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Dental and Cardiac Risk Factors for Infective Endocarditis: A Population-Based, Case-Control Study

Brian L. Strom, MD, MPH; Elias Abrutyn, MD; Jesse A. Berlin, ScD; Judith L. Kinman, MA; Roy S. Feldman, DDS, DMSc; Paul D. Stolley, MD, MPH; Matthew E. Levison, MD; Oksana M. Korzeniowski, MD; and Donald Kaye, MD
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From the University of Pennsylvania School of Medicine, Veterans Affairs Medical Center, and Allegheny University of the Health Sciences, Philadelphia, Pennsylvania; and the University of Maryland, Baltimore, Maryland. Grant Support: By grant R01 HL 39000 from the National Heart, Lung, and Blood Institute. Acknowledgments: This study would not have been possible without the contributions of the following infectious disease physicians: Paul Alessi, Bonnie Lee Ashby, Ronald Asper, John Bartels, Michael Braffman, R. Michael Buckley, Jeffrey Darnall, Floyd Eisenberg, Robert Fischer, Kathleen Gekowski, Ronald Goren, Mark Ingerman, Steven Katz, John Kelly, Richard Levy, Bennett Lorber, Alex Makris, Donald Marcus, William McNamee, Abdolghader Molavi, Sheila Murphey, George Poporad, William Raverby, Jerome Santoro, David Schlossberg, Andrew Schwartz, Alan Silverberg, Chester Smialowicz, John Stern, Bonnie Van Uitert, Joan Waller, Steven Weber, and Dean Winslow. The authors also acknowledge the assistance of personnel from the infection control, utilization review, and medical records departments, especially those of the following hospitals: Abington Memorial Hospital, Albert Einstein Medical Center, Brandywine Hospital, Bryn Mawr Hospital, Chester County, Chestnut Hill Hospital, Cooper Hospital/University Medical Center, Crozer-Chester Medical Center, Delaware County Memorial Hospital, Delaware Valley Medical Center, Doylestown Hospital, Episcopal Hospital, Frankford Hospital, Germantown Hospital, Graduate Hospital, Grandview Hospital, Allegheny University of the Health Sciences/Hahnemann University Hospital, Mercy Haverford Hospital, Holy Redeemer Hospital, Hospital of the University of Pennsylvania, Jefferson Park Hospital, Thomas Jefferson University, Lankenau Hospital, Lower Bucks Hospital, Medical Center of Delaware, Allegheny University of the Health Sciences/MCP, Mercy Catholic Medical Center, Methodist Hospital, Montgomery Hospital, Nazareth Hospital, Northeastern Hospital, Our Lady of Lourdes Hospital, Paoli Memorial Hospital, Pennsylvania Hospital, Pottstown Memorial Hospital, Presbyterian University Medical Center, Quakertown Hospital, Riddle Memorial Hospital, Rolling Hill Hospital, Roxborough Hospital, Springfield Hospital, St. Agnes Medical Center, Taylor Hospital, Temple University Hospital, Veterans Affairs Medical Center (Philadelphia), Warminster General Hospital, and West Jersey Health System. Requests for Reprints: Brian L. Strom, MD, MPH, Center for Clinical Epidemiology and Biostatistics, Room 824, Blockley Hall, 423 Guardian Drive, University of Pennsylvania School of Medicine, Philadelphia, PA 19104-6021; e-mail, bstrom@cceb.med.upenn.edu. Current Author Addresses: Dr. Strom: Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania, 824 Blockley Hall, 423 Guardian Drive, Philadelphia, PA 19104-6021.

Copyright ©2004 by the American College of Physicians

Ann Intern Med. 1998;129(10):761-769. doi:10.7326/0003-4819-129-10-199811150-00002
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Background: Although antibiotic prophylaxis against infective endocarditis is recommended, the true risk factors for infective endocarditis are unclear.

Objective: To quantitate the risk for endocarditis from dental treatment and cardiac abnormalities.

Design: Population-based, case–control study

Setting: 54 hospitals in the Philadelphia area.

Patients: Persons with community-acquired infective endocarditis not associated with intravenous drug use were compared with community residents, matched by age, sex, and neighborhood of residence.

Measurements: Information on demographic characteristics, host risk factors, and dental treatment was obtained from structured telephone interviews, dental records, and medical records.

Results: During the preceding 3 months, dental treatment was no more frequent among case-patients than controls (adjusted odds ratio, 0.8 [95% CI, 0.4 to 1.5]). Of 273 case-patients, 104 (38%) knew of previous cardiac lesions compared with 17 controls (6%) (adjusted odds ratio, 16.7 [CI, 7.4 to 37.4]). Case-patients more often had a history of mitral valve prolapse (adjusted odds ratio, 19.4 [CI, 6.4 to 58.4]), congenital heart disease (adjusted odds ratio, 6.7 [CI, 2.3 to 19.4]), cardiac valvular surgery (adjusted odds ratio, 74.6 [CI, 12.5 to 447]), rheumatic fever (adjusted odds ratio, 13.4 [CI, 4.5 to 39.5]), and heart murmur without other known cardiac abnormalities (adjusted odds ratio, 4.2 [CI, 2.0 to 8.9]). Among case-patients with known cardiac lesions-the target of prophylaxis-dental therapy was significantly (P = 0.03) less common than among controls (adjusted odds ratio, 0.2 [CI, 0.04 to 0.7] over 3 months). Few participants received prophylactic antibiotics.

Conclusions: Dental treatment does not seem to be a risk factor for infective endocarditis, even in patients with valvular abnormalities, but cardiac valvular abnormalities are strong risk factors. Few cases of infective endocarditis would be preventable with antibiotic prophylaxis, even with 100% effectiveness assumed. Current policies for prophylaxis should be reconsidered.




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