Introduction
For a long time, the oral cavity has been considered the main bacterial gateway for many focal infections to other sites of the human body.1 This has led to radical interventionist attitudes and a renunciation of endodontic care, most often unjustified.2, 3 Since then, these drifts have been corrected, the risk of focal infection of oral origin has been put into perspective and in the vast majority of cases, dental care in general and endodontics, in particular, are possible in patients with an infectious risk linked to a or several general pathologies.4
However, in recent years, epidemiological and experimental investigations have highlighted an association between patients poor oral health and their poor general health.5, 6, 7 Thus, dental and periodontal pathogens are now considered a risk factor among others such as smoking, overweight, physical inactivity and age.8, 9
Endodontic treatment with instrumental maneuvers if not performed properly may cause the release of microorganisms. These germs pass into the blood or lymphatic circulation and attach to the endocardium.6 It is the focal infection at the dental gateway.
In the heart, germs cause complications such as infective endocarditis.10 Bacterial endocarditis occurs in about a third of cases in subjects presumed healthy, outside gestures, which pleads for a global prevention, especially oral, adapted to the whole population.11 On the other hand, carrying out gestures liable to cause bacteremia in cardiac patients known to have endocarditis is a risky situation.12, 13
The dental surgeon's preventive approach to IA consists of avoiding spontaneous bacteremia by suppressing dental infectious foci and in combating bacteremia caused by antibiotic prophylaxis.14, 15, 16, 17, 18
Unfortunately, most of the previous studies conducted in other countries have shown a lack of consistency in the knowledge and practice of dentists in the management of cardiac patients.19, 20, 21
The objective of this study was to assess the knowledge of practitioners in the Abidjan district on current guidelines for the endodontic management of heart patients.2
Materials and Methods
A self-administered questionnaire was distributed to a representative sample of dentists in Abidjan between April and June 2019. The sample was selected from dentists practicing in private, public and university hospitals using a convenience sampling method. The information sought included demographics of the respondents, awareness of the current guidelines which was based on the consensus opinion of experts on preventing infective endocarditis and sources of knowledge regarding that guidance. The questions were focused on the different types of heart disease and the indications or contraindications of endodontic therapy for the treatment of irreversible pulpopathies.
Data analysis was done using SPSS for Windows (12.0 version, Chicago, IL). Descriptive statistics and tests of significance (p≤0.05) were used as appropriate.
Results
The time since graduation from dental school ranged from 1 to 26 years (mean 11 years). Most respondents (79%) were trained in Abidjan. More than 50% of respondents do not participate in continuing education. All the respondents wanted to participate in continuing education on the management of heart disease.
Only 123 respondents (80%) knew about heart disease, and the most common source of this knowledge was their initial training (Table 2). Almost all respondents reported knowledge of Infective Endocarditis (96%) and focal infection (97%).
One Hundred Twenty Three (123) respondents (80%) indicated that they were aware of the current Infectious Endocarditis Prevention Guidelines, and the most common source of this knowledge was their pre-service training (Table 2).
Fifty-two (52%) percent of respondents were unaware of high-risk heart disease (Group A) and lower-risk heart disease (Group B) (Table 2). 50% of the practitioners were not aware of the contraindications of endodontic treatment in cardiopathy. When endodontic treatment was indicated, practitioners did not apply recommendations such as treatment in one session (Table 3), and antibiotic prophylaxis limited to 1 hour before treatment (75.17%).
Finally, 26.21% of the respondents did not find it necessary to establish a dialogue with the general practitioner (Table 2).
Table 1
Characteristics of the respondents
Table 2
The proportion of correct responses for each item for the question
Discussion
Our sample is made up of 145 dentists. Men represent 64.83% against 35.17% of women, a sex ratio of 1.84 in favor of men. (Table 1). Most of the dentists surveyed practiced in the private sector (66.90%) (Table 1). These findings may be linked to an uneven distribution of survey sheets.
Regarding knowledge regarding the management of heart disease in endodontics, most of the respondents 84.83% (Table 1 ) said that they had received notions during their initial training. With regard to IEs and RUs, almost all (90% of the dental surgeons surveyed) admit having received training for this purpose. (Table 2). However, more than 50% of practitioners are unable to distinguish a heart patient from group A and group B. (Table 2). Our results agree with those of Kazuma et al. who had shown in their study that in pediatric dentists in Japan, it was difficult to identify which cardiac diseases are at high risk for AE, probably due to a lack of training in cardiology.22
Concerning the international recommendations on antibiotic prophylaxis for AE, our study revealed that more than three quarters (3/4) of the respondents do not know these recommendations (Table 2). This could be due to the modalities of prescription which remain little particular. In fact, it is recommended that a prescription for an antibiotic be made one hour before the procedure at a rate of 3g per os in a single dose.23 For patients weighing less than 60kg, this is reduced to 2g per os, one hour before treatment in a single dose. This, therefore, makes it possible to maintain a high serum concentration and good digestive tolerance. Our results are largely disproportionate compared to those of Errahmouni7 who noted that only half of the dentists in the city of Marrakech knew the antibiotic prophylaxis of the IS, contrary to 24.8% noted in our study. Adeyemo et al. also made the same observation in Nigeria. They observed a low level of knowledge of current guidelines among dentists for antibiotic prophylaxis for AE.19
Most of the molecules recommended for the antibiotic prophylaxis of AE are from the β-lactam family (Ex: Amoxicillin). In our study, out of 36 practitioners, only 25 practitioners (71.72%) prescribed β-lactams in accordance with the recommendations (Table 2). This result is close to that of Errahmouni which collected 74% of its sample.20 In addition, the study carried out by Kapitchet in 2017 on the prescription of antibiotics in endodontics showed a higher rate (98.20% of prescriptions).11
Carrying out endodontic care in heart patients is very complex. In group A patients endodontic care should be exceptional. They can only be carried out after verification of the vitality of the tooth by appropriate tests. In addition, care must be carried out under a dike, in a single session, with an apex locator while being sure that all of the canal lumen is accessible. In any event, the idea of carrying out the treatment in a single session responds to a principle of minimizing the risks of colonization and/or recolonization of the endodont by microorganisms.
Out of 81 practitioners who perform endodontic treatment, only 28 do so in a single session (Table 3). However, this treatment should be reserved for monoradiculated teeth and, if necessary, the first premolar if both channels are accessible.23 All these precautions are necessary to work in an aseptic environment and avoid introducing germs into the periapex.
When evaluating endodontic procedures, our study found that almost all practitioners (92%) did not use a dam or apex locator (Table 3). Most dentists (95.80%) used manual canal preparation techniques and 80% performed canal filling with the non-compressive technique (Table 3). However, it has been proven that these techniques do not guarantee the seal sought during endodontic treatment. Indeed, with manual canal preparation techniques, the major risk of bacteremia is located during the initial phase of treatment: when the instruments seeking to reach the working length through a channel whose taper has not been established, entrain and pack bacteria in an apical situation or even propel them in an extra-radicular situation. This risk persists during shaping in the absence of adequate hypochlorite irrigation and during obturation in the event of non-compliance with the apical limits.
With the development of new techniques of corono-apical preparation in continuous rotation such as "pressureless/crowndown", it is possible to prevent these incidents and the risks of bacteremia, which result from them. However, whatever the operator's vigilance, insofar as the canal must be cleaned up to the foramen while maintaining the apical patency, it is impossible to avoid even minimal instrumental overshoot and to exclude a foraminal crossing of bacteria.
Conclusion
The practice of endodontics cannot be conceived outside the medical context of the patient. This first determines the indication or contraindication for therapy, regardless of the feasibility and prognosis of endodontic treatment, depending on local factors.
When endodontic treatment is indicated, compliance with consensus recommendations and the application of good practice standards are essential for the practitioner to prevent infectious complications that can be life-threatening. Thus, the limits and biomechanical requirements of endodontic treatment argue in favor of antibiotic prophylaxis in patients at risk of infection from a distance.
Our study has shown that few dental surgeons know the precautions to be taken during endodontic treatment in heart patients. Better still, the practical situation showed that in reality, almost all of the practitioners interviewed found it difficult to correctly apply the prescribed recommendations
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