YIJOM-2906; No of Pages 4
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.04.015, available online at http://www.sciencedirect.com
Clinical Paper Medicine
Dental implants in patients at high risk for infective endocarditis: a preliminary study
M. Findler1, T. Chackartchi2, E. Regev3 1
Department of Oral Medicine, The Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, Israel; 2Department of Periodontology, The Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, Israel; 3Department of Oral and Maxillofacial surgery, The Hebrew University – Hadassah Medical Center and Faculty of Dental Medicine, Jerusalem, Israel
M. Findler, T. Chackartchi, E. Regev: Dental implants in patients at high risk for infective endocarditis: a preliminary study. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. 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.
Patients at high risk for infective endocarditis (IE) may be at risk of an endocardial infection in the case of bacteremia1. The oral cavity is known to be a source of pathogens that may affect the heart valves and other heart anatomic anomalies2. In the case of IE, bacterial seeding takes place by direct hematogenous spread. It has been suggested that bacteremia occurs during dental treatments, as well as during 0901-5027/000001+04
everyday activities such as tooth brushing and mastication. It is believed that some patients are more susceptible than others, and therefore at higher risk3. Major medical authorities have recently published new clinical guidelines for the prevention of IE. These protocols suggest that the use of antibiotics as a prophylactic measure for reducing the incidence of IE should be reserved only for those at high
Key words: dental implants; high risk patients; infective endocarditis.. Accepted for publication 16 April 2014
risk for IE. In 2006, the British Society for Antimicrobial Chemotherapy (BSAC) was the first to call for the use of prophylactic antibiotics to be minimalized4. Nevertheless the new protocol still recognizes the group of patients at high risk for IE as being exposed to an increased risk of infection. From 2006 to 2009, four new evidence-based clinical guidelines4–7 were
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
YIJOM-2906; No of Pages 4
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Findler et al.
Table 1. Patient characteristics, diagnosis, implants, anti-thrombotic treatment, thrombotic events, and implant failure.
Patient Procedure 1 2 3 4 5 6 7 8 9 10 11 12 13
Diagnosis
1
AVR
2 3 4 5 6 7 8
AVR MVR MVR MVR TOF MVR AVR + MVR + IE AVR MV plasty AVR AVR MV plasty MV plasty MVR MVR
9 10 11 12 13 14 15 16
Age, Follow-up, Number of implants Sex years years F M F F M M M M M M F F M
Number of Number of Discontinued implants, implants, Failure of anti-thrombotic Thrombotic treatment events maxilla mandible implants
75
8
7
7
0
0
Yes
80 71 72 59 45 70 65
3 6 5 3 7 13 18
2 2 3 4 2 4 1
0 2 0 0 2 0 0
2 0 3 4 0 4 1
0 0 0 0 0 0 0
No No No No No No No
7 5 4 4 2 2 3 2
16 1 1 1 1 1 4 7
9 0 0 1 0 1 0 7
7 1 1 0 1 0 4 0
2 0 0 0 0 0 0 0
Yes No No No No No No No
N/A N/A 82 N/A 65 64 78 79
Valve thrombosis
Stroke
F, female; M, male; AVR, aortic valve replacement; MVR, mitral valve replacement; MV plasty, mitral valvuloplasty; IE, infective endocarditis; TOF, tetralogy of Fallot; N/A, not available.
published, providing a definition of highrisk patient groups and the dental treatments requiring prophylactic therapy. In general, patients with an artificial heart valve, those with a history of IE, and those with certain congenital defects remained the only patients considered at high risk. The National Institute for Health and Care Excellence (NICE; Department of Health, UK), which provides recommendations and clinical guidelines for the UK National Health Service, revised its guidelines in 2008 and ended the concept of pre-treatment with antibiotics, except in the group of patients at high risk for IE6. The list of dental treatments requiring prophylactic antibiotics included periodontal procedures and peri-apical manipulation, but with no specific reference to dental implants4–7. This begs the question whether the use of dental implants is safe and justified in patients at high risk for IE. The spread of infection from dental implants may occur at various stages. The early stage is the time at which the implant is inserted8,9. A later stage relates to bacterial mucositis – the implant equivalent to gingivitis. This infection is evident in the peri-implant mucosa following the healing phase10. Following implant exposure and placement of the prosthesis, bacteremia may originate from extensively inflamed and infected tissue around the implant with loss of alveolar bone, known as peri-implantitis11. This risk remains for as long as the implant is in place and is similar to periodontitis around natural teeth.
No information regarding the safety of dental implant placement is available in the medical literature. This article summarizes our experience of dental implant placement in patients at high risk for IE. Patients and methods
Data on patients at high risk for IE who underwent dental implant procedures were collected retrospectively from the registries of two oral medicine clinics in Israel. Between 1995 and 2012, 13 patients underwent 16 implant placement procedures in which 57 implants were inserted by several dentists. The surgical procedure for all patients was a two-stage implant placement. Data retrieved from the medical records included demographic details, number of procedures performed and implants placed, medical diagnosis, and anti-thrombotic and antibiotic prophylaxis therapy provided. Patient follow-up was at least 2 years. The institutional ethics board approved the data collection. Results
Between 1995 and 2012, 13 patients at high risk for IE, eight males and five females ranging in age from 45 to 82 years (mean 69.5 years), underwent 16 surgical procedures for the insertion of 57 implants (three patients had two separate procedures). A total of 29 implants were placed in the maxilla and 28 in the mandible. Four of the patients had an aortic valve replacement (patients 1, 7, 9, 10), four had a mitral valve replacement (patients 2, 3,
5, 13), one had combined aortic and mitral valve replacement (patient 6), one had a cyanotic congenital malformation with an incomplete repair (patient 4), and three were after repair of the mitral valve with synthetic material (patients 8, 11, 12) (Table 1). All patients received prophylactic antibiotic treatment with 2 g of amoxicillin orally at 1 h prior to the surgery, followed by 1.5 g per day for 5 days postoperatively. All patients rinsed their mouth with chlorhexidine prior to the surgical procedure. Two implants in the mandible of one patient failed to osseointegrate before exposure and had to be removed. No case of IE or suspected IE was reported in the entire patient group. All the patients were on anti-thrombotic treatment, which was discontinued only in two patients 3 days prior to surgery and was resumed thereafter. During the postoperative period, two patients developed major thrombotic events. One patient had a stroke 6 months after implant placement. The second patient suffered from mitral valve thrombosis that developed 14 days after the dental procedure. This patient was one of the two patients who discontinued their anti-thrombotic treatment (Table 1). Discussion
In the 1997 American Heart Association/ American College of Cardiology (AHA/ ACC) guidelines for a prophylactic antibiotic treatment by Dajani et al., dental implant placement was one of the indications for prophylactic treatment12.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
YIJOM-2906; No of Pages 4
Dental implants in patients at high risk for IE Thereby, the board indirectly confirmed the legitimacy of implant treatment, even though no specific clinical data were provided. This in turn opened the door for the dental practitioner to perform dental implant placement in patients at high risk for IE. The new AHA/ACC guidelines published by Wilson et al. in 2007 no longer mention dental implant treatment in relation to prophylactic measures, but state that antibiotic prophylactic treatment is indicated for general surgical peri-apical and dento-gingival manipulations5. This may indicate some second thoughts about specific dental treatment rather than the exclusion of dental implant treatment for patients at high risk for IE. In this study we report our experience with 57 dental implants placed in 13 patients classified as being at high risk for IE, with an acceptable success rate. Two implants failed before exposure in one patient, similar to the 95% success rate in the general population. The major risk for patients at high risk for IE is an oral source of infection concomitant with a port of entry, leading to bacteremia and eventually endocarditis. Dental implants are a potential risk for such bacteremia at different stages. The first stage is the surgical placement procedure. During insertion of the implants in the alveolar bone, soft and hard tissues are surgically manipulated, leaving the tissue exposed and vulnerable to bacterial contamination. In two different studies, Pin˜eiro et al.8 and Bo¨lu¨kbas¸ı et al.9 reported bacteremia following the implant surgical procedure. In both studies, patients did not receive prophylactic antibiotics. Pin˜eiro et al. reported the prevalence of bacteremia at 30 s and 15 min postoperatively in healthy individuals to be 6.7% and 3.3%, respectively, when chlorhexidine mouth rinse was not used prior to the procedure. Prophylactic chlorhexidine rinses reduced the bacteremia to 0%8. In another study, Bo¨lu¨kbas¸ı et al. found bacteremia in 23% of patients at 30 min post-implant surgery and in 0% after 24 h9. Toma´s et al.13 found the prevalence of bacteremia following dental extractions to be 96.2% at 30 s, 64.2% at 15 min, and 20% at 1 h after completing the surgical procedure. Other studies have shown 40% to 74% of bacteremia after dental extractions14,15. Thus the rate of bacteremia during implantation appears to be lower than the rate of bacteremia following tooth extraction. The use of prophylactic antibiotics and antiseptic solution oral rinses before implant placement for patients at high risk for IE is, therefore, merited.
As patients at high risk for IE with artificial heart valves are under anticoagulant treatment, surgery may cause hematomas, raising the risk of infection. In the later stages of implant placement, periimplant mucositis and peri-implantitis11 may become a source of infection, as well as a port of entry for the spread of infection. After completion of the bone and gingival healing process, osseointegration is expected. Chronic peri-implant infections such as peri-implant mucositis is found in about 50% of implants, whereas peri-implantitis is evident in 12–43% of implants16 and may be a source of bacterial invasion. The actual biological behaviour of an osseointegrated implant with regard to dissemination of bacterial inoculums has never been reported. The extent of the infectious threat from bacterial penetration into the blood stream from the infected site is not known. The integrated interface between bone and the implant outer surface is meant to stabilize the artificial device in the surrounding hard tissue. Whether this bone–implant interface is tight enough to prevent bacteremia has never been tested. Its ability to block bacterial penetration into the bone and the surrounding soft tissue has also never been proved. Thus, the safety of dental implant treatment for patients at high risk for IE has never been documented. No case of IE was reported in our group of patients within the follow-up period of 2–17 years. During the postoperative period, two patients developed major thrombotic events (two events out of 16 procedures = 12.5%). One patient suffered a stroke at 6 months after implant placement and experienced residual permanent hemiplegia; the other patient was admitted to the intensive care unit for thrombosis of the artificial valve 2 weeks following the surgical procedure. The second patient was instructed to discontinue anticoagulant treatment 3 days before surgery. The first event was too remote to be related to surgery, however the valve thrombosis in the second patient may have been a direct consequence of the discontinued antithrombotic therapy. This patient underwent a second implant procedure a few years later with no problems. The management policy for placement of dental implants in patients under anti-thrombotic treatment should not be different from other oral surgical procedures and should follow the current clinical guidelines, i.e. non-discontinuation of anticoagulant treatment17. In another study, placement of implants in patients with artificial heart valves was mentioned indirectly while
3
reporting implant placement procedures under anticoagulant therapy18. In our small group of patients, no major postoperative bleeding was reported. Considering the small group of patients described here and the known low prevalence of IE, the results of this study do not show the risk of the disease to be eliminated or establish the safety of dental implant placement in high-risk patients. The lifetime risk for patients at high risk of infection is between 300 and 2160 patients per 100,000 patient-years19. Nevertheless, this report may encourage the dental health provider to consider patients at high risk for IE eligible for dental implant prosthodontic treatment plans. The role of antiseptic implant placement procedures followed by meticulous oral hygiene to prevent peri-implant gingivitis and peri-implantitis should not be underestimated. This may minimize the risk of bacteremia originating from the implants. To assess the risk associated with implant placement, major efforts should be directed to identify the outcomes of patients at high risk who have undergone dental implant surgery, as well as the prevalence of patients with dental implants among those hospitalized with IE. Funding
None. Competing interests
None declared. Ethical approval
The Hadassah-Hebrew University Ethics Board approved the retrieval of data from the patient files. References 1. Karchmer AW. Infective endocarditis. In: Longo DL, Fauci AS, Kaspar DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison’s principals of internal medicine. 18th ed. New York: McGraw Hill Medical; 2012. p. 1065. 2. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 8th ed. St Louis: Mosby Evolve Elsevier; 2013: 20–36. 3. Karchmer AW. Infective endocarditis. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. Philadelphia: Saunders Elsevier; 2012 . p. 1713–38.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
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4. Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Working Party of the British Society for Antimicrobial Chemotherapy. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;57:1035–42. 5. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al., American Heart Association Rheumatic Fever; Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease of the Young and the Council on Clinical Cardiology, the Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcome Research Interdisciplinary Working Group. Circulation 2007;116:1736–54. 6. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London, UK: NICE; 2008 . CG64, Available at: http://www.nice.org.uk/cg064 [accessed 16.04.14].
7. Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al., ESC Committee for Practice Guidelines. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369–413. 8. Pin˜eiro A, Toma´s I, Blanco J, Alvarez M, Seoane J, Diz P. Bacteraemia following dental implants’ placement. Clin Oral Implants Res 2010;21:913–8. ¨ zdemir T, O ¨ ksu¨z L, Gu¨rler N. 9. Bo¨lu¨kbas¸ı N, O Bacteremia following dental implant surgery: preliminary results. Med Oral Pathol Oral Cir Bucal 2012;17:e69–75. 10. Zitzmann NU, Berglundh T. Definition and prevalence of peri-implant diseases. J Clin Periodontol 2008;35(8 Suppl.):286–91. 11. Algraffee H, Borumandi F, Cascarini L. Periimplantitis. Br J Oral Maxillofac Surg 2012;50:689–94. 12. Dajani AS, Taubert KA, Wilson W, Bolger AF, Bayer A, Ferrieri P, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. Clin Infect Dis 1997;25:1448–58. 13. Toma´s I, Alvarez M, Limeres J, Potel C, Medina J, Diz P. Prevalence, duration and aetiology of bacteremia following dental extractions. Oral Dis 2007;13:56–62. 14. Otten JE, Pelz K, Christmann G. Aerobic bacteremia following tooth extraction and
15.
16.
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18.
19.
removal of osteosynthesis plates. J Oral Maxillofac Surg 1987;45:477–80. Takai S, Kuriyama T, Yanagisawa M, Nakagawa K, Karasawa T. Incidence and bacteriology of bacteremia associated with various oral and maxillofacial surgical procedures. Oral Surg Oral Med Oral Pathol Oral Radiol 2005;99:292–8. Lang NP, Berglundh T. Peri-implant diseases: where are we now? Consensus of the Seventh European Workshop on Periodontology. J Clin Periodontol 2011;38(Suppl. 11):178–81. Madrid C, Sanz M. What influence do anticoagulants have on oral implant therapy? A systematic review. Clin Oral Implants Res 2009;20(Suppl. 4):96–106. Bacci C, Berengo M, Favero L, Zanon E. Safety of dental implant surgery in patients undergoing anticoagulation therapy: a prospective case–control study. Clin Oral Implants Res 2011;22:151–6. Steckelberg JM, Wilson WR. Risk factors for infective endocarditis. Infect Dis Clin North Am 1993;7:9–19.
Address: E. Regev Department of Oral and Maxillofacial Surgery The Hebrew University-Hadassah Medical Center and Faculty of Dental Medicine POB 12272 Jerusalem 91120 Israel Tel: +972 2 6776148; Fax: +972 2 6779110 E-mail: [email protected]
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx http://dx.doi.org/10.1016/j.ijom.2014.04.015, available online at http://www.sciencedirect.com
Clinical Paper Medicine
Dental implants in patients at high risk for infective endocarditis: a preliminary study
M. Findler1, T. Chackartchi2, E. Regev3 1
Department of Oral Medicine, The Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, Israel; 2Department of Periodontology, The Hebrew University – Hadassah Faculty of Dental Medicine, Jerusalem, Israel; 3Department of Oral and Maxillofacial surgery, The Hebrew University – Hadassah Medical Center and Faculty of Dental Medicine, Jerusalem, Israel
M. Findler, T. Chackartchi, E. Regev: Dental implants in patients at high risk for infective endocarditis: a preliminary study. Int. J. Oral Maxillofac. Surg. 2014; xxx: xxx–xxx. # 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Abstract. 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.
Patients at high risk for infective endocarditis (IE) may be at risk of an endocardial infection in the case of bacteremia1. The oral cavity is known to be a source of pathogens that may affect the heart valves and other heart anatomic anomalies2. In the case of IE, bacterial seeding takes place by direct hematogenous spread. It has been suggested that bacteremia occurs during dental treatments, as well as during 0901-5027/000001+04
everyday activities such as tooth brushing and mastication. It is believed that some patients are more susceptible than others, and therefore at higher risk3. Major medical authorities have recently published new clinical guidelines for the prevention of IE. These protocols suggest that the use of antibiotics as a prophylactic measure for reducing the incidence of IE should be reserved only for those at high
Key words: dental implants; high risk patients; infective endocarditis.. Accepted for publication 16 April 2014
risk for IE. In 2006, the British Society for Antimicrobial Chemotherapy (BSAC) was the first to call for the use of prophylactic antibiotics to be minimalized4. Nevertheless the new protocol still recognizes the group of patients at high risk for IE as being exposed to an increased risk of infection. From 2006 to 2009, four new evidence-based clinical guidelines4–7 were
# 2014 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
YIJOM-2906; No of Pages 4
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Findler et al.
Table 1. Patient characteristics, diagnosis, implants, anti-thrombotic treatment, thrombotic events, and implant failure.
Patient Procedure 1 2 3 4 5 6 7 8 9 10 11 12 13
Diagnosis
1
AVR
2 3 4 5 6 7 8
AVR MVR MVR MVR TOF MVR AVR + MVR + IE AVR MV plasty AVR AVR MV plasty MV plasty MVR MVR
9 10 11 12 13 14 15 16
Age, Follow-up, Number of implants Sex years years F M F F M M M M M M F F M
Number of Number of Discontinued implants, implants, Failure of anti-thrombotic Thrombotic treatment events maxilla mandible implants
75
8
7
7
0
0
Yes
80 71 72 59 45 70 65
3 6 5 3 7 13 18
2 2 3 4 2 4 1
0 2 0 0 2 0 0
2 0 3 4 0 4 1
0 0 0 0 0 0 0
No No No No No No No
7 5 4 4 2 2 3 2
16 1 1 1 1 1 4 7
9 0 0 1 0 1 0 7
7 1 1 0 1 0 4 0
2 0 0 0 0 0 0 0
Yes No No No No No No No
N/A N/A 82 N/A 65 64 78 79
Valve thrombosis
Stroke
F, female; M, male; AVR, aortic valve replacement; MVR, mitral valve replacement; MV plasty, mitral valvuloplasty; IE, infective endocarditis; TOF, tetralogy of Fallot; N/A, not available.
published, providing a definition of highrisk patient groups and the dental treatments requiring prophylactic therapy. In general, patients with an artificial heart valve, those with a history of IE, and those with certain congenital defects remained the only patients considered at high risk. The National Institute for Health and Care Excellence (NICE; Department of Health, UK), which provides recommendations and clinical guidelines for the UK National Health Service, revised its guidelines in 2008 and ended the concept of pre-treatment with antibiotics, except in the group of patients at high risk for IE6. The list of dental treatments requiring prophylactic antibiotics included periodontal procedures and peri-apical manipulation, but with no specific reference to dental implants4–7. This begs the question whether the use of dental implants is safe and justified in patients at high risk for IE. The spread of infection from dental implants may occur at various stages. The early stage is the time at which the implant is inserted8,9. A later stage relates to bacterial mucositis – the implant equivalent to gingivitis. This infection is evident in the peri-implant mucosa following the healing phase10. Following implant exposure and placement of the prosthesis, bacteremia may originate from extensively inflamed and infected tissue around the implant with loss of alveolar bone, known as peri-implantitis11. This risk remains for as long as the implant is in place and is similar to periodontitis around natural teeth.
No information regarding the safety of dental implant placement is available in the medical literature. This article summarizes our experience of dental implant placement in patients at high risk for IE. Patients and methods
Data on patients at high risk for IE who underwent dental implant procedures were collected retrospectively from the registries of two oral medicine clinics in Israel. Between 1995 and 2012, 13 patients underwent 16 implant placement procedures in which 57 implants were inserted by several dentists. The surgical procedure for all patients was a two-stage implant placement. Data retrieved from the medical records included demographic details, number of procedures performed and implants placed, medical diagnosis, and anti-thrombotic and antibiotic prophylaxis therapy provided. Patient follow-up was at least 2 years. The institutional ethics board approved the data collection. Results
Between 1995 and 2012, 13 patients at high risk for IE, eight males and five females ranging in age from 45 to 82 years (mean 69.5 years), underwent 16 surgical procedures for the insertion of 57 implants (three patients had two separate procedures). A total of 29 implants were placed in the maxilla and 28 in the mandible. Four of the patients had an aortic valve replacement (patients 1, 7, 9, 10), four had a mitral valve replacement (patients 2, 3,
5, 13), one had combined aortic and mitral valve replacement (patient 6), one had a cyanotic congenital malformation with an incomplete repair (patient 4), and three were after repair of the mitral valve with synthetic material (patients 8, 11, 12) (Table 1). All patients received prophylactic antibiotic treatment with 2 g of amoxicillin orally at 1 h prior to the surgery, followed by 1.5 g per day for 5 days postoperatively. All patients rinsed their mouth with chlorhexidine prior to the surgical procedure. Two implants in the mandible of one patient failed to osseointegrate before exposure and had to be removed. No case of IE or suspected IE was reported in the entire patient group. All the patients were on anti-thrombotic treatment, which was discontinued only in two patients 3 days prior to surgery and was resumed thereafter. During the postoperative period, two patients developed major thrombotic events. One patient had a stroke 6 months after implant placement. The second patient suffered from mitral valve thrombosis that developed 14 days after the dental procedure. This patient was one of the two patients who discontinued their anti-thrombotic treatment (Table 1). Discussion
In the 1997 American Heart Association/ American College of Cardiology (AHA/ ACC) guidelines for a prophylactic antibiotic treatment by Dajani et al., dental implant placement was one of the indications for prophylactic treatment12.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
YIJOM-2906; No of Pages 4
Dental implants in patients at high risk for IE Thereby, the board indirectly confirmed the legitimacy of implant treatment, even though no specific clinical data were provided. This in turn opened the door for the dental practitioner to perform dental implant placement in patients at high risk for IE. The new AHA/ACC guidelines published by Wilson et al. in 2007 no longer mention dental implant treatment in relation to prophylactic measures, but state that antibiotic prophylactic treatment is indicated for general surgical peri-apical and dento-gingival manipulations5. This may indicate some second thoughts about specific dental treatment rather than the exclusion of dental implant treatment for patients at high risk for IE. In this study we report our experience with 57 dental implants placed in 13 patients classified as being at high risk for IE, with an acceptable success rate. Two implants failed before exposure in one patient, similar to the 95% success rate in the general population. The major risk for patients at high risk for IE is an oral source of infection concomitant with a port of entry, leading to bacteremia and eventually endocarditis. Dental implants are a potential risk for such bacteremia at different stages. The first stage is the surgical placement procedure. During insertion of the implants in the alveolar bone, soft and hard tissues are surgically manipulated, leaving the tissue exposed and vulnerable to bacterial contamination. In two different studies, Pin˜eiro et al.8 and Bo¨lu¨kbas¸ı et al.9 reported bacteremia following the implant surgical procedure. In both studies, patients did not receive prophylactic antibiotics. Pin˜eiro et al. reported the prevalence of bacteremia at 30 s and 15 min postoperatively in healthy individuals to be 6.7% and 3.3%, respectively, when chlorhexidine mouth rinse was not used prior to the procedure. Prophylactic chlorhexidine rinses reduced the bacteremia to 0%8. In another study, Bo¨lu¨kbas¸ı et al. found bacteremia in 23% of patients at 30 min post-implant surgery and in 0% after 24 h9. Toma´s et al.13 found the prevalence of bacteremia following dental extractions to be 96.2% at 30 s, 64.2% at 15 min, and 20% at 1 h after completing the surgical procedure. Other studies have shown 40% to 74% of bacteremia after dental extractions14,15. Thus the rate of bacteremia during implantation appears to be lower than the rate of bacteremia following tooth extraction. The use of prophylactic antibiotics and antiseptic solution oral rinses before implant placement for patients at high risk for IE is, therefore, merited.
As patients at high risk for IE with artificial heart valves are under anticoagulant treatment, surgery may cause hematomas, raising the risk of infection. In the later stages of implant placement, periimplant mucositis and peri-implantitis11 may become a source of infection, as well as a port of entry for the spread of infection. After completion of the bone and gingival healing process, osseointegration is expected. Chronic peri-implant infections such as peri-implant mucositis is found in about 50% of implants, whereas peri-implantitis is evident in 12–43% of implants16 and may be a source of bacterial invasion. The actual biological behaviour of an osseointegrated implant with regard to dissemination of bacterial inoculums has never been reported. The extent of the infectious threat from bacterial penetration into the blood stream from the infected site is not known. The integrated interface between bone and the implant outer surface is meant to stabilize the artificial device in the surrounding hard tissue. Whether this bone–implant interface is tight enough to prevent bacteremia has never been tested. Its ability to block bacterial penetration into the bone and the surrounding soft tissue has also never been proved. Thus, the safety of dental implant treatment for patients at high risk for IE has never been documented. No case of IE was reported in our group of patients within the follow-up period of 2–17 years. During the postoperative period, two patients developed major thrombotic events (two events out of 16 procedures = 12.5%). One patient suffered a stroke at 6 months after implant placement and experienced residual permanent hemiplegia; the other patient was admitted to the intensive care unit for thrombosis of the artificial valve 2 weeks following the surgical procedure. The second patient was instructed to discontinue anticoagulant treatment 3 days before surgery. The first event was too remote to be related to surgery, however the valve thrombosis in the second patient may have been a direct consequence of the discontinued antithrombotic therapy. This patient underwent a second implant procedure a few years later with no problems. The management policy for placement of dental implants in patients under anti-thrombotic treatment should not be different from other oral surgical procedures and should follow the current clinical guidelines, i.e. non-discontinuation of anticoagulant treatment17. In another study, placement of implants in patients with artificial heart valves was mentioned indirectly while
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reporting implant placement procedures under anticoagulant therapy18. In our small group of patients, no major postoperative bleeding was reported. Considering the small group of patients described here and the known low prevalence of IE, the results of this study do not show the risk of the disease to be eliminated or establish the safety of dental implant placement in high-risk patients. The lifetime risk for patients at high risk of infection is between 300 and 2160 patients per 100,000 patient-years19. Nevertheless, this report may encourage the dental health provider to consider patients at high risk for IE eligible for dental implant prosthodontic treatment plans. The role of antiseptic implant placement procedures followed by meticulous oral hygiene to prevent peri-implant gingivitis and peri-implantitis should not be underestimated. This may minimize the risk of bacteremia originating from the implants. To assess the risk associated with implant placement, major efforts should be directed to identify the outcomes of patients at high risk who have undergone dental implant surgery, as well as the prevalence of patients with dental implants among those hospitalized with IE. Funding
None. Competing interests
None declared. Ethical approval
The Hadassah-Hebrew University Ethics Board approved the retrieval of data from the patient files. References 1. Karchmer AW. Infective endocarditis. In: Longo DL, Fauci AS, Kaspar DL, Hauser SL, Jameson JL, Loscalzo J, editors. Harrison’s principals of internal medicine. 18th ed. New York: McGraw Hill Medical; 2012. p. 1065. 2. Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient. 8th ed. St Louis: Mosby Evolve Elsevier; 2013: 20–36. 3. Karchmer AW. Infective endocarditis. In: Bonow RO, Mann DL, Zipes DP, Libby P, editors. Braunwald’s heart disease: a textbook of cardiovascular medicine. 9th ed. Philadelphia: Saunders Elsevier; 2012 . p. 1713–38.
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
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4. Gould FK, Elliott TS, Foweraker J, Fulford M, Perry JD, Roberts GJ, et al. Working Party of the British Society for Antimicrobial Chemotherapy. Guidelines for the prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;57:1035–42. 5. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al., American Heart Association Rheumatic Fever; Endocarditis, and Kawasaki Disease Committee; American Heart Association Council on Cardiovascular Disease in the Young; American Heart Association Council on Clinical Cardiology; American Heart Association Council on Cardiovascular Surgery and Anesthesia; Quality of Care and Outcomes Research Interdisciplinary Working Group. Prevention of infective endocarditis. Guidelines from the American Heart Association. A guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease of the Young and the Council on Clinical Cardiology, the Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcome Research Interdisciplinary Working Group. Circulation 2007;116:1736–54. 6. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis: antimicrobial prophylaxis against infective endocarditis in adults and children undergoing interventional procedures. London, UK: NICE; 2008 . CG64, Available at: http://www.nice.org.uk/cg064 [accessed 16.04.14].
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Address: E. Regev Department of Oral and Maxillofacial Surgery The Hebrew University-Hadassah Medical Center and Faculty of Dental Medicine POB 12272 Jerusalem 91120 Israel Tel: +972 2 6776148; Fax: +972 2 6779110 E-mail: [email protected]
Please cite this article in press as: Findler M, et al. Dental implants in patients at high risk for infective endocarditis: a preliminary study, Int J Oral Maxillofac Surg (2014), http://dx.doi.org/10.1016/j.ijom.2014.04.015
