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Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished.

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Presentation on theme: "Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished."— Presentation transcript:

1 Perspectives on the 2007 AHA guidelines for the prevention of infective endocarditis Nelson L. Rhodus, DMD, MPH, FACD Professor Academy of Distinguished Professors Director, Division of Oral Medicine, Dental School Adjunct Professor, Otolaryngology, Medical School Diplomate, American Board of Oral Medicine Diplomate, American Board of Oral Medicine University of Minnesota

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5 QUIZ

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7 Basis for Past AHA Guidelines 1.True or false Dental procedures were the source of the bacteremias leading to IE Dental procedures were the source of the bacteremias leading to IE

8 Basis for Past AHA Guidelines Dental procedures were the source of the bacteremias leading to IE Dental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source) (False, Daily activities much more likely the source)

9 Basis for Past AHA Guidelines 2.True or false 2.True or false Magnitude of dental procedure bacteremias were far greater than daily activities Magnitude of dental procedure bacteremias were far greater than daily activities

10 Basis for Past AHA Guidelines Magnitude of dental procedure bacteremias were far greater than daily activities Magnitude of dental procedure bacteremias were far greater than daily activities (False, they are about the same, both relatively low magnitude) (False, they are about the same, both relatively low magnitude)

11 Basis for Past AHA Guidelines 3.True or false 3.True or false Bleeding is the indication for bacteremia occurring Bleeding is the indication for bacteremia occurring

12 Basis for Past AHA Guidelines Bleeding is the indication for bacteremia occurring Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia) (False, it is not a reliable predictor for bacteremia)

13 Basis for Past AHA Guidelines 4.True or false Prophylaxis reduces the risk of IE from occurring 4.True or false Prophylaxis reduces the risk of IE from occurring

14 Basis for Past AHA Guidelines Prophylaxis reduces the risk of IE from occurring Prophylaxis reduces the risk of IE from occurring (False, antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE) (False, antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)

15 Basis for Past AHA Guidelines 5. True or false The new 2007 guidelines are significantly different than any previous guidelines 5. True or false The new 2007 guidelines are significantly different than any previous guidelines

16 Basis for Past AHA Guidelines The new 2007 guidelines are significantly different than any previous guidelines The new 2007 guidelines are significantly different than any previous guidelines TRUE ! TRUE !

17 Basis for Past AHA Guidelines Based on unproven assumptions Based on unproven assumptions Dental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source) Dental procedures were the source of the bacteremias leading to IE (False, Daily activities much more likely the source) Magnitude of dental procedure bacteremias were far greater than daily activities (False, they are about the same, both relatively low magnitude) Magnitude of dental procedure bacteremias were far greater than daily activities (False, they are about the same, both relatively low magnitude) Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia) Bleeding is the indication for bacteremia occurring (False, it is not a reliable predictor for bacteremia) Prophylaxis reduces the risk of IE from occurring (antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE) Prophylaxis reduces the risk of IE from occurring (antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IE)

18 Rational for 2007 Guidelines Previous 9 AHA Guidelines – Based on the lifetime risk for IE Previous 9 AHA Guidelines – Based on the lifetime risk for IE New Guidelines – Based on the risk for an adverse outcome New Guidelines – Based on the risk for an adverse outcome

19 2007 AHA Guidelines First made public at the annual American Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA. First made public at the annual American Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Circulation 2007; 115:1-17. Available at DOI: /circulationAHA Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Circulation 2007; 115:1-17. Available at DOI: /circulationAHA Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. J Am Dent Assoc 2007:138 (6): Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. J Am Dent Assoc 2007:138 (6):

20 Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesions High-risk lesions Prosthetic heart valves Prosthetic heart valves Previous endocarditis Previous endocarditis Cyanotic CHD Cyanotic CHD Aortic valve disease Aortic valve disease Mitral regurgitation Mitral regurgitation Patent ductus arteriosus Patent ductus arteriosus Ventricular septal defect Ventricular septal defect Coarctation of aorta Coarctation of aorta Intermediate-risk Intermediate-risk MVP with regurgitation MVP with regurgitation Mitral stenosis Mitral stenosis Tricuspid valve disease Tricuspid valve disease Pulmonary stenosis Pulmonary stenosis Septal hypertrophy Septal hypertrophy Degenerative valvular disease in older patients Degenerative valvular disease in older patients Nonvalvular intracardiac prosthetic implants Nonvalvular intracardiac prosthetic implants

21 IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure Prophylaxis may prevent an exceedingly small number, if any, cases of IE in individuals who undergo a dental procedure Prophylaxis may prevent an exceedingly small number, if any, cases of IE in individuals who undergo a dental procedure The risk of antibiotic associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy The risk of antibiotic associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE The AHA cites the following reasons for revision of the 1997 guidelines:

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23 Infective Endocarditis: hypothetical association with dental treatment ? Invasive dental procedures>>>>transient systemic bacteremia (6 min.) Invasive dental procedures>>>>transient systemic bacteremia (6 min.) transient systemic bacteremia (6 min.) >>>>> colonization of susceptible endocardial surfaces ?????? transient systemic bacteremia (6 min.) >>>>> colonization of susceptible endocardial surfaces ?????? colonization of susceptible endocardial surfaces ??????>>>>>>>>IE ?????? colonization of susceptible endocardial surfaces ??????>>>>>>>>IE ??????

24 Infective Endocarditis: hypothetical association with dental treatment ? J. Antimicrobial Chemotherapy, J. Antimicrobial Chemotherapy, A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med :761-9) A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med :761-9) Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006) Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006) Evidence-based…doesnt exist Evidence-based…doesnt exist

25 Rheumatic Heart Disease immune reaction to Streptococci or products immune reaction to Streptococci or products fibrosis, calcification, scarring on valve ( usually mitral or aortic) fibrosis, calcification, scarring on valve ( usually mitral or aortic) damaged & dysfunctional valve leaflets damaged & dysfunctional valve leaflets murmur murmur ventricular dilatation and hypertrophy ventricular dilatation and hypertrophy CHF CHF

26 Rheumatic Heart Disease: concerns angina angina Arrhythmia Arrhythmia dyspnea dyspnea epistaxis epistaxis CHF CHF PV PV IE IE

27 Prosthetic heart valve usually mitral dysfunction RF...RHD……... CHF synthetic replacement = PV

28 Tissue Prosthetic Heart Valve Little JW, Dental Management of the Medically Compromised Patient, Mosby, 2007, p 21

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31 Infective endocarditis fever, murmur, weakness, fatigue, malaisse, anemia,visual problems, GI, weight loss, fever, chills, night sweats, arthralgia, ngina, hematuria, paresthesias or paralysis, petechiae, Osler nodes, Janeway lesions, retinal hemorrhages fever, murmur, weakness, fatigue, malaisse, anemia,visual problems, GI, weight loss, fever, chills, night sweats, arthralgia, ngina, hematuria, paresthesias or paralysis, petechiae, Osler nodes, Janeway lesions, retinal hemorrhages

32 Infective endocarditis Has the risk changed ? Has the risk changed ? Dx (Duke) criteria Dx (Duke) criteria The use of antibiotic prophylaxis has not changed the incidence of IE in > 50 years! The use of antibiotic prophylaxis has not changed the incidence of IE in > 50 years!

33 Infective endocarditis Risk of a brain abcess resulting from extracting a tooth is 1: 10 million ! Risk of a brain abcess resulting from extracting a tooth is 1: 10 million ! Risk of a LPJRI resulting from extracting a tooth is 1: 2.5 million ! Risk of a LPJRI resulting from extracting a tooth is 1: 2.5 million ! Risk of IE resulting with a MVP-r from extracting a tooth is 1: 1 million ! Risk of IE resulting with a MVP-r from extracting a tooth is 1: 1 million ! Risk of IE resulting with RHD from extracting a tooth is 1: 150,000 ! Risk of IE resulting with RHD from extracting a tooth is 1: 150,000 ! Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 ! Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !

34 Infective endocarditis Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 ! Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 ! Risk of IE resulting with any heart condition from any dental procedure is 1:14 million ! Risk of IE resulting with any heart condition from any dental procedure is 1:14 million ! If 10 million patients at risk undergo dental treatment without prophylaxis 20 will get IE and 2 will die, but more than 10 will die from acute anaphylaxis from the PCN ! If 10 million patients at risk undergo dental treatment without prophylaxis 20 will get IE and 2 will die, but more than 10 will die from acute anaphylaxis from the PCN ! Agha Z, et.al. Med. Dec. Mak :

35 Rheumatic Fever and Rheumatic Heart Disease mitral valve damaged 60% of those defects mitral valve damaged 60% of those defects as many as % of cases are un-diagnosed as many as % of cases are un-diagnosed Signs-symptoms Signs-symptoms pharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnea pharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnea lab values: ESR, EKG( PR interval ), strep Ab lab values: ESR, EKG( PR interval ), strep Ab

36 Reported Frequency of Bacteremias Associated With Various Dental Procedures and Daily Activities Procedure Procedure Tooth extraction Tooth extraction Periodontal surgery Periodontal surgery Scaling and root planing Scaling and root planing Teeth cleaning Teeth cleaning Rubber dam matrix/wedge placement Rubber dam matrix/wedge placement Endodontic procedures Endodontic procedures Daily Activities Daily Activities Tooth brushing and flossing Tooth brushing and flossing Use of wooden toothpicks Use of wooden toothpicks Use of water irrigation devices Use of water irrigation devices Chewing food Chewing food Frequency of bacteremia Frequency of bacteremia % % 36-88% 36-88% 8-80% 8-80% 40% 40% 9-32% 9-32% 20% 20% 20-68% 20-68% 20-40% 20-40% 7-50% 7-50% 7-51% 7-51%

37 Initiating Bacteremia Dental Procedures Dental Procedures Most (if not all) are not associated with the onset of IE. Most (if not all) are not associated with the onset of IE. If a dental procedure is possibly associated with the cause of IE, the symptoms of IE should appear within less than 2 weeks. If a dental procedure is possibly associated with the cause of IE, the symptoms of IE should appear within less than 2 weeks. (2:300 law suits…Pallasch)

38 Endocarditis prophylaxis recommended The new guidelines recommend that only individuals who are at the highest risk of an adverse outcome receive antibiotic prophylaxis, and they include:

39 Endocarditis prophylaxis recommended *Prosthetic cardiac valve *Previous infective endocarditis (IE) *Congenital heart disease (CHD) with :

40 Endocarditis prophylaxis recommended - Unrepaired cyanotic CHD, including palliative shunts and conduits - Completely repaired CHD defect with prosthetic material or device for first 6 months after procedure - Repaired CHD with residual defects at the site or adjacent to site of prosthetic patch/ device which inhibit endothelializtion - Cardiac transplantation recipients who develop cardiac valvulopathy

41 Endocarditis prophylaxis Compared with previous AHA guidelines, far fewer patients will receive IE prophylaxis. Consequently, many patients who previously were premedicated for dental procedures are no longer recommended for prophylactic antibiotic coverage.

42 Endocarditis prophylaxis * The AHA committee feels that IE is much more likely to result form frequent exposure to transient bacteremia associated with daily activities (brushing, chewing food) than from bacteremia caused by a dental procedures.. *Prophylaxis may prevent an exceedingly small number of cases of IE (if any) in individuals who undergo a dental procedure.

43 Endocarditis prophylaxis *The risk of antibiotic-associated adverse events exceeds the benefit (if any) from prophylactic antibiotic therapy. *Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure in reducing the risk of IE.

44 Conditions Recommended for Coverage in 2007 Based on greatest risk for adverse outcome Based on greatest risk for adverse outcome Prosthetic Cardiac Valve Prosthetic Cardiac Valve Previous Infective Endocarditis Previous Infective Endocarditis Congenital Heart Disease (CHD) Congenital Heart Disease (CHD) Unrepaired cyanotic CHD including those with palliative shunts and conduits Unrepaired cyanotic CHD including those with palliative shunts and conduits Completely repaired CHD with prosthetic material or device for first 6 months Completely repaired CHD with prosthetic material or device for first 6 months Repaired CHD with residual defects at the site Repaired CHD with residual defects at the site Cardiac Transplantation Recipients who Develop Cardiac Valvulopathy Cardiac Transplantation Recipients who Develop Cardiac Valvulopathy

45 Endocarditis prophylaxis NOT recommended (1997 vs 2007) functional heart murmurs functional heart murmurs post-coronary surgeries > 6 mos. post-coronary surgeries > 6 mos. RF, RHD, most congential defects RF, RHD, most congential defects MVP with or without regurgitation MVP with or without regurgitation pacemakers pacemakers

46 Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesions High-risk lesions Prosthetic heart valves Prosthetic heart valves Previous endocarditis Previous endocarditis Cyanotic CHD Cyanotic CHD Aortic valve disease Aortic valve disease Mitral regurgitation Mitral regurgitation Patent ductus arteriosus Patent ductus arteriosus Ventricular septal defect Ventricular septal defect Coarctation of aorta Coarctation of aorta Intermediate-risk Intermediate-risk MVP with regurgitation MVP with regurgitation Mitral stenosis Mitral stenosis Tricuspid valve disease Tricuspid valve disease Pulmonary stenosis Pulmonary stenosis Septal hypertrophy Septal hypertrophy Degenerative valvular disease in older patients Degenerative valvular disease in older patients Nonvalvular intracardiac prosthetic implants Nonvalvular intracardiac prosthetic implants

47 1997 : Endocarditis prophylaxis NOT recommended routine restorative procedures routine restorative procedures placement of rubber dams placement of rubber dams routine local anesthetic injections routine local anesthetic injections intracanal endo; suture removal intracanal endo; suture removal impressions, fluoride, radiographs impressions, fluoride, radiographs insertion or adjustment of removable prosthetic or ortho appliances insertion or adjustment of removable prosthetic or ortho appliances

48 1997 : Endocarditis prophylaxis recommended extractions extractions perio surgery-scaling-probing-prophy perio surgery-scaling-probing-prophy implants( or re-implantation) implants( or re-implantation) endo(only beyond apex) endo(only beyond apex) subgingival manipulation( antibiotic fibers) subgingival manipulation( antibiotic fibers) initial placement of ortho bands initial placement of ortho bands intraligamentary injections intraligamentary injections

49 2007 : Endocarditis prophylaxis recommended Any procedure which abrogates the mucosal barrier and causes ANY bleeding ! Any procedure which abrogates the mucosal barrier and causes ANY bleeding ! The amount of bleeding has no impact upon the risk for IE ! The amount of bleeding has no impact upon the risk for IE !

50 2007 AHA Guidelines – Dental Procedures recommended for Prophylaxis All Dental Procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (Includes many procedures that in the 1997 guidelines were not recommended for coverage) All Dental Procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (Includes many procedures that in the 1997 guidelines were not recommended for coverage)

51 Prevention of Infective Endocarditis : NOTE The MOST important factor is to maximize oral health and reduce oral microflora The MOST important factor is to maximize oral health and reduce oral microflora minimize oral tissue trauma minimize oral tissue trauma periodontal and plaque control periodontal and plaque control antimicrobial mouthrinses antimicrobial mouthrinses proper AHA prophylactic regimen ONLY when indicated proper AHA prophylactic regimen ONLY when indicated

52 Prevention of Infective Endocarditis : standard : Amoxicillin- 2 g; min. pre-op standard : Amoxicillin- 2 g; min. pre-op IM or IV: Ampicillin-2g; 30 min. pre-op IM or IV: Ampicillin-2g; 30 min. pre-op allergic : Clindamycin- 600mg; min. pre-op Cephalexin- 2 g one-hour pre-op allergic : Clindamycin- 600mg; min. pre-op Cephalexin- 2 g one-hour pre-op Cefadroxil Cefadroxil Azithromycin or Clarithromycin- 500mg-1 hr. Azithromycin or Clarithromycin- 500mg-1 hr. aller-npo: Clindamycin- 600mg -IV; aller-npo: Clindamycin- 600mg -IV; - or Cefazolin- 1 g; 30 min. pre-op - or Cefazolin- 1 g; 30 min. pre-op

53 Antibiotic prophylaxis Does it really do any good ? Does it really do any good ?

54 Amoxicillin Bioavailability > 95 % Bioavailability > 95 % Rapid GI absorption from po Rapid GI absorption from po Works fast Works fast Resistance ( >95 % K. pneumoniae in Japan) Resistance ( >95 % K. pneumoniae in Japan)

55 Antibiotic Prophylaxis Antibiotic Resistance Antibiotic Resistance About 17% to 50% of the viridans group of streptococci are resistant to penicillin and 13% to 27% are resistant to clindamycin. About 17% to 50% of the viridans group of streptococci are resistant to penicillin and 13% to 27% are resistant to clindamycin. Impact on IE prevention is unknown. Impact on IE prevention is unknown.

56 Infective endocarditis 2007…..there is no evidence that dental treatment causes infective endocarditis or that antibiotic prophylaxis is preventive 2007…..there is no evidence that dental treatment causes infective endocarditis or that antibiotic prophylaxis is preventive >95% of IE = no relation at all to dental Tx >95% of IE = no relation at all to dental Tx physiologic bacteremias regular toothbrushing= 0-40% chewing= % cleaning-irrigating devices= 7-50% random periodontal disese= 11-20% physiologic bacteremias regular toothbrushing= 0-40% chewing= % cleaning-irrigating devices= 7-50% random periodontal disese= 11-20%

57 Infective endocarditis Toothbrushing 2 x daily = 150,000 times risk if IE than extracting a tooth ! Toothbrushing 2 x daily = 150,000 times risk if IE than extracting a tooth ! All daily activities= 5 million times risk if IE than extracting a tooth ! All daily activities= 5 million times risk if IE than extracting a tooth !

58 Endocarditis prophylaxis issues already on previous regimen already on previous regimen already on an antibiotic ( lower dose) already on an antibiotic ( lower dose) how much dental treatment (appt. length) how much dental treatment (appt. length) interval between appointments interval between appointments Patient forgot to take the antibiotic Patient forgot to take the antibiotic IBD( colitis) and clindamycin IBD( colitis) and clindamycin not the same as prevention of late prosthetic joint infections not the same as prevention of late prosthetic joint infections

59 Antibiotic prophylaxis If prophylaxis is not possible, administering the antibiotic within 2 hours may help prevent IE If prophylaxis is not possible, administering the antibiotic within 2 hours may help prevent IE time between prophylaxis coverage periods = 10 days ! Do as much treatment as possible during coverage period time between prophylaxis coverage periods = 10 days ! Do as much treatment as possible during coverage period Rxd antibiotics (not sufficient type or dose) Rxd antibiotics (not sufficient type or dose) Pre-op antimicrobial mouthrinses have not shown any benefit Pre-op antimicrobial mouthrinses have not shown any benefit monitor for signs-symptoms of IE monitor for signs-symptoms of IE

60 2007 AHA Guidelines Patients who undergo cardiac surgery Patients who undergo cardiac surgery A careful dental evaluation is recommended so that required dental treatment may be completed whenever possible before cardiac valve surgery or replacement or repair of CHD. A careful dental evaluation is recommended so that required dental treatment may be completed whenever possible before cardiac valve surgery or replacement or repair of CHD.

61 Endocarditis Prevention Current practice Current practice Identify the susceptible patient and use antibiotic prophylaxis for indicated dental procedures Identify the susceptible patient and use antibiotic prophylaxis for indicated dental procedures Medical referral to establish current status may be needed to for patients with CHD corrected with prosthetic material or devices. Medical referral to establish current status may be needed to for patients with CHD corrected with prosthetic material or devices. Within 6 months of corrective surgery Within 6 months of corrective surgery Residual defect (leakage) Residual defect (leakage)

62 Nonvalvular Cardiovascular Devices AHA does not recommend prophylaxis Pacemakers Pacemakers Defibrillators Defibrillators Left ventricular assist devices Left ventricular assist devices Total artificial hearts Total artificial hearts Arteriovenous fistulae Arteriovenous fistulae Closure devices for ASD, PDA, AVF Closure devices for ASD, PDA, AVF Hemodialysis grafts Hemodialysis grafts Vascular grafts Vascular grafts Intra-aortic balloon pumps Intra-aortic balloon pumps Dacron grafts and patches Dacron grafts and patches Vena caval filters Vena caval filters Vascular closure devices Vascular closure devices Ventriculoatrial shunts Ventriculoatrial shunts Coronary artery stents Coronary artery stents AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

63 Nonvalvular Cardiovascular Devices AHA does recommend Prophylaxis AHA does recommend Prophylaxis Incision and Drainage of infection at other sites (I & D of dental abscess) Incision and Drainage of infection at other sites (I & D of dental abscess) Extraction of teeth or surgical procedures performed in areas of acute infection Extraction of teeth or surgical procedures performed in areas of acute infection Residual leak following closure of PDA, ASD, VSD (follow AHA guidelines) Residual leak following closure of PDA, ASD, VSD (follow AHA guidelines) AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

64 Impact of 2007 Guidelines Patients who have taken antibiotics for years to prevent IE and now no longer are recommended to do such. Patients who have taken antibiotics for years to prevent IE and now no longer are recommended to do such. Patients who are still recommended to be covered but now for just about all dental procedures. Patients who are still recommended to be covered but now for just about all dental procedures. Explain rational for new guidelines, answer questions, consult with patients physician – informed consent (record in progress notes). Explain rational for new guidelines, answer questions, consult with patients physician – informed consent (record in progress notes).

65 Impact of 2007 Guidelines Pallasch TJ. CDAJ 2007:35(7): MD or patient non-acceptance: they can provide the Rx upon their own authority MD or patient non-acceptance: they can provide the Rx upon their own authority Based upon the best current scientific evidence as published by the AHA, and my best clinical judgement. Based upon the best current scientific evidence as published by the AHA, and my best clinical judgement.

66 Congenital heart disease- dental concerns Endocarditis Endocarditis Congestive heart failure Congestive heart failure Endarteritis Endarteritis Excessive bleeding Excessive bleeding Cyanosis Cyanosis Infection Infection

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68 What is Next 2007 Guidelines – Foundation set 2007 Guidelines – Foundation set Dental procedures not cause Dental procedures not cause No evidence that prophylaxis is effective No evidence that prophylaxis is effective Adverse reactions to antibiotics Adverse reactions to antibiotics Increasing rate of resistance to antibiotics Increasing rate of resistance to antibiotics The next set of AHA guidelines will not recommend prophylaxis for any dental procedure even in patients with cardiac lesions with the greatest risk for adverse outcomes The next set of AHA guidelines will not recommend prophylaxis for any dental procedure even in patients with cardiac lesions with the greatest risk for adverse outcomes

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71 Prevention of Endocarditis General concepts General concepts Goal of infection free oral cavity Goal of infection free oral cavity Follow the current (2007) AHA guidelines for selection of cardiac conditions and dental procedures needing prophylaxis Follow the current (2007) AHA guidelines for selection of cardiac conditions and dental procedures needing prophylaxis Reduce gingival inflammation before performing restorative procedures Reduce gingival inflammation before performing restorative procedures Establish effective home care practices Establish effective home care practices Chlorhexidine mouth rinse can be used prior to periodontal or surgical procedures, however several studies suggest no real benefit Chlorhexidine mouth rinse can be used prior to periodontal or surgical procedures, however several studies suggest no real benefit

72 Prevention of Endocarditis General principles Cont. General principles Cont. Coverage is effective for 4-6 hours Coverage is effective for 4-6 hours Do as much dental treatment as possible during each coverage period Do as much dental treatment as possible during each coverage period Allow at least 9 days to elapse between coverage periods. If this is not possible select an alternant antibiotic Allow at least 9 days to elapse between coverage periods. If this is not possible select an alternant antibiotic Be alert for signs and symptoms of IE in patients receiving antibiotic prophylaxis and those with cardiac lesions at risk for IE Be alert for signs and symptoms of IE in patients receiving antibiotic prophylaxis and those with cardiac lesions at risk for IE

73 hours µg/ml 3g Amox 1.5 g Amox 1 g PenVK plasma levels of prophylactic antibiotics 2 g Amox

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75 Late Prosthetic Joint Infections Wahls myths: #1: There are similarities between IE (PVE) and LPJI.NO. #2: Dental treatment is a probable cause of LPJI.NO. #3: Animal experiments document dental bacteremias as cause of LPJI.NO. #4: To protect patients DDS should always cover patients with PJ.NO. Wahls myths: #1: There are similarities between IE (PVE) and LPJI.NO. #2: Dental treatment is a probable cause of LPJI.NO. #3: Animal experiments document dental bacteremias as cause of LPJI.NO. #4: To protect patients DDS should always cover patients with PJ.NO.

76 Prevention of late Prosthetic joint infections: 1997 changes ADA/AAOS advisory statement ADA/AAOS advisory statement medical consultation with Orthopod medical consultation with Orthopod No prophylaxis for pins, rods, screws, plates, wires, implants, etc. No prophylaxis for pins, rods, screws, plates, wires, implants, etc. healthy patient: < 2 yrs. after TJR healthy patient: < 2 yrs. after TJR chronic RA or other infection of TJR chronic RA or other infection of TJR immunocompromised patients immunocompromised patients

77 Prevention of late Prosthetic joint infections: 1997 changes Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op Cephalexin ( Keflex) 2g ; po ; 1 hr. pre-op Cephazolin; 1 g; IM/IV; 1 hr. pre-op Cephazolin; 1 g; IM/IV; 1 hr. pre-op Clindamycin; 600mg.; po; 1 hr. pre-op Clindamycin; 600mg.; po; 1 hr. pre-op

78 ANTIBIOTICS Other indications for antibiotic prophylaxis: Other indications for antibiotic prophylaxis: HIV HIV ESRD : hemodialysis ESRD : hemodialysis IDDM IDDM Autoimmune diseases; SLE Autoimmune diseases; SLE Splenectomy Splenectomy CHF, CVA; thromboemboli CHF, CVA; thromboemboli Liver disease Liver disease Organ transplants Organ transplants

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80 Congenital heart disease- dental concerns Endocarditis Endocarditis Congestive heart failure Congestive heart failure Endarteritis Endarteritis Excessive bleeding Excessive bleeding Cyanosis Cyanosis Infection Infection

81 Rheumatic Heart Disease DETECTION history echocardiography chest radiographs EKG auscultation DETECTION history echocardiography chest radiographs EKG auscultation

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84 Basis for 2007 Guidelines Adverse Outcomes Adverse Outcomes Valvular dysfunction Valvular dysfunction Congestive heart failure Congestive heart failure Need for valvular replacement Need for valvular replacement Multiple embolic events Multiple embolic events Death Death


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