Archives of Gerontology and Geriatrics
Volume 36, Issue 1 , Pages 49-55, January 2003

Bacterial endocarditis of oral etiology in an elderly population

  • I. Tomás Carmona

      Affiliations

    • Department of Special Needs, Faculty of Medicine and Dentistry, Entrerrı́os s/n, Santiago de Compostela University, Santiago de Compostela, Spain
    • ,
  • J. Limeres Posse

      Affiliations

    • Department of Special Needs, Faculty of Medicine and Dentistry, Entrerrı́os s/n, Santiago de Compostela University, Santiago de Compostela, Spain
    • ,
  • P. Diz Dios

      Affiliations

    • Department of Special Needs, Faculty of Medicine and Dentistry, Entrerrı́os s/n, Santiago de Compostela University, Santiago de Compostela, Spain
    • Corresponding Author InformationCorresponding author. Tel.: +34-981-563100x2344; fax: +34-981-562226
    • ,
  • C. Mella Pérez

      Affiliations

    • Department of Internal Medicine, University Hospital, Santiago de Compostela, Spain

Received 24 January 2002; received in revised form 10 June 2002; accepted 29 June 2002.

Article Outline

Abstract 

The aim of this study was to analyze the prevalence and characteristics of bacterial endocarditis (BE) of oral origin in a group of elderly people. A retrospective study of 115 BE clinical records was performed, focusing on the demographic and predisposing features, as well as on the analytical and clinical variables. Twenty-two of the 115 cases were excluded as they were detected in intravenous drug users. Of the remaining 93 cases, 54.8% were diagnosed in patients older than 60 years of age (group A) and 45.2% in patients younger than 60 years (group B). There were 16 cases (17.2%) of oral origin; 4 BE cases mainly associated with tooth extractions were found in group A and 12 BE (most of them related with odontogenic abscesses) in group B. Within group A, 1 patient (25%) had not an underlying cardiac condition versus 5 cases (41.6%) in group B. Even though the prevalence of BE of oral origin in patients older than 60 is low, the high frequency of cardiopathies, poor oral health and high number of dental procedures shown by the old population makes them a risk group for BE of oral origin.

Keywords: Bacterial endocarditis, Oral etiology, Elderly patients

 

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1. Introduction 

In the past few years, several epidemiological studies have shown an increase in the incidence of bacterial endocarditis (BE), particularly in the elderly population (Watanakunakorn and Burkert, 1993, Hogevik et al., 1995). In Spain, in a series of 35 BE, Ribera Casado et al. (1971) observed that the patient mean age was 34 years and that only 1 patient was over 65. In 1995 a new review was carried out in the same hospital showing that the mean age of the BE patients had increased to 60 years of age and that 50% of them were over 65 (Domı́nguez Arganda et al., 1995).

Despite the controversy about the role of intraoral infections and dental procedures in the development of BE (Strom et al., 1998), several authors (Sandre and Shafran, 1996, Hricak et al., 1998, Sekido et al., 1999) have considered that the oral etiology is responsible for an important percentage of cases. Nevertheless, the studies in which the characteristics and the prevalence of BE of oral origin in the elderly population are specifically analyzed have been scarce (Terpenning et al., 1987, Selton-Suty et al., 1997), which in our opinion justified the present study.

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2. Material and methods 

Information was retrospectively collected from 115 cases of BE diagnosed in 108 patients, which were hospitalized between 1997 and 2001 in three public hospitals located in Galicia (Northwest Spain). The medical records were reviewed to obtain information about the patient's age and sex, BE diagnostic criteria, identified microorganisms in the blood cultures, underlying cardiac condition, presence of other diseases or concomitant infective processes, and surgical, medical or dental manipulations carried out within the 3 months previous to the development of BE. The cases were classified according to Duke's criteria (Durack et al., 1994). Twenty-two of the 115 cases of BE were excluded, since they were detected in intravenous drug users. Out of the other 93 cases, 51 (54.8%) were diagnosed in patients over 60 years of age (group A) and 42 (45.2%) in patients below 60 (group B). The oral cavity was considered to be the site of entry of the microorganisms in 17.2% of the cases (n=16) (Table 1).

Table 1. Age and sex distribution of a BE series
Age groups<20 years-old n (%)20–40 years-old n (%)40–60 years-old n (%)60–80 years-old n (%)>80 years-old n (%)
Total BE cases (n=93)2 (2.1)a11 (11.9)a29 (31.2)a48 (51.6)a3 (3.2)a
Male1825302
Female134181
Oral origin BE cases (n=16)1 (50)b3 (27.2)b8 (27.5)b4 (8.3)b0 (0)b
Male02710
Female11130

BE, Bacterial endocarditis.

a Percentage in relation to the total number of cases.

b Percentage in relation to the cases belonging to each age group.

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3. Results 

The number of patients suffering BE of oral etiology was 7.8% in group A (4 patients) and 28.5% in group B (12 patients) (Table 1). According to Duke's criteria, 75% were considered as definite BE and 25% as possible BE in both groups. While 75% of BE of oral origin (3 out of 4 cases) in patients over 60 years were female, only 25% in patients below 60 were women (3 out of 12 cases). In group A, 2 patients (50%) had no underlying ‘at risk’ cardiac condition according to the criteria of the American Heart Association (AHA) (Dajani et al., 1997) versus 5 cases (41.6%) in group B. In group A, 3 cases (75%) were related to previous dental treatment (mainly tooth extractions) and 1 patient (25%) had a concomitant oral infection. By contrast, most cases in group B (n=9; 75%) were associated with intraoral infections (mainly odontogenic abscesses). In group A, Streptococcus viridans was identified in 2 patients and Staphylococcus aureus in another patient. In group B, Streptococcus viridans caused 4 BE cases and microorganisms of the HACEK group 3 cases. These results are detailed in Table 2.

Table 2. Characteristics of patients with BE of oral origin (n=16)
Age (years)SexDuke's criteria‘At risk’ cardiac disease aType of oral infection or dental treatmentBloodstream culture
5FPossibleDuctus arteriosusOdontogenic abscessNegative
21FDefiniteValvular diseaseTooth extractionStreptococcus sanguis
27MDefiniteUnknownOdontogenic abscessStreptococcus viridans
38MDefiniteUnknownPulpitisStreptococcus viridans
48MDefiniteProsthetic valve and previous BEPeriodontal disease and pulpitisNegative
49MDefiniteProsthetic valveFillingsActinobacillus actinomycetemcomitans
49MPossibleUnknownPeriodontal disease and pulpitisNegative
49MDefiniteValvular diseaseScalingActinobacillus actinomycetemcomitans
50MDefiniteValvular diseasePulpitisStreptococcus bovis
54MDefiniteValvular diseasePulpitisKingella kingae
55FDefiniteUnknownOdontogenic abscessStreptococcus mutans
59FPossibleUnknownOdontogenic abscessNegative
66MDefiniteUnknownTooth extractionStreptococcus viridans
69FDefiniteHypertrophic cardiomyopathyProfessional cleaningStreptococcus mutans
69FDefiniteProsthetic valvePeriodontal diseaseStaphylococcus aureus
74FPossibleUnknownbTooth extractionNegative

F, Female; M, Male.

a ‘At risk’ cardiac disease defined following the AHA recommendation on antibiotic prophylaxis of BE (Dajani et al., 1997).

b Patient carriers of a pacemaker.

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4. Discussion 

In agreement with the findings from studies carried out in other countries (Sandre and Shafran, 1996, Hricak et al., 1998, Sekido et al., 1999), our results show that 17% of the BE have an oral origin. This etiology appears to be the most common in some series (Terpenning et al., 1987, Castillo Domı&#x0301;nguez et al., 2000). Nevertheless, Selton-Suty et al. (1997), in a prospective study of 114 cases diagnosed between 1990 and 1993, observed that the incidence of BE of oral origin in patients over 70 years of age was significantly lower than in younger patients (14.3% versus 31.1%). Although this conclusion was not shared by other authors (Terpenning et al., 1987), in our series the proportion of BE of oral origin decreased significantly in patients over 60 in relation to younger adults. This finding could be due to the fact that more than 50% of Spanish elderly are edentulous (Rodrı&#x0301;guez Baciero et al., 1998a), which results in a decreased risk of intraoral infections and dental interventions.

The majority of cases of BE of oral origin were detected in women. This result agrees with the predominance of women among the elderly, the high frequency of systemic and cardiac conditions predisposing to BE observed in women (Ribera Casado, 1998) and the preservation of a higher number of teeth in aged women than in men (Rodrı&#x0301;guez Baciero et al., 1998b).

It has been demonstrated that between 43% (Nissen et al., 1992) and 66% (Delahaye et al., 1995) of BE appear in patients who have suffered a previous heart disease. In our study, more than 55% of the BE cases of oral origin in patients below 60 and 75% in those over 60 had a previous diagnosis of cardiac pathology, which confirms that predisposing heart disease constitutes the main risk factor for BE (Strom et al., 1998), including those of oral etiology. Although 2 cases of BE of oral origin in patients over 60 presented ‘at risk’ heart disease according to the AHA criteria (Dajani et al., 1997), there was another case in a patient with a pacemaker. Changes in the heart morphology associated with aging and the high number of elderly patients with pacemaker, can predispose to endocardic discontinuity and bacterial invasion (Ribera Casado, 1998), which suggests a need to update the indications of BE prophylaxis in this age group.

Most patients below 60 suffered from BE of oral origin due to dental infections while the BE of those over 60 was often due to previous dental manipulation (mainly tooth extractions). Although aging is linked to progressive damage of the immunological system that increases the susceptibility to infections (Navazesh and Mulligan, 1995, Ribera Casado and Lázaro del Nogal, 1995), it has been shown that non-specific defense mechanisms (such as chemotactic capacity and intracellular killing activity of granulocytes) only decrease at a very advanced age (Corberand et al., 1981). Accordingly, studies about the prevalence of oral infections in elderly patients have shown that most odontogenic infections are chronic, asymptomatic and only detected by radiological study (Meurman et al., 1997, Narhi et al., 2000).

The number of tooth extractions increases with age, becoming one third of the dental treatments in patients over 65 (Estudio prospectivo Delphi, 1997a), which could explain why the risk of BE of oral origin becomes usually associated to dental procedures resulting in bleeding in this age group. Besides, in the elderly population is quite frequent the non-fulfilment of antibiotic therapy (Ribera Casado, 1998), with concomitant increase in the number of haemorrhage-causing dental interventions without appropriate antibiotic prophylaxis. In agreement with previous studies (Terpenning et al., 1987), Streptococcus viridans was the most common oral pathogen in the BE of oral etiology regardless the age group. Although Staphylococcus aureus is considered a skin microorganism and nocosomial pathogen, it has also been found in elderly subjects suffering from periodontitis (Owen, 1994, Younessi et al., 1998). This would explain why this microorganism was identified in the bloodstream cultures of one case of BE presumably related to periodontal disease, in the present series.

Taking into account the limitations related to retrospective studies, our results suggest that prevalence of BE of oral origin is lower in patients over 60, probably because of the high number of edentulous patients (Rodrı&#x0301;guez Baciero et al., 1998a). Nevertheless, the significant frequency of cardiac conditions, high levels of caries and periodontal disease (Rodrı&#x0301;guez Baciero et al., 1998a, Rodrı&#x0301;guez Baciero et al., 1998c), scarce self-awareness of the oral health problems, insufficient oral hygiene habits (Estudio prospectivo Delphi, 1997b) and the rather high number of oral surgical procedures carried out on these patients, make the population over 60 an important risk group of BE of oral origin.

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PII: S0167-4943(02)00054-7

Archives of Gerontology and Geriatrics
Volume 36, Issue 1 , Pages 49-55, January 2003

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