Dentistry and Cardiology relationship?

[DarkProtonics]

Since cardiac diseases can lead to endocarditis, so pts need antibiotics before dental procedures, has this ever happened:

A pt c/o to the ED w/ a fever, swelling of the jaw, clots in his fingernails, and an TTE indicating aortic regurgitation and vegetations on the --bicuspid!-- aortic valve, and a blood culture indicating staphylococcus. IV imipenem+cilastatin is administered, and endodontics is consulted to perform an apicoectomy to drain the abscess, while interventional cardiology is consulted to perform a percutaneous aortic valve replacement. Meanwhile, the ED pages the pt's general cardiologist, and lectures him for not informing the pt's dentist of his heart condition.

Is this a possibility? Could the apicectomy and PAVR be performed concurrently? Has something liked this ever happened?

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[Dukie]

Since cardiac diseases can lead to endocarditis, so pts need antibiotics before dental procedures, has this ever happened:

A pt c/o to the ED w/ a fever, swelling of the jaw, clots in his fingernails, and an TTE indicating aortic regurgitation and vegetations on the --bicuspid!-- aortic valve, and a blood culture indicating staphylococcus. IV imipenem+cilastatin is administered, and endodontics is consulted to perform an apicoectomy to drain the abscess, while interventional cardiology is consulted to perform a percutaneous aortic valve replacement. Meanwhile, the ED pages the pt's general cardiologist, and lectures him for not informing the pt's dentist of his heart condition.

Is this a possibility? Could the apicectomy and PAVR be performed concurrently? Has something liked this ever happened?

I suppose it is possible. What is the point of this thread? To demonstrate how many medical terms you know?

 

[tinman831]

Someone's homework question? Sounds a little detailed to be hypothetical scenario.

Since cardiac diseases can lead to endocarditis, so pts need antibiotics before dental procedures, has this ever happened:

A pt c/o to the ED w/ a fever, swelling of the jaw, clots in his fingernails, and an TTE indicating aortic regurgitation and vegetations on the --bicuspid!-- aortic valve, and a blood culture indicating staphylococcus. IV imipenem+cilastatin is administered, and endodontics is consulted to perform an apicoectomy to drain the abscess, while interventional cardiology is consulted to perform a percutaneous aortic valve replacement. Meanwhile, the ED pages the pt's general cardiologist, and lectures him for not informing the pt's dentist of his heart condition.

Is this a possibility? Could the apicectomy and PAVR be performed concurrently? Has something liked this ever happened?

 

[DarkProtonics]

Someone's homework question? Sounds a little detailed to be hypothetical scenario.

No, it isn't...I just enjoy writing up detailed hypothetical scenarios of weird medical emergencies. Really.

 

[DarkProtonics]

I suppose it is possible. What is the point of this thread? To demonstrate how many medical terms you know?

It was to ask whether a cavity can get so bad it leads to sepsis and endocarditis.

 

[aphistis]

1) Just as we don't keep femoral artery introducers in our offices, I doubt the cath lab has any retrograde endodontic sealer sitting around.

2) An apicoectomy isn't going to fix a diffuse cellulitis. For that matter, has the tooth even undergone orthograde endo? If not, an apico would be worthless. My treatment would be I&D + extraction + abx, then let cardiology figure the rest out.

3) The moral of this story is that the infection should be treated *prior* to replacing the valve, or the new valve will end up infected just like the old one. It's a basic principle of surgery that you don't operate on someone with an active systemic infection (unless that's why you're doing the procedure). This happened multiple times to my GPR co-resident and I last year, and we managed the all the same way--we treat anything that's currently acutely infected or likely to become so in the next six months (when the new valve is at highest risk of being colonized), and then they get the valve replaced a day or two later.

 

[DarkProtonics]

1) Just as we don't keep femoral artery introducers in our offices, I doubt the cath lab has any retrograde endodontic sealer sitting around.

2) An apicoectomy isn't going to fix a diffuse cellulitis. For that matter, has the tooth even undergone orthograde endo? If not, an apico would be worthless. My treatment would be I&D + extraction + abx, then let cardiology figure the rest out.

3) The moral of this story is that the infection should be treated *prior* to replacing the valve, or the new valve will end up infected just like the old one. It's a basic principle of surgery that you don't operate on someone with an active systemic infection (unless that's why you're doing the procedure). This happened multiple times to my GPR co-resident and I last year, and we managed the all the same way--we treat anything that's currently acutely infected or likely to become so in the next six months (when the new valve is at highest risk of being colonized), and then they get the valve replaced a day or two later.

That's the answer I'm looking for. But let's say the valve was so badly damaged by the staph infection it MUST be replaced ASAP.

But treatment was commenced in the ED; isn't imipenem+cilastatin an effected treatment for staph infections?

Btw, would the jaw abscess be a job for OMFS, IR, or ENT?

I suppose the procedure would be:

1. Start IV antibiotics ASAP in the ED
2. Have endodontics extract the abscessed tooth
3. Have OMFS, IR or ENT drain the jaw abscess
3. Have interventional cardiology/cardiac surgery replace the aortic valve

 

[aphistis]

That's the answer I'm looking for. But let's say the valve was so badly damaged by the staph infection it MUST be replaced ASAP.

But treatment was commenced in the ED; isn't imipenem+cilastatin an effected treatment for staph infections?

Btw, would the jaw abscess be a job for OMFS, IR, or ENT?

I suppose the procedure would be:

1. Start IV antibiotics ASAP in the ED
2. Have endodontics extract the abscessed tooth
3. Have OMFS, IR or ENT drain the jaw abscess
3. Have interventional cardiology/cardiac surgery replace the aortic valve

1) Antibiotics can treat the soft tissue infection, but they can't get into the tooth where the infection originated. There's no blood supply to a necrotic dental pulp. The only cures are extraction or endodontics.

2) Either OMFS or ENT could drain the abscess, but an OMFS is as good as it gets when it comes to managing odontogenic infections. Plus, this patient is now a sick puppy; you might as well get the tooth out while you're already in a controlled environment in the OR. Interventional radiology? Are you serious? No way.

One of my patients was just like you're describing here. His aortic valve was next to worthless and already scheduled for replacement, but then had a heart attack one weekend while he was waiting. We took him to the OR on Tuesday for his teeth, then CT surg took on Thursday for his valve. My main point doesn't seem to be sinking in, so I want to repeat it: hospitals have a whole battery of drugs doctors can give to temporarily support a failing heart valve, but replacing it in the setting of active infection is asking for failure. In the scenario you're describing here, "ASAP" is still after the acute infections are treated.

The treatment sequence in this scenario goes 1) antibiotics 2) extraction + I&D 3) valve replacement--in that order.

 

[aphistis]

Also, one more thing: why would anyone get a TEE for an obvious, clinically-diagnosed facial abscess?

 

[DarkProtonics]

Also, one more thing: why would anyone get a TEE for an obvious, clinically-diagnosed facial abscess?

B/c a med student just bought a fancy pocket echocardiograph and wanted to test it?

 

[armorshell]

I suppose it is possible. What is the point of this thread? To demonstrate how many medical terms you know?

My impression exactly.