CDHO Advisory Infective Endocarditis and Associated Conditions

CDHO Advisory | I nfective E ndocarditis, H eart C onditions

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 with infective endocarditis associated with certain heart conditions.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Infective Endocarditis Associated with Certain Heart Conditions, 2021-06-14

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Infective endocarditis associated with certain heart conditions

INTENDED USERS

Advanced practice nurses Nurses Dental assistants Patients/clients Dental hygienists Pharmacists Dentists Physicians Denturists Public health departments Dieticians Regulatory bodies Health professional students

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have infective endocarditis associated with certain heart conditions, chiefly as follows.

1 Persons includes young persons and children

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1. Understanding the medical condition. 2. Sourcing medications information. 3. Taking the medical and medications history. 4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice. 5. Understanding and taking appropriate precautions prior to and during the Procedures proposed. 6. Deciding when and when not to proceed with the Procedures proposed. 7. Dealing with adverse events arising during the Procedures. 8. Keeping records. 9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years) Adolescent (13 to 18 years) Adult (19 to 44 years) Middle Age (45 to 64 years) Aged (65 to 79 years) Aged 80 and over Male Female Parents, guardians, and family caregivers of children, young persons and adults with infective endocarditis associated with certain heart conditions.

MAJOR OUTCOMES CONSIDERED

For persons who have infective endocarditis associated with certain heart conditions: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory Resources consulted . Canadian Dental Association . American Heart Association o 2021 AHA Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis o 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Diseas) o ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis o Prevention of Infective Endocarditis: Guidelines From the American Heart Association [2007]

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o Infective Endocarditis . American Association of Endodontists

Infective endocarditis 1. is an infection of the endocardium or the heart valves, which may damage or even destroy heart valves 2. occurs when certain bacteria in the bloodstream lodge on and infect abnormal heart valves or other damaged heart tissue 3. is a life-threatening illness.

Other terminology used in this Advisory is as follows. 1. Atrial septal defect, a congenital heart defect in which the wall that separates the atria, the upper heart chambers, does not close completely. 2. Bacteremia, bacteria in the bloodstream. 3. Endocarditis, abbreviation for infective endocarditis. 4. Endocardium, the heart’s inner lining. 5. Hemodialysis, a procedure that uses a dialysis machine to filter waste products from the blood and to restore normal constituents to it. 6. Hypertrophic cardiomyopathy, a rare disorder, the abnormal thickening of the heart muscle that affects one or two people in every 1,000. 7. Infectious endocarditis, alternative term for infective endocarditis. 8. Janeway lesions, red and painless skin spots on the palms and soles. 9. Palliative care, services of care for persons towards the end of life with terminal illnesses such as cancer, when the focus of the care a. is relieving symptoms b. is attending to physical and spiritual needs. 10. Patent ductus arteriosus, a condition a. where the ductus arteriosus, a blood vessel, fails to close normally in an infant soon after birth b. which causes abnormal blood flow between the aorta and pulmonary artery, two major blood vessels that carry blood from the heart. 11. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the heart condition or its treatment. 12. Ventricular septal defect a. one or more holes in the wall that separates the right and left ventricles of the heart b. one of the most common congenital heart defects c. may occur by itself or with other congenital diseases.

Overview of infective endocarditis associated with certain heart conditions

Resources consulted . College of Dental Hygienists of Ontario: Infective Endocarditis Fact Sheet . College of Dental Hygienists of Ontario: Recommended Antibiotic Prophylaxis Regimens for the Prevention of Infective Endocarditis and Hematogenous Joint Infection . Canadian Dental Association

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. American Heart Association o 2021 AHA Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis o 2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease o ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis o Prevention of Infective Endocarditis: Guidelines From the American Heart Association [2007] o Infective Endocarditis . American Association of Endodontists . Mayo Clinic . Medline Plus . Infective Endocarditis: Medscape . Prophylaxis Against Infective Endocarditis: 2016 Partial Update to 2008 NICE Clinical Guidelines . Prophylaxis Against Endocarditis: 2008 NICE Clinical Guidelines

Policy positions of major organizations 1. The American Heart Association’s position on infective endocarditis is supported by the Canadian and American Dental Associations, and the Canadian Cardiovascular Society. 2. The American Heart Association states that a. infective endocarditis is a very serious disease with i. many people at increased risk ii. relatively few people who develop it b. bacteremia i. is the precursor to infective endocarditis ii. is common after the Procedures, among other invasive dental procedures iii. involves the bacteria normally resident in the mouth and upper respiratory system c. infective endocarditis occurs when certain bacteria in the bloodstream lodge on abnormal heart valves or other damaged heart tissue d. the Association’s Endocarditis Committee, together with national and international experts on infective endocarditis, concluded that i. there is no conclusive evidence linking dental or certain non-dental procedures with the development of infective endocarditis ii. infective endocarditis is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental procedure. 3. The American Heart Association believes that a. infective endocarditis rarely occurs in people with normal hearts b. the risk of antibiotic-associated adverse events exceeds the benefit, if any, from antibiotic prophylaxis for most persons c. antibiotic prophylaxis i. to prevent endocarditis is unnecessary for non-invasive dental/dental hygiene procedures

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ii. may prevent an exceedingly small number of cases of infective endocarditis, if any, in individuals who undergo a dental procedure iii. is reasonable before certain dental/dental hygiene procedures (i.e., those that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa) for persons with 1. prosthetic cardiac valve or material that includes a. presence of cardiac prosthetic valve b. transcatheter implantation of prosthetic valves c. cardiac valve repair with devices, including annuloplasty, rings, or clips d. left ventricular assist devices or implantable heart 2. previous, relapse, or recurrent infective endocarditis 3. congenital2 heart disease (CHD)3 that includes a. unrepaired cyanotic CHD4, including palliative shunts and conduits b. completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure5 c. repaired CHD with residual defects6 at the site of or adjacent to the site of a prosthetic patch or prosthetic device d. surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit 4. cardiac valvulopathy after cardiac transplant7.

Occurrence The US incidence of infective endocarditis is some 2–4 cases per 100,000 persons per year, a rate that 1. defines it as an uncommon disease 2. has not changed in the past 50 years 3. is similar to that in other countries.

2 congenital = present from birth 3 Except for the conditions listed here, antibiotic prophylaxis is no longer recommended by the AHA for any other form of CHD. 4 Common types of cyanotic congenital heart disease (i.e., birth defects resulting in oxygen levels lower than normal) include tetralogy of Fallot (TOF, in which there are 4 defects that affect the heart; namely, ventricular septal defect [VSD], pulmonary stenosis, right ventricular hypertrophy, and overriding aorta) and transposition of the great arteries (TGA, in which the pulmonary artery is attached to the left side of the heart, and the aorta is attached to the right side of the heart). 5 Prophylaxis is reasonable during this period, because endothelialization of prosthetic materials requires 6 months. 6 Residual defects include persisting leaks or abnormal flow. 7 in particular, cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve

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Cause Infective endocarditis 1. most commonly results from a blood infection that arises when the infection-causing bacteria a. enter the bloodstream and travel to the heart, where the infection locates on damaged heart valves or other damaged heart components b. form infected clots that break off and are carried to the i. brain ii. lungs iii. kidneys iv. spleen 2. may result from infection with a. Streptococcus viridans, which is responsible for about half of all infective endocarditis instances b. Staphylococcus aureus, which i. may infect normal heart valves ii. is the most common cause of infective endocarditis in intravenous drug users c. Enterococci, which are i. part of the normal intestinal flora of humans and animals ii. important pathogens responsible for infective endocarditis and other serious infections d. Candida albicans, thrush, a fungus which i. causes candidiasis of the mouth and genital system ii. occasionally leads to infective endocarditis.

Risk factors For infective endocarditis, risk factors 1. are strongly linked with the mouth because the bacteria prominently associated with bacteremia which lead to infective endocarditis are found in the mouth. 2. are associated with a. dental procedures, which carry particular risks for children with certain congenital heart conditions b. poor dental hygiene. 3. include a. artificial heart valves b. unrepaired cyanotic congenital heart disease, including i. tetralogy of Fallot ii. transposition of the great arteries c. damaged heart valves d. history of rheumatic heart disease e. intravenous use of drugs of abuse because unsterile needles may introduce bacteria to the bloodstream (CDHO Advisory).

Signs and symptoms Infective endocarditis signs and symptoms 1. may develop slowly or suddenly 2. may first manifest as fever, which

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a. is the typical sign b. can persist for days before any other indications appear 3. include warning symptoms alerting to the need for medical investigation, such as a. blood in urine b. chest pain c. numbness or weakness of muscles d. weakness e. weight loss without change in diet 4. variously include other symptoms and signs, such as a. chills b. excessive sweating c. facial pallor d. fatigue e. joint pain f. muscle aches and pains g. night sweats h. painful, red nodes in the pads of the fingers and toes (Osler nodes) i. shortness of breath with activity j. Janeway lesions k. swelling of feet, legs, and abdomen.

Medical investigation For infective endocarditis, medical investigation 1. involves exploring the medical history for congenital or other heart disease 2. includes physical examination for a. enlarged spleen b. heart murmurs c. retinal bleeding d. splinter hemorrhages in the fingernails 3. includes tests and investigations, such as a. blood culture to detect bacteria b. chest x-ray c. complete blood count to detect anemia d. CT scan of the chest e. echocardiogram f. erythrocyte sedimentation rate (ESR).

Treatment For infective endocarditis, treatment 1. requires admission to hospital for intravenous antibiotics for long-term, high-dose treatment needed to eliminate the bacteria, accompanied by frequent blood tests 2. may require surgery to replace dysfunctional heart valves.

Prevention For prevention of infective endocarditis, see also oral health considerations, the American Heart Association suggests 1. preventive antibiotics before certain dental procedures for people at highest risk of adverse outcome from infectious endocarditis, specifically those persons with

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a. prosthetic cardiac valve or material that includes i. presence of cardiac prosthetic valve ii. transcatheter implantation of cardiac valves iii. cardiac valve repair with devices, including annuloplasty, rings, or clips iv. left ventricular assist devices or implantable heart b. previous, relapse, or recurrent infective endocarditis c. congenital heart disease8 that includes i. unrepaired cyanotic CHD9, including palliative shunts and conduits ii. completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure 10 iii. repaired CHD with residual defects11 at the site of or adjacent to the site of a prosthetic patch or prosthetic device iv. surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit d. cardiac valvulopathy after cardiac transplant12. 2. continued medical follow-up for persons with prior history of infective endocarditis. 3. for persons who use intravenous drugs a. treatment for addiction b. use of i. injection sites ii. new needles for each injection iii. alcohol pads before injecting c. avoidance of sharing any injection-related paraphernalia.

Prognosis For infective endocarditis depends on 1. whether or not complications develop 2. whether it is left untreated; if so infective endocarditis is generally fatal 3. early detection and appropriate treatment, which can be life-saving.

Social considerations Surveys indicate that few persons at risk of developing infective endocarditis understand the importance of prevention and prevention principles, which include 1. appropriate oral hygiene

8 Except for the conditions listed here, antibiotic prophylaxis is no longer recommended by the AHA for any other form of CHD. 9 Common types of cyanotic congenital heart disease (i.e., birth defects resulting in oxygen levels lower than normal) include tetralogy of Fallot (TOF, in which there are 4 defects that affect the heart; namely, ventricular septal defect [VSD], pulmonary stenosis, right ventricular hypertrophy, and overriding aorta) and transposition of the great arteries (TGA, in which the pulmonary artery is attached to the left side of the heart, and the aorta is attached to the right side of the heart).

10 Prophylaxis is reasonable during this period, because endothelialization of prosthetic materials requires 6 months. 11 Residual defects include persisting leaks or abnormal flow. 12 in particular, cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve

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2. antibiotic prophylaxis as prescribed 3. the importance of drug rehabilitation and injection sites for those who use intravenous drugs of abuse 4. the risks of nonmedical invasive procedures such as body piercing and tattooing.

Multimedia and images

Infective endocarditis Janeway lesion on the finger

Comorbidity, complications and associated conditions Comorbid conditions are those which co-exist with infective endocarditis but which are not believed to be caused by it or to have caused it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice. 1. Comorbid conditions, complications and associated conditions for infective endocarditis variously include a. blood clots that travel to brain, kidneys, lungs, or abdomen b. brain abscess c. congestive heart failure (CDHO Fact Sheet) d. glomerulonephritis (CDHO Advisory) e. jaundice f. neurological changes g. rapid or irregular heartbeats, including atrial fibrillation h. severe valve damage i. stroke (CDHO Advisory) 2. Relative to the risk of infective endocarditis arising from the Procedures, orthodontic and restorative practices, and other invasive interventions, specialist advice is necessary regarding a. the underlying heart condition b. the numerous conditions that are comorbid to or complications of heart conditions, such as i. advancing age ii. diabetes mellitus (CDHO Advisory) iii. hemodialysis iv. immunosuppression (CDHO Advisory).

Oral health considerations Resources consulted . 2021 AHA Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis . Focused Update on Infective Endocarditis: ACC/AHA 2008 Practice Guideline Update on Valvular Heart Disease . Infective Endocarditis: American Heart Association . Prophylaxis Against Infective Endocarditis: 2016 Partial Update to 2008 NICE Clinical Guidelines . Prophylaxis Against Endocarditis: 2008 NICE Clinical Guidelines

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1. The 2021 American Heart Association Scientific Statement on Prevention of Viridans Group Streptococcal Infective Endocarditis, similar to the 2008 American College of Cardiology/American Heart Association practice guideline update for endocarditis prophylaxis, advises that a. antibiotic prophylaxis i. is reasonable for patients with the highest risk of adverse outcomes who undergo dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of the oral mucosa ii. is not recommended for 1. anesthetic injections through non-infected tissue 2. dental radiographs 3. placement or removal of prosthodontic or orthodontic appliances 4. adjustment of orthodontic appliances 5. placement of orthodontic brackets 6. shedding of deciduous teeth 7. bleeding from trauma to the lips or oral mucosa b. with the relaxation of the criteria for antibiotic prophylaxis, oral hygiene requires greater emphasis i. for all persons at risk of endocarditis ii. because the prevention of oral disease, relative to routine daily activities such as tooth-brushing and chewing, can be expected to 1. decrease the burden and frequency of bacteremia 2. limit the cumulative risk from cumulative bacteremia c. the risks of antibiotic-associated adverse events exceed the benefits, if any, from antibiotic prophylaxis for most persons d. antibiotic prophylaxis against infective endocarditis is i. reasonable for certain heart conditions, which put persons undergoing dental procedures at highest risk of infective endocarditis, namely 1. prosthetic cardiac valve or material that includes a. presence of cardiac prosthetic valve b. transcatheter implantation of prosthetic valves c. cardiac valve repair with devices, including annuloplasty, rings, or clips d. left ventricular assist devices or implantable heart 2. previous, relapse, or recurrent infective endocarditis 3. congenital13 heart disease (CHD)14 that includes a. unrepaired cyanotic CHD15, including palliative shunts and conduits

13 congenital = present from birth 14 Except for the conditions listed here, antibiotic prophylaxis is no longer recommended by the AHA for any other form of CHD. 15 Common types of cyanotic congenital heart disease (i.e., birth defects resulting in oxygen levels lower than normal) include tetralogy of Fallot (TOF, in which there are 4 defects that affect the heart; namely, ventricular septal defect [VSD], pulmonary stenosis, right ventricular hypertrophy, and overriding aorta) and transposition of the great arteries (TGA, in which the pulmonary artery is attached to the left side of the heart, and the aorta is attached to the right side of the heart). Page | 10 CDHO Advisory | I nfective E ndocarditis, H eart C onditions

b. completely repaired congenital heart defect repaired with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure16 c. repaired CHD with residual defects17 at the site of or adjacent to the site of a prosthetic patch or prosthetic device d. surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit e. cardiac valvulopathy after cardiac transplant ii. recommended for 1. procedures that involve manipulation of either gingival tissue or the periapical region of the teeth or perforation of the oral mucosa. 2. Factors taken into account in the 2021 AHA Statement and the 2008 American College of Cardiology/American Heart Association practice guidelines include a. the wide understanding that i. invasive procedures commonly result in transient bacteremia, which have been observed in up to 100 percent of invasive dental procedures ii. transient bacteremia plays a pivotal role in the pathogenesis of infective endocarditis, an understanding that prompted the development and evolution of antibiotic prophylaxis guidelines b. the knowledge that transient bacteremia occurs frequently and is often qualitatively similar to that induced during activities of daily living, such as i. tooth-brushing ii. chewing food c. analyses of the estimated cumulative monthly bacterium exposure from activities of daily living, which are found to substantially exceed the exposure following extraction of a single tooth d. the broadly held medical view that infective endocarditis is more likely to result from routine bacteremias associated with daily activities than from bacteremia caused by an invasive dental procedure e. the apparent lack of proven efficacy of antibiotic prophylaxis in preventing infective endocarditis or bacteremia f. the potential for adverse effects or undesired outcomes with antibiotic prophylaxis, such as i. adverse reactions directly related to the antibiotic, such as immediate or delayed hypersensitivity ii. adverse consequence of antibiotic use, such as antibiotic-associated colitis

16 Prophylaxis is reasonable during this period, because endothelialization of prosthetic materials requires 6 months. 17 Residual defects include persisting leaks or abnormal flow.

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iii. increasing concerns over the past few years regarding the role of indiscriminate antibiotic use in the emergence of antibiotic-resistant organisms. 3. Medical advice, prior to the Procedures, regarding antibiotic prophylaxis, which is necessary for a. children with congenital heart disease b. adults with heart valve conditions c. persons with ventricular assist devices or implantable hearts.

MEDICATIONS SUMMARY

Sourcing medications information 1. Adverse effect database . Health Canada’s Marketed Health Products Directorate toll-free 1-866-234-2345 . Health Canada’s Drug Product Database

2. Specialized organizations . US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information

3. Medications considerations All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications. 4. Information on herbals and supplements . US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information All Herbs and Supplements

5. Complementary and alternative medicine . National Center for Complementary and Alternative Medicine

Types of medications . amoxicillin . ampicillin (Principen®) . azithromycin (Zithromax®) . cefadroxil (Duricef®) . cefazolin (Ancef®) . ceftriaxone injection (Rocephin®) . cephalexin (Keflex®) . clarithromycin (Biaxin®) . daptomycin injection (Cubicin®) . doxycycline (Vibramycin® + numerous other brand names) . vancomycin (Vancocin®)

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Antibiotic Prophylaxis Regimens for Patients/Clients at Highest Risk of Adverse Outcome from Infective Endocarditis Who Are Undergoing Dental/Dental Hygiene Procedures (based on 2021 “American Heart Association Scientific Statement: Prevention of Viridans Group Streptococcal Infective Endocarditis”, which updates 2007/2008 AHA Guidelines) Clinical situation Medication Single dose 30–60 minutes pre-procedure Adults Children Person able to take oral amoxicillin 2 g 50 mg/kg medication ampicillin 2 g IMi or IVii 50 mg/kg IM/IV Person unable to take oral cefazolin 1 g IM or IV 50 mg/kg IM or IV medication ceftriaxone 1 g IM or IV 50 mg/kg IM or IV cephalexiniii/v 2 g 50 mg/kg Person allergic to penicillins azithromycin 500 mg 15 mg/kg or ampicillin but able to take clarithromycin 500 mg 15 mg/kg iv oral medication <45 kg, 4.4 mg/kg doxycycline 100 mg >45 kg, 100mg Person allergic to penicillins cefazolin 1 g IM or IV 50 mg/kg IM or IV or ampicillin and unable to v take oral medication ceftriaxone 1 g IM or IV 50 mg/kg IM or IV i IM = intramuscular ii IV = intravenous iii or other first- or second-generation oral cephalosporin in equivalent adult or paediatric dosage iv Clindamycin is no longer recommended for antibiotic prophylaxis for dental/dental hygiene procedures. It may cause more frequent and severe reactions than other antibiotics used for antibiotic prophylaxis. v Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins (including ampicillin).

Side effects of medications See the links above to the specific medications.

THE MEDICAL AND MEDICATIONS HISTORY

The dental hygienist in taking the medical and medications history-taking should 1. focus on screening the patient/client prior to treatment decision relative to a. key symptoms b. medications considerations c. contraindications d. complications e. comorbidities f. associated conditions 2. explore the need for advice from the primary or specialized care provider(s) 3. inquire about a. the advice received by the patient/client from the appropriate primary or specialist care provider regarding antibiotic prophylaxis and other relevant matters

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b. pointers in the history of significance to infective endocarditis and heart conditions c. the patient/client’s understanding and acceptance of the need for oral healthcare d. medications considerations, including over-the-counter medications, herbals and supplements e. problems with previous dental/dental hygiene care f. problems with infections generally and specifically associated with dental/dental hygiene care g. the patient/client’s current state of health h. how the patient/client’s current symptoms relate to i. oral health ii. health generally i. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client The dental hygienist should 1. record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number 2. obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider 3. use a consent/medical consultation form, and be prepared to fax the form to the provider 4. include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Infection Control Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to 1. the CDHO’s Infection Prevention and Control Guidelines (2019) 2. relevant occupational health and safety legislative requirements 3. relevant public health legislative requirements 4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

The dental hygienist 1. is required to consult with the patient/client’s physician, dentist, or registered nurse in the extended class [RN(EC)] to obtain advice about implementing or clearance for implementing the Procedures for a patient/client with any cardiac condition for which antibiotic prophylaxis is recommended in the guidelines set from time to time by the American Heart Association (pursuant to Ontario Regulation 501/07) 2. may postpone the Procedures pending medical advice if the patient/client has a. symptoms or signs of fever or is feeling unwell

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b. recently changed medications, under medical advice or otherwise c. recently experienced changes in his/her medical condition. d. symptoms or signs suggestive of comorbidity, complication or associated condition e. not recently or ever sought and received medical advice relative to oral healthcare procedures f. recently changed significant medications, under medical advice or otherwise g. recently experienced changes in his/her medical condition such as medication or other side effects of treatment h. deep concerns about any aspect of his or her medical condition.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client. First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) for a patient/client with a history of infective endocarditis associated with certain heart conditions, the dental hygienist should specifically record 1. a summary of the medical and medications history 2. any advice received from the physician/primary care provider relative to the patient/client’s condition 3. the decision made by the dental hygienist, with reasons 4. compliance with the precautions required 5. all Procedure(s) used 6. any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The dental hygienist should 1. where appropriate, urge the patient/client or the family caregiver to alert any healthcare professional who proposes any intervention or test a. that the patient/client has a history of i. infective endocarditis ii. a heart condition b. to the medications the patient/client is taking 2. should discuss, as appropriate a. the importance of the patient/client’s i. complying with all prescribed pre-medication including antibiotic prophylaxis, if any ii. self-checking the mouth regularly for suspicious signs or symptoms iii. reporting to the appropriate healthcare provider any changes in the mouth indicative of suspicious lesions b. the need for regular oral health examinations and preventive oral healthcare c. oral self-care including information about i. choice of toothpaste

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ii. tooth-brushing techniques and related devices iii. dental flossing iv. mouth rinses v. management of a dry mouth d. the importance of an appropriate diet in the maintenance of oral health e. for persons at an advanced stage of a disease or debilitation i. regimens for oral hygiene as a component of supportive care and palliative care ii. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves iii. scheduling and duration of appointments to minimize stress and fatigue f. comfort level while reclining, and stress and anxiety related to the Procedures g. medication side effects such as dry mouth, and recommend treatment h. mouth ulcers and other conditions of the mouth relating to infective endocarditis associated with certain heart conditions, comorbidities, complications or associated conditions, medications or diet i. pain management.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

1. Reducing the risk of infective endocarditis and stress on patients/clients who are debilitated by heart conditions, whether or not they are prescribed antibiotic prophylaxis, of adverse effects of the Procedures, by a. taking medical, nurse-practitioner or specialist advice before implementing the Procedures b. encouraging dental hygiene and self-care of oral health c. generally increasing the comfort level of persons in the course of dental hygiene interventions d. using appropriate techniques of communication e. providing advice on scheduling and duration of appointments. 2. Reducing the risk that oral health needs are unmet.

POTENTIAL HARMS

1. Causing infection that increases the risk of infective endocarditis associated with certain heart conditions. 2. Performing the Procedures at an inappropriate time, such as a. when the patient/client is feeling unwell or has an elevated body temperature b. in the presence of complications for which prior medical advice is required c. in the presence of acute oral infection without prior medical advice. 3. Disturbing the normal dietary and medications routine of a person with infective endocarditis associated with certain heart conditions. 4. Inappropriate management of pain or medication.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

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ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2014-02-18; 2019-08-07; 2021-06-14

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA Dr Kevin Glasgow MD, MBA, MHSc, DTM&H, CHE, CCFP, FCFP, LFACHE, FACPM, FRCPC Lisa Taylor RDH, BA, MEd Robert Farinaccia RDH, BSc Kyle Fraser RDH, BComm, BEd, MEd Carolle Lepage RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services. Denise Lalande Final layout and proofreading

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