GENERAL DISEASES AND CONSERVATIVE DENTISTRY ENDODONTICS

Introduction :

The dental practitioner is confronted daily with patients with different types of general pathologies.
Any action, whatever its nature, must be adapted to the physiological (pregnancy), pathophysiological (allergy) and “therapeutic” (drug interactions) background of the patient.
Knowledge of the terrain effectively allows the practitioner to take the necessary precautions in order to preserve the organic and/or functional integrity of his patient.
Inadequate consideration of such history can in some cases lead to potentially fatal accidents.
The practitioner must therefore take into consideration the general condition, medical and surgical history as well as current treatments;
Consider the relationships between the general condition and pulpal and periapical pathologies, knowing that these can lead to inflammatory and infectious complications “local, regional or distant” “focal infection theory”.
On the endodontic level, decision-making takes into account the act itself but also the functional and strategic future of the tooth.
We are not going to make an exhaustive list of all the pathologies but of those encountered most often by the dentist.
- Concept of Bacteremia:

Bacteremia is defined as the presence of bacteria in the blood. Oral flora is extremely diverse: more than 700 species.
This flora is not uniform, it differs according to the oral-dental areas and is organized into biofilms.

These bacteria can therefore, during a dental procedure but also during daily activities (chewing, brushing teeth, flossing), pass into the bloodstream.

In order to quantify these bacteremias, it is necessary to note their duration, frequency and intensity.

Endodontic treatments generate low bacteremia, particularly compared to extractions and periodontal care.
On the other hand, everyday activities (brushing, chewing) have a higher probability of triggering it.
These so-called high-risk procedures are not likely to cause problems in the general population . However, they can create or increase a problem in a so-called high-risk patient.

… “ SEE FOCAL INFECTIONS COURSE”

I – Conservative dentistry Endodontics and heart disease:

Heart disease can expose you to three risks: infection, hemorrhagic risk, and syncope.

The risk of bleeding:

Anticoagulants are prescribed for preventive and curative purposes in patients at risk of arterial or venous thrombosis.

Biological monitoring of anticoagulant therapy :

To standardize results, the WHO recommends the use of the INR (International Normalized Ratio).

The latter must be:

Recent, care eve; Must meet therapeutic areas.

The trunk at the Spix’s spine should be avoided.
Certain drug combinations with anticoagulants should be avoided: such as barbiturates which reduce the anticoagulant effect and anti-inflammatories as well as salicylic acids which potentiate their effect.
Key takeaways: consensus:
“Continuing treatment with AVKs or AAPs does not contraindicate the practice of conservative dental care, surgical or non-surgical periodontal care

.surgical, oral or implant surgery, when local hemostasis measures are judiciously applied”.

The risk of syncopation:

To avoid this type of discomfort, you must:

Properly install the patient,
Establish a good patient-practitioner relationship,
Reduce anxiety, and assess the patient’s level of anxiety,
Possible postponement if the conditions are not met,
Premedication as needed:
- Analgesic purpose: Paracetamol® 500mg,
- Sedative and tranquilizing purpose: Valium® 2mg,
- Anxiolytic purpose; Hydroxyzine = Atarax® 25mg.
Limit the factors that contribute to discomfort:
- Fasting / Heat: ventilation / Tight collar and belt / Sudden change of position.
Contraindications of vasoconstrictors:
- Unstable angina : increased cardiac output
- Recent myocardial infarction: electrical instability (3-6 months);
- Coronary artery bypass surgery: ischemia, ventricular arrhythmias, etc. (3 months)
- Refractory arrhythmias : tachycardias, ventricular fibrillations, high risk of sudden death
- Poorly controlled high blood pressure: increased systolic pressure
- Poorly controlled heart failure: high risk of ventricular arrhythmias

Infectious risk “Infective endocarditis”:

To date, the cardiac repercussions of endodontic procedures have still not been scientifically demonstrated and further clinical research is still necessary to confirm or refute this hypothesis.

Diagnosis of infective endocarditis:

May be clinically suspected in the following situations:

Appearance of a new heart murmur;
Embolic event of unknown cause;
Bacteremia of unknown cause;
Fever, especially in the presence of intracardiac prosthetic equipment (valve, pacemaker, defibrillator)
History of endocarditis.
History of congenital valvular or heart disease.

Bacteremia and endocarditis:

It was observed that spontaneous bacteremia was certainly low and limited in time but occurred several times a day and therefore very frequently; this emphasizes the importance of maintaining oral hygiene and regular monitoring.

Even if divergences remain, all these recommendations come together on three points:

Antibiotic prophylaxis should be limited to patients at high risk of endocarditis;
Good oral hygiene and regular follow-up are key elements in the prevention of IE;
The widespread prescription of prophylactic antibiotics is no longer relevant.

Principles of the new recommendations: Distinguish between at-risk patients and at-risk procedures.

Patients at risk:
- Wearer of a prosthetic valve or prosthetic valve repair material.
- History of infective endocarditis.
- Carriers of cyanotic congenital heart disease:
  - Unoperated or systemic pulmonary surgical bypass.
  - Operated on, but with a residual shunt.
  - Operated with placement of prosthetic material, without residual leakage within 06 “six” months.
  - Operated with placement of prosthetic material by surgical or transcutaneous route with residual shunt.

NON-RISKY DENTISTRY PROCEDURES;
- Preventive actions “fluoride application; sealing of furrows”
- Dentin capping without risk of gingival injury.
- Post-operative suture removal.
- Dental x-rays.
RISKY DENTISTRY PROCEDURES:
- Truncal anesthesia
- Endodontic treatments, rubber dam placement; treatment of teeth with vital pulp.
High-risk dental procedures
- Surgical procedures “apical resection; root amputation”
- Intraligamentary anesthesia.
- Endodontic treatment “with non-vital pulp; treatment restart”.

ANTIBIOPROPHYLAXIS FOR EI	Adult	Child	Single socket per Os
Amoxicillin	2 g	50 mg/KG	30 to 60 minutes before the act.
B-lactam allergy: ClindamycinCephalexinAzithromycinOr clarithromycin	600 mg2 g 500 mg	20 mg/kg50 mg/kg15 mg/kg
Group A: High-risk heart disease		Group B: lower risk heart disease

Valve prostheses. Non-operated cyanotic congenital heart disease and surgical shunts. History of infective endocarditis.		Valvulopathies: IA . MI . RA . PVM with MI and/or valvular thickening . Aortic bicuspidy . Non-cyanotic congenital heart diseases except ASD . Obstructive hypertrophic cardiomyopathy.

If antibiotic prophylaxis has not been initiated beforehand, the antibiotic can be administered within one hour of the procedure.
It is recommended:
- To practice oral care in a minimum number of sessions.
- Space them out by at least 10 days.
- To choose pristinamycin or clindamycin when carrying out the second antibiotic prophylaxis.
- Patients who have received antibiotic therapy in the days preceding dental treatment should preferably receive pristinamycin or clindamycin during antibiotic prophylaxis.
Before any action the practitioner must;

High blood pressure:

Definition :

HBP is defined by a Systolic Blood Pressure (SBP) greater than or equal to 140 mmHg and/or a Diastolic Blood Pressure (DBP) greater than or equal to 90 mmHg.

Classification:

	NOT PAD
Normal	120-129	and/or	80-84
High normal	130-139	and/or	85-89
HTA grade I	140-159	and/or	90-99
HTA grade II	160-179	and/or	100-109
HTA grade III	Above or below 180	and/or	sup or = 110

The objective of the management is to obtain a PAS<140 mmHg and a PAD<90 mmHg.

Patients suffering from hypertension may be on diuretics; beta-blockers; calcium channel blockers; angiotensin II antagonists; angiotensin converting enzyme (ACE) inhibitors. This may be used as monotherapy or in combination with several antihypertensive drugs.
The oral repercussions are not due to the disease but to the different treatments “xerostomia, gingival hyperplasia, lichenoid reactions, etc.”

General precautions:

For all patients:

Prevent orthostatic hypotension at the end of care by raising the patient slowly.
Precautions regarding drug interactions.
For patients with grade I, II, III hypertension:
Measure the patient’s blood pressure before treatment.
Sedative premedication and/or MEOPA depending on the patient’s stress level.
Limit the total dose of VC.
In case of surgery: provide hemostasis equipment.
If during treatment the patient feels unwell and experiences headaches, dizziness, visual disturbances, tinnitus or confusion, blood pressure monitoring is required and rapid cardiologist advice is required.

Precautions regarding anesthesia:

In hypertensive patients with grade I, II or III hypertension:

Limit the dose of vasoconstrictors to 4 adrenaline cartridges at 1/200,000. Beyond this, use anesthesia cartridges without vasoconstrictors.

Precautions regarding common prescriptions in dentistry:

NSAIDs are not recommended in patients treated with diuretics when they are elderly and/or dehydrated (risk of acute renal failure).
When prescribing NSAIDs or corticosteroids, increased monitoring of blood pressure should be recommended “possibility of antihypertensive effect”.
Take into account other possible pathologies and/or medications.

Acts contraindicated in the dental office:

HBP does not contraindicate any procedure, but it is necessary to refer to general precautions and clinical situations to adapt the treatment.

Patients with joint prostheses and OC. Endodontics:

These are mainly patients with total hip and knee replacements.

Infection of an arthroplasty is a devastating complication, particularly in terms of functionality, with the most dramatic outcomes being amputation of the affected limb and, in extreme cases, death of the patient.
Prevention of this risk must be done by screening and treating oral infectious foci.

Two situations exist:

) Before fitting the prosthesis:

All necessary care for the restoration of the oral cavity must be carried out.

Since, in most cases, the fitting of a prosthesis is not an urgent surgery, it is preferable to carry out the treatment as soon as possible to allow for healing to take place.

Pulpless teeth with perfectly treated canals for more than a year and showing no periapical lesions are not considered to be a source of infection.
Periapical surgery must be performed at least 3 months before the joint prosthesis is fitted. The tooth will be retained if there is any evidence of calcification after this period, otherwise it must be extracted;
root amputations, transplantations, reimplantation, periodontal surgery are contraindicated due to prognostic uncertainties;
Implant placement is also contraindicated, as the occurrence of peri-implantitis is unpredictable.
On the other hand, an implant placed for more than a year, perfectly integrated, with a normal gingival setting can be kept.
Root fractures will require extraction.
Patients with one of the following conditions are considered at-risk patients and “candidates for orthoplastic surgery”:

Type 1 and 2 diabetes; Hemophilia; Malnutrition; Cancer in development; Renal or hepatic failure, depending on the biological assessment Constitutional immunosuppression

acquired or of therapeutic origin; AIDS in triple therapy; Long-term medication use (corticosteroid therapy, NSAIDs, chemotherapy, etc.); Rheumatoid arthritis, lupus erythematosus.

The following rules may apply to devitalized teeth:

Pulp-free teeth with perfectly treated canals: to be preserved.
Pulpless teeth with not fully treated canals: extraction even in the absence of periapical lesions.
Resumption of root canal treatments: contraindicated.
Endodontic treatments will also be performed, if possible, three months before the joint intervention. They will take place under a waterproof surgical field (dam), in one session, on perfectly accessible canals (mainly single-rooted ones), under antibiotic cover.

After fitting the prosthesis:

According to the AFSSAPS: “Data from the scientific literature no longer allow patients with joint prostheses to be included in a group likely to develop an infection at the prosthesis level when an oral dental procedure is performed.” Consequently, any initial endodontic treatment or endodontic retreatment may be performed without antibiotic prophylaxis in patients with orthopedic prostheses.

However, some authors speak of a period of risk which would be located in the two years following joint surgery.

Diabetes and Conservative Dentistry Endodontics:
General information:

Diabetes is the leading cause of blindness before the age of 65, as well as of non-traumatic amputation. It is also one of the main causes of dialysis and a major source of cardiovascular complications.

There are two types of diabetes:

Type I “also called insulin-dependent” which affects young people.
Type II affects people over 50 years old who are often overweight.

We speak of diabetes when fasting blood sugar is higher than 1.26 g/l during two consecutive measurements, or when blood sugar is higher than 2 g/l regardless of the time of day.
The monitoring of a diabetic patient is done by measuring the glycated hemoglobin “HBA1c” carried out every 3 to 4 months.
- Up to 6.5% control is optimal.
- Below 7% is acceptable.
- Above 8% is bad and treatment needs to be reviewed.

Oral implications:

The following complications are often observed:

Xerostomia and increased frequency and severity of carious lesions;
Infections and increased risk of candidiasis;
Delayed healing;
Gingivitis and periodontitis.

Endodontic implications:

Diabetic patients have an increased prevalence of apical periodontitis compared to non-diabetic patients “Britto et all 2003”
Flare-ups after endodontic treatment are more frequent “Fouad 2003”.

Management of diabetic patients:

It is important to contact the diabetologist in order to know:

Precisely the status of the patient “balanced or not”
Possible complications of the disease: “cardiac, ophthalmological, nervous, etc.”
The balanced patient is considered a healthy subject.
The unbalanced patient in whom emergency endodontic treatment must be considered has two possible scenarios:
- If this is an initial treatment on a pulped tooth, treatment may be considered.
- If it is an initial treatment or a retreatment on an infected tooth with a periapical lesion, antibiotic prophylaxis based on the EI protocol may be necessary if the risk of bacteremia is high “high oral sepsis, long duration of treatment”.
- We will favor single-session treatments to avoid repeating antibiotic prophylaxis.

OCE and HIV:
General information:

The human immunodeficiency virus “HIV” is a retrovirus responsible for acquired immunodeficiency syndrome “AIDS”.

It is transmitted through several bodily fluids: blood, vaginal secretions, semen, and breast milk.

Nearly a third of patients infected with HIV are also infected with hepatitis C.

Oral and endodontic repercussions:

HIV positivity does not predispose to the disease; it is hyposialia resulting from taking certain psychotropic drugs that promotes the formation of cervical carious lesions.

Action to take:

Contact with the attending physician is important in order to clarify:

CD4+ lymphocyte count “ < 200 /mm3 = major infectious risk =

antibiotic prophylaxis”.

Viral load.
Platelet count.
Neutrophil count “ < 800/mm3 = major infectious risk = antibiotic prophylaxis”.
The nature of the current drug treatment.
In case of disturbed hemostasis and/or disturbed immune function, endodontic surgery is contraindicated.

Drug-induced immunodeficiency:

The dental surgeon may be required to treat an immunodepressed patient “on immunosuppressants” in three situations:

The patient has undergone an allogeneic organ or hematopoietic stem cell transplant;
Needs background treatment for an autoimmune disease;
Needs background treatment for chronic inflammatory disease.

Odontostomatological complications : linked to immunosuppressive or immunodepressive treatment are dominated by:

Fungal or viral infections;
Hairy leukoplakia;
Cancerous lesions;
Gingivitis and ulcers.

When there is an organ allograft, the patient must be placed on antibiotic prophylaxis for any endodontic procedure;
Apart from allografts, initial treatment and re-treatment do not require any special precautions;
In the case of endodontic surgery and especially if the patient is on glucocorticoids, an antibiotic prescription is required.
Special attention for kidney transplant recipients regarding drugs prescribed in odontostomatology “drug interaction and nephrotoxicity”.
The precautionary principle prevails.

VII -) Endodontics and Bisphophonates:

Bisphosphonates have been prescribed for many years for conditions related to bone remodeling. Their main action is to inhibit the action of osteoclasts.
These molecules are used in the treatment of hypercalcemia (metastatic processes, cancer) and in the treatment of osteoporosis.
Since 2002, publications have reported complications such as osteonecrosis of the jaws occurring in particular after surgery in patients treated with bisphosphonates mainly by parenteral route.
The risk is much greater for antitumor therapies.
It is therefore important to know the current therapeutic strategies using bisphosphonates in order to carry out preventive assessment and, if necessary, oral medical management of osteonecrosis.
The goal of prevention is to avoid any bone injury that could lead to osteonecrosis.
Thus, it is possible and desirable to consider endodontic treatments in order to avoid avulsions; on the other hand, endodontic surgery should be avoided, given the risk incurred locally.

VIII- ) Endodontics and radiotherapy:

Radiotherapy, along with chemotherapy and surgery, is one of the treatment methods for cancers of the upper aerodigestive tract.
Exposure of the oral cavity and salivary glands to high doses of radiation can lead to harmful side effects:

xerostomia
mucositis
susceptibility to periodontal disease
progressive polycaries
fungal and bacterial infections
fibrosis of the masticatory muscles
osteoradionecrosis
- The objective, from an endodontic point of view, is to eliminate or reduce the risk of infection which could lead to osteoradionecrosis.
- The rate of osteoradionecrosis varies between 1 and 9% and depends in particular on the dose: (< 6% if 40 Gy 14% between 40 and 60 Gy; ≥ 20% if > 60 Gy).

The dentist plays an important role in preventing complications related to radiotherapy, before irradiation, and must also know what to do after radiotherapy in the event of oral and dental care in the irradiation field.

IX- ) MEDICATION AND ENDODONTICS:

General pathology in a patient also means the existence of drug prescriptions and therefore a reciprocal impact on endodontic practice.

Pharmacological accident or drug iatrogenesis:

The dentist may be required to intervene on patients who are also ill and for whom the drug prescription may interfere with, or be disrupted by, the ongoing medical treatment.
Although it remains rare in endodontics to observe serious medical accidents, the

precautionary principle prevails.

The priority is based on a rigorous medical interview in order to know the patient’s pathologies, their medications in relation to the latter, but also their self-medications, in order to avoid possible overdoses, allergic reactions or drug interactions.
The first step is to contact the referring physician or

specialist in order to clarify each of these elements.

X) Anesthesia and pharmacological balance:

Before any anesthesia, it is advisable to psychologically prepare the patient to reduce anxiety and stress and thus reduce the release of endogenous catecholamines.
The injection of an anesthetic solution with or without vasoconstrictor (VC) should be

carried out with a solution warmed to 20°C . Infiltration must always be slow (1 ml/min) and fractionated in order to monitor possible signs of a deleterious effect of the injection, avoiding inflammatory and infected areas .

Adrenaline is the leading vasoconstrictor for local anesthesia.
A 1.8 ml cartridge dosed at 1/200000 corresponds to an intake of 9 μg of VC.
Without being negligible, this quantity remains very low compared to the significantly higher endogenous discharges caused by stress or pain in a poorly anesthetized patient (2 to 30 times higher according to the authors and up to 280 μg/min in a healthy adult).
The formal contraindications of vasoconstrictors are:
- pheochromocytoma,
- in corticosteroid-dependent asthmatic patients or those taking bisphosphonates.
In an area irradiated beyond 30 grays, locoregional anesthesia will be preferred, but if a parapical injection is necessary, it seems desirable to avoid the use of VC.
Similarly, intraosseous injection of an adrenaline local anesthetic should be avoided.

in arrhythmic patients,

just like locoregional injection in patients with hemostasis pathology and patients on anti-vitamin K anticoagulants, because it exposes to a risk of hematoma.
However, it will be appropriate to reduce the total amount of anesthesia with VC in the following cases:
severe liver damage, unbalanced type I or II diabetes with sudden transition from hypoglycemia to hyperglycemia,
in the elderly, and depending on the metabolic state of the subject.

XI -) Risks linked to dental prescriptions:

Every dental surgeon is required to issue a drug prescription, depending on the clinical situation, either to eradicate or prevent pain, or to combat an infection, in addition to the technical procedure.
Painkillers: According to the HAS recommendations of 2005, it is necessary to treat without

wait for the onset of pain, cover the entire nycthemeron and prescribe at regular intervals.

The assessment of pain intensity is an essential prerequisite because it allows

to adapt the analgesic prescription by referring to the WHO levels.

Level I (mild pain – EVA 1 to 3): Paracetamol is commonly prescribed as an analgesic in oral and dental pathology, because it is well tolerated at therapeutic doses and has few contraindications.

NSAIDs are more effective than paracetamol on postoperative pain, but the prescription must be as short as possible (72 hours) and take into account their precautionary use.

Level II (moderate pain – VAS 4 to 7):

– monotherapy: weak central analgesics are represented by codeine and tramadol hydrochloride.

The latter does not exhibit the respiratory depressant effect of codeine.

– multimodal analgesia: level II drugs can be combined with level I drugs to combine their effects.

Antibiotics can be prescribed prophylactically or for curative purposes.
- Their use involves individual and collective risks such as resistance.
- It should be prescribed sparingly and rationally and, therefore, in clinical situations where bacterial etiology is strongly suspected and antibiotic efficacy demonstrated or strongly presumed.
- The most commonly used products are amoxicillin and macrolides (or related macrolides) in cases of allergy to beta-lactams and in patients with renal failure (because elimination is biliary and fecal).
- In infections where anaerobic germs are known to predominate, a combination of one of these products with metronidazole may be considered.
- Curative antibiotic therapy aims to treat an oral infection. It should always be used, whenever possible, in addition to appropriate local treatment.
- This antibiotic therapy should only replace and therefore delay non-drug etiological treatment by a few days.
- In patients with renal failure, the prescription will be directed towards a macrolide (+/- metronidazole).
- For transplant patients, caution should be exercised regarding drug interactions between immunosuppressive treatments and dental treatments.

Pregnant woman:
- Pregnancy is classically divided into three periods:
- First trimester: the most critical period in terms of fetal sensitivity; it corresponds to embryogenesis and organogenesis.
- Second trimester: maturation of organs.
- Third trimester: end of organ maturation.
- Beware of vena cava syndrome from the 24th week. In the supine position.
- Compression of the inferior vena cava by the uterus; reduction of venous return.
- Favoring Articaine “crosses the placental barrier less.”
- For the radio, provide a “forensic” lead apron.

SUMMARY:

More specifically, in 2012 the AFSSAPS* established “recommendations for good practice in the prescription of antibiotics in practice

For comparison, this table also includes recommendations for 3 types of patients: – the general population including group B of at-risk patients, i.e. the largest number of patients,

immunocompromised patients (congenital or acquired origin), at risk of local infection and its possible spread after assessment with the doctors concerned,
patients at high risk of IE (Group A). “See table”.

CONCLUSION :

The relationships between general pathologies and endodontics are sometimes complex and two-way.

It is therefore imperative to follow the evolution of the recommendations.

The most striking example is that of managing the risk of infective endocarditis and the need to prescribe antibiotic prophylaxis.

We must not lose sight of the fact that the objective is better care for patients on an individual and collective level.

Appendix