P R E V E N T I O N O F I N F E C T I V E E N D O C A R D I T I S I N C H I L D R E N

A R T I C L E

Spec Care Dent is t 29(4 ) 2009 175©2009 Special Care Dentistry Association and Wiley Periodicals, Inc.doi: 10.1111/j.1754-4505.2009.00087.x

A B S T R A C TThis preliminary study assessed the

knowledge and practices of dentists in

the prevention of infective endocarditis

(IE). The study included 21 dentists

working at two public hospitals in Brazil

who cared for children with special

needs who also have cardiac conditions.

The data from a semistructured interview

were processed for qualitative and

quantitative analysis. All subjects

defined IE correctly. Most subjects

(81%) said they had treated patients

with a previous history of IE and 7 (33%)

stated that many guardians seemed to

be afraid to mention that their child had

a previous history of IE. The main risk of

infectivity was the oral cavity according

to 16 subjects (76%). Nine subjects

(43%) considered a dental procedure

involving any amount of bleeding as

being a risk, and periodontal/endodontic

treatments were mentioned by 5 (24%)

as procedures that needed antibiotic

prophylaxis. As for prophylactic treat-

ment, only 7 subjects (33%) said they

followed the American Heart Association

guidelines. The authors concluded that

the subjects’ knowledge and practices

in preventing IE were inadequate.

Knowledge and practices of dentists in preventing infective endocarditis in children

Ana Claudia Coutinho, DDS, MSD;1 Gloria Fernanda Castro, DDS, MSD, PhD;2

Lucianne Cople Maia, DDS, MSD, PhD2*

1Post-graduate Student; 2Associate Professor in Pediatric Dentistry, Department of Pediatric Dentistry

and Orthodontics, School of Dentistry, Federal University of Rio de Janeiro, Brazil.

*Corresponding author e-mail: rorefa@terra.com.br

Spec Care Dentist 29(4): 175-178, 2009

Under physiological circumstances inindividuals with poor oral hygiene,organisms may gain entry into the bloodstream.4,5 This transient bacteremia isusually cleared by the host’s defenseswithin 10 minutes.9,10 Movement of thetooth in its socket during function maycause microscopic damage to the gingivalvessels.3,5 For this reason, the AHA andEuropean guidelines8,10 highlighted theimportance of maintaining control of thebiofilm through professional and dailyoral home care, to avoid frequent bac-teremias. Nevertheless, there seems to bea dilemma about which dental proce-dures and under what circumstancessignificant risk occurs. The risk of aller-gic reactions to antibiotics and thedevelopment of resistant bacterial strainsin susceptible patients with cardiac con-ditions is real.10,11

The aim of this preliminary study wasto evaluate the knowledge and practicesof dentists who cared for children andadolescents who had cardiac conditions,to evaluate how they used antibiotic prophylaxis, and how they preventedinfective endocarditis from the oral cavity.

MethodsSample selectionThe local ethics committee of the FederalUniversity of Rio de Janeiro authorizedthis study. The subjects invited to partici-pate in this study comprised all 21dentists working at two public hospitals,to which children and adolescents whohave special needs and who also havecardiac conditions, are referred for dental treatment in Rio de Janeiro, Brazil.

I n t r oduc t i onInvasive dental procedures have often been regarded as the main cause of infectiveendocarditis (IE). The prevention of IE has been debated and has remained controversialin the dental profession.1-4 There is an ongoing debate5-7 about which dental procedureswarrant antibiotic prophylaxis (AP). The latest recommendations stress using AP priorto dental procedures associated with significant bleeding in patients with high and moderate risk of endocarditis. These include periodontal and/or periapical infections,directly proportional to the incidence and magnitude of bacteremias they produce.4,8

The updated recommendations of the American Heart Association (AHA)4 clearlystates that most cases of IE are not attributable to invasive dental procedures. It usuallydevelops in individuals with previous IE, complex cyanotic congenital heart disease,and prosthetic heart valves.

KEY WORDS: knowledge, preven-

tion, oral health, infective endocarditis,

children, dentists, antibiotic prophylaxis

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Inclusion criteria required the dentists tohave worked with children with specialneeds and cardiac conditions for at least1 year.

Data collectionThe data were collected by means of apretested semistructured interview, with12 open-ended questions (Figure 1) thatwere taped and transcribed by theauthor. The aim of the interview was toobtain information from the subjectsabout infective endocarditis and whichdental procedures they considered poseda risk, such as the time frame of infectiv-ity; how and when they prescribedantibiotic prophylaxis, the medicationsand dosage they chose; the explanationand counseling of guardians concerningoral health and IE prevention; and theiropinion on the risk of bacterial resistanceand anaphylaxis.

Statistical and interview analysisThe data were processed by SPSS 11.0and a descriptive analysis was usedwhenever appropriate.

Resu l t sAll the dentists from both public hospitals(n � 21) agreed to participate in the study.The dentists were aged from 28 to 57 years(mean age 43.65, SD 8.91). The majority(72%, n � 15) had undergone postgradu-ate training and 12 (57%) had cared forspecial needs children, some with complexheart diseases, for more than 15 years.

All subjects defined IE properly,pointing out that it was an infection ofthe endocardium, and identified the riskthat patients with an underlying cardiacdefect might face whenever exposed tobacteremia. When asked to identify theindividuals with the highest risk ofacquiring IE, almost all subjects (86%, n � 18) mentioned individuals withcongenital heart diseases, rheumaticfever, and prosthetic heart valves. Onesubject (5%) related IE to sickle cellanemia, one mentioned tonsillitis, andanother reported that IE could affect anyperson, even if they had no history ofprevious cardiac disease.

Most subjects (81%, n � 17) saidthey had treated patients with a previous

history of IE, although 7 (33%) statedthat many guardians seemed to be reluc-tant to mention a previous episode of IE,because they were afraid the dentistmight be unwilling to treat their child.The site of infectivity was declared to bethe oral cavity by 16 subjects (76%); 2(10%) also pointed out that the tonsilswere a major point of entry. A dentalprocedure involving any amount ofbleeding was considered by 9 (43%) asbeing a risk for IE in need of AP, while 2(10%) stated that they prescribed AP forany cardiac patient on all occasions,including examinations, irrespective ofthe cardiac problem the child mighthave. Five subjects (24%) mentionedperiodontal and endodontic treatmentsas procedures that could pose a majorrisk, and only 3 (14%) declared that adental procedure that caused bleeding, inassociation with the presence of gingivi-tis, should always be covered with AP formoderate- or high-risk patients.

With regard to prophylactic treat-ment, only 7 subjects (33%) stated thatthey followed the AHA guidelines (withspecific antibiotic and dosage); one-thirdmentioned that they always referred thepatient to the cardiologist, because theAP prescription was the physician’sresponsibility. Another one-third eithernamed different antibiotics or used inade-quate or incorrect doses before and afterdental procedures. When asked whetherthey offered guardians and patients anexplanation about the risk of bacteremiaassociated with the patient’s inadequateoral health, as well as about the reasonfor the prescription of AP for some dentalprocedures, only 33% emphasized theneed for giving this explanation. Morethan half of the subjects interviewed(52%, n � 11) said these patients wereusually informed by their cardiologists; 3 (14%) mentioned lack of time duringconsultation to go over such details.

The appropriate intervals betweendental procedures that required an APprescription were as follows: 10 dentists(48%) indicated 7 days; 6 (29%) saidwhenever necessary; and 5 (24%) recom-mended 14–15 days. Bacterial resistanceand anaphylaxis were considered a possi-ble problem by only 3 of the dentists

Figure 1. Questions of the interview applied to dentists.

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(14%), although they did not considerthemselves responsible if any complica-tion should arise. Two of the dentists(10%) mentioned fear of legal claims ifthere was an onset of IE right after adental procedure that was not covered byinsurance. Seven subjects (33%) declaredthat they performed a combination ofprocedures at the same consultation toavoid overuse of AP, and 12 (57%) neverconsidered it a problem to use AP.

Neither of the two hospitals usedchlorhexidine rinses for the patientsbefore dental procedures, nor did thedentists have any protocol or guidelinesestablished by the institutions as a refer-ence guide.

Di scus s i onSeveral studies1,3,6,7,10,12 have reportedcontroversies and deficiencies in theknowledge and consequently in the prac-tice of dentists and their use of antibioticprophylaxis for preventing infectiveendocarditis in cardiac patients.Preliminary research suggests that thisissue may have been overlooked by thedental profession, during theireducation.13 Among the dentists weinterviewed for the current study, 67%declared that they did not give patientsadvice about the dangers of inadequateoral hygiene, IE, and how AP may pro-tect the heart during a dental procedure.The gap in dental education seems tohave multiple causes: it comes from aprobable lack of knowledge about thepatient’s cardiac condition, coupled withindifference or lack of concern regardingthe importance of continuing educationof current protocols. But more funda-mental, it might be due to a lack ofpatient/guardian education concerningthe importance of and need for oralhome care, which has been previouslyreported1,14 and which we also found. Indental practice, it is extremely importantto provide the patient with informationabout the mechanisms that cause bac-teremias of oral origin and the dangers ofAP, which probably outweigh the risk ofIE.7 It is important to emphasize that thereal risks of transient bacteremias arethose which occur on a daily basis, if

there is inadequate oral hygiene.10-12,15,16

In comparison with other stud-ies,6,13,15 our study found a low level ofcompliance with the latest guidelines, asonly 33% of the dentists followed anupdated protocol; these subjects may notbe representative of all dentists, but theyrepresent the city’s primary referencesource for dental treatment of cardiacpatients. The dentists’ mean age wasolder, which might explain their lack ofknowledge about current guidelines.Moreover, neither of the two hospitalshad an IE protocol, and most dentistsrelied on the hospitals’ cardiologists forAP prescription guidance. The results ofthis preliminary study are in agreementwith some other reviews,9,12,17 which havesuggested that many dentists do not con-sult IE guidelines. Current protocols havebeen variably applied.6,9,10 The misuse ofantibiotics and their overprescription forprophylaxis is a major concern, as is thelack of knowledge of cardiologists anddentists in failing to instruct patients howto effectively prevent dentally inducedbacteremias. Those dentists who followedthe AHA guidelines were the same den-tists who emphasized the importance ofeducating the patient about oral healthand the risk of everyday bacteremias.They also said they avoided the frequentuse of AP, and so carried out severaldental procedures at the same visit, withintervals of at least 14 days. These den-tists considered it their responsibility toconsult the current guidelines, regardingnot only AP prescriptions, but also howto prevent and treat IE.

Recent articles and editori-als1,7,9,10,12,15,18,19 debate the real efficacyand health risks of the use of AP fordental procedures. Frequently, it has beenstated7,12,20,21 that there is no scientificevidence of an existing link betweendental treatment and IE, with dentist-induced bacteremias causing 4% or less ofall cases of IE. Moreover, the chance ofbacteremia arising from normal routineactivities may be directly proportional tothe condition of gingiva and the oralflora,22 which has been estimated to be1,000–8,000 times greater than from adental procedure.7 Unfortunately, 14% ofthe dentists in our study indicated that

risk should be considered only whenbleeding was associated with unhealthygingival tissues. Again, 43% of the den-tists interviewed considered any amountof bleeding a risk for IE and 24% alsoregarded all periodontal and endodonticprocedures a risk. There is considerableevidence that except for tooth extractionand intraligamental analgesia,1 a bac-teremia may occur whenever there isclinically discernible bleeding, which hasnot been found to be a good predictor ofodontogenic bacteremia.5 Furthermore,there is evidence that AP does not pre-vent bacteremia, but does decreasemicrobial adherence to damaged cardiacvalves and eliminates bacteria after theirattachment to valves.12 In accordancewith recommendations by the AHA4,10

and the European guidelines,8 procedurescausing bleeding are limited to surgicalprocedures, such as one or multipledental extractions, raising of mucope-riosteal flaps or surgical endodontics. APis not recommended for restorative den-tistry. Periodontal (scalings) andendodontic (limited within the root apex)procedures were not found to causeextensive bacteremias.23-25 Therefore, thehealth of the dentogingival complex maybe of greater importance.3,5,7

Although our study was based on asmall, localized sample, two aspects ofsome of the subjects’ statements broughtup the “possibility of litigation.” As foundin this and other studies,17,26 the hesita-tion that guardians had in telling dentistsabout their children’s real cardiac condi-tion, such as a previous IE, shows howunaware parents are of the consequencesof this omission, which could be fatal forthe child. Some dentists may find it easiernot to contest the cardiologist’s AP pre-scription, or inquire about the patient’sheart condition, or give the guardians anyadvice on how to maintain the child’s oralhealth to prevent daily bacteremias. Thespectrum of legal claims reported by twodentists in this study and corroborated inother reviews7,12 shows the superficialitywith which IE of oral origin has beenregarded, despite increasing scientificefforts to provide guidelines for the use of AP for cardiac patients about toundergo dental procedures. Dentists are

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responsible for their patients’ oral healthand maintenance; most important, theyare responsible for educating high-riskpatients about how the biofilm, if notproperly removed daily, builds up intogingivitis which may be a danger to thepatient, not only during dental proce-dures, but constantly in his/her routinephysiological function such as eating and chewing.

Conc lu s i onThe knowledge of the dentists in thesurvey was inadequate. Based on theseresults, it appears that more needs to bedone to improve the dissemination ofknowledge about antibiotic prophylaxisamong dentists. Furthermore, research isstill needed to accurately determinewhether dental procedures are dangerousfor a specific group of cardiac patients,and which procedures are significant.However, there seems to be a consensusthat there is an overuse of antibiotics forprophylactic purposes partly due to anegligence of acquiring the necessaryknowledge of current infective endocardi-tis protocols. These, in turn, need to bebetter clarified and disseminated. It is thedentist’s responsibility to ensure the ade-quacy of the patients’ oral health beforeany elective treatment procedure, as wellas to inform guardians/patients about therisk of oral diseases and adverse reactionsto antibiotics. Oral health conditions andrelated risk procedures can only be evalu-ated by the dentist, as the patient’scardiac risk can only be diagnosed by thecardiologist. Both health professionalshave the obligation to know current pro-tocols and use their own clinicaljudgment for the prevention of infectiveendocarditis in their at-risk patients.

Re fe r ences1. Wilson W, Taubert KA, Gewitz M, et al.

Prevention of infective endocarditis.

Guidelines from the American Heart

Association, Outcomes Research

Interdisciplinary Working Group. April,

2007. Available at http://circ.ahajournals.org/

cgi/content/abstract/CIRCULATIONAHA.

106.183095v1.

2. Knirsch W, Hassberg D, Beyer A, et al.

Knowledge, compliance and practice of

antibiotic endocarditis prophylaxis of

patients with congenital heart disease.

Pediatr Cardiol 2003;24:344-9.

3. Roberts GJ, Gardner P, Longhurst P, Black A,

Lucas VS. Intensity of bacteraemia associated

with conservative dental procedures in chil-

dren. Br Dent J 2000;188:95-8.

4. Wilson W, Taubert KA, Gerwitz M, et al.

Prevention of infective endocarditis: a guide-

line from the American Heart Association

Rheumatic Fever, Endocarditis, and

Kawasaki Disease Committee, Council on

Cardiovascular Disease in the Young, and

the Council on Clinical Cardiology, Council

on Cardiovascular Surgery and Anesthesia,

and the Quality of Care and Outcomes

Research Interdisciplinary Working Group.

Circulation 2007;116:1736-54.

5. Roberts GJ. Dentists are innocent!

“Everyday” bacteremia is the real culprit: a

review and assessment of the evidence that

dental surgical procedures are a principal

cause of bacterial endocarditis in children.

Pediatr Cardiol 1999;20:317-25.

6. Carmona IT, Dios PD, Posse JL, et al.

Chemoprophylaxis of bacterial endocarditis

recommended by general dental practition-

ers in Spain. Med Oral 2004;9:56-62.

7. Pallasch TJ. Antibiotic prophylaxis:

problems in paradise. Dent Clin North Am

2003;47:665-79.

8. Horstkotte D, Follath F, Gutschik E, et al.

The task force of the European Society of

Cardiology. Guidelines on the prevention,

diagnosis and treatment of infective endo-

carditis. Eur Heart J 2004;25:267-76.

9. Singh J, Straznicky I, Avent M, Goss AN.

Antibiotic prophylaxis for endocarditis:

time to reconsider. Aust Dent J 2005;(50

Supp):S60-8.

10. Bashore TM, Cabell C, Fowler V Jr. Update

on Infective Endocarditis. Curr Probl Cardiol

2006;31:274-352.

11. Martin M. Is there a link between tooth

brushing and infective endocarditis? Int Dent

J 2003;53:187-90.

12. Seymour RA, Lowry R, Whitworth JM,

Martin MV. Infective endocarditis, dentistry

and antibiotic prophylaxis: time for a

rethink? Br Dent J 2000;189:610-6.

13. Badoual T, Lellouche N, Bourraindeloup M,

et al. Pathologies et soins dentaires dans le

cadre des affections cardiovasculaires:

mythes, croyances et réalités. Arch Mal

Couer Vaiss 2003;96:637-44.

14. Lowry RJ, Maunder P, Steele JG, et al. Hearts

and mouths: perceptions of oral hygiene by

at-risk heart surgery patients. Br Dent J

2005;199:449-51.

15. Lockhart PB, Brennan MT, Fox PC, Norton

HJ, Jernigan DB, Strausbaugh LJ. Decision-

making on the use of antimicrobial

prophylaxis for dental procedures: a survey

of infectious disease consultants and review.

Clin Infect Dis 2002;34:1621-6.

16. Tomás-Carmona I, Diz-Dios P, Limeres-Posse J,

González Quintela A, Martínez Vázquez C,

Castro Iglesias A. An update on infective endo-

carditis of dental origin. J Dent 2002;30:37-40.

17. Basilio RC, Loducca FE, Haddad P. Medical

dental prophylaxis of endocarditis. Braz J

Infect Dis 2004;8:340-7.

18. Durack D. Antibiotics for prevention of

endocarditis during dentistry: time to scale

back? Ann Intern Med 1998;129:829-31.

19. Lockhart PB, Brennan MT, Kent L, Norton

KJ, Weinrib DA. Impact of amoxicillin pro-

phylaxis on the incidence, nature and

duration of bacteremia in children after

intubation and dental procedures.

Circulation 2004;109:2878-84.

20. Strom BL, Abrutyn E, Berlin JA, et al. Dental

and cardiac risk factors for infective endo-

carditis. A population-based, case-control

study. Ann Intern Med 1998;129:761-9.

21. Pallasch TJ. A critical appraisal of antibiotic

prophylaxis. Int Dent J 1989;39:183-96.

22. Tzukert AA, Leviner E, Sela M. Prevention

of infective endocarditis: not by antibiotics

alone. A 7-year follow-up of 90 dental

patients. Oral Surg Oral Med Oral Pathol

1986;62:385-8.

23. Baumgartner JC, Heggers JP, Harrison JW.

The incidence of bacteremias related to

endodontic procedures I. Nonsurgical

endodontics. J Endod 1976;2:135-40.

24. Baumgartner JC, Heggers JP, Harrison JW.

Incidence of bacteraemia related to

endodontic procedures II. Surgical endodon-

tics. J Endod 1977;3:399-402.

25. Kinane DF, Riggio MP, Walker KF,

MacKenzie D, Shearer B. Bacteraemia

following periodontal procedures. J Clin

Periodontol 2005;32:708-13.

26. Buckingham JK, Gould IM, Tervitt G,

Williams S. Prevention of endocarditis: com-

munication between doctors and dentists. Br

Dent J 1992;172:414-5.

scd_087.qxd 6/25/09 6:23 PM Page 178