Director, Division of Oral Medicine, Dental School

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

2. Dr. Robert Gorlin 1923-2006 50 yrs. at UM

5. QUIZ

6. QUIZ

7. Basis for Past AHA Guidelines 1. True or false • 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 • (False, Daily activities much more likely the source)

9. Basis for Past AHA Guidelines • 2. True or false • 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 • (False, they are about the same, both relatively low magnitude)

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

12. Basis for Past AHA Guidelines • Bleeding is the indication for bacteremia occurring • (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

14. Basis for Past AHA Guidelines • 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)

15. Basis for Past AHA 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 • TRUE !

17. Basis for Past AHA Guidelines • Based on unproven assumptions • 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) • 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)

18. Rational for 2007 Guidelines • Previous 9 AHA Guidelines – Based on the lifetime risk for IE • 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. www.aaom.com • 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 http://www.circulationaha.org, DOI:10.1116/circulationAHA.106.18309. • 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): 739-760.

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

21. The AHA cites the following reasons for revision of the 1997 guidelines: • 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 • The risk of antibiotic associated adverse eventsexceeds 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

22. ~40 % morbidity-mortality acute IE ( staph aureus)- aortic v.

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

24. Infective Endocarditis: hypothetical association with dental treatment ? • J. Antimicrobial Chemotherapy, 4-19-2006 • A study of 273 patients = no link between dental treatment and IE (Strom BL., Ann Int Med 1998 129:761-9) • Cochrane review: no evidence to support antimicrobial prophylaxis to prevent IE in invasive dental procedures( Oliver R. 2006) • Evidence-based…doesn’t exist

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

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

29. Prosthetic valve endocarditis ( PVE)

30. Prosthetic valve endocarditis ( PVE)

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

32. Infective endocarditis • Has the risk changed ? • Dx (Duke) criteria • 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 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 RHD from extracting a tooth is 1: 150,000 ! • 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 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 ! Agha Z, et.al. Med. Dec. Mak. 2005 25:308-320.

35. Rheumatic Fever and Rheumatic Heart Disease • mitral valve damaged 60% of those defects • as many as 30-40 % of cases are un-diagnosed • Signs-symptoms • pharyngitis, athralgia,carditis, chorea, fever, erythema marginatum, sub-q nodules, dyspnea • lab values: ESR, EKG( PR interval), strep Ab

36. Procedure Tooth extraction Periodontal surgery Scaling and root planing Teeth cleaning Rubber dam matrix/wedge placement Endodontic procedures Daily Activities Tooth brushing and flossing Use of wooden toothpicks Use of water irrigation devices Chewing food Frequency of bacteremia 10-100% 36-88% 8-80% ≤ 40% 9-32% ≤ 20% 20-68% 20-40% 7-50% 7-51% Reported Frequency of Bacteremias Associated With Various Dental Procedures and Daily Activities

37. Initiating Bacteremia • Dental Procedures • 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. (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 • Prosthetic Cardiac Valve • Previous Infective Endocarditis • Congenital Heart Disease (CHD) • Unrepaired cyanotic CHD including those with palliative shunts and conduits • Completely repaired CHD with prosthetic material or device for first 6 months • Repaired CHD with residual defects at the site • Cardiac Transplantation Recipients who Develop Cardiac Valvulopathy

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

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

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

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

49. 2007 : Endocarditis prophylaxis recommended • Any procedure which abrogates the mucosal barrier and causes ANY bleeding ! • 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)