Pathology, v. I, ed. Louis, C. Mosby Co. Antibiotic cover for dental extractions. Br Med.

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Medical dental prophylaxis of endocarditis. Regina C. Basilio I ; Francisco E. Loducca II ; Paulo C. Haddad III. Antibiotics have long been the main reason for the increase in man's longevity. Since their discovery, man has tried to reduce the level of infection by treating with antibiotics. At the same time, prophylactic use has been suggested, although this is controversial. Their routine use is not recommended, and empirical treatments at non-therapeutic doses, and indiscriminately, should be avoided, because they may become dangerous and harmful, causing among other things, the prevalence of resistant microorganisms and the eventual potentiation of an increase in morbid states.

The main goal is to prevent or to fight against the transient bacteremia, reducing its intensity and duration, and also to kill the bacteria in at-risk patients. In this way, infectious endocarditis can be prevented; the dental surgeon plays an important role in the prevention of this condition, which joins medical and dental aspects. This can be done by antibiotic prophylaxis. The dentist needs to be acquainted with the medical protocols of the heart health societies.

Infectious endocarditis is an uncommon cardiopathy, with a high rate of morbidity, being fatal when not diagnosed and treated in time. Nowadays the negative impact that buccal infection can have on systemic health is known to be due to the resultant bacteremia. This bacteremia is the entrance point for microorganisms or their products into the blood stream. There are some ways of avoiding, or at least easing this impact. One of these ways would be antibiotic prophylaxis.

The prophylactic use of antibiotics avoids its presurgical use, before the occurrence of bacteremia. Antibiotic prophylaxis, however, has been controversial and polemic. We must not make antibiotics a panacea, thinking that they will solve the problem, and consequently forget about means of prevention, such as the maintenance of biosafety, which, when correctly used, can reduce the occurrence of contamination and infection. Correct preventive use of antibiotics demands great pharmacological knowledge of the drugs that will be used, because if correctly used these drugs will be effective, but if not, there can be a increase in the patient's morbid status, without any benefit.

In the specific case of infectious endocarditis, we find that there is a great deal of difficulty even greater than for other conditions to choose the right preventive medicine, because there's a great range of etiological agents; there is also a possibility of an incorrect diagnosis, due to the similarity of other pathologies.

Several rules for the application of antimicrobial medicines have appeared over time, and they have been used according to the evolution of research in period. Nowadays, studies such as that of Wippel [1] show that the application of antimicrobial agents has definite rules and can be accomplished with precision. The professional has to keep in mind that the prophylactic procedure does not redeem him of any kind of responsibility towards the patient and that endocarditis can appear despite the use of good prophylaxis.

It is not possible to always foresee the infectious process. The literature relates that most patients who were thought to have some kind of disease, either did not have it or were afraid of telling it to the professional, and omitted the information. Most of them do not know how dangerous their morbid status may be, nor are they aware of the consequences of this omission.

The patient's cooperation is necessary for the success of the adopted propaedeutic; that is why the professional should always keep his patient abreast of what is happening, because, when the patient is included as "part of the team", he becomes co-responsible for the success of the treatment.

The interchange between health professionals and, at the same time, between professionals and patients, facilitating the desired interchange of information, creates a channel of communication that will make the choice of the best procedure and prophylactic medicine for the patient's condition possible. The great frequency of infection after dental treatment, with infectious endocarditis being one of theses clinical conditions, associated with important morbidity and high lethality, is well known; Bear [2], Sonis [3], Passeri [4], Dajani [5], Durack [6] have indicated that antibiotics should be used to prevent post-dental procedure infections.

Endocarditis is an infectious process that affects the endocardium, not only in normal hearts, but also in those that may have some kind of disease that can come from a bacteremia in the buccal cavity [7]. This bacteremia occurs spontaneously way, in daily processes, such as chewing and brushing the teeth.

It is therefore transitory, and rarely lasts more than 15 minutes [8]. The risk of this kind of bacteremia seems to depend on two points: the extension of the traumatism of the soft tissue and the degree of preexistent inflammatory disease [3].

The microorganisms take advantage of the break in the skin mucosal anatomic barriers to break into the deeper tissues and reach the blood stream and, by doing so, also get to more distant places in the organism [9]. Bacteremia may occur in any process that provokes bleeding. The bacteria transported by the blood can accommodate themselves in injured heart valves in the endocardium or in the endothelium, near congenital defects [10].

Consequently, bacteremia commonly occurs with the manipulation of infected tissues, and also in traumatic procedures, being eliminated by the defense mechanism of the host. But when the microorganisms reach the circulation in large enough numbers and remain there for appropriated time, the endocarditis may install itself [11]. So, the role of bacteremia in the aetiopathogeny of infectious endocarditis systemic disease, which involve medical and odontological aspects, is known and it can be prevented.

The participation of the dental surgeon in this prevention is extremely important. The primordial goal is to avoid or fight against transient bacteremia in susceptible individuals [12]. The professional should also be informed about microbiology, and the bacterial pattern of susceptibility to the antibiotics in the oropharynx, as well as phamacokinetics, in order to select and prescribe the best medication.

While Lavelle [18] indicated a few studies that proved the effectiveness of the antibiotics in the prophylaxis of infectious endocarditis, Rahn [19] and Durack [6] showed that although we could not prevent transient bacteremia and that there was no evidence that antibiotics can effectively prevent infectious endocarditis in human beings, they found clear signs that antibiotic treatment could decrease bacteremia and that they could prevent infectious endocarditis in animals.

However, though it is not the objective, prophylaxis can probably decrease the occurrence of these infections. Consequently, they agree with Sonis [3]: "although there isn't direct evidence that the prophylaxis with antibiotics is capable in the prevention of infectious endocarditis there's adequate evidence that it decreases the incidence of bacteremia.

Lavelle [18] mentioned that failures in prophylaxis have already been demonstrated and related them to an increase in the resistance to beta-lactam and also to other antibiotics.

Roberts [21] alerted that not all the failures gave rise to infectious endocarditis. Soares [22] related the occurrence of cases of infectious endocarditis, even with etiological agents sensitive to the antibiotic that was used, while Howe [23] indicated that the parenteral regime can be counterproductive, causing failure in the prophylaxis, as the patients could deliberately omit information, in an attempt to avoid intravenous medicine.

Howe [23] advocated that the total prevention of infectious endocarditis, associated with dental procedures is an impossibility. So, penicillin, erythromycin, cephalosporin, tetracycline and clindamycin would be the drugs chosen. As the scientific literature has established Streptococcus viridians alpha-hemolytic streptococci and Staphylococcus aureus , as the most common etiological agents in infectious endocarditis of dental origin, from the upper respiratory tract and from the esophagus, it's against them that prophylaxis should be used.

Initially, penicillin would be the drug chosen, however, Lopes [31], White [32,33], and Zerbal [29] have alerted about the existence of resistant staphylococcus strains. While for the antistaphylococcal penicillins oxacillin, methicillin there are already reports about resistant sprains, as was already found for microorganisms resistant to cephalosporins, an alternative antibiotic group for people who are allergic to penicillin.

Consequently, the staphylococci already are among the most serious therapeutic problems. Nevertheless, the protocols of medical associations for the prevention of infectious endocarditis indicate since amoxacillin as the right drug to be taken because it's better absorbed by the gastrointestinal tract than its "mother", ampicillin, producing a higher and longer lasting serum level hours.

According to Moore [36], when we talk about buccal infection, medicals have used erythromycin. Since its introduction in , it has been the first alternative for people who are allergic to penicillin. Currently, there are no data that indicate greater cross reactions in individuals with a history of anaphylaxis or immediate reaction to penicillin. So, the use of this medicine is generally safe for a patient who has skin eruption caused by penicillin.

In , Dajani [5] ratified the alteration in the protocol of before mentioning clindamycin as an alternative prophylactic antibiotic for patients with hypersensitivity to penicillin, but they also suggest two late generation macrolides as an alternative. They are azythromycin and claritromycin, however both are hard on the patient. Dajani [43] quoted by Andrade [44], proved, comparing doses of 2. Sonis [3], Lopes [31], Bear [2], Howe [23], following the directives suggested by entities responsible for research about infectious endocarditis prevention, indicated, up to , a parenteral application as preferred for the administration of antibiotics due to its superior effect on blood serum levels.

Subsequently, the same entities have given little emphasis to the parenteral procedure, possibly because of logical and financial considerations, being used only under some alternative prophylactic regimes or under specific conditions, such as for patients who will undergo surgery under general anesthesia and are fasting and are unable to ingest or absorb oral medications.

Rahn [19] alerted that the prophylactic use of antibiotics can decrease the risk of infectious endocarditis, but it does not present bacteremia. This way, the addition of topical antiseptics to antibiotics has been used in an attempt to reduce the occurrence of bacteremia. Roberts [21], Rahn [19], Zerbal [29] and Prado [9] alerted that treatment with topical antiseptics does not mean substituting prophylaxis by systemic antibiotics.

They have a preventive effect, but they ca not do away with the bacteremia completely. They represent, together with the maintenance of a good buccal health, a complementary way to the resolution of events that can lead to infectious endocarditis. Antibiotics may prevent infectious endocarditis , but they cannot avoid bacteremia. Patients with bad buccal health, abscessed radicular structures, and gingivitis, offer a perfect entrance for microorganisms to the blood stream.

So, the maintenance of good buccal health should be emphasized to the maximum. The use of medicines may help; it does help! Although we cannot forget that many rules about this use are a result of in vitro experiments, they do not substitute security norms and are not the solution for everything either; on the contrary, they can create problems. Each one has a side effect; and needs to be prescribed by a professional, so that he can use them in the best way. The prophylactic use of antibiotics in infectious endocarditis of dental origin is often valued as new concepts arise; that's why entities like the AHA American Heart Association and the BSAC British Society of Antimicrobial Chemotherapy are always going over their directives.

The dental surgeon must keep abreast of these changes and know that these rules are only a guide, and his clinical judgment is sovereign, because he knows the patient and his necessities; he is the responsible professional. The dental surgeon should be aware that total prevention, independent of what the infection is, does not exist. But he has the moral obligation of preventing serious complications in the treatment.

The mouth is part of a system that interacts with itself. An anamnesis that values the patient will certainly assist the professional in the choice of the medicine that will stimulate the answers of the host at that moment, according to his systemic conditions.

Wippel A. J Bras Med ;76 4 Bear S. In: Kruger G.. Cirurgia bucal e maxilo-facial. Rio de Janeiro: Guanabara Koogan. Sonis S. Medicina oral. Passeri L. Rev Bras Odontol ;48 5 Dajani A. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA ; 22 Durack D.



Important User Information: Remote access to EBSCO's databases is permitted to patrons of subscribing institutions accessing from remote locations for personal, non-commercial use. However, remote access to EBSCO's databases from non-subscribing institutions is not allowed if the purpose of the use is for commercial gain through cost reduction or avoidance for a non-subscribing institution. Infective endocarditis is an infection on the surface of the endocardium, characterized as a rare disease, but which, if triggered, can cause inflammation and destruction of the endocardium, heart valves or vascular endothelium. As the discussion on the use or not of obtaining protocols for antibiotic prophylaxis is not fully pacified in the literature, this paper aims to review the need for antibiotic prophylaxis in those patient groups most at risk, with potential risk or low risk. However, users may print, download, or email articles for individual use. This abstract may be abridged.



Oral health evaluation of cardiac patients admitted to cardiovascular presurgery intervention. Presidente Prudente, SP, Brasil. Objective To assess the oral health status of patients admitted to pre-intervention heart surgery, observing the need index concerning invasive treatment. Methods hospitalized volunteers in number of 75 were evaluated in order to be investigated concerning which systemic changes were occurring, the patients' oral health conditions as well as the need for invasive dental procedures. Results Volunteers analyzed in the study were:

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