Posted at 10.11.2018
Your Uncle different then last time who may have been taking clopidogrel for several years approaches you, a oral student, to describe something to him. After two weeks of weariness and fever, his doctor lately diagnosed Infective Endocarditus by blood vessels ethnicities. An echocardiogram suggested a bicuspid aortic valve, and hearing the chest utilizing a stethoscope the physician could also find hook murmur. His doctor had asked him whether he had had any dental treatment recently. He accepted that he previously not seen a dentist for several years and a cursory investigation revealed dental caries and infection of the gums. His reason for avoiding the dental practitioner was because of bleeding in the mouth area following appointments.
Your Uncle was quizzical in regards to a amount of things and has called for your advice. He needs to know what information the echocardiogram and stethoscope can expose. Further, he wants to understand the bond between teeth's health and an individual's general condition. Specifically, what dental bacteria are present, what assignments do they play in oral biology, that they might lead to systemic problems, and what type of strategies could be used to prevent infection.
Working in your groups, generate a set of leaning outcomes for this topic and go back an individual duplicate by 23rd November by email to
These learning final results will be assessed, and meant learning outcomes went back to work with you with your statement.
Individually write a 2000 word manuscript in a technological manner addressing the learning benefits by 7th January (2013) and upload via QMplus. Please be aware that with QMplus enough time 'cut-off' is 23:55.
1. To recognize the connection between clopidogrel and abnormal bleeding gums.
2. To spell it out normal and excessive center valve formations.
3. To comprehend and describe the info that echocardiograms and stethoscope can provide regarding heart and soul function.
4. To describe how oral derived bacterial flora can colonise center valves.
5. To make clear why the center valves are susceptible to bacterial colonisation.
6. To spell it out when prophylactic antibiotics should be prescribed prior to dental treatments.
Bacteraemia is a disorder that is brought on when bacteria enters the bloodstream. When large amount of bacteria are present in the blood it can cause infections such as meningitis, pericarditis and endocarditus. People with heart and soul valve disorders, prosthetic joints, long-term diseases or weakened immune system are at increased risk of developing microbe infections during Bacteraemia. Teeth induced Bacteraemia is caused by minor accident from tooth cleaning or from oral procedures. Within the above problem established learning scenario we have been presented with 'our uncle' who have been taking Clopidogrel for a number of years and has now been identified as having Infective Endocarditis by blood cultures. Below I am going to increase on the proposed learning outcomes.
 FIG. 1Identify the bond between Clopidogrel and excessive bleeding gums.
Clopidogrel is an oral antiplatelet medicine which reduces the risk of blood clots creating. It works by protecting against Adenosine diphosphate (ADP), which causes platelets aggregation, from binding to its P2Y12 receptors on platelets and ceases activation of the glycoprotein GPIIb/IIIa organic. This protection reduces the probability of clots forming.  Source:Harvey, R; Champe, P "Lippincott illustrated reviews: Pharmacology", 4th edition. LWW: 2009.
Blood clots can be quite dangerous as they can cause blockages of arteries reducing the blood supply to a organ. A decrease in blood circulation to the brain or heart can cause a stroke or heart attack. This clarifies Clopidogrel's biggest use in patients who have had a recently available coronary attack or stroke; it can help to stop a reoccurrence. 
Taking Clopidogrel therefore can cause increased bleeding gums. When a blood vessels vessel ruptures when cleaning the teeth, through dental treatment or even by eating the gums will carry on bleeding for longer than common because of the lack of platelet aggregation. http://birthnow. com/wp-content/uploads/2012/05/Clopidogrel. gif
A healthy human being heart includes four chambers; two higher atria and two lower ventricles and four valves; two semilunar and two atrioventricular valves. The aortic and pulmonic valves are both semilunar valves and found in the arteries going out of the heart. The tricuspid and mitral valves will be the atrioventricular valves and are found between the atria and ventricles. 
Valves are made up of cusps which quite simply become flaps or leaflets that are accountable for the main one way blood circulation going into and out of the ventricle. Each valve has three leaflets, except the mitral valve, which only has two.
 FIG. 3Strong fibrous cords called chordae tendineae also called heart strings are attached to the papillary muscles found on the floor of the ventricles and they become anchors to avoid the valves from inverting back into the atria. Once the valve closes the papillary muscles deal and tenses the chordae tendineae to ensure the one way flow of blood. The valves are also reinforced and encircled by a fibrous skeleton called annuli that also operates as another anchor. http://www. tokresource. org/tok_classes/biobiobio/biomenu/transport_system/heart-valves. jpg
 FIG. 4Blood flows from the right and kept atria into the ventricles through the wide open tricuspid and mitral valves respectively. When the ventricles are full, the tricuspid and mitral valves shut. The ventricles now begin to written agreement and the pulmonic and aortic valves are forced open and bloodstream is pumped out. Blood from the right ventricle moves through the open up pulmonic valve into the pulmonary artery and carries deoxygenated blood to the lungs while blood vessels from the still left ventricle is oxygenated and travels through the open aortic valve in to the aorta and goes to all of those other body. This happens in a circuit, between heartbeats the ventricles will then relax, the semilunar valves will close and the atrioventricular valves will open up and allow bloodstream from the body and lungs to enter in the heart. http://mitral-valve-repair. com/wp-content/uploads/2011/01/heart-valves_heart-chambers. jpg
Heart valves can however malfunction in several ways. Abnormal heart valve formations fall into two main teams; Regurgitation and Stenosis. Regurgitation of the valves is when they neglect to close properly which in turn causes the backward leakage of blood vessels, this is happens consequently of cardiovascular system disease, rheumatic heart disease or because or bacterial and viral attacks including infective endocarditus. 
Mitral regurgitation is the most frequent heart and soul valve disorder being within 20% of parents over the age of 55. 
The backward leakage of bloodstream causes a rise in atrial pressure and the wall of the still left atrium will thicken by hypertrophy and possibly dilate. The pulmonary venous pressure will also climb which produces pulmonary oedema (substance build up in the air spaces). It also reduces the blood circulation to all of those other so the left ventricle will also become thicker and the heart rate will increase to maintain normal cardiac output. Medical indications include shortness of breath, chest aches and pains, dizziness and the pulse becomes faster.  
Stenosis of the center valves occurs when the valve is narrowed and obstructs the forward flow of blood, it is usually a result of a congenital defect which includes brought on the valve to become swollen or calcified.
 FIG. 5 Aortic Stenosis Aortic valve Stenosis is one of the most frequent valve disorders, when the valve doesn't open effectively there is reduced blood flow from the kept ventricle into the aorta. In severe instances the surfaces of the remaining ventricle will become wider as it must work harder to keep cardiac output in to the aorta. Medical indications include dizziness, breasts pain and an unusual pulse. If the problem worsens it can lead to heart failure and even more uncommonly to endocarditus. http://www. heart-valve-surgery. com/Images/aortic-stenosispicture-275. jpg
Aortic Stenosis grows as time passes because or turbulent blood circulation through the usually bicuspid aortic valve. Calcific valvular disease can be an inflammatory process and the largest cause of the disorder, calcification of the valve helps it be very stiff and makes it problematic for the valve to start easily. Again as with regurgitation rheumatic fever and endocarditis are also factors behind Stenosis.  
Valve deformations are more prevalent in the still left aspect of the heart and soul nonetheless they do also appear in the right hands aspect. Stenosis and regurgitation can affect all four valves and not only the two mentioned previously.  Other excessive valve formations are congenital heart and soul valve diseases which are those present at delivery when the aortic or pulmonary valves don't form properly.
Echocardiography is a non-invasive technique used to examine cardiac composition and function through ultrasound. Echoes are being used to listen for congestion in the lungs, unusual heartbeats and murmurs. 
There are various kinds echocardiograms; transthoracic (TTE) are the most common. A tool called a probe or transducer is positioned on the breasts and high rate of recurrence sound waves are used to produce sounds and images of the heart and soul. It picks up echoes of reasonable waves and transmits them as electrical impulses that happen to be then changed into 2D or 3D moving pictures on the screen. A Doppler echocardiogram shows the movements of blood. In case a clear picture cannot be formed a little amount of water can be injected via IV to give a much better picture. 
Echocardiograms show details of the chambers including size, size and width of the surfaces which helps to identify certain disorders including hypertension, the pumping function can be reviewed and this can show conditions such as cardiomyopathy. Echoes also improve diagnosis of heart and soul valve disorders including those mentioned previously. It identifies the basic buildings of the valve including thickness and movement and shows any abnormalities such as calcification and scaring. The Doppler will show any leakage through the center valves and when there is a limitation in blood flow.
Echoes of mitral regurgitation will show a dilated left atrium and kept ventricle and echoes of aortic Stenosis will show the thickened calcified leaflets.
In conditions of suspected endocarditis a transesophageal echo can be utilized instead showing high-quality images of the heart and soul and its own valves. It really is slightly more intrusive and an extended tube is passed on the oesophagus. 
A stethoscope is a non invasive diagnostic tool used to hear or auscultate a patient's heart, lungs, pulse and tummy. It can also be used to help check blood pressure by listening to blood flow recovery when the sphygmomanometer cuff is removed. The diaphragm is put on the patient's chest where it accumulates vibrations and amplifies them as sounds to the earpieces going via a hollow tube. http://upload. wikimedia. org/wikipedia/commons/3/3c/Stethoscope_(PSF). png
A healthy heart produces a dual whip or 'lub dub' with little other sound when the semi lunar valves open up and close. A stethoscope helps discover a heart and soul murmur making a whooshing sound after the heartbeat, this can point out serious other problems such as infective endocarditis. 
 FIG. 6 S Mutans adhering to surface of mitral valve Explain how oral derived bacterial flora can colonise heart and soul valves & Explain why the center valves are vunerable to bacterial colonisation.
Streptococcus mutans are a type of bacteria found in oral plaque of the mouth that is basically responsible for creating teeth decay and cavities via the procedure of demineralisation. However sometimes after dental care or from cleaning one's teeth if blood is revealed it can go into the bloodstream and cause bacteraemia. Diseased Aortic Valve
Endocarditis typically builds up on areas of the heart, that have become hard and sticky after sustaining endothelial harm after being at the mercy of turbulent blood flow. (In bicuspid valves blood flow is more turbulent and this creates a higher pressure making the top of valve rough plus more vunerable to bacterial colonisation). 
Platelets and fibrin put on the endochardium surface and form a system which the bacterias can put on; 'vegetation' is currently developed. This vegetation can damage the heart valves and affect how they open and close, or breakaway and cause problems in other areas of the body. The aortic and mitral valves of the remaining part of the heart are the most common to be influenced. S mutants are thought to be responsible for 50% of most bacterial endocarditus cases. Staphylococci found on the epidermis can also cause it. 
The risk of expanding endocarditis is increased in a person who has already acquired artificial heart and soul valves, general heart and soul valve conditions, congenital beginning problems, rheumatic fever and the ones with a lower life expectancy immune system.
The problem with when bacterias colonises heart and soul valves would be that the valves don't have a designated blood supply to them so white bloodstream cells are unable to fight the infection that is creating there.  Full-size image (41 K)
 FIG. 7 Transthoracic echocardiogram (a) and apical four-chamber view (b) demonstrating a well circumscribed vegetation measuring 2 - 1 cm, limited to the posterior mitral valve leaflet and impinging on the remaining atrium.
The term prophylactic antibiotics refer to when antibiotics receive prior to a meeting as a preventative strategy to illness. 'Where rheumatic fever continues to be common, control and reduction will prevent rheumatic heart disease and associated endocarditis. ' Recently people with heart valve conditions and manufactured valves were regarded as at high risk of expanding endocarditus when acquiring dental care and other surgical operations so cure of antibiotics, usually penicillin were given prior to the procedure involved. Today however this practice is questioned as there were no placebo trials conducted. The large range use of penicillin as a preventative strategy comes with hazards such as anaphylactic distress so now as advised by the Country wide Institute for Health insurance and Clinical Excellence (NICE) it is principally only wanted to those patients who have an infection beforehand and those with artificial valves.
In conclusion to this PBL I now understand that the presence of bacteria in the blood can have serious outcomes all around the body and not simply at the site of accessibility. In answer to 'my uncles' question about protecting against infection it might be worthwhile noting that meticulous oral and skin area hygiene is significant in stopping such attacks like endocarditis. In relation to oral hygiene a dental practitioner should be seen at least every 6 months so any issues that may be there can be solved before they develop further. Cleaning twice every day, flossing and keeping ones toothbrush clean are always that can prevent bacteraemia.