Increased susceptibility to gingival colonization by specific HACEK microbes in children with congenital heart disease

It is well established that infective endocarditis (IE) involving the HACEK (Hemophilus, Actinobaccillus, Cardiobacter, Eikenella, Kingella) group of microbes occurs in patients with congenital heart defects (CHD) and in those with prosthetic grafts. Dental caries and gingival disease have been presumed to be the focus of microbial shedding. The purpose of this study was to determine if children with CHD had a more severe gingival inflammatory condition and harbored the HACEK group of microbes to a greater extent than normal children. Two groups of 12 age and sex matched children were selected for this study. The experimental group consisted of twelve children with CHD, 1-1/2 to 8 years of age. The control group consisted of 12 healthy children 2 to 8 years of age. Each child had a gingival index score recorded as described by Massler. Subgingival cultures were obtained. Gingival samples were cultured for HACEK microbes and total Streptococcus (spp) using standard techniques. Fisher’s exact test was performed with significance defined at P<0.05. Children with CHD had more severe gingival inflammatory index than the control group (P<0.05). 8/12 CHD patient had Actinobacillus actinomycetemcomitans (A.a.) as compared with 2/12 controls (P<0.05). Furthermore, all cyanotic CHD patients (4/4) had A.a. whereas, only 2/12 controls did (P<0.05). 4/12 CHD patients harbored Eikenella corrodens (E.c.) compared to 1/12 controls (N.S.). There was no significant difference in colonization with E.c. or A.a. between cyanotic and acyanotic patients. No significant difference in total Streptococcus (spp) was found between the two groups. This study suggests that children with CHD have a more severe gingival inflammatory index and are colonized with specific HACEK microbes more so than normal children.

1. Hallett KB, Radford DJ, Seow WR. Oral health of children with congenital heart diseases: a controlled study. Peds Dent 14: 224- 230, 1992.

2. Gould MSE, Picton DCA. The gingival condition of congenitally cyanotic individuals. Br Dent J 109: 96-110, 1960.

3. Franco E, Saunders CP, Roberts GJ, Suwanprasit A. Dental disease, caries, related microflora and salivary IgA of children with severe congenital cardiac disease: an epidemiological and oral microbial survey. Peds Dent 18: 228-235, 1996.

4. Roberts GJ, Roberts IF. Dental disease in chronically sick children. J Dent Child 48: 346-351, 1981.

5. Dajani AS, Taubert RA, Wilson W, Bolger AF, Beyer A, Ferrieri P, Gewitz MH, Schulman ST, Noun S, Newberger JW, Hutto C, Pallasch TJ, Gage TW, Levison ME, Peter G, Zuccaro G. Prevention of bacterial endocarditis. Recommendations by The American Heart Association. JAMA 227: 1794-1801, 1997.

6. Awadallab SM, Kavey REW, Byrum CJ, Smith FC, Kveselis DA., Blackman MS.The Changing Pattern of Infective Endocarditis in Childhood Am J Cardiol 68: 90-94, 1991.

7. Bayliss R, Clarke C, Oakley CM, Somerville W, Somerville A, Whitfield A.G.W. Young SEJ. The microbiology and pathogenesis of infective endocarditis. Br Heart J 50: 513-519, 1983.

8. Johnson DH, Rosenthal A, Nadas AS. A forty year review of bacterial endocarditis in infancy and childhood. Circ 51: 581-588, 1975.

9. Tornos P, Sanz E, Permanyer-Miralda G, Almirante B, Planes AM, SolerSoler J. Acute prosthetic valve endocarditis: Immediate and long term prognosis. Chest 10l: 37-41, 1992.

10. Wilson WR, Karchmer AR, Dejani AS, Taubert RA, Bayer A, Kaye D, Bisno AL, Ferrieri P, Shulman ST, Duraek DT. Antibiotic treatment of adults with infective endocarditis due to Streptococci, Enterococci, Staphylococci and HACEK microorganisms. JAMA 274: 1706-1713, 1995.

11. Berbari EF, Cockerill FR, Steckelberg JM. Infective endocarditis due to unusual or fastidious microorganisms. Mayo Clin Proc 72: 532-542, 1997.

12. ElIner HJ, Rosenthal MS, Lerner Pl, McHenry MC. Infective endocarditis caused by slow growing, fastidious, gram negative bacteria. Medicine 58: 145-158, 1979.

13. Das M, Badley AD, Cockerill FR, Steckelberg JM, Wilson WR. Infective endocarditis caused by HACEK microorganisms. Ann Rev Med 48: 25-33, 1997.

14. Geraci JE, Wilson WR. Endocarditis due to gram negative bacteria: Report of 56 cases. Mayo Clin Proc 57: 145-148, 1982.

15. Chen YC, Chang SC, Luh KT, Hsieh WC. Actinobacillus actinomycetecomitans endocarditis: A report of four cases and review of the literature. Quant J Med 8 1:871-878, 1991.

16. Walterspiel, J.N. and Kaplan, S.L. Incidence and clinical characteristics of “culture negative” infective endocarditis in a pediatric population. Ped Inf Dis 5: 328-332, 1986.

17. Karl T, Wensley D, Star J, DeLaval M, Rees P, Taylor JFN. Infective endocarditis in children with congenital heart disease: Comparison of selected features in patients with surgical correction or palliation and those without. Br Heart J 58: 57-65, 1987.

18. Felius A, Fleer A, Maulaert A. Actinobacillus actinomycetemcomitans endocarditis in a child with a prosthetic heart valve. Infect 12: 260-261, 1984.

19. Anolik R, Berkowitz RJ, Campos JM, Friedman A.D. Actinobacillus endocarditis associated with periodontal disease. Clin Peds 20: 653-655, 1981.

20. Massler, M. The P-M-A Index for the assessment of gingivitis. J Perio 38: 592-597, 1967.

21. Hall G. Non-fermenting gram negative Bacilli and miscellaneous gram-negative rods. In Diagnostic microbiology, Philadelphia, Saunders Company, pp 534-537, 1995.

22. Gochenour L.The prevalence of gingival disease in children with congenital heart disease: A preliminary analysis. M.S. Thesis, West Virginia University, Morgantown, WV, 1998.