Heart and oral cavity
- INTRODUCTION:
The management of cardiopathic patients, described as “at-risk patients” par excellence, is increasingly taking up space in the daily practice of the Dentist.
When faced with these patients, the practitioner is confronted with the risk of infection, hemorrhage, or syncope or the combination of 2 or 3 risks.
To achieve this, it is essential that the practitioner has a perfect knowledge of the disease and its risks, the treatment taken by his patients as well as the conduct to be adopted that is specific to them.
2- REMINDERS :
2.1- Anatomy:
The heart is located in the thoracic cavity and occupies the anterior mediastinum between the two lungs. Pyramidal in shape, with a horizontal major axis, the heart is a hollow organ.
A watertight partition (the septum) divides the heart into two chambers – the right heart and the left heart – each comprising an atrium at the back and a ventricle at the front, separated by valves. There are four valves:
-2 atrioventricular valves (tricuspid valve – 3 valves – and a mitral valve formed by 2 valves),
-2 arterial valves (1 pulmonary and 1 aortic with 3 sigmoid valves each)
The role of these valves is to allow the passage of blood in one direction only, that is, from the atria to the ventricles (mitral valve on the left and tricuspid on the right) and from the ventricles to the arteries that leave the heart (aortic valve on the left and pulmonary valve on the right)
The heart wall is made up of 3 layers:
- the endocardium which lines the inner surface of the heart cavities and the surfaces of the valves.
- The myocardium resembles a striated muscle and contracts spontaneously
- The pericardium is formed of two layers (visceral pericardium and parietal pericardium)
2.2- Physiology:
The heart works in cycles, where systole (contraction) and diastole (relaxation and filling) follow one another. The right heart receives deoxygenated blood through the two vena cavae.
This blood passes from the atrium to the ventricle, which sends it to the lungs through the pulmonary artery.
The left heart receives oxygenated blood through the 4 pulmonary veins, the atrium to the ventricle, which ejects it into the aorta. The latter distributes it to the entire body and to the heart through the coronary arteries.
- The electrical activity of the heart:
The electrical activity of the heart consists of electrical signals that make it beat at a regular rhythm and normal rate. The path of these signals begins with an impulse from the sinus node, or sinoatrial (SA) node (= Keith-Flack node), located in the right atrium. The electrical impulse passes through the heart from top to bottom, from the atria to the ventricles. In turn, the parts of the heart contract while the others expand.
First, the electrical impulse is emitted by the SA node and transmitted to the atria, which contract and expel blood into the ventricles.
The impulse reaches the atrioventricular (AV) node (Aschoff-Tawara), located on the wall that separates the atria from the ventricles. It remains there for a moment, while the ventricles fill with blood.
The electrical impulse travels to the ventricles through muscle fibers located in the septum (atrioventricular bundle or bundle of His) and in the internal walls of the ventricles (Purkinje fibers).
Finally, the impulse triggers the ventricles to contract, which pushes blood into the lungs and the rest of the body.
An electrocardiogram (ECG) is a test that helps diagnose a problem with the electrical activity of the heart. It measures electrical activity by plotting the signals seen on a sheet.
3- What to do when dealing with a cardiopath:
- Examination
– Type of disease and its age
– Treatment followed
– Concomitant general diseases and their treatment.
- Contact the attending physician by letter, requesting a detailed report including:
the diagnosis, current treatment, whether the patient has had surgery or is due to have surgery, and their current condition.
Heart and oral cavity
- A panoramic dental X-ray should be systematically requested.
RISK MANAGEMENT IN THE HEAD DOCTOR:
1- The risk of hemorrhage
1.1 -Classification of patients according to bleeding risk:
The American Society of Anesthesiologists ( ASA ) classifies patients into three categories:
- High-risk patients are those with abnormal laboratory tests (INR greater than 2 in patients on AVK) and/or undiagnosed primary hemostasis, as well as patients with a known abnormality of coagulation and/or primary hemostasis.
- Moderate risk patients are on chronic medication based on aspirin and derivatives, NSAIDs, and patients on anticoagulants whose INR is less than or equal to 2
- Low-risk patients are patients with normal clinical examination and laboratory tests.
1.2 -Hemorrhagic risk heart disease:
These are all heart patients whose treatment is based on an antiplatelet agent, an anticoagulant or an antifibrinolytic agent:
- Thromboembolic disorders (chronic obliterative arteritis of the lower limbs, venous thrombosis, pulmonary embolism)
- Ischemic heart disease (myocardial infarction, angina pectoris)
- History of cardiovascular surgery (transluminal coronary angioplasty, coronary stent, aorto-coronary bypass, etc.)
- Valvular heart disease and wearers of valve prostheses
- Rhythm disorders
1.3 – Management of patients at risk of bleeding:
Patients on antiplatelet drugs:
These are mainly: aspirin (or its derivatives), under Ticlopidine, or under NSAIDs:
- Acetylsalicylic acid (Aspégic®)
- Ticlopedine (Ticlid®).
- Clopidogrel (Plavix®)
- Acetylsalicylate (Kardégic®)
If the TS is normal (less than 10 min, according to the Ivy method) any type of procedure can be considered by taking basic hemostasis measures.
If the TS is prolonged, the surgical procedure must be postponed in agreement with the treating physician, stopping the prescription must be considered for a week to normalize the TS, the procedures will then be carried out; the resumption of aspirin will be decided as soon as any risk of post-operative bleeding has been ruled out.
For patients taking clopidogrel:
– FNS complete
– Hemostasis assessment
NB : TS tends to be abandoned to estimate the hemorrhagic risk of a patient under treatment with (AAP), its sensitivity being inconsistent.
Currently, there is no routinely valid biological test to identify patients on APA who are likely to have an increased risk of bleeding during surgery.
The precise assessment of the risk of bleeding therefore relies mainly on medical questioning and clinical examination.
Patients on anticoagulants:
Anticoagulants:
- Heparins
– Unfractionated heparin (calciparin ® )
– Low molecular weight heparins:
– Enoxaparin sodium (Lovenox ® )
-Tinzaparin sodium (Innohep®)
- Anti-vitamin K:
– Acenocoumarol (Sintrom ® )
-Fluindione (previscan ® )
-Warfarin (coumadin ® )
- New oral anticoagulants (NOACs):
-Rivaroxaban (Xarelto ® ): Direct factor Xa inhibitors
-Dabigatran (Pradaxa ® ): Direct thrombin inhibitor
Patients treated with AVK :
They are assessed by a TP or an INR before any surgical procedure.
Request a coagulability assessment for the day of the procedure 24 hours before the procedure): TP (Prothrombin Rate) and INR ( International Normalized Ratio ).
– If INR (2-3) or TP (30%-45%) intervention is possible.
– Patients with mechanical valve prostheses, severe mitral valve disease with INR contributing factors (3 – 4.5)
– If INR > 3 or < 2 or TP ≤ 30 or > 45 refer the patient to their Cardiologist.
Subjects on heparin: monitored by platelet count and activated cephalin time. But the only reliable test is the dosage of anti-Xa activity
– Balance sheet in the meantime 🡪 possibility of intervention
– Otherwise 🡪 refer the patient to their Cardiologist
- During the operation:
- Intervention should only be carried out if perfect local hemostasis technique is available.
- Schedule the act at the beginning of the day and at the beginning of the week.
- Loco-regional anesthesia using the Spix spine is formally contraindicated (risk of pharyngeal hematoma).
- Periapical anesthesia with vasoconstrictor.
- Minimize trauma and extent of the surgical site.
- If an alveolectomy is necessary, a very small amount of bone tissue must be removed.
- Granulation tissue, granulomas and cysts should be curetted completely and mainly after extraction of teeth with affected periodontium.
- The systematic use of local hemostasis methods remains the rule:
- Immediate local compression for 10 minutes with compresses soaked in tranexamic acid (Exacyl ®)
- Alveolar filling :
- biological hemostatic glues of human origin (Biocol®, Tissucol®, Bériplaste®)
- plant-based oxycellulose (Surgicel®)
not recommended for bone contact
- Making sutures ( with absorbable thread ) :
🡪placement of separate single stitches.
🡪Continuous sutures should be avoided.
Silicone compression splints represent a complementary compression technique.
- Post-operative precautions
– Do not prescribe aspirin as a pain reliever.
– Avoid prescribing NSAIDs for pain control.
– If an anti-inflammatory prescription proves necessary, short-term corticosteroid treatment is preferred
– Antibiotics, such as penicillin, erythromycin, tetracycline, metronidazole, ampicillin/clavulanic acid and amoxicillin/clavulanic acid combinations, should be avoided.
- Rinsing the mouth with mouthwash is contraindicated for the first 24 hours.
- Give some clear instructions:
• Do not eat or drink for 2 to 3 hours after surgery.
• No hot food for the rest of the day.
• Chew on the side opposite the surgical site.
• If bleeding occurs, apply pressure for 20 minutes with gauze; if the bleeding does not stop, contact the dentist.
- A follow-up consultation at 24-48 hours or a simple telephone contact is recommended in order to verify proper compliance with post-operative advice.
Heart and oral cavity
2 – Syncopal risk:
2.1- Definition:
It is a brief, complete, sudden and reversible loss of consciousness, following a reduction in cerebral oxygenation.
2.2- Causes of syncope:
It is due to anoxia or cerebral ischemia. It can be linked to :
- a cardiovascular condition
- A rhythm disorder
- asphyxiation
- a sudden change from a lying to a standing position (orthostatic hypotension)
- hypokalemia (decreased blood potassium levels)
Most often, syncope is due to hyperactivity of the parasympathetic autonomic nervous system, we then speak of vagal or reflex syncope. It occurs in cases of intense pain, emotion (fear, stress, etc.), compression of the neck (carotid sinus)
2.3- clinic:
Syncope is manifested by a sudden loss of consciousness and results in a complete muscular contraction, often with the patient falling. The patient is pale, no longer reacts to noises or pinching, and has no pulse.
The duration of loss of consciousness is minimal, most often less than 1 minute
Recovery is spontaneous, complete, very rapid and preceded by a recoloring of the face. When the loss of consciousness is prolonged, we then speak of Coma.
2.4- Classification of syncopal risk:
All patients may experience syncope except those with pacemakers .
- High risk :
– High blood pressure.
– Rhythm disorders.
– Ischemic heart disease.
– Aortic stenosis
- At risk :
– Cardiomyopathies.
– Pulmonary embolisms.
– Cyanotic congenital heart disease.
– Heart failure.
2.5- Prevention of syncopal risk:
These patients may experience syncope due to:
- their cardiovascular disease
- of their treatment (antihypertensives)
- of the emotional factor or stress specific to all individuals
- of anesthesia
Stress control and reduction should be included in the precautions to be taken by the practitioner. If premedication must be prescribed, it will be done in agreement with the treating cardiologist.
*Prevention of syncope:
– psychological preparation;
– sedative preparation to reduce stress: hydroxyzine (Atarax ® 25 mg) or diazepam (Valium ® 5 mg: 1 tablet the day before and 1 tablet 1 hour before the act);
– do not intervene on a tired or fasting patient;
– the patient must be comfortably installed, in a lying position during anesthesia:
🡪 the cartridge must be lukewarm, the injection must be slow
🡪 use vasoconstrictors without exceeding 0.04mg
🡪 avoid painful acts;
🡪 avoid long interventions;
🡪 monitor the patient for half an hour after the procedure.
*Treatment of syncope
When faced with fainting, you must:
– Stop treatment;
– Assess vital signs: BP, pulse, state of consciousness.
– Ensure the emptiness of the oral cavity;
– Place the patient in a lying position with the head hyperextended;
🡪If the discomfort persists, external cardiac massage is performed, accompanied by artificial ventilation by mouth to mouth or using a special device, or a subcutaneous injection of atropine at a rate of 0.5 mg is given (while waiting for the medical team)
NB:
If the myocardial infarction occurred more than a month ago, the dentist will only act if the general condition is deemed satisfactory and stable, so he will be able to carry out the treatment in the office and the extractions in a hospital setting [Yvon Roche 2010].
Heart and oral cavity
3- Risk of infective endocarditis:
3.1 – Definition:
Infective endocarditis is defined as damage to the endocardium, which is the inner lining of the heart, by germs whose passage into the blood is caused by a mucosal or cutaneous breach.
The incidence of IE is estimated at 30 cases per million inhabitants in France. Mortality remains stable (15 to 25%).
This is an uncommon but serious disease.
Contributing factor: valvulopathy, valvular prosthesis, especially of the left heart.
IE can be acute (most often in a healthy heart) or subacute in a previously damaged endocardium (this is Osler’s disease).
3.2 – Physiopathology:
In the development of EI, 3 stages are described:
- 1st stage: Deposition of fibrin and platelets on the valvular endothelium facilitated by pre-existing mechanical or inflammatory endothelial lesions
- 2nd stage : Bacterial adhesion to the valves during transient bacteremia
- 3rd stage : multiplication of bacteria in the valves with local extension and destruction (abscess and heart failure due to valvular destruction) followed by distant dissemination.
3.3 Pathogenesis (bacteremia):
It is through bacteremia that the occurrence of IE is explained. This pathogenic process, which is part of the theories on focal infection, is explained by the passage of bacteria into the bloodstream and which will graft themselves onto the endocardium.
3.4 Clinic:
Clinical signs are often insidious. Systemic infection manifests itself with chills, fever, sweating, general malaise, weight loss and musculoskeletal pain.
The disease sometimes reveals itself immediately by a complication such as right or left heart failure, or embolic manifestations.
Additional examinations are:
– blood cultures: performing 3 pairs of blood cultures over 24 hours, spaced one hour apart, before taking any ATB
- If negative, repeat the blood cultures 3 days later.
– cardiac ultrasound: transesophageal ultrasound is the most sensitive for the diagnosis of vegetations and abscesses
3.5 Modalities of antibiotic prophylaxis:
Evolution of recommendations and modalities of antibiotic prophylaxis:
- 1997 Recommendations: American cardiologists proposed 3 risk groups (high, moderate, low).
- 2002 Recommendations: The French moved from 3 groups to 2 groups of at-risk patients (high risk, lower risk) recommending formal antibiotic prophylaxis for the first group (group A) and optional antibiotic prophylaxis for the second group (group B).
- In 2007 they moved to a single risk group (group A).
- In 2008, English experts proposed the complete abandonment of antibiotic prophylaxis.
Heart and oral cavity
In practice, the French recommendations of 2002 remain the best adapted to our populations:
(French recommendations of 2002):
- High-risk heart disease:
Valve prostheses (mechanical, homografts or bioprostheses)
Unoperated cyanotic congenital heart disease and surgical shunts (pulmonary-systemic)
History of EI
Lower risk heart disease:
- Valvulopathies: IA, IM, RA
- PVM with IM and/or valvular thickening
- Aortic bicuspidy
- Non-cyanotic congenital heart disease except CIA
- Obstructive hypertrophic cardiomyopathy (with murmur on auscultation)
A recent study published in 2021 reports this observation.
Heart and oral cavity
Heart and oral cavity
*actions at risk of infective endocarditis:
- Dental extractions
- Periodontal acts
- Dental reimplantation
- Implant placement
- Endodontic surgery
- Intraligamentous anesthesia
- All procedures where bleeding is expected
*non-risky actions:
- Ttt of superficial caries
- Supragingival prosthetic preparations
- Local anesthesia (except intra-ligamentary)
- Endodontic treatment without apex overshoot and post placement
- Suture removal
- Fingerprinting
- Laying of dike order
- Taking X-rays
- Fluoridation
- Indications for precautions against the risk of infection
They aim to reduce spontaneous and induced bacteremia by the application of measures to prevent infective endocarditis.
– establishment of rigorous oral hygiene;
– search for and eradication of any source of infection.
So, depending on the risk, it is necessary to:
In high-risk patients
– Periodontal diseases require extraction
– Scaling is only offered in gingivitis
– Only teeth with healthy or sanitized periodontium will be kept at the end of the treatment.
– Styling techniques can be implemented excluding direct styling and pulpotomy.
– Extract teeth with pulp damage, as well as traumatized teeth;
– Abstention from extraction of deep impacted teeth that do not present a risk of disinclusion or pericoronitis.
Contraindicate periodontal surgery, implants and periapical surgery;
– Prior to valve replacement surgery, patients fall into the high risk category for infective endocarditis
🡪A complete dental imaging assessment must be carried out;
🡪 Only teeth with pulp or perfect endodontic treatment, without desmodontal widening, dating back more than one year and with healthy periodontium will be kept.
🡪 All other devitalized teeth with incomplete endodontic treatment, teeth with periodontal lesions, persistent roots and apices will be extracted at least 15 days before the cardiac intervention (except in emergencies).
In patients at risk
- Teeth with periodontal disease: same as for high-risk patients;
- Periodontal surgery, implants and periapical surgery are not recommended.
- In case of pulp inflammation
- Single-rooted teeth: it is recommended to perform pulp removal while taking into account the elements of reflection under antibiotic prophylaxis.
- Multirooted teeth: the indication for conservation is the domain of the specialist under antibiotic prophylaxis.
– In case of pulp necrosis: extraction is necessary.
Heart and oral cavity.
Heart and oral cavity
| Antibiotic prophylaxis | Heart disease at risk Group A | Lower risk heart disease Group B |
| Risky oral-dental gesture | Recommended | Optional |
| Non-risky oral-dental gesture | Not recommended | Not recommended |
NB : for group B, these are the risk factors which guide this choice:
In favor of prescription:
– age over 65 years
– associated pathology: diabetes, heart failure, kidney failure, etc.
– poor oral health
– dental procedure : significant bleeding, technically difficult
In favor of abstention:
– allergy to many ATBs
– patient’s wish
3.4 Modalities of antibiotic prophylaxis
- -in the absence of allergy to b-lactams:
2g of moxicillin (75mg/kg in children), orally 1/2 hour before treatment (adult < 60kg) otherwise 3g.
- If general anesthesia is planned: 2g of amoxicillin (50mg/kg in children) by IV infusion over 30 min in the hour preceding treatment followed by 1g per os 6 hours later.
- -in case of allergy to b-lactams (or long-term prophylaxis with penicillin):
600mg of clindamycin (15mg/kg in children) orally one hour before treatment
Or 1g of pristinamycin orally one hour before treatment.
- In case of general anesthesia, Vancomycin is used at 1g by IV drip for 60 min in the hour preceding the procedure.
Or 400mg of Teicoplanin directly IV.
Currently, we also speak of spontaneous bacteremia , that which occurs during everyday activities, such as brushing teeth and chewing. It would be 0 to 26% during simple brushing and 0 to 51% during chewing. Theoretically, the normal epithelial attachment represents an effective barrier and would prevent the penetration of microorganisms into the bloodstream. The risk would come with the appearance of inflammation produced by deposits of bacterial plaque at the neck of the teeth. This spontaneous bacteremia is therefore correlated with insufficient oral hygiene.
This concept justifies the use of local antiseptics based on chlorhexidine in the form of 30-second mouthwashes which must precede dental procedures and oral care in a minimum of sessions. If these require several sessions, space them out by at least 10 days, if antibiotic prophylaxis is used.
Heart and oral cavity
In the event of an oral-dental procedure at risk of EI:
- Schedule the patient preferably in the morning, to avoid the stress of the day,
- Pre-operative rinse with Chlorhexidine mouthwash
- Antibiotic prophylaxis for bloody procedures
- The gestures must be as non-traumatic as possible.
- If several treatment sessions are planned, a minimum interval of 10 to 15 days must be respected between each session or the antibiotic must be alternated (amoxicillin; azithromycin; pristinamycin);
- In case of infective endocarditis, intervene at least 1 month later.
- In case of isolated acute rheumatic fever (ARF) (without cardiac involvement); bring the procedure closer to the date of the Extencillin injection
- In case of RAA with cardiac involvement; put the patient on antibiotic prophylaxis: Pristinamycin or Azythromycin.
- All patients in groups A and B must be informed on a regular basis of the need to consult their cardiologist quickly in the event of a fever .
Heart and oral cavity
- CONCLUSION :
The care of a cardiopath must be carried out in a climate of trust without forgetting appropriate premedication knowing that the cardiopath is confronted with 3 major risks, namely: the risk of infection, the risk of hemorrhage, and the risk of syncope.
Some of the cardiac pathologies require hospitalization of the patient for the restoration of the oral cavity, others require antibiotic prophylaxis, preventive hemostasis measures or a set of precautions.
Heart and oral cavity
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.