THE CORRELATION BETWEEN EXTRACTION AND INFECTIVE ENDOCARDITIS

Presented By:

Ayu Rahmi Mutmainah 030.09.038

EXTRACTIO N
Also reffered as Exodontia Extraction is defined as : The removal of a tooth from oral cavity by means of elevators and forceps.

INDICATIONS OF EXTRACTION:
A tooth that cannot be restored
Pulp necrosis or periapical abses ; untreatable by endodontic therapy, root canal treatment patient refusal Severe periodontal disease; Bone loss,grade 3 mobility,furaction involvement

Overcrowding of teeth in the dental arch

INDICATIONS OF EXTRACTION:
Malposed teeth Suprenumerary teeth
Economic considerations

Cracked teeth from trauma Teeth in the line fracture Aesthetic considerations
Planned radiation or IV bisphosphonate treatment

CONTRAINDICATIONS OF EXTRACTION

LOCAL
Therapeutic irradation

SYSTEMIC

Teeth in area of malignant

tumor Impacted third molar associated with pericoronitis Adjacent to the site of jaw fracture

Systemic Contraindications of extraction

Uncontrollable metabolic disease
Pregnancy 1st & 3rd is a relative
contraindication

Uncontrollable cardiac disease

Uncontrollable bleeding diathesis

Uncontrollable Leukemia & Lymphoma

PREPARATION

Medical history Antibiotics The tooth X-rayed (escpecially if it is impacted)

Anasthesia
The patient should not eat or drink anything for at least

six hours before the procedure

Should be made for a friend or relative to drive the patient home after surgery.

PROCEDURE

elevate the gingival soft tissue attachment luxate the tooth with small and large straight elevators

adapt the forceps to the crown of the tooth

Luxation requires apical pressure, buccal force, lingual pressure, rotational pressure, and tractional forces The operator continues to luxate the tooth with the

forceps in a buccolingual direction with slight

PROGNOSIS

the wound heals completely in about 2 weeks. multiple teeth are extracted, the healing time may be longer. A 3 to 6 month period may be required for bone and soft tissue to be completely healed and restructured, especially in more complex procedures. More than six teeth extracted in each arch is considered a more complex procedure with increased healing time. Most extractions result in complete healing without complications.

INFECTIVE ENDOCARDITIS
Infective Endocarditis (IE): an infection of the hearts endocardial surface

Classified into five groups: Native Valve E Prosthetic Valve IE Intravenous drug abuse (IVDA) IE Nosocomial IE Pacemakeer IE

NVE Classification

Acute Affects normal heart valves Rapidly destructive Metastatic foci Commonly Staph. If not treated, usually fatal within 6 weeks

Subacute Often affects damaged heart valves Indolent nature If not treated, usually fatal by one year

Etiology and sources of infection

Epidemiology

Incidence - varies according to location Males > females May occur at any age and increasingly common in elderly (> 50 y) Mortality 20-30%

Predisposing Factors
Iv drug use Central line Prosthetic valve Previous IE Murmur Dental procedure Rheumatic disease Miscellaneous

Representation of the pathophysiological role of the endothelium in endocarditis. Once bacteria have entered the blood stream and attached to the endothelium of the heart valves, bacterial virulence factors induce endothelial damage. Alternatively (in non- bacterial) or concomitantly (in infective endocarditis) increased shear stress also induces endothelial damage. The stressed endothelial cells produce tissue factor and induce platelet activation with the consequence of vegetation formation. Moreover, endothelial activation attracts inflammatory cells that lead to the destruction of the valve leaflets. Vegetation is then again colonized by more bacteria thereby initiating an ongoing process

Clinical features

Clinical features

Laboratory Findings in IE

Normochromic, Normocytic anemia (90%) WBC usually normal, can be increased High ESR (90-100%) Positive Rheumatoid factor (50%) Hypergammaglobulinemia (20-30%) (false positive lyme or VDRL serology) Proteinuria (50-65%), hematuria (30-50%)

The Essential Blood Test

Blood Cultures
Minimum of three blood cultures Three separate venipuncture sites 5- 10mL in children to 1hr apart Out of three one should be for anaerobic organisms Positive Result

Typical organisms present in at least 2 separate samples

Detects over 95% of cases

Negative blood culture

Previous antibiotic Technical errors Unusual organisms- anaerobic organisms,fungus

Imaging

Chest x-ray
Look

for multiple focal infiltrates and calcification of heart valves

EKG
Rarely

diagnostic Look for evidence of ischemia, conduction delay, and arrhythmias

Echocardiography- diagnostic tool for culture negative cases

Diagnostic criteria (Modified Dukes Criteria)

Major criteria: A positive blood culture for IE. Typical organism growing in 2 cultures in absence of a primary focus. A persistently positive blood culture A positive serological test for Q fever. ECHO evidence-mass, abscess, dehiscence. New valvular regurgitation.

Minor criteria:

Predisposition: predisposing heart condition or intravenous drug use. Fever: temperature 38C (100.4F). Vascular phenomena: major arterial emboli, septic pulmonary infarcts, mycotic aneurysm, intracranial haemorrhage, conjunctival haemorrhages, Janeways Lesion. Immunologic phenomena: glomerulonephritis, Oslers nodes, Roths spots, rheumatoid factor. Microbiological evidence: a positive blood culture but not meeting a major criterion as noted above, or serological evidence of an active infection with an organism that can cause infective endocarditis. Echocardiogram: findings consistent with infective endocarditis but not meeting a major criterion as noted above.

Treatment

Parenteral antibiotics Surgery

Intracardiac

complications

Surveillance blood cultures

CORRELATION EXTRACTION AND IE

Patients with extractions especially periodontal diseases are at higher risk from infective endocarditis than people who have healthy gingivae Periodontopathic bacteria which seem to be less important etiologic agents of infective endocarditis may play important roles in the induction of this disease by causing gum inflammation and opening a route toward the blood circulation for endocardiopathic viridans streptococci. Indirect evidence for relationship between extraction and infective endocarditis .

And then direct evidence for the relationship between the prevalence of
periodontal disease and the incidence of infective endocarditis remains to be investigated. Cohort studies are expected to provide better evidence to

elucidate this relationship.

Pathophysiology
Early steps in bacterial valve colonisation(A) Colonisation of damaged epithelium: exposed stromal cells and extracellular matrix proteins trigger deposition of fibrinplatelet clots to which streptococci bind (upper panel); fibrin-adherent streptococci

attract monocytes and induce them to produce tissue-factor activity (TFA) and
cytokines (middle panel); these mediators activate coagulation cascade, attract and activate blood platelets, and induce cytokine, integrin, and TFA production from neighbouring endothelial cells (lower panel), encouraging vegetation

growth.(B) Colonisation of inflamed valve tissues: in response to local inflammation, endothelial cells express integrins that bind plasma fibronectin, which microorganisms adhere to via wall-attached fibronectin-binding proteins, resulting

in endothelial internalisation of bacteria (upper panel); in response to invasion,

endothelial cells produce TFA and cytokines, triggering blood clotting and extension of inflammation, and promoting formation of the vegetation (middle panel); internalised bacteria eventually lyse endothelial cells (green cells) by secreting

Pathophysiology of IE

CONCLUSION

Common extraction, even non-surgical dental procedures, often cause bacteremia that can result in infective endocarditis in people who have a predisposing risk for this disease, such as valvular heart diseases including prosthetic valves, congenital heart diseases, cardiomyopathy, coronary artery disease, pacemaker implantation, etc. The infection is established when all 3 conditions simultaneously occur, i.e., a predisposing impairment in the heart, the introduction of bacteremia and the virulence of the introduced bacteria. Common dental procedures often cause bacteremia and periodontally diseased patients may even suffer from bacteremia after extraction. Antibiotics have to be used adequately in order to prevent such infections during dental procedures, however, theirfrequent use can also generate drug-resistant mutant bacteria. The development of novel drugs to be used as an alternative to the current antibiotics is therefore highly desired.

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