Dental Procedures In Patients Research Articles

Identification of the degree of knowledge of doctors about the use of vasoconstrictor in cardiac patients

Introduction: There is a clear lack of knowledge among professionals about the use of local anesthesia during dental treatment in cardiac patients, coming to delay emergency care or to indicate the use of vasopressors erroneously since its use brings benefi ts to the patient and the professional. Objective: To evaluate professionals’ perception of the use of local anesthetics with vasoconstrictors to perform dental procedures in patients with heart disease. Methods: This study was conducted by the application of a questionnaire that contained 12 questions which 100 professionals answered from January to September 2014. Results: 61% of professionals recommend that the use of local anesthesia associated with a vasoconstrictor to dental treatment for a cardiac patient. Half of them did not know to answer, “What is the concentration of vasoconstrictor recommended for use in a cardiac patient?” 81 professionals choose the lidocaine as the best anesthesia. Conclusion: The professionals demonstrate to know about the use of vasoconstrictors associated with local anesthetics in dental procedures; however, the total amount and concentration of the vasoconstrictors are unknown.

Incidence of infective endocarditis in England, 2000–13: a secular trend, interrupted time-series analysis

Antibiotic prophylaxis given before invasive dental procedures in patients at risk of developing infective endocarditis has historically been the focus of infective endocarditis prevention. Recent changes in antibiotic prophylaxis guidelines in the USA and Europe have substantially reduced the number of patients for whom antibiotic prophylaxis is recommended. In the UK, guidelines from the National Institute for Health and Clinical Excellence (NICE) recommended complete cessation of antibiotic prophylaxis for prevention of infective endocarditis in March, 2008. We aimed to investigate changes in the prescribing of antibiotic prophylaxis and the incidence of infective endocarditis since the introduction of these guidelines. We did a retrospective secular trend study, analysed as an interrupted time series, to investigate the effect of antibiotic prophylaxis versus no prophylaxis on the incidence of infective endocarditis in England. We analysed data for the prescription of antibiotic prophylaxis from Jan 1, 2004, to March 31, 2013, and hospital discharge episode statistics for patients with a primary diagnosis of infective endocarditis from Jan 1, 2000, to March 31, 2013. We compared the incidence of infective endocarditis before and after the introduction of the NICE guidelines using segmented regression analysis of the interrupted time series. Prescriptions of antibiotic prophylaxis for the prevention of infective endocarditis fell substantially after introduction of the NICE guidance (mean 10,900 prescriptions per month [Jan 1, 2004, to March 31, 2008] vs 2236 prescriptions per month [April 1, 2008, to March 31, 2013], p<0·0001). Starting in March, 2008, the number of cases of infective endocarditis increased significantly above the projected historical trend, by 0·11 cases per 10 million people per month (95% CI 0·05-0·16, p<0·0001). By March, 2013, 35 more cases per month were reported than would have been expected had the previous trend continued. This increase in the incidence of infective endocarditis was significant for both individuals at high risk of infective endocarditis and those at lower risk. Although our data do not establish a causal association, prescriptions of antibiotic prophylaxis have fallen substantially and the incidence of infective endocarditis has increased significantly in England since introduction of the 2008 NICE guidelines. Heart Research UK, Simplyhealth, and US National Institutes of Health.

Hemorrhagic Complications of Dental Extractions in 181 Patients Undergoing Double Antiplatelet Therapy

There is limited information on hemorrhagic complications during invasive dental procedures in patients treated with double antiplatelet therapy. The objective of this study is to assess the frequency of hemorrhagic complications of patients taking dual antiplatelet medication undergoing dental extractions. An observational, multicenter, prospective, cohort study was performed in 11 oral and dental care units of primary care. The study sample was derived from the population of patients aged 18 years or older who were undergoing double antiplatelet therapy and presented to the oral and dental care units requiring dental extraction. Double antiplatelet therapy is the combination of 100 mg per day of acetylsalicylic acid and a second antiplatelet agent. The predictor variables were type of extraction performed, number of extracted teeth, number of extracted roots, and presence of inflammation. The primary outcome variable was intraoperative hemorrhage, and the secondary outcome variables were hemorrhage at 24 hours and hemorrhage at 10 days. First, a univariate analysis that considered all studied variables was performed. All variables with P < .25 in the univariate analysis were included in a multivariate analysis. The association between hemorrhage severity and its relevant factors was evaluated using logistic regression analysis. The study included 181 patients. Light hemorrhage (<30 minutes) was observed in 165 patients (91.2%). Intraoperative hemorrhage lasted more than 30 minutes in 15 patients (8.3%) and more than 60 minutes in only 1 patient, whose hemorrhage was controlled by local hemostatic measures. The presence of inflammation and 3-root extractions increased the probability of hemorrhage persisting for more than 30 minutes by factors of 10 and 7.3, respectively. In 8.3% of patients treated with dual antiplatelet therapy, dental extractions cause hemorrhagic complications lasting more than 30 minutes are resolved using local hemostatic measures. The results of this study support the safety of dental extraction without withdrawal double antiplatelet therapy.

General Anesthesia for Dental Procedures in Patients With Fibrodysplasia Ossificans Progressiva

General Anesthesia for Dental Procedures in Patients With Fibrodysplasia Ossificans Progressiva

Antibiotic prophylaxis during dental procedures in patients with in situ lower limb prosthetic joints.

The average age of patients presenting for total joint arthroplasty is decreasing. The number of primary and revision arthroplasty procedures performed in the UK, Europe and USA is increasing annually. As number of procedures performed increases, the life expectancy of our patients and therefore the in vivo duration of prosthetic joints increase, and the potential for complications such as infection increases. One potential source for this is bacterial dissemination during dental surgery. Many attempts have been made to address this issue in the form of national guidelines, but there is no clear consensus on antibiotic prophylaxis before these procedures in order to decrease the risk of prosthetic joint infection. This continues to be an area of indecision and uncertainty resulting in patients having delays in their treatment while decisions are made by oral and orthopaedic surgeons about prophylactic antibiotic use. This article reviews the existing national guidelines, highlighting the current views and issues surrounding this subject, and a critical appraisal of current evidence for the use of prophylactic antibiotics in this patient population is presented. We will also review the response in literature to the 2009 American Academy of Orthopaedic Surgeons information statement release on antibiotic prophylaxis in joint arthroplasty patients undergoing dental procedures.

Managing Endodontic Patients with Severe Gag Reflex by Glossopharyngeal Nerve Block Technique

IntroductionGagging is a protective reflex, but when the gag reflex becomes abnormally active, it poses a difficulty for the dentist because it hinders all aspects of dental procedures including diagnosis, radiography, and any form of active procedure. MethodsIn this case report, to overcome this difficulty the authors used a glossopharyngeal nerve block technique that is used by anesthetists and otolaryngologists, but its endodontic use has gone previously unreported. ResultsResponse to gag reflex decreases after successful glossopharyngeal nerve block. ConclusionsThe glossopharyngeal nerve block technique is a relatively safe, simple, and easy to master technique as compared with general anesthesia for treating a patient with an exaggerated gag reflex. The glossopharyngeal nerve block technique may be used in dental procedures in patients with an exaggerated gag reflex or when performing procedures in the posterior aspect of the mouth. Due caution should be exercised to prevent inadvertent intravascular administration of local anesthetic when using this procedure.

General Anesthesia for Dental Procedures in Patients with Fibrodysplasia Ossificans Progressiva

Fibrodysplasia ossificans progressiva (FOP) is a rare genetic condition characterized by progressive heterotopic ossification of skeletal muscle and soft connective tissues, leading to progressive ankylosis of all joints of the axial and appendicular skeleton. Cervical spine fusion, ankylosis of the temporomandibular joints, thoracic insufficiency syndrome, restrictive chest wall disease, and sensitivity to oral trauma complicate airway management and anesthesia and pose life-threatening risks. We conducted a retrospective chart review at 1 institution of patients with FOP who underwent general anesthesia (GA) for dental procedures. Thirty patients underwent 42 general anesthetics. In 35 of 42 cases, GA was induced after the airway was secured by an awake fiberoptic intubation. In 4 of 42 cases, all of them pediatric, GA was first induced with maintenance of spontaneous ventilation, and the trachea was then intubated using a fiberoptic scope. In 2 cases, 1 adult and 1 pediatric, GA was first induced, and the trachea was then intubated using a GlideScope. In 1 case, the patient had a cuffed tracheostomy device in place that was accessed for GA. In 36 of 42 cases, the patients were discharged home on the same day as their dental procedure. No significant postoperative complications were encountered. GA can be administered safely to patients with FOP for dental procedures with attention to perioperative and airway management using a multidisciplinary approach. An awake nasal fiberoptic intubation should be considered the first choice for airway management. Most patients can be discharged home on the same day as their dental procedure.

Anesthetic management of dental procedures in patients with special needs: A retrospective analysis of 519 patients in North of Turkey

Special need patients have increased risk for oral diseases throughout their life. Sedation and general anesthesia is generally the preferred treatment for special needs patients though it provides optimal conditions for dental treatment. This study was aimed to describe our anesthetic experience in dental treatments of 519 special needs patients at a dental faculty in the north side of Turkey during a three-year period. The data referring to patient’s demographic information, anesthetic techniques, agents, dental treatment duration and the type of dental procedure during the period from 2009 to 2012 were retrospectively collected. All of the patients had moderate or severe intellectual disability, and not cooperating fully with dental treatment. There were for different anesthetic techniques in application: face mask, face mask combined with intravenous sedation, total intravenous anesthesia, and nasal entubating general anesthesia. Two intravenous (IV) anesthesic agent, Propofol (Propofol) and Midazolam (Dormicum) were used either alone or combined. Sevoflurane (Sevorane) was used as inhalation anesthesia and Vecuronium bromide (Norcuron) was used in patients that require nasal entubation. The mean age was 19 yr (range 3 to 81), and males predominated females by a ratio of 271A248. Of 519 patients, 204 patients were ASA grade 1, 315 patients were ASA grade 2. Cognitive impairments include; Alzheimer disease (1 patient) and dementia (1 patient). Central nervous system disorders (CNS) include; ataxia (1 patient), autism (38 patients), cerebral palsy (7 patients), hydrocephaly (1 patient), multiple sclerosis (1 patient). Specific syndromes include; Down syndrome (35 patients), Epidermolysisbullosa (1 patient), Reye’s syndrome (1 patient). Only minor complications such as nose bleeding, nausea/vomiting, restlessness, dizziness, shivering and desaturation (saturation under 90) were seen during the immediate postoperative period. A multidisciplinary approach between the dentist and anesthesiologist are important to manage successful treatment of these patients.

Dental Procedures in Patients with Atrial Fibrillation and New Oral Anticoagulants.

This review discusses the basic pharmacology of new oral anticoagulants that are used for prevention of thromboembolism in patients with atrial fibrillation. It presents available evidence, and provides recommendations for the management of patients requiring invasive procedures in dental practice.

Safety and cost-effectiveness of bridge therapies for invasive dental procedures in patients with mechanical heart valves.

PurposeBridge anticoagulation therapy is mostly utilized in patients with mechanical heart valves (MHV) receiving warfarin therapy during invasive dental procedures because of the risk of excessive bleeding related to highly vascular supporting dental structures. Bridge therapy using low molecular weight heparin may be an attractive option for invasive dental procedures; however, its safety and cost-effectiveness compared with unfractionated heparin (UFH) is uncertain.Materials and MethodsThis study investigated the safety and cost-effectiveness of enoxaparin in comparison to UFH for bridge therapy in 165 consecutive patients (57±11 years, 35% men) with MHV who underwent invasive dental procedures.ResultsThis study included 75 patients treated with UFH-based bridge therapy (45%) and 90 patients treated with enoxaparin-based bridge therapy (55%). The bleeding risk of dental procedures and the incidence of clinical adverse outcomes were not significantly different between the UFH group and the enoxaparin group. However, total medical costs were significantly lower in the enoxaparin group than in the UFH group (p<0.001). After multivariate adjustment, old age (≥65 years) was significantly associated with an increased risk of total bleeding independent of bridging methods (odds ratio, 2.51; 95% confidence interval, 1.15-5.48; p=0.022). Enoxaparin-based bridge therapy (β=-0.694, p<0.001) and major bleeding (β=0.296, p=0.045) were significantly associated with the medical costs within 30 days after dental procedures.ConclusionConsidering the benefit of enoxaparin in cost-effectiveness, enoxaparin may be more efficient than UFH for bridge therapy in patients with MHV who required invasive dental procedures.

Antibiotic prophylaxis for pre–liver transplant patients: where is the evidence?

Radmand et al. provided valuable information for oral health care providers in their recently published article “Pre-liver transplant protocols in dentistry”.1 However, we express concern regarding their recommendation for antibiotic prophylaxis (AP) for dental procedures, because they appear to be creating a new, opinion-based recommendation for this patient population. The authors state, “although there are no standard guidelines concerning antibiotic prophylaxis in pre-liver transplant patients, preoperative prophylactic antibiotic coverage may be considered to reduce the incidence of postoperative infection, based on the extent of the procedure and the severity of the liver disease.” The authors then claim that transient bacteremia in patients with ascites may lead to spontaneous bacterial peritonitis with additional increase in the mortality rate, and they recommend specific antibiotics to use before dental procedures for patients with refractory ascites and hypoalbuminemia/severe synthetic dysfunction.

Predisposition to Infection and Bleeding in Mechanical Assist Devices (LVADs) Recepients after Dental Procedures: A Single Center Experience

<h3>Purpose</h3> Currently more than 7,000 patients with heart failure are supported with LVADs. Few patients with LVADs undergo dental procedures and are at risk of bleeding due to their anticoagulation/antiplatelet medication profile and acquired VWF deficiency. Many centers follow the AHA guidelines for the prophylaxis of bacterial endocarditis in patients with prosthetic devices. Though these guidelines are comprehensive, they do not specifically address prophylactic recommendations for patients with LVADs. We would assume that these guidelines hold true for LVADs; however there is no current evidence. <h3>Methods and Materials</h3> To assess the risk of infections and bleeding complications during dental procedures in patients with LVADs, we designed a protocol based pilot study of LVAD patients using the AHA guidelines. We followed 19 patients respective clinical course for administration of preprocedural antibiotics, continuation of their anticoagulation/antiplatelet medication, episodes of infective endocarditis, bacteremia, dental abscess, and bleeding episodes till six months after the procedure. <h3>Results</h3> [figure 1] <h3>Conclusions</h3> There was no increased risk of infections (dental abscess, pneumonia, infective endocarditis, and bacteremia) and no bleeding complications when the designed protocol was followed.

Review of postoperative bleeding risk in dental patients on antiplatelet therapy

We conducted a review of the literature to assess risk for oral bleeding complications after dental procedures in patients on antiplatelet therapy. We conducted a search in Medline, Embase, and National Guideline Clearinghouse databases for studies involving patients on single and dual antiplatelet therapy that had invasive dental procedures or manipulations that induce oral bleeding. The literature search yielded 15 studies that met inclusion criteria. There is a trend toward increased occurrence of immediate postoperative bleeding for dual antiplatelet therapy, but there is no increase in the occurrence of intra- or late postoperative bleeding complications. We found no clinically significant increased risk of postoperative bleeding complications from invasive dental procedures in patients on either single or dual antiplatelet therapy. These findings support the recommendation that there is no indication to alter or stop these drugs, and that local hemostatic measures are sufficient to control bleeding.

Can fasting plasma glucose and glycated hemoglobin levels predict oral complications following invasive dental procedures in patients with type 2 diabetes mellitus? A preliminary case-control study

OBJECTIVE:To evaluate the effects of the levels of glycemic control on the frequency of clinical complications following invasive dental treatments in type 2 diabetic patients and suggest appropriate levels of fasting blood glucose and glycated hemoglobin considered to be safe to avoid these complications.METHOD:Type 2 diabetic patients and non-diabetic patients were selected and divided into three groups. Group I consisted of 13 type 2 diabetic patients with adequate glycemic control (fasting blood glucose levels <140 mg/dl and glycated hemoglobin (HbA1c) levels <7%). Group II consisted of 15 type 2 diabetic patients with inadequate glycemic control (fasting blood glucose levels >140 mg/dl and HbA1c levels >7%). Group III consisted of 18 non-diabetic patients (no symptoms and fasting blood glucose levels <100 mg/dl). The levels of fasting blood glucose, glycated HbA1c, and fingerstick capillary glycemia were evaluated in diabetic patients prior to performing dental procedures. Seven days after the dental procedure, the frequency of clinical complications (surgery site infections and systemic infections) was examined and compared between the three study groups. In addition, correlations between the occurrence of these outcomes and the glycemic control of diabetes mellitus were evaluated.RESULTS:The frequency of clinical outcomes was low (4/43; 8.6%), and no significant differences between the outcome frequencies of the various study groups were observed (p>0.05). However, a significant association was observed between clinical complications and dental extractions (p = 0.02).CONCLUSIONS:Because of the low frequency of clinical outcomes, it was not possible to determine whether fasting blood glucose or glycated HbA1c levels are important for these clinical outcomes.

Risk of postoperative bleeding after dental procedures in patients on warfarin: a retrospective study

The purpose of this retrospective study was to investigate the frequency of bleeding complications after invasive dental procedures in warfarinized patients and the possible risk factors. The CoaguChek System was used to obtain an in-office international normalized ratio (INR) value for 122 patients (240 appointments), of which the mean age was 57.0 ± 15.9 years and 50% were males. Demographic and clinical information were obtained retrospectively from dental and medical records. Five episodes (mean INR: 2.0 ± 0.8) of persistent bleeding were identified; 4 were after extractions and 1 was after implant placement. The frequency of bleeding was 4.8%, if only considering surgical procedures. Postoperative bleeding was significantly higher (P < .05) in patients who were taking anti-thrombotic medications in addition to warfarin. There is a low incidence of persistent bleeding after invasive dental procedures in warfarinized patients but the risk appears to increase with the use of concomitant anti-thrombotic medications.

Dental postoperative bleeding complications in patients with suspected and documented liver disease

The aims of this study were to determine the frequency of bleeding complications following dental procedures in patients with known or suspected chronic liver disease and whether international normalized ratio (INR) determination could aid in predicting bleeding complications in these patients. We identified 90 patients (mean age: 51 ± 9 years) in this retrospective chart review. Sixty-nine patients had a known history of chronic liver disease and 21 had suspected chronic liver disease. Descriptive statistics were determined. Independent sample t-test and one-way variance test were utilized for continuous variables and chi-square test for dichotomous variables. The mean INR value for all patients was 1.2 ± 0.3. The INR value was significantly associated with the diagnosis of liver cirrhosis, the diagnoses of Hepatitis B and C together, the presence of ascites alone, and the number of clinical signs and symptoms (i.e. ascites, jaundice and encephalopathy) present. Nine patients with INR values between 1.5 and 2 underwent invasive dental procedures without postoperative bleeding complications. There were no episodes of postoperative bleeding in patients. The findings suggest that clinicians should not rely solely on an INR value to predict post-procedure bleeding in patients with liver disease.

Infective endocarditis: the impact of the nice guidelines for antibiotic prophylaxis

Infective endocarditis (IE) is a serious, life-threatening disease and oral bacteria are implicated in 35-45% of cases. This has led to the development of guidelines recommending the use of antibiotic prophylaxis (AP) prior to invasive dental procedures in patients at risk of IE. There is considerable controversy about the value of AP in preventing IE, resulting in guideline changes and different guidelines in different parts of the world. In March 2008, NICE recommended the complete cessation of AP prior to dental procedures in the UK. The effects of this controversial change were not entirely as anticipated and may provide important lessons about the role of AP in preventing IE. The debate over the value of providing antibiotic prophylaxis to prevent infective endocarditis in patients undergoing invasive dental procedures is of importance to dentists worldwide. The effect of the NICE guidelines on antibiotic prophylaxis prescribing and incidence of infective endocarditis in the UK has contributed important new evidence to this ongoing debate.

Treating dental patients who use oral antithrombotic medication: A survey of dentists in the Netherlands

For many years, international guidelines have advised health care professionals not to adjust oral antithrombotic medication (OAM) regimens before invasive dental procedures. The authors conducted a study to examine the opinions of Dutch general dentists regarding the dental care of patients receiving treatment with these medications.The authors invited via e-mail 1,442 general dentists in the Netherlands to answer a 20-item Internet-based questionnaire that they developed. Survey items consisted of questions about medical history taking, number of patients in the dental practice receiving OAM therapy, frequency of consulting with medical and dental colleagues and suggested dental treatment of patients during various invasive dental procedures.A total of 487 questionnaires were returned (response rate of 34 percent). The mean age of respondents was 47 years, and 77 percent were male. The majority of dentists responded that they obtain medical histories, but that they did not know how many of their patients were receiving OAM treatment. Dentists reported that they consult with medical colleagues frequently about antithrombotic medication. Ninety-one percent of respondents stated that they obtained their medical knowledge primarily in dental school. More than 50 percent of the dentists reported that they were not familiar with the international normalized ratio. The majority of dentists responded that they felt a need for clinical practice guidelines.According to the results of our survey, most dentists remain cautious when performing invasive dental procedures in patients who are treated with OAMs. Moreover, survey respondents tended to estimate that the risk of bleeding during dental procedures when OAM therapy is continued is higher than the risk of rethrombosis when use of antithrombotic medication is interrupted.A growing proportion of elderly patients and those with medically complex conditions are being treated in dental practices in the Netherlands. Consequently, more needs to be done to ensure that dentists are offered evidence-based guidance when treating patients who receive OAMs.

Selective serotonin reuptake inhibitors and oral bleeding complications after invasive dental treatment

The purpose of this study was to examine the frequency of oral bleeding complications after invasive dental procedures in patients taking selective serotonin reuptake inhibitor (SSRI) medications. In this retrospective cohort study, we included dental patients who had invasive dental treatment and were taking an SSRI medication. Data collected included demographics, medical history, dental visits and procedures, and use of adjunctive measures to control bleeding. Primary outcomes included documentation of return visits or phone calls to the dental clinic or emergency department (ED) for oral bleeding, and oral bleeding or use of blood products for inpatients. There were 92 patients taking SSRIs who had 145 invasive procedure visits, consisting of extractions, implant surgery, alveoloplasty, periodontal surgery, subgingival scaling and root planning, and biopsy. There were 110 extraction visits yielding a total of 167 extractions. Among all patients, there was 1 return visit to the clinic and 1 telephone call with a chief complaint of oral bleeding. The frequency of oral bleeding complications after invasive dental treatment is low to negligible in patients on SSRI medications.

Antibiotic Prophylaxis for Dental Procedures

The long-standing practice of antibiotic prophylaxis before dental procedures in patients at risk for infective endocarditis (IE) was recently