Definujte zápatí – název prezentace nebo pracoviště1 Focal infection Restorative dentistry – differential diagnosis Seminar 1 The infuence of oral microbs and oral inflammations on distant tissues and organs Oral microbiom ̶ Microbs living in oral cavity are saprohytic and opportunistic pathogens ̶ Most of them live in the biofilm - Dental biofilm (plaque) – on teeth or dentures - Oral mucous membrane biofilm Microbs are in a close contact with tissues Dental biofilm Pelicle ̶ A layer of proteins from saliva that precipitate on the tooth Dental biofilm • Adherence Dental biofilm • Colonization and coaggregation Dental biofilm • Maturation lenoubalikova@tiscali.cz 9 Dental biofilm Comunity More species, Better conditions for survival Higher resistancy Higher virulency Structure of the biofilm Inflammation in oral cavity ̶ Infectious origin or secondary contamination (e.g. traumatic aethiology) ̶ The most common diseases: ̶ dental caries ̶ periodontitis Dental caries ̶ Penetration to dental pulp – invasion of microbs, pulpitis, necrosis, gangraena, apical periodontitis: The inflammation affects connective tissue in periodontal space and alveolar bone Dental caries ̶ Penetration to dental pulp – invasion of microbs, pulpitis, necrosis, gangraena, apical periodontitis: The inflammation affects connective tissue in periodontal space and alveolar bone Periodontitis ̶ Penetration of microbs into soft tissues, connective tissues in periodontal space and alveolar bone. Dentitio dificilis, radicular cysts, apical periodontitis ̶ The infection can penetrate per continuitatem into soft tissues around manbible or maxilla as well as into the bone. Spreading of infection per continuitatem Definujte zápatí – název prezentace nebo pracoviště16 Source: anat.l.lf.cuni.cz Source: telemedicína.med.muni. z Microbs from oral microflora as well as microbs from inflammatory focus Can have an influence on distant structures without any signs of propagation per continuitatem Source: www.zuby.cz Three ways of microbial injury ̶ Metastatic infection ̶ Immunomodulation and immunotoxic injury ̶ Metastatic toxic injury Metastatic infection ̶ Dissemination of saprophytic and opportunistic microflora Bacteriemia – adherence microbs on surfaces other tissues esp. when damaged due to pathologic process Streptococci, staphylococci, actinobacilli Endocard and endothel when damaged Metastatic infection Endocarditis Vasculitis Inflammation of the socket of arteficial valve Immunomodulation and immunotoxic effect ̶ Bacterial antigens provoke immune response that can damage similar antigens from tissue of organism Sterile consequences of angina,erysipel, glomerulonephritis or pancreatitis Immunomodulation and immunotoxic effect ̶ Bacterial antigens + circulating antibodies Immunocomplexes Adsorption in tissues Activation of pathological processes Uveitis, iridocyclitis, rosacea, glomerulonephritis, rheumatic fever Metastatic effect of bacterial toxins ̶ Parts of bacterial cells – endotoxin, lipopolysacharids, peptidoglykan Histotoxic and cytotoxic properties Toxic damage of neurons (algia or paresis),pyrexins (subfebriles), damage of leucocyts and macrofags (immunodefect) Reasons of bacteriaemia ̶ Mastication ̶ Practising of oral hygiene ̶ Dental treatment procedures ̶ Inflammatory focuses Pathological consequences can be expected esp. when immunity of the organism is decreased Focal infection ̶ Two principal levels of the approach: Diagnostic-therapeutical Prophylaxis of the distant effect of oral microflora The dentist can be asked for ̶ Exclusion of focal infection in certain diagnosis ̶ Exclusion of possible risks in certain situations Definujte zápatí – název prezentace nebo pracoviště26 Causal consequences ̶ Increased temperature (subfebril temperature) ̶ Uveitis, iridocyclitis ̶ Orofacial nauralgia and paresis of unknown origin ̶ Rheumatic fever (subacute) ̶ Neuralgia n. trigemini ̶ Endocarditis ̶ Cellulitis (localised abscesses of unknown origin) ̶ Asthma bronchiale Definujte zápatí – název prezentace nebo pracoviště27 Prophylactic approach ̶ Preparation for transplantation ̶ Imunosupressive therapy ̶ Intensive chemotherapy ̶ Surgical intervention on open heart and big blood vessels ̶ Valve and vessel implantation Definujte zápatí – název prezentace nebo pracoviště28 Dentists can ask general practicioner or specialist for consultation in patients with ̶ Congenital and aquired immunideficiency ̶ Disorders of leucocyts and reticuloendothelial system ̶ Decompensated diabetes mellitus and hypoproteinaemia ̶ Congenital and aquired disorders of endocard ̶ Endocarditis in patient´s history ̶ Active glomerulonephritis ̶ Preparation for radiotherapy in orofacial region ̶ Drug addiction ̶ Status post splenectomy Definujte zápatí – název prezentace nebo pracoviště29 Examination of the patient ̶ History ̶ Clinical examination ̶ Imaging methods – x ray ̶ Laboratory examinations should be available Definujte zápatí – název prezentace nebo pracoviště30 History ̶ Possible relation between problems in oral cavity and other disease. Definujte zápatí – název prezentace nebo pracoviště31 Clinical examination ̶ Non vital teeth esp. periapical lesions ̶ Cysts of odontogenic or other origin ̶ Impacted teeth ̶ Roots ̶ Periodontal status – periodontal pockets esp. when BOP is positive or if the suppuration is present ̶ Dentitio difficilis Definujte zápatí – název prezentace nebo pracoviště32 Clinical examination ̶ Regional lymphatic nodes ̶ Oral hygiene ̶ Iatrogenic damage ̶ Therapeutical suggestions Definujte zápatí – název prezentace nebo pracoviště33 Radiographic examination ̶ OPG and i.o. examination of necessary Investigation: Apical and other radiolucences Osteolytic focuses Periodontal pockets Residual roots Definujte zápatí – název prezentace nebo pracoviště34 Laboratory examinations ̶ FW (sedimentation of erythrocyts) ̶ CRP ̶ Leucocytosis Others Definujte zápatí – název prezentace nebo pracoviště35 Report - conclusion ̶ Clear statement if focal infection could be excluded or not. ̶ If not: suggestion: Treatment of high quality Extraction Endodontic treatment (if good prognosis is predictable) Antibiotic prophylaxis Definujte zápatí – název prezentace nebo pracoviště36 Report - conclusion ̶ Clear statement if focal infection could be excluded or not. ̶ If not: suggestion: Treatment of high quality Extraction Endodontic treatment (if good prognosis is predictable) Antibiotic prophylaxis Individual approach is necessary!!! Definujte zápatí – název prezentace nebo pracoviště37 Antibiotic prophylaxis ̶ Short antibiotic medication before and sometimes after the treatment, high dosis. ̶ Aim: elimination of microbs from blood circulation Minimized risk of the metastatic infection Definujte zápatí – název prezentace nebo pracoviště38 Prophylaxis of bacterial endocarditis Degree of risk: ̶ 1. High degree • Patients with surgically replaced heart valve • Patients with recent surgical repair of a cardiovascular defect • Patients with a history of a previous attack of infective endocarditis ̶ 2. Moderate degree • Congenital heart disease • Rheumatic heart disease • SLE ̶ 3.Low degree • Coronary sclerosis • Cardiac pacemaker Definujte zápatí – název prezentace nebo pracoviště39 Indication ATB prophylaxis ̶ Cardiologic indication: High risk: Artificial valves, vessel implants Endocarditis in the history Cyanotic heart faults Surgical reconstructions of pulmonary nad heart vessels Definujte zápatí – název prezentace nebo pracoviště40 Indication of atb prophylaxis ̶ Cardiologic indication: ̶ Standard risk: Other congenital heart malformations Aquired valve dysfunctions Hypertrophic cardiomyopathy Prolaps of the mitral valve with regurgitation Definujte zápatí – název prezentace nebo pracoviště41 Atb prophylaxis is not strictly required ̶ Low risk: ̶ Isolated defect od auricle septum ̶ Status post surgical reconstruction of auricle or ventricle septum ̶ Before arterial coronary bypass ̶ Prolapsus of the mitral valve without regurgitation ̶ Implantedp Pacemakers and defibrilatosrs ̶ Slight murmusr ̶ Status post rheumatic fever without valve dysfunctionDefinujte zápatí – název prezentace nebo pracoviště42 Atb prophylaxis – other indications Status post angioplasty and application of the stent till 4 weeks after the treatment ̶ Non compensated diabetes mellitus (insulin or pad) ̶ Chronic renal insuffiency (invasive teatment in dialysed patients, dosage. Consultation) ̶ Arteficial joint ̶ Autoimmune diseases (e.g. Systemic lupus erythematodes) Definujte zápatí – název prezentace nebo pracoviště43 Procedures that requires atb prophylaxis in indications ̶ Extractions ̶ Surgical treatment of periodontal tissues including the scaling ̶ Enosseal implantation ̶ Reimplantation ̶ Endodontic treatment (instrumentation in the root canal – with the possibility of penetration through the apex) ̶ Subgingival application of therapeutical tools (e.g. Retraction cords) ̶ Application of orthodontic wires ̶ Intraligementary anaesthesia ̶ Scaling, root planning, dental calculus removal ̶ Removal of implants Definujte zápatí – název prezentace nebo pracoviště44 Atb prophylaxis is not necessary ̶ Restorative and prosthetic procedures ̶ Local anesthesia ̶ Endodontic treatment when apex is not reached (preparation for root canal inlay) ̶ Application of rubber dam ̶ Surgical suture removal ̶ Application of removable dentures and orthodontic appliances Definujte zápatí – název prezentace nebo pracoviště45 Atb prophylaxis is not necessary Definujte zápatí – název prezentace nebo pracoviště46 ̶ Local fluoridation ̶ Intraoral radiogram ̶ Cementation of brackets ̶ Extraction of completely resorbed primary tooth ATB prophylaxis ̶ Standard: Amoxycilin p.os.: adults 2g. Children 50 mg/kg 1 hour before the treatment If it is not possible p. os: adults ampicilin 2g, children 50 mg/kg i.m. or i.v. 30 min before the treatment Definujte zápatí – název prezentace nebo pracoviště47 ATB prophylaxis if allergy on PNC ̶ Clindamycin p.os: adults 600 mg,children 60 mg/kg 1 hour before the treatment ̶ Cephalexin p.os: adults 2g, children 50 mg/kg 1 hour before the treatment ̶ Azithromycin p.os: adults 500 mg, children 15 mg/kg 1 hour before the treatment. Definujte zápatí – název prezentace nebo pracoviště48 ATB prophylaxis if allergy on PNC and p.os is not possible Definujte zápatí – název prezentace nebo pracoviště49 ̶ Clindamycin: ̶ Adults 600 mg, children 20 mg/kg iv.v 30 min before the treatment ASA Group Physical status - description Importannce for oral care ASA 1 Healthy patients No limitations ASA 2 Mild to moderate systemic diseas medically well controlled Low importance for dental care. Preacaution when the status aggravated. Treatment instandard dental offices ASA 3 Severe disease process which limits activity but is not incapatitating Consultation with the physician or specialist is strongly recommended. The treatmen coule be preformed acc this recommendation in dental office or the patient must be send to the institution with special care. Minimize stress! ASA 4 Severe incapacitating diseas process that is a constant threat to life Ony necessary treatment after consultation. The care should be preformed in the hospital (dental clinic) ASA 5 Moribund patient nor expected to survive 24 hours No dental care ASA 6 Declared brain dead patient, organs can be removed for donor ůurposes No dental care Definujte zápatí – název prezentace nebo pracoviště50 Definujte zápatí – název prezentace nebo pracoviště51 Good level of the dental care all the time is the best prevention of metastatic infection Definujte zápatí – název prezentace nebo pracoviště52 Definujte zápatí – název prezentace nebo pracoviště53 Definujte zápatí – název prezentace nebo pracoviště54 Definujte zápatí – název prezentace nebo pracoviště55 Definujte zápatí – název prezentace nebo pracoviště56 Definujte zápatí – název prezentace nebo pracoviště57 Definujte zápatí – název prezentace nebo pracoviště58