Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei (T.-T.C., Y.-C.Y., K.-L.C., M.-S.L., Y.-K.T.).
Department of Medical Research, National Taiwan University Hospital, Taipei (Y.-C.Y.).
Circulation. 2018 Jul 24;138(4):356-363. doi: 10.1161/CIRCULATIONAHA.117.033131.
Invasive dental treatments (IDTs) can yield temporary bacteremia and have therefore been considered a potential risk factor of infective endocarditis (IE). It is hypothesized that, through the trauma caused by IDTs, bacteria gain entry to the bloodstream and may attach to abnormal heart valves or damaged heart tissue, giving rise to IE. However, the association between IDTs and IE remains controversial. The aim of this study is to estimate the association between IDTs and IE.
The data in this study were obtained from the Health Insurance Database in Taiwan. We selected 2 case-only study designs, case-crossover and self-controlled case series, to analyze the data. The advantage of these methods is that confounding factors that do not vary with time are adjusted for implicitly. In the case-crossover design, a conditional logistic regression model with exposure to IDTs was used to estimate the risks of IE following an IDT with 4, 8, 12, and 16 weeks delay, respectively. In the self-controlled case series design, a conditional Poisson regression model was used to estimate the risk of IE for the risk periods of 1 to 4, 5 to 8, 9 to 12, and 13 to 16 weeks following an IDT.
In total, 9120 and 8181 patients with IE were included in case-crossover design and self-controlled case series design, respectively. In the case-crossover design, 277 cases and 249 controls received IDTs during the exposure period, and the odds ratio was 1.12 (95% confidence interval, 0.94-1.34) for 4 weeks. In the self-controlled case series design, we observed that 407 IEs occurred during the first 4 weeks after IDTs, and the age-adjusted incidence rate ratio was 1.14 (95% confidence interval, 1.02-1.26) for 1 to 4 weeks after IDTs.
In both study designs, we did not observe a clinically larger risk for IE in the short periods after IDTs. We also found no association between IDTs and IE among patients with a high risk of IE. Therefore, antibiotic prophylaxis for the prevention of IE is not required for the Taiwanese population.
侵袭性牙科治疗（IDT）会引起一过性菌血症，因此被认为是感染性心内膜炎（IE）的潜在危险因素。据推测，通过 IDT 造成的创伤，细菌进入血液，并可能附着在异常的心脏瓣膜或受损的心组织上，从而引发 IE。然而，IDT 与 IE 之间的关联仍存在争议。本研究旨在评估 IDT 与 IE 之间的关联。
本研究的数据来自台湾的健康保险数据库。我们选择了 2 种仅病例研究设计，病例交叉和自身对照病例系列，来分析数据。这些方法的优点是隐含地调整了不随时间变化的混杂因素。在病例交叉设计中，使用暴露于 IDT 的条件逻辑回归模型，分别估计在 IDT 后 4、8、12 和 16 周发生 IE 的风险。在自身对照病例系列设计中，使用条件泊松回归模型估计在 IDT 后 1 至 4、5 至 8、9 至 12 和 13 至 16 周的风险期内发生 IE 的风险。
共纳入病例交叉设计 9120 例和自身对照病例系列设计 8181 例 IE 患者。在病例交叉设计中，277 例病例和 249 例对照在暴露期内接受 IDT，4 周时比值比为 1.12（95%置信区间，0.94-1.34）。在自身对照病例系列设计中，我们观察到在 IDT 后 4 周内发生了 407 例 IE，1 至 4 周后年龄调整发病率比为 1.14（95%置信区间，1.02-1.26）。
在这两种研究设计中，我们都没有观察到 IDT 后短期内心内膜炎的风险显著增加。我们还发现，在 IE 高危患者中，IDT 与 IE 之间没有关联。因此，对于台湾人群，不需要抗生素预防来预防 IE。
