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Article

Theoretical and Practical Knowledge Regarding Infective Endocarditis Prevention Among Dentists and Physicians: A Questionnaire-Based Survey

by
Claudia Salerno
1,2,
Silvia Cirio
1,
Nicole Camoni
1,3,
Guglielmo Campus
4,5,6 and
Maria Grazia Cagetti
1,*
1
Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via Beldiletto 1, 20142 Milan, Italy
2
Graduate School for Health Sciences, University of Bern, 3012 Bern, Switzerland
3
Asst Valle Olona, Dental Unit, Via Eusebio Pastori 4, 21013 Gallarate, Italy
4
Department of Cariology, Institute of Odontology, Sahlgrenska Academin, University of Gothenburg, Medicinaregatan 12 E, 413 90 Gothenburg, Sweden
5
Department of Cariology, Saveetha Dental College and Hospitals (SIMATS), No. 162, Poonamallee High Road, Velappanchavadi, Chennai 600 077, India
6
Department of Oral and Maxillofacial Sciences, Sapienza University of Rome, Via Caserta 6, 00161 Rome, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(17), 9532; https://doi.org/10.3390/app15179532
Submission received: 21 July 2025 / Revised: 25 August 2025 / Accepted: 28 August 2025 / Published: 29 August 2025
Versions Notes

Abstract

Featured Application

This study highlights existing gaps in the appropriate use of endocarditis prophylaxis for invasive dental and non-dental medical procedures among dentists and physicians, particularly regarding risk assessment and adherence to current guidelines. The findings underscore the need for enhanced education and clearer clinical protocols to support accurate risk stratification, reducing missed prophylaxis in high-risk patients and minimizing unnecessary antibiotic use in low-risk individuals, with the overarching goal of preventing infective endocarditis and curbing antibiotic resistance.

Abstract

Infective endocarditis (IE) is a rare but potentially life-threatening infection, often triggered by invasive procedures, dental or otherwise, in at-risk individuals. This study aimed to assess the knowledge of IE prophylaxis among healthcare professionals, focusing on dentists and physicians. Two validated, anonymous questionnaires were emailed to 27,000 healthcare providers in the province of Milan (Italy). A total of 970 responses were collected (response rate just over 3%), with 49.2% from physicians and 50.8% from dentists. No significant differences were found between the two groups regarding years of experience or guideline usage (p > 0.05), although more physicians (12.7%) than dentists (6.7%) reported unfamiliarity with any guidelines. Physicians often misclassified the risk associated with certain cardiac conditions and overprescribed prophylaxis for low-risk procedures, with overall accuracy falling below the expected performance benchmark (H0: 58.0% ± 2.0%). Dentists showed a better understanding of high-risk dental procedures, yet performance remained suboptimal, with multiple scores below the expected benchmark (H0: 68.0% ± 2.0%). These findings highlight widespread knowledge gaps and inconsistent adherence to IE prophylaxis guidelines. The results align with international observations and emphasize the urgent need for continuing education and improved dissemination of evidence-based recommendations across medical and dental settings.

1. Introduction

Infective endocarditis (IE) is a rare but potentially life-threatening infection that affects the endocardial surface of the heart, usually involving the heart valves. In 2019, its global incidence was estimated at 13.8 cases per 100,000 individuals per year, accounting for approximately 66,300 deaths worldwide [1]. Despite its relatively low incidence, IE is associated with high morbidity and mortality, particularly in individuals with pre-existing cardiac conditions or prosthetic valves. The disease may have an insidious or acute onset and often leads to severe complications such as heart failure, systemic embolization, and cerebrovascular events [2,3].
According to current International Guidelines, such as those issued by the American Heart Association and the European Society of Cardiology [4,5], antibiotic prophylaxis (AP) for IE prevention is recommended only for high-risk patients undergoing invasive procedures. High-risk individuals include those with prosthetic heart valves or prosthetic material used in valve repair, a history of previous infective endocarditis, specific forms of congenital heart disease, particularly if uncorrected, and heart transplant recipients who develop valvulopathy.
Dental procedures involving manipulation of the gingival tissues, the periapical region of the teeth, or perforation of the oral mucosa are recognized as major sources of transient bacteremia in at-risk patients. Such procedures include tooth extractions, endodontic treatments involving instrumentation beyond the apex, periodontal or oral surgery involving bone (e.g., implant placement or surgical removal of impacted teeth), subgingival scaling and root planning, and biopsies [6,7,8].
Current recommendations advise the administration of a single dose of antibiotics 30–60 min before the invasive procedure, for both adults and children at high risk. Amoxicillin is the first-line agent, administered orally at a dose of 2 g for adults and 50 mg/kg for children. In patients allergic to penicillin, alternative regimens include clindamycin (600 mg for adults, 20 mg/kg for children), azithromycin, or clarithromycin (500 mg for adults, 15 mg/kg for children). If oral administration is not feasible, parenteral options such as ampicillin or cefazolin may be used at equivalent dosages [9].
Conversely, antibiotic prophylaxis is not indicated in non-high-risk patients or for non-invasive procedures such as local anesthesia, dental radiographs, superficial restorations, orthodontic adjustments, or the application of topical agents. These guidelines aim to prevent infection while avoiding unnecessary antibiotic use, which contributes to antimicrobial resistance and adverse effects. Antimicrobial resistance has been identified by the World Health Organization as one of the top ten global public health threats, and inappropriate antibiotic use, such as unnecessary prophylaxis, is a major contributing factor [10]. Ensuring that AP is prescribed only when indicated is therefore essential not only for individual patient safety but also for preserving antibiotic efficacy on a broader scale.
Within this framework, the role of healthcare professionals is crucial. Dentists are often the first to encounter patients who may be eligible for prophylaxis, while physicians, particularly cardiologists, pediatricians, and general practitioners, play a key role in identifying high-risk individuals and are frequently consulted for clinical guidance. Nonetheless, inconsistencies in the interpretation and application of existing guidelines remain common, highlighting the need for improved interdisciplinary communication and shared educational strategies [11].
Based on these premises, the present study aims to assess the theoretical and practical knowledge of infective endocarditis prophylaxis among healthcare professionals, focusing particularly on dentists and physicians. Specifically, it explores their familiarity with current guidelines, clinical decision-making regarding AP, and the appropriateness of their prescribing behaviors. By identifying knowledge gaps and practice variations, this study seeks to inform the development of targeted educational interventions and promote more consistent, evidence-based use of antibiotics in both dental and medical settings.

2. Materials and Methods

This study was designed as an observational, cross-sectional survey questionnaire-based, in compliance with the Declaration of Helsinki and approved by the Ethics Committee of the University of Sassari, Sassari, Italy (N°AOU_SS 386 on 22 March 2022). The reporting follows the guidelines outlined in the Standards for Reporting of Diagnostic Accuracy.
Two anonymous, previously validated questionnaires were used in this survey, as developed by De Wolf et al. [12]. Each questionnaire comprised three sections: demographic information, theoretical knowledge, and decision-making behavior (practical knowledge) (see Supplementary File S1).
The quantitative evaluation of the questionnaires’ accuracy was conducted by submitting them to a panel of 11 experts, comprising three pediatric dentists, three general dentists, three pediatricians, and two family physicians. The content validity of each item was assessed using both the Content Validity Index (CVI) and the Content Validity Ratio (CVR) [13]. The Scale-Level Content Validity Index (S-CVI) was calculated using the universal agreement method. Based on expert assessments, the S-CVI for the entire instrument was 1.00, and the S-CVR was 1.00 (Supplementary File S2).
The questionnaires were pre-tested in October 2023 to assess their comprehensibility using a convenience sample of 15 dentists and 15 physicians who were not included in the main survey. After completing the questionnaire, participants were contacted to determine whether they had experienced any difficulties in understanding the questions. Comprehension was evaluated using a 5-point scale, where 1 indicated extreme difficulty and 5 indicated no difficulty. The mean comprehension score was 4.37 ± 0.26, indicating a high level of clarity.
Both questionnaires included two shared items to gather demographic data: medical specialty and years of professional experience. The assessment of theoretical knowledge consisted of three questions for dentists and four for physicians, focusing on the guidelines consulted and the factors related to both patient characteristics and dental or surgical procedures that influence decisions regarding antibiotic prophylaxis. The questionnaire for physicians explored clinical scenarios related to infective endocarditis risk. Conditions for which antibiotic prophylaxis is recommended (e.g., cyanotic congenital heart disease, shunts, prosthetic valves, prior endocarditis, transplant with valve disease) were contrasted with conditions generally not requiring prophylaxis (e.g., noncyanotic congenital defects, native or rheumatic valve disease, bicuspid aortic valve, calcific stenosis, cardiomyopathy, and post-surgery beyond six months). The dental procedures investigated covered a broad spectrum of noninvasive and invasive clinical interventions. Noninvasive procedures included intra-oral radiography, infiltration of local anesthetic, management of post-traumatic lip bleeding and loss of deciduous teeth, as well as preventive measures such as dental dam application to isolate the operative field and supragingival scaling to remove plaque and calculus above the gum line. A group of orthodontic procedures included the placement and removal of brackets, bands, and arch wires. Invasive interventions comprised tooth extractions, incision and drainage of abscesses, and root canal therapy (involving the removal of infected pulp tissue), along with periodontal procedures (subgingival), such as scaling and root planning. Surgical procedures included dental implant placement, replantation of avulsed teeth, and apical root resection (apicoectomy). Practical knowledge was evaluated through three additional questions based on two clinical case scenarios, which were specifically tailored to the professional context of each group to reflect their respective clinical practice.
The questionnaires were distributed via email to healthcare professionals. Based on the respondent’s medical specialty, declared at the beginning of the form, the system automatically directed participants to one of two tailored versions: one designed specifically for dentists, and the other for physicians. Contact information was obtained from the registry of the Italian Federation of Doctors and Dentists in the province of Milan, Italy, where all licensed professionals are required to provide a valid email address. A follow-up invitation was sent to non-respondents one month after the initial distribution. Before accessing the first question, participants were presented with a brief description of the study’s objectives and were asked to provide electronic informed consent. If consent was not granted, the questionnaire was automatically terminated. Approximately 27,000 healthcare professionals are registered with the Federation in this region, including around 4000 dentists.
To estimate the required sample size, an a priori power analysis was performed. Based on an assumed expected frequency of 50%, a statistical power of 99.00%, a 5% alpha error, and a design effect of 1, the minimum necessary sample size was calculated to be 648 participants.
The survey was conducted between October and December 2024, and data were extracted in January 2025.

Statistical Analysis

All statistical analyses were conducted using Stata SE 18 (StataCorp, College Station, TX, USA). Descriptive statistics were reported for different variables. The Shapiro–Wilk test was used to assess the normality of continuous data. Associations between categorical variables were assessed using the Chi-square test or Fisher’s exact test, as appropriate. For continuous variables, comparisons between group means were conducted using Student’s t-test, provided that the assumption of normality was met. Participants’ knowledge was assessed using a mixed-effects logistic regression model (‘meqrlogit’ in Stata), with responses coded as 1 (correct) or 0 (incorrect). The model included cross-classified random intercepts for both participant ID and question ID to account for clustering within individuals and items, and no fixed-effect predictors were specified. Missing or “uncertain” responses were excluded. Estimated log-odds of a correct response were transformed into probabilities using the inverse logit function. To quantify uncertainty, 95% confidence intervals for the predicted probabilities were obtained through nonparametric bootstrapping (100 replications). To assess the influence of years of experience (categorized into five groups), type of specialization, and use of clinical guidelines on the knowledge score, a robust linear regression model was fitted. All predictors were treated as categorical variables, and robust standard errors were employed to account for potential heteroskedasticity. Reference categories were set as follows: less than 5 years of experience, pediatric specialization, and familiarity with American Heart Association (AHA) guidelines. A p-value of <0.05 was considered statistically significant.

3. Results

A total of 978 online questionnaires were completed by healthcare professionals. Eight were excluded from the analysis due to incomplete responses, resulting in 970 valid questionnaires: 477 (49.2%) completed by physicians and 493 (50.8%) by dentists. This corresponded to an overall response rate of just over 3% (Table 1).
A significant majority of respondents reported more than 20 years of professional experience, both among physicians (58.7%; p = 0.02) and dentists (51.3%; p = 0.05), indicating that the sample largely comprised established professionals. No statistically significant difference was found between the two groups regarding overall years of experience (p = 0.20). Among dentists, 21.9% were orthodontists, 10.1% oral surgeons, and 6.5% pediatric dentists, while 61.5% reported other dental specialties. Among physicians, 38.2% were pediatricians, 12.2% general or family practitioners, and 49.7% belonged to other medical specialties. Most dentists and physicians reported primarily using the American Heart Association (AHA) endocarditis prophylaxis guidelines (50.1% and 46.1%, respectively), followed by the European Society of Cardiology (ESC) guidelines (29.6% and 26.6%, respectively). A higher proportion of physicians (12.7%) indicated unfamiliarity with any guidelines compared to dentists (6.7%) (Table 1).

3.1. Survey for Physicians

When deciding whether to administer endocarditis prophylaxis, the majority of physicians correctly identified that the patient’s age is not a determining factor (90.6%). However, less than half (46.5%) recognized that the type of procedure is a key consideration, and only slightly more than half (53.9%) reported considering the type of heart disease (Table 2). While most physicians were aware of which heart conditions are classified as high risk for developing endocarditis, notable knowledge gaps were identified in four critical areas. Specifically, 60.6% of physicians did not recognize unrepaired cyanotic congenital heart disease as high risk, and 55.1% failed to identify congenital heart disease with a shunt as a high-risk condition. Conversely, 63.5% of physicians incorrectly considered congenital valvular defects (e.g., insufficiency, stenosis) to be high-risk conditions, while 69.8% mistakenly identified acquired or rheumatic valvular defects as high risk. Regarding procedures requiring endocarditis prophylaxis, 56.6% of physicians erroneously believed that prophylaxis is indicated for all dental procedures, reflecting a common misconception. Furthermore, a substantial proportion (82.3%) reported that they would prescribe prophylaxis in a clinical scenario where it is not recommended, indicating a tendency toward overprescription. Notably, only 47.4% of physicians correctly identified the appropriate antibiotic for patients with beta-lactam allergies, highlighting a significant knowledge gap in the management of antibiotic prophylaxis (Table 2).
For the physician questionnaire, the estimated log-odds of providing a correct answer was 0.32, corresponding to an estimated probability of 57.9%. The 95% confidence interval, calculated from 100 bootstrap replications, ranged from 55.6% to 60.2%. Notably, physicians failed to correctly classify the risk associated with five heart diseases and incorrectly identified all dental procedures as high-risk requiring prophylaxis (Table 2).
A multivariable linear regression model was used to evaluate whether the total knowledge score was influenced by years of experience, type of specialization, and clinical guideline preference. Years of professional experience demonstrated an inverse relationship with total knowledge score. Participants with more than 20 years of experience scored significantly lower than those with less than 5 years (β = −1.54, p < 0.01), indicating an average adjusted decrease of approximately 1.5 points. Those with 5–10 years of experience also showed a marginally significant negative association (β = −0.91, p = 0.05). In contrast, the 11–15 and 16–20 years categories did not show statistically significant differences compared to the reference group. Specialty also had a significant impact on performance. General practitioners scored, on average, 1.14 points lower than pediatricians (β = −1.14, p < 0.01), after adjusting for other variables. No statistically significant differences were observed between pediatricians and other medical specialties. With regard to guideline preference, participants familiar with the National Institute for Health and Care Excellence (NICE) guidelines scored significantly lower than those using AHA guidelines (β = −0.78, p = 0.04). Those who reported not using any guidelines also tended to score lower, although the association was only marginally significant (β = −0.53, p = 0.07). No significant differences were found for users of ESC or other guidelines. The overall model was statistically significant (F = 5.46, p < 0.01) but explained a modest portion of the variability in scores (R2 = 0.09) (Supplementary File S5).

3.2. Survey for Dentists

The majority of dentists correctly did not consider patient age a determining factor in the decision to administer endocarditis prophylaxis (94.5%). However, only 49.1% considered the type of dental procedure, and 58.6% considered the type of heart disease in their decision-making (Table 3). No statistically significant differences were observed between dentists and physicians for these items.
Overall, dentists demonstrated a good general understanding of which dental procedures are classified as high risk for endocarditis. However, notable gaps emerged: only 22.5% correctly identified endodontic treatments as high-risk procedures, and just 6.1% were aware that the placement or removal of orthodontic appliances does not require prophylaxis. Furthermore, only 51.5% indicated that they would prescribe prophylaxis for a high-risk patient undergoing reimplantation of an avulsed tooth, despite clinical guidelines recommending it. Notably, only 5.7% of dentists would prescribe prophylaxis in the case of a tooth extraction in a patient with cyanotic Fallot’s defect without seeking the opinion of a cardiologist or pediatrician, representing a significant underestimation of risk. Furthermore, only 47.3% of respondents correctly identified the appropriate antibiotic dosage for endocarditis prophylaxis in children, while 60.0% were aware of the recommended first-line antibiotic for individuals with beta-lactam allergies (Table 3).
For the dentist questionnaire, the estimated log-odds of providing a correct response was 0.77, corresponding to a predicted probability of 68.3%. The 95% confidence interval, ranged from 65.7% to 70.8%. Dentists failed to recognize seven procedures classified as high-risk for endocarditis prophylaxis (Table 3).
As for physicians, a multivariable linear regression analysis was conducted to evaluate whether years of experience, type of specialization, and use of clinical guidelines influenced the total knowledge score. The model was not statistically significant (p = 0.25) and explained only a small proportion of the score variance (R2 = 0.03). Among the included predictors, lack of familiarity with any clinical guideline was significantly associated with lower performance compared to those who reported using AHA guidelines (β = −1.59, p = 0.02). No significant differences were observed in relation to years of experience or type of dental specialty (Supplementary File S5).

4. Discussion

This study highlights substantial gaps in both theoretical and practical knowledge concerning infective endocarditis prophylaxis among physicians and dentists, even though most respondents reported over two decades of clinical experience. These findings are consistent with existing literature, which has shown that both cardiologists and dentists frequently prescribe antibiotic prophylaxis for patients classified as high or moderate risk, while demonstrating only partial adherence to current guidelines [14]. The regression analysis indicated that physicians with more than 20 years of experience obtained significantly lower scores than those with fewer years in practice. This inverse association between clinical experience and knowledge accuracy may reflect insufficient engagement in continuing professional development or reluctance to modify entrenched clinical routines. Among dentists, no significant relationship was observed between years of experience and performance, suggesting that other variables, such as access to updated educational resources or adherence to institutional protocols, may play a greater role in shaping their knowledge.
The majority of professionals, including both dentists and physicians, reported being familiar with and utilizing international guidelines for the prophylaxis of infective endocarditis. Nonetheless, a notable proportion of physicians (12.7%) declared no awareness of any existing guidelines, which raises concerns regarding the dissemination and uptake of clinical recommendations. It should be noted that sources of information and preferred guidelines may vary across countries, potentially contributing to inconsistencies in clinical practice [15].
The novelty of this study lies in the fact that, although similar investigations have been carried out in other European countries and worldwide, in the Italian context, only two comparable studies have been published. One focused on dental hygienists rather than dentists [16], while the other investigated dentists’ prescribing habits with regard to antibiotic therapy [17], including a section on infective endocarditis prophylaxis but without specific reference to the dental procedures for which it is required. Moreover, no study to date has investigated physicians’ knowledge in this field. Considering the cross-country differences in healthcare systems, professional training, and clinical practice, the present survey addresses an important gap and underscores the potential for substantial variations in findings between national contexts. International evidence confirms this variability. In Flanders, most dentists rely on their respective scientific societies for information about endocarditis prophylaxis, as well as on the patient’s physician, whether a primary care provider or cardiologist [12]. In France, dentists primarily consult scientific literature, university-acquired knowledge, and online resources [18]. In Japan, clinical guidelines and direct communication with the patient’s physician are the main sources of information [19,20]. In Canada, dentists frequently rely on advice provided by cardiologists. In a similar survey conducted in Jordan, respondents were nearly evenly split between those who independently determined when to administer endocarditis prophylaxis and those who relied on consultation with the treating physician [21]. These variations in information sources highlight the diverse approaches to guideline dissemination and interprofessional collaboration across different countries, which may influence the consistency and accuracy of prophylaxis practices [22].
In this survey, physicians appeared prone to overprescription, with 82.3% indicating they would do so in a scenario where it is not recommended. Similar trends have been observed in surveys conducted in the United States, where adherence to guidelines for infective endocarditis prophylaxis remains suboptimal and many clinicians persist in outdated practices despite updated recommendations [23]. Comparable results were observed among Flemish pediatricians, who generally recognized high-risk procedures but showed limited awareness regarding low-risk interventions that do not require prophylaxis. This pattern of overprescription may lead to adverse consequences, including increased antibiotic resistance, unnecessary healthcare costs, and the risk of severe, though rare, anaphylactic reactions [24,25,26]. Conversely, after the implementation of the NICE guidelines, which significantly restricted the indications for prophylaxis, a rise in the incidence of infective endocarditis was reported in the UK, raising concerns about the potential consequences of underprescription [27]. Dentists, on the other hand, generally demonstrated a good understanding of current guidelines but showed a tendency toward underprescription in specific high-risk scenarios, an error that could have serious clinical consequences. Notably, only approximately 20% of respondents correctly identified root canal treatment as a high-risk procedure requiring antibiotic prophylaxis. Similar findings have been reported in two surveys conducted in Jordan [21] and in the Dominican Republic [28], where more than half of the respondents failed to recognize root canal therapy as a high-risk procedure. Even among experienced dentists in Japan and Belgium, root canal treatment has been consistently underestimated in this regard, with practitioners having more than 20 years of experience being particularly prone to this oversight. Collectively, these findings suggest a widespread tendency to underestimate the risk of infective endocarditis in procedures that are not overtly surgical in nature [12,18].
Regarding antibiotic selection, both physicians and dentists demonstrated limited competence in identifying the appropriate agent and prescribing the correct dosage in pediatric patients. Nevertheless, dentists appeared to have a better grasp of guideline recommendations, particularly with respect to the choice of alternative antibiotics for patients with known allergies. The limited awareness of pediatric dosing regimens has also been consistently reported in previous studies, suggesting that this represents a widespread issue across different healthcare settings [12,18,19,29].
Another noteworthy finding of this study is that physicians with more than 20 years of experience scored lower than those with fewer than 5 years, a pattern that was not observed among dentists. This difference may reflect variations in clinical exposure between the two professions. Dentistry is inherently more procedure-oriented and surgical, and dentists may occasionally encounter patients with cardiac conditions in the context of routine practice. In contrast, physicians who are not specialized in surgery may have fewer opportunities to apply knowledge of infective endocarditis prevention. As a result, information acquired during undergraduate training may fade over time if it is not regularly reinforced in daily practice. Conversely, the procedural nature of dental care may encourage dentists to remain more attentive to guideline recommendations, which could explain why years of experience did not significantly influence their scores. Interestingly, a survey among Iranian dentists showed that they possessed greater knowledge compared to other healthcare professionals, including cardiologists, further supporting the notion that this pattern is also observed in settings far removed from the Italian context [30].
When comparing the overall level of knowledge on the prevention of bacterial endocarditis among dentists in the present study with that of Italian dental hygienists [16], an interesting difference emerges. While dental hygienists demonstrated good awareness of high-risk procedures relevant to their practice, they also showed notable gaps regarding the need for prophylaxis, including a tendency to overprescribe an uncertainty about appropriate regimens. Similar shortcomings have also been reported among dental students in Nepal, particularly regarding the unnecessary use of antibiotic prophylaxis [31]. Enhancing knowledge and adherence to guidelines for infective endocarditis prophylaxis is crucial not only for patient safety but also for preserving antibiotic effectiveness and maintaining alignment with current best practices. Given the high morbidity and mortality associated with infective endocarditis, accurate risk stratification and strict adherence to established guidelines are essential. The identified knowledge gaps, particularly in relation to guideline awareness and antibiotic selection in specific patients such as children and patients with beta-lactam allergies, highlight the need for targeted educational interventions. In this regard, the observed differences among physicians between guideline users are noteworthy: physicians familiar with AHA and ESC guidelines scored higher than those following NICE, likely because AHA and ESC provide more detailed and frequently updated recommendations, whereas the more restrictive approach historically adopted by NICE may have generated uncertainty or gaps in practical knowledge. These findings reinforce the need for tailored interventions aimed at improving clinical decision-making [32]. Such interventions should include interdisciplinary training modules involving cardiologists, infectious disease specialists, and dental professionals in order to promote a shared and consistent understanding of guideline recommendations across specialties. Decision-support tools, including mobile applications, could be effectively integrated into routine clinical practice to support decision making regarding antibiotic prophylaxis, particularly by tailoring recommendations to individual patient risk profiles. Furthermore, the implementation of national audit and feedback systems is recommended to systematically monitor adherence to current guidelines and to identify specific areas requiring improvement.
Although this study offers valuable insights into the knowledge and practices related to infective endocarditis prophylaxis, its findings should be interpreted with certain limitations in mind. The research was conducted solely in the province of Milan, a densely populated and urbanized area in Northern Italy. While this context provided access to a large number of healthcare professionals, it may not fully represent the experiences or practices of clinicians in other regions, particularly those in rural or underserved settings, where knowledge and behavior may vary. Additionally, the study had a relatively low response rate, raising the potential for self-selection bias: participants with a stronger interest or background in the topic may have been more likely to respond. However, low response rates have been reported in other surveys conducted among dentists in Italy, suggesting a generally limited propensity of Italian dental professionals to participate in questionnaire-based studies [33,34]. Moreover, although data on years of professional experience were collected, the study did not explore whether respondents had received specific postgraduate training in endocarditis prevention.
The use of bootstrapping provided a robust estimate of the intercept’s confidence interval, thereby enhancing the reliability of the model. Nevertheless, in the multivariable linear regression, the low R-squared value indicates that only a small proportion of the variance in scores is explained by the included predictors, suggesting the influence of unmeasured variables. This limitation is not unexpected in studies of knowledge and behavior, where outcomes are typically shaped by a complex interplay of personal, educational, and organizational factors. Future surveys could therefore incorporate additional items exploring dimensions such as geographic area of residence (e.g., urban vs. rural), workplace setting (e.g., hospital, private practice), frequency of exposure to at-risk patients, extent of continuing professional education, or other contextual aspects not captured in the present study. Accounting for these variables may improve the explanatory power of the models and yield a more nuanced understanding of the determinants of knowledge regarding infective endocarditis prophylaxis.

5. Conclusions

In conclusion, this survey reveals a situation in a sample of clinicians from Northern Italy that closely parallels findings reported in other countries. The clinical implications of these results are significant. Inappropriate use of antibiotic prophylaxis, whether through overprescription or omission, can lead, on one hand, to an increased risk of infectious endocarditis in high-risk patients due to missed prophylaxis, and on the other hand, to antibiotic resistance and unnecessary exposure to adverse drug effects in low-risk patients. Furthermore, legal and ethical concerns arise from deviations from evidence-based practice, underscoring the importance of adherence to established guidelines.

Supplementary Materials

The following supporting information can be downloaded at: https://www.mdpi.com/article/10.3390/app15179532/s1, File S1. Survey for dentist; File S2. Survey for physicians; File S3. Variables re-coding in numerical score; File S4. Content Validity Index and Content Validity Ratio; File S5. Multivariable linear regression analysis.

Author Contributions

Conceptualization, S.C. and N.C.; methodology, C.S.; validation, M.G.C. and G.C.; formal analysis, C.S.; investigation, S.C. and N.C.; data curation, S.C.; writing—original draft preparation, S.C., C.S. and M.G.C.; writing—review and editing, M.G.C. and G.C.; supervision, M.G.C. and G.C. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the University of Sassari, Sassari, Italy (N°AOU_SS 386 on 22 March 2022).

Informed Consent Statement

Informed consent was obtained from all subjects involved in the study.

Data Availability Statement

Data are available on https://dataverse.unimi.it/dataset.xhtml?persistentId=doi:10.13130/RD_UNIMI/DPDWTY, accessed on 22 March 2022.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
IEInfective endocarditis
APAntibiotic Prophylaxis
AHAAmerican Heart Association
ESCEuropean Society of Cardiology
NICENational Institute for Health and Care Excellence

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Table 1. Characteristics of the sample.
Table 1. Characteristics of the sample.
SpecialitiesPediatric DentistsOrthodontistsOral SurgeonsOther Dental SpecialtiesDentists (n = 493)PediatriciansGeneral/Family PhysiciansOther Medical SpecialtiesPhysicians (n = 477)
N (%)
Working experience
<5 years4 (12.5)20 (18.5)2 (4.0)47 (15.5)73 (14.8)15 (8.2)14 (24.1)25 (10.5)54 (11.3)
6–10 years8 (25.0)12 (11.1)5 (10.0)27 (8.9)52 (10.6)26 (14.3)3 (5.2)19 (8.0)48 (10.1)
11–15 years5 (15.6)20 (18.5)7 (14.0)35 (11.6)67 (13.6)20 (11.0)8 (13.8)26 (11.0)54 (11.3)
16–20 years3 (9.4)12 (11.1)5 (10.0)28 (9.2)48 (9.7)15 (8.2)3 (5.2)23 (9.7)41 (8.6)
>20 years12 (37.5)44 (40.8)31 (62.0)166 (54.8)253 (51.3)106 (58.3)30 (51.7)144 (60.8)280 (58.7)
Guideline followed
AHA21 (65.6)55 (50.9)28 (56.0)143 (47.2)247 (50.1)94 (51.7)25 (43.1)101 (42.6)220 (46.1)
ESC5 (15.6)30 (27.8)16 (32.0)95 (31.4)146 (29.6)38 (20.9)19 (32.8)70 (29.5)127 (26.6)
NICE1 (3.1)4 (3.7)2 (4.0)17 (5.6)24 (4.9)16 (8.8)3 (5.2)22 (9.3)41 (8.6)
Another guideline4 (12.5)7 (6.5)4 (8.0)28 (9.2)43 (8.7)13 (7.1)5 (8.6)13 (5.5)31 (6.5)
I don’t know the guidelines1 (3.1)12 (11.1)0 (0.0)20 (6.6)33 (6.7)21 (11.5)6 (10.3)31 (13.1)58 (12.2)
Total32 (6.5)108 (21.9)50 (10.1)303 (61.5)493 (100.0)182 (38.3)58 (12.2) 237 (49.7)477 (100.0)
AHA: American Heart Association; ESC: European Society of Cardiology; NICE: National Institute for Health and Care Excellence; N: number.
Table 2. Survey for physicians.
Table 2. Survey for physicians.
Survey for Physicians (n = 477)
ItemN (%) of Correct Answers
Does … influence your decision for endocarditis prophylaxis?
Type of procedure222 (46.5) *
Type of heart disease257 (53.9) *
Age432 (90.6)
Clinical history of patients 270 (56.6)
Which heart disease is a high-risk disease, and when would you give endocarditis prophylaxis? (multiple choice)
Uncorrected noncyanotic congenital heart disease337 (70.7)
Uncorrected cyanotic congenital heart disease188 (39.4) *
Congenital heart disease palliated with a shunt214 (44.9) *
Congenital valvar disease (insufficiency, stenosis)174 (36.5) *
Acquired/Rheumatic valvar disease144 (30.2) *
Bicuspid aortic valve273 (57.2)
Aortic valve stenosis calcified322 (67.5)
Heart transplant, with secondary valve disease287 (60.2)
Mechanical prosthetic valve313 (65.6)
Bioprosthetic valve256 (53.7) *
Previous endocarditis338 (70.9)
Post-cardiac surgery within 6 months after cardiac surgery275 (57.7)
Post-cardiac surgery beyond 6 months after cardiac surgery378 (79.3)
Cardiomyopathy365 (76.5)
When you treat a high-risk patient, which procedure do you prescribe prophylaxis for? (multiple choice)
Surgical procedures with infection221 (46.3) *
All dental procedures207 (43.4) *
All diagnostic procedures458 (96.0)
Surgical procedures without infection335 (70.2)
A 7-year-old with uncomplicated ASD is scheduled for a high-risk dental procedure. The patient has no history of antibiotic allergies. Do you prescribe endocarditis prophylaxis?
No83 (17.4) *
A 13-year-old with unoperated tetralogy of Fallot needs surgical drainage of a pulmonary abscess. The patient has no history of allergy to antibiotics. Do you prescribe endocarditis prophylaxis?
Yes, 50 mg/kg amoxicillin230 (48.2) *
If you prescribe antibiotic prophylaxis, which antibiotics do you prescribe if the patient is allergic to beta-lactams?
Doxycycline226 (47.4) *
* The scores were statistically below the expected minimum threshold for correct responses (H0: 58.0 ± 2.0%).
Table 3. Survey for dentists.
Table 3. Survey for dentists.
Survey for Dentists (n = 493)
ItemN (%) of Correct Answers
Does … influence your decision for endocarditis prophylaxis?
Type of procedure 242 (49.1) *
Type of heart disease289 (58.6) *
Age466 (94.5)
Clinical history of patients 292 (59.3) *
Do you apply endocarditis prophylaxis if high-risk CHD patients need the following interventions? (multiple choice)
Intra-oral radiography487 (98.8)
Local anesthesia438 (88.8)
Post-traumatic lip bleeding343 (69.6)
Loss of milk teeth459 (93.1)
Application of a dental dam469 (95.1)
Supragingival scaling364 (73.8)
Orthodontic brackets489 (99.2)
Extraction344 (69.8)
Incision of an abscess300 (60.8) *
Root canal treatment111 (22.5) *
Placement of orthodontic bands30 (6.1) *
Scaling and root planning268 (54.4) *
Insertion of implants297 (60.2) *
Replantation of an avulsed tooth254 (51.5) *
Apex resection288 (58.4) *
Insertion and removal of an orthodontic arch490 (99.4)
What dosages of antibiotics prophylaxis do you prescribe for a child (8 years, 30 kg) who is not allergic to penicillin or ampicillin?
50 mg/kg amoxicillin of ampicillin233 (47.3) *
If you prescribe antibiotic prophylaxis, which antibiotics do you prescribe if the patient is allergic to beta-lactams?
Doxycycline 296 (60.0) *
* The percentage is statistically below the expected minimum threshold for correct responses (H0: 68.0% ± 2.0%).
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Salerno, C.; Cirio, S.; Camoni, N.; Campus, G.; Cagetti, M.G. Theoretical and Practical Knowledge Regarding Infective Endocarditis Prevention Among Dentists and Physicians: A Questionnaire-Based Survey. Appl. Sci. 2025, 15, 9532. https://doi.org/10.3390/app15179532

AMA Style

Salerno C, Cirio S, Camoni N, Campus G, Cagetti MG. Theoretical and Practical Knowledge Regarding Infective Endocarditis Prevention Among Dentists and Physicians: A Questionnaire-Based Survey. Applied Sciences. 2025; 15(17):9532. https://doi.org/10.3390/app15179532

Chicago/Turabian Style

Salerno, Claudia, Silvia Cirio, Nicole Camoni, Guglielmo Campus, and Maria Grazia Cagetti. 2025. "Theoretical and Practical Knowledge Regarding Infective Endocarditis Prevention Among Dentists and Physicians: A Questionnaire-Based Survey" Applied Sciences 15, no. 17: 9532. https://doi.org/10.3390/app15179532

APA Style

Salerno, C., Cirio, S., Camoni, N., Campus, G., & Cagetti, M. G. (2025). Theoretical and Practical Knowledge Regarding Infective Endocarditis Prevention Among Dentists and Physicians: A Questionnaire-Based Survey. Applied Sciences, 15(17), 9532. https://doi.org/10.3390/app15179532

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