1. The aim of focal infections in dentistry
Dr. Mensch Károly
2018

2. Questions
1 . Contraindication of dental treatment related to general health condition
2. What are the problems associated with chronic myeloproliferative diseases from in dentistry?
3. List some states with immundeficiency
4. What kind of INR should not be changed the anticoagulkant therapy?
5. When not to recommand /prescribe a conventional non-steroid medication?

3. Answers
Acut infestive diseases, AMI, hospitalisation (psychiatric diseases, anaphylaxia in anamnesis…)
Haemorrhagia, immundeficiency, ulcus
Transplantation, chemoth, HIV, biological th
Under 3,5
Gastroduodenal ulcer, gastrointestinal bleeding in anamnesis

4. Importance Organism affects the oral cavity
BUT the oral cavity affects the organism
Oral cavity: the most infected organ
Role of dentists: Identificate the lesions of oral cavity, prevent and treat them

7. Definition- Focal infection
An acute or chronic infection in which bacteria are localized in some region of the body, as the tonsils or the periodontal tissue, from which they or their metabolites or toxines may spread to some other organ or structure of the body causing secunder diseases

8. Characteristics of focal infections
Chronically infected areas
Asymptomatic or few symptomes
Encumbering the organisation via various mechanism
Open or closed focals

9. Dental Focuses Open focuses
Caries lesions: microorganism from the caries surface can pass into the blood-stream via micro-traumas
Gingivitis, periodontitis: OPEN focuses
Alveolitis: bacteria can pass into the blood-stream from destructed and infected coagulum

10. Periodontitis- as focus
The cause is the dental plaque: >99% of microorganisms
Deep pockets contact with the periodontal connective tissue and capillars
In the case of it, the bacteria can spread during chewing and tooth-brushing
IF, we hypotize 5mm deep pockets around every teeth = 100 squarecentimeter wound

11. Dental Focuses Closed focuses: Necrosis of pulp Periapical lesions
Incomplete root-canal fillings (theoretically every root canal treated teeth are focus, we have to reflect the case.. )
Radix relicta
Residual cyst
Impacted teeth with follicular cyst

12. Mechanisms of focal infections
Metastatic infection from oral cavity via transient bacteremia
Metastatic toxical effect: via toxins of oral microorganisms
Metastatic inflammation: cascade of immune-mechanisms
Via inflammatory cytokines: microorganisms product cytokines: damage in an other area of body

13. Bacteriemia Dental treatmens with bacteriemia!
Supra and subgingival scaling, curettage
Extraction, oral-surgical treatments
Endodontic treatments
Intraligamental anesthesia
BUT during tooth-brushing also (poor oral hygiene)
30 sec after treatment, but latest in 10 Min

14. By Zaid Muwafaq

15. Focal infections
If the cause of some disease of an organ is a chronical inflammation of an other organ (far from the damaged area)= focal infection
Most common chronical inflammations causing focal infection:
Dental focus- MOST COMMON
Common: upper respiratory-tract: Tonsillitis follicularis
10%: gall bladder, appendix, prostata, female genital tract

16. Secunder focal infections
Cardiovascular diseases: Atherosclerosis, AMI, STROKE, IE
Respiratory diseases
Diabetes Mellitus
Premature birth
Rheumatoid arthritis
Nephritis
Inflammation of the Iris
Allopecia areata
Eczema

17. Cardiovascular focal-infections
Atherosclerosis: Chr. Periodontitis: Porphyromonas ging, Tenerella forsythia isolates from atheroma
Ischemic heart diseases, acute myocardial infarct
Stroke
Infective endocarditis: Streptococcus, Actinobacillus, Fusobacterium, Eikenella Bacteremia case of poor oral hygiene, during chewing or bleeding dental treatment ANAMNESIS, ORAL HYGIENE, PROPHYLAXIS

18. By Sarah BC Williams

19. Infective Endocarditis prophylaxis
Injure of endotheldeposit of thrombocyts bacteriemia: bacteria into this deposits: endocardial vegetations
High mortality
NOT common: souls- 30 cases /year

20. Need of IE prophylaxis Moderate Risk patients: High Risk Patients:
heart valve diseases
hypertrophic cardiomyopathy
mitrale valve prolapse
High Risk Patients:
artificial heart valve
pulmonal shunt
anamnesis: endocarditis
cyanotic heart diseases

21. IE Prophylax NOT needed:
Atrial heart diseases
Operated ventriculare diseases
Operated coronary diseases
Pacemaker
Making prostese, Impression, Filling, X-ray

22. IE prophylaxis Moderate Risk patients: High Risk Patients:
2g Penicillin, 1h before the treatment,
Penicillin allergy: 600 mg Clyndamycin per os, or 1g vancomycin IV
High Risk Patients:
+ 1,5 mg gentamycin before the treatment, 6 hours after treatmen again
If possible in one seat! RESISTENCE

23. Respiratory focal-deseases
Aspiration Pneumonia: Periodontopathogens: Actinobacillus, Eikenella, Fusobacterium: NOSOCOMIAL PNEUMONIA. Intubation, artifitial respiration: CHX prophylax
COPD: Case of Periodontitis: more common

24. Rheumatoid Arthritis Autoimmun Desease
Porphyromonas ging. was isolated from synovia: CCP (cyclic citrullinated peptide) catalysis: Autoimmun process

25. Diabetes Mellitus, as Focal Disease
There-and-back effect!
Mainly: cause of NIDDM
Bekteriemia: Increas the inzulinresistance of tissues
Untreated periodontitis: more severe Diabetes

26. Premature birth- dental focus
According to literature: >4mm Pocket + 50% BOP significant higher risk to premature birth
Mother with vs without periodontitis? weight of newborns: 2834g vs 3180g
Group of mothers has premature birth: more komplex microflora in the oral cavity
Porphyromonas gingivalis, Fusobacterium nucleatum, Lactobacillus: leading role in premature-birth causing by periodontitis. Increased Prostaglandin level, (contraction of myometrium)

27. Alopecia areata Follicular hair loss Unclear pathomechanism
Dental focal: sure, IF the hair-loss will end after remove the focal-tooth.
Lokalization: same side, Maxilla: cranial direction; Mandibula: caudal direction

29. Psoriasis Papulosqamous skin-disease
White or red hyperkeratotic maculas overall the body
Caused by extrinsic or intrinsic triggers
Dental focal can be a trigger also
Unclear!

30. Uveitis Inflammatory desease of the eyes (Iris, Uvea, Corpus ciliare)
Pain, twinge of the eye, red eyes, unclear view
Focal infection??? BUT Have to think!

31. Dental focal- consultation
Every day in the praxis
Responsibility!
Clinical and radiological examination
Expertise

32. Where are the patiens coming from?
Dermatologist- alopecia areata, ekzema, psoriasis
Gynecologist, Urologist
Rheumatologist
CARDIOLOGIST
Prior to TRANSPLANTATION
Prior to Bispfosphonate treatment ?? 

33. Steps of dental focal examination
General anamnesis- e.g. IE
Extraoral examination- Lymphnodes (acute, mobile, painful!!)
Examination of teeth
OPG, intraoral X-ray
Expertise
We have to give coverage for the Patient

34. Clinical examination of teeth
BOP, Pocket depth !!!
Mobile teeth- Periodontis
Big caries leasions, fillings, crowns:
Sensibility examination
Vertical and horizontal percussion
Palpation of apical region

35. Radiological examination
OPG: not enough!- only show us which teeth we have to make an IO X-rey from- RCT, Radix, periapical tissue. BUT able to examine the Periodontal status.
IO X-ray needed, if:
Sensibility neg.
Percussion: sensitive teeth
Teeth with sensitive periapical region
Big caries, fillings or teeth with crowns

37. Evaluation of clinical and radiological examination
We have to reflect the secunder focal disease. E.g: prior to a heart transplantation. Radical elimination of every potentially focals (every RCT teeth) but alopecia areata: only the really focals have to be eliminated
RCT teeth:
WITH periapical lesions: really focals
Without of periapical lesions: potentially focals

38. Focal-finding Responsibility
We write our findings only in the case of wroten ask
We have to write: According to our clinical and radiological examination, XY :
Without of any dental focals
Closed focal: e.g. periodontitis apicalis chronica of upper first molar left.
Open focal: caries, gingivitis, periodontitis
Potentially focals: RCT teeth without of periapical lesion

39. Coverage for Patients Why are we looking for a focal?
We write only the Dg, the specialist has to indicate the treatment (Cardiologist, Dermatologist..)!
 Prior to Bisphosphonate treatment: radical elimination of focals would be needed
Where can be treated?

40. Thank you for your attention!