NICE Rethink Urged for Antibiotic Prophylaxis in Dentistry

Peter Russell

November 07, 2018

An international study supports the use of antibiotic prophylaxis (AP) to prevent infective endocarditis (IE) in high-risk dental patients.

Researchers said it provided further evidence that the National Institute for Health and Care Excellence (NICE) was wrong to issue guidance that AP was not routinely recommended for people in England and Wales undergoing dental procedures.

The study, led by the University of Sheffield's School of Clinical Dentistry, investigated how a change in US guidelines on the prescribing of AP affected rates of IE in patients having invasive dental treatment. The 2007 updated recommendations by the American Heart Association (AHA) advised that AP should not be prescribed for people at moderate-risk of IE but should be given to those at high-risk.

Fewer High-Risk Patients Received AP

After 8 years, the new US guidelines were associated with an estimated 64% fall in AP prescribing for moderate-risk individuals. However, the researchers also found an estimated 20% fall for those at high-risk, despite the AHA's recommendation that high-risk individuals should continue to receive AP before invasive dental treatment. 

Over the same period, there was a barely significant 75% estimated increase in IE incidence among moderate-risk individuals, but a significant 177% estimated increase among those at high-risk. 

In patients who were low-risk, or whose risk was unknown, there was a significant 52% estimated fall in AP prescribing, but no significant increase in IE incidence.

NICE Recommendations 'Probably Wrong'

Professor Martin Thornhill from the University of Sheffield, who led the study, published in the Journal of the American College of Cardiology , said: "Although the data do not prove a cause-effect relationship between AP reduction and IE increase, they are very supportive of the AHA recommendation to give AP to those at high-risk but not to those at moderate-risk of endocarditis.

"It also provides further evidence that the 2008 NICE recommendation that AP should cease completely in the UK, was probably wrong and should be changed."

NICE reviewed its 2008 guidelines after a study suggested that the incidence of IE may have increased since the change was implemented. However, the guideline, updated in 2015, and amended in 2016, ruled out making any changes to the existing guidance, adding that "the longstanding increase in the incidence of infective endocarditis in the UK and other countries globally is not well understood and could be due to a number of factors".

When Medscape News UK asked NICE whether it would be reviewing the guidelines in the wake of the latest evidence, it declined to offer a specific comment until it had the opportunity to review the findings in detail. However, it said it would consider how the study could affect the guideline, and "if we believe the study is likely to affect the guideline recommendations we’ll perform a check to consider its impact on the current guideline recommendations and incorporate feedback from topic experts in this area".

A 'Significant Challenge' to Dentists

Prof Thornhill commented: "Current NICE guidance on the use of AP to prevent IE is confusing and unhelpful for clinicians and patients, and probably wrong.

"In the absence of clear and sensible advice from NICE, the recent attempt by the Scottish Dental Clinical Effectiveness Program (SDCEP) to provide advice for dentists about how to implement the NICE guidelines – effectively suggesting they follow the AHA recommendations – is very welcome."

In August 2018, the SDCEP said that dentists in the UK faced a "significant challenge" because the 2016 amendment to the NICE guideline, stating that AP was not routinely recommended for people undergoing dental procedures, did not define which individual patient should be considered for 'non-routine' management. Additionally, there was no information on which AP regimen would be appropriate for use in a dental setting, it said.

Susie Sanderson, president of the British Dental Association (BDA), told Medscape News UK: "The British Dental Association advises its members to always to act in the best interests of their patients, which includes being familiar with current guidelines.  

"In the case of antibiotic prophylaxis against infective endocarditis, the NICE guidance was developed by a highly respected expert group following an extensive review of the available evidence. In 2015, NICE added its recommendation that such prophylaxis should not be given 'routinely' for people undergoing dental procedures. 
"The BDA and other significant stakeholders have welcomed helpful assistance from the Scottish Dental Clinical Effectiveness Program on the implementation of the NICE guidelines. 

"Whether or not antibiotic prophylaxis is prescribed for a patient will depend on individual circumstances informed by advice from their medical teams, the values and preferences of the patient, and following a process to achieve valid consent."

Data from the Sheffield study will also be presented by Dr Pat O’Gara, chair of Cardiology at Harvard Medical School and Brigham Women's, at the AHA Annual Scientific Meeting in Chicago on November 11th, 2018.

The study was funded by Delta Dental of Michigan and its Research and Data Institute.

Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations, M Thornhill et al, JACC. Paper.

Editor's note: This article was updated after publication updated to include BDA comment.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.
Post as: