Infective Endocarditis Caused by Oral Microorganisms and Entrance Door and Previous Dental Procedures: Does a Relationship Exists?

A B S T R A C T

There are no recent studies that have evaluated the epidemiological relationship between dental manipulations the etiology of IE by these microorganisms, basically Streptococcus viridans. Our objective is to analyse the relationship between these variables and the possible therapeutic implications. For this, we have analysed a prospective single-center series of IE in patients not addicted to parenteral drugs collected and followed between 1987 and 2018. 403 cases of native and late prosthetic IE were diagnosed and followed up in our center. Of them, 91 were produced by oral streptococci (22.6%). The percentage of this microorganism has remained constant throughout the 30 years (24.8% of the cases from 1987-1997, 25% of those from 1998-2007 and 19.1% from 2008-2018. Although there was a history of dental manipulation in a greater proportion in cases of IE due to Streptococcus viridans (24% vs. 6.5%, p <0.001), in most cases due to Streptococcus viridans (76% of them) there was no previous dental manipulation. In these cases, the infection may be due to the usual daily manipulations of the mouth (brushing, dental floss) or periodontal disease. Given this low sensitivity, it cannot be ruled out that IE is caused by this microorganism in the absence of a history of visiting the dentist, with the implications for empirical antibiotic treatment that this entails.

Keywords

Infective endocarditis, streptococcus viridans, dental procedures

Introduction

The classic pathogenesis of infective endocarditis (IE) is based on the infection of a previous cardiac lesion by microorganisms originating from bacteremia produced through an entrance door from outside the bloodstream, the typical example being the passage of bacteria from the microoral flora produced during dental procedures and manipulations [1]. This is the basis of the recommendation for endocarditis prophylaxis [2]. However, there are no recent studies that have evaluated the epidemiological relationship between dental manipulations and visits to the dentist and the etiology of IE by these microorganisms, basically Streptococcus viridans. Our objective is to analyse the relationship between these variables and the possible therapeutic implications.

For this, we have analysed a prospective single-center series of IE in patients not addicted to parenteral drugs collected and followed between 1987 and 2018. The diagnostic criteria of Von Reyn, Durack and the European Society of Cardiology were used, depending on the time [2, 3]. A history of a visit to the dental office, with orodental procedures, in the 6 months prior to the diagnosis of IE, was prospectively collected in all cases of IE, and this variable was correlated with the causative microorganism. Due to their different pathogenesis, early cases of prosthetic IE were excluded.

Between 1987 and 2018, 403 cases of native and late prosthetic IE were diagnosed and followed up in our center (in addition, there were 59 early prosthetic IE). Of the 403 cases, 91 were produced by S. Viridans (22.6%). The percentage of this microorganism has remained constant throughout the 30 years (24.8% of the cases from 1987-1997, 25% of those from 1998-2007 and 19.1% from 2008-2018, NS) (Figure 1).

Figure 1: Proportion of endocarditis caused by Streptococcus viridans in our hospital during the study period.

Although there was a history of visiting the dentist and oral manipulation in a greater proportion in cases of IE due to S. viridans (24% vs. 6.5%, p <0.001), in the vast majority (76%) of cases due to S. Viridans there was no previous dental manipulation, while up to 6.5% of IE due to other microorganisms did. Furthermore, 3 cases of early prosthetic IE were caused by S. viridans, with no history of visiting the dentist (5.1% of all early prosthetic IE). Thus, the history of a visit to the dentist had a sensitivity of 24%, a specificity of 93%, a positive predictive value of 52% and a negative predictive value of 19% to identify cases of IE due to S. viridans. There were no differences between the clinical characteristics, treatment or prognosis of S. viridans IE cases with or without a history of visits to the dentist (Table 1).

Table 1: Characteristics of infective endocarditis due to Streptococcus viridans with or without history of a visit to dental clinic within previous 6 months in our series.

 

Yes (n=22)

No (n= 69)

p

Age (years)

53,63±18,73

53,34 ± (18,62)

0,167

Sex (male)

14 (63,6%)

50 (72,4%)

0,216

Prior endocarditis

1 (4,5%)

0

0,975

Location of infection

 

 

0,124

                      Mitral

10 (45,4%)

35 (50,7%)

 

                      Aortic

12 (54,6%)

34 (49,3%)

 

Vegetations in transthoracic echocardiogram

13 (59,1%)

60 (76,8%)

0,681

Vegetations in transoesophageal echocardiogram

80 (98,8)

105 (86,9%)

0,346

Vegetation diameter (mm)

11,13±4,35

11,60 ± (4,23)

0,725

Epidemiological features

 

 

 

Entrance door

 

 

 

                        Dental

22 (100%)

0

<0,001

                        Respiratory

0

0

0,968

                        Digestive

1 (4,5%)

2 (2,9%)

0,788

                        Urinary

1 (4,5%)

1 (1,4%)

0,835

                        Intravascular catheter

0

0

0,968

                        Unknown

0

66 (95,6%)

<0,001

Underlying cardiac lesion

 

 

0,351

                        Rheumatic

6 (27,3%)

18 (14,5%)

 

                        Congenital

5 (22,7%)

16 (23,2%3)

 

                        Degenerative

7 (31,8%)

19 (27,5%)

 

                        No cardiac lesion

4 (18,2%)

16 (23,2%)

 

Permanent vesical caterer

3 (2,8)

0 (0,0)

0,266

Endocarditis related to sanitary assistance

38 (36,1)

13 (9,6)

<0,001

                        Nosocomial

10 (9,5)

1 (0,7)

0,042

                        Nosohusial

28 (26,6)

12 (8,8)

0,035

Complications, mortality and surgery

 

 

 

Severe complications (overall)

87 (83,6)

103 (76,3)

0,143

Type of complications

 

 

 

                       Herat failure/Valvular dysfunction

66 (63,4)

74 (54,4)

0,159

                       Embolisms

21 (20,2)

34 (25,0)

0,380

                       Central nervous system

25 (24)

25 (18,4)

0,285

                       Uncontrolled infection

24(23,1)

21 (15,4)

0,133

                       Acute renal failure

10 (9,6)

8 (5,9)

0,277

                       Intracardiac abscess

18 (17,5)

22 (16,2)

0,790

Cardiac surgery during active phase of endocarditis

 

 

 

                       Urgent/Emergent

20 (19,2)

29 (21,3)

0,714

                        Elective

43 (41,3)

53 (39,0)

0,697

                        Overall

63 (60,5)

82 (60,3)

0,985

Early in-hospital mortality

32 (30,8)

30 (22,1)

0,172


From our results it is possible to conclude that although the antecedent of a visit to the dentist in the previous 6 months is more frequent in cases of IE due to S. viridans, three-quarters of these IE did not have such antecedent, the infection may be due to the usual daily manipulations of the mouth (brushing, dental floss) or periodontal disease [4, 5]. Given this low sensitivity, it cannot be ruled out that IE is caused by this microorganism in the absence of a history of visiting the dentist, with the implications for empirical antibiotic treatment that this entails [3].

Disclosure

None.

Article Info

Article Type
Research Article
Publication history
Received: Mon 04, May 2020
Accepted: Mon 18, May 2020
Published: Mon 25, May 2020
Copyright
© 2023 Manuel Anguita Sánchez. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Hosting by Science Repository.
DOI: 10.31487/j.DOBCR.2020.02.10

Author Info

Corresponding Author
Manuel Anguita Sánchez
Department of Cardiology, Hospital Universitario Reina Sofía, Córdoba, Spain

Figures & Tables

Table 1: Characteristics of infective endocarditis due to Streptococcus viridans with or without history of a visit to dental clinic within previous 6 months in our series.

 

Yes (n=22)

No (n= 69)

p

Age (years)

53,63±18,73

53,34 ± (18,62)

0,167

Sex (male)

14 (63,6%)

50 (72,4%)

0,216

Prior endocarditis

1 (4,5%)

0

0,975

Location of infection

 

 

0,124

                      Mitral

10 (45,4%)

35 (50,7%)

 

                      Aortic

12 (54,6%)

34 (49,3%)

 

Vegetations in transthoracic echocardiogram

13 (59,1%)

60 (76,8%)

0,681

Vegetations in transoesophageal echocardiogram

80 (98,8)

105 (86,9%)

0,346

Vegetation diameter (mm)

11,13±4,35

11,60 ± (4,23)

0,725

Epidemiological features

 

 

 

Entrance door

 

 

 

                        Dental

22 (100%)

0

<0,001

                        Respiratory

0

0

0,968

                        Digestive

1 (4,5%)

2 (2,9%)

0,788

                        Urinary

1 (4,5%)

1 (1,4%)

0,835

                        Intravascular catheter

0

0

0,968

                        Unknown

0

66 (95,6%)

<0,001

Underlying cardiac lesion

 

 

0,351

                        Rheumatic

6 (27,3%)

18 (14,5%)

 

                        Congenital

5 (22,7%)

16 (23,2%3)

 

                        Degenerative

7 (31,8%)

19 (27,5%)

 

                        No cardiac lesion

4 (18,2%)

16 (23,2%)

 

Permanent vesical caterer

3 (2,8)

0 (0,0)

0,266

Endocarditis related to sanitary assistance

38 (36,1)

13 (9,6)

<0,001

                        Nosocomial

10 (9,5)

1 (0,7)

0,042

                        Nosohusial

28 (26,6)

12 (8,8)

0,035

Complications, mortality and surgery

 

 

 

Severe complications (overall)

87 (83,6)

103 (76,3)

0,143

Type of complications

 

 

 

                       Herat failure/Valvular dysfunction

66 (63,4)

74 (54,4)

0,159

                       Embolisms

21 (20,2)

34 (25,0)

0,380

                       Central nervous system

25 (24)

25 (18,4)

0,285

                       Uncontrolled infection

24(23,1)

21 (15,4)

0,133

                       Acute renal failure

10 (9,6)

8 (5,9)

0,277

                       Intracardiac abscess

18 (17,5)

22 (16,2)

0,790

Cardiac surgery during active phase of endocarditis

 

 

 

                       Urgent/Emergent

20 (19,2)

29 (21,3)

0,714

                        Elective

43 (41,3)

53 (39,0)

0,697

                        Overall

63 (60,5)

82 (60,3)

0,985

Early in-hospital mortality

32 (30,8)

30 (22,1)

0,172


Science Repository

Figure 1: Proportion of endocarditis caused by Streptococcus viridans in our hospital during the study period.



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