The nature of AAP treatment
the nature of the act to be performed
the presence of another risk factor for bleeding (liver disease, thrombocytopenia, etc.)
- unless contraindicated, use an anesthetic with vasoconstrictor
CARE FOR HEART PATIENTS
- LOCAL HEMOSTASIS PROTOCOL
- Mandatory post-extraction curettage
- Placement of an intra-alveolar resorbable hemostatic material
- Sutures
- Immediate compression with a compress soaked in 5% tranexamic acid
- Compression splint or immediate removable prosthesis
- No mouthwash for 48 to 72 hours
- Do not smoke or drink alcohol for 48 hours.
- Checking mucosal healing after 7 to 10 days
SPECIAL CASE OF HIGH-DOSE ASPIRIN: Taking aspirin at a total daily dose of 500 mg responds to analgesic and/or antipyretic and/or inflammatory indications
It is advisable to stop treatment after 5 days if we take into account the haemostatic competence or after 10 days if we want the aspirin action to have completely disappeared.
- PRECAUTIONS REGARDING ANESTHESIA
- Locoregional anesthesia is not recommended due to the risk of expanding hematoma.
PRECAUTIONS REGARDING COMMON PRESCRIPTIONS:
NSAIDs are not recommended because there is an increased risk of ulceration and digestive hemorrhage.
Fluconazole (triflucan) is not recommended
- ANTIVITAMIN K ANTICOAGULANT AGENTS (AVK)
- MODE OF ACTION: These are substances which reduce the plasma concentration of vitamin-dependent coagulation factors (factors II, VII, IX and X). They then cause a disorder of the 2nd phase of hemostasis.
- DRUGS THAT DISRUPT COAGULATION :
- ANTI VITAMIN K (AVK): they interfere with the metabolism of vitamin K (X, IX, VII, II)
- Biological monitoring: carried out by an INR
- Different substances:
- Coumarinics: Sintrom®; Coumadin®; Apegmone®
- Indanedione derivatives: Préviscan®; Pindione®
Indications and Target INR
- MANAGEMENT OF PATIENTS ON AVK: according to (SFMBCB 2014 Recommendations)
- Contraindicated acts (absolute contraindications):
- Insufficient technical platform
- Mandibular foramen anesthesia
- Risk-free actions:
- Conservative care
- Supragingival prosthetic care
- Para apical, intra ligamentous and intra septal anesthesia
- Spragingival scaling
- Simple dental extraction: If INR<4. Continue treatment and local hemostasis
- Moderate risk acts
- Localized sector avulsions
- Single implant
- Surfacing
- CAT:
- INR less than 24 hours old and less than 4
- Local compression, hemostatic material
- Sutures
- Tranexamic acid
- High risk acts
- Cystic enucleation, endodontic surgery
- Avulsion of impacted teeth
- Avulsions > 3 teeth, in several quadrants
- Periodontal surgery
- Disinclusion Orthodontic surgery
- Local inflammatory state
- Multiple implants
- Avulsion of temporary teeth
- Tooth avulsion weakened periodontium
- Biopsies
- CAT:
IF INR < 4
- Local compression, hemostatic material
- Sutures
- Tranexamic acid
- Biological glue (hospital environment)
- Exceptional HBPM/HNF relay (contact doctor to define perioperative management)
IF INR > 4 : Reassess treatment
NOTE : In all cases, dental extractions must be carried out while maintaining AVKs.
- If impossible: we relay AVK with Heparin (HNF or LMWH)
- Rarely: Temporary discontinuation of AVKs
- NON-ANTIVITAMIN K ANTICOAGULANT AGENTS (HEPARINS)
- INDICATIONS : Stroke, acute ischemia of the lower limbs, prevention of venous thrombosis, DIC
- MECHANISM OF ACTION
- Antithrombotics and anticoagulants
- Acceleration of Factor Inhibition by Antithrombin
- TYPES OF HEPARIN:
- Unfractionated heparin: UFH
- Low molecular weight heparins: (LMWH)
- MANAGEMENT OF PATIENTS ON HEPARIN
- Low to moderate risk of bleeding: no window but act as far away as possible from the last injection
- High bleeding risk:
HNF: 6-8h window
HBPM: 24h window
C/ SYNCOPAL RISK:
- Definition of syncope: Syncope is a very short cardio-respiratory arrest with complete loss of consciousness occurring suddenly. In the event of syncope, the patient is immobile, pale, inert; but may also sometimes have a very short convulsive seizure. His breathing is non-existent and his pulse imperceptible.
- Heart diseases predisposing to the risk of syncope
– ischemic heart diseases,
– valvulopathies,
– congenital heart diseases,
– aortic valve stenosis… - Treatment of syncope: is preventive
- establish a good relationship with the patient by putting them at ease and avoiding stressful situations,
- resort to psychological preparation if the patient is reluctant to receive treatment,
- reduce stress by sedative premedication preferably based on benzodiazepines.
D/CONCLUSION: The management of cardiac patients must be based on close collaboration with the cardiologist. This doctor must be contacted before performing any diagnostic or therapeutic act in order to establish a thoughtful treatment plan taking into account the risks incurred by the patient. Furthermore, it is important to emphasize the importance of oral-dental and especially periodontal management of patients exposed to the risk of infection, which helps to reduce the rate of bacteremia caused by periodontal disease, and consequently to reduce the risk of endocarditis.
CARE FOR HEART PATIENTS
Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.