Endodontics and infective endocarditis

Antibiotic prophylaxis for preventing bacterial endocarditis following dental procedures

BACKGROUND

Infective endocarditis is a severe infection arising in the lining of the chambers of the heart. It can be caused by fungi, but most often is caused by bacteria. Many dental procedures cause bacteraemia, which could lead to bacterial endocarditis in a small proportion of people. The incidence of bacterial endocarditis is low, but it has a high mortality rate.  Guidelines in many countries have recommended that antibiotics be administered to people at high risk of endocarditis prior to invasive dental procedures. However, guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales states that antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures. This is an update of a review that we first conducted in 2004 and last updated in 2013.

OBJECTIVES

Primary objective To determine whether prophylactic antibiotic administration, compared to no antibiotic administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis, influences mortality, serious illness or the incidence of endocarditis. Secondary objectives To determine whether the effect of dental antibiotic prophylaxis differs in people with different cardiac conditions predisposing them to increased risk of endocarditis, and in people undergoing different high risk dental procedures. Harms Had we foundno evidence from randomised controlled trials or cohort studies on whether prophylactic antibiotics affected mortality or serious illness, and we had found evidence from these or case-control studies suggesting that prophylaxis with antibiotics reduced the incidence of endocarditis, then we would also have assessed whether the harms of prophylaxis with single antibiotic doses, such as with penicillin (amoxicillin 2 g or 3 g) before invasive dental procedures, compared with no antibiotic or placebo, equalled the benefits in prevention of endocarditis in people at high risk of this disease.

SEARCH METHODS

An information specialist searched four bibliographic databases up to 10 May 2021 and used additional search methods to identify published, unpublished and ongoing studies SELECTION CRITERIA: Due to the low incidence of bacterial endocarditis, we anticipated that few if any trials would be located. For this reason, we included cohort and case-control studies with suitably matched control or comparison groups. The intervention was antibiotic prophylaxis, compared to no antibiotic prophylaxis or placebo, before a dental procedure in people with an increased risk of bacterial endocarditis. Cohort studies would need to follow at-risk individuals and assess outcomes following any invasive dental procedures, grouping participants according to whether or not they had received prophylaxis. Case-control studies would need to match people who had developed endocarditis after undergoing an invasive dental procedure (and who were known to be at increased risk before undergoing the procedure) with those at similar risk who had not developed endocarditis.  Our outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse effects of the antibiotics; and the cost of antibiotic provision compared to that of caring for patients who developed endocarditis.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened search records, selected studies for inclusion, assessed the risk of bias in the included study and extracted data from the included study. As an author team, we judged the certainty of the evidence identified for the main comparison and key outcomes using GRADE criteria. We presented the main results in a summary of findings table.

MAIN RESULTS

Our new search did not find any new studies for inclusion since the last version of the review in 2013. No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included in the previous versions of the review, but one case-control study met the inclusion criteria. The trial authors collected information on 48 people who had contracted bacterial endocarditis over a specific two-year period and had undergone a medical or dental procedure with an indication for prophylaxis within the past 180 days. These people were matched to a similar group of people who had not contracted bacterial endocarditis. All study participants had undergone an invasive medical or dental procedure. The two groups were compared to establish whether those who had received preventive antibiotics (penicillin) were less likely to have developed endocarditis. The authors found no significant effect of penicillin prophylaxis on the incidence of endocarditis. No data on other outcomes were reported. The level of certainty we have about the evidence is very low.

AUTHORS' CONCLUSIONS

There remains no clear evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in at-risk people who are about to undergo an invasive dental procedure. We cannot determine whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners should discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Antibiotics for the prophylaxis of bacterial endocarditis in dentistry

BACKGROUND

Infective endocarditis is a severe infection arising in the lining of the chambers of the heart with a high mortality rate.Many dental procedures cause bacteraemia and it was believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries have recommended that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, recent guidance by the National Institute for Health and Care Excellence (NICE) in England and Wales has recommended that antibiotics are not required.

OBJECTIVES

To determine whether prophylactic antibiotic administration, compared to no such administration or placebo, before invasive dental procedures in people at risk or at high risk of bacterial endocarditis influences mortality, serious illness or the incidence of endocarditis.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group's Trials Register (to 21 January 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 12), MEDLINE via OVID (1946 to 21 January 2013) and EMBASE via OVID (1980 to 21 January 2013). We searched for ongoing trials in the US National Institutes of Health Trials Register (http://clinicaltrials.gov) and the metaRegister of Controlled Trials (http://www.controlled-trials.com/mrct/). No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case-control studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of antibiotic, compared to no such administration, before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those individuals at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received or not. Included case-control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were mortality or serious adverse events requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who developed endocarditis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion then assessed risk of bias and extracted data from the included study.

MAIN RESULTS

No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over two years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines, and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxies). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days, and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes.

AUTHORS' CONCLUSIONS

There remains no evidence about whether antibiotic prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically, practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Antibiotics for the prophylaxis of bacterial endocarditis in dentistry

BACKGROUND

Infective endocarditis is a severe infection arising in the lining of the heart with a high mortality rate.Many dental procedures cause bacteraemia and it was believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries have recommended that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, recent guidance by the National Institute for Health and Clinical Excellence (NICE) in England and Wales has recommended that antibiotics are not required.

OBJECTIVES

To determine whether prophylactic antibiotic administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness or endocarditis incidence.

SEARCH STRATEGY

The search strategy from the previous review was expanded and run on MEDLINE (1950 to June 2008) and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers, as well as the following databases: CENTRAL (The Cochrane Library 2008, Issue 2); EMBASE (1980 to June 2008); and the metaRegister of Controlled Trials (to June 2008).

SELECTION CRITERIA

Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case-control studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of antibiotic compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included case-control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were: mortality or serious adverse event requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who develop endocarditis.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies for inclusion, then assessed quality and extracted data from the included study.

MAIN RESULTS

No randomised controlled trials (RCTs), controlled clinical trials (CCTs) or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in The Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes.

AUTHORS' CONCLUSIONS

There remains no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support previously published guidelines in this area. It is not clear whether the potential harms and costs of antibiotic administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Endodontics and infective endocarditis – is antimicrobial chemoprophylaxis required?

The purpose of this review is to evaluate the evidence implicating nonsurgical endodontic procedures in inducing infective endocarditis (IE). The literature is reviewed and findings about dental procedures that elicit bacteraemia [in particular root canal treatment (RCT)], sequelae of bacteraemia, relationship between IE and RCT and variation between antibiotic prophylaxis (AP) guidelines are highlighted. At present, there is still significant debate as to which dental procedures require chemoprophylaxis and what antibiotic regimen should be prescribed. Currently, there are insufficient primary data to know whether AP is effective or ineffective against IE. Practitioners are bound by current guidelines and medico-legal considerations. Thus, the profession requires clear, uniform guidelines that are evidence-based.

Penicillins for the prophylaxis of bacterial endocarditis in dentistry

BACKGROUND

Many dental procedures cause bacteraemia and it is believed that this may lead to bacterial endocarditis (BE) in a few people. Guidelines in many countries recommend that prior to invasive dental procedures antibiotics are administered to people at high risk of endocarditis. However, it is unclear whether the potential risks of this prophylaxis outweigh the potential benefits.

OBJECTIVES

To determine whether prophylactic penicillin administration compared to no such administration or placebo before invasive dental procedures in people at increased risk of BE influences mortality, serious illness or endocarditis incidence.

SEARCH STRATEGY

The search strategy was developed on MEDLINE and adapted for use on the Cochrane Oral Health, Heart and Infectious Diseases Groups' Trials Registers (to October 2003), as well as the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 2, 2002), OLDMEDLINE (1966 to June 2002); EMBASE (1980 to June 2002); SIGLE (to June 2002); and the Meta-register of current controlled trials.

SELECTION CRITERIA

Due to the low incidence of BE it was anticipated that few if any trials would be located. For this reason, cohort and case controlled studies were included where suitably matched control or comparison groups had been studied. The intervention was the administration of penicillin compared to no such administration before a dental procedure in people with an increased risk of BE. Cohort studies would need to follow those at increased risk and assess outcomes following any invasive dental procedures, grouping by whether prophylaxis was received. Included case control studies would need to match people who had developed endocarditis (and who were known to be at increased risk before undergoing an invasive dental procedure preceding the onset of endocarditis) with those at similar risk but who had not developed endocarditis. Outcomes of interest were: mortality or serious adverse event requiring hospital admission; development of endocarditis following any dental procedure in a defined time period; development of endocarditis due to other non-dental causes; any recorded adverse events to the antibiotics; and cost implications of the antibiotic provision for the care of those patients who develop endocarditis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently selected studies for inclusion, then assessed quality and extracted data from the included study.

MAIN RESULTS

No RCTs, CCTs or cohort studies were included. One case-control study met the inclusion criteria. It collected all the cases of endocarditis in the Netherlands over 2 years, finding a total of 24 people who developed endocarditis within 180 days of an invasive dental procedure, definitely requiring prophylaxis according to current guidelines and who were at increased risk of endocarditis due to a pre-existing cardiac problem. This study included participants who died because of the endocarditis (using proxys). Controls attended local cardiology outpatient clinics for similar cardiac problems, had undergone an invasive dental procedure within the past 180 days and were matched by age with the cases. No significant effect of penicillin prophylaxis on the incidence of endocarditis could be seen. No data were found on other outcomes.

REVIEWERS' CONCLUSIONS

There is no evidence about whether penicillin prophylaxis is effective or ineffective against bacterial endocarditis in people at risk who are about to undergo an invasive dental procedure. There is a lack of evidence to support published guidelines in this area. It is not clear whether the potential harms and costs of penicillin administration outweigh any beneficial effect. Ethically practitioners need to discuss the potential benefits and harms of antibiotic prophylaxis with their patients before a decision is made about administration.

Endodontics in the adult patient: the role of antibiotics

OBJECTIVES

The aim of this study was to review the published work on the indications and efficacy for antibiotics in endodontic therapy.

DATA SOURCES

Published works in the medical and dental literature.

STUDY SELECTION

Evaluation of published clinical trials in endodontic and other pertinent literature.

CONCLUSIONS

Antibiotics are not routinely indicated in the practice of endodontics. Therapeutic antibiotics may be required as an adjunct to operative treatment when there is pyrexia and/or gross local swelling; they are only rarely indicated in the absence of operative intervention. Prophylactic antibiotics may be required for certain patients who are susceptible to serious infective sequaelae.

Bacteriemia após exodontia unitária, empregando dois métodos de anti-sepsia intrabucal

O objetivo do trabalho foi avaliar a freqüência de bacteriemias pós-exodontia utilizando dois métodos de anti-sepsia pré-operatória, identificando os microrganismos isolados de hemoculturas pós-extração e avaliando a sua suscetibilidade a antibióticos. Vinte e seis pacientes tiveram 33 dentes extraídos. Dezesseis casos foram submetidos a anti-sepsia com bochecho com 15 ml de gluconato de clorexidina a 0,12% por um minuto, seguido da fricção das faces dentais com cotonete embebido na mesma solução (método 1) e 17 à anti-sepsia com dois bochechos com 15 ml de cloreto de cetilpiridínio a 1:4.000 por um minuto, intercalados pela fricção das faces dentais com peróxido de hidrogênio a 3,0% (método 2). Previamente à extração dental e cerca de 1 a 3 minutos após a mesma, colhiam-se 5,0 ml de sangue que eram semeados em meios de cultura e incubados por 20 dias. As cepas provenientes de hemoculturas positivas foram identificadas e submetidas ao antibiograma. Do total de casos, 68,8% apresentaram hemocultura positiva para o método 1 e 70,6% para o método 2. Houve maior prevalência de Actinomyces nos dois métodos, seguido de Streptococcus, Staphylococcus e Peptostreptococcus. O maior índice de resistência aos antibióticos testados esteve relacionado à oxacilina, enquanto não foi observada nenhuma cepa resistente à amoxicilina ou à cefalotina. Conclui-se que a freqüência de bacteriemia pós-exodontia foi elevada, independentemente do método de anti-sepsia empregado, prevalecendo microrganismos anaeróbios, os quais foram mais suscetíveis a amoxicilina e a cefalotina.

Root canal treatment and general health: a review of the literature

REVIEW

The focal infection theory was prominent in the medical literature during the early 1900s and curtailed the progress of endodontics. This theory proposed that microorganisms, or their toxins, arising from a focus of circumscribed infection within a tissue could disseminate systemically, resulting in the initiation or exacerbation of systemic illness or the damage of a distant tissue site. For example, during the focal infection era rheumatoid arthritis (RA) was identified as having a close relationship with dental health. The theory was eventually discredited because there was only anecdotal evidence to support its claims and few scientifically controlled studies. There has been a renewed interest in the influence that foci of infection within the oral tissues may have on general health. Some current research suggests a possible relationship between dental health and cardiovascular disease and published case reports have cited dental sources as causes for several systemic illnesses. Improved laboratory procedures employing sophisticated molecular biological techniques and enhanced culturing techniques have allowed researchers to confirm that bacteria recovered from the peripheral blood during root canal treatment originated in the root canal. It has been suggested that the bacteraemia, or the associated bacterial endotoxins, subsequent to root canal treatment, may cause potential systemic complications. Further research is required, however, using current sampling and laboratory methods from scientifically controlled population groups to determine if a significant relationship between general health and periradicular infection exists.

Estudo comparativo da eficiência de três métodos de anti-sepsia intrabucal na redução do número de estreptococos do sulco gengival

Este trabalho foi feito com o objetivo de avaliar três métodos de anti-sepsia intrabucal na redução do número de estreptococos do sulco gengival. Os resultados obtidos demonstraram que os três tratamentos promoveram a redução do número de estreptococos do sulco gengival. A análise estatística mostrou que, ao nível de 1% de significância, o método que empregou um bochecho com clorexidina a 0,12% associado à limpeza das faces dentais com cotonete embebido nesta mesma solução foi semelhante àquele que empregou dois bochechos com cloreto de cetilpiridínio intercalados com a limpeza das faces dentais com cotonete embebido em peróxido de hidrogênio a 3%. Esses dois métodos foram mais eficientes na redução do número de estreptococos do que o que empregou apenas um bochecho com clorexidina.

The prevention of infective endocarditis-paedodontic considerations. British Society for Antimicrobial Chemotherapy

This review of the literature considers the pathology and epidemiology of infective endocarditis (IE), dental procedures that may precipitate IE and prophylaxis against dentally induced IE. The most recent recommendations published in May 1992 by the British Society for Antimicrobial Chemotherapy are outlined and discussed.

Oral hygiene and the prevalence of oral group D streptococci in medically-physically compromised and periodontal disease patients

The relationship between oral hygiene and oral Group D streptococcal carrier status was examined in two groups of dental clinic patients. Eighteen medically-physically compromised and 20 periodontitis patients were selected for study. Oral hygiene status was assessed and the prevalence of oral Group D streptococci was determined by sampling the oral cavity with a vigorous 15 second rinse with 5 ml peptone-saline solution. Three ml of each sample was cultured at 40 degrees C in 30 ml of SF broth for 72 hours. Esculin fermenting colonies isolated from the SF broth were characterized biochemically according to standardized procedures and patients were classified as either carriers or non-carriers. Group D streptococci were detected in 27.8% of the medically-physically compromised group and 4.5% of the periodontal disease patients. The mean DI-S score of the medically-physically compromised group was significantly lower than in the periodontal group. Within the medically-physically compromised group, the DI-S means of carriers and non-carriers were not significantly different. The data indicated no important relationship between oral hygiene and the prevalence of oral Group D streptococci in the groups studied.

Carriage rates of enterococci in the dental plaque of haemodialysis patients in Dublin

The incidence of carriage of enterococci in dental plaque was determined in haemodialysis patients attending three clinics in the Dublin area either as outpatients or as hospitalised patients. Their carriage rates were compared with a University group comprising normal healthy students, academic staff, technicians and ancillary personnel and with a cohort of otherwise healthy toothache patients. The carriage rates among the staffs of the dialysis units also were examined. The overall carriage rates of enterococci of the University group, the toothache patient group, the haemodialysis patients and the dialysis unit staffs did not differ significantly from each other, ranging from 5%-20%. However, the dental plaque of a mainly hospitalised group of haemodialysis patients and their attendant staff at one clinic was colonised to a statistically significant higher degree with enterococci than that of the haemodialysis patients and the staff at the outpatient clinics, both separately and as combined patient and staff groups. Age, sex, a history of recent antibiotic therapy, and elapsed time since the last dental visit did not affect isolation rates to a significant extent. The commonest enterococcus isolated from subjects was Streptococcus faecalis, followed by its variety liquefaciens. Only one subject harboured Streptococcus durans in dental plaque. Ten of the 21 subjects yielding enterococci harboured two different enterococci in their plaque. The isolation of S. faecalis var liquefaciens alone or in combination with S. faecalis did not correlate with subject-history parameters. The findings obtained imply that antibiotic prophylaxis specifically against enterococci may be necessary only for a small number of haemodialysis patients in whom oral carriage of enterococci has been demonstrated bacteriologically.