Infective endocarditis and dental procedures: evidence, pathogenesis, and prevention

Dental implant considerations in patients with systemic diseases: An updated comprehensive review

BACKGROUND

Various medical conditions and the drugs used to treat them have been shown to impede or complicate dental implant surgery. It is crucial to carefully monitor the medical status and potential post-operative complications of patients with systemic diseases, particularly elderly patients, to minimize the risk of health complications that may arise.

AIM

The purpose of this study was to review the existing evidence on the viability of dental implants in patients with systemic diseases and to provide practical recommendations to achieve the best possible results in the corresponding patient population.

METHODS

The information for our study was compiled using data from PubMed, Scopus, Web of Science and Google Scholar databases and searched separately for each systemic disease included in our work until October 2023. An additional manual search was also performed to increase the search sensitivity. Only English-language publications were included and assessed according to titles, abstracts and full texts.

RESULTS

In total, 6784 studies were found. After checking for duplicates and full-text availability, screening for the inclusion criteria and manually searching reference lists, 570 articles remained to be considered in this study.

CONCLUSION

In treating patients with systemic conditions, the cost-benefit analysis should consider the patient's quality of life and expected lifespan. The success of dental implants depends heavily on ensuring appropriate maintenance therapy, ideal oral hygiene standards, no smoking and avoiding other risk factors. Indications and contraindications for dental implants in cases of systemic diseases are yet to be more understood; broader and hardcore research needs to be done for a guideline foundation.

Infective endocarditis: prevention strategy and risk factors in an animal model

INTRODUCTION

Infective endocarditis is a serious infection of the endocardium, especially the heart valves, which is associated with a high mortality rate. It generally occurs in patients with altered and abnormal cardiac architecture combined with exposure to bacteria from trauma and other potentially high-risk activities with transient bacteremia.

Platelets, Bacterial Adhesins and the Pneumococcus

Systemic infections with pathogenic or facultative pathogenic bacteria are associated with activation and aggregation of platelets leading to thrombocytopenia and activation of the clotting system. Bacterial proteins leading to platelet activation and aggregation have been identified, and while platelet receptors are recognized, induced signal transduction cascades are still often unknown. In addition to proteinaceous adhesins, pathogenic bacteria such as Staphylococcus aureus and Streptococcus pneumoniae also produce toxins such as pneumolysin and alpha-hemolysin. They bind to cellular receptors or form pores, which can result in disturbance of physiological functions of platelets. Here, we discuss the bacteria-platelet interplay in the context of adhesin–receptor interactions and platelet-activating bacterial proteins, with a main emphasis on S. aureus and S. pneumoniae. More importantly, we summarize recent findings of how S. aureus toxins and the pore-forming toxin pneumolysin of S. pneumoniae interfere with platelet function. Finally, the relevance of platelet dysfunction due to killing by toxins and potential treatment interventions protecting platelets against cell death are summarized.

Medicolegal Causation Investigation of Bacterial Endocarditis Associated with an Oral Surgery Practice Using the INFERENCE Approach

Investigating causation is a primary goal in forensic/legal medicine, aiming to establish the connection between an unlawful/negligent act and an adverse outcome. In malpractice litigation involving a healthcare-associated infection due to a failure of infection prevention and control practices, the medicolegal causal analysis needs to quantify the individual causal probabilities to meet the evidentiary requirements of the court. In this paper, we present the investigation of the most probable cause of bacterial endocarditis in a patient who underwent an invasive procedure at a dental/oral surgical practice where an outbreak of bacterial endocarditis had already been identified by the state Department of Health. We assessed the probability that the patient’s endocarditis was part of the outbreak versus that it was an unrelated sporadic infection using the INFERENCE (Integration of Forensic Epidemiology and the Rigorous Evaluation of Causation Elements) approach to medicolegal causation analysis. This paper describes the step-by-step application of the INFERENCE approach to demonstrate its utility in quantifying the probability of causation. The use of INFERENCE provides the court with an evidence-based, transparent, and reliable guide to determine liability, causation, and damages.

Infective Endocarditis: A Focus on Oral Microbiota

Infective endocarditis (IE) is an inflammatory disease usually caused by bacteria entering the bloodstream and settling in the heart lining valves or blood vessels. Despite modern antimicrobial and surgical treatments, IE continues to cause substantial morbidity and mortality. Thus, primary prevention and enhanced diagnosis remain the most important strategies to fight this disease. In this regard, it is worth noting that for over 50 years, oral microbiota has been considered one of the significant risk factors for IE. Indeed, among the disparate recommendations from the American heart association and the European Society of Cardiology, there are good oral hygiene and prophylaxis for high-risk patients undergoing dental procedures. Thus, significant interest has grown in the role of oral microbiota and it continues to be a subject of research interest, especially if we consider that antimicrobial treatments can generate drug-resistant mutant bacteria, becoming a severe social problem. This review will describe the current knowledge about the relationship between oral microbiota, dental procedures, and IE. Further, it will discuss current methods used to prevent IE cases that originate from oral pathogens and how these should be focused on improving oral hygiene, which remains the significant persuasible way to prevent bacteremia and systemic disorders.

Exodontia associated bacteremia in horses characterized by next generation sequencing

Bacteremia resulting from dental surgery is increasingly recognized as a health risk, especially in older and immunocompromised patients. Dentistry-associated bacteremia can lead to remote infections, as exemplified by valvular endocarditis. Emerging evidence points to a novel role played by oral cavity commensals in the pathogenesis of diabetes, respiratory disease, cardiovascular disease, and adverse pregnancy outcomes. Whether dental extraction, a commonly undertaken procedure in old horses, causes bacteremia has not been reported extensively. In a prospective clinical study using next generation sequencing (based on bacterial 16S rRNA), the circulating blood microbiome was characterized before and at 1 h following extraction of incisor, canine or cheek teeth from 29 adult horses with dental disease. 16S rRNA gene sequencing results from the blood microbiome were compared with those from gingival swab samples obtained prior to extraction at the location of the diseased tooth. Bacteremia associated with translocated gingival commensals was demonstrated in horses undergoing exodontia and was, in some cases, still evident one hour post-operatively.

mOral Health in India: Current Scenario and Future Perspectives

Oral diseases affect half of the world's population and found to be the most common and preventable noncommunicable diseases worldwide. The World Health Organization Oral Health Programme work plan 2018–2020 is to prevent the burden of oral diseases using digital technology. With 5 billion mobile phone subscribers in the world, covering over 85% of the world's population, the utilization of technology-based interventions for oral health promotion is no different. In India, numerous medical applications such as eRaktkosh and mDiabetes have been developed for the improvement of general health, whereas few initiatives such as mCessation and National Quitline services for oral health have been undertaken. Digitalization and oral health forms a crucial component in the future of oral health, which should be utilized in ensuring oral health for all.

In vitro antimicrobial activity against Abiotrophia defectiva and Granulicatella elegans biofilms

OBJECTIVES

To determine the efficacy of different antibiotics (alone or in combination) against Abiotrophia defectiva and Granulicatella elegans biofilms and to investigate the anti-biofilm activity of gentamicin alone versus blood culture isolates from both species.

METHODS

The activity of benzylpenicillin, clindamycin, daptomycin, fosfomycin, gentamicin, levofloxacin and rifampicin against 24-hour-old biofilms of A. defectiva and G. elegans was investigated in vitro by conventional microbiological methods and isothermal microcalorimetry.

RESULTS

For planktonic bacteria, the MIC values of tested antibiotics ranged from 0.016 to 64 mg/L, as determined by microcalorimetry. Higher antibiotic concentrations, ranging from 1 to >1024 mg/L, were needed to produce an effect on biofilm bacteria. Gentamicin was an exception as it was active at 1 mg/L against both planktonic and biofilm G. elegans. A synergistic effect was observed when daptomycin was combined with benzylpenicillin, gentamicin or rifampicin against A. defectiva biofilms and when gentamicin was combined with rifampicin or levofloxacin against G. elegans biofilms. A. defectiva clinical isolates displayed greater variability in gentamicin susceptibility as compared with G. elegans strains.

CONCLUSIONS

Antimicrobial susceptibility profiles vary widely between Abiotrophia and Granulicatella biofilms, and synergistic effects of the tested antibiotics were heterogeneous. The clinical relevance of these in vitro observations needs to be confirmed in experimental in vivo conditions and human trials, before guidelines for the treatment of A. defectiva and G. elegans infections are established. This study suggests the benefit of further clinical exploration of antibiotic combinations with anti-biofilm effect.

Contribution of Severe Dental Caries Induced by Streptococcus mutans to the Pathogenicity of Infective Endocarditis

Streptococcus mutans, a major pathogen of dental caries, is regarded as a causative agent of infective endocarditis (IE), which mainly occurs in patients with underlying heart disease. However, it remains unknown whether severe dental caries that extend to pulp space represent a possible route of infection. In the present study, we evaluated the virulence of S. mutans for IE development using rats with concurrent severe dental caries and heart valve injury. Dental caries was induced in rats through the combination of a caries-inducing diet and the administration of S. mutans into the oral cavity. Then, the heart valves of a subset of rats were injured using a sterile catheter and wire under general anesthesia. The rats were euthanized at various times with various stages of dental caries. The number of teeth affected by dental caries with pulp exposure was increased in the rats in a time-dependent manner. S. mutans was recovered from injured heart tissue, which was mainly observed in rats with higher number of S. mutans bacteria in mandibular bone and a larger number of teeth in which caries extended to pulp. Dental caries was more severe in rats with heart injury than in rats without heart injury. Sequencing analysis targeting 16S rRNA revealed that specific oral bacteria appeared only in rats with heart injury, which may be related to the development of dental caries. Our findings suggest that dental caries caused by the combination of S. mutans infection and sucrose intake may contribute to S. mutans colonization in injured heart tissue.

Myricetin Inhibition of Peptidoglycan-Induced COX-2 Expression in H9c2 Cardiomyocytes

Peptidoglycan (PGN) is a cell wall constituent in dental plaque bacteria that triggers inflammatory responses. PGN binds Toll-like receptors, leading to increases in prostaglandin E2 and interleukin-1β, which play crucial roles in the inflammatory response and tissue destruction. Dental surgery can give plaque bacteria access to blood circulation, thereby creating a risk of septic inflammation of the endocardium. Plant-derived flavonoids have been reported to reduce inflammatory cytokine secretion by host cells. In the present study, we investigated the effects of flavonoid myricetin on expression of cyclooxygenase 2 (COX-2) in the H9c2 cells treated with PGN from Streptococcus sanguinis, a bacterial constituent of dental plaque associated with infective endocarditis. Myricetin exposure resulted in dose-dependent suppression of PGN-induced COX-2 expression, diminished phosphorylation of p38, extracellular signal regulated kinase 1/2, and c-Jun N-terminal kinase, and reduced IκB-α degradation, consistent with decreased COX-2 activity. In conclusion, the aforementioned results suggest that myricetin is useful for moderating the inflammatory response in infective endocarditis.

Dental treatment and recommended management in patients at risk of infective endocarditis

Infective endocarditis (IF) is found in high-risk groups with congenital or acquired cardiac defects. It is caused by episodes of short bacteraemia. The magnitude and duration of bacteraemia caused by dental procedures are decreased by using antibiotic prophylaxis (AP). The aim of this study is to describe and discuss all clinical implications related to IF and dental procedures, and AP before invasive dental procedures. Maintenance of optimal oral health and hygiene is more important than AP in decreasing the risk of IF. Routine daily activities are associated with a similar risk of bacteraemia. It is estimated that antibiotics use in dentistry may represent up to 10% of total antibiotics use, and the risk of developing bacterial resistance should be taken into account.

Oral health status among newly arrived refugees in Germany: a cross-sectional study

Background

The objectives of this study were to determine the status of oral health among newly arrived refugees in Germany and to explore their knowledge, attitude and practices on oral hygiene.

Methods

All participants (n = 386) were adults, 18–60 years of age, coming from Syria and Iraq and registered as refugees in Germany within one year prior to the enrollment in the study. Clinical oral assessments in addition to a survey on knowledge, attitude and practice were carried out. The survey was conducted through a questionnaire translated into Arabic.

Results

Eighty seven point 5 % of the participants had untreated caries. The mean DMFT score was 6.38 with DT, MT and FT showing mean scores of 4.00, 1.46 and 0.92 respectively. Seventy nine percent had bacterial plaque in all six sextants, 60 % had calculus in at least three sextants and 6 % showed various magnitudes of enamel fluorosis. DMFT score was significantly associated with age (Regression Coefficient 0.031, P-value < 0.001) and with education (Regression Coefficient − 0.019, P-value 0.037) and females had significantly less missing teeth (Regression Coefficient-0.398, P-value 0.001) compared to males. The participants had in general high levels of knowledge and attitude on oral hygiene. The findings however showed a gap between their knowledge and practice.

Conclusions

The findings show high prevalence of untreated caries and poor oral hygiene among newly arrived refugees in Germany. The study recommends to lay emphasis on motivation in oral health promotion campaigns among refugees and to provide them with adequate guidance, preferably in their native language, on how to access oral health care in the host country.

Assessment of periodontitis and its role in viridans streptococcal bacteremia and infective endocarditis

OBJECTIVES

To evaluate the role of periodontitis in viridans group streptococci (VGS) bacteremia and infective endocarditis (IE).

METHODS

A total of 200 subjects including two groups. Group A- 34 subjects undergoing tooth extraction with periodontitis, 46 subjects undergoing tooth extraction without periodontitis and 40 healthy controls. Group B: 40 confirmed cases of IE (17 with and 23 without periodontitis) and 40 healthy controls. Subgingival plaque and blood samples were obtained and processed by standard procedures.

RESULTS

A total of 53 blood samples (66.25%) yielded positive cultures after tooth extraction. The relationship between the presence of periodontitis and a positive blood culture was significantly higher (p=0.05) for tooth extraction cases with periodontitis (79.40%) than tooth extraction cases without periodontitis (56.50%). Periodontitis was observed in 42.5% of IE cases. Out of the 40 patients of IE, the blood samples yielded 40 different isolates, majority were viridans streptococci 15 (37.5%) and staphylococci nine (22.5%). No statistically significant difference was observed between the subgingival plaque and blood isolates of periodontitis in both the groups, indicating similarity of biotypes of viridans streptococci isolated from the blood and the subgingival plaque. Similarity was also observed between the antibiogram profiles of viridans streptococci from both the groups.

CONCLUSIONS

Periodontitis enhances viridans streptococcal bacteremia and may be a potential risk factor for IE.

Efficacy of Antibiotic Prophylactic Regimens for the Prevention of Bacterial Endocarditis of Oral Origin

Despite the controversy about the risk of individuals developing bacterial endocarditis of oral origin, numerous Expert Committees in different countries continue to publish prophylactic regimens for the prevention of bacterial endocarditis secondary to dental procedures. In this paper, we analyze the efficacy of antibiotic prophylaxis in the prevention of bacteremia following dental manipulations and in the prevention of bacterial endocarditis (in both animal models and human studies). Antibiotic prophylaxis guidelines remain consensus-based, and there is scientific evidence of the efficacy of amoxicillin in the prevention of bacteremia following dental procedures, although the results reported do not confirm the efficacy of other recommended antibiotics. The majority of studies on experimental models of bacterial endocarditis have verified the efficacy of antibiotics administered after the induction of bacteremia, confirming the efficacy of antibiotic prophylaxis in later stages in the development of bacterial endocarditis. There is no scientific evidence that prophylaxis with penicillin is effective in reducing bacterial endocarditis secondary to dental procedures in patients considered to be "at risk". It has been suggested that there is a high risk of severe allergic reactions secondary to prophylactically administered penicillins, but, in reality, very few cases have been reported in the literature. It has been demonstrated that antibiotic prophylaxis could contribute to the development of bacterial resistance, but only after the administration of several consecutive doses. Future research on bacterial endocarditis prophylactic protocols should involve the re-evaluation of the time and route of administration of antibiotic prophylaxis, and a search for alternative antimicrobials.

Enterococcal Infective Endocarditis following Periodontal Disease in Dogs

In humans, one of the major factors associated with infective endocarditis (IE) is the concurrent presence of periodontal disease (PD). However, in veterinary medicine, the relevance of PD in the evolution of dogs’ endocarditis remains poorly understood. In order to try to establish a correlation between mouth-associated Enterococcus spp. and infective endocarditis in dogs, the present study evaluated the presence and diversity of enterococci in the gum and heart of dogs with PD. Samples were collected during necropsy of 32 dogs with PD and visually diagnosed with IE, which died of natural causes or euthanasia. Enterococci were isolated, identified and further characterized by Pulsed-Field Gel Electrophoresis (PFGE); susceptibility to antimicrobial agents and pathogenicity potential was also evaluated. In seven sampled animals, PFGE-patterns, resistance and virulence profiles were found to be identical between mouth and heart enterococci obtained from the same dog, allowing the establishment of an association between enterococcal periodontal disease and endocarditis in dogs. These findings represent a crucial step towards understanding the pathogenesis of PD-driven IE, and constitute a major progress in veterinary medicine.

Bacteremia following dental implant surgery: preliminary results

OBJECTIVES

The aims of this study were to investigate the incidence of bacteremia, bacteriology and antibiotic susceptibility against to causative bacteria associated with dental implant installation.

STUDY DESIGN

30 generally healthy patients were enrolled in this study. Blood samples were collected at baseline and at 30 minutes after dental implant installation and 24 hours after dental implant surgery. Blood samples were cultured in a BACTEC system. The isolated bacteria were identified using conventional methods. Antimicrobial sensitivity tests were performed by disc diffusion.

RESULTS

No bacteria were isolated at the baseline and 24 hours after surgery, whereas the prevalence of bacteremia at 30 minutes after dental implant installation was 23%. The isolated bacteria species were Staphylococcus epidermidis, Eubacterium spp., Corynebacterium spp. and Streptococcus viridans. The Staphylococcus epidermidis, which was isolated in three patients, was found to be resistant to penicillin which is first choice of many clinicians.

CONCLUSION

Our findings suggest that installation of dental implants can produce bacteremia. Within the limitations of this study, it can be speculated that the resistance of antibiotics may compromise the routine prophylaxis against infective endocarditis. Therefore use of blood cultures and antibiograms may be suggested in risky patients. The outcome of the present study should be verified using a larger patient group with varying conditions.

Can we really do without antibiotic prophylaxis for infective endocarditis?

Current guidance recommends against the use of antibiotic prophylaxis around the time of dental intervention for the prevention of infective endocarditis. The authors report the case of a previously well-patient with an asymptomatic isolated ventricular septal defect (VSD) who developed evidence of infective systemic and pulmonary emboli following dental treatment. A diagnosis of severe endocarditis of a previously normal native mitral valve was made. She subsequently underwent surgical repair of her mitral valve, and closure of her VSD. She was deemed fit for discharge on parenteral antibiotics on the thirtieth postoperative day. The authors highlight the need for further re-evaluation of the issues surrounding antibiotic prophylaxis for endocarditis in the context of dental procedures.

Antibiotic prophylaxis in dentistry: part II. A qualitative study of patient perspectives and understanding of the NICE guideline

BACKGROUND

The National Institute for Health and Clinical Excellence (NICE) recommendations in 2008 for antibiotic prophylaxis before dental treatment contradict previous practice. There is a potential difficulty in explaining the new guidance to patients who have long believed that they must receive antibiotics before their dental treatment.

AIM

This study investigated the patient-related barriers and facilitating factors in implementation of the NICE guidance.

METHODS

In-depth interviews were conducted with nine patients concerning their views about barriers and factors that could influence the implementation of the NICE guidance on antibiotic prophylaxis before dental treatment. Data were analysed using framework analysis.

RESULTS

For patients the rationale for the NICE guidance was unclear. They understood that at the population level the risk of infective endocarditis was less than the risk of adverse reaction to antibiotics. However, on an individual level they felt that the latter risk was negligible given their previous experience of antibiotics. They were aware that standards of care change over time but were concerned that this may be an example where a mistake had been made. Patients felt that the characteristics of the person advising them about the new guidance were important in whether or not they would accept them - they wished to be advised by a clinician that they knew and trusted, and who was perceived as having appropriate expertise.

CONCLUSIONS

Patients generally felt that they would be most reassured by information provided by a clinician who they felt they could trust and who was qualified to comment on the issue by respecting their autonomy. The implications of the findings for the development of patient information are discussed.

Evaluation of madurahydroxylactone as a slow release antibacterial implant coating

Madurahydroxylactone (MHL), a secondary metabolite with antibacterial activity was evaluated for its suitability to generate controlled drug release coatings on medical implant materials. A smooth and firmly attached layer could be produced from a precursor solution on various metallic implant materials. In physiological salt solutions these coatings dissolved within a time period up to one week. A combination of MHL with a broad spectrum fluoroquinolone antibiotic was used to create a coating that was active against all bacterial strains tested. The time period during which the coating remained active against Pseudomonas aeruginosa was investigated. The results indicated a delayed drug release from single layer coatings in the course of seven days. MHL was biocompatible in cell culture assays and could after a delay even serve as a cell adhesion substrate for human or murine cells. The findings indicate a potential for MHL for the generation of delayed release antimicrobial implant coatings.

[Dental extraction and infective endocarditis prophylaxis: current recommendations]

PURPOSE

Antibiotic prophylaxis for infective endocarditis is still debated because of unproven efficacy and risk of side effects. French recommendations for infective endocarditis prophylaxis were revised in 2002 and its indications were restricted.

CURRENT KNOWLEDGE AND KEY POINTS

Several arguments plead against prophylaxis: the absence of scientific evidence of its efficacy, the very high number of antibiotic doses required to prevent a very small number of endocarditis, the possible failure of prophylaxis even if correctly administered and a lack of compliance with current recommendations. High-risk patients for whom dental extraction is required should receive prophylaxis. For moderate-risk patients, prophylaxis is optional and should be discussed for each case individually.

FUTURE PROSPECTS AND PROJECTS

Although prophylaxis is discussed, one should focus on prevention measures, such as dental hygiene and education of physicians, dentists and patients.