Dental Tourists to Turkey Report Less Than Desirable Results: Think you’re getting a deal by traveling abroad for your dental work. Dental tourism is common with residents of many countries, including the United States, who seek dental care in regions that offer services for a significantly reduced cost. Turkey hosts more than 150,000 travelers each year who come to receive dental care. Hungary, Thailand, and Dubai are also popular destinations for dental treatment. Some Britons, however, learned the hard way that dental tourism is not without risk. The British Dental Association warned United Kingdom residents of seeking inexpensive care in Turkey after many Brits returned with substandard work including unnecessary tooth extraction, failed implants, poorly fitting crowns, and subsequent infection. So as is always the case of if it sounds too good to be true it probably is.
Why do I need to premedicate before my dental appointment? : In May 2021, the American Heart Association (AHA) updated its antibiotic prophylaxis guidelines for the prevention of infective endocarditis (IE).1 As some dental and dental hygiene procedures may increase the risk of this potentially life-threatening infection in at-risk patients, oral health professionals must have a thorough understanding of this serious, albeit rare infection of the heart and understand appropriate precautions for treatment.
IE is an infection of the inner lining of the heart, frequently involving the heart valves. Sequela of an IE infection may lead to heart failure, stroke, heart valve damage that requires valve replacement, and death.
A significant public health issue, IE affects three to 10 individuals per 100,000 globally with a 20% mortality rate. IE is most common among persons who inject drugs (PWID). Also at increased risk for IE are patients with cardiovascular disease who develop nosocomial (acquired or occurring in a hospital) infections and patients undergoing dental procedures that produce significant bacteremia.
There are two types of IE: Native valve endocarditis and Prosthetic valve endocarditis.
Prosthetic valve endocarditis, however, has grown over the past decade due to an increase in the number of surgical replacements of damaged valves. Requiring complex medical management, prosthetic valve endocarditis has higher mortality and morbidity rates than native valve endocarditis. Patients with prosthetic valve endocarditis may be better served in a hospital-based dental setting.
Native Valve Endocarditis: Involves a combination of factors, including an injured (roughened) endothelial lining, damaged or roughed heart valve, host immune response, and bacteremia in the systemic circulation, can lead to IE. IE cannot occur unless the heart has a nonbacterial thrombotic endocarditis (NBTE) lesion. A NBTE lesion forms in the presence of inflammation or injury to the heart’s endothelial cells or valves, which causes an immune response. This response results in the platelets and fibrins adhering to the area of injury, causing vegetation’s or NBTE. When the integrity of the dermis is disrupted via an open skin wound, needle puncture, or surgical procedure, bacteremia may result, possibly leading to a NBTE lesion. Bacteremia may also originate from an internal source such as an abscess or dental infection. Due to bacteremia, an NBTE lesion in the heart can transition from noninfected tissue to infected tissue, causing IE.
IE most frequently impacts the left side of the heart (70%), especially the mitral or aortic valves. IE occurs in the right side of the heart involving the tricuspid or pulmonic valve approximately 10% to 20% of the time. The only exception to this pattern is among persons who inject drugs, (PWID), who most often present with right side IE due to a needle skin puncture with Staphylococcus aureus as the etiologic pathogen.
Some bacteria are more likely to cause IE. Approximately 90% of community-acquired cases are caused by streptococci, staphylococci, or enterococci species. S. aureus is a normal inhabitant of the skin and mucous membranes of the mouth and nose. When S. aureus enters the bloodstream due to drug injection or stab wound, it may cause IE in at-risk patients.
The streptococci species is the most common cause of native valve IE among those who are not intravenous drug users. Viridans streptococci, a heterogeneous group of alpha-hemolytic streptococci, are part of the normal flora of the mouth, and play a role in the formation of dental caries (Streptococcus mutans, S. sanguinis) and pericoronitis. They also cause subacute IE. Viridans streptococci are responsible for approximately 40% to 60% of native valve IE. They are also the most common dental-derived pathogen to cause IE.
Another virulent but rare (1% to 3%) IE pathogen is a group of Gram-negative bacteria composed of Haemophilus, Aggregatibacter, Cardiobacterium hominis, Eikenella corrodens, and Kingella species (HACEK).11 HACEK organisms are a normal part of the human microbiota living in the oral-pharyngeal (throat) region.
Aggregatibacter actinomycetemcomitans is a Gram-negative bacterium linked to periodontal diseases. It is found in 90% of localized aggressive periodontitis cases and 30% to 50% of severe adult periodontitis.12 This is important information for dental hygienists, as the presence of periodontal diseases in patients at risk for IE will increase the virulence of their bacteremia.
Infective Endocarditis is classified as subacute and acute.
Subacute IE is related to dental treatment, dental injections, hygiene and restorative procedures, and typically presents a week to several months after a procedure. It is predominantly caused by S. viridans which is bacteria that normally inhabits the mouth.
Acute IE is a bacterial endocarditis—most common among PWID—caused by an infection or port of entry. Acute IE is most commonly caused by S. aureus which is found in the mouth and on the skin. Dental injections as well as hygiene and restorative procedures can introduce these bacteria into the blood stream.
PWID ( People Who Inject Drugs) who have acute IE are typically young, and present with native valve infections 90% of the time. An acute IE related to intravenous drug use is more complex to manage.
Clinical manifestations of IE may include the following: fever, night sweats, fatigue, Olser nodes (painful, red blisters on the hands and feet), Janeway lesions (irregular, nontender hemorrhagic macules found on the hands and toes), splinter hemorrhages (thin, reddish-brown lines under the nails), conjunctival petechiae (broken capillaries in the eyes) and/or hemorrhages, Roth spots (retinal hemorrhages), and nail clubbing (enlarged fingertips with the nails curving around the tips). Olser nodes and Janeway lesions are cutaneous nodules associated with an IE infection. Roth spots can be seen with other medical conditions, but are most often associated with IE, detected in 80% of subacute bacterial endocarditis.