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Extraoral infections caused by oral bacteria Endocarditis Infective endocarditis Infection of endocardium acute subacute chronic About 2 to 3 out of 100,000 people develop bacterial endocarditis each year in the US Risk factors Defective valves Prosthetic valves Congenital heart defects e.g. Ventricular septal defect Patent ductus arteriosus Causative organisms Viridans streptococci (50%) (S. mutans, S. sanguis) Staphylococcus aureus Enterococcus faecalis More uncommonly other bacteria, fungi Pathogenicity Bacteremia Biofilm along valve edges Infectious organisms Mass of fibrin Platelets Clinical Features Valve destruction heart failure Embolic events Immune complex deposition vasculitis arthralgia glomerulonephritis Malaise, fever, night sweats, weight loss, anaemia abscesses in brain, liver Diagnosis Blood cultures – repeated samples Anaemia white blood cell count erythrocyte sedimentation rate Echocardiography Mortality Fatal if untreated 6% sensitive streptococci 30% Staphylococcus aureus Management Antibiotics i.v. (penicillin and gentamicin before AST results) Oral antibiotics Bacteremia Frequency of bacteremia Procedure Extraction % 10-100 Scaling and root planing 8-80 Rubber dam matrix/wedge placement 9-32 Tooth brushing and flossing Chewing food 20-68 7-51 Magnitude of bacteremia Dental procedures <104 CFU/ml Routine daily activities <104 CFU/ml Experimental endocarditis 106 – 108 CFU/ml Persistance of bacteremia Most positive blood cultures were within 10 mins after extraction. 6-30 minutes with single extraction Only a small no. of positive blood cultures between 30-60 minutes Control and prevention Oral hygiene Antibiotics Dental procedures All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa, e.g. Extraction Periodontal probing, scaling, root planing and surgery Biopsy Suture removal Subgingival restorations Orthodontic band placement ATB One hour pre-operation Amoxycillin If penicillin allergic, clindamycin 600mg po Allergic to penicillin and unable to swallow capsules, azithromycin 500mg po Alternatively intravenous options Pre-operative chlorhexidine (0.2%) mouthrinse Amoxycillin Drug of 1st choice Well absorbed from GIT High serum concentrations Few side-effects BUT increasing resistance to penicillin in viridans streptococci Adverse reactions Check for drug allergy Check for antibiotic treatment in last 4 weeks If patient is on other drugs, antibiotics may interfere with.