Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study

Niko Vähäsarja; Bodil Lund; Anders Ternhag; Bengt Götrick; Lars Olaison; Margareta Hultin; Carina Krüger Weiner; Aron Naimi-Akbar

doi:10.1016/j.eclinm.2023.102184

Oral streptococcal infective endocarditis among individuals at high risk following dental treatment: a nested case-crossover and case-control study

EClinicalMedicine. 2023 Aug 30:63:102184. doi: 10.1016/j.eclinm.2023.102184. eCollection 2023 Sep.

Authors

Niko Vähäsarja^{1

2}, Bodil Lund^{1

3}, Anders Ternhag⁴, Bengt Götrick⁵, Lars Olaison⁶, Margareta Hultin¹, Carina Krüger Weiner¹, Aron Naimi-Akbar^{1

2

7}

Affiliations

¹ Division of Oral Diagnostics and Rehabilitation, Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden.
² Department of Oral and Maxillofacial Surgery, Eastmaninstitutet, Folktandvården Stockholms Län AB, Folktandvården Eastmaninstitutet, Stockholm, Sweden.
³ Medical Unit of Plastic Surgery and Oral and Maxillofacial Surgery, Department for Oral and Maxillofacial Surgery and Jaw Orthopedics, Karolinska University Hospital, Stockholm, Sweden.
⁴ Division of Infectious Diseases, Department of Medicine Solna, Karolinska Institutet, Stockholm 171 77, Sweden.
⁵ Department of Oral Diagnostics Faculty of Odontology, Malmö University, Malmö 205 06, Sweden.
⁶ Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska University Hospital, Blå Stråket 5, Göteborg 413 45, Sweden.
⁷ Health Technology Assessment-Odontology (HTA-O), Faculty of Odontology, Malmö University, Malmö 205 06, Sweden.

Abstract

Background: It is not clear whether Viridans Group Streptococcal Infective Endocarditis (VGS-IE) among individuals at high risk is more frequent following bacteraemia caused by invasive dental procedures (IDPs) than after daily bacteraemia caused by chewing and tooth brushing. The aim of this nested study was to assess if VGS-IE was temporally associated with IDPs in a national cohort of individuals at high risk.

Methods: This nested case-control and case-crossover study was based on a Swedish national cohort study of 76,762 individuals at high risk of IE due to complex congenital heart disease, prosthetic heart valve or previous IE. Participants were living in Sweden between July 1st, 2008 and January 1st, 2018. The frequency of IDPs during the 3 months before VGS-IE was calculated and compared to controls (sampled 1:10). A case-crossover study was conducted to account for residual confounders. Participants were identified using the national patient register, and IDPs were identified using the national dental health register.

Findings: 98,247 IDPs were carried out in the cohort during the study period: 624 occasions of oral surgery, 44,190 extractions and 53,433 sessions of subgingival scaling. The study could not confirm that IDPs were more common among cases (4.6%) than controls (4.1%), OR = 1.22 [95% Confidence Interval (CI) 0.64-2.3], or during case- (3.3%) than reference periods (3.8%), OR = 0.89 [95% CI: 0.68-1.17]. Restricting the analysis to the period when cessation of antibiotic prophylaxis for the prevention of IE in Swedish dentistry was recommended, from the 1st of October 2012 to the 1st of January 2018, did not alter the results of the case-control study: OR 0.64, 95% CI: 0.20-2.09, or the case-crossover study: OR 0.58, 95% CI: 0.15-2.19.

Interpretation: The study could not confirm that VGS-IE is associated with IDPs among individuals at high risk. A study with larger sample size could clarify whether there is a lack of association. The finding of a small (<5%) proportion of cases temporally associated with IDPs is similar to that of the previous large-scale study on IDPs and VGS-IE.

Funding: Funding was provided by the Board of doctoral education at Karolinska Institutet, the Public Health Agency of Sweden, Folktandvården Stockholm AB, Steering Group for Collaborative Odontological Research at Karolinska Institutet and Stockholm City County, and the Swedish Dental Association.

Keywords: Dentistry; Infective endocarditis; Prophylactic antibiotics; Viridans group streptococci.