ORIGINAL ARTICLE

Infective endocarditis and orthodontic
implications in children: A review of theliterature
Yona R. Vandersluisa and Sunjay Suria,bToronto, Ontario, Canada
Introduction: Owing to access to high-quality medical care, more medically compromised patients are seeking
orthodontic therapy, including those at risk of developing infective endocarditis (IE). The current guidelines fororthodontic therapy and IE are few. The objective of this review is to provide an evidence-based update on
the relationship between orthodontic procedures and IE in children. Methods: A comprehensive review of the
English language literature available through PubMed, Ovid Medline, and Google Scholar without any limitsof years of publication was conducted to analyze the evidence regarding IE and orthodontics. Literature
Review: A necessary prerequisite for IE is bacteremia. Although the only orthodontic procedure included in
the current American Heart Association guidelines is the placement of bands, placement of separators has
also been found to lead to signiﬁcant bacteremia. Procedures with possible clinical signiﬁcance include removalof expanders, placement of separators, and placement of bands. Because of the unavailability of high-quality
evidence, elective invasive procedures prone to causing bacteremia should be avoided. Conclusions: Evidence regarding orthodontic treatment and IE is limited because of ethical considerations of conducting trials
in patients who are at risk for IE. Clinical interpretation based on a comprehensive review of the available literature is therefore essential. Clinical Implications: Before initiating orthodontic therapy in cardiac patients, thepatient's IE risk is best determined by referring to the current American Heart Association guidelines and throughconsultation with the patient's cardiologist. Procedures that can lead to tissue injury or bacteremia should be
avoided. Oral hygiene must be reinforced because inﬂammation inﬂuences bacteremia. (Am J Orthod
Dentofacial Orthop 2020;157:19-28)

O

rthodontic treatment is an elective procedure forall patients.1 On average, 67% of patients in orthodontic practices are children aged 8-17 years.2
Owing to improvements in medical care and life expectancies and increased expectations for enhanced qualityof life, a greater number of children with medical conditions receive orthodontic treatment today.1,3 Children
with cardiac disorders may be encountered in orthodontic practice because the annual birth prevalence ofcongenital cardiac defects ranges from 2.4 to 13.7 per1000 live births.4 Although orthodontics is perceivedaGraduate Orthodontics, Faculty of Dentistry, University of Toronto, Toronto,
Ontario, Canada.
bDivision of Orthodontics, Department of Dentistry, The Hospital for Sick Children, Toronto, Ontario, Canada.
All authors have completed and submitted the ICMJE Form for Disclosure of Potential Conﬂicts of Interest, and none were reported.
Address correspondence to: Sunjay Suri, Graduate Orthodontics, Faculty of
Dentistry, University of Toronto, Room 345-B, 124 Edward Street, Toronto, Ontario M5G 1G6, Canada; e-mail, sunjaysuri@hotmail.com.
Submitted, February 2019; revised and accepted, March 2019.
0889-5406/$36.00
Ó 2019 by the American Association of Orthodontists. All rights reserved.
https://doi.org/10.1016/j.ajodo.2019.03.027

to be the least invasive form of dentistry, there are potential risks for cardiac compromised patients thatmust be considered, and special precautions are required
to minimize complications.3,5
Infective endocarditis (IE), an infection of the endocardial surface of the heart, including the heart valves,the mural endocardium, and the septum,5 has serious
and life-threatening implications.6,7 Its incidence isrelatively low, ranging from 0.05 to 0.12 cases per1000 pediatric admissions.8 Although hard to measure,most cases of IE are not attributed to invasive dental
procedures.7
For more than 50 years, the American Heart Association (AHA) has provided guidelines for the prevention of
IE in association with dental procedures,9 based on an
accumulation of the best available evidence. However,
the guidelines for orthodontic therapy and IE are minimal, and the available literature is unclear because of alack of high-quality evidence. The purpose of this narrative review is to provide an evidence-based update on
the relationship between orthodontic procedures and
IE in children with cardiac conditions.
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MATERIAL AND METHODS

PubMed, Ovid Medline, and Google Scholar weresearched for published English language articles on IE
and orthodontics. The literature search was conducted
between October 2017 and December 2018, and thesearch terms included endocarditis, antibiotic prophylaxis, cardiac, medical disorders, medically compromised, orthodontics, and dentistry. A manual search of
the references of selected articles was also conducted.
There were no limits regarding the years of publication.
Because of the nature of this serious and life-threatening
condition, high-quality studies, such as randomized
controlled trials, were lacking. The available literature allowed interpreting and reporting a narrative synthesis.
LITERATURE REVIEW
Pathophysiology of IE

A necessary prerequisite for the development of IE isbacteremia. When bacteria enter the bloodstream in
healthy individuals, the immune system clears the bacteria within a few minutes.10 This is not the case in patientswith cardiac abnormalities who are predisposed to developing IE, where bacteremia can have dangerous consequences.10,11
Viridans group streptococci, found on the skin, oral
mucosa, gastrointestinal (GI) ﬂora, and respiratory tract,cause at least 50% of native valve IE.9 Endothelial damage and high pressure or turbulent blood ﬂow attracts
ﬁbrin and platelets, which create a nonbacterial thrombotic endocarditis.10,11 Mucosal surfaces of the body are
populated by endogenous microﬂora and damage tothese surfaces (caused by dental or medical proceduresor daily activities such as chewing or tooth brushing) creates a pathway for microbes to enter the bloodstream.9,12 Blood-borne microbes adhere to andreplicate within the nonbacterial thrombotic endocarditis, which protects the organisms from host defense
mechanisms.10,11 Bacteria also stimulate further ﬁbrin
and platelets deposition, which enlarges the vegetation.9
This vegetation can spread systemically or embolize, resulting in several life-threatening complications, such as
ischemic stroke, cerebral hemorrhage, mycotic aneurysm, brain abscess, and meningitis.12
Clinical presentation of IE

IE generally presents with a broad range of nonspeciﬁc, ﬂu-like symptoms, most often with fever (90% ofcases) and a heart murmur (85% of cases).10,13,14 Other
symptoms range from general malaise with loss of appetite, unexplained weight loss or tiredness, headaches,
backache, paleness, confusion, shortness of breath, joint

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pain, weakness in the face or limbs to signs of systemic
toxicity.10,15,16 Some classic symptoms include cutaneous signs such as petechiae and splinter hemorrhages
under the nails (red to brown in color and linear) andsplenomegaly.14,16 Secondary complications such as
stroke, heart failure, and systemic embolism may alsopresent.14 Any of these features in combination withpersistent fever or malaise necessitates a medical
referral.10
Antibiotic prophylaxis for IE in association withdental procedures

In 2007, the AHA released its most recent guidelines
regarding antibiotic prophylaxis for IE in the dental
setting.9 The available evidence used for these guidelines
was limited because there are ethical concerns in conducting controlled trials that test the efﬁcacy of antibiotic prophylaxis against IE during invasive
procedures.17
The 2007 guidelines established that bacteremia
from daily activities was more likely to cause IE thanbacteremia following a dental procedure.9 Transient
bacteremia has been found to occur after routine daily
activities such as ﬂossing, tooth brushing, and chewing,10,11,17-21 and the cumulative exposure tobacteremia from routine daily activities over 1 year far
exceeds those that follow a single dental procedure.9
In addition, the AHA states that the effectiveness of antibiotic prophylaxis for IE is still unknown,9 but even if
100% effective, prophylaxis may only prevent IE in asmall number of cases.18 Antibiotic prophylaxis recommendations are therefore based exclusively on an
increased lifetime risk of acquiring IE, where prophylaxis
is deemed “reasonable” for cardiac conditions associatedwith the highest risk of adverse outcome from IE.9 These
conditions include the following: prosthetic cardiac
valve or the use of prosthetic material for valve repair;previous IE; speciﬁc congenital heart diseases (CHDs)
namely unrepaired cyanotic CHD, completely repaired
CHD during the ﬁrst 6 months after intervention, and repaired CHD with residual defects; and cardiac transplantpatients who develop cardiac valvulopathy.9
The recommended antibiotic regimen is a single doseof antibiotic given 30-60 minutes before the dental procedure.9 If antibiotic administration is inadvertently
forgotten, it can still be given up to 2 hours after the procedure. Amoxicillin is the preferred oral antibiotic
because of its rapid GI tract absorption, which provides
high serum concentrations. For patients with allergies
to penicillin, cephalexin or other cephalosporins, clindamycin, azithromycin, or clarithromycin is recommended(Table I). Cephalosporins should not be administered toAmerican Journal of Orthodontics and Dentofacial Orthopedics

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Table I. Recommended prophylactic antibiotic regimen in children with highest risk of adverse outcome from IE

9No allergies
Allergy to penicillins
or ampicillin

Oral medication
50 mg/kg amoxicillin
50 mg/kg cephalexin (or ﬁrst- or second-generation oral
cephalosporin in appropriate dosage) or 20 mg/kg
clindamycin or 15 mg/kg azithromycin orclarithromycin

Cannot take oral
medication
50 mg/kg IM or IV ampicillin or 50 mg/kg IM or IV
cefazolin or ceftriaxone
50 mg/kg IM or IV cefazolin or ceftriaxone or 20 mg/kg
IM or IV clindamycin

IM, Intramuscular; IV, intravenous.

patients with a positive history of anaphylaxis, urticaria,
or angioedema following penicillin usage because of thepotential for cross-reaction.9
Antibiotics are not free of risk, and this must be
considered before their administration.19,20 Risks of antibiotics include allergy, anaphylaxis (which can befatal), GI upset, microbial resistance, and interaction
with other drugs.21 Thus far, there have been no reports
in the literature concerning fatal anaphylaxis afteradministration of oral amoxicillin for IE prophylaxis ina dental setting.22
The beneﬁts of antibiotic prophylaxis in the prevention of IE can be seen from recent trends reported in the
United Kingdom. In 2008, the National Institute for
Health and Care Excellence recommended ceasing antibiotic prophylaxis before invasive dental procedures forpatients at risk for IE.19 Following this change in policy,
a signiﬁcant increase in the incidence of IE was observed,
with an estimated 34.9 additional cases of IE presenting
per month.23 A recent cost-effectiveness analysis in the
United Kingdom found that antibiotic prophylaxis in
high-risk patients was associated with lower healthcare costs, better health outcomes, and a low incidenceof adverse drug reactions.24 This corroborates the AHA
guidelines and illustrates the importance of antibiotic
prophylaxis in patients who are at high-risk for developing IE.

Fig 1. A, Patients at risk for IE must maintain excellent
oral hygiene during treatment with ﬁxed orthodontic appliances. B, If oral hygiene worsens during orthodontic therapy, and the patient presents with inﬂamed, hyperplastic
and bleeding gingival tissues, the orthodontist should
consider removing the appliances.

development of bacteremia after tooth brushing was reported. Therefore, good oral hygiene practices must beemphasized to all orthodontic patients but especiallyto those with cardiac diseases.
Dental procedures and bacteremia

Bacteremia from daily activities in orthodontic
patients

Tooth brushing in patients with orthodontic appliances leads to a prevalence of transient bacteremia of
25%,25 which is similar to tooth brushing in patients
without orthodontic appliances (26%).26 Bacteremia isinﬂuenced by the level of inﬂammation or infection at
the site, and available evidence supports the notionthat good oral hygiene and absence of dental disease decreases the frequency of bacteremia induced fromnormal daily activities9 (Fig 1). In a systematic review
by Tomas et al,27 an association between increased plaque accumulation and gingival inﬂammation and the

Owing to the absence of prospective clinical trials, therisk of developing bacteremia after dental procedures is
unclear.28 Whereas bleeding is a poor predictor ofbacteremia, and bacteremia can occur even in theabsence of bleeding,28-31 the relationship between
bacteremia and procedures that involve dentogingival
manipulation has been better documented.32 According
to the AHA, the dental procedures that should becovered with antibiotic prophylaxis include “all dental
procedures that involve manipulation of gingival tissueor the periapical region of teeth or perforation of theoral mucosa” because transient bacteremia may result
from these procedures9 (Table II).

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Table II. Dental procedures that require antibiotic prophylaxis

9

Prophylaxis
All dental procedures that involve manipulation of gingival tissue or theperiapical region of teeth or perforation of the oral mucosa
Placement of orthodontic bands
Suture removal
Biopsies
Extractions

No prophylaxis
Placement of orthodontic brackets

The dental procedure most likely to lead to bacteremia is extraction, with a reported prevalence of
10%-100%.16,30,33 From an orthodontic perspective,
extractions are sometimes required as part of the treatment plan for overcrowding or dental protrusion. For
patients at risk for IE, extractions, when required, should
be undertaken under antibiotic prophylaxis, though it isbest to try to avoid elective orthodontic extractions whileconsidering orthodontic treatment plans.
The risk of IE itself in association with invasive dental
procedures is controversial in the literature, with somestudies showing an increased risk,33-36 and otherstudies showing no increased risk.18,37-42 Because it isunethical to conduct prospective clinical trials to assess
the relationship between invasive dental procedures,
antibiotic prophylaxis, and IE, the literature is limited.
Recently, Chen et al43 conducted a case-only study
with a large sample size of adults. The authors reported
that there was no increased risk for IE following invasive
dental procedures, and therefore no beneﬁt from antibiotic prophylaxis.43 Although the evidence from thisstudy was of improved quality, high-quality evidence isstill lacking owing to the unavailability of studies thatcan be considered well-designed clinical trials. Because
more evidence is required to resolve this controversy,
including evidence for these risks in children, additionallarge center studies should be conducted. Until morehigh-quality evidence is obtained, dental practitioners
should abide by the AHA guidelines for patients at
high-risk for IE.

Placement of removable prosthodontic or orthodontic appliances
Adjustment of orthodontic appliances
Bleeding from trauma to the lips or oral mucosa
Dental radiographs
Shedding of deciduous teeth
Routine anesthetic injections through noninfected tissue

literature,44-47 and a survey of 1038 orthodontists by
Hobson and Clark48 found 8 cases of IE diagnosed during or after orthodontic treatment. All cases were associated with minor orthodontic adjustments where
antibiotic prophylaxis is not usually required.31
Although some of these articles hypothesized that theadjustment of the appliance led to mucosal injury thatmight have contributed to IE,49 no causal relationshiphas been proven, and the development of IE was likely
coincidental.50
Multiple authors have looked into the prevalence ofbacteremia after different orthodontic procedures(Table III). In some orthodontic procedures, bacteremia
did not increase but rather was maintained30,32,51 oreven declined.52,53 Differences between the results ofthe studies may have been due to the following reasons:(1) Greater precision in bacteremia detection has
occurred with time and technologic advancements.27(2)

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Different timings of postoperative measurements
 The optimum time to detect bacteremia following
dentogingival manipulation is 30-60 seconds(bacterial levels peak at this time).54 The prevalence of bacteremia decreases after 60 seconds,44and samples should not be collected after 2 minutes.55
 In published studies, time of measurement
included 30 seconds,32,53,56,57 60 seconds,58,59
2 minutes,28,51,59-62 3 minutes,25,31,63 and 15 minutes.52 Some studies did not provide time details.30,64

Orthodontic procedures and bacteremia

Bacteremia in association with orthodontic procedures is not well understood.28 Owing to the less invasivenature of orthodontics, it is often assumed that the riskof bacteremia is small. However, there have been cases oforthodontic-associated IE reported in the literature,illustrating the need for orthodontic treatment providers
to recognize at-risk patients.3 Four published case reports of IE in orthodontic patients are present in the

Methodological problems in detecting bacteremia(3)

Small sample sizes
 Most publications had small sample sizes without
power calculations. In some publications, bacteremia was only reported in 1 subject postprocedure.29,51

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Table III. Reported prevalence of bacteremia in orthodontic patients before and after orthodontic procedures

Orthodontic procedure
Banding*

DebandingBanding with chlorhexidine
rinsing
Debanding with chlorhexidine
rinsing
Debonding and debanding
Archwire adjustment

Bonded palatal expander
removalHaas palatal expander removal
Mini implant insertion
Mini implant removal
Separator placement*

Tooth brushing in orthodontic
patients
Gold chain adjustment
Alginate impression

Orthodontic stripping(including wedge
placement)
Peizocision

Prevalence of bacteremia
before and after procedure(% before/% after)
NC/064
3.3/1058
0/7.562
36/4453
4/16 ory 20/2860
10/50*,z,59 (P \0.05)
NC/064
19/2632
0/2.530
2.5/2.530
3/1356
6.6/6.651
33/19.453
0/4 ory 16/3060
10/3059
0/32z,31
0/50z,63
0/2.561
0/049
27/36#,53 (P \0.02)
8/36 ory 16/44*,z,60 (P \0.02)
0/40*,z,59 (P \0.05)
66.7/2052
0/25z,25
57/5732
23/3153
0/8 ory 16/1660
0/20590/3.428(5)

Different levels of oral hygiene Some studies controlled for inﬂammation andincluded only patients with good oral hygiene to
study the intervention itself.25,28,30,51,57,58,62
Other authors argued that controlling for oral hygiene would not be representative of typical orthodontic patients.49

Different population characteristics
 Most studies observed orthodontic patients, but 1
study observed volunteer dental school staff andstudents.58(6)

Differing amounts of gingival manipulation duringorthodontic procedures In banding studies, the methodology typically
included placement of only 1 band.
 In debanding studies, all bands were typicallyremoved (with or without brackets).

0/1057NC, blood sample not collected before the procedure.
*Statistically signiﬁcant in terms of prevalence; yDepending on
microbial analysis method; zPossible clinical signiﬁcance; #Statistically signiﬁcant with regard to increase in intensity of bacteremia(total number of anaerobes and aerobes).

(4)

Fig 2. Elastomeric separator placement has the potential
for subgingival interaction and may lead to a statisticallyand clinically signiﬁcant increase in the level of bacteremia.

(7)

Variations in volume of blood removed
 Theoretically, the greater the volume of bloodtaken, the easier it is to detect bacteremia.65

Overall, the reported prevalence following orthodontic procedures was generally lower than those reported
after daily activities such as tooth brushing (25%),62
ﬂossing (20%-58%),26 using wooden toothpicks (20%40%),9 and chewing food (7%-51%).9 The only statistically signiﬁcant procedure reported by more than 1
author was the placement of a separator53,59,60 (Fig 2),
though 1 author found statistically signiﬁcant results after placement of a band.59 Livas et al49 reported that anincrease in the prevalence of bacteremia from 10% toAmerican Journal of Orthodontics and Dentofacial Orthopedics

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2435%, that is, a 25% difference, is considered clinicallysigniﬁcant. Besides tooth brushing, the studies withpossible clinical signiﬁcance include the removal of abonded palatal expander,31 removal of a Haas type of
palatal expander,63 placement of a separator,59,60 andplacement of a band.59 However, because of the inherent
limitations in all of these studies, the actual clinical signiﬁcance is uncertain.
The orthodontic banding and debanding
controversy

The current AHA guidelines (2007) only recommend
antibiotic prophylaxis for the initial placement of orthodontic bands,9 where the increased risk is related to thesubgingival location of the band margins. However,many recent review articles still report that antibiotics
should also be given for high-risk patients when debanding.66-68
After the 2007 AHA guidelines were published, Leonget al17 in 2012 reported from a survey that 98.4% of
American Association of Orthodontists (AAO) members
recommended antibiotics for the placement of molar
bands and 90.2% for the removal of bands. This showsa relative consensus among orthodontists that the placement and removal of bands have nearly the same chances of bacteremia but a lack of adherence with the AHA
guidelines.
The ﬁrst author to study the relationship between orthodontic banding and debanding and IE was Degling in
1972.64 No bacteremia was detected during the ﬁtting or
removal of orthodontic bands, either because banding
does not always produce detectable bacteremia69 or
because of the difﬁculty in detecting bacteria with older
microbial isolation techniques.56 In 1996, McLaughlin
et al58 reported an increase in bacteremia from 3.3%
to 10% of patients after banding, whereas in 1999, Erverdi et al62 found an increase from 0% to 7.5% frombanding. A possible etiology for bacteremia after banding is that the placement of bands may push bacterial
deposits from the tooth surface into the gingival sulcus
by the hydraulic effect of the banding cement.51
It could be argued that a higher prevalence of bacteremia should result from the removal of bands because thegingival tissues adjacent to the bands are often inﬂamed.
Erverdi et al51,62 found a slightly lower prevalence ofbacteremia at debanding than at band ﬁtting, but patients with poor oral hygiene were excluded from theirstudy.56 Burden et al56 studied all orthodontic patients
regardless of oral hygiene and found an increased prevalence of bacteremia after debonding and debanding.
However, unlike Erverdi et al,51,62 the authors removed
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Fig 3. A, It is debatable whether there is an increased riskof bacteremia in the closed eruption approach related tothe conduit along the length of the chain from theimpacted tooth in the alveolar bone to the mucosal surface. B, In contrast, the open exposure approach involves
uncovering the impacted tooth and leaving it uncovered,
thereby preventing the formation of a conduit.

debanding with a tungsten carbide bur, and this could
have possibly led to the bacteremia.
Rosa et al63 found an increased prevalence of bacteremia after the removal of a Haas palatal expander(0%-50%). This banded expander, which has palatalcoverage acrylic pads, is difﬁcult to clean and often
retains dietary debris and bioﬁlm63 that can increase
the risk of bacteremia. Because the difference was large(50%), this procedure may have clinical signiﬁcance.
However, the study sample size was small, and statisticalanalysis was not undertaken.
Placement of separators

In the survey by Leong et al,17 60.7% of AAO members recommended antibiotic prophylaxis in high-riskpatients for placement of separators. This illustrates
that more than half of the orthodontists perceive that
antibiotic prophylaxis is important for separator placement though it is not listed speciﬁcally in the AHA
guidelines.
Lucas et al53 was the ﬁrst to report a statistically signiﬁcant result for bacteremia after an orthodontic

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Vandersluis and Suriprocedure, speciﬁcally the placement of a separator.
Although there was no statistically signiﬁcant differencewith respect to the prevalence of bacteremia, the intensity of bacteremia (ie, total number of aerobic and anaerobic bacteria isolated from the blood samples)signiﬁcantly increased. The importance of this ﬁnding
is questionable because no data is available on the levelof intensity of bacteremia that “causes” IE.53
According to Roberts et al,70 the placement of awooden wedge and matrix band could break up plaqueinto small pieces giving bacteria easier access into thegingival tissues. A similar mechanism may occur
following the placement of separators. Elastomeric rings
are also plaque retentive,71 and occlusal forces on separators may traumatize the gingival margin enough toallow bacteria to enter the bloodstream (Fig 2).58
Exposure of impacted teeth

Patients with cardiac disorders are generally smaller
and may be more likely to have crowding72 and impacted
canines. The exposure of impacted teeth is a surgicalprocedure, and therefore requires antibiotic prophylaxis
in patients susceptible to IE. However, after exposure,the movement of the tooth is analogous to normal tooth
eruption and does not require further prophylaxis.69 Lucas et al32 found no signiﬁcant difference in the intensityand prevalence of bacteremia after gold chain adjustment of impacted teeth after exposure.
An increased risk of bacteremia could arise owing to
the conduit along the length of the chain from the tooth
impacted in the alveolar bone to the mucosal surface.
Some authors recommend open surgical exposures
where possible, because it has been debated whether
traction after closed techniques increases risks of infection (Fig 3).1,66 There is a lack of high-quality evidence
on this; therefore, it is suggested that orthodontic treatment providers consider all options, including premolar
substitution, in patients with IE risk and deeply impacted
canines.1
Prevention of IE with other antibacterial agents

In addition to systemic antibiotic prophylaxis, antiseptic mouth rinses have been recommended immediately before dental procedures to reduce the severity
and incidence of bacteremia,73,74 but this is not without
controversy. Chlorhexidine gluconate (0.12% or 0.2%)
can reduce plaque and gingival inﬂammation in orthodontic patients.75-78 Because of the disadvantages ofantibiotics, some authors state that chlorhexidine could
be a good alternative for procedures with lower risks ofbacteremia.30 Pallasch et al26 found that antiseptic
mouthwash may reduce the severity of bacteremia.

25

However, Erverdi et al30 found no signiﬁcant difference
in bacteremia prevalence with or without chlorhexidine.
Lockhart et al79,80 reported that antimicrobial rinses do
not penetrate more than 3 mm into the gingival sulcus,
and therefore do not reach the area where bacteria enter
the systemic circulation. Some authors have recommended daily use of chlorhexidine during orthodontic treatment in at-risk patients, but the evidence is lacking andpatient compliance may be reduced because of the side
effect of tooth staining.3
Practical implications: guidelines for orthodontic
treatment providers

Before starting orthodontic therapy in cardiac patients, the patient's level of risk for IE should be determined by referring to the current (2007) AHA
guidelines.20 Because of unresolved controversies surrounding orthodontic procedures other than banding,
it is best for orthodontic treatment providers to consult
the patient's cardiologist to discuss the individual patient's risk of IE.62 In the survey by Leong et al,17 forthose patients who required medical clearance for a positive history of heart problems, 69.8% of AAO members
reported infrequent or total lack of communication withthe patient's primary physician. Advice from the patient's cardiologist or primary physician is important
both for the patient's overall health and legally.
Orthodontic therapy should not be initiated unlessthe patient's oral hygiene and dental health is impeccable because inadequate oral hygiene during orthodontic
treatment with ﬁxed appliances can lead to gingival
inﬂammation (Fig 1).50 Some authors recommend thepatient sign a document stating that they will maintaina very high standard of oral hygiene during orthodontic
therapy.66 During treatment, the orthodontist should
monitor for any deterioration in gingival health.50 Regular periodontal therapy is also advised, and patientsshould be aware of the signs and symptoms of IE andseek specialist advice if these symptoms present.20 Any
sign of infection in patients who are at risk for IE should
be investigated and treated promptly.20
If possible, clinicians should avoid the use of orthodontic bands and use bonded attachments instead.1,50,58
In addition, tissue injury during orthodontic treatment
should be prevented by not leaving sharp edges aroundappliance margins that can injure the soft tissues,51
securing archwires with elastomeric instead of wire ligatures, placing and removing archwires carefully to avoid
mucosal injury,50 and avoiding ﬁxed acrylic appliances,which can cause inﬂammation of the mucosa (eg, Haas
rapid palatal expander and Nance palatal button).25 Clearaligner therapy of the malocclusion can also be

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considered for this patient population because it is aminimally invasive, removable orthodontic treatment
modality. However, no studies have measured the levelsof bacteremia potentially associated with this technique,and a recent randomized controlled trial reported no difference in oral hygiene between clear aligners and ﬁxed
orthodontic brackets.81 Oral hygiene must be reinforced
to patients at risk for IE with all orthodontic treatment
modalities.
CONCLUSIONS

High-quality evidence is lacking on the relationshipbetween orthodontic procedures and IE owing to ethicalconsiderations for conducting prospective clinical trials.
This limits the possibilities of conducting systematic reviews of high-quality evidence in this area currently. Until such time that such reviews are possible, clinicalinterpretation based on a comprehensive review of theavailable literature is essential. Because the AHA guidelines are based on the best-available evidence and are
representative of the current standard of care, theyshould be referred to before the orthodontic treatmentof patients with cardiac conditions. Consultation withthe patient's physician or cardiologist is also imperative.
When possible, it is preferable to avoid elective procedures that may lead to bacteremia, for example, by using
all bonded brackets and tubes instead of bands. In addition, oral hygiene must be reinforced to the patient sinceplaque accumulation increases the risk of bacteremia.69
If oral hygiene worsens during treatment, and compliance with oral hygiene measures remains poor, removalof the orthodontic appliances can be considered.
SUPPLEMENTARY DATA

Supplementary data associated with this article canbe found, in the online version, at https://doi.org/10.
1016/j.ajodo.2019.03.027.
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