152 Stom Glas S, vol. 52, 2005.

Prevencija nastanka inIektivnog

endokarditisa u toku stomatoloskih
intervencija
Prevention oI the inIective endocarditis
during the dental procedures
SGS YU ISSN 0039-1743-
COBISS. SR-ID 8417026
KRATAK SADRZAJ
Infektivni endokarditis je endovaskularna zarazna
bolest intrakardijalnih struktura koje su u dodiru sa
krvlfu. I:a:ivaci su nafcesce Staphilococus aureus i
Streptococus viridans, koji su stanovnici usne duplje.
Prilikom stomatolokih intervencija sa traumom
gingive (ri:icne stomatoloske intervencife) mo:e aoci
ao proaora mikroorgani:ama i:a:ivaca infektivnog
enaokaraitisa u krvotok. U grupu ri:icnih pacifenata :a
nastanak infektivnog endokarditisa spadaju pacijenti
sa prebolelim infektivnim endokarditisom, pacijenti sa
vestackim :aliscima ili arugim stranim enaovaskularnim
telima, uroaene srcane mane, stecene srcane mane,
prolaps mitralnog zalistka sa registrovanom mitralnom
regurgitacifom i hipertroficna karaiomiopatifa. Koa
ovih grupa pacijenata potrebno je sprovesi prevenciju
infektivnog enaokaraitisa pre svake ri:icne stomatoloske
intervencije baktericidnim dozama antbiotika irokog
spektra 1 sat pre procedure.
Kljucne reci: infektivni endokarditis, prevencija
InIektivni endokarditis je endovaskularna zarazna
bolest intrakardijalnih struktura koje su u dodiru sa krvlju,
ukljucujuci i inIekcije velikih krvnih sudova ili inIekcije
intrakardijalnih stranih tela (vestacke valvule, elektrode
pace-makera).
1
Povezanost bakterijemije i posledicnog
srcanog oboljenja prvi put je uocena i opisana 1923.
godine (Lewis)
2
. U slucaju da se dijagnoza postavi kasno
i bolest ne leci pravovremeno, inIektivni endokarditis
je bolest sa visokim stepenom mortaliteta. U odnosu na
Endocarditis is endovascular inIective disease oI
intracardiac structures which are in contact with blood,
including inIections oI great blood vessels or inIections
oI intracardiac Ioreign bodies (prosthetic heart valves,
electrodes oI pacemaker)
1
. The connection between
bacterization and consequent heart disease was spotted
and described Ior the Iirst time in 1923 (Lewis)
2
. II it is
the case, that the disease is not noticed or not treated on
time, inIective endocarditis is the disease with large rate
SUMMARY
Endocarditis is endovascular infective disease of
intracardiac structures, which are in contact with blood.
The most common cause is Staphylococcus aureus and
Streptococcus viridans, which inhabit oral cavity. During
dental intervention, which includes gingival trauma (risky
dental intervention) microorganisms that cause infective
endocarditis could penetrate into circulation of the blood.
The group of high risk patients consists of patients which
have already had infective endocarditis, patients with
prosthetic heart valves or other foreign endovascular
bodies, patients with congenital heart defect, patients
with acquired heart defect, prolapse of mitral valve
with registered mitral regurgitation and hyphertrophic
cardiomiopathy. Those groups of patients should have
prevention from infective endocarditis before any risky
dental intervention with bactericidal dosage of wide
spectrum antibiotics at least an hour before the procedure.
Key words: infective endocarditis, prevention
Tatjana Pukar
1
, S.Pukar
2
, Z.Nikoli
2
1
Univerzitet u Novom Sadu, Medicinski Fakultet, Klinika za Stomatologiju,
2
Vojnomedicinska
akademija Beograd, Klinika za Kardiologiju
1
Faculty oI Medicine, Novi Sad, Clinic oI Dentistry,
2
Military medical academy, Belgrade, Clinic Ior
Cardiology
INFORMATIVNI RAD (IR)
INFORMATIVE ARTICLE
Serbian Dental J, 2005, 52 153
raniju klasiIikaciju bolesti na akutni, subakutni i hronicni,
sada se inIektivni endokarditis klasiIikuje i u odnosu na
aktivnost bolesti ( akutno ili izleceno stanje), patogenezu,
anatomsko mesto lokalizacije bolesti i mikrobioloskog
uzrocnika. Rane ehokardiograIske karakteristicne lezije
su vegetacije, koje mogu biti razlicite velicine, a mogu se
videti i destrukcije, ulceracije, abscesi i slicno.
3,4
Vegetacije se sastoje od amorIne mase trombocita i
Iibrina, inicijalno su sterilne, potom se inIiciraju i sadrze
mnostvo mikroorganizama i inIlamatornih celija.
3,4
Lokalizacija vegetacija je prvenstveno na srcanim
zaliscima, rede na muralnom endokardu. Incidenca inIek-
tivnog endokarditisa je oko 2 na 100.000 stanovnika.
Endokarditis nativne valvule je do 2,5 puta cesci kod
muskaraca, cesce se javlja kod osoba starijih od 50 godina.
Oko 75 pacijenata ima predisponirajuce srcano obolen-
je: reumatsko valvularno obolenje, urodenu srcanu manu,
prolaps mitralne valvule, degenerativna obolenja srcanih
zalistaka (aortna stenoza).
5
Po toku inIektivni endokarditis moze biti akutni
(izazivac je najcesce Staphilococcus aureus, moguc smrt-
ni ishod za manje od 6 nedelja), subakutni (izazivac je
najcesce Streptococcus viridans, moguc smrtni ishod za
vise od 6 nedelja, pa i do godinu dana). Bakterije izazivaci
inIektivnog endokarditisa su stanovnici usne duplje.
3
Kardioloska oboljenja kod kojih postoji visok rizik za
nastanak inIektivnog endokarditisa su: prethodni inIektiv-
ni endokarditis, vestacke valvule ili drugi strani materijal i
urodene srcane mane sa cijanozom.
6,7

Kardioloska oboljenja kod kojih postoji umereno
visok rizik za nastanak inIektivnog endokarditisa su:
stecene srcane mane, propalps mitralne valvule sa regis-
trovanom mitralnom regurgitacijom, urodene srcane mane
bez cijanoze, ukljucujuci i bikuspidnu aortnu valvulu,
ali iskljucujuci atrijalni septum deIekt tip secundum i
hipertroIicna kardiomiopatija.
6,7
Pacijenti kod kojih ne postoji rizik za nastanak
inIektivnog endokarditisa su: starije osobe, osobe sa
registrovanim nebakterijskim trombotickim vegetacijama
na srcanim zaliscima i pacijenti sa kompromitovanom
imunoloskom sistemskom i lokalnom odbranom.
6,7
Rizicne stomatoloske intervencije su sve den-
talne procedure sa traumom gingive, dok su nerizicne
stomatoloske intervencije sve procedure gde se ne ocekuje
gingivalno krvarenje (npr. korekture proteza, ispuni iznad
ivice gingive).
6-9
Prevenecija inIektivnog endokarditisa kod kardijalno
rizicnih pacijenata sprovodi se antibioticima pre ocekivane
bakterijemije ili eventualno 2-3 sata nakon stomatoloske
intervencije sa traumom gingive.
7
Prevencija inIektivnog
endokarditisa vrsi se prema smernicama Evropskog
udruzenja kardiologa iz 2004. godine.
9

Kod pacijenata koji nisu alergicni na penicilin
primenjuje se amoxicilin 2,0 g per os ( deca 50 mg/kg TT)
1 sat pre stomatoloske intervencije.
8-13
oI mortality. According to earlier classiIication oI disease
to: acute, subacute and chronic, nowadays, it is classiIied
according to: activity oI the disease (acute or healed state),
pathogenesis, anatomic position oI disease localization
and cause oI microbiological origin. Early made ehocar-
diographic lesions are vegetations, which can be oI
diIIerent size; and the destructions, ulcerations, abscesses
etc. could be seen, too.
3,4

Vegetations are made oI amorphous mass oI
thrombocyte and Iibrin, they are initially sterile, and
aIterwards they are inIected and then contain a large
number oI microorganisms and inIlammatory cells.
3,4
Vegetations are primary localised on heart valves,
rarely on mural endocard. Incidence oI inIective
endocarditis is about 2 on 100 000 inhabitants. Endocarditis
oI native valve is 2.5 times more oIten at male population,
and persons older than 50.About 75 oI patients have
predisposition Ior a heart disease: rheumatic valvular
disease, congenital heart deIect, prolapse oI mitral valve,
degenerative diseases oI heart valves (aortic stenosis).
5
According to its course, inIective endocarditis can be
acute (the most common cause is Staphylococcus aureus,
mortality is possible in less then six weeks), sub-acute (the
most common cause is Streptococcus viridans, mortality is
possible in six weeks and more, even a year). Bacteria that
cause inIective endocarditis are inhabitants oI oral cavity.
3
Cardiac diseases which are highly risk Ior inIective
endocarditis are: at patients which have already had
inIective endocarditis, patients with artiIicial heart valves
or other endovascular Ioreign bodies, patients with
congenital heart deIect with cyanosis.
6,7
Cardiac diseases which are moderately highly risk Ior
inIective endocarditis are: at patients with acquired heart
deIect, prolapse oI mitral valve with registered mitral
regurgitation, patients with congenital heart deIect without
cyanosis, including bicuspid aortic valve, but excluding
atrial septum deIect type secundum and hyphertrophic
cardiomyopathy.
6,7
Patients who have no risk oI gaining inIective
endocarditis are old people, persons who are registered
Ior non-bacterial thrombocytic vegetations on heart valves
and patients with compromised immunological systemic
and local deIence.
6,7
Risky dental intervention are all dental procedures
that include gums trauma, while on the other hand non-
risky dental interventions are all procedures where gums
bleeding is to be expected (Ior example: braces correction,
Iillings above the edge oI gums).
6-9
Prevention oI inIective endocarditis at the patients with
cardiac disease risk is conducted with antibiotics beIore
expected bacterial inIection or, eventually, 2-3 hours aIter
dental procedure that includes gums trauma.
7
Prevention
oI inIective endocarditis is conducted according to the
directives oI European society oI cardiologists Irom 2004.
9
Patients who are not allergic to the penicillin are
using amoxicylin 2,0 g per os (children 20 mg/kg BW) or
154 Stom Glas S, vol. 52, 2005.
Kada pacijent ima alergiju na penicilin primenjuje se
clindamicin u dozi od 600 mg per os ( deca 20 mg/ kgTT)
ili azitromicin 500 mg (deca 15 mg/kgTT) jedan sat pre
planirane intervencije.
8-13
Kod pacijenta kod kojih je potrebna antibiotska
prevencija bakterijskog endokarditisa, a ne mogu da dobiju
peroralnu terapiju, primenju se amoxilcilin 2,0 g i.v. ( za
decu 50 mg/ kgTT) pola sata pre intervencije.
8-13

Veci broj studija pokazao je da i nakon primene
adekvatne doze baktericidnih antibiotika dolazi do prolazne
bakterijemije, ali se antibiotskom proIilaksom smanjuje i
adhezivnost mikroorganizama za endovaskularne strukture
cime se sprecava nastanak inIektivnog endokarditisa.
9,13
Sve do sada navedeno potseca nas na vaznost i znacaj
dobro uzete anamneze pre pocetka bilo koje intervencije.
Pacijenta treba obavezno pitati da li boluje srcanog
oboljenja i kojeg i da li se ranije lecio kod kardiologa.
Ukoliko pacijent navede da ima bilo koje oboljenje
ili stanje za koje je dokazano da predstavlja rizik za
nastanak inIektivnog endokarditisa stomatolog moze sam
izvrsiti prevenciju na prethodno opisan nacin. Ukoliko
pacijent navede da boluje ili je ranije bolovao od srcanog
oboljenja, a ne zna koje je oboljenje u pitanju, potrebno
je konsultovati kardiologa i stomatoloskoj intervenciji
koja dovodi do prolazne bakterijemije pristupiti tek uz
saglasnost kardiologa.
Prilikom bilo koje terapijske procedure treba imati
na umu osnovni princip u medicini 'PRIMUM NON
NOCERE.
azitromycin 500mg (children 15mg/kgBW) an hour beIore
intervention planned.
8-13
Patients who need antibiotic prevention oI bacterial
endocarditis, but who cannot get per-oral therapy, are
using amoxicylin 2,0 g I.V. (children 50mg/kgBW) halI an
hour beIore intervention planned.
8-13
A great number oI studies have shown that aIter the
adequate dosage oI bactericide antibiotic is applied, there
is temporary bacterial inIection, but antibiotic prophylaxis
lessens adhesion oI microorganisms Ior endovascular
structures which enables inIective endocarditis to
appear.
9,13
All that is mentioned reminds us oI the importance
and signiIicance oI a good taken anamnesis beIore any
intervention is going to start. The patient should be asked
iI he/she is suIIering oI any heart condition and iI he/she
is, which one, and iI it was treated at cardiologist`s. II the
patient states that he/she has any disease or condition that
is proved to be a risk Ior inIective endocarditis to appear,
the dentist can apply prevention as it is described. II the
patient states that he/she has or had heart disease, but he
/she doesn`t know which one, the cardiologist should be
consulted and then the dental intervention which leads
to temporary bacterial inIection should be done with
cardiologist`s agreement.
While any therapy procedure is conducted one should
have the main medical principle on mind 'PRIMUM NON
NOCERE.
Literatura / References
1. Harrison principles oI internal medicine-15th edition, New
York, McGraw-Hill, 2001
2. Taran LM. Rheumatic Iever in its ralation to dental disease.
NY J Dent 1944;14:107-13
3. Selton-Suty CH, Hoen B,Grentzimger A et al. Clinical and
bacteriological characteristics oI inIective endocarditis in
elderly. Heart 1997;77:260-3
4. American Heart Assotiation. Prevention oI bacterial endo-
carditis. Am Dent Assoc 1972;85:1377-9
5. Van Der Meer JT, Thompson J, Valkenburg HA et al. Epi-
demiology oI bacterial endocaditis in the Netherlands. Arch
Intern Med 1992;152:1863-8
6. Steckelberg JM, Wilson WR. Risk Iactors Ior inIective endo-
carditis. InI Dis Clin North Am 1993;7:9-19
7. Durack DT. Prevention oI inIective endocarditis. N Engl J
Med 1995;332:28-44
8. Van Der Meer JT, Van Wijk W, Thompson J, et al. EIIica-
cy oI antibiotic prophylaxis Ior prevention oI native valve
endocarditis. Lancet 1992;339:135-9
9. ESC Guidelines. Guidelines on Prevention,Diagnosis and
Treatment oI InIective Endocarditis. Eur Heart J 2004;00:1-37
10. Glauser MP, Bernard JP, Morellion P et al. SuccsesIul sin-
gle-dose amoxicilin prophylaxix against experimental strep-
tococcal endocarditis:evidence oI two mechanisms oI pro-
tection. J InIect Dis 1983;147:568-75
11. Malinverni R, Overholser CD,Bille J et al. Antibiotic proph-
ylaxix oI experimental endocarditis aIter dental extraction.
Circulation 1988;77:182-7
12. Horstkotte D, Rosin H, Fridrichs W et al. Contribution Ior
choosin the optimal prophylaxix oI bacterial endocarditis.
Eur Heart J 1987;8(Suppl J):379-91
13. American Heart Assotiation. Comittee report on prevention
oI rhematic Iever and bacterial endocarditis through control
oI streptococcal inIections.Circulation 1995;11:317-20
Autor odgovoran za korespondenciju
Asist mr sci Tatjana Puskar
1300 Kaplara 2
21000 Novi Sad
Address for correspondence
Asist mr sci Tatjana Puskar
1300 Kaplara 2
21000 Novi Sad