Indications for antibiotic prophylaxis, and algorithms for dental management after open and endovascular surgery in patients with aortic diseases

Abstract

As the population of patients with aortic prostheses continues to grow, it becomes increasingly vital to implement comprehensive and rigorous protocols for antibiotic prophylaxis during dental procedures. That ensures strict adherence to the updated guidelines in order to effectively prevent the risk of life-threatening infections associated with vascular grafts and stent-grafts, thus safeguarding patient outcomes over the long term.

Keywords: stent-graft, dentistry, recommendations, VGEIs, antibiotic prophylaxis

Introduction

Cardiovascular diseases (CVD) are the leading cause of death worldwide, including the rising incidence of aortic aneurysms.^{1, 2} An aortic aneurysm is defined as a dilation of the aortic cross-section by more than 50% of its normal diameter. Abdominal aortic aneurysms (AAAs) affect 2–8% of patients in developed countries and are mostly asymptomatic, with a high mortality rate of approx. 80% if the aneurysm ruptures.³

Recent advancement in radiological preventive examinations (e.g., the Healthy Aorta Program in Poland), along with the development of surgical techniques, material science and endovascular procedures, have led to an increasing number of patients reporting to vascular departments for treat­ment.^{4, 5} The two primary surgical approaches for treating AAAs are open aneurysm repair and endovascular aneurysm repair (EVAR). Both procedures involve the insertion of alloplastic material intended to restore or protect the pathologically altered segment of the aorta. Significant complications of such treatment are vascular graft or endograft infections (VGEIs), which can result from transient bacteremia related to various medical procedures, including dental procedures.^{6, 7, 8, 9, 10} Therefore, preoperative and postoperative dental consultations are essential to identify and eliminate potential odontogenic sources of infection. Unfortunately, there is limited data regarding antibiotic prophylaxis in patients with vascular grafts or endografts.

The present study aims to provide practical recommendations for the management and prophylaxis of infections in patients with vascular prostheses, with a focus on dental care.

Methods

Purpose of the guidelines

Current European and American guidelines lack specific recommendations for antibiotic prophylaxis during dental procedures for patients with vascular prostheses. The existing preventive strategies are primarily based on guidelines for infectious endocarditis. To fill this gap, a multidisciplinary team of vascular surgeons, maxillo­facial surgeons and dentists developed these guidelines to assist healthcare professionals in preventing infections in this high-risk group. The guidelines target dentists, maxillo­facial surgeons and other providers involved in the care of patients with vascular grafts, including those with grafts in the supra-aortic trunks, thoracic or abdominal aorta. They aim to ensure effective prophylaxis against VGEIs during and after dental procedures.

Authors

These guidelines have been developed by a multi­disciplinary team composed of experts in vascular surgery, maxillofacial surgery and dentistry. The collaborative effort ensures that the recommendations reflect a comprehen­sive and specialized approach to antibiotic prophylaxis in dental settings for patients with vascular prostheses, integrating expertise from multiple fields to address this specific clinical need.

Literature selection

The literature search for these guidelines utilized PubMed and Scopus, covering the period from January 2000 to December 2023. Studies were selected based on their peer-review status and relevance, following a hierarchy of evidence: systematic reviews and meta-analyses were prioritized, followed by randomized controlled trials (RCTs), observational studies and expert opinions.

Study protocol

These recommendations were prepared using the international Appraisal of Guidelines for Research and Evaluation (AGREE) Reporting Checklist (supplementary material, available from the corresponding author on reason­able request).

Recommendations

Management of the patient qualified for vascular treatment due to an aortic aneurysm

Before undergoing vascular treatment, it is essential for the patient to have a dental consultation that includes both a clinical examination and radiological diagnostics, such as a pantomographic X-ray or cone-beam computed tomography (CBCT). The patient must obtain a statement from a dentist, confirming the absence of odonto­genic foci. It is important to emphasize that a clinical dental examination alone is not sufficient for a complete assessment; a thorough radiological evaluation is neces­sary for surgical qualification.

Management of the patient after aortic surgery

According to the guidelines of the European Society for Vascular Surgery (ESVS),¹⁰ and the Society for Vascular Surgery,¹¹ antibiotic prophylaxis in the dental office is currently recommended after both open repair surgery with alloplastic vascular prostheses and EVAR with a stent-graft. It is also recommended before any dental procedures involving the manipulation of the gingival or apical regions of the teeth, or the perforation of the oral mucosa, including scaling and root planing, and endo­dontic treatment.^{10, 11}

The types of dental procedures with recommendations for antibiotic therapy in patients after vascular proc­edures are shown in Table 1. However, in the afore­mentioned guidelines, there are statements where antibiotic prophylaxis is required for certain dental procedures, but no information is provided about the type and exact dosage of antibiotics. Additionally, these guidelines are based on the American College of Cardiology/American Heart Association (ACC/AHA) guidelines for patients with endocarditis.¹²

Based on the previously published guidelines,^{10, 11, 12, 13} recent literature on infectious endocarditis, VGEIs and oral bacterial flora,^{14, 15, 16, 17} and clinical experience, the authors of this article have prepared recommendations regarding antibiotic prophylaxis for patients with vascular pros­theses (Table 2 and Table 3).

Discussion

With over 35 million pulsatile movements per year, the aorta presents a challenging environment for the im­plantation of vascular prostheses and stent-grafts, which must endure over time without complications, such as endoleaks, false aneurysms, or one of the most challenging complications, VGEIs. As the number of patients treated with aortic prostheses or stent-grafts continues to rise, particularly in an aging population, it is crucial to develop management algorithms for this patient group, especially in the dental office, to eliminate potential sources of infec­tion.¹⁸

The etiology of prosthetic infections, including those caused by bacteria of dental origin, is complex and closely related to the unique microenvironment where the prostheses are implanted, namely the aorta and the aortic aneurysm itself. The aorta, being a large-diameter artery with wave-like variations in blood flow velocity, creates challenging conditions for graft implantation. The mate­rial of the endograft is subjected to tension stress and constant pulsatile movements, which can cause micro­movements. These micromovements may lead to the displacement of the stent-graft, resulting in blood leakage between the stent-graft and the vessel wall, or even the rupture of the endograft. Consequently, a reservoir of extravasated blood can form along the outer wall of the prosthesis/graft, which may serve as a breeding ground for bacteria, leading to the persistent superinfection of the vascular prosthesis.¹⁹

Abnormal epithelialization can lead to the exposure of alloplastic material within the aortic lumen, thereby increasing the risk of infection. Abnormalities in epithelia­lization within the graft are confirmed through the forma­tion of a very thin layer of neointima and/or the segmental exposure of graft components, such as the wire elements of the crown, abutments and fragments of the covering material. The exposed covering material of the prosthesis and the stent-graft provides a potential site for bacterial accumulation.¹⁸

In the examinations of the explanted prostheses and stent-grafts, the bacterial contamination of the pros­thesis wall was confirmed, particularly on the external side (aneurysm sac side). For the prostheses made of poly­tetrafluoroethylene (PTFE) and polyethylene terephthalate, bacterial presence was found in 84.3% and 94.7% of cases, respectively, as determined by electron microscopy.¹⁸

Recent studies indicate that up to 58% of VGEIs are attributed to Gram-positive bacteria, including Staphylococcus aureus, enterococci and coagulase-negative staphylococci. In the oral cavity, Gram-positive bacteria, predominantly streptococci, are most common. Therefore, β-lactams, including penicillins and cephalosporins, as well as macrolides, are recommended for the prevention of VGEIs. β-lactams should be considered the first-line treatment due to their efficacy against the predominant bacterial pathogens involved. Additionally, a single administration of antibiotics for prophylaxis provides coverage for approx. 4 h.^{10, 20, 21, 22, 23, 24, 25}

The radiological signs of prosthetic infection include the presence of fluid around the vascular prosthesis and gas bubbles in the tissue adjacent to the prosthesis or the aortic aneurysm sac in the case of EVAR, particularly when contamination involves anaerobic bacterial flora.²⁶

During a single procedure, the removal of the vascular prosthesis typically requires reconstruction with an extra-anatomical bypass or the use of the previously contaminated environment to restore blood flow distal to the operated area. This necessity increases the risk of subsequent infection. Additionally, patients initially deemed suitable for endovascular surgery often cannot be considered for open vascular prosthesis replacement due to their overall condition, comorbidities or medications.²⁷ As a result, the only remaining therapeutic options are chronic antibiotic therapy and the drainage of the periprosthetic abscess. However, such treatment may have many adverse side effects and is often ineffective. Therefore, the importance of eliminating any risk factors for vascular prosthesis infection cannot be overstated.

Dental procedures are associated with transient bactere­mia. The guidelines from vascular surgery societies for managing aortic prostheses and stent-grafts emphasize the need for antibiotic prophylaxis in all dental proce­dures that involve the disruption of the oral mucosa and periapical surgery, including endodontic treatment, as well as scaling and root planing.

It is important to note that current vascular surgery guidelines do not provide specific recommendations regarding the optimal duration of antibiotic prophylaxis, nor do they explicitly address whether prophylaxis should be continued until the full epithelialization of the vascular prosthesis is achieved. This uncertainty may be partly attributed to the previously mentioned abnormal and often incomplete epithelialization of vascular grafts. In contrast, cardiological guidelines recommend a prophylactic period of 6 months. This discrepancy highlights a key difference between vascular and cardiological guidelines, owing to the previously discussed epithelialization issues associated with aortic prostheses.¹⁸

The European and American guidelines do not specify the exact doses of antibiotics to be used for dental pro­phylaxis.^{10, 11, 28} They only suggest the use of prophylaxis (recommendation level 1B), referencing practices from infectious endocarditis. The authors of this article based their recommendations on the general vascular surgery guidelines for antibiotic prophylaxis in dentistry related to infectious endocarditis, as well as on the Polish recommenda­tions regarding antibiotic groups and the recommended doses from the National Antibiotic Program.¹³ However, given recent publications questioning the necessity of antibiotic prophylaxis for dental procedures in the context of infectious endocarditis,²⁹ it is crucial to continually monitor this topic and update guidelines in accordance with the latest evidence.

There is no contraindication to conservative dental treatment in patients with implanted prostheses or stent-grafts, provided that the oral mucosa is not compromised. The guidelines do not recommend antibiotic prophylaxis for the local anesthesia of non-infected tissues.³⁰

Endodontic treatment is essential for patients with vascular prostheses or stent-grafts, as these patients are at increased risk of infection due to potential bacteremia during procedures. Vascular surgery guidelines stress the importance of antibiotic prophylaxis to mitigate this risk, which arises from bacteria potentially entering the periapical area during canal preparation, whether manual or mechanical, and through the irrigating solutions or sealing materials extending beyond the apex.³¹ To reduce the risk of infection, endodontic treatment should adhere to rigorous protocols. Using a rubber dam is crucial for maintaining a sterile environment, and efforts should be made to complete the treatment in a single session to limit exposure to pathogens. Additionally, the radiological assessment of the endodontically treated teeth is necessary to ensure treatment success and monitor for any complica­tions.³¹

While endodontic treatment is generally preferred over extraction, the long-term prognosis of the tooth must be carefully evaluated. Teeth with extensive periapical lesions or questionable restorability are at high risk of be­coming sources of chronic infection. If the long-term survival of the tooth is uncertain, its potential to harbor infection should be weighed, and the patient must be informed of the risk. The choice between endodontic treat­ment and extraction should be based on a comprehensive assessment of the condition of the tooth and the likelihood of a successful, infection-free outcome. If extraction is necessary, antibiotic prophylaxis is strongly recommend­ed to prevent the introduction of pathogens into the bloodstream during the procedure.³¹

The decisions regarding modifications to antiplatelet or anticoagulant therapy must be made in close collabora­tion with a vascular surgeon to avoid compromising systemic health and increasing the risk of postoperative complications. Tokarek et al. noted a concerning trend where dentists independently modify or discontinue these therapies without proper consultations, potentially leading to adverse outcomes.³² Therefore, it is essential that dentists adhere strictly to the established guidelines and work closely with the patient’s medical team to ensure the best possible treatment outcomes and minimize the risk of complications.³³

Patients with branched stent-grafts require special consideration. This innovative endovascular procedure involves reconstructing the aorta and its branches, necessitating the implantation of multiple vascular pros­theses. Due to the novel nature of this procedure and the absence of specific guidelines for this patient group, extra caution is required during dental procedures. It is crucial to address any potential inflammatory foci that may arise after the implantation of a branched stent-graft, as infection could complicate the situation significantly, given the difficulty of replacing or removing the implanted prostheses.

Currently, researchers recommend antibiotic pro­phylaxis for all dental procedures that involve the disruption of the oral mucosa. If odontogenic inflammation is pre­sent, the source of infection should be addressed and anti­biotic therapy should be extended by 3–5 days based on the patient’s clinical condition. Additionally, close post­operative monitoring is essential, as potential sources of infection pose a direct risk of prosthesis infection, sepsis, and potentially, death.

In the opinion of the authors, prolonged postoperative antibiotic therapy is indicated in cases of complicated peritoneal inflammation, such as those with concomitant purulent exudation, massive inflammatory infiltration, peritoneal abscess, or the infiltration of the surrounding soft tissues. This approach aims to limit the existing bacteremia and prevent the bacterial contamination of the vascular prosthesis; however, further studies are required to validate its effectiveness.

Qualification for implant procedures in patients with implanted vascular prostheses or stent-grafts should be always carefully considered by a dentist. Patients need to be informed about potential complications, including local inflammation immediately after surgery and the development of chronic inflammation in the implant area. While there are no available studies specifically addressing peri-implantitis in this patient group, various therapeutic options should be presented to the patient, including both fixed and removable prostheses. Currently, there are no clear guidelines for the treatment of this patient group, and this type of procedure is not specifically addressed within the guidelines of vascular surgery societies.

Patients who have been diagnosed and treated for a vascular prosthesis infection should be considered at particularly high risk.

While hygienization in the dental office is typically performed by qualified hygienists, eligibility for such procedures should be assessed by a dentist. This is crucial for this patient group. Scaling and root planing, in particular, is an indication for antibiotic prophylaxis, and this requirement must not be overlooked during patient prepara­tion.³⁴

Nonetheless, an article by Özdemir Kabalak et al. underscores the fact that despite the realized need for anti­biotic prophylaxis, barriers such as inconsistent adherence to guidelines, the lack of education and varying practices in dental settings continue to impede rational antibiotic use.³⁴ The effective management of these issues requires a standardized approach to prophylaxis and improved adherence to guidelines to minimize the risk of anti­biotic resistance and optimize patient outcomes. Thus, the continuous monitoring and updating of guidelines in line with recent literature are essential to address the evolving challenges in dental care for patients with aortic pros­theses and stent-grafts.

Strengths and limitations of the guidelines

The guidelines are strengthened by a comprehensive literature review from January 2000 to December 2023 across multiple reputable databases, ensuring an up-to-date evidence base. A hierarchical approach prioritizing systematic reviews, meta-analyses and RCTs adds reliability, while a multidisciplinary team brings diverse expertise to the recommendations. However, limitations include limited specific data on antibiotic prophylaxis for patients with vascular grafts or endografts in dental settings, leading to reliance on broader guidelines. Additionally, while the guidelines are built on the existing strategies for infectious endocarditis, they may not fully address the unique needs of patients with vascular prostheses.

Conclusions

In conclusion, as the number of patients with vascular diseases, including aortic conditions, continues to grow, it is crucial to address the evolving needs of this popula­tion. Increased patient awareness regarding oral health will likely lead to a higher demand for dental procedures. Ensuring that these procedures are performed safely and in accordance with current standards is essential to prevent complications and maintain optimal outcomes. The guidelines provided emphasize the importance of tailored antibiotic prophylaxis, and highlight the need for ongoing research and updates to refine these strategies. Adhering to these recommendations will help manage the risk of infection effectively and enhance patient care in this high-risk group.

Potential resource implications

Implementing these comprehensive recommendations may increase demands for healthcare resources, as the emphasis on preoperative and postoperative dental con­sultations could lead to additional costs and time commit­ments, requiring better coordination between dental and vascular care teams. Enhanced antibiotic prophylaxis protocols might raise procedure costs and necessitate ongoing monitoring. Additionally, healthcare providers may need further training, potentially involving workshops or updated materials. While these preventive measures could reduce infections and improve outcomes, they may also impact overall healthcare resource utilization and costs. Integrating these guidelines into clinical workflows may require administrative adjustments and new protocols, making effective planning crucial to addressing these resource implications while aiming to enhance patient outcomes and prevent complications.

Update of the guidelines

To ensure the continuity and relevance of these guidelines, the authors emphasize the need for their inclusion in the forthcoming European as well as Polish recommenda­tions for dental prophylaxis and antibiotic therapy.