Transcript Prevention of Infective Endocarditis: New guidelines 2007

Invasive Dental
Procedures:
“Primum non nocere”
Arnold Seto, MD, MPA
Assistant Professor, Cardiology
UC-Irvine and Long Beach VA
Goals
Medical risk assessment for dental
procedures
New Guidelines on Antibiotic prophylaxis
for infective endocarditis
Evidence
Can we provide dental treatment to
the patient without endangering their (or
our) health and well being?
Is the benefit of having dental treatment
worth the risk to the patient?
What do you do in the course of
providing dental care that can affect the
health and well being of a patient?
Instill fear
Inflict pain
Inject local
anesthetic
solutions
Inject potent
vasoconstrictors
Cause bleeding
Control body
position
Expose to radiation
Expose to dental
materials
Prescribe
medications
Alter oral function
Cause inflammation
Most Common Medical
Emergencies in Dental Practice
(4000 dentists over 10 years)
Syncope 15,407
Mild Allergic Reaction 2,583
Angina Pectoris 2,552
Postural Hypotension 2,475
Seizures 2,195
Asthmatic Attack 1,392
Hyperventilation 1,326
“Epinephrine Reaction” 913
Insulin Shock 890
Cardiac Arrest 331
Anaphylaxis 304
Myocardial Infarction 289
Many of these events are preventable, or at least the chances
of them occurring can be reduced
Risk of Vascular Events
Risk Factors for the Occurrence of
Adverse Events
Dependent upon 4 factors:
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The medical condition of the patient (diagnosis,
severity, stability, control)
The nature of the dental procedure (invasiveness,
length of procedure, blood loss, type of anesthesia,
use of vasoconstrictor)
The cardiopulmonary reserve which is the ability to
respond to physical/emotional challenges (METs;
oxygen utilization); can the patient climb a flight of
stairs without chest pain or shortness of breath = 4
METs
The emotional stability of the patient (fear, anxiety)
Risk Assessment
Increased Risk
Medical Condition?
Severity
Stability
Control
Functional Capacity?
METs
Emotional Status?
Fear
Anxiety
Decreased Risk
Dental Procedure?
Invasiveness
Length of procedure
Blood Loss
Vasoconstrictor use
Risk Assessment
Increased Risk
Medical Condition?
Recent heart attack
Labile Hypertension
Dental Procedure?
Full mouth extraction
Functional Capacity?
Climbing a flight of
stairs causes
chest pain and
shortness of breath
Emotional Status?
Afraid of the dentist
Risk Assessment
Medical Condition?
Stable Angina
Dental Procedure?
Exam and x-rays
Functional Capacity?
Can climb a flight
of stairs
Emotional Status?
Doesn’t like dentists
Decreased Risk
Risk Assessment?
Can we provide routine dental treatment to this
patient without endangering their (or our) health and
well being?
Yes. No problems are anticipated, and treatment
can be delivered in the usual manner.
(Benefit >> Risk)
Yes, but potential problems may be anticipated,
and modifications in the delivery of treatment are
necessary. (Benefit > Risk)
No. Potential problems exist that are serious
enough to make it inadvisable to provide elective
dental treatment. (Risk > Benefit)
Risk vs Benefit
You may not be able to completely eliminate the
risk of an adverse event occurring during dental
treatment or as a result of dental treatment,
however, our goal is to reduce that risk as much
as possible
The issue then becomes whether the remaining
risk is acceptable and that having the dental
treatment is of more benefit than not having it
Biggest risk?
Delaying needed dental care
Periodontal disease is a chronic gram-negative
infection, affecting up to 75% of adults
Periodontal disease is associated with markers
of chronic inflammation like CRP
Chronic inflammation has been associated with
progression of coronary artery disease, which is
itself an inflammatory state
Periodontal treatment reduces markers of
inflammation
Collected studies suggest an 24-35% increased
risk of CAD in patients with periodontal disease
CV risk in Periodontal Patients
Humphrey, J. Gen Int Med 23 (12): 2079-86
Effect of periodontal treatment
on vascular endothelium
Flow-Mediated Dilatation during the 6-Month Study Period
Tonetti MS et al. N Engl J Med 2007;356:911-920
Circulating Biomarkers in the Two Groups during the 6-Month Study Period
Intensive periodontal
treatment resulted in
acute, short-term
systemic
inflammation and
endothelial
dysfunction
However, 6 months
after therapy, the
benefits in oral health
were associated with
improvement in
endothelial function
Tonetti MS et al. N Engl J Med 2007;356:911-920
Periodontal disease and
medical risk
In general, most periodontal procedures
are low risk and likely have CV benefits.
Only patients at highest risk of medical
instability require delay of care and
medical evaluation
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Unstable angina
Uncontrolled hypertension
Decompensated congestive heart failure
Management of antiplatelet agents
during dental procedures
Aspirin – should generally be continued for
all coronary artery disease patients
Clopidogrel (Plavix) – should be continued
for up to 1 year after myocardial infarction
and stenting, to minimize the risk of stent
thrombosis
Subacute stent thrombosis
Management of anticoagulants
Warfarin (Coumadin) – can usually be stopped
for 5-7 days preoperatively, and restarted
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Most patients – Atrial fibrillation, stroke, history of
deep venous thrombosis
Other patients at higher risk – recent DVT/PE,
artificial heart valves require close monitoring and
possibly bridging therapy with heparin. CONSULT.
Dabigatran (Pradaxa) – new oral anticoagulant
replacing warfarin. Can be stopped just 1 day
prior to procedure, and restarted thereafter
Dental management of
hypertension
Identify patients with hypertension both diagnosed or
undiagnosed.
Medical history include diagnosis of it, how it is being
treated, identification of antihypertension drugs,
compliance of the patient, the presence of the
symptoms associated with hypertension and stability of
the disease.
Blood pressure measurement should be routinely
performed for all new patient and recall appointments
Stress and anxiety management which increase
BP(relationship among dentists, patient & office staff and
longer stressful appointment are best avoided and short
morning appointment are recommended) .
Management of antihypertensives
Most should generally be continued to
minimize hypertensive reactions to
Clonidine is especially prone to withdrawal
hypertension and should be continued
Abort the procedure if BP > 180/110
Highest Risk Patients
Recent myocardial infarction (< 3months)
Active unstable angina
Decompensated congestive heart failure
Recommendations:
Avoid elective care
If treatment is necessary , consult with physician and limit
treatment to pain relief, treatment of acute infection, or control
bleeding
Consider including the following:
A.
B.
C.
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Prophylactic nitroglycerin
Placement of intravenous line
Sedation
Oxygen
Continuous electrocardiodiographic monitoring
Pulse oximeter
Frequent monitoring of BP
Cautious use of epinephrine in local anesthetic.
Other risk reduction measures
(Intermediate risk patients)
A.
B.
C.
D.
E.
F.
Morning appointment
Short appointment
Comfortable chair position
Pretreatment vital signs
Nitroglycerin readily available
Stress-reduction measures
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G.
H.
I.
Good communication
Oral sedation(e.g triazolam 0.125-0.25mg on the night before & 1hr
before appointment
Intraoperative N2O/O2
Excellent local anesthesia
Limit use of vasoconstrictor (max.0.038mg epinephrine)
Avoidance of epinephrine-impregnated retraction cord
Adequate postoperative pain control
Bacterial Endocarditis
A microbial
infection of the
endothelial lining of
the heart; most
commonly
occurring as a
vegetation on the
valve leaflets
Mortality Rates
100% fatal if not treated
With antibiotic treatment, fatality
rate:
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NVE (native valve)
Streptococcus <10%
Staphylococcus 25-40%
Gram negatives 75-83%
Fungi 50-60%
Late PVE (prosthetic valve) 30-53%
Endocarditis
description
“At any rate, at approximately onequarter to twelve that night, I
remember distinctly getting up from my
chair and from the table, where my
books lay, and taking off my suit coat.
No sooner had I removed the left arm
of my coat, than there was on the
ventral aspect of my left wrist a sight
which I shall never forget until I die.
There greeted my eyes about fifteen or
twenty bright red, slightly raised,
hemorrhagic spots about 1 millimeter
in diameter which did not fade on
pressure and which stood defiant as if
they were challenging the very gods of
Olympus. ... I took one glance at the
pretty little collection of spots and
turned to my sister-in-law, who was
standing nearby, and calmly said: ‘I
shall be dead within six months.”
- Alfred Reinhardt, Harvard Medical
Student, 1931
Pathogenesis of BE
Anatomic/physiologic
predisposition
(endothelial damage)
Non-bacterial thrombotic
endocarditis(NBTE)
Bacteremia (source??)
Bacterial colonization of
vegetation
Additional deposition and
growth of thrombus
Embolization and
bacteremia
Pathogenesis
Mandell
Board Review Question
Which organism is the most commonly
cause of endocarditis in periodontal
disease patients?
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A) Strep viridans
B) Staph aureus
C) Candida albicans
D) Coagulase negative staph
E) Enterococcus
Diagnosis
Modified Duke Criteria
Modified Duke Criteria
Osler’s Node
Tender subcutaneous nodules
Pulps of digits or thenar
eminence
Janeway Lesions
Nontender
Hemorrhagic
Palms and soles
Erythematous
Splinter Hemorrhage
Finger and toenails
Nonspecific
Linear and red
Brown after 2-3 d
Roth Spots
Valve Surgery
Prophylaxis for IE: First origins
1943, Northrup and Crowley postulated that
most IE were caused by dental extractions and
that Abx would prevent IE.
Identified 20% of patients with IE had preceding
dental procedures
Gave sulfa to separate cohort receiving dental
extractions and found that all patients had sterile
blood cultures.
Concluded that Abx prevent IE and should be
given.
AHA issued first recommendations in 1955
Northrup, Crowley. J Oral Surgery 1943; 1:19-29
Circulation, published online April 19, 2007
Guidelines
American Heart Association
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Committee on Rheumatic Fever, Endocarditis, and
Kawasaki Disease
Council on Cardiovascular disease in the Young
Council on Clinical Cardiology
Council on Cardiovascular Surgery and Anesthesia
Quality of Care and Outcomes Research Working Grp
Endorsed by:
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American Dental Association
Infectious Diseases Society of America
Pediatric Infectious Diseases Society
Previous Guidelines
1960 – emphasized PCN resistance, suggested chloramphenicol for
PCN allergic patients
1965 – First guideline dedicated solely on prophylaxis, recognized
enterococci after GI, GU procedures as a risk
1972 – Joined by ADA, emphasized importance of good oral
hygiene
1977 – introduced high vs. low risk groups
1984 – simplified antibiotic regimens
1990 – complete list of procedures and cardiac conditions made,
with statement that “these serve as a guideline and not as
established standard of care”
1997 – high/moderate/low risk groups made, acknowledgement that
most cases of IE are not due to a procedure
Previous Guidelines
Durack NEJM 1995; 332(1): 38-44
Estimated risk of IE per procedure
1 case of IE per 14 million dental
procedures
MVP: 1:1.1 million procedures
Congenital Heart Disease: 1:475,000
Rheumatic Heart Disease: 1:142,000
Prosthetic Valve: 1:114,000
Previous IE: 1:95,000
Guidelines
Prophylaxis in 1997
Recommended for:
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High Risk: previous IE, prosthetic heart valve,
cyanotic congenital heart disease
Moderate Risk:
Hypertrophic cardiomyopathy
Acquired valvular disease
Mitral valve prolapse with regurgitation
Other congenital anomalies
Not recommended for:
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Isolated ASD, MVP without regurg, previous CABG,
previous pacemaker, surgically repaired
ASD/VSD/PDA
Rationale in 1997
1. IE is an uncommon but life threatening disease, and
prevention is preferable to treatment
2. Certain underlying cardiac conditions predispose to IE
3. Bacteremia with organisms known to cause IE occors
commonly in association with invasive dental, GI, GU
procedures
4. Antimicrobial prophylaxis was proven to be effective
for prevention of experimental IE in animals
5. Antimicrobial prophylaxis was thought to be effective
in prevention of IE in humans
Summary of Changes
“only an extremely small number of cases of infective endocarditis
might be prevented by antibiotic prophylaxis for dental procedures
even if such therapy was 100% effective.”
“Infective endocarditis prophylaxis for dental procedures should be
recommended only for patients with underlying cardiac conditions
associated with the highest risk of adverse outcome from infective
endocarditis.”
Prophylaxis is not recommended based solely on an increased
lifetime risk of acquisition of infective endocarditis.
Change in approach
Antibiotic prophylaxis is now
recommended only for those patients with
the highest risk of adverse outcome from
IE, not just those with highest lifetime risk
of IE
Prophylaxis for dental procedures even for
these highest risk patients is reasonable
but with poor evidence (Class IIb, LOE B)
Treatment
Rationale for Revision
Additional Reasons
Over years, guidelines became complicated
Poor recollection of guidelines by practitioners
Poor compliance amongst patients and dentists
Ambiguities and inconsistencies were subject to
wide interpretations in malpractice cases
Previous guidelines not evidence based
Desire to stimulate research on IE prophylaxis
Nonadherence to prophylaxis
70% of 455 Dutch patients recalled being
warned to take IE prophylaxis, but only
22% reported actually taking them.
Prophylaxis was given to young patients
4x more than older patients.
Surgeons are twice as likely to
recommend prophylaxis for patients with
pacemakers than cardiologists.
As summarized in Durack NEJM 1995; 332(1): 38-44
Quiz Question:
According to the 1997 AHA Guidelines on
endocarditis prophylaxis, which of the following
conditions require antibiotic prophylaxis?
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Mitral valve prolapse
Previous CABG with tricuspid annuloplasty ring
Previous pacemaker
Secundum atrial septal defect
Mild aortic regurgitation
Mild mitral regurgitation
Mild aortic stenosis
Aortic sclerosis without stenosis
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Mitral valve prolapse
Previous CABG with tricuspid annuloplasty ring
Previous pacemaker
Secundum atrial septal defect
Mild aortic regurgitation
Mild mitral regurgitation
Mild aortic stenosis
Aortic sclerosis
Seto, Am J Med, 2001; 111:657-660
Scope of patients
How many adults over age 60 would be eligible
for IE prophylaxis based on prevalence of
cardiac conditions and 1997 guidelines?
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A) 2%
B) 6%
C) 10%
D) 24%
E) 50%
Croft Am J Card 2004; 94:386-89
Croft Am J Card 2004; 94:386-89
Croft Am J Card 2004; 94:386-89
40% of cases of IE occurs in patients
without previously identified risk factors.
Bacteremia and Dental Procedures
Lancet 1935
Bacteremia
Widely studied
Frequency/intensity
related to
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Density of flora
Degree of inflammation
Degree of infection
Magnitude of tissue trauma
Peak 10 minutes after
tooth extraction, drops off
between 10-30 minutes
Durack NEJM 1995; 332(1): 38-44
Guntheroth. Am J Card 1984;54:797-801
Chewing?
60 normal healthy patients
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Supervised brushing for 2 minutes
Chewing gum for 10 minutes
Scaling/Root planing
None were culture positive before
4/20 with periodontal disease had bacteremia
from chewing gum, 1/20 after brushing
Scaling caused bacteremia in 2/20 healthy
patients, 4/20 gingivitis patients, 15/20
periodontal disease patients
Forner. J Clin Periodontology 2006; 33:401-407
Bacteremia in Dental Procedures
735 pediatric patients with blood cultures drawn 30 seconds after procedure.
Cardiac patients received antibiotic prophylaxis.
Roberts, Pediatric Cardiology 1997; 18:24-27
Cumulative Risk:
Total duration of bactermia
Almost 1000x more risk in the month of extraction to daily activities than
from extraction.
Guntheroth. Am J Card 1984;54:797-801
Bacteremia
Dental procedures: 104 CFU/ml
Routine daily activities: same
Experimental IE in animal studies: 106-108
Cumulative risk from daily activities:
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Risk from brushing teeth over 1 year may be
154,000 times greater than single extraction.
Risk from all daily activities may be 5.6
million:1
Roberts Pediatric Cardiology 1999. 20: 317-325
Cumulative risk
Roberts. Pediatric Cardiology. 1999;20:317-325
Bacteremia
“In patients with underlying cardiac conditions,
lifelong antibiotic therapy is not recommended to
prevent IE that might result from bacteremias
associated with routine daily activities.”
The focus on the “frequency of bacteremia have
resulted in an overemphasis on antibiotic
prophylaxis and an underemphasis on
maintanence of good oral hygiene”; which is
“likely more important in reducing the lifetime
risk of IE than the administration of antibiotic
prophylaxis for a dental procedure.”
Do Abx Reduce Bacteremia?
Reductions on variety of microbes and
duration of positivity demonstrated in
some studies, not in others
Not 100% effective in preventing
bacteremia
Probably 75% effective at best
Does Prophylaxis Work in
Humans?
No prospective, randomized, placebo
controlled studies in patients
Retrospective and prospective case-cohort
trials limited by:
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1) Low incidence of IE
2) Large variety of underlying conditions
3) Large variety of dental procedures/states
Dutch Case-control study
Nationwide case control study in Netherlands
14.5 million patients screened over 2 years.
All patients in country with suspected IE reported
to author.
438 patients with IE over 2 years,
48 included (had surgical/dental procedure
within 6 months)
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Only 18 patients had IE within 30 days
Compared with 200 patients with same cardiac
diagnosis, similar procedure
Van der Meer. Lancet 1992; 339:135-139
Dutch Case-control study
Only 1:6 in both groups had IE prophylaxis
Only 12.7% of patients with IE had procedure
within 30 days
Possible 49% risk reduction with Abx, but not
significant (11-229%)
At best, full compliance with prophylaxis might
prevent:
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17.1% of 275 patients with an incubation of 180 days
At most 23 /275 (8.4%) if 30 days.
Might prevent 5.3% of all cases with endocarditis.
Van der Meer. Lancet 1992; 339:135-139
Summary: Case Control Trials
Possible benefit for prophylaxis cannot be
excluded
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Yale and French studies suggest possible statistically
significant benefit
Small numbers, 12 week association, recall bias a problem
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Dutch study had non-significant difference
Prophylaxis for IE is inconsistently prescribed
Infective endocarditis is not consistently
associated with a dental procedure
French study
1 year epidemiological study of IE in an area of
16 million people
Estimates of predisposing cardiac conditions
(PCC), # of dental procedures, whether
antibiotics were given obtained from survey of
2805 people
Results extrapolated to country population
PCCs restricted. Highest-risk only in French
recommendations 2002 (prosthetic valve,
previous endocarditis) Heart 2005 91:715-8
Duval. Clin Infect Dis. 2006;42:e102-e107
French study: Conclusions
Estimated Risk of IE:
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1:46,000 for unprotected procedures
1:10,700 for prosthetic valves
1:54,300 for native valves
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1:150,000 for protected procedures
Even if antibiotics were 66% effective,
large number needed to treat, even for
high risk patients isolated using French
standards
Duval. Clin Infect Dis. 2006;42:e102-e107
Decision Analysis
Markov multiple states model
Take estimates of benefit, cost,
complications, incidence from literature
and calculate likelihood of possible options
Agha. Medical Decision Making 2005;25:308
Decision Analysis Results
If 10 million patients underwent prophylaxis with
amoxicillin
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19 cases of IE prevented
Net loss of 181 lives due to anaphylaxis
If 10 million patients underwent prophylaxis with
clarithromycin
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119 cases of IE prevented, 19 deaths prevented
Incremental cost effectiveness of $88,007/QALY
Valve replacement/previous IE patients had much better
CE ratio of $14,000-38,000
If true incidence of cases of IE due to dental procedures
were less than 17% used in model, cost would increase.
Agha. Medical Decision Making 2005;25:308
Future Directions
Due to the low rate of endocarditis,
An adequately powered RCT would require
6,000 – 60,000 patients over 2 years, and
screening of many more patients than this.
A prospective cohort study would require 18,000
patients over 10 years
Only possible in countries with large organized
health systems with centralized records, and
including every patient in that system
Cochrane Review 2004
Future Directions
Large case-control trial would be more
feasible
Selecting appropriate matched controls for
cases would be required
Cochrane Review 2004
Medical Malpractice
Four criteria must be met
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Duty was owed to patient
Duty was breached – failure to conform to
standard of care
Breach caused an injury and was proximate
cause of the injury
Damages occurred
Recent malpractice cases
Failure to diagnose endocarditis:
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Shea v Dr. F. Mohebban 1999, Minella v. Dr. E Antelis
Settled for $1.2 million, $1.95 million after MD failed to order blood
Cx
Failure to prescribe prophylaxis and failure to diagnose
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Mullen v Zylstra MD, Pederson MD, Maynard DDS 1991
28 yo man with abnormal bicuspid AV
After tooth loosened by trauma, DDS attempted to reinsert. No
abx given despite history of bicuspid AV.
Weeks later, tooth was grossly infected, constitutional symptoms
of endocarditis. MD failed to listen to heart or order blood cx,
diagnosis delayed, AVR required.
$3 million finding against MD. DDS settled for $25,000
MoreLaw database
Other Cases
Failure to ask?
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Bacon v Kentopp DDS, 2000, Nebraska
Patient required AVR and MVR after “dental
induced endocarditis”. Filed against DDS for
failure to ask whether she had heart
problems, claimed that Abx would have been
prescribed and would have prevented
endocarditis
Defendant (DDS) won verdict.
Treatment
Dental procedures and IE
prophylaxis: Recommended
Dental extractions
Periodontal procedures
Dental implants and reimplantation of avulsed teeth
Endodontic proceures
Subgingival placement of antibiotic fibers and strips
Initial placement of orthodontic bands (not brackets)
Intraligamentary local anesthetic injections
Prophylactic cleaning
Dental procedures and IE
prophylaxis: Not recommended
Restorative dentistry
Non-intraligamentary local anesthetic injections
Taking oral impressions
Fluoride treatments
Oral radiographs
Orthodontic appliance adjustment
Shedding primary teeth
Discussion?
Criteria for effective prophylaxis
Is the disease preventable?
Is it worth preventing?
Can patients at risk be identified?
Is prophylaxis clinically effective?
Is prophylaxis safe and well tolerated?
Can prophylaxis be delivered consistently
and easily?
Is prophylaxis cost effective?
Prophylaxis in 1997
Dental:
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“Any procedure that might induce bleeding”
Amoxicillin 2gm PO, 1 hour preprocedure
GI
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ERCP, stricture dilatation, varices, surgery
GU
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Cystoscopy, prostate surgery, ureteral stent
Pulmonary
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T&A, rigid bronchoscopy
Rx:
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Ampicillin/Gentamicin for non dental procedures.
Unfortunately this table does not match the text of the van de Meer article!
Do Abx Reduce Bacteremia?
Animal studies in the 1970s used rabbits,
valve damage from catheter, and large
inoculum (108 CFU/ml) S. viridans to
generate IE.
Vancomycin and PCN uniformly effective
in preventing IE.
Single dose Abx failed when even larger
doses of inoculum used.
Do Abx Reduce Bacteremia in
Humans?
RCT of 100 children in dental OR given amoxicillin
Lockhart. Circulation 2004; 109:2878-2884
Do Abx Reduce Bacteremia?
Erythromycin 1.5 gm oral before tooth
extraction.
Randomized double blind trial
S. viridans recovered in:
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6/40 (15%) treated patients
18/42 (43%) control patients
Do Abx Reduce Bacteremia?
39 patients randomized to cefaclor or
placebo prior to extraction
S. viridans recovered from
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79% in treated group
50% in placebo group
60 patients randomized to PCN,
amoxicillin, placebo in another study
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95%, 90%, 85% positive blood cultures
Hall. Eur J Clin Microbiol Infectious Dis 1995;15:646-649
Hall Clin Infect Dis 1993; 188-94
Do Abx Reduce Bacteremia?
Reductions on variety of microbes and
duration of positivity demonstrated in
some studies, not in others
Not 100% effective in preventing
bacteremia
Probably 75% effective at best
Yale-New Haven
Case-control trial, 2 hospitals
34 patients with IE between 1980-1986
with oral flora and cardiac lesion
8/34 (23%) of patients had dental
procedure within 12 weeks
Controls matched for same lesion, same
procedure
Imperiale. Am J Med 1990; 88: 131-136
Yale-New Haven
Imperiale. Am J Med 1990; 88: 131-136
Lacassin study
Case control trial
18.5 million population in 1 year, 1990-1
Endocarditis, excluding IVDU, Q-fever
171 cases, matched to control by age,
sex, cardiac condition
Questionnaire to recollect procedures
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
Lacassin study
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
Lacassin study
Dental procedures as a whole were not
associated with increased risk, although scaling
and root canal had trend (P=0.065)
In multivariate analysis, only skin wounds and
other infections increased overall risk of
endocarditis.
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But when selecting only S. viridans endocarditis,
scaling was a significant risk independent of other
factors (but data not shown)
Tooth extraction was not
Skin and other infections were significantly more
prevalent in case group (19% vs 5%)
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
Lacassin study
Lacassin Eur Heart Journal 1995; 16(12) 1968-74
Rejected
Both these positive studies rejected from
an analysis by Cochrane Database as
potentially being “seriously biased.”
Prolonged duration (12 weeks) considered
too long by Cochrane committee
Recall bias a concern
Other limitations:
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Confounders
Association without causation
Oliver. Cochrane Database 2004.
Philadelphia Project
Case-control study: 8 counties around
Philadelphia and Delaware, 54 hospitals
273 cases with community acquired, non IVDU
endocarditis
Controls were matched only to age, sex
No association found with dental care, frequency
of tooth brushing, use of irrigators, dentures
Very few patients in either group received Abx
prophylaxis (2.2% case, 0.7% controls)
Case patients were more likely to have cardiac
lesions, be on VA or Medicaid insurance
Strom Ann Int Med 1998; 129(10) 761-769, Circulation 2000; 102:2842-2848
Case patients with IE no more likely to have received dental procedure (OR 0.8 CI 0.41.5)
Strom Ann Int Med 1998; 129(10) 761-769, Circulation 2000; 102:2842-2848
Philadelphia Project
Strom Circulation 2000; 102:2842-2848
French Estimate
Duval. Clin Infect Dis. 2006;42:e102-e107
French Estimate
Duval. Clin Infect Dis. 2006;42:e102-e107