Antibiotic prophylaxis seldom needed for dental procedures, say updated recommendations

April 19, 2007

Dallas, TX - Prophylactic antibiotic therapy for dental procedures is unlikely to prevent many cases of infective endocarditis and should be restricted to patients who would be at highest risk from the infection, such as those with prosthetic valves or certain congenital heart defects, according to updated guidelines issued this week by the American HeartAssociation (AHA) and published online April 19, 2007 in Circulation [1].

"We've concluded that if giving prophylactic antibiotics prior to a dental procedure works at all—and there's no evidence that it does work—we should reserve that preventive treatment only for those people who would have the worst outcomes if they get infective endocarditis," according to the chair of the new guidelines' writing group, Dr Walter R Wilson (Mayo Clinic, Rochester, MN), as quoted in a statement issued by the AHA. "This changes the whole philosophy of how we have constructed these recommendations for the past 50 years." 

Based on an analysis of available literature, the document concludes that "random bacteremia" resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause infective endocarditis than bacteremia secondary to dental procedures.

"There should be a shift in emphasis away from a focus on a dental procedure and antibiotic prophylaxis toward a greater emphasis on improved access to dental care and oral health in patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis and those conditions that predispose to the acquisition of infective endocarditis," according to the updated guidelines.

Prophylactic antibiotics, they state, should not be given based on a lifetime risk of infective endocarditis but are recommended for high-risk patients undergoing "procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." Such "high-risk" patients, according to the report, include recipients of cardiac transplants who develop cardiac valvulopathy and patients with:

  • Prior infective endocarditis.

  • Prosthetic cardiac valves.

  • Unrepaired cyanotic congenital heart defects, including palliative shunts and conduits.

  • Congenital heart defects completely repaired with prosthetic material or a device, whether placed by surgery or by catheter intervention, during the first six months after the procedure.

  • Repaired congenital defects with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device.

Patient groups that may have received routine antibiotic prophylaxis in the past but are now inappropriate for it include those with mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy, according to the AHA statement.

The revised guidelines were developed with the participation of and have been endorsed by the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics.

Disclosures of potential conflicts of interest for the writing group and the document's reviewers are included in the report.

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