perspectives on the 2007 aha guidelines for the prevention of infective endocarditis nelson l....

Perspectives on the 2007 AHA guidelines for the prevention of infective

endocarditis Nelson L. Rhodus, DMD, MPH, FACD

ProfessorAcademy of Distinguished Professors

Perspectives on the 2007 AHA guidelines for the prevention of infective

endocarditis Nelson L. Rhodus, DMD, MPH, FACD

ProfessorAcademy of Distinguished Professors

Director, Division of Oral Medicine, Dental SchoolDirector, Division of Oral Medicine, Dental School

Adjunct Professor, Otolaryngology, Medical SchoolAdjunct Professor, Otolaryngology, Medical School

Diplomate, American Board of Oral MedicineDiplomate, American Board of Oral Medicine

University of MinnesotaUniversity of Minnesota

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Basis for Past AHA GuidelinesBasis for Past AHA Guidelines

1.1. True or falseTrue or false Dental proceduresDental procedures were the source of the were the source of the

bacteremias leading to IEbacteremias leading to IE


Dental proceduresDental procedures were the source of the were the source of the bacteremias leading to IE bacteremias leading to IE

((False, Daily activities much more likely the False, Daily activities much more likely the sourcesource))


2.2. True or falseTrue or false Magnitude of dental procedure bacteremiasMagnitude of dental procedure bacteremias

were far greater than daily activitieswere far greater than daily activities


Magnitude of dental procedure bacteremiasMagnitude of dental procedure bacteremias were far greater than daily activitieswere far greater than daily activities

((False, they are about the same, both relatively False, they are about the same, both relatively low magnitudelow magnitude))


3.3. True or falseTrue or false

Bleeding Bleeding is the indication for bacteremia is the indication for bacteremia occurringoccurring


Bleeding Bleeding is the indication for bacteremia is the indication for bacteremia occurring occurring

((False, it is not a reliable predictor for False, it is not a reliable predictor for bacteremiabacteremia))


4.4. True or falseTrue or false Prophylaxis reduces the risk Prophylaxis reduces the risk of IE from occurringof IE from occurring


Prophylaxis reduces the risk of IE from occurringProphylaxis reduces the risk of IE from occurring (False, (False, antibiotics may reduce the magnitude of antibiotics may reduce the magnitude of

the bacteremia, no evidence they will reduce the the bacteremia, no evidence they will reduce the incidence of IEincidence of IE))


5. 5. True or falseTrue or false The new 2007 guidelines are The new 2007 guidelines are significantly different than any previous guidelinessignificantly different than any previous guidelines


The new 2007 guidelines are significantly The new 2007 guidelines are significantly different than any previous guidelinesdifferent than any previous guidelines

TRUE !TRUE !

Basis for Past AHA GuidelinesBasis for Past AHA Guidelines Based on unproven assumptionsBased on unproven assumptions Dental procedures were the source of the bacteremias Dental procedures were the source of the bacteremias

leading to IE (leading to IE (False, Daily activities much more likely the False, Daily activities much more likely the sourcesource))

Magnitude of dental procedure bacteremias were far greater Magnitude of dental procedure bacteremias were far greater than daily activities (than daily activities (False, they are about the same, both False, they are about the same, both relatively low magnituderelatively low magnitude))

Bleeding is the indication for bacteremia occurring (Bleeding is the indication for bacteremia occurring (False, False, it is not a reliable predictor for bacteremiait is not a reliable predictor for bacteremia))

Prophylaxis reduces the risk of IE from occurring Prophylaxis reduces the risk of IE from occurring ((antibiotics may reduce the magnitude of the bacteremia, antibiotics may reduce the magnitude of the bacteremia, no evidence they will reduce the incidence of IEno evidence they will reduce the incidence of IE))

Rational for 2007 GuidelinesRational for 2007 Guidelines

Previous 9 AHA Guidelines – Based on the Previous 9 AHA Guidelines – Based on the lifetime risk for IElifetime risk for IE

New Guidelines – Based on the risk for an New Guidelines – Based on the risk for an adverse outcomeadverse outcome

2007 AHA Guidelines2007 AHA Guidelines

First made public at the annual First made public at the annual American Academy of Oral MedicineAmerican Academy of Oral Medicine meeting on May 19, 2007 in San Diego, CA. www.aaom.commeeting on May 19, 2007 in San Diego, CA. www.aaom.com

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et

al. Prevention of Infective Endocarditis: Guidelines From The American Heart al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Association. CirculationCirculation 2007; 115:1-17. Available at 2007; 115:1-17. Available at http://www.http://www.circulationahacirculationaha.org.org, DOI:10.1116/circulationAHA.106.18309., DOI:10.1116/circulationAHA.106.18309.

Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From The American Heart al. Prevention of Infective Endocarditis: Guidelines From The American Heart Association. Association. J Am Dent AssocJ Am Dent Assoc 2007:138 (6): 739-760. 2007:138 (6): 739-760.

Conditions Recommended for Prophylaxis in 1997 vs 2007Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesionsHigh-risk lesions Prosthetic heart valvesProsthetic heart valves Previous endocarditisPrevious endocarditis Cyanotic CHDCyanotic CHD Aortic valve diseaseAortic valve disease Mitral regurgitationMitral regurgitation Patent ductus arteriosusPatent ductus arteriosus Ventricular septal defectVentricular septal defect Coarctation of aortaCoarctation of aorta

Intermediate-riskIntermediate-risk MVP with regurgitationMVP with regurgitation Mitral stenosis Mitral stenosis Tricuspid valve diseaseTricuspid valve disease Pulmonary stenosisPulmonary stenosis Septal hypertrophySeptal hypertrophy Degenerative valvular Degenerative valvular

disease in older patientsdisease in older patients Nonvalvular intracardiac Nonvalvular intracardiac

prosthetic implantsprosthetic implants

IE is much more likely to result from frequent exposure to IE is much more likely to result from frequent exposure to random bacteremias associated with random bacteremias associated with daily activitiesdaily activities than than from bacteremia caused by a dental procedurefrom bacteremia caused by a dental procedure

Prophylaxis may prevent an exceedingly small numberProphylaxis may prevent an exceedingly small number, ,

if any,if any, cases of IE in individuals who undergo a cases of IE in individuals who undergo a dental dental procedureprocedure

The risk of The risk of antibiotic associated adverse eventsantibiotic associated adverse events exceeds exceeds the benefit,the benefit, if any, from prophylactic antibiotic therapy if any, from prophylactic antibiotic therapy

Maintenance of Maintenance of optimal oral health and hygieneoptimal oral health and hygiene may may reduce the incidence of bacteremia from daily activities and reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IEprocedure to reduce the risk of IE

The AHA cites the following reasons for

revision of the 1997 guidelines: The AHA cites the following reasons for

revision of the 1997 guidelines:

Infective Endocarditis: hypothetical association with dental treatment ?


Invasive dental procedures>>>>transient Invasive dental procedures>>>>transient systemic bacteremia (6 min.) systemic bacteremia (6 min.)

transient systemic bacteremia (6 min.) transient systemic bacteremia (6 min.) >>>>> colonization of susceptible >>>>> colonization of susceptible endocardial surfaces ?????? endocardial surfaces ??????

colonization of susceptible endocardial colonization of susceptible endocardial surfaces ??????>>>>>>>>IE ??????surfaces ??????>>>>>>>>IE ??????



J. Antimicrobial Chemotherapy, 4-19-2006J. Antimicrobial Chemotherapy, 4-19-2006 A study of 273 patients = no link between A study of 273 patients = no link between

dental treatment and IE (Strom BL., dental treatment and IE (Strom BL., Ann Int Med 1998 129:761-9)Ann Int Med 1998 129:761-9)

Cochrane review: no evidence to support Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006)invasive dental procedures( Oliver R. 2006)

Evidence-based…doesn’t existEvidence-based…doesn’t exist

Rheumatic Heart DiseaseRheumatic Heart Disease

immune reaction immune reaction to Streptococci or productsto Streptococci or products fibrosis, calcification, scarring on valve fibrosis, calcification, scarring on valve

( usually mitral or aortic)( usually mitral or aortic) damaged & dysfunctional valve leafletsdamaged & dysfunctional valve leaflets murmurmurmur ventricular dilatation and hypertrophyventricular dilatation and hypertrophy CHFCHF

Rheumatic Heart Disease: concernsRheumatic Heart Disease: concerns anginaangina ArrhythmiaArrhythmia dyspnea dyspnea epistaxisepistaxis CHFCHF PVPV IEIE

Prosthetic heart valveProsthetic heart valve

usually mitral dysfunctionusually mitral dysfunction

RF...RHD……... CHFRF...RHD……... CHF

synthetic replacement = PVsynthetic replacement = PV

Tissue Prosthetic Heart ValveTissue Prosthetic Heart Valve

Little JW, Dental Management of the Medically Compromised Patient, Mosby, 2007, p 21

Infective endocarditisInfective endocarditis

fever, murmur, weakness, fatigue, malaisse, fever, murmur, weakness, fatigue, malaisse, anemia,visual problems, GI, weight anemia,visual problems, GI, weight

loss,loss, fever, chills, night sweats, arthralgia,fever, chills, night sweats, arthralgia,ngina, hematuria, paresthesias or ngina, hematuria, paresthesias or

paralysis, petechiae, Osler paralysis, petechiae, Osler nodes, nodes, Janeway lesions, retinal Janeway lesions, retinal hemorrhageshemorrhages


Has the risk changed ?Has the risk changed ? Dx (Duke) criteriaDx (Duke) criteria The use of antibiotic prophylaxis has not The use of antibiotic prophylaxis has not

changed the incidence of IE in > 50 years!changed the incidence of IE in > 50 years!


Risk of a brain abcess resulting from extracting a tooth is Risk of a brain abcess resulting from extracting a tooth is 1: 10 million !1: 10 million !

Risk of a LPJRI resulting from extracting a tooth is Risk of a LPJRI resulting from extracting a tooth is 1: 2.5 million !1: 2.5 million !

Risk of IE resulting with a MVP-r from extracting a tooth Risk of IE resulting with a MVP-r from extracting a tooth is is 1: 1 million !1: 1 million !

Risk of IE resulting with RHD from extracting a tooth is Risk of IE resulting with RHD from extracting a tooth is 1: 150,000 !1: 150,000 !

Risk of IE resulting with PVR from extracting a tooth is Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !1: 95,000 !


Risk of IE resulting with PVR from extracting a tooth is Risk of IE resulting with PVR from extracting a tooth is 1: 95,000 !1: 95,000 !

Risk of IE resulting with any heart condition from any Risk of IE resulting with any heart condition from any dental procedure is 1:14 million !dental procedure is 1:14 million !

If 10 million patients at risk undergo dental treatment If 10 million patients at risk undergo dental treatment without prophylaxis 20 will get IE and 2 will die, but more without prophylaxis 20 will get IE and 2 will die, but more than 10 will die from acute anaphylaxis from the PCN !than 10 will die from acute anaphylaxis from the PCN !

Agha Z, et.al. Med. Dec. Mak. 2005 25:308-320.Agha Z, et.al. Med. Dec. Mak. 2005 25:308-320.

Rheumatic Fever and Rheumatic Heart DiseaseRheumatic Fever and Rheumatic Heart Disease mitral valve damaged mitral valve damaged 60%60% of those defects of those defects

as many as as many as 30-40 %30-40 % of cases are of cases are un-diagnosed un-diagnosed

Signs-symptomsSigns-symptoms pharyngitis, athralgia,carditis, chorea, fever,pharyngitis, athralgia,carditis, chorea, fever,

erythema marginatum, sub-q nodules, dyspneaerythema marginatum, sub-q nodules, dyspnea lab values: ESR, EKG( lab values: ESR, EKG( PR intervalPR interval), strep Ab ), strep Ab

Reported Frequency of Bacteremias Associated With

Various Dental Procedures and Daily Activities Reported Frequency of Bacteremias Associated With

Various Dental Procedures and Daily Activities ProcedureProcedure Tooth extractionTooth extraction Periodontal surgeryPeriodontal surgery Scaling and root planingScaling and root planing Teeth cleaningTeeth cleaning Rubber dam matrix/wedge Rubber dam matrix/wedge

placementplacement Endodontic proceduresEndodontic procedures Daily ActivitiesDaily Activities Tooth brushing and flossingTooth brushing and flossing Use of wooden toothpicksUse of wooden toothpicks Use of water irrigation devicesUse of water irrigation devices Chewing foodChewing food

Frequency of bacteremiaFrequency of bacteremia 10-100%10-100% 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%

Initiating Bacteremia Initiating Bacteremia

Dental Procedures Dental Procedures Most (if not all) are not associated with the Most (if not all) are not associated with the

onset of IE.onset of IE. If a dental procedure is possibly associated If a dental procedure is possibly associated

with the cause of IE, the symptoms of IE with the cause of IE, the symptoms of IE should appear should appear within less than 2 weeks.within less than 2 weeks.

(2:300 law suits…Pallasch) (2:300 law suits…Pallasch)

Endocarditis prophylaxis recommendedEndocarditis 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:

Endocarditis prophylaxis recommendedEndocarditis prophylaxis recommended

* Prosthetic cardiac valve* Previous infective

endocarditis (IE)* Congenital heart disease

(CHD) with :

Endocarditis prophylaxis recommendedEndocarditis 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

Endocarditis prophylaxisEndocarditis 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.


* 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.


* 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.

Conditions Recommended for Coverage in 2007 Conditions Recommended for Coverage in 2007 Based on greatest risk for adverse outcomeBased on greatest risk for adverse outcome Prosthetic Cardiac ValveProsthetic Cardiac Valve Previous Infective EndocarditisPrevious Infective Endocarditis Congenital Heart Disease (CHD)Congenital Heart Disease (CHD)

Unrepaired Unrepaired cyanotic CHDcyanotic CHD including those with including those with palliative shunts and conduitspalliative shunts and conduits

Completely repaired CHD with prosthetic material or Completely repaired CHD with prosthetic material or device for device for first 6 monthsfirst 6 months

Repaired CHD with Repaired CHD with residual defectsresidual defects at the site at the site Cardiac Transplantation Recipients who Develop Cardiac Transplantation Recipients who Develop Cardiac Cardiac

ValvulopathyValvulopathy

Endocarditis prophylaxis NOT recommended (1997 vs 2007)Endocarditis prophylaxis NOT recommended (1997 vs 2007) functional heart murmursfunctional heart murmurs post-coronary surgeries > 6 mos.post-coronary surgeries > 6 mos. RF, RF, RHDRHD, most congential defects, most congential defects MVP MVP withwith or without regurgitation or without regurgitation pacemakerspacemakers

Conditions Recommended for Prophylaxis in 1997 vs 2007Conditions Recommended for Prophylaxis in 1997 vs 2007 High-risk lesionsHigh-risk lesions Prosthetic heart valvesProsthetic heart valves Previous endocarditisPrevious endocarditis Cyanotic CHDCyanotic CHD Aortic valve diseaseAortic valve disease Mitral regurgitationMitral regurgitation Patent ductus arteriosusPatent ductus arteriosus Ventricular septal defectVentricular septal defect Coarctation of aortaCoarctation of aorta

Intermediate-riskIntermediate-risk MVP with regurgitationMVP with regurgitation Mitral stenosis Mitral stenosis Tricuspid valve diseaseTricuspid valve disease Pulmonary stenosisPulmonary stenosis Septal hypertrophySeptal hypertrophy Degenerative valvular Degenerative valvular

disease in older patientsdisease in older patients Nonvalvular intracardiac Nonvalvular intracardiac

prosthetic implantsprosthetic implants

1997 : Endocarditis prophylaxis NOT recommended1997 : Endocarditis prophylaxis NOT recommended routine restorative proceduresroutine restorative procedures placement of rubber damsplacement of rubber dams routine local anesthetic injectionsroutine local anesthetic injections intracanal endo; suture removalintracanal endo; suture removal impressions, fluoride, radiographsimpressions, fluoride, radiographs insertion or adjustment of removable insertion or adjustment of removable

prosthetic or ortho appliancesprosthetic or ortho appliances

1997 : Endocarditis prophylaxis recommended1997 : Endocarditis prophylaxis recommended extractionsextractions perio surgery-scaling-probing-prophyperio 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 bandsinitial placement of ortho bands intraligamentary injectionsintraligamentary injections

2007 : Endocarditis prophylaxis recommended2007 : Endocarditis prophylaxis recommended

Any procedure which abrogates the mucosal Any procedure which abrogates the mucosal barrier and causes ANY bleeding !barrier and causes ANY bleeding !

The amount of bleeding has no impact upon The amount of bleeding has no impact upon the risk for IE !the risk for IE !

2007 AHA Guidelines – Dental Procedures recommended for Prophylaxis2007 AHA Guidelines – Dental Procedures recommended for Prophylaxis

All Dental Procedures that involve All Dental Procedures that involve manipulation of gingival tissuemanipulation of gingival tissue or the or the periapical regionperiapical region of teeth or of teeth or perforationperforation of the oral mucosa. of the oral mucosa. (Includes many (Includes many procedures that in the 1997 guidelines were procedures that in the 1997 guidelines were not recommended for coverage)not recommended for coverage)

Prevention of Infective Endocarditis : NOTEPrevention of Infective Endocarditis : NOTE The MOST important factor is to maximize The MOST important factor is to maximize

oral health and reduce oral microfloraoral health and reduce oral microflora minimize oral tissue traumaminimize oral tissue trauma periodontal and plaque controlperiodontal and plaque control antimicrobial mouthrinsesantimicrobial mouthrinses proper AHA prophylactic regimen ONLY proper AHA prophylactic regimen ONLY

when indicatedwhen indicated

Prevention of Infective Endocarditis :Prevention of Infective Endocarditis : standard : Amoxicillin- 2 g; 30-60 min. pre-opstandard : Amoxicillin- 2 g; 30-60 min. pre-op IM or IV: Ampicillin-2g; 30 min. pre-opIM or IV: Ampicillin-2g; 30 min. pre-op allergic : Clindamycin- 600mg; 30-60 min. allergic : Clindamycin- 600mg; 30-60 min.

pre-op pre-op Cephalexin- 2 g one-hour pre- Cephalexin- 2 g one-hour pre-

opop CefadroxilCefadroxil 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

Antibiotic prophylaxisAntibiotic prophylaxis

Does it really do any Does it really do any good ?good ?

AmoxicillinAmoxicillin

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

Antibiotic ProphylaxisAntibiotic Prophylaxis

Antibiotic ResistanceAntibiotic Resistance

About 17% to 50% of the viridans group of About 17% to 50% of the viridans group of streptococci are resistant to penicillin and 13% to streptococci are resistant to penicillin and 13% to 27% are resistant to clindamycin27% are resistant to clindamycin..

Impact on IE prevention is unknown.Impact on IE prevention is unknown.


2007…..there is no evidence that dental treatment 2007…..there is no evidence that dental treatment causes infective endocarditis or that antibiotic causes infective endocarditis or that antibiotic prophylaxis is preventiveprophylaxis is preventive

>95% of IE = no relation at all to dental Tx>95% of IE = no relation at all to dental Tx physiologic bacteremiasphysiologic bacteremias

regular toothbrushingregular toothbrushing = 0-40%= 0-40%chewingchewing = 17-51 %= 17-51 %cleaning-irrigating devicescleaning-irrigating devices = 7-50%= 7-50%random periodontal diseserandom periodontal disese = 11-20%= 11-20%


Toothbrushing 2 x daily = 150,000 times Toothbrushing 2 x daily = 150,000 times risk if IE than extracting a tooth !risk if IE than extracting a tooth !

All daily activities= 5 million times risk if All daily activities= 5 million times risk if IE than extracting a tooth !IE than extracting a tooth !

Endocarditis prophylaxis issuesEndocarditis prophylaxis issues

already on previous regimenalready 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 appointmentsinterval between appointments Patient forgot to take the antibioticPatient forgot to take the antibiotic IBD( colitis) and clindamycinIBD( colitis) and clindamycin not the same as prevention of late prosthetic joint not the same as prevention of late prosthetic joint

infectionsinfections

Antibiotic prophylaxisAntibiotic prophylaxis

If prophylaxis If prophylaxis is not possibleis not possible, administering the , administering the antibiotic within 2 hours antibiotic within 2 hours may helpmay help prevent IE prevent IE

time between prophylaxis coverage periodstime between prophylaxis coverage periods

== 10 days ! 10 days ! Do as much treatment as Do as much treatment as possible during coverage periodpossible during coverage period

Rx’d antibiotics (not sufficient type or dose)Rx’d antibiotics (not sufficient type or dose) Pre-op antimicrobial mouthrinses have not shown Pre-op antimicrobial mouthrinses have not shown

any benefitany benefit monitor for signs-symptoms ofmonitor for signs-symptoms of IE IE

2007 AHA Guidelines2007 AHA Guidelines

Patients who undergo cardiac Patients who undergo cardiac surgerysurgery

A careful dental evaluation is recommended A careful dental evaluation is recommended so that requiredso that required dental treatmentdental treatment may be may be completed whenever possible completed whenever possible before before cardiaccardiac valve surgery or replacement or valve surgery or replacement or repair of CHD.repair of CHD.

Endocarditis PreventionEndocarditis Prevention

Current practiceCurrent practice Identify the Identify the susceptible patientsusceptible patient and use antibiotic and use antibiotic

prophylaxis for indicated dental proceduresprophylaxis for indicated dental procedures Medical referral to establish current status may be needed Medical referral to establish current status may be needed

to for patients with to for patients with CHD corrected with prosthetic CHD corrected with prosthetic material or devicesmaterial or devices. .

Within 6 months of corrective surgeryWithin 6 months of corrective surgery Residual defect (leakage)Residual defect (leakage)

Nonvalvular Cardiovascular Devices

AHA does not recommend prophylaxis Nonvalvular Cardiovascular Devices

AHA does not recommend prophylaxis PacemakersPacemakers Defibrillators Defibrillators Left ventricular assist Left ventricular assist

devices devices Total artificial heartsTotal artificial hearts Arteriovenous fistulaeArteriovenous fistulae Closure devices for ASD, Closure devices for ASD,

PDA, AVF PDA, AVF Hemodialysis graftsHemodialysis grafts

Vascular graftsVascular grafts Intra-aortic balloon pumpsIntra-aortic balloon pumps Dacron grafts and patchesDacron grafts and patches Vena caval filtersVena caval filters Vascular closure devicesVascular closure devices Ventriculoatrial shunts Ventriculoatrial shunts Coronary artery stentsCoronary artery stents

AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

Nonvalvular Cardiovascular DevicesNonvalvular Cardiovascular Devices

AHA does recommend ProphylaxisAHA does recommend Prophylaxis Incision and Drainage of infection at other sites (Incision and Drainage of infection at other sites (I & D of dental I & D of dental

abscessabscess) ) Extraction Extraction of teeth or of teeth or surgical proceduressurgical procedures performed in areas of performed in areas of

acute infectionacute infection Residual leakResidual leak following closure of PDA, ASD, VSD (follow AHA following closure of PDA, ASD, VSD (follow AHA

guidelines) guidelines)

AHA, Scientific statement on Nonvalvular Cardiovascular Devices. Circulation, 108: 2015, 2003.

Impact of 2007 GuidelinesImpact of 2007 Guidelines

Patients who have taken antibiotics for years to prevent IE Patients who have taken antibiotics for years to prevent IE and now no longer are recommended to do such.and now no longer are recommended to do such.

Patients who are still recommended to be covered but now Patients who are still recommended to be covered but now for just about all dental procedures.for just about all dental procedures.

Explain rational for new guidelines, answer questions, Explain rational for new guidelines, answer questions, consult with patient’s physician – informed consent consult with patient’s physician – informed consent (record in progress notes).(record in progress notes).

Impact of 2007 GuidelinesPallasch TJ. CDAJ 2007:35(7): 507-11

Impact of 2007 GuidelinesPallasch TJ. CDAJ 2007:35(7): 507-11

MD or patient non-acceptance: they can provide MD or patient non-acceptance: they can provide the Rx “upon their own authority “the Rx “upon their own authority “

“ “ Based upon the best current scientific Based upon the best current scientific evidence as published by the AHA, and evidence as published by the AHA, and my best clinical judgement. “my best clinical judgement. “

Congenital heart disease-dental concernsCongenital heart disease-dental concerns

EndocarditisEndocarditis Congestive heart failureCongestive heart failure EndarteritisEndarteritis Excessive bleedingExcessive bleeding CyanosisCyanosis InfectionInfection

What is NextWhat is Next

2007 Guidelines – Foundation set 2007 Guidelines – Foundation set Dental procedures not causeDental procedures not cause No evidence that prophylaxis is effectiveNo evidence that prophylaxis is effective Adverse reactions to antibioticsAdverse reactions to antibiotics Increasing rate of resistance to antibioticsIncreasing rate of resistance to antibiotics The next set of AHA guidelines will not The next set of AHA guidelines will not

recommend prophylaxis for any dental procedure recommend prophylaxis for any dental procedure even in patients with cardiac lesions with the even in patients with cardiac lesions with the greatest risk for adverse outcomesgreatest risk for adverse outcomes

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Prevention of EndocarditisPrevention of Endocarditis

General conceptsGeneral concepts Goal of “Goal of “infection freeinfection free” oral cavity” oral cavity Follow the Follow the current (2007) AHA guidelinescurrent (2007) AHA guidelines for selection of cardiac for selection of cardiac

conditions and dental procedures needing prophylaxisconditions and dental procedures needing prophylaxis Reduce gingival inflammationReduce gingival inflammation before performing restorative before performing restorative

proceduresprocedures Establish Establish effective home careeffective home care practices practices Chlorhexidine mouth rinseChlorhexidine mouth rinse can be used prior to periodontal or can be used prior to periodontal or

surgical procedures, however several studies suggest no real benefit surgical procedures, however several studies suggest no real benefit

Prevention of EndocarditisPrevention of Endocarditis

General principles Cont. General principles Cont. Coverage is effective for Coverage is effective for 4-6 hours4-6 hours Do Do as much dental treatment as possibleas much dental treatment as possible during each during each

coverage periodcoverage period Allow at least Allow at least 9 days9 days to elapse between coverage periods. to elapse between coverage periods.

If this is not possible select an alternant antibiotic If this is not possible select an alternant antibiotic Be alert for Be alert for signs and symptoms of IEsigns and symptoms of IE in patients in patients

receiving antibiotic prophylaxis and those with cardiac receiving antibiotic prophylaxis and those with cardiac lesions at risk for IElesions at risk for IE

1 4 6 10hours

5

3

7

------------------------------------------------

µg/ml 3g Amox

1.5 g Amox

1 g PenVK

plasma levels of prophylactic antibiotics

2 g Amox

Late Prosthetic Joint InfectionsLate Prosthetic Joint Infections

Wahl’s myths:Wahl’s myths:#1: There are similarities between IE #1: There are similarities between IE

(PVE) and LPJI.(PVE) and LPJI. NO.NO.#2: Dental treatment is a probable cause #2: Dental treatment is a probable cause

of LPJI.of LPJI. NO.NO.#3: Animal experiments document #3: Animal experiments document

dental bacteremias as cause of LPJI.dental bacteremias as cause of LPJI. NO.NO.#4: To protect patients DDS should #4: To protect patients DDS should

always cover patients with PJ.always cover patients with PJ. NO.NO.

Prevention of late Prosthetic joint infections: 1997 changesPrevention of late Prosthetic joint infections: 1997 changes ADA/AAOS advisory statementADA/AAOS advisory statement medical consultation with Orthopodmedical consultation with Orthopod No prophylaxis for pins, rods, screws, No prophylaxis for pins, rods, screws,

plates, wires, implants, etc.plates, wires, implants, etc. healthy patient: < 2 yrs. after TJRhealthy patient: < 2 yrs. after TJR chronic RA or other infection of TJRchronic RA or other infection of TJR immunocompromised patientsimmunocompromised patients

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

ANTIBIOTICSANTIBIOTICS Other indications for antibiotic prophylaxis:Other indications for antibiotic prophylaxis: HIVHIV ESRD : hemodialysisESRD : hemodialysis IDDMIDDM Autoimmune diseases; SLEAutoimmune diseases; SLE SplenectomySplenectomy CHF, CVA; thromboemboliCHF, CVA; thromboemboli Liver diseaseLiver disease Organ transplantsOrgan transplants

Congenital heart disease-dental concernsCongenital heart disease-dental concerns

EndocarditisEndocarditis Congestive heart failureCongestive heart failure EndarteritisEndarteritis Excessive bleedingExcessive bleeding CyanosisCyanosis InfectionInfection

Rheumatic Heart DiseaseRheumatic Heart Disease

DETECTIONDETECTION

historyhistoryechocardiographyechocardiography

chest radiographschest radiographsEKGEKG

auscultationauscultation

Basis for 2007 GuidelinesBasis for 2007 Guidelines

Adverse OutcomesAdverse Outcomes Valvular dysfunctionValvular dysfunction Congestive heart failureCongestive heart failure Need for valvular replacementNeed for valvular replacement Multiple embolic eventsMultiple embolic events Death Death

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