CDHO Advisory Infective Endocarditis And Associated Conditions

CDHO Advisory | Infective Endocarditis, Heart Conditions

ADVISORY TITLE

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with infective endocarditis associated with certain heart conditions.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Infective Endocarditis Associated with Certain Heart Conditions, 2021-06-14

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions ("the Procedures").

DISEASE/CONDITION(S)/PROCEDURE(S)

SCOPE

Infective endocarditis associated with certain heart conditions

INTENDED USERS

Advanced practice nurses Dental assistants Dental hygienists Dentists Denturists Dieticians Health professional students

Nurses Patients/clients Pharmacists Physicians Public health departments Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have infective endocarditis associated with certain heart conditions, chiefly as follows.

1 Persons includes young persons and children

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CDHO Advisory | Infective Endocarditis, Heart Conditions

1. Understanding the medical condition. 2. Sourcing medications information. 3. Taking the medical and medications history. 4. Identifying and contacting the most appropriate healthcare provider(s) for medical

advice. 5. Understanding and taking appropriate precautions prior to and during the Procedures

proposed. 6. Deciding when and when not to proceed with the Procedures proposed. 7. Dealing with adverse events arising during the Procedures. 8. Keeping records. 9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years) Adolescent (13 to 18 years) Adult (19 to 44 years) Middle Age (45 to 64 years) Aged (65 to 79 years) Aged 80 and over Male Female

Parents, guardians, and family caregivers of children, young persons and adults with infective endocarditis associated with certain heart conditions.

MAJOR OUTCOMES CONSIDERED

For persons who have infective endocarditis associated with certain heart conditions: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted Canadian Dental Association American Heart Association o 2021 AHA Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis o 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseas) o ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis o Prevention of Infective Endocarditis: Guidelines From the American Heart Association [2007]

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CDHO Advisory | Infective Endocarditis, Heart Conditions

o Infective Endocarditis American Association of Endodontists

Infective endocarditis 1. is an infection of the endocardium or the heart valves, which may damage or even destroy heart valves 2. occurs when certain bacteria in the bloodstream lodge on and infect abnormal heart valves or other damaged heart tissue 3. is a life-threatening illness.

Other terminology used in this Advisory is as follows. 1. Atrial septal defect, a congenital heart defect in which the wall that separates the atria,

the upper heart chambers, does not close completely. 2. Bacteremia, bacteria in the bloodstream. 3. Endocarditis, abbreviation for infective endocarditis. 4. Endocardium, the heart's inner lining. 5. Hemodialysis, a procedure that uses a dialysis machine to filter waste products from the

blood and to restore normal constituents to it. 6. Hypertrophic cardiomyopathy, a rare disorder, the abnormal thickening of the heart

muscle that affects one or two people in every 1,000. 7. Infectious endocarditis, alternative term for infective endocarditis. 8. Janeway lesions, red and painless skin spots on the palms and soles. 9. Palliative care, services of care for persons towards the end of life with terminal

illnesses such as cancer, when the focus of the care a. is relieving symptoms b. is attending to physical and spiritual needs.

10. Patent ductus arteriosus, a condition a. where the ductus arteriosus, a blood vessel, fails to close normally in an infant soon after birth b. which causes abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart.

11. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the heart condition or its treatment.

12. Ventricular septal defect a. one or more holes in the wall that separates the right and left ventricles of the heart b. one of the most common congenital heart defects c. may occur by itself or with other congenital diseases.

Overview of infective endocarditis associated with certain heart conditions

Resources consulted College of Dental Hygienists of Ontario: Infective Endocarditis Fact Sheet College of Dental Hygienists of Ontario: Recommended Antibiotic Prophylaxis Regimens for the Prevention of Infective Endocarditis and Hematogenous Joint Infection Canadian Dental Association

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CDHO Advisory | Infective Endocarditis, Heart Conditions

American Heart Association o 2021 AHA Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis o 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease o ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis o Prevention of Infective Endocarditis: Guidelines From the American Heart Association [2007] o Infective Endocarditis

American Association of Endodontists Mayo Clinic Medline Plus Infective Endocarditis: Medscape Prophylaxis Against Infective Endocarditis: 2016 Partial Update to 2008 NICE Clinical

Guidelines Prophylaxis Against Endocarditis: 2008 NICE Clinical Guidelines

Policy positions of major organizations 1. The American Heart Association's position on infective endocarditis is supported by the Canadian and American Dental Associations, and the Canadian Cardiovascular Society. 2. The American Heart Association states that a. infective endocarditis is a very serious disease with i. many people at increased risk ii. relatively few people who develop it b. bacteremia i. is the precursor to infective endocarditis ii. is common after the Procedures, among other invasive dental procedures iii. involves the bacteria normally resident in the mouth and upper respiratory system c. infective endocarditis occurs when certain bacteria in the bloodstream lodge on abnormal heart valves or other damaged heart tissue d. the Association's Endocarditis Committee, together with national and international experts on infective endocarditis, concluded that i. there is no conclusive evidence linking dental or certain non-dental procedures with the development of infective endocarditis ii. infective endocarditis is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure. 3. The American Heart Association believes that a. infective endocarditis rarely occurs in people with normal hearts b. the risk of antibiotic-associated adverse events exceeds the benefit, if any, from antibiotic prophylaxis for most persons c. antibiotic prophylaxis i. to prevent endocarditis is unnecessary for non-invasive dental/dental hygiene procedures

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CDHO Advisory | Infective Endocarditis, Heart Conditions

ii. may prevent an exceedingly small number of cases of infective endocarditis, if any, in individuals who undergo a dental procedure

iii. is reasonable before certain dental/dental hygiene procedures (i.e., those that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa) for persons with 1. prosthetic cardiac valve or material that includes a. presence of cardiac prosthetic valve b. transcatheter implantation of prosthetic valves c. cardiac valve repair with devices, including annuloplasty, rings, or clips d. left ventricular assist devices or implantable heart 2. previous, relapse, or recurrent infective endocarditis 3. congenital2 heart disease (CHD)3 that includes a. unrepaired cyanotic CHD4, including palliative shunts and conduits b. completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure5 c. repaired CHD with residual defects6 at the site of or adjacent to the site of a prosthetic patch or prosthetic device d. surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit 4. cardiac valvulopathy after cardiac transplant7.

Occurrence The US incidence of infective endocarditis is some 2?4 cases per 100,000 persons per year, a rate that 1. defines it as an uncommon disease 2. has not changed in the past 50 years 3. is similar to that in other countries.

2 congenital = present from birth 3 Except for the conditions listed here, antibiotic prophylaxis is no longer recommended by the AHA for any other form of CHD. 4 Common types of cyanotic congenital heart disease (i.e., birth defects resulting in oxygen levels lower than normal) include tetralogy of Fallot (TOF, in which there are 4 defects that affect the heart; namely, ventricular septal defect [VSD], pulmonary stenosis, right ventricular hypertrophy, and overriding aorta) and transposition of the great arteries (TGA, in which the pulmonary artery is attached to the left side of the heart, and the aorta is attached to the right side of the heart). 5 Prophylaxis is reasonable during this period, because endothelialization of prosthetic materials requires 6 months. 6 Residual defects include persisting leaks or abnormal flow. 7 in particular, cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve

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CDHO Advisory | Infective Endocarditis, Heart Conditions

Cause Infective endocarditis 1. most commonly results from a blood infection that arises when the infection-causing bacteria a. enter the bloodstream and travel to the heart, where the infection locates on damaged heart valves or other damaged heart components b. form infected clots that break off and are carried to the i. brain ii. lungs iii. kidneys iv. spleen 2. may result from infection with a. Streptococcus viridans, which is responsible for about half of all infective endocarditis instances b. Staphylococcus aureus, which i. may infect normal heart valves ii. is the most common cause of infective endocarditis in intravenous drug users c. Enterococci, which are i. part of the normal intestinal flora of humans and animals ii. important pathogens responsible for infective endocarditis and other serious infections d. Candida albicans, thrush, a fungus which i. causes candidiasis of the mouth and genital system ii. occasionally leads to infective endocarditis.

Risk factors For infective endocarditis, risk factors 1. are strongly linked with the mouth because the bacteria prominently associated with bacteremia which lead to infective endocarditis are found in the mouth. 2. are associated with a. dental procedures, which carry particular risks for children with certain congenital heart conditions b. poor dental hygiene. 3. include a. artificial heart valves b. unrepaired cyanotic congenital heart disease, including i. tetralogy of Fallot ii. transposition of the great arteries c. damaged heart valves d. history of rheumatic heart disease e. intravenous use of drugs of abuse because unsterile needles may introduce bacteria to the bloodstream (CDHO Advisory).

Signs and symptoms Infective endocarditis signs and symptoms 1. may develop slowly or suddenly 2. may first manifest as fever, which

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CDHO Advisory | Infective Endocarditis, Heart Conditions

a. is the typical sign b. can persist for days before any other indications appear 3. include warning symptoms alerting to the need for medical investigation, such as a. blood in urine b. chest pain c. numbness or weakness of muscles d. weakness e. weight loss without change in diet 4. variously include other symptoms and signs, such as a. chills b. excessive sweating c. facial pallor d. fatigue e. joint pain f. muscle aches and pains g. night sweats h. painful, red nodes in the pads of the fingers and toes (Osler nodes) i. shortness of breath with activity j. Janeway lesions k. swelling of feet, legs, and abdomen.

Medical investigation For infective endocarditis, medical investigation 1. involves exploring the medical history for congenital or other heart disease 2. includes physical examination for a. enlarged spleen b. heart murmurs c. retinal bleeding d. splinter hemorrhages in the fingernails 3. includes tests and investigations, such as a. blood culture to detect bacteria b. chest x-ray c. complete blood count to detect anemia d. CT scan of the chest e. echocardiogram f. erythrocyte sedimentation rate (ESR).

Treatment For infective endocarditis, treatment 1. requires admission to hospital for intravenous antibiotics for long-term, high-dose treatment needed to eliminate the bacteria, accompanied by frequent blood tests 2. may require surgery to replace dysfunctional heart valves.

Prevention For prevention of infective endocarditis, see also oral health considerations, the American Heart Association suggests 1. preventive antibiotics before certain dental procedures for people at highest risk of adverse outcome from infectious endocarditis, specifically those persons with

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CDHO Advisory | Infective Endocarditis, Heart Conditions

a. prosthetic cardiac valve or material that includes i. presence of cardiac prosthetic valve ii. transcatheter implantation of cardiac valves iii. cardiac valve repair with devices, including annuloplasty, rings, or clips iv. left ventricular assist devices or implantable heart

b. previous, relapse, or recurrent infective endocarditis c. congenital heart disease8 that includes

i. unrepaired cyanotic CHD9, including palliative shunts and conduits ii. completely repaired congenital heart defect repaired with prosthetic

material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure 10 iii. repaired CHD with residual defects11 at the site of or adjacent to the site of a prosthetic patch or prosthetic device iv. surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit d. cardiac valvulopathy after cardiac transplant12. 2. continued medical follow-up for persons with prior history of infective endocarditis. 3. for persons who use intravenous drugs a. treatment for addiction b. use of i. injection sites ii. new needles for each injection iii. alcohol pads before injecting c. avoidance of sharing any injection-related paraphernalia.

Prognosis For infective endocarditis depends on 1. whether or not complications develop 2. whether it is left untreated; if so infective endocarditis is generally fatal 3. early detection and appropriate treatment, which can be life-saving.

Social considerations Surveys indicate that few persons at risk of developing infective endocarditis understand the importance of prevention and prevention principles, which include 1. appropriate oral hygiene

8 Except for the conditions listed here, antibiotic prophylaxis is no longer recommended by the AHA for any other form of CHD. 9 Common types of cyanotic congenital heart disease (i.e., birth defects resulting in oxygen levels lower than normal) include tetralogy of Fallot (TOF, in which there are 4 defects that affect the heart; namely, ventricular septal defect [VSD], pulmonary stenosis, right ventricular hypertrophy, and overriding aorta) and transposition of the great arteries (TGA, in which the pulmonary artery is attached to the left side of the heart, and the aorta is attached to the right side of the heart).

10 Prophylaxis is reasonable during this period, because endothelialization of prosthetic materials requires 6 months. 11 Residual defects include persisting leaks or abnormal flow. 12 in particular, cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve

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