Mordechai Findler

Dentists' knowledge and implementation of the 2007 American Heart Association guidelines for prevention of infective endocarditis

OBJECTIVES Our aim was to evaluate the knowledge and implementations of the 2007 American Heart Association guidelines for the prevention of infective endocarditis (IE) among practicing Israeli dentists, 12 months after their publication. STUDY DESIGN A total of 118 dentists completed a questionnaire regarding required antibiotic prophylaxis for 10 specific cardiac patient subtypes before invasive dental treatment, prophylactic need in at-risk patients for IE in 10 dental procedures, and prophylactic regimen for nonallergic patients. RESULTS Correct answer response for cardiac conditions was 81.3% (highest failure: mitral valve prolapse [MVP] with regurgitation). There was a consensus among the participants regarding antibiotic regimen for high-risk patients during several dental procedures, such as intraoral radiography, tooth extraction, and periodontal surgery, but a controversy for other procedures. The procedures of disagreement were endodontic treatment, tooth preparation with oral impressions, and restoration of class II caries lesion. Correct antimicrobial agent, dose, and timing were prescribed by 99%, 93.8%, and 100% of the respondents, respectively. CONCLUSIONS Relatively high level of knowledge of the new guidelines was found among dentists, reflecting both familiarity of the practitioners with the guidelines and acceptance of guidelines. Prophylactic need is ambiguous during restorative, endodontic and prosthetic procedures. Educational resources should emphasize these guidelines, specifically the reduced risk level for MVP with regurgitation patients.

A critically severe gingival bleeding following non‐surgical periodontal treatment in patients medicated with anti‐platelet

BACKGROUND Only a few dental procedures have been reported to cause life-threatening bleeding. All of these cases followed surgical intervention. MATERIAL AND METHODS In this paper, we report a case of severe bleeding following non-surgical periodontal procedures in a patient treated with a dual anti-platelet regimen post-coronary stent insertion. RESULTS Her medical history included ischaemic heart disease, hypertension and diabetes mellitus. Haemostasis was achieved at the conclusion of the non-surgical periodontal treatment. However, several hours later, the patient arrived at the emergency room and was diagnosed with hypovolemic shock. CONCLUSION This case should raise the clinicians awareness of bleeding complications in non-surgical procedures as well as the risk for bleeding when a dual anti-platelet regimen is administered. The importance of patient monitoring and the use of local haemostatic agents is demonstrated in these cases.

A new management approach for dental treatment after a cerebrovascular event: a comparative retrospective study.

OBJECTIVE Current literature recommends postponing dental treatment until 6-12 months after a stroke, based on the presumed risk of recurrent stroke. The purpose of this study was to suggest that the importance of dental care during this period exceeds the risk of medical complications in this patient population. STUDY DESIGN Two groups were compared: 1) a cerebrovascular (CrbV) study group: patients (n = 16) who had suffered from a CrbV event within the 12 months preceding their dental procedure; and 2) a cardiovascular (CV) control group: patients (n = 25) suffering from ischemic CV disease. Patients were monitored during and after the dental treatment. Treatment parameters and outcome were compared. RESULTS Patients received various essential dental treatments with intense monitoring during their dental management. Dental procedures were invasive in 68.8% and 0% of CrbV and CV groups, respectively. Dental treatments were completed uneventfully. No clinical CrbV or CV complications were noted in either group after the dental treatment. CONCLUSION Within the limits of this small retrospective study, it appears that dental treatment may be safely administered in patients a few weeks after the CrbV event as long as these patients are kept under optimal medical surveillance.

Dental implants in patients at high risk for infective endocarditis: a preliminary study

The safety of dental implant placement in patients at high risk for infective endocarditis (IE) has never been shown. The outcome of osseointegrated implants in patients with artificial heart valves or with a history of an infected valve is not known. In this article we describe our experience of dental implant placement in patients at high risk for IE. A retrospective study was conducted on patients at high risk for IE who underwent dental implant placement. All the patients received prophylactic antibiotic treatment before the surgical procedure, in accordance with the relevant American Heart Association guidelines. A total 13 patients underwent 16 surgical procedures for the placement of 57 dental implants over a period of 17 years. Within the follow-up period, no case of IE was reported. Two implants failed before exposure in one patient, one patient suffered from mitral valve thrombosis 14 days after the dental procedure, and another patient suffered a stroke 6 months following treatment. Despite the limitation of the small group of patients and the known low incidence of IE, dental implants may be regarded as a legitimate procedure for patients at high risk for IE.

A 78-year-old woman with bilateral tongue necrosis

A 78-year-old woman presented to the emergency department complaining of a sore tongue. Her medical history included essential hypertension managed with atenolol, 100 mg/d, and enalapril, 5 mg/d, osteoporosis managed with calcium and vitamin D (with no past bisphosphonate treatment), and gastroesophageal reflux disease managed with omeprazole, 20 mg/d. Seventeen years before admission, she had suffered from ovarian carcinoma that was treated by chemotherapy and oophorectomy without therapeutic irradiation. She had no known hypersensitivities or drug allergies. The patient reported pain of the right head, neck, face, and shoulder (ranked 8 on a 0 to 10 visual analog scale, with “10” the most painful), especially while eating. She also reported fatigue, and visual blurring that had developed 2 months before, weight loss over the preceding 8 weeks (from 67 to 60 kg; a 10.4% reduction), and tongue pain of 4-weeks’ duration, which she rated as 10 on a 10-point scale. Ten days before presentation at the emergency room, she had undergone a complete blood count (CBC) and computed tomography (CT) of the head to rule out any underlying systemic conditions and space-occupying lesions. CBC and CT results at that time were normal, except for a mild anemia (hemoglo-

Permanent neurologic deficit after inferior alveolar nerve block: A case report

Permanent neurologic damage after an inferior dental nerve block is reported. Clinical manifestations included hemisensory syndrome, facial nerve palsy, hearing impairment, and ataxia. Possible mechanisms and preventive measures are discussed.

Dental treatment of a patient with an implanted left ventricular assist device: expanding the frontiers

BACKGROUND The left ventricular assist device (LVAD) is used as a bridge to heart transplantation. Currently, these devices are being used for longer periods of time than in previous years for the purpose of bridge to life, thus the need for dental assistance will emerge. CASE DESCRIPTION A female with severe acute congestive heart failure, owing to dilated cardiomyopathy, needed implantation of an LVAD as a bridge to heart transplantation. Six months after insertion of the device she suffered from spontaneous gingival bleeding and sought dental treatment. She presented with several dento-medical problems that required resolution before commencement of dental treatment. CONCLUSIONS Management of a patient with LVAD opens new frontiers for the dental team regarding treatment of the medically severely compromised patient who may present with multiple intervening medical aspects: profound antithrombotic therapy, high risk of device infection, possible magnetic interference with dental instruments, and even assessment of vital signs.

Dental treatment in the era of new anti-thrombotic agents

BACKGROUND In recent years, there have been dramatic changes in anti-thrombotic treatment as a result of new anti-thrombotic agents, as well as changes in the indications for their use. As a consequence, dentists are encountering larger numbers of patients who are undergoing anti-thrombotic treatment and who have increased risk for bleeding. The current paper aims to review the literature regarding up-to-date anti-thrombotic treatment and provide information regarding their implications on dentistry. METHODS An online search was performed of the literature published between 2000 and 2016. Articles dealing with evidence-based clinical guidelines for anti-thrombotic treatments, as well as literature reporting the use of anti-thrombotic medications were included. The manuscripts were screened according to their relevance to dentistry as well as their treatment protocol guidelines. RESULTS In total, 5,539 publications were identified: 56 of 554 evidence-based clinical guidelines were found that dealt with treatment protocols with anti-thrombotic agents; and 132 of 5,539 articles describe direct anti-thrombotic medications. CLINICAL IMPLICATIONS Dental treatment includes a risk for bleeding. As a result of the increasing number of patients taking new-generation anti-thrombotic drugs, dentists must be up to date regarding the implications of such drugs on dental treatment as well as the practical means to achieve haemostasis.

Er:yag Laser assisted Endodontic Surgery in the Era of New Antithrombotic Treatments

Background and Objective: The effectiveness of lasers and their use in many fields of dentistry have been reported. To our knowledge, lasers have not been employed to prevent operative bleeding and maintain a sterile surgical field in patients treated with antithrombotics. Furthermore, new generation anticoagulant and antiplatelet treatments have led to a significant increase in the number of individuals under antithrombotic medications, leading to increased risk for bleeding during treatment as well as post-operative hematomas and infections. Our aim was to review current surgical protocols and clinical guidelines for the management of patients using antithrombotic during minor oral surgery, and determine whether lasers may offer an advantage in the clinical management of such cases. Methods: A literature search for protocols and clinical guidelines for the management of patients treated with antithrombotic medications and its association with excessive bleeding during minor oral surgery was done. Publications which clear relevance to the topic of the current review were included. Results: 794 relevant publications were identified, of which 29 were with clinical guidelines and 9 were evidence based studies. Relevant information and guidelines from the publications were extracted and summarized. Furthermore, evidence of bleeding and infection control by laser therapy was reviewed to address the possible advantage of such approach in anti-thrombotic treated patients. Conclusions: Using lasers during intra-oral surgery seems to be beneficial in patients medicated with antithrombotics. The clinical guidelines indicate that anti-thrombotic treatment should not be interrupted for minor oral surgical procedures.