Perioperative hemodynamic changes in ischemic heart disease patients undergoing dental treatment.

Twenty patients with stable ischemic heart disease in functional capacity Class II-IV underwent dental treatment. Scaling was performed in seven patients without local anesthesia. In the remaining 13 patients, pain control for restoration placement was obtained by local anesthesia: in seven patients, the anesthetics contained epinephrine, while in six this drug was omitted. Heart rate, blood pressure, and electrocardiograph were continuously monitored during the dental session. All patients had elevated systolic blood pressure and rate pressure product during treatment. In the patients who received plain local anesthetics only, the elevation in systolic blood and rate pressures was, however, significantly lower than the ischemic threshold. Arrhythmia or ST segment depression of > or = 1 millimeter were not recorded in any of the subjects. In severely compromised ischemic heart disease patients undergoing routine dental procedures of limited chair time, plain local anesthesia seems to be the preferred analgesic modality.

Development of resistant oral viridans streptococci after administration of prophylactic antibiotics: time management in the dental treatment of patients susceptible to infective endocarditis.

The American Heart Association recommends prophylactic administration of penicillin before each dental session to patients susceptible to infective endocarditis. Such preventive treatment, however, may trigger the transient appearance of penicillin-resistant bacterial strains. In order to investigate the behavior of oral streptococci, 29 healthy volunteers who did not harbor penicillin-resistant viridans streptococci received 4 gm of phenoxymethyl penicillin orally over a period of 10 hours. This amount constituted the sole dose of antibiotics administered in the entire experiment. Daily specimens of oral flora were obtained for 14 successive days from each participant and incubated aerobically with a penicillin-saturated disk for 24 hours. Viridans streptococci were considered resistant when bacterial colonies grew adjacent to the disk for 1 day or more. The study population was divided into high- and low-resistance groups, according to the individual antibiograms. Resistant viridans streptococci were already detected at 6 hours after penicillin ingestion in nine (31%) of the subjects. Six months later, oral specimens were taken from ten randomly selected participants; these specimens served as a control. The difference in bacterial resistance between the high- and low-resistance groups was significant for the duration of 9 days, as was that between the high-resistance and control groups (p less than 0.05 in both cases). In order to minimize the odds that penicillin-resistant bacterial strains will develop in patients susceptible to infective endocarditis, elective dental treatments in these persons should be scheduled in intervals of not less than 10 days.

Prevention of infective endocarditis: not by antibiotics alone. A 7-year follow-up of 90 dental patients.

Ninety patients (thirty-nine men, fifty-one women with a mean age of 45.4 years with rheumatic heart disease or prosthetic heart valves, were subjected to a total of 1617 dental procedures, which required about 3400 patient/dentist encounters. All treatments were performed according to the protocol described in the present article. Although theory expects three to six cases of infective endocarditis cases in the described population, none of the patients have encountered the disease (p = 0.0013). A conceptual approach, as well as the protocol, is presented. Properly applied, the protocol will reduce the probability of iatrogenic and self-inflicted bacteremia, thus elevating the efficacy of the preventive process.

Analysis of the American Heart Association's recommendations for the prevention of infective endocarditis.

A probabilistic model analyzes the American Heart Association's (AHA) recommendations for the prevention of infective endocarditis (IE) of dental origin. The model, presented in the form of a flow chart, combines available data elements with the AHA recommendations; mortality serves as the sole valued outcome and payoff measure. The analysis shows that an annual death rate of 1.36 per million population is attributable to the antibiotics administered in an attempt to prevent IE, whereas not more than 0.26 annual deaths per million are traceable to IE of dental origin. Sensitivity and threshold analyses were conducted to determine the conditions under which the recommended prophylactic policy will prove beneficial. The model suggests that the standard AHA antibiotic regimen should be exploited only in IE susceptible patients belonging to the high risk categories and that its value in moderate, low, and negligible risk patients is doubtful. When the use of antibiotics is unavoidable, oral administration is the preferable route.

How often should a preventive procedure be repeated? An economic analytic model applied to dentistry.

Operation research techniques have successfully been applied to economical order situations. An Economical Recall System (ERS) model, based on this theory, is proposed for curative and preventive dental care. The ERS model assumes a preventive procedure with no lead time between application and initiation of effect, an immediate decline in morbidity level once the effect is initiated, and linear increasing rate of morbidity. The model also assumes a positive net present value of the prevention program and therefore the question approached is the optimal time sequence at minimal cost. The model supplies a valuable tool for analyzing the effect of the curative, preventive and administrative components of a program and how changes in each, or any combination, of these variables will affect the end results.