Academic Unit of Oral and Maxillofacial Medicine, Surgery and Pathology, School of Clinical Dentistry, University of Sheffield, Sheffield, UK.
Department of Oral Medicine, Atrium Health, Carolinas Medical Center, Charlotte, NC, USA.
Health Technol Assess. 2022 May;26(28):1-86. doi: 10.3310/NEZW6709.
Infective endocarditis is a heart infection with a first-year mortality rate of ≈ 30%. It has long been thought that infective endocarditis is causally associated with bloodstream seeding with oral bacteria in ≈ 40-45% of cases. This theorem led guideline committees to recommend that individuals at increased risk of infective endocarditis should receive antibiotic prophylaxis before undergoing invasive dental procedures. However, to the best of our knowledge, there has never been a clinical trial to prove the efficacy of antibiotic prophylaxis and there is no good-quality evidence to link invasive dental procedures with infective endocarditis. Many contend that oral bacteria-related infective endocarditis is more likely to result from daily activities (e.g. tooth brushing, flossing and chewing), particularly in those with poor oral hygiene.
The aim of this study was to determine if there is a temporal association between invasive dental procedures and subsequent infective endocarditis, particularly in those at high risk of infective endocarditis.
This was a self-controlled, case-crossover design study comparing the number of invasive dental procedures in the 3 months immediately before an infective endocarditis-related hospital admission with that in the preceding 12-month control period.
The study took place in the English NHS.
All individuals admitted to hospital with infective endocarditis between 1 April 2010 and 31 March 2016 were eligible to participate.
This was an observational study; therefore, there was no intervention.
The outcome measure was the number of invasive and non-invasive dental procedures in the months before infective endocarditis-related hospital admission.
NHS Digital provided infective endocarditis-related hospital admissions data and dental procedure data were obtained from the NHS Business Services Authority.
The incidence rate of invasive dental procedures decreased in the 3 months before infective endocarditis-related hospital admission (incidence rate ratio 1.34, 95% confidence interval 1.13 to 1.58). Further analysis showed that this was due to loss of dental procedure data in the 2-3 weeks before any infective endocarditis-related hospital admission.
We found that urgent hospital admissions were a common cause of incomplete courses of dental treatment and, because there is no requirement to record dental procedure data for incomplete courses, this resulted in a significant loss of dental procedure data in the 2-3 weeks before infective endocarditis-related hospital admissions. The data set was also reduced because of the NHS Business Services Authority's 10-year data destruction policy, reducing the power of the study. The main consequence was a loss of dental procedure data in the critical 3-month case period of the case-crossover analysis (immediately before infective endocarditis-related hospital admission), which did not occur in earlier control periods. Part of the decline in the rate of invasive dental procedures may also be the result of the onset of illness prior to infective endocarditis-related hospital admission, and part may be due to other undefined causes.
The loss of dental procedure data in the critical case period immediately before infective endocarditis-related hospital admission makes interpretation of the data difficult and raises uncertainty over any conclusions that can be drawn from this study.
We suggest repeating this study elsewhere using data that are unafflicted by loss of dental procedure data in the critical case period.
This trial is registered as ISRCTN11684416.
This project was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme and will be published in full in ; Vol. 26, No. 28. See the NIHR Journals Library website for further project information.
感染性心内膜炎是一种心脏感染，其第一年的死亡率约为 30%。长期以来，人们一直认为感染性心内膜炎与口腔细菌在 ≈40-45%的病例中经血流播散有关。这一定论导致指南委员会建议感染性心内膜炎风险增加的个体在接受侵入性牙科手术前应接受抗生素预防。然而，据我们所知，从未有临床试验证明抗生素预防的有效性，也没有高质量的证据将侵入性牙科手术与感染性心内膜炎联系起来。许多人认为，与口腔细菌相关的感染性心内膜炎更可能是由日常活动（如刷牙、使用牙线和咀嚼）引起的，尤其是在口腔卫生较差的人群中。
本研究旨在确定侵入性牙科手术与随后发生感染性心内膜炎之间是否存在时间关联，特别是在感染性心内膜炎高危人群中。
这是一项自身对照的病例交叉设计研究，比较感染性心内膜炎相关住院前 3 个月内与前 12 个月对照期内侵入性牙科手术的数量。
该研究在英国国民保健系统内进行。
所有在 2010 年 4 月 1 日至 2016 年 3 月 31 日期间因感染性心内膜炎住院的个体均有资格参加。
这是一项观察性研究；因此，没有干预。
感染性心内膜炎相关住院前几个月的侵入性和非侵入性牙科手术数量。
NHS Digital 提供了感染性心内膜炎相关住院数据，NHS 商业服务管理局提供了牙科手术数据。
感染性心内膜炎相关住院前 3 个月内侵入性牙科手术的发生率下降（发病率比 1.34，95%置信区间 1.13 至 1.58）。进一步分析表明，这是由于在任何感染性心内膜炎相关住院前的 2-3 周内丢失了牙科手术数据。
我们发现紧急住院是导致牙科治疗不完全的常见原因，由于没有要求记录不完全的牙科手术数据，因此在感染性心内膜炎相关住院前的 2-3 周内丢失了大量的牙科手术数据。由于 NHS 商业服务管理局的 10 年数据销毁政策，数据集也有所减少，从而降低了研究的效力。主要后果是在病例交叉分析的关键 3 个月病例期（感染性心内膜炎相关住院前）内丢失了牙科手术数据，而这种情况在早期对照期内不会发生。侵入性牙科手术率的下降部分可能是由于感染性心内膜炎相关住院前的疾病发作，部分可能是由于其他未定义的原因。
在感染性心内膜炎相关住院前的关键病例期内丢失牙科手术数据使得对数据的解释变得困难，并对从这项研究中得出的任何结论提出了疑问。
我们建议在其他地方使用不受关键病例期内牙科手术数据丢失影响的数据重复这项研究。
本试验在英国国家卫生与保健优化研究所（NIHR）卫生技术评估计划下注册，并将在 ; 第 26 卷，第 28 期全文发表。请访问 NIHR 期刊库网站以获取更多项目信息。
