Oral health is of particular importance in patients with heart valve diseases because of the risk of infective endocarditis. Recommendations for antibiotic prophylaxis before dental procedures have been restricted, but the modalities of oral evaluation and dental care are not detailed in guidelines. Therefore, a multidisciplinary working group reviewed the literature to propose detailed approaches for the evaluation and management of buccodental status in patients with valvular disease. Simple questions asked by a non-dental specialist may draw attention to buccodental diseases. Besides clinical examination, recent imaging techniques are highly sensitive for the detection of inflammatory bone destruction directly related to oral or dental infection foci. The management of buccodental disease before cardiac valvular surgery should be adapted to the timing of the intervention. Simple therapeutic principles can be applied even before urgent intervention. Restorative dentistry and endodontic and periodontal therapy can be performed before elective valvular intervention and during the follow-up of patients at high risk of endocarditis. The detection and treatment of buccodental foci of infection should follow specific rules in patients who present with acute endocarditis. Implant placement is no longer contraindicated in patients at intermediate risk of endocarditis, and can also be performed in selected high-risk patients. The decision for implant placement should follow an analysis of general and local factors increasing the risk of implant failure. The surgical and prosthetic procedures should be performed in optimal safety conditions. It is therefore now possible to safely decrease the number of contraindicated dental procedures in patients at risk of endocarditis.

No abstract

An 87-year-old patient was referred by his dentist for multiple tooth extractions following pain on the lower right jaw (quadrant 4) and one month of unsuccessful antibiotics treatment. The patient had a medical history of slow progressing myeloma for more than two years with no treatment required, chronic kidney failure and atrial fibrillation. Extraoral examination revealed a right submandibular lymphadenopathy. Intraoral examination revealed severe periodontitis characterized by poor oral hygiene, tooth mobility especially in the molars sectors (score 3 and 4 of Muhlemann) and necrotic gum on quadrant 4. The patient also reported spontaneous loss of teeth. The orthopantomogram (OPT) showed a radiographic bone loss extending to mid third of the roots and beyond. The patient was treated by apixaban and bisoprolol. He had never received biphosphonate or RANK/RANKL inhibitor. The main complaint was pain in quadrant 4. Teeth 45 46 47 were hopeless and their extraction was planned. Extractions were performed with no premedication. After local anesthesia, analgesia was hard to obtain. The extractions revealed a necrotic aspect of the underlying bone and a biopsy was performed looking for osteitis or malignant disease (Fig. 1). Medication-related jaw osteonecrosis was excluded after exhaustive anamnesis. A CBCT was performed to evaluate the extension of the bone necrosis. At this stage it was not informative (Fig. 2). At follow-up appointment two weeks later, a worsening of the wound was observed, with pain preventing alimentation. A new CBCT was performed and showed small radiolucent lesions in the cortical bone surrounding the extraction site (Fig. 2). Surprisingly, histological result was in favor of actinomycosis.

Evolution des modèles de prophylaxie de l'endocardite Infectieuse. Point de vue d'experts sur la prise en charge bucco-dentaire des patients valvulaires. L'endocardite infectieuse (EI) est une pathologie grave associée à une mortalité hospitalière de 20% à la phase aigue et de 40% à 5 ans. Malgré des progrès considérables en microbiologie et imagerie, son incidence est restée stable (1500 cas par an en France). Le traitement médical est lourd et dans un cas sur deux associé à une chirurgie (remplacement /réparation valvulaires). Le profil bactériologique de cette pathologie a été modifié et les Staphyloccoques occupent la première place dans la répartition des germes responsables. Les Streptocoques oraux sont encore à l'origine de 20% des EI. Pour différentes raisons, les modèles de prophylaxie de l'EI ont beaucoup évolué, en Europe et aux Etats Unis tendant au fur à mesure à restreindre les groupes de patients à risque, les doses d'antibiotiques, la liste des actes dentaires invasifs contre indiqués responsables de bactériémie.