Heart and oral cavity
Plan
1. Introduction
2. Reminders:
2.1. Anatomy of the heart
2.2. Physiology of the heart
3. Conduct to be adopted
3.1. Infectious risk,
3.1.1. Definition
3.1.2. Pathophysiology
3.1.3. Diagnosis
3.1.4. Evolution of recommendations and modalities of antibiotic prophylaxis
3.1.5. Heart diseases with infectious risk
3.1.6. Precautions to take against the risk of infection
3.1.7. Modalities of antibiotic prophylaxis of infective endocarditis
3.2. Hemorrhagic risk
3.2.1. Heart diseases with hemorrhagic risk
3.2.2. Coagulation modifiers
3.2.3. Management of patients at risk of bleeding
3.2.4. Precautions to take
3.3. Risk of syncope
3.3.1. Definition of syncope
3.3.2- Etiologies of syncope
3.3.3- clinic
3.3.4. Patients at risk of syncope
3.3.5. Prevention of syncope
3.3.6. Treatment of syncope
4. Conclusion.
BIBLIOGRAPHY
1. Introduction
The management of cardiopathic patients, described as “at-risk patients” par excellence, is increasingly taking up a place 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. For 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 which is specific to them.
2. Reminders
2.1. Anatomical reminder
The heart is a muscle essential to the circulation of blood in the body. It is driven by regular rhythmic contractions and acts as a pump that ensures the distribution of blood to all the organs of the body. It sends – via the arteries – oxygenated blood to the organs and ensures the circulation of venous blood to the lungs, which will then be recharged with oxygen.
The heart is placed in the thoracic cavity and occupies in this cavity the anterior mediastinum between the 2 lungs. A watertight partition (the septum) divides the heart into 2 cavities (the right heart) and the (left heart) each comprising an atrium at the back and a ventricle at the front, separated by valves (Fig 1). There are 4 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)
Heart and oral cavity
The role of these valves is to allow blood to pass in only one direction, that is, from the atria to the ventricles (mitral valves on the left and tricuspid on the right) and from the ventricles to the arteries that leave the heart (aortic valves on the left and pulmonary valves 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, which constitutes the envelope of the heart, is formed of two layers (visceral pericardium and parietal pericardium).
2.2. Physiological reminder
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 venae cavae. This blood passes from the atrium to the ventricle, which sends it to the lungs through the pulmonary artery. The left heart receives reoxygenated blood through the 4 pulmonary veins. This blood passes from 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 ( FIG 2).
Heart and oral cavity
3. The conduct to be adopted :
The management of cardiac patients is frequent in the dental office, a certain number of precautions are necessary (questioning, premedication, etc.) in order to avoid a state of cardio-respiratory distress, hemorrhage or infectious disease.
The first step in preventing these risks consists of a thorough questioning of the patient which should bring out 3 essential points:
• The illness: nature (diagnosis), start date, development, current state.
• The treatment(s) followed, past or present, medicinal or surgical.
• Assessments carried out to assess the effectiveness and stability of current treatment (e.g. anticoagulant)
In most cases, contact with the treating physician will be necessary. It is in agreement with the latter that premedication or modification of current treatment will possibly be instituted.
3.1. The risk of infection
In a healthy subject, the passage of commensal germs into the blood only causes a transient bacteremia. In a subject with heart disease, whether operated on or not, this bacteremia can cause an infectious accident. The heart lesion being the bed of this infection: OSLER bacterial endocarditis can then be caused.
3.1.1. Definition:
Infective endocarditis (IE) is an attack on the endocardium by germs whose passage into the blood is caused by a mucosal or cutaneous breach. These germs then graft themselves onto the endocardium, particularly at the valves, creating vegetations that can detach at any time and create septic emboli.
This is an uncommon but serious disease. The contributing factors are: valvulopathy, valvular prosthesis, especially of the left heart. The IE can be acute (most often on a healthy heart) or subacute on a previously damaged endocardium (this is Osler’s disease).
The entry point for the germ is:
- The most frequent is the oral route in 27% of cases
- 20% of cases in cardiac surgeries, catheterization, perfusions.
- 18% of cases: urology and obstetric surgery
- 16% of cases: ENT
- 10% of cases: extracardiac surgery, parenteral injection.
- 7% of cases: the cutaneous route.
3.1.2. Pathophysiology:
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.
3.1.3. Diagnosis:
Clinical signs are often insidious. Systemic infection manifests itself by 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.
3.1.4. 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).
The reasons why the indication for antibiotic prophylaxis has been limited are:
- Bacteremia at risk of inducing infective endocarditis is more likely due to the daily passage of germs into the bloodstream linked to everyday activities (chewing, brushing) “notion of spontaneous bacteremia” than occasional oral-dental activities.
- There is no evidence of either the effectiveness or ineffectiveness of antibiotic prophylaxis.
- Widespread use of ATB prophylaxis leads to the emergence of resistant microorganisms.
- Even perfectly applied antibiotic prophylaxis only prevents a small number of cases of IE.
3.1.5. Heart diseases with infectious risk
Heart and oral cavity
IA: aortic regurgitation; MI: mitral regurgitation; RA: aortic stenosis; MVP: mitral valve prolapse; ASD: atrial septal defect (non-risk heart disease)
3.1.6. Precautions to take 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. Thus, depending on the risk, it is necessary to:
In high-risk patients:
- Periodontal diseases require extraction
- Scaling is only offered in cases of gingivitis
- Only teeth with healthy or healed periodontium will be kept at the end of 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 with 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.
- multi-rooted teeth: the indication for conservation is the domain of the Specialist under antibiotic prophylaxis. In case of pulp necrosis: extraction is necessary.
| Antibiotic prophylaxis | High risk heart disease | Lower risk heart disease |
| Risky oral 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
3.1.7. Modalities of antibiotic prophylaxis of infective endocarditis
Modalities of antibiotic prophylaxis of infective endocarditis: AFSSAPS 2011
| Product | Dosage and route of administration (single dose 30-60 min before | |
| No allergy to ß-lactams | Amoxicillin | 2 g/per os |
| Allergy to ß-lactams | Clindamycin/Pristinamycin | 600 mg/per os1 g/per os |
Pediatric Dosage: per os
Amoxicillin 50 mg/Kg;
Clindamycin 20 mg/Kg;
Pristinamycin 25mg/Kg
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; clindamycin; 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, Clindamycin 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.
3.2. The risk of bleeding
3.2.1. Heart diseases with a risk of hemorrhage:
These are all heart patients whose treatment is based on an antiplatelet agent, an anticoagulant or an antifibrinolytic agent:
- Thromboembolic diseases.
- Ischemic heart disease.
- History of cardiovascular surgery.
- Valvular heart disease and people with valve prostheses.
- Rhythm disorders.
3.2.2. Coagulation modifiers
3.2.2.1. Anticoagulants:
- Heparins:
- Unfractionated heparin (calciparin®)
- Low molecular weight heparins:
* Enoxaparin sodium (Lovenox®)
* Tinzaparin sodium (Innohep®)
- Anti-vitamin K:
They interfere with vit K, which is necessary for coagulation. They prolong TP and are used in thromboembolic conditions, rhythm disorders and cerebral conditions…
The therapeutic zone corresponds to an INR between 2 and 3 (i.e. TP between 45 and 30%).
The most commonly prescribed anticoagulants
- Acenocoumarol (Sintrom®)
- Fluindione (previscan®)
- Warfarin (Coumadin®)
New oral anticoagulants
- Rivaroxaban (Xarelto®): Direct factor Xa inhibitors
- Dabigatran (Pradaxa ®): Direct thrombin inhibitor
Direct oral anticoagulants (DOACs) (Xarelto ®) specifically and directly inhibit activated coagulation factors which are either thrombin (factor IIa) or activated Stuart factor. They are intended to be widely used in the treatment of venous thromboembolic disease or in atrial fibrillation as a replacement for vitamin K antagonists (VKAs).
3.2.2.2. Antiplatelet agents:
- Acetylsalicylic acid (Aspégic®).
- Ticlopedine (Ticlid®).
- Clopidogrel (Plavix®).
- Acetylsalicylate (Kardégic®).
NB: there are new antiplatelet agents:
- Prasugrel; Ticagrelor; Cangrelor:
3.2.2.3. Fibrinolysis modifiers:
Fibrinolytics are used in hospitals for the treatment of embolisms, to dissolve clots (Steptase ®, Urokinase ®)
Fibrinolysis inhibitors act by inhibiting the activation of plasmogen (Exacyl ®, Hemocaprol ®, Capramol ®, Frenolyse ®) or the activity of plasmin (Iniprol ®, Zymofren ®)
3.2.3. Management of patients at risk of bleeding:
- Patients on anticoagulants:
- Under anti-vitamin K:
Request a coagulability assessment for the day of the procedure 24 hours before the procedure): TP (Prothrombin Rate) and INR (International Normalized Ratio).
- The INR (patient TQ / control TQ, this ratio being raised to the ISI power
– ISI: International Sensitivity Index or International Standardized Index; is a mode of expression of the Quick time used to avoid variability of results depending on the thromboplastin used and therefore the laboratories .
- If INR (2-3) or TP (30%- 45%): intervention is possible.
- Surgery should be delayed in cases where the INR is greater than 4
NB: For patients with mechanical valve prostheses, severe mitral valve disease with contributing factors: the therapeutic window for INR is: (3 – 4.5).
- patients taking heparin (CALCIPARINE®) :
– Biological evaluation by HOWELL time which must be 2mn 30 and 4mn 30
– Assessment in the meantime: possibility of intervention
– Otherwise, refer the patient to their cardiologist
- Patients taking antiplatelet drugs :
• Subject under Clopidogrel: – Complete FNS
– Hemostasis assessment
• The TS should not be performed to estimate the bleeding risk of a patient under treatment with (Anti-Platelet Aggregants), its sensitivity being inconsistent.
-Currently, there is no routinely valid biological test to identify patients on AAP who are likely to have an increased risk of bleeding during surgery.
-The precise assessment of the risk of hemorrhage is therefore based mainly on medical questioning and clinical examination .
3.2.4. Precautions to take
- Pre- and per-operative precautions:
- It will only be necessary to intervene if you have perfect local hemostasis technique.
– Schedule the procedure 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 the extent of the surgical site.
– The systematic use of local hemostasis methods remains the rule:
- Immediate local compression for 10 minutes with compresses soaked in tranexamic acid (Exacyl ®)
- An alveolar filling with:
- biological hemostatic glues of human origin (Biocol®, Tissucol®, Bériplaste®)
- plant-based oxycellulose (Surgicel®): not recommended for bone contact
- Making sutures (with absorbable thread):
- 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
- Rinsing the mouth with mouthwash is contraindicated for the first 24 hours.
- Provide appropriate post-operative advice.
- 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.
3.3. The risk of syncope
3.3.1. Definition of syncope:
It is a brief, complete, sudden and reversible loss of consciousness, resulting from a reduction in cerebral oxygenation.
3.3.2- Etiologies 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 position 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 and which occurs in the event of intense pain, emotion (fear, stress, etc.), compression of the neck (carotid sinus)
3.3.3- 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 noise or pinching, and has no pulse. The duration of the loss of consciousness is minimal, most often less than 1 minute. Recovery is spontaneous, total, very rapid and preceded by a recoloring of the face. When the loss of consciousness is prolonged, it is called a coma.
3.3.4. Patients at risk of syncope
All patients may experience syncope except those with pacemakers.
- High-risk patients:
– High blood pressure.
– Rhythm disorders.
– Ischemic heart disease.
– Aortic stenosis
- Patients at risk:
– Cardiomyopathies.
– Pulmonary embolisms.
– Cyanotic congenital heart disease.
– Heart failure.
These patients may experience syncope due to their cardiovascular disease, their treatment (antihypertensives) and the emotional factor or stress specific to all individuals and the anesthesia.
NB / Beta blockers (prescribed in cases of angina pectoris, rhythm disorders and certain types of hypertension) associated with local anesthesia can lead to cardiovascular (bradycardia, hypotension) and bronchial (bronchospasm) risks.
3.3.5. Prevention of syncope:
- Psychological preparation (It is necessary to establish a climate of trust between the practitioner and the patient).
- A 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:
- Remove vasoconstrictors from the anesthetic solution
- Avoid painful acts;
- Avoid long interventions;
- Monitor the patient for half an hour after the procedure .
3.3.6. Treatment of syncope:
When faced with fainting, you must:
– Stop treatment;
– Assess vital signs: BP, pulse, level of consciousness.
– Ensure the emptiness of the oral cavity;
– Place the patient in a lying position with the head in hyperextension;
If the discomfort persists, external cardiac massage is carried out, which will be accompanied by a
artificial ventilation by mouth to mouth or using a special device, or else carry out a
subcutaneous injection of atropine at a dose of 0.5 mg (while waiting for the medical team)
Conclusion:
If the decision to operate on a patient with heart disease is the sole responsibility of the practitioner concerned, this decision must be based on reflection based on a preoperative medical investigation, the necessary additional examinations but above all on full cooperation between cardiologist and stomatologist.
Therefore, contact with the treating physician should constitute the first step in treating this type of patient.
Bibliography:
- Roche Y. Medical risks in the dental office in daily practice 2010 2nd edition.
- Parize P, Mainardi JL. Current developments in infective endocarditis. Internal Medicine Review 2010
- Delahaye F, Harbaoui B, Cart-Regal V, de Gevigney G. Recommendations on the prevention of infective endocarditis: a major development over the last seven years 2009.
- Perioperative management of patients treated with antithrombotic drugs in oral surgery/ Recommendations. SFCO July 2011
- Direct oral anticoagulants: what is the role of biology in their monitoring and/or use? Ann BiolClin2016; 74 (1): 69-77
- Ibourk A, Kissi L, Ben Yahya I. Management of patients with heart disease in oral surgery: update. Le courrier du dentiste 2018.
END
Good oral hygiene is essential to prevent cavities and gum disease.
Regular scaling at the dentist helps remove plaque and maintain a healthy mouth.
Dental implant placement is a long-term solution to replace a missing tooth.
Dental X-rays help diagnose problems that are invisible to the naked eye, such as tooth decay.
The dentist uses local anesthesia to minimize pain during dental treatment.