A survey to evaluate the management of orthodontic patients with a history of rheumatic fever or congenital heart disease

A survey to evaluate the management of orthodontic patients with a history of rheumatic fever or congenital heart disease

A Dr. Gaidry

Donald Gaidry, D.D.S.: Earl M. Kudlick, D.D.S., M.S.D.,** Jack G. Hutton, Jr., Ph.D.,** and Donald M. Russell, D.D.S.**** Washington, D.C. A survey concerning the orthodontic management of patients with a history of rheumatic fever or congenital heart disease was mailed to a random sample of 5SO orthodontists throughout the United States. Two hundred thirtytwo surveys were completed and returned. Analysis revealed that 88% of the respondents were aware that they should screen for patients with a history of rheumatic fever or congenital heart disease, only 11% used the antibiotic regimen recommended in 1977 by the American Heart Association” (see Fig. 2) one half of the respondents thought it was necessary to provide antibiotic coverage during banding, and 38% deemed it necessary for debanding procedures which were likely to cause some degree of bleeding from the gingival sulcus. Only one half of the respondents would discontinue treatment if a condition of gingivitis developed which did not show signs of improvement, and only 70% provided medication for orthodontic procedures that could result in bacteremia. Furthermore, the results of this survey indicated that there was a great variation in the antibiotic regimen of orthodontic treatment for patients at risk of developing endocarditis and that there was a need to make the orthodontist more aware of the 1977 recommendations of the American Heart Association.” Finally, a comparison between the year of graduation from an orthodontic program and the number of respondents who did not screen for or did not premeditate at-risk patients revealed a direct relationship. The earlier the education, the smaller the number of respondents who screened or premed&ted. This survey revealed that a relatively high percentage of orthodontists do not premeditate patients who are at risk of developing bacterial endocarditis, and it was found that, of those who did premedicate, a great variation existed in their premeditation regimens. This information indicates a need for the practicing orthodontist to review the most current recommendations of the American Heart Association, but it must be emphasized that the American Heart Association guidelines have just been revised (see Fig. 1) and, therefore, the orthodontist should be alerted for future changes in order to be current and also to be legally protected.

Key words: Management, rheumatic fever, congenital heart disease,patients

I

t has generally been accepted that dental procedures performed without appropriate precautions on patients with predisposing conditions, such as rheumatic heart disease, congenital cardiac malformations, previous cardiac surgery, and the use of prosthetic heart valves, may lead to the development of infectious endocarditis. Endocarditis is defined as an inflammation of the endocardium (lining membrane of the heart). It may involve only the membrane covering the valves (valvular) or the general lining of the heart (mural). When the endocardium becomes infected with microorganisms that have entered the circulation (via dental procedures, through the gingiva, and/or the oral muFrom Howard University College of Dentistry. This paper was submitted as a thesis to the Department of Orthodontics by Donald Gaidry in partial fulfillment of the requirements for a certificate of proficiency in orthodontics in 1980. *Now practicing at 1549-C Polk St., Houma, La. **Associate Professor, Department of Orthodontics. ***Educational Psychologist and Professor. ****Acting Chairman, Department of Orthodontics.

338

cosa), the progressive destruction of the endocardium may lead to anemia, toxemia, and ultimately cardiac failure, the most common cause of death in these patients. The purpose of this study was to investigate the management of orthodontic patients by orthodontists who are at risk of developing bacterial endocarditis. It was conducted through a survey taken from a large random sample of practicing orthodontists in the United States. REVIEW OF THE LITERATURE

Degling6 stated that no reference could be found specifically tailoring antibiotic coverage for orthodontic treatment of the heart-damaged patient. Mostaghim and Millard” examined the medical records of 60 patients with bacterial endocarditis at the University of Michigan Hospital from 1962 to 1972. Oral conditions and dental procedures were related to

Volume 81 Number 4

Management

the onset of bacterial endocarditis in 14% of these patients. The dental procedures included prophylaxis, tooth capping, orthodontic treatment, root canal therapy, and extractions. In addition, treatment was given for periocoronitis and dental abscess. The mortality rate for these patients during the 10 years of study was 3ygo 1.4, 5,7,8. 18 Although the risks of bacterial endocarditis in patients with a history of rheumatic fever or congenital heart disease were small, patients with a previous episode of bacterial endocarditis or patients with prosthetic heart valves were very susceptible to bacterial endocarditis. Morgan and Bland’* have shown that, of 119 patients successfully treated for subacute bacterial endocarditis, there was an 8.5% recurrence 6 months to 10 years after the initial episode. Kay14.stated that transient bacteremia that could result in the development of endocarditis has been known to be caused by a variety of dental procedures, such as extraction of teeth, periodontal surgery, endodontic procedures, brushing of teeth, dental prophylaxis, filling of teeth, and the use of oral irrigation devices. Some of these procedures were more likely to produce a bacteremia than others, and it appeared to be related to the amount of tissue manipulation involved and to the condition of the gingival tissues. In spite of the fact that a variety of dental procedures produce a bacteremia, many patients with a history of rheumatic fever or congenital heart disease were not adequately protected during such procedures. McGowan and Tuohy,” in a survey of 113 patients with heart lesions in which prophylactic antibiotic therapy would have been appropriate prior to dental treatment, found that 77% of these patients were not given prophylactic antibiotic therapy. In 1977 the American Heart Association’s Committee on Prevention of Bacterial Endocarditis met and reported on current recommendations for dental and surgical procedures of the upper respiratory tract.” It was suggested that patients at risk of developing infectious endocarditis should maintain the highest level of oral health possible in order to reduce potential sources of bacterial seeding. “3 “, 24 In 1984 the American Heart Association Committee on Prevention of Bacterial Endocarditis met and updated the 1977 report (see Fig. 1). This adds more significance to results of an investigation by Bloom and Brown3 which established that the mean population of bacteria in the oral cavity increases with the placement of orthodontic bands. However, Degling6 did not find transient bacteremia on banding and debanding procedures. Zachrisson and Zachrissonz6 conducted a clinical study of 49 patients

of patients with rheumatic fever or congenital

heart disease

339

with fixed appliances. The results demonstrated that, in spite of good cleaning, most children developed generalized moderate hyperplastic gingivitis within 1 to 2 months after the placement of appliances. It has been recommended that any orthodontic procedure that would induce bleeding, such as banding or debanding, should be preceded by chemoprophylaxis 30 minutes to 1 hour prior to the procedure.16 Premedication was not considered necessary for routine orthodontic adjustments. I6 Antibiotics should not be administered for too long a period of time before the dental procedure. Garrod and Waterworth have shown that this practice would allow a resistant flora to be established in the oral cavity; therefore, penicillin coverage for dental treatment should begin immediately before the procedure. Patients receiving penicillin in a minimal daily dosage not related to dental treatment should have received prophylactic coverage with another bactericidal agent prior to dental procedures. ” The American Heart Association committee recognized that it was not possible to make recommendations for all clinical situations. It suggested that practitioners exercise clinical judgment in determining the duration and choice of antibiotic prophylaxis. Physicians and dentists should maintain a high index of suspicion in the interpretation of any unusual clinical events following a procedure that could produce a bacteremia. Early diagnosis would be important in order to reduce complications, sequelae, and mortality.” MATERIALS AND METHODS

A list of questions considered pertinent to orthodontic treatment of patients with a history of rheumatic fever or congenital heart disease was constructed (see Fig. 2). These questions were grouped into the following areas: medical history, medication and treatment, and oral hygiene procedures. In order to improve the design and thereby increase the rate of response, the questionnaire was pretested by having members of the Howard University orthodontic faculty review it and comment upon the relevance and clarity of the questions, and then it was sent to a professional research corporation for criticism. Most questions were designed to allow the participant an opportunity for comment under the category “Other.” The last question was designed to see if those orthodontists who graduated earlier placed less emphasis on premeditation and medical history screening of rheumatic fever and patients with congenital heart defects (see Fig. 3). A covering letter (see Fig. 4), the questionnaire, and a postage-paid return envelope were sent to a ran-

340

Gaidry et al. TABLE

1

TABLE

Cardiac

Conditions*

Summary

Endocarditis

Prophylaxis

Prosthetic

cardiac

Most congenital

cardiac

constructed

Rheumatic

and other acquired

Mitral

history

of bacterial

proccdurcs

shunts

gingival

bleeding.

dysfunction

spirarory

stenosis

Standard chat cause and or&c-

tract surgery

without

a patch

and divided

six or more

of

surgery

e.g.. for parients with prosthetic valves

but is not meant to be all-inclu-

mitral valve prolapse are particularly

in managemenr limited.

units six hours substirutcd

later may

one-half

procedure.

Which

Endocnrditis

Prophylaxis

adjuslmenl teeth) Tonsillectomy Surgical Incision

and/or

procedures

Bronchoscopy,

for penicillin-aller-

Erythromycin

10 induce

gingival

appliances

bleeding

or shedding

or biopsy

respirarory

of infected

(not simple

fore. sary doses: Ampicillin

mucosa

penicillin

as listed in text

is low. but the necessity TABLE Summary urinnry

for follow-up);

(25,000

units/kg

intervals

between doses are rhe same as for ndulrs

vancomycin

G 50.000

Regimens

Total due\

for GaslrointeslinallGenito-

Procedures Standard Regimen Ampicillin

For gcnitourinarylgastroinlestinal tract procedures

listed

in rhe

text

2.0 g IM or IV plus

gentamicin

I.5

mglkg

IM

or

IV. given one-half 10 one hour before procedure. One followup dose may be given eight hours lawr Special Regimens

Oral regimen for minor or repethive procedures

in low-risk

pa-

Amoxicillin 3.0 g orally one hour before procedure and I .5 g six hours later

rienrs Fenicillin-allergic

patients

Vancomycin I .O g IV s/o+ over one hour. plus gentamicin I .5 mg/kg IM OF IV given one hour before procedure. May be repeated once 8-l 2 hours later

Note: Pediorricdoses:

Ampicillin

mg/kg per dose; amoxicillin

50 @kg

50 mgikgperdose:

genramicin

per dose; vancomycin

2.0

20 mg/kg

per dose. The intervals between doses are the same as for adults. Total doses should not exceed adult doses.

Fig. 1. Tables l123A-1127A,

1 through 4 from 1984 (reproduced

Shulman ST: Prevention of bacterial by permission of the American Heart

endocarditis. Association).

adull

unicsikp

20 mgikg per dose

4 of Recommended

one

2.0 mg/kg per dose.

V full adult dose if greater than 60 lb (27 kg), one-half

not exceed adult doses.

for

g orally

rhen 500 mg SIX

50 mgikg per dose; erythromyclrl

20 mg/kg for first dose, then IO mg/kg; gentamicin

tissue

AThe risk with flexible bronchoscopy prophylaxis is not yet defined.

parcnrer;~l

No rcpunt dose is neces-

dose if less than 60 lb (27 kg); aqueous pemcillin

procedures

the

Vancomycln I .O g IV .s/ow/~ over one hour, :.inning ow iuii h:

of deciduous

with a rigid bronchoscope”

and gastmintesrinal

for penicillin-

paticms

Note: Pediatric

involving

V six hours law

I.0

hour before, hours later

Parenteral regimen

Is Indicaled

adenoidectomy

especially

and drainage

Genitourinary

likely

of orthodontic

before

by I 0 p

eighr hours law Oral regimen

allergic All dental procedures

hc

regimen may be repeated once

Ir is clear 01~ in general

gic patients

for

hour

followed

Alternatively.

of patients with

such patients are at low risk of development ofendocarditis, but Ihe riskbenefit ratio of prophylaxis in mitral valve prolapse is uncertain.

TABLE 2 Procc~luws

minutes beand I m11!1otl

oral pemcillin data lo provide guidance

Imilllon

penia!hn

fore a procedure

or IV,

sive. BDcfinilivc

2

aqueous

Special Regimens for use when Ampicillin 1.0-2.0 g IM or IV protection desired; plus gentamicin I .5 mgikg IM

maximal artery bypass graft (CABG) conditions

unable 10 t.tkc

mcdicaions,

Parenteral regimen

months earlier

AThis table lists common

V 2 0 g orally one houi then I .O g six hour\ 1:,1-

G IV or IM 30-60

earlier

coronary

Penicillin bcfvrc.

units

atrial septal defect

six or more months

for Dental/Respi-

Regimen

oral

Not Recommended:

Parenr ducrus a~teriosus ligarcd

Regimens

cr. For palicnts

(IHSS)

endocarditis

atrial septal defect repaired

Postoperative

Antibiotic

with insuficiencyB

Prophylaxis

Isolated secundum Sccundum

valvular

subsonic

valve prolapse

Endocarditis

valves) For dcnlal

systemic-pulmonary

Idiopa.lhic hypertrophic Previous

biosynthetic

malformarions

Surgically

of Recommended Tract Procedures

ratory

Recommended:

valves (including

3

Circulation

70:

The

should

Volume 87 Number 4

Management

of patients with rheumatic fever or congenital

341

heart disease

QUESTIONNAIRE RESULTS Question 1. Do you screen for patients with a history of rheumatic fever or congenital heart disease in your method of obtaining the patient’s medical history? A. Yes B. No 2. Do you request a medical consultation with the physician of the rheumatic fever or congenital heart disease patient? A. Yes B. No C. Other 3. Do you refuse orthodontic treatment to patients with a history of rheumatic fever or congenital heart disease? A. Yes B. No C. Other 4. Do you refuse orthodontic treatment to rheumatic fever or congenital heart disease patients who have been treated for bacterial endocarditis? A. Yes B. No C. Other 5. What is your regimen of antibiotic treatment for patients with history of rheumatic fever or congenital heart disease who are on daily doses of antibiotics for their condition? A. No change in their regular daily doses of antibiotics B. Consult with physician C. Other 6. Do you premeditate with antibiotics patients with history of rheumatic fever or congenital heart disease for one or any of the following procedures? (May have multiple response) A. Alginate impressions B During palatal expansion with a Haas appliance C. Manipulation or activation of an attachment to an impacted tooth such as an impacted cuspid D. Banding procedures E. Debanding procedures F. Bonding procedures G. Debonding procedures H. Other 7. What is your regimen of antibiotic medication for orthodontic patients with a history of rheumatic fever or congenital heart disease? (May have multiple response)

Percentage of response

88 12

8.

64 26

10

a.4 93 6.6

9. 0.4 80 19.6

21 75 4

10.

4 18 42

11.

51 38 7

Question A. No medication B. Medication during the entire duration of treatment (daily) C. Medication for the day of the procedure and two days following the procedure D. Medication for the day previous to the procedure, the day of the procedure, and two days following the procedure E. Other Given an office emergency situation in which orthodontic appliances cause minor laceration or ulcer formation of oral mucosa in patients with history of rheumatic fever or congenital heart disease, what procedure would you follow? (May have multiple response)* A. Remove the appliance causing the irritation B. Prescribe antibiotics C. Consult physician D. Other What type of oral hygiene aid devices or procedures do you recommend for patients with a history of rheumatic fever or congenital heart disease?* A. Toothbrush B. Floss C Water-Pik D. Perio-Aid or Stimudent E. Plaque-staining tablets or liquids F. Tongue scraper G. Diet control (reduce sugars) H. Other What procedure would you follow if, during the course of treatment, the patient with history of rheumatic fever or congenital heart disease no longer demonstrated adequate periodontal health with accompanying hypertrophy of the gingival tissue?* A. Continue treatment with reinforced oral hygiene techniques B. Discontinue treatment if there is no improvement in gingival tissue condition C. Other? Year of graduation See Fig. 3.

Percentage of response 21 2

11 35

23

52 26 54

1

92 33 54 12 28 4 36 3

49 50 22

*Percentage of responses is more than 100% because of single and conwined answers. tin addition to answers A and B, some practitioners added their own procedures.

15 16

Fig.

2.

342

Gaidry et al.

Comparison between the year of graduation and the number of respondents who did not screen for or did not premeditate at-risk patients Group I Pi-e-1950 201232

Group II 1950-1959 471232

Group III 1960-1969 761232

Group IV 1970-1979 891232

30% 45%

17% 28%

6.6% 17%

5% 11%

Did not screen for at-risk patients Did not premeditate at-risk patients

Flg. 3. Response to Question 11. Dear

Doctor:

The Department of Orthodontics at Howard University part of its ongoing research program is collecting c'ata regarding the regimen of orthodontic treatment of patients a history of rheumatic fever or cogenital heart disease.

as a with

The research design provides for the selection of orthodontists, from a random sample, throughout the United States. In this regard, I am asking that you assist us by providing information regarding your management of patients with rheumatic fever or congenital heart disease. Your reply will research project. A data collected to be identify yourself in collected and assessed bias.

be most helpful to the success of this large response is needed in order for the statistically significant. Please do not any manner, since we wish the data to be with anonymity and with the least possible

Your cooperation in completing the questionnaire at your earliest convenience and returning it to us in the enclosed preaddressed stamped envelope will be greatly appreciated. A resume of the results will be available upon request sometime Requests should be sent to: in late 1980. Don Gaidry, D.D.S. Department of Orthodontics Howard University College of Dentistry 600 W Street, N.W. Washington, D.C. 20059 Thank

you

for

your

cooperation

in

this

research

project.

Sincerely,

.Dod fL+&+ Don

Gaidry,

D.D.S.

Fig. 4.

dom sample of 500 practicing orthodontists in the United States whose names appeared in the index of the 1978 Orthodontic Directory. The response to each question of the survey was recorded in percentages indicating the frequency of response (see Fig.2). RESULTS

The number of questionnaires completed and returned was 232 (46%) while twenty-five questionnaires (5%) were returned with notices of incorrect addresses. Some participants elected to comment rather than answer a particular question. In response to questions 2

through 4 several participants, under the reply of “Other,” indicated that they would consult with a physician. The responses of the participants to the questionnaire may be found in Fig. 2. Each question in the table is listed with the percentage of responses to enable the reader to evaluate the question and the response for himself. The results of this survey indicated that 21% of a representative sample of United States orthodontists did not use prophylactic antibiotic protection for their patients with rheumatic fever or congenital heart disease. Of the 79% who did, only 11% demonstrated knowl-

Volume 81 Number 4

Management of patients with rheumatic fever or congenital heart disease 343

edge of the current antibiotic regimen recommended by the American Heart Association. Although the survey indicated that 88% of the orthodontists did screen for patients who were at risk of developing bacterial endocarditis, most did not follow pretreatment recommendations. It was interesting to note that 35% of the practitioners began to premeditate their patients the day prior to the procedures, which is unnecessary and might induce growth of antibiotic-resistant strains of bacteria.’ Twenty-one percent of the respondents did not change the regimen of antibiotic treatment for patients already on daily doses of antibiotics. I2 The American Heart Association” has recommended that patients receiving continuous oral penicillin should be covered with erythromycin or a combination of penicillin and streptomycin for dental or surgical procedures involving the upper respiratory tract. Ninety-three percent of the respondents thought that a history of rheumatic fever or congenital heart disease was not a contraindication to orthodontic treatment, and 80% indicated that they would treat patients with a history of bacterial endocarditis. In an orthodontic emergency situation in which orthodontic appliances would cause minor laceration or ulcer formation of the oral mucosa, only 52% of the practitioners would remove the appliance causing the irritation; 26% would prescribe antibiotics. The dosage and duration of antibiotics listed by the respondents were quite varied. Forty-one respondents listed their choice of dosage and duration of antibiotics. When the responses were grouped according to similarity, it was found that there were 21 different responses. Fifty-four percent believed it would be necessary to consult a physician in emergency cases. The orthodontic procedures considered by the respondents most likely to need antibiotic coverage were banding (5 I%), manipulation of an attachment to an impacted tooth (42%), and debanding (38%). These responses should be considered far too low, assuming that bleeding could be a common occurrence in any of the procedures in question 6. Any oral procedures that would cause bleeding may be considered a risk to these patients. Sixteen percent answered question 6 with a comment that they would consult with a physician for all of the listed procedures. It is preferable that oral hygiene be maximized before orthodontic procedures are undertaken. The oral hygiene aid devices most frequently recommended were the toothbrush (92%) and the Water-Pik (54%). Approximately 33% suggested that their patients use floss and diet control. A small percentage incorporated the use of the Perio-Aid (12%) and the tongue scraper (4%). When at-risk patients developed gingivitis during the

course of orthodontic treatment, their treatment was discontinued by 50% of the respondents. Thirty percent of Group I respondents (orthodontists who graduated before 1950) did not screen for patients with a history of rheumatic fever or congenital heart disease, and 45% of Group I respondents did not prescribe antibiotics for at-risk patients. Five percent of Group IV (orthodontists who graduated between 1970 and 1978) did not screen for rheumatic fever or congenital heart disease patients, and 11% of Group IV respondents did not premeditate such patients. DISCUSSION

Patients are more susceptible to gingival tissue problems when orthodontic appliances are placed. Oral hygiene and periodontal conditions should be closely scrutinized since the American Heart Association” stated: “Even in the absence of dental procedures, poor dental hygiene or other disease such as periodontal or periapical infections may induce bacteremia.” In the American Heart Association committee report,” it was suggested that ulcers caused by ill-fitting dentures could be a source of bacteremia and should be cared for promptly. This situation could be likened to the orthodontic office emergency situation in which the source of irritation should be cared for by adjustment or removal of the appliance and antibiotics should be administered if bacteremia was suspected. The American Heart AssociatiotQ3 further suggested that the toothbrush, floss, disclosing tablets, diet control, and fluoride be used. .In these patients dental floss should never be snapped into the gingivae but should be moved carefully up and down, scraping the sides of the tooth. Mention was made that oral irrigation devices may cause bacteremia and that patients should check with their physicians before using such devices. Although intravascular localization of microbes was a rare event, considering the frequency of bacteremia,” it has been demonstrated by Morgan and Bland’* that there was an 8% to 9% recurrence rate of bacterial endocarditis in patients with a previous episode. However, 80% of the respondents indicated that they would treat patients who had a history of bacterial endocarditis . Premeditation for routine appointments such as changing of orthodontic arch wires is not necessary but depends upon the judgment of the dentist and the maintenance of good oral hygiene by the patient. It should be noted that “home-care” procedures, such as flossing (which is accompanied by bleeding), should be cause for concern and the patient’s physician may be consulted. However, bacterial endocarditis associated with the use of dental floss has not been reported.” Similarly,

344

Am. J. Orthod. April 1985

Gaidry et al.

the spontaneous loss of deciduous teeth has not been shown to cause bacteremia.” It should be noted that question 11 (see Fig. 2) requested the year of graduation; it was assumed that the respondents would list the date of completion of their orthodontic training. In light of the recommendations of the American Heart Association (see Fig. l), it seems appropriate to conclude that a number of orthodontic practitioners should review their patient-management procedures with a view to more fully following present state-ofthe-art therapeutic measures. REFERENCES 1. Bender IB, et al: Dental procedures in patients with rheumatic heart disease. Oral Surg Oral Med Oral Path01 16: 466-473, 1963. 2. Berger SA, et al: Bacteremia after the use of an oral irrigation device; a controlled study in subjects with normal appearing gingiva; comparison with use of toothbrush. Ann Intern Med 90: 510-511, 1974. 3. Bloom RH, Brown ER Jr: A study of the effects of orthodontic appliances on the oral flora. Oral Surg Oral Med Oral Path01 17: 658-667, 1964. 4. Cates JE, Christie RV: Subacute bacterial endocarditis; a review of 442 patients treated in 14 centres appointed by Trails Committee of Medical Research Council. Q .I Med 20: 93, 1951. 5. Croxan MS, Altmann MM, O’Grien KP: Dental status and recurrence of Streptococcus viridans endocarditis. Lancet 1: 12051207, 1971. 6. Degling TB: Orthodontics, bacteremia, and the heart damaged patient. Angle Orthod 42: 399-402, 1972. 7. Dormer AE: Bacterial endocarditis; survey of patients between 1945 and 1956. Br Med J 1: 63-69, 1958. 8. Eisenbud L: Subacute bacterial endocarditis precipitated by nonsurgical dental procedures. Oral Surg Oral Med Oral Path01 15: 624-627, 1962. 9. Garrod LP, Waterworth PM: The risks of dental extraction during penicillin treatment. Br Heart J 24: 39-46, 1962. 10. Harvey PW, Gapone MA: Bacterial endocarditis related to cleaning and filling of teeth. Am J Cardiol 7: 793-798, 1961.

11. Kaplan EL, et al: Prevention of bacterial endocarditis. Circulation 56: 139A-143A, 1977. 12. Kaplan EL, et al: Prevention of rheumatic fever. Circulation 55: 1-4, 1977. 13. Kaplan EL, et al: Dental care for children with heart disease. Dallas, 1979, American Heart Association. 14. Kaye D: Infective endocarditis. Baltimore, 1976, University Park Press, pp. 247-250. 15. McGowan DA, Tuohy 0: Dental treatment of patients with valvular heart disease. Br Dent J 124: 519-520, 1968. 16. Millard I-ID (representative of the American Heart Association; Council: Cardiovascular Disease in the young; Committee: Rheumatic Fever and Cardiovascular Disease): Personal comrnunication, Nov. 26, 1978. 17. Monroe CO, Lazarus TL: Predisposing conditions of infective endocarditis. Can Dent Assoc J 42: 483-488, 1976. 18. Morgan WL, Bland El? Bacterial endocarditis in the antibiotic era with special reference to the later complications. Circulation 19: 753-765, 1959. 19. Mostaghim D, Millard HD: Bacterial endocarditis: a retrospective study. Oral Surg Oral Med Oral Path01 40: 219-233, 1975. 20. Pankey GA: Subacute bacterial endocarditis at the University of Minnesota Hospital, 1939 through 1959. Ann Intern Med 55: 550-561, 1961. 21. Pogrel MA, Welsby PD: The dentist and prevention of infective endocarditis. Br Dent J 139: 12-16, 1975. 22. Professional Research, Inc: Personal communication, Oct. 12, 1979. 23. Sipes JN, Thompson RL, Hook EW: Prophylaxis of infective endocarditis: a reevaluation. AM Rev Med 28: 371-391, 1977. 24. Slaughter L, Morris JE, Starr A: Prosthetic valvularendocarditis; a 12-year review. Circulation 47: 1319-1326, 1973. 25. Macedo-Sobrinho B: Infective endocarditis: is it being neglected within the dental profession. Clin Prev Dent 1: 14-19, 1979. 26. Zachrisson S, Zachrisson BU: Gingival condition associatedwith orthodontic treatment. Angle Orthod 42: 26-33, 1972. 27. Shulman ST: Prevention of bacterial endocarditis. Circulation 70: 1123A-1127A, 1984. Reprint

requests

to:

Dr. Earl Kudlick 2277 Be1 Pre Rd. Silver Spring, MD 209%