Introduction
Owing to access to high-quality medical care, more medically compromised patients are seeking orthodontic therapy, including those at risk of developing infective endocarditis (IE). The current guidelines for orthodontic therapy and IE are few. The objective of this review is to provide an evidence-based update on the relationship between orthodontic procedures and IE in children.
Methods
A comprehensive review of the English language literature available through PubMed, Ovid Medline, and Google Scholar without any limits of years of publication was conducted to analyze the evidence regarding IE and orthodontics.
Literature Review
A necessary prerequisite for IE is bacteremia. Although the only orthodontic procedure included in the current American Heart Association guidelines is the placement of bands, placement of separators has also been found to lead to significant bacteremia. Procedures with possible clinical significance include removal of expanders, placement of separators, and placement of bands. Because of the unavailability of high-quality evidence, elective invasive procedures prone to causing bacteremia should be avoided.
Conclusions
Evidence regarding orthodontic treatment and IE is limited because of ethical considerations of conducting trials in patients who are at risk for IE. Clinical interpretation based on a comprehensive review of the available literature is therefore essential.
Clinical Implications
Before initiating orthodontic therapy in cardiac patients, the patient’s IE risk is best determined by referring to the current American Heart Association guidelines and through consultation with the patient’s cardiologist. Procedures that can lead to tissue injury or bacteremia should be avoided. Oral hygiene must be reinforced because inflammation influences bacteremia.
Highlights
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Bacteremia is a necessary prerequisite for infective endocarditis.
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Expander removal and separator or band placement may increase bacteremia.
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Because evidence is limited, invasive procedures should be avoided if possible.
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Optimal oral hygiene is imperative.
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American Heart Association guidelines should always be consulted.
Orthodontic treatment is an elective procedure for all patients. On average, 67% of patients in orthodontic practices are children aged 8-17 years. Owing to improvements in medical care and life expectancies and increased expectations for enhanced quality of life, a greater number of children with medical conditions receive orthodontic treatment today. , Children with cardiac disorders may be encountered in orthodontic practice because the annual birth prevalence of congenital cardiac defects ranges from 2.4 to 13.7 per 1000 live births. Although orthodontics is perceived to be the least invasive form of dentistry, there are potential risks for cardiac compromised patients that must be considered, and special precautions are required to minimize complications. ,
Infective endocarditis (IE), an infection of the endocardial surface of the heart, including the heart valves, the mural endocardium, and the septum, has serious and life-threatening implications. , Its incidence is relatively low, ranging from 0.05 to 0.12 cases per 1000 pediatric admissions. Although hard to measure, most cases of IE are not attributed to invasive dental procedures.
For more than 50 years, the American Heart Association (AHA) has provided guidelines for the prevention of IE in association with dental procedures, based on an accumulation of the best available evidence. However, the guidelines for orthodontic therapy and IE are minimal, and the available literature is unclear because of a lack of high-quality evidence. The purpose of this narrative review is to provide an evidence-based update on the relationship between orthodontic procedures and IE in children with cardiac conditions.
Material and methods
PubMed, Ovid Medline, and Google Scholar were searched for published English language articles on IE and orthodontics. The literature search was conducted between October 2017 and December 2018, and the search terms included endocarditis, antibiotic prophylaxis, cardiac, medical disorders, medically compromised, orthodontics, and dentistry. A manual search of the references of selected articles was also conducted. There were no limits regarding the years of publication. Because of the nature of this serious and life-threatening condition, high-quality studies, such as randomized controlled trials, were lacking. The available literature allowed interpreting and reporting a narrative synthesis.
Literature review
Pathophysiology of IE
A necessary prerequisite for the development of IE is bacteremia. When bacteria enter the bloodstream in healthy individuals, the immune system clears the bacteria within a few minutes. This is not the case in patients with cardiac abnormalities who are predisposed to developing IE, where bacteremia can have dangerous consequences. ,
Viridans group streptococci, found on the skin, oral mucosa, gastrointestinal (GI) flora, and respiratory tract, cause at least 50% of native valve IE. Endothelial damage and high pressure or turbulent blood flow attracts fibrin and platelets, which create a nonbacterial thrombotic endocarditis. , Mucosal surfaces of the body are populated by endogenous microflora and damage to these surfaces (caused by dental or medical procedures or daily activities such as chewing or tooth brushing) creates a pathway for microbes to enter the bloodstream. , Blood-borne microbes adhere to and replicate within the nonbacterial thrombotic endocarditis, which protects the organisms from host defense mechanisms. , Bacteria also stimulate further fibrin and platelets deposition, which enlarges the vegetation. This vegetation can spread systemically or embolize, resulting in several life-threatening complications, such as ischemic stroke, cerebral hemorrhage, mycotic aneurysm, brain abscess, and meningitis.
Clinical presentation of IE
IE generally presents with a broad range of nonspecific, flu-like symptoms, most often with fever (90% of cases) and a heart murmur (85% of cases). , , Other symptoms range from general malaise with loss of appetite, unexplained weight loss or tiredness, headaches, backache, paleness, confusion, shortness of breath, joint pain, weakness in the face or limbs to signs of systemic toxicity. , , Some classic symptoms include cutaneous signs such as petechiae and splinter hemorrhages under the nails (red to brown in color and linear) and splenomegaly. , Secondary complications such as stroke, heart failure, and systemic embolism may also present. Any of these features in combination with persistent fever or malaise necessitates a medical referral.
Antibiotic prophylaxis for IE in association with dental procedures
In 2007, the AHA released its most recent guidelines regarding antibiotic prophylaxis for IE in the dental setting. The available evidence used for these guidelines was limited because there are ethical concerns in conducting controlled trials that test the efficacy of antibiotic prophylaxis against IE during invasive procedures.
The 2007 guidelines established that bacteremia from daily activities was more likely to cause IE than bacteremia following a dental procedure. Transient bacteremia has been found to occur after routine daily activities such as flossing, tooth brushing, and chewing, , , and the cumulative exposure to bacteremia from routine daily activities over 1 year far exceeds those that follow a single dental procedure. In addition, the AHA states that the effectiveness of antibiotic prophylaxis for IE is still unknown, but even if 100% effective, prophylaxis may only prevent IE in a small number of cases. Antibiotic prophylaxis recommendations are therefore based exclusively on an increased lifetime risk of acquiring IE, where prophylaxis is deemed “reasonable” for cardiac conditions associated with the highest risk of adverse outcome from IE. These conditions include the following: prosthetic cardiac valve or the use of prosthetic material for valve repair; previous IE; specific congenital heart diseases (CHDs) namely unrepaired cyanotic CHD, completely repaired CHD during the first 6 months after intervention, and repaired CHD with residual defects; and cardiac transplant patients who develop cardiac valvulopathy.
The recommended antibiotic regimen is a single dose of antibiotic given 30-60 minutes before the dental procedure. If antibiotic administration is inadvertently forgotten, it can still be given up to 2 hours after the procedure. Amoxicillin is the preferred oral antibiotic because of its rapid GI tract absorption, which provides high serum concentrations. For patients with allergies to penicillin, cephalexin or other cephalosporins, clindamycin, azithromycin, or clarithromycin is recommended ( Table I ). Cephalosporins should not be administered to patients with a positive history of anaphylaxis, urticaria, or angioedema following penicillin usage because of the potential for cross-reaction.
| Oral medication | Cannot take oral medication | |
|---|---|---|
| No allergies | 50 mg/kg amoxicillin | 50 mg/kg IM or IV ampicillin or 50 mg/kg IM or IV cefazolin or ceftriaxone |
| Allergy to penicillins or ampicillin | 50 mg/kg cephalexin (or first- or second-generation oral cephalosporin in appropriate dosage) or 20 mg/kg clindamycin or 15 mg/kg azithromycin or clarithromycin | 50 mg/kg IM or IV cefazolin or ceftriaxone or 20 mg/kg IM or IV clindamycin |
Antibiotics are not free of risk, and this must be considered before their administration. , Risks of antibiotics include allergy, anaphylaxis (which can be fatal), GI upset, microbial resistance, and interaction with other drugs. Thus far, there have been no reports in the literature concerning fatal anaphylaxis after administration of oral amoxicillin for IE prophylaxis in a dental setting.
The benefits of antibiotic prophylaxis in the prevention of IE can be seen from recent trends reported in the United Kingdom. In 2008, the National Institute for Health and Care Excellence recommended ceasing antibiotic prophylaxis before invasive dental procedures for patients at risk for IE. Following this change in policy, a significant increase in the incidence of IE was observed, with an estimated 34.9 additional cases of IE presenting per month. A recent cost-effectiveness analysis in the United Kingdom found that antibiotic prophylaxis in high-risk patients was associated with lower health-care costs, better health outcomes, and a low incidence of adverse drug reactions. This corroborates the AHA guidelines and illustrates the importance of antibiotic prophylaxis in patients who are at high-risk for developing IE.
Bacteremia from daily activities in orthodontic patients
Tooth brushing in patients with orthodontic appliances leads to a prevalence of transient bacteremia of 25%, which is similar to tooth brushing in patients without orthodontic appliances (26%). Bacteremia is influenced by the level of inflammation or infection at the site, and available evidence supports the notion that good oral hygiene and absence of dental disease decreases the frequency of bacteremia induced from normal daily activities ( Fig 1 ). In a systematic review by Tomás et al, an association between increased plaque accumulation and gingival inflammation and the development of bacteremia after tooth brushing was reported. Therefore, good oral hygiene practices must be emphasized to all orthodontic patients but especially to those with cardiac diseases.
Dental procedures and bacteremia
Owing to the absence of prospective clinical trials, the risk of developing bacteremia after dental procedures is unclear. Whereas bleeding is a poor predictor of bacteremia, and bacteremia can occur even in the absence of bleeding, the relationship between bacteremia and procedures that involve dentogingival manipulation has been better documented. According to the AHA, the dental procedures that should be covered with antibiotic prophylaxis include “all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa” because transient bacteremia may result from these procedures ( Table II ).
| Prophylaxis | No prophylaxis |
|---|---|
| All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa | Placement of orthodontic brackets |
| Placement of orthodontic bands | Placement of removable prosthodontic or orthodontic appliances |
| Suture removal | Adjustment of orthodontic appliances |
| Biopsies | Bleeding from trauma to the lips or oral mucosa |
| Extractions | Dental radiographs |
| Shedding of deciduous teeth | |
| Routine anesthetic injections through noninfected tissue |
The dental procedure most likely to lead to bacteremia is extraction, with a reported prevalence of 10%-100%. , , From an orthodontic perspective, extractions are sometimes required as part of the treatment plan for overcrowding or dental protrusion. For patients at risk for IE, extractions, when required, should be undertaken under antibiotic prophylaxis, though it is best to try to avoid elective orthodontic extractions while considering orthodontic treatment plans.
The risk of IE itself in association with invasive dental procedures is controversial in the literature, with some studies showing an increased risk, and other studies showing no increased risk. , Because it is unethical to conduct prospective clinical trials to assess the relationship between invasive dental procedures, antibiotic prophylaxis, and IE, the literature is limited. Recently, Chen et al conducted a case-only study with a large sample size of adults. The authors reported that there was no increased risk for IE following invasive dental procedures, and therefore no benefit from antibiotic prophylaxis. Although the evidence from this study was of improved quality, high-quality evidence is still lacking owing to the unavailability of studies that can be considered well-designed clinical trials. Because more evidence is required to resolve this controversy, including evidence for these risks in children, additional large center studies should be conducted. Until more high-quality evidence is obtained, dental practitioners should abide by the AHA guidelines for patients at high-risk for IE.
Orthodontic procedures and bacteremia
Bacteremia in association with orthodontic procedures is not well understood. Owing to the less invasive nature of orthodontics, it is often assumed that the risk of bacteremia is small. However, there have been cases of orthodontic-associated IE reported in the literature, illustrating the need for orthodontic treatment providers to recognize at-risk patients. Four published case reports of IE in orthodontic patients are present in the literature, and a survey of 1038 orthodontists by Hobson and Clark found 8 cases of IE diagnosed during or after orthodontic treatment. All cases were associated with minor orthodontic adjustments where antibiotic prophylaxis is not usually required. Although some of these articles hypothesized that the adjustment of the appliance led to mucosal injury that might have contributed to IE, no causal relationship has been proven, and the development of IE was likely coincidental.
Multiple authors have looked into the prevalence of bacteremia after different orthodontic procedures ( Table III ). In some orthodontic procedures, bacteremia did not increase but rather was maintained , , or even declined. , Differences between the results of the studies may have been due to the following reasons:
- (1)
Methodological problems in detecting bacteremia
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Greater precision in bacteremia detection has occurred with time and technologic advancements.
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- (2)
Different timings of postoperative measurements
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The optimum time to detect bacteremia following dentogingival manipulation is 30-60 seconds (bacterial levels peak at this time). The prevalence of bacteremia decreases after 60 seconds, and samples should not be collected after 2 minutes.
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In published studies, time of measurement included 30 seconds, , , , 60 seconds, , 2 minutes, , , 3 minutes, , , and 15 minutes. Some studies did not provide time details. ,
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- (3)
Small sample sizes
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Most publications had small sample sizes without power calculations. In some publications, bacteremia was only reported in 1 subject postprocedure. ,
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- (4)
Different levels of oral hygiene
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Some studies controlled for inflammation and included only patients with good oral hygiene to study the intervention itself. , , , , , , Other authors argued that controlling for oral hygiene would not be representative of typical orthodontic patients.
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- (5)
Different population characteristics
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Most studies observed orthodontic patients, but 1 study observed volunteer dental school staff and students.
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- (6)
Differing amounts of gingival manipulation during orthodontic procedures
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In banding studies, the methodology typically included placement of only 1 band.
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In debanding studies, all bands were typically removed (with or without brackets).
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- (7)
Variations in volume of blood removed
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Theoretically, the greater the volume of blood taken, the easier it is to detect bacteremia.
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