Abstract
Infective endocarditis (IE) is a potentially fatal condition caused by bacterial growth on heart valves. Bacteremia-inducing dental procedures are key factors contributing to IE development. Congenital heart disease, the most common risk factor for IE in children, may require antibiotic prophylaxis before invasive dental procedures. In Japan, guidelines for IE prevention were updated in 2018 (The JCS2017 guidelines). However, the current understanding of IE prevention among Japanese dentists remains unclear. We invited members of the Japanese Society of Pediatric Dentistry to participate in a survey regarding IE prevention; in total, 313 responses were received. Over 90% of respondents administer antibiotics for IE prevention, and nearly 80% limit prophylaxis to patients at high risk for IE. Most respondents indicated that invasive dental procedures require antibiotic prophylaxis only in patients at risk for IE. More than 80% of dentists reported using oral amoxicillin as a prophylactic antibiotic, and approximately 60% administered a 50 mg/kg dose to pediatric patients 1 h before a dental procedure. Over 70% of respondents administered antibiotic prophylaxis based on guidelines or advice from medical doctors. Our findings demonstrate that most dentists affiliated with the Japanese Society of Pediatric Dentistry understand appropriate antibiotic administration protocols for IE prevention in accordance with the JCS2017 guidelines, indicating a high level of interest in preventing dental procedure-related IE.
1
Introduction
Infective endocarditis (IE) is a life-threatening septic disease characterized by severe cardiac valvular dysfunction and multiple complications [ , ]. The in-hospital mortality rate is approximately 17%, and morbidity remains a key concern among patients with left-sided IE, with a 30% risk of systemic embolism and 33% risk of heart failure; additionally, over 50% of such patients require cardiac surgery [ , ]. Risk factors for IE include several types of underlying heart diseases, and the annual incidence of IE is 3–7 cases per 100,000 population [ , ]. Among children, approximately 50%–70% of IE cases occur in patients with congenital heart disease [ ]. The estimated overall incidence of IE in children is relatively low, ranging from 0.34 to 0.64 cases per 100,000, but the incidence in children with congenital heart disease is higher (41 cases per 100,000) [ ]. The estimated prevalence of congenital heart disease is 1 in 100 [ , ]; among individuals with congenital heart disease, 25% have critical heart disease and are at high risk for IE [ ]. According to a survey by the Ministry of Health, Labour and Welfare, the number of births in 2023 was approximately 727,000 [ ], including an estimated 7700 patients with congenital heart disease; of these patients, fewer than 2000 were expected to have severe cases.
The most common IE-causing bacteria in Japan are oral streptococci, followed by staphylococci [ ]. Therefore, invasive dental procedure-induced bacteremia is closely linked to the development of IE [ ]. Bacteremia can be caused by invasive dental procedures such as tooth extraction, periodontal surgery, scaling, and root planing [ ]. In at-risk patients who undergo various types of dental treatment, guidelines for IE prevention recommend antibiotic prophylaxis [ ]. Routine oral care (e.g., tooth brushing, dental flossing, and interdental brush cleaning) can also induce bacteremia, and there remains disagreement concerning whether invasive dental treatment is the primary cause of IE [ ].
The Japanese Circulation Society (JCS) released the first edition of its guidelines for IE prevention and treatment in 2003 (the JCS2003 guidelines), followed by a revised edition in 2008 (the JCS2008 guidelines) and a further revision in 2018 (the JCS2017 guidelines) [ ]. In 2017, we conducted a survey regarding IE prevention among dentists affiliated with the Japanese Society of Pediatric Dentistry, receiving responses from approximately 100 dentists [ ]. However, no surveys have been conducted among pediatric dentists since the publication of the JCS2017 guidelines. In the present study, we conducted a larger survey of dentists affiliated with the Japanese Society of Pediatric Dentistry to analyze their current knowledge of IE prevention.
2
Materials and methods
2.1
Participants
This study was approved by the Ethics Committee of Osaka University Graduate School of Dentistry (approval: R6-E2). The survey was conducted online from May to June 2024 via the members page on the website of the Japanese Society of Pediatric Dentistry. In total, 313 completed questionnaires were returned.
2.2
Questionnaire
The questionnaire, adapted from a previous study with some modifications [ ], consisted of 15 items ( Table 1 ). Briefly, Questions 1 through 3 inquired about the background of the pediatric dentist (Question 1: clinical experience, Question 2: workplace, Question 3: specialty). Question 4 asked whether antibiotics were administered for IE prevention, and Question 5 asked those who answered “yes” to Question 4 about the types of heart conditions for which they prescribe antibiotics. Question 6 asked about heart diseases with high risk for IE, and Question 7 asked about dental procedures with high risk for IE. Questions 8 through 10 inquired about preoperative antibiotic administration (Question 8: timing, Question 9: method, Question 10: type or dosage). Question 11 asked about sources of information regarding antibiotic prophylaxis, and Question 12 asked about any problems encountered with antibiotic prophylaxis. Question 13 addressed knowledge of the JCS guidelines for IE prevention and treatment, and Question 14 asked about experiences with IE occurrence after dental procedures. Finally, Question 15 asked pediatric dentists to freely describe their thoughts regarding IE.
| 1. How many years of clinical experience do you have? |
| 2. Where is your workplace? |
| 3. What is your specialty? |
| 4. Do you have experience that give antibiotics for infective endocarditis prevention at dental procedure? |
| 5. What type of heart disease do you give the antibiotics? |
| 6. What type of heart disease do you think high risk for infective endocarditis? |
| 7. What type of dental procedures do you think high risk for infective endocarditis? |
| 8. When is the timing of taking antibiotics? |
| 9. What is the method of administration of antibiotics? |
| 10. What are the type and dosage of antibiotics? |
| 11. What are the information sources of antibiotic prophylaxis? |
| 12. Have you ever encountered the problem about antibiotic prophylaxis? |
| 13. Do you know the Japanese Circulation Society guidelines for the prevention and treatment of infective endocarditis? |
| 14. Have you ever experienced the occurrence of infective endocarditis after dental procedures? |
| 15. Freely description about infective endocarditis. |
3
Results
3.1
Background information about the respondents
Among the 313 dentists who answered the questionnaire, 185 (59.1%) had more than 20 years of clinical experience, followed by 84 (26.8%) with 10–19 years, 32 (10.2%) with 5–9 years, and 12 (3.8%) with fewer than 5 years (Question 1) ( Table 2 ). Regarding their workplace, 206 (65.8%) dentists worked in private clinics, followed by 73 (23.3%) in university hospitals, and 34 (10.9%) in other hospitals (Question 2) ( Table 3 ). In terms of specialty, 245 (78.3%) were pediatric dentists, 45 (14.4%) were general dentists, and 23 (7.3%) reported other specialties (Question 3) ( Table 4 ).
| Clinical experience | Number (%) |
|---|---|
| Over 20 years | 185 (59.1) |
| 10–19 years | 84 (26.8) |
| 5–9 years | 32 (10.2) |
| Lower than 5 years | 12 (3.8) |
| Total | 313 (100.0) |
| Workplace | Number (%) |
|---|---|
| Private clinic | 206 (65.8) |
| University hospital | 73 (23.3) |
| Other hospital | 34 (10.9) |
| Total | 313 (100.0) |
| Specialty | Number (%) |
|---|---|
| Pediatric dentistry | 245 (78.3) |
| General dentistry | 45 (14.4) |
| Other specialties | 23 (7.3) |
| Total | 313 (100.0) |
3.2
Antibiotic prophylaxis for IE prevention in patients with heart disease
When asked whether they administered antibiotic prophylaxis for IE prevention (Question 4), 290 (92.7%) of the 313 dentists responded affirmatively ( Fig. 1 A). Dentists who answered “yes” to Question 4 were then asked who received antibiotic prophylaxis (Question 5); 225 of 290 (77.6%) answered that they limited prophylaxis to patients with heart diseases associated with high risk for IE, whereas 58 (20.0%) provided prophylaxis to patients with any heart disease, and seven (2.4%) did not respond ( Fig. 1 B).
