CONSERVATIVE DENTISTRY AND GENERAL DISEASES
Infective endocarditis, described by Osler in 1885, is defined as the consequence of a bacterial or fungal graft on the endocardium, which constitutes the innermost layer of the heart, in direct contact with the bloodstream.
II/ NATURE OF RISKS
There are 4 types:
1/ Infectious
2/ Hemorrhagic
3/ Syncopal
4/ Delayed healing
- Heart Diseases
1.1. Heart diseases presenting an infectious risk
a) Definition of endocarditis: this is a bacterial infection of the endocardium affecting the valves and more generally the endocardial wall. A distinction is made between acute endocarditis in a healthy heart and subacute endocarditis in an already damaged heart, or Osler’s endocarditis.
Two conditions must be met for the development of endocarditis.
1- A bacterial entry point into the circulation
2- A susceptible site. The predisposing lesion is not always known.
b) Consequences of endocarditis: appear once the bacteria are established: valvular destruction with perforations, worsen the condition of the valvular apparatus friable, septic vegetations which can fragment and migrate. Septic emboli will cause:
– infarctions by arterial obstruction
– aneynisms developing on the endothelium of the large vessels
– complex immunological phenomena which can cause skin and kidney lesions.
High-risk heart diseases:
-All valve prostheses without exception
-All cyanotic congenital heart diseases
-History of bacterial endocarditis
Medium-risk heart diseases:
-Valvuloplasties: aortic, mitral and tricuspid
-Non-cyanotic heart diseases
-Obstructive heart diseases.
Low-risk heart diseases:
-Hypertensive heart diseases
-Bypasses
-Pacifiers and pacemakers
-Acute rheumatic fever
-Thromboembolic diseases
-Ischemic heart diseases: infarction and angina
-Intercommunicable diseases
-Heart failure.
c) Oral manifestations: Chaput, Myall, and Gregory described these oral signs. They consist of small mucous petechiae that resemble red or purple macules that do not fade on pressure, and larger purpuric lesions.
Slightly raised, causing some discomfort. In fact. These signs are neither pathognomonic nor specific.
d) Precautions to take during treatment: The dentist participates in the treatment of endocarditis at two levels:
a- As a preventive measure: he must be fully aware of the various heart diseases at risk Oslerian. Any dental focus in a carrier of heart disease at risk must be treated under antibiotic cover classically started the day before the extractions and continued for 5 to 6 days. Depending on the case, the combination of bipenicillin (2MU) + streptomycin (1g) before the extraction and repeated for 3 days or monotherapy with ampicillin (4g) or amoxicillin (2g). is used. In case of allergy to β-Lactams, Clindamycin (600mg) or Pristinamycin (1g) will be used. Pediatric doses: amoxicillin 75mg/Kg, Clindamycin 15mg/Kg or Pristinamycin 25mg/Kg. It is essential to ask the patient to take his temperature morning and evening. The occurrence of a fever, or even a simple temperature difference in high-risk patients, should raise the diagnosis. The patient should then be sent to their cardiologist so that the diagnosis can be established and confirmed, in particular by blood cultures. -Avoid long interventions -Try to complete the work in a single session to avoid the inconvenience of too long an antibiotic prophylaxis and the appearance of bacterial resistance phenomena. -Otherwise, 2 antibiotics should be alternated -In case of ARF, the protocol to follow is that of Clindamycin or Pristinamycin -Abstain from any intervention in a subject who has had a myocardial infarction 3 months ago or endocarditis less than 6 months ago.
b- As a curative measure: given the frequency of streptococcal endocarditis of oral and dental origin, a careful dental examination is part of the assessment required in the case of endocarditis and any dental or periodontal infectious focus must be removed, otherwise the endocarditis will recur.
1.2. Heart diseases presenting a risk of hemorrhage
Anti-platelet agents: prevent the transformation of arachidonic acid into thromboxane. They affect the vascular and platelet time, thus prolonging the bleeding time, which in a normal subject is 2 to 4 minutes. Anti-vitamin K: anti-prothrombin. They aim to reduce the TP, which is responsible for the formation of red thrombus. The most commonly used anti-vitamin K agents are: Sintron and Pindlome. The TP in a normal subject is 70% to 100%, in a subject taking anti-vitamin K 25 to 45%. Heparin: it is an anti-thrombin that promotes fibrinolytic activity. TH: Howell time or clotting time of recalcified plasma at 37°C. In a normal subject, the TH is 1 minute 30 to 2 minutes, and in a subject taking heparin, it is 2 minutes 30 to 4 minutes 30. For these patients it is necessary to: -Collaborate with the treating physician by requesting specific hemostasis tests -It may be possible to consider: -stopping the anticoagulant treatment -modifying the dosage -continuing the treatment without any modification. -The dental surgeon must ensure good hemostasis during the procedure.
-48 hours are enough for the effect of reducing or stopping treatment to be reflected in the TP.
-The action of heparin lasts between 8 and 9 hours
1.3. Heart diseases presenting a risk of syncope
Risk present in patients with a rhythm disorder and high blood pressure. It manifests itself either by:
Lipothymia: a feeling of faintness, lightheadedness, blurred vision, temporary loss of consciousness, pallor and sweating.
Syncope: sudden loss of consciousness, rapidly reversible (less than 1 minute) due to diffuse cerebral hypoxia, it is accompanied by a sudden dissolution of muscle tone and an absent pulse.
To avoid this, good psychological preparation is required, and if necessary, sedative premedication: Atarax 3 doses/day 2 to 3 days before the procedure.
Cardiac pathologies presenting an osierian risk (descending order) table summarizing the antibiotic prophylaxis of
IE for dental care according to the recommendations issued by the 5th consensus conference on anti-infectious therapy
Pediatric dosages:
Amoxicillin75mg/Kg
Clindamycin 15 mg/Kg
Pristamycin 25mg/Kg
3/- Valvulopathies:
The dental surgeon will have to assess four risks:
*osieric
*hemorrhagic
*syncopal
*and risk of complication
Therefore: he can decide whether to carry out the treatment in a hospital setting or in the office
2/ blood diseases and vascular conditions
1°omemia:
CAT
iron deficiency, causes at the level of the oral cavity (a diffuse atrophy of the oral mucosa which becomes thin and pale aphthous ulcers on the tongue and the inner side of the cheeks … etc.
– the practitioner must take into account the delay in healing.
– a hemostasis assessment is essential
– prohibit aspirin in case of thrombopathies. and contact the treating physician
– no special precautions in cases of vitamin B12 and folic acid deficiencies otherwise avoid irritating substances (dental products and mouthwash
– a hemostasis assessment is essential
– prohibit aspirin in case of thrombopathies. and contact the treating physician
– no special precautions in cases of vitamin B12 and folic acid deficiencies otherwise avoid irritating substances (dental products and mouthwash
- bone marrow failure:
CAT
In these patients it is necessary to:
– only intervene after agreement from the hematologist
– request a blood test
– prescribe broad-spectrum antibiotics before any intervention.
a*hemophilia:
-prescribe sedative medication to compensate for the fibrinolytic action on the clot of anxiety or
stress
– use local rather than regional anesthesia
b*angloma:
corticosteroid therapy recommended in the treatment of subcutaneous angiomas must be taken into account.
c*purpura:
*request a hemostasis assessment
*obtain the opinion of the hematologist
*avoid prescribing penicillins, sulfonamides and pyrazoles in case of purpura
lymphoma medication :
*have the opinion of the hematologist before any procedure or prescription, the latter will specify the
premedications
*avoid brushing teeth and wearing prostheses in leukemia with bone marrow depression
*allow mouthwashes with 0.12% chlorhexidine gluconate.
3/NEUROPATHIES
3.1. *Epilepsy:
CAT
– Ensure that the patient takes their treatment regularly
– Use anesthetic solutions with vasoconstrictors sparingly
– Take into account the risk of potentiation of current medication by other drugs:
*Macrolides with tegretoi – risk of coma
*Miconazole with di hydan
– Prohibit the prescription of
neuroleptics: lowering of the epileptogenic threshold
3.2. *Essential facial neuralgia:
-The dental surgeon must in his prescriptions:
-avoid giving ATBs from the macrolide family because in association with carbamazepines they
can cause a coma
– take into account the antidepressants taken by the patient when choosing the anesthetic solution (without
adrenaline)
3.3*spasmophilia or hyperventilation syndrome:
CAT:
-In order to avoid a tetany attack during treatment, it is necessary to: -reassure the patient
– inject 1g of calcium IV or IM or 0.5 to 2g of calcium chloride IV or a benzodiazepine type
Valium IM 5410 mg
3.4*Multiple neurisms and mononeurisms:
4
/This is an attack on one or more nerve trunks.
CAT:
-The dental surgeon must consider the reduction in the threshold of vibration and pain sensitivity during
treatment. He must also take into account:
-orthostatic hypotension
-gastric and intestinal disorders (be careful with prescriptions
-reflexes which are reduced
- Psychopathies and psychiatries
4.1/Anxiety (anxiety neurosis):
CAT
-Work with the psychiatrist
-Some anxious people will undergo preventive therapy with antidepressants, so precautions must be
taken during anesthesia
-Relax the patient by removing the stress factor
-Have verbal communication with the patient
-Have precise gestures, do not show hesitation,
-Transient anxiety in the face of care will be prevented 1 hour before or 24 or 48 hours preoperatively by
benzodiazepines (diazepam-temesta 3mg/24h -valium 5 to 15 mg /24h) anxiolytics (atarax –
buspart – tenormine) in children teralene will be given at a rate of one dose in the evening for 48 hours
before the intervention, and one dose 1 hour before the intervention
-In the event of an acute crisis of anxiety, use injectable tranquilizers
-In the event of established anxiety, work with the attending physician.
4.2/Depression:
/It goes without saying that depression causes a whole series of disturbances in the
oral cavity, which the dental surgeon must not ignore and which he must treat taking into account
anti-depressant medications.
- Hepatobiliary disorders
5.1/Cirrhosis:
*Liver damage resulting in mutilating fibrosis .
CAT:
*The dental surgeon must recognize the
following oral changes in an alcoholic at an advanced stage:
– presence of jugal varicosities, tremulous tongue , characteristic breath, reactive keratosis,
candidiasis, glossitis, parotidomegaly and poor hygiene.
– He must ensure strict asepsis and antisepsis rules, especially in post-hepatic cirrhosis
– he must restore the oral cavity and expect anesthetic failures (kalemia and
natremia)
– he must consider the risk of infection, hemorrhage and metabolism, hence the need for a
biological assessment (FNS, TP, TCA, fibrinogen dosage), transaminase, gamma globulin
and transferase dosage).
-he must prescribe broad-spectrum antibiotics while avoiding hepatotoxic medications
as well as those that interfere with other medications.
-In sodium-free diets, alcoholic mouthwashes and effervescent forms.
5.2/Viral hepatitis:
-These are conditions characterized by damage to the liver parenchyma with an inflammatory reaction -There are 5 forms: A, B, D, C and G
CAT:
*Given the % of virus transmission (30% for B, 10% for C)
*The practitioner must only carry out essential care and must therefore: -work with gloves, a mask, glasses, a dam and use single-use equipment as much as possible.
*Remove aerosols, ultrasonic scalers and air polishers.
*Decontamination and sterilization of all dental unit equipment.
*Limit the use of any medication metabolized in the liver in terms of dose when possible
*Be up to date with your hepatitis B vaccination.
- PATIENTS WITH ENDOCRINE DISORDERS
6.1/ DIABETES
6.1.1: Definition: Diabetes is a pathological condition characterized by a disorder of carbohydrate metabolism accompanied biologically by hyperglycemia, glucosuria and acetonuria (sometimes).
6.1.2: Classification: they were previously clinical (diabetes in thin or obese subjects, in young subjects or in adults), therapeutic (insulin-dependent or non-insulin-dependent). Currently, they call upon physiopathological notions:
- Type 1 diabetes : is a disease with autoimmune components appearing in a predisposed environment (presence of certain genes dependent on the major histocompatibility system). These are subjects in whom signs of anti-Langerhans glia autoimmunity can be highlighted. It is approximately insulin-dependent diabetes.
- Type II diabetes : on the other hand, concerns subjects in whom there is no evidence of immunodeficiency. It includes the other types of diabetes. Overall, it corresponds to non-insulin-dependent diabetes.
CAT:
/if the non-insulin-dependent diabetes mellitus is well controlled:
-Dental care can be performed without an antibiotic prescription
-Local anesthesia may contain a vasoconstrictor
-Do not perform traumatic care under hypoglycemic sulfonamides, especially if the patient cannot eat (risk of hypoglycemia)
/if the diabetes is insulin-dependent and if the practitioner’s actions are traumatic:
-The patient must be under rapid-acting insulin.
-Do not operate under delayed-acting insulin, because the accident to be feared in these patients is hypoglycemia
-Never stop insulin.
/in case of hypoglycemia:
-Give three lumps of sugar to relieve the discomfort, otherwise give an intramuscular injection of 1mg of glucagon (active in 30 seconds)
/in case of profound hypoglycemia
-Inject 20cm3 of 30% hypertonic glucose serum.
6.2.*Adrenal cortex
These are very sensitive patients from a psychological and organic point of view with a tendency to diabetes, high blood pressure and heart disease. Any dental intervention must be carried out with the agreement of the treating physician, taking into account the risk of hemorrhage (hypertension) and possible fractures caused by osteoporosis.
6.3*Hyperthyroidism
-It is defined by the increase in the secretion of thyroid hormones
-The dental surgeon is attracted by:
*Goiter
*Exophthalmos
*Increased salivary flow
*Decreased lingual mobility
CAT:
-When treating these patients it will be necessary to:
*Prescribe antibiotics if exophthalmos is significant
*Use a sedative, check the blood pressure
*Avoid the use of an adrenaline anesthetic solution.
*Request a blood test
6.4*Hypothyroidism:
CAT:
-The simultaneous prescription of AIS and tetracyclines should be avoided, because endouterine contraception would be ineffective. It is necessary to:
-know that rifamycin reduces the effectiveness of low-dose contraceptives
- Dermatology:
CAT:
-The dental surgeon must consult the dermatologist and obtain his opinion before undertaking treatment or prescribing medication
-Look for infectious oral-dental foci and remove them
- Gastroenteric:
CAT:
*Request a blood test before any surgical intervention.
*Restore the oral cavity, remove infectious dental foci.
*Treat oral lesions with local (Bétneval buccal) or general corticosteroids.
*Avoid prescriptions for rectal or even oral administration.
*Ensure that a good occlusion is reestablished while preserving the remaining teeth and replacing missing teeth.
*Avoid the supine position when treating patients with a hiatal hernia.
*In case of duodenal and gastric ulcers *avoid prescribing NSAIDs, otherwise prescribe antiulcer drugs to be taken 2 hours before treatment.
9*Bone decalcification:
This is a decrease in bone calcium content.
CAT:
Generally speaking, it is necessary to:
– delay bone resorption as much as possible by preserving the dental organ, by preventive measures and by oral hygiene rules.
– Look for the etiology, possibly related
to hepatic, renal, digestive and endocrine pathology
– Take into account the risk of hemorrhage
– Take into account stress and prolonged hypocalcemia which can induce tetany and muscle spasm
- Myopathies:
CAT:
-patient in semi-sitting position
-take into account current drug therapy
-hemostasis - Nephropathies:
CAT:
The dental surgeon will have to adapt his drug prescription, particularly with regard to antibiotics and analgesics.
– macrolides have no contraindications
– b-lactams, flagyl and cephalosporins are a supplement after dialysis
– paracetamol is a supplement after dialysis, no changes for morphines and ANIS.
– local anesthetics do not present any renal toxicity at usual levels.
– sedatives will be prescribed with caution because their accumulation can lead to neurological and psychological disorders, or even a comatose state.
– The same applies to tetracyclines, fungisone, vancomycin. - Allergy: C AT: It is necessary
– To have an emergency kit in the office
– To know that this type of patient can have a serious or minor allergy to certain antibiotics, antiseptics, anti-inflammatories, mouthwashes, without forgetting latex, amalgams, resins, etc. - Pneumopathies:
1*Asthma:
CAT:
With these patients it is necessary to:
*contact the attending physician
*Careful questioning
*Avoid all allergenic medications
*Avoid macrolides, AI NS.
*Avoid anxiolytics
*Avoid penicillin
*Use anesthesia with vaso
*Plan psycho-sedative premedication
*Intervene under antibiotic therapy if the patient is on general corticosteroid therapy
8
*In case of crisis, spray with Ventolin
*Restore the oral cavity
14/Other conditions:
1*AIDS
CAT:
-2 risks: infectious and hemorrhagic: for this
*ask the opinion of the attending physician
*only intervene if the platelet count is greater than 50,000/mm3
*prescribe prophylactic antibiotic therapy before each procedure
*avoid any instrumental injury
*work with a mask, gloves, and glasses
*use single-use equipment
*in the event of an accidental wound, wash the wound with soap, rinse it, then disinfect it with alcohol
*disinfection of instruments with 12° sodium hypochlorite for 1 hour, 70° alcohol for 10 minutes or even glutaraldehyde
2*drug addiction:
CAT:
*Take into account numerous mental disorders
*Establish a quality therapeutic relationship during care
*Request a blood test
*Prescribe sedatives before any procedure
*Carry out short-term care
*Prescribe simple analgesics
*Take into account the risk of hepatitis and AIDS
3*ETHYLISM:
CAT:
*Administer local anesthesia with or without adrenaline
*Avoid weaning the patient before treatment, ensuring that he is not fasting
*Perform local hemostasis
*Prescribe antibiotics postoperatively
4*Syphilis:
CAT:
As this is a contagious disease, the usual precautionary measures will be taken, as well as a limitation of dental care if the patient is undergoing treatment.
5*Tuberculosis:
CAT:
*Avoid overdoses of anesthetic solutions
*Avoid hepatotoxic medications
*Avoid prescribing aminoglycosides
- Special physiological cases:
1*Menstruation:
*The majority of women experience instability during this period which leads to the prescription of sedatives.
9
- It should be noted, however, that there are no contraindications to intervention and no risk
of hemorrhage.
2*Contraception:
It will be necessary to:
-avoid all medications which would have an interaction with contraceptives
-avoid rifamycin, which reduces the effectiveness of low-dose contraceptives -avoid tetracyclines, AIS or NSAIDs.
3*Brush:
*only undertake treatment if the patient’s physical condition and the age of the pregnancy allow it
*perform short and gentle sessions
*place the patient in left lateral decubitus
*if surgery is necessary, it is preferable to intervene after the 3rd month and before the 9th month
*reassure the patient
*choose the least toxic anesthesia and avoid those of the para group
*the addition of vasoconstrictor is not recommended
*if an X-ray proves necessary, it will only be carried out if the patient’s pelvis is protected by a lead apron.
4*menopause:
*when treating these patients, it will be necessary to take into account their psychological state and, above all, assess the risks of possible bone fractures.
III/ conclusion Every
dental surgeon is expected to:
*know without fail and master all the procedures to follow when dealing with any patient presenting with a high-risk illness
*protect themselves from patients who are unaware of their health status while respecting the rules of asepsis
*always work in close collaboration with the treating physician
*be aware of any possible drug interaction
—to preserve the lives of their patients as much as possible, as well as their own
CONSERVATIVE DENTISTRY AND GENERAL DISEASES
Wisdom teeth can cause pain if they erupt crooked.
Ceramic crowns offer a natural appearance and great strength.
Bleeding gums when brushing may indicate gingivitis.
Short orthodontic treatments quickly correct minor misalignments.
Composite dental fillings are discreet and long-lasting.
Interdental brushes are essential for cleaning narrow spaces.
A vitamin-rich diet strengthens teeth and gums.