With input from the ADA, the American Heart Association (AHA) released guidelines for the prevention of infective endocarditis in 2007,7 which were approved by the CSA as they relate to dentistry in 2008.8 These guidelines were updated by a 2021 scientific statement by the AHA that recommended no changes to the 2007 guideline recommendations. 9 The AHA continues to recommend infective endocarditis prophylaxis “only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all.”9 In 2017, the AHA and American College of Cardiology (ACC) published a focused update10 to their 2014 guidelines on the management of valvular heart disease that also reinforced the previous recommendations.
These current guidelines support infective endocarditis premedication for a relatively small subset of patients. This is 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.
In addition, 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 valvular disease management guidelines10 recommend that persons at risk of developing bacterial infective endocarditis (see “Patient Selection”) establish and maintain the best possible oral health to reduce potential sources of bacterial seeding. They state, “Optimal oral health is maintained through regular professional dental care and the use of appropriate dental products, such as manual, powered, and ultrasonic toothbrushes; dental floss; and other plaque-removal devices.”
The current infective endocarditis/valvular heart disease guidelines7, 8, 10 state that use of preventive antibiotics before certain dental procedures is reasonable for patients with:
- prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts;
- prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords;
- a history of infective endocarditis;
- a cardiac transplanta with valve regurgitation due to a structurally abnormal valve;
- the following congenital (present from birth) heart disease:b
- unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device
a According to limited data, infective endocarditis appears to be more common in heart transplant recipients than in the general population; the risk of infective endocarditis is highest in the first 6 months after transplant because of endothelial disruption, high-intensity immunosuppressive therapy, frequent central venous catheter access, and frequent endomyocardial biopsies.9
b Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease.
Congenital heart disease can indicate that prescription of prophylactic antibiotics may be appropriate for children. It is important to note, however, that when antibiotic prophylaxis is called for due to congenital heart concerns, they should only be considered when the patient has:
- Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had a surgical shunts and conduits.
- A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure.
- Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.
Antibiotic prophylaxis is not recommended for any other form of congenital heart disease.
Beyond identifying the specific patient population for whom antibiotic prophylaxis is appropriate, special consideration should be given to the antibiotic dose prescribed to children, as it will vary according to the child’s weight. Weight-based regimens for children are outlined in Table 2 of the 2007 American Heart Association guidelinesand Table 5 of the 2021 AHA scientific statement.7-9As with any medication, check with the primary caregiver to determine whether the child has an allergy to antibiotics or other antibiotic-related concerns before prescribing.
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)
The 2021 AHA scientific statement on prevention of infective endocarditis no longer recommends use of clindamycin as an oral or parenteral alternative to amoxicillin or ampicillin in individuals with allergies to these drugs because clindamycin “may cause more frequent and severe reactions than other antibiotics used for [antibiotic prophylaxis]” (including C. difficile infection).9 The AHA recommends that in individuals who are allergic to penicillin or ampicillin and who can take oral medication, cephalexin (or other first- or second-generation cephalosporins), azithromycin, clarithromycin, or doxycycline be used as alternatives.9 In individuals who are penicillin or ampicillin allergic and who cannot take oral medication, the AHA recommends cefazolin or ceftriaxone as alternatives.9 However, the AHA also recommends that cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.9 The current medication regimens recommended (when indicated) are listed in Table 5 of the 2021 AHA scientific statement.
Sometimes, patients forget to premedicate before their appointments. The recommendation is that for patients with an indication for antibiotic prophylaxis, 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 endocarditis7, 8 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.” If a patient with an indication for prophylaxis who appropriately received antibiotic premedication prior to a dental procedure one day and who is then scheduled the following day for a dental procedure also warranting premedication (e.g., dental prophylaxis), the antibiotic prophylaxis regimen should be repeated prior to the second appointment. Because of the nature of the pharmacokinetics of an antibiotic prophylaxis regimen, a single loading dose is given in order to cover the period of potential bacteremia produced by a single procedure.11-13
Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the AHA guidelines and 2021 AHA scientific statement for infective endocarditis7, 9 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 azithromycin or clarithromycin for prophylaxis.
Other patient groups also may merit special consideration, which is discussed more fully in the AHA 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.13 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/ACC guidelines discussed above. Dental professionals should periodically visit the ADA website for updates on this issue.