Endocarditi infettive e patologia del cavo orale

Introduction. The Infective Endocarditis is a rare disease of the endocardium and subendocardium. If untreated it is always fatal. Prophylaxis guidelines that have been published since the 1950s, always focused on dental procedures as a source of bacteremia causing Infective Endocarditis, rather than on daily activities like tooth brushing or chewing food. Aim of the study. To assess if the state of oral health in patients with Infective Endocarditis may be considered a predisposing factor for developing Infective Endocarditis; to analyse underlying cardiac conditions associated with the risk to develop Infective Endocarditis and if presence of comorbid factors such as diabetes mellitus, immunosuppression and dialysis may increase the risk of adverse outcome from Infective Endocarditis in these patients. To define when Infective Endocarditis prophylaxis is or is not recommended for dental procedures. Material and Methods. We enrolled two patients groups: Group Cases 1 from the Unit of Cardiovascular Pathology database, Hospital of Padova (177 patients), Group Cases 2 from the Unit of Infective and Tropical Diseases database, Hospital of Padova (70 patients). For each patient medical records were taken in order to analyse the presence of underlying cardiac conditions, stratified according to the American Heart Association classification 1997, and to review radiographic material useful for the state of health of the oral cavity. Three Control Groups were identified: the Control Group 1, constituted by healthy patients (70 patients), the Control Group 2 constituted by patients with not infective cardiovascular diseases (50 patients), the Control Group 3 constituted by patients with comorbid conditions. Group Cases 2 and Control Groups were separately analyzed with Chi Square test with 95% Confidence; Odd Ratio, Sensibility and Specificity tests, Positive and Negative Likelihood Ratio. Results. In Group Cases 1 and 2, Aortic Valve is the most affected site (57.9%), followed by Mitral Valve (31.2%) and both Aortic and Mitral Valve (4.4%). The most frequent underlying cardiac conditions were: bicuspid aortic valve (11.9%), aortic bioprosthesis (11.9%) and “floppy” mitral valve (10.7%) in Group Cases 1; aortic valve bioprosthesis (11.4%), non-rheumatic aortic valve stenosis (8.6%) and bicuspid aortic valve (5.7%) in Group Cases 2. In Group Cases 1 death occurred in patients with underlying cardiac conditions associated with high, moderate and negligible risk of adverse outcome according to American Heart Association 2007 and with systemic comorbid conditions. In Group 2 death occurred only in 4 patients with underlying cardiac conditions associated with high-risk of adverse outcome. Microorganisms were identified in only 60 cases in patients of Group Cases 1; 30% of them belonged to the oropharyngeal flora. in the two patients who underwent dental procedures in 3 previous months it was not possible to isolate the microorganism. In two patients affected by endo-periodontal disease endocarditis ascribable to microbic flora, arose without any dental procedures. In the Group Cases 2, in 15 patients endocarditis was due a microorganism belonging to oral flora. Dental procedure were performed in four cases and in only one antibiotic prophylaxis was done. Endodontic and/or parodontic diseases were present in 81.4% of patients from Group Cases 2, in 55.9% of patients from Control Group 1 , in 75% of patients from Control Group 2 and in 88% of patients of Control Group 3. Thus, patients with endodontic and/or parodontic diseases present an high risk for developing Infective Endocarditis in Control Group 1 (OR 3.692) and in Control Group 3 (OR 1.406) compared with Control Group 2 (OR 0.598). Conclusions. Infective Endocarditis arose mainly in bicuspid aortic valve and bioprosthesis valve followed by floppy mitral valve. An important relationship exists between systemic co-morbid factors and underlying cardiac conditions at high risk for poor prognosis for Infective Endocarditis. We didn’t find association between dental care and occurrence of Infective Endocarditis due to microorganisms of the oral cavity. Nevertheless patients with endo-periodontal diseases are prone to development of endocarditis. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities (brushing teeth and chewing). Thus people at risk of developing Infective Endocarditis should have an high standard of oral health including endodontic and periodontal therapy