Oral Health Topics
Infective Endocarditis
Before some dental treatments, patients who have certain heart conditions and those with artificial joints take antibiotics. These people may be at risk of developing an infection in the heart or at the site of the artificial joint, respectively. Antibiotics reduce this risk. This is called antibiotic prophylaxis (pronounced pro-fuh-lax-iss).
When treating patients with heart conditions, dentists follow guidelines developed by the American Heart Association (AHA), with input from the ADA. For patients who have total joint replacements, they refer to guidelines developed by the American Academy of Orthopedic Surgeons (AAOS).
Guidelines for People with Heart Conditions
The AHA guidelines are meant to reduce the risk of infective endocarditis (pronounced end-o-car-die-tiss). Infective endocarditis (IE) is an infection of the lining inside the heart or the heart valves.
In the past, a number of heart conditions were thought to put patients at risk for IE. When writing the new guidelines, the AHA looked at published research and other scientific articles. They found that fewer conditions were associated with IE. As a result, a smaller group of patients needs to premedicate before dental treatments.
Why did the guidelines change?
After looking at the published scientific reports and articles, the AHA concluded that:
- the risks of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. Adverse reactions can range from mild (rashes) to severe (breathing problems that could result in death).
- when all the study results were looked at together, it wasn’t clear that premedication prevented IE.
- bacteria from the mouth can enter the bloodstream during daily activities like brushing or cleaning between the teeth. Once in the bloodstream, it can travel to the heart. People at risk of infection might be more likely to develop IE from these activities than after a dental treatment.
- Also, bacteria that cause infections can become resistant to antibiotics if those drugs are used too often. Because of this, doctors try to limit the use of antibiotics.
Patient selection
The current guidelines recommend use of preventive antibiotics before certain dental procedures for people with:
- artificial heart valves
- a history of infective endocarditis
- a cardiac transplant that develops a heart valve problem
- the following congenital (present from birth) heart conditions:*
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device* Check with your cardiologist if you’re not sure whether or not you fall into one of these categories.
People who took prophylactic antibiotics in the past but no longer need them include those with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.
Talk to your dentist about how these guidelines might apply to you.
Additional resources
- American Heart Association downloadable wallet card (available in English and Spanish)
- For the Dental Patient: Antibiotics and Your Heart
Guidelines for People with Total Joint Replacements
Guidelines from the AAOS are meant to reduce the risk of infections at the site of an artificial joint. They apply to people who have total joint replacements. Patients who have pins, plates or other orthopedic hardware are not affected.
AAOS recommends that all patients who have total joint replacements should take antibiotics before certain types of dental procedures. Talk to your dentist about how these guidelines might apply to you.
Overview
For decades, the American Heart Association (AHA) recommended that patients with certain heart conditions take antibiotics shortly before dental treatment. This was done with the belief that antibiotics would prevent infective endocarditis (IE), previously referred to as bacterial endocarditis. The AHA’s latest guidelines were published in its scientific journal, Circulation, in October 2007 and there is good news: the AHA recommends that most of these patients no longer need short-term antibiotics as a preventive measure before their dental treatment.
The American Dental Association participated in the development of the new guidelines and has approved those portions relevant to dentistry. The guidelines were also endorsed by the Infectious Diseases Society of America and by the Pediatric Infectious Diseases Society.
The guidelines are based on a growing body of scientific evidence that shows the risks of taking preventive antibiotics outweigh the benefits for most patients. The risks include adverse reactions to antibiotics that range from mild to potentially severe and, in very rare cases, death. Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria.
Scientists also found no compelling evidence that taking antibiotics prior to a dental procedure prevents IE in patients who are at risk of developing a heart infection. Their hearts are already often exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing. The new guidelines are based on a comprehensive review of published studies that suggests IE is more likely to occur as a result of these everyday activities than from a dental procedure.
The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.
The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection.
Preventive antibiotics prior to a dental procedure are advised for patients with:
- artificial heart valves
- a history of infective endocarditis
- certain specific, serious congenital (present from birth) heart conditions, including
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
- a cardiac transplant that develops a problem in a heart valve.
The new recommendations apply to many dental procedures, including teeth cleaning and extractions. Patients with congenital heart disease can have complicated circumstances. They should check with their cardiologist if there is any question at all as to the category that best fits their needs.
