With input from the ADA, the American Heart Association (AHA) released guidelines for the prevention of infective endocarditis in 2007,5
which were approved by the CSA as they relate to dentistry in 2008.6
The current guidelines support infective endocarditis premedication for a smaller group of patients than previous versions. This change was based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics generally outweigh the benefits of prophylaxis for many patients who would have been considered eligible for prophylaxis in previous versions of the guidelines. Concern about the development of drug-resistant bacteria also was a factor.
Also, the data are mixed as to whether prophylactic antibiotics taken before a dental procedure prevent infective endocarditis. The guidelines note that people who are at risk for infective endocarditis are regularly exposed to oral bacteria during basic daily activities such as brushing or flossing.
The current infective endocarditis guidelines state that use of preventive antibiotics before certain dental procedures is reasonable for patients with:
- prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- a history of infective endocarditis
- a cardiac transplant that develops cardiac valvulopathy
- the following congenital (present from birth) heart disease:a
- unrepaired cyanotic congenital heart disease, including 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 procedureb
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device (that inhibit endothelialization)
a Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease.
b Prophylaxis is reasonable because endothelialization of a prosthetic material occurs within six months after the procedure.
Prophylaxis is recommended for the patients identified in the previous section for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
Additional Considerations About Infective Endocarditis Antibiotic Prophylaxis (when indicated)
Sometimes patients forget to premedicate before their appointments. The recommendation is that the antibiotic be given before the procedure. This is important because it allows the antibiotic to reach adequate blood levels. However, the guidelines to prevent infective endocarditis5, 6 state, “If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.”
Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the guidelines for infective endocarditis5, 6 recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.
Other patient groups also may merit special consideration, which is discussed more fully in the guidelines.
In 2015, The Lancet published a study out of the United Kingdom that reported a correlation between institution of more limited antibiotic prophylaxis guidelines by the National Institute for Health and Clinical Evidence (NICE) in 2008 and an increase in cases of infective endocarditis.7 Because of the retrospective and observational nature of the study, the authors acknowledged that their “data do not establish a causal association.” At this time, the ADA recommends that dentists continue to use the AHA guidelines discussed above. Dental professionals should periodically visit the ADA website for updates on this issue.