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Overview 

In new guidelines from the American Heart Association (AHA), fewer patients with heart conditions are recommended to receive antibiotic prophylaxis before dental procedures for the prevention of infective endocarditis* (IE). Antibiotic prophylaxis is now recommended only for patients at greatest risk of negative outcomes from infective endocarditis when they undergo dental procedures that involve manipulation of the gingival tissues, periapical region of teeth or perforate the oral mucosa. The updated AHA guidelines, prepared with input from the ADA, appear in the April 2007 issue of Circulation, and portions of the AHA report that are pertinent to dentistry will be published in the June 2007 Journal of the American Dental Association.

The new AHA guidelines are a significant departure from previous AHA recommendations for IE prophylaxis, which were last published in 1997. For the first time, the recommendation for antibiotic prophylaxis before dental procedures is no longer based on the patient’s lifelong risk of acquiring infective endocarditis (based on underlying cardiac conditions). Rather, the recommendations are based on how serious the outcome would be if the patient developed infective endocarditis. Antibiotic prophylaxis is recommended only for patients with the following conditions: artificial cardiac valve or certain congenital heart diseases; cardiac transplantation recipients who develop cardiac valve problems; patients who have received an artificial patch to repair a congenital heart defect within the past six months; and patients who have had previous infective endocarditis.

Additional findings presented in the AHA report include the following:

  • Infective endocarditis is more likely to result from frequent exposure to random bacteremia caused by routine everyday activities, such as chewing and brushing, than from dental procedures. 
  • Evidence supports an emphasis on maintaining good oral hygiene and eradicating dental disease to decrease the frequency of bacteremia from routine daily activities. 
  • Only an extremely small number of IE cases might be prevented with antibiotic prophylaxis, even if prophylactic therapy were 100% effective. 
  • There are no data to support visible bleeding during dental treatment as a reliable predictor of bacteremia. 
  • The risk of antibiotic-associated adverse outcomes, including development of drug-resistant microorganisms and risk for anaphylaxis, exceeds the overall benefit of IE prophylaxis before dental procedures for most patients, except for those few at greatest risk for a negative outcome. 
  • Patients for whom prophylactic antibiotics are no longer recommended include individuals with mitral valve prolapse, rheumatic heart disease and bicuspid valve disease.
An abridged ADA version of the AHA report, which includes those portions that are pertinent to dentistry, is now available at ADA.org, with several tables summarizing key revisions within the new recommendations. The ADA version will also be published in the June 2007 JADA, and will include a “For the Dental Patient” page that dentists can photocopy and share with patients and other health care providers.

Dentists are encouraged to consult the new AHA recommendations for the prevention of infective endocarditis and to promote the importance of maintaining good oral health and hygiene as a preventive approach to reduce the incidence of bacteremia from routine daily activities. Also, as stated in a 2004 ADA report on antibiotic resistance, “[a]ny perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy, and the development, selection and transmission of microbial resistance.” For additional information, see the April 2007 JADA cover story on the evidence base for the efficacy of antibiotic prophylaxis in dental practice

*The AHA and other organizations worldwide are now using the term infective endocarditis instead of the previously used term bacterial endocarditis.  

Additional Resources  

Science in the News is a service by the American Dental Association (ADA) to present current information about science topics in the news. The ADA is a professional association of dentists committed to the public's oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards. As a science-based organization, the ADA's evaluation of the scientific evidence may change as more information becomes available. Your thoughts would be greatly appreciated.

Document Posted April 2007