Invasive Dental Procedures: “Primum non nocere”

1. Invasive Dental Procedures: “Primum non nocere” Arnold Seto, MD, MPA Assistant Professor, Cardiology UC-Irvine and Long Beach VA

2. Goals • Medical risk assessment for dental procedures • New Guidelines on Antibiotic prophylaxis for infective endocarditis • Evidence

3. Can we provide dental treatment to the patient without endangering their (or our) health and well being? Is the benefit of having dental treatment worth the risk to the patient?

4. Instill fear Inflict pain Inject local anesthetic solutions Inject potent vasoconstrictors Cause bleeding Control body position Expose to radiation Expose to dental materials Prescribe medications Alter oral function Cause inflammation What do you do in the course of providing dental care that can affect the health and well being of a patient?

5. Syncope 15,407 Mild Allergic Reaction 2,583 Angina Pectoris 2,552 Postural Hypotension 2,475 Seizures 2,195 Asthmatic Attack 1,392 Hyperventilation 1,326 “Epinephrine Reaction” 913 Insulin Shock 890 Cardiac Arrest 331 Anaphylaxis 304 Myocardial Infarction 289 Most Common Medical Emergencies in Dental Practice (4000 dentists over 10 years) Many of these events are preventable, or at least the chances of them occurring can be reduced

6. Risk of Vascular Events

9. Risk Factors for the Occurrence of Adverse Events • Dependent upon 4 factors: • The medical condition of the patient (diagnosis, severity, stability, control) • The nature of the dental procedure (invasiveness, length of procedure, blood loss, type of anesthesia, use of vasoconstrictor) • The cardiopulmonary reserve which is the ability to respond to physical/emotional challenges (METs; oxygen utilization); can the patient climb a flight of stairs without chest pain or shortness of breath = 4 METs • The emotional stability of the patient (fear, anxiety)

10. Risk Assessment Medical Condition? Severity Stability Control Functional Capacity? METs Emotional Status? Fear Anxiety Dental Procedure? Invasiveness Length of procedure Blood Loss Vasoconstrictor use Increased Risk Decreased Risk

11. Risk Assessment Increased Risk Medical Condition? Recent heart attack Labile Hypertension Dental Procedure? Full mouth extraction Functional Capacity? Climbing a flight of stairs causes chest pain and shortness of breath Emotional Status? Afraid of the dentist

12. Risk Assessment Medical Condition? Stable Angina Dental Procedure? Exam and x-rays Functional Capacity? Can climb a flight of stairs Emotional Status? Doesn’t like dentists Decreased Risk

13. Risk Assessment? Can we provide routine dental treatment to this patient without endangering their (or our) health and well being? Yes. No problems are anticipated, and treatment can be delivered in the usual manner. (Benefit >> Risk) Yes, but potential problems may be anticipated, and modifications in the delivery of treatment are necessary. (Benefit > Risk) No. Potential problems exist that are serious enough to make it inadvisable to provide elective dental treatment. (Risk > Benefit)

14. Risk vs Benefit • You may not be able to completely eliminate the risk of an adverse event occurring during dental treatment or as a result of dental treatment, however, our goal is to reduce that risk as much as possible • The issue then becomes whether the remaining risk is acceptable and that having the dental treatment is of more benefit than not having it

15. Biggest risk? Delaying needed dental care • Periodontal disease is a chronic gram-negative infection, affecting up to 75% of adults • Periodontal disease is associated with markers of chronic inflammation like CRP • Chronic inflammation has been associated with progression of coronary artery disease, which is itself an inflammatory state • Periodontal treatment reduces markers of inflammation • Collected studies suggest an 24-35% increased risk of CAD in patients with periodontal disease

16. CV risk in Periodontal Patients Humphrey, J. Gen Int Med 23 (12): 2079-86

19. Effect of periodontal treatmenton vascular endothelium Flow-Mediated Dilatation during the 6-Month Study Period Tonetti MS et al. N Engl J Med 2007;356:911-920

20. Circulating Biomarkers in the Two Groups during the 6-Month Study Period • Intensive periodontal treatment resulted in acute, short-term systemic inflammation and endothelial dysfunction • However, 6 months after therapy, the benefits in oral health were associated with improvement in endothelial function Tonetti MS et al. N Engl J Med 2007;356:911-920

21. Periodontal disease and medical risk • In general, most periodontal procedures are low risk and likely have CV benefits. • Only patients at highest risk of medical instability require delay of care and medical evaluation • Unstable angina • Uncontrolled hypertension • Decompensated congestive heart failure

22. Management of antiplatelet agents during dental procedures • Aspirin – should generally be continued for all coronary artery disease patients • Clopidogrel (Plavix) – should be continued for up to 1 year after myocardial infarction and stenting, to minimize the risk of stent thrombosis

24. Subacute stent thrombosis

26. Management of anticoagulants • Warfarin (Coumadin) – can usually be stopped for 5-7 days preoperatively, and restarted • Most patients – Atrial fibrillation, stroke, history of deep venous thrombosis • Other patients at higher risk – recent DVT/PE, artificial heart valves require close monitoring and possibly bridging therapy with heparin. CONSULT. • Dabigatran (Pradaxa) – new oral anticoagulant replacing warfarin. Can be stopped just 1 day prior to procedure, and restarted thereafter

27. Dental management of hypertension • Identify patients with hypertension both diagnosed or undiagnosed. • Medical history include diagnosis of it, how it is being treated, identification of antihypertension drugs, compliance of the patient, the presence of the symptoms associated with hypertension and stability of the disease. • Blood pressure measurement should be routinely performed for all new patient and recall appointments • Stress and anxiety management which increase BP(relationship among dentists, patient & office staff and longer stressful appointment are best avoided and short morning appointment are recommended) .

28. Management of antihypertensives • Most should generally be continued to minimize hypertensive reactions to • Clonidine is especially prone to withdrawal hypertension and should be continued • Abort the procedure if BP > 180/110

29. Highest Risk Patients • Recent myocardial infarction (< 3months) • Active unstable angina • Decompensated congestive heart failure • Recommendations: • Avoid elective care • If treatment is necessary , consult with physician and limit treatment to pain relief, treatment of acute infection, or control bleeding • Consider including the following: • Prophylactic nitroglycerin • Placement of intravenous line • Sedation • Oxygen • Continuous electrocardiodiographic monitoring • Pulse oximeter • Frequent monitoring of BP • Cautious use of epinephrine in local anesthetic.

30. Other risk reduction measures(Intermediate risk patients) • Morning appointment • Short appointment • Comfortable chair position • Pretreatment vital signs • Nitroglycerin readily available • Stress-reduction measures • Good communication • Oral sedation(e.g triazolam 0.125-0.25mg on the night before & 1hr before appointment • Intraoperative N2O/O2 • Excellent local anesthesia • Limit use of vasoconstrictor (max.0.038mg epinephrine) • Avoidance of epinephrine-impregnated retraction cord • Adequate postoperative pain control

32. Bacterial Endocarditis A microbial infection of the endothelial lining of the heart; most commonly occurring as a vegetation on the valve leaflets

33. Mortality Rates • 100% fatal if not treated • With antibiotic treatment, fatality rate: • NVE (native valve) • Streptococcus <10% • Staphylococcus 25-40% • Gram negatives 75-83% • Fungi 50-60% • Late PVE (prosthetic valve) 30-53%

34. Endocarditis description • “At any rate, at approximately one-quarter to twelve that night, I remember distinctly getting up from my chair and from the table, where my books lay, and taking off my suit coat. No sooner had I removed the left arm of my coat, than there was on the ventral aspect of my left wrist a sight which I shall never forget until I die. There greeted my eyes about fifteen or twenty bright red, slightly raised, hemorrhagic spots about 1 millimeter in diameter which did not fade on pressure and which stood defiant as if they were challenging the very gods of Olympus. ... I took one glance at the pretty little collection of spots and turned to my sister-in-law, who was standing nearby, and calmly said: ‘I shall be dead within six months.” • - Alfred Reinhardt, Harvard Medical Student, 1931

35. Pathogenesis of BE • Anatomic/physiologic predisposition (endothelial damage) • Non-bacterial thrombotic endocarditis(NBTE) • Bacteremia (source??) • Bacterial colonization of vegetation • Additional deposition and growth of thrombus • Embolization and bacteremia

36. Pathogenesis Mandell

38. Board Review Question • Which organism is the most commonly cause of endocarditis in periodontal disease patients? • A) Strep viridans • B) Staph aureus • C) Candida albicans • D) Coagulase negative staph • E) Enterococcus

40. Diagnosis

41. Modified Duke Criteria

42. Modified Duke Criteria

43. Tender subcutaneous nodules Pulps of digits or thenar eminence Osler’s Node

45. Janeway Lesions • Nontender • Hemorrhagic • Palms and soles • Erythematous

46. Splinter Hemorrhage • Finger and toenails • Nonspecific • Linear and red • Brown after 2-3 d

47. Roth Spots

49. Valve Surgery

50. Prophylaxis for IE: First origins • 1943, Northrup and Crowley postulated that most IE were caused by dental extractions and that Abx would prevent IE. • Identified 20% of patients with IE had preceding dental procedures • Gave sulfa to separate cohort receiving dental extractions and found that all patients had sterile blood cultures. • Concluded that Abx prevent IE and should be given. • AHA issued first recommendations in 1955 Northrup, Crowley. J Oral Surgery 1943; 1:19-29