Do Patients Undergoing Dental Procedures Require Endocarditisprophylaxis?

Do Patients Undergoing Dental Procedures Require Endocarditisprophylaxis?

Q&A 187.3

Do patients undergoing dental procedures require endocarditisprophylaxis?

Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals

Before using this Q&A, read the disclaimer at

Date reviewed: September 2011

Summary

Antibiotic prophylaxis is not recommended for the prevention of infective endocarditis in patients undergoing dental procedures.

Background

Infective endocarditis is an inflammation of the inner lining of the heart (endocardium), particularly affecting the heart valves and caused mainly by bacterial infection. Patients with structural abnormalities of the heart, hypertrophic cardiomyopathy, replacement heart valves or with a history of infective endocarditis are considered to be at risk of developing infective endocarditis.

Traditionally, prophylactic antibiotics have been given to patients at risk of infective endocarditis before undergoing dental procedures. Typically, three grams of oral amoxicillin would be taken one hour beforehand. The rationale for using antibiotics wasthat dental procedures lead to increased numbers of bacteria in the blood (bacteraemia) and it was assumed that bacteraemia was a key factor in the development of infective endocarditis.

Prior to 2008 there were conflicting guidelines as to which patients and dental procedures warranted the use of prophylactic antibiotics(1, 2, 3). This led to confusion for health professionals and patients.In April 2008, the National Institute for Health and Clinical Excellence (NICE) issued definitive, evidence-based guidance on the prophylaxis of infective endocarditis (4). This guidancehas been adopted nationally and is reflected in the British National Formulary(5).

Answer

Antibiotic prophylaxis is not recommended for the prevention of infective endocarditis in adults or children undergoing any dental procedure (4).

The basis for this recommendation is:

  • There is no consistent association between dental procedures and an increased risk of infective endocarditis;
  • Bacteraemia associated with dental procedures is no greater than that from toothbrushing; Regular toothbrushing almost certainly presents a greater risk of infective endocarditis than a single dental procedure because of repetitive exposure to bacteraemia;
  • Antibiotics are not proven to reduce the risk of infective endocarditis;
  • Antibiotics are themselves not without risk and can cause fatal anaphylaxis.

Patients who previously received endocarditis prophylaxis for dental procedures will require a clear explanation as to why prophylaxis is no longer recommended. A summary of the NICE guideline for patients (6) and a ‘quick reference leaflet’ (7) are available online. Printed copies can be ordered from NICE Publications via 0845 003 7783 or (quotereference numbers N1488and N1487 when ordering the patient summary and quick reference leaflet, respectively).

NICE states that healthcare professionals should offer clear and consistent advice to patients on four points, details of which are on page 2 of this document.

The NICEsummary for patients (6) includes a list of questions that patients might ask their healthcare team; answers are suggested on page 3 of this document.

Advice for healthcare professionals to offer to patients

Patients at risk of infective endocarditis should be reassured that antibiotic prophylaxis is no longer recommended and offered information regarding:

  • The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer recommended:

Patients at risk of infective endocarditis have traditionally received prophylactic antibiotics prior to dental procedures. Procedures that disturb bacteria in the mouth increase the number of bacteria in the blood (bacteraemia). High levels of bacteraemia have been shown (in animal models) to increase the risk of infective endocarditis. On this basis, it was considered prudent to provide antibiotic prophylaxis to reduce bacteraemia in patients considered to be at risk of infective endocarditis. Over recent years, there have been conflicting guidelines as to which patients required antibiotic prophylaxis and for which dental procedures.

NICE has reviewed the evidence regarding infective endocarditis and concluded that there is no clear association between dental procedures and infective endocarditis.Evidence shows that levels of bacteraemia associated with dental procedures are no greater than those associated with regular toothbrushing. The risk of infective endocarditis is almost certainly greater from toothbrushing than from a single dental procedure due to repeated exposure to bacteraemia with regular toothbrushing.

Antibiotic prophylaxis given before dental procedures has not been shown to eliminate bacteraemia or to reduce the risk of infective endocarditisand is associated with risks of its own. Antibiotics can cause adverse reactions including fatal anaphylaxis. Using antibiotics when not indicated puts patients at risk from adverse effects and can increasebacterial resistance to antibiotics. For all these reasons, antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis in patients undergoing dental procedures.

  • The importance of maintaining good oral health:

Maintaining good oral health reduces the numbers of bacteria in the mouth and helps prevent tooth decay and gum disease. Patients should be advised to keep their mouth and teeth clean with twice-daily toothbrushing, to have regular dental check-ups and not to let any dental problems such as abscess or gum disease go untreated.

  • Symptoms that may indicate infective endocarditis and when to seek expert advice:

Infective endocarditis is rare and patients are unlikely to develop it. Early symptoms of infective endocarditisare similar to flu-symptoms: fever, night sweats and chills, weakness and tiredness, and also breathlessness, weight loss and joint pain. Patients at risk of infective endocarditis should be advised to see a GP if they have such symptoms for longer than a week (8).

  • The risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing:

Bacteraemia can develop following piercing or tattooing, particularly if non-sterile equipment or techniques are involved. Patients at risk of infective endocarditis should be discouraged from having procedures such as piercing or tattooing(8).

People with the following cardiac conditions are considered to be at risk of developing infective endocarditis and would have received antibiotics for endocarditis prophylaxis in the past:

  • Previous infective endocarditis,
  • Replacement heart valve,
  • Structural congenital heart disease

(but not isolated atrial septal defect, fully repaired septal defect, fully repaired patent ductus arteriosus or congenital heart disease repaired with closure devices that are judged to be endothelialised),

  • Valvular heart disease with stenosis or regurgitation,
  • Hypertrophic cardiomyopathy.

Questions patients may ask

  • In the past I have been given antibiotics to prevent infective endocarditis for the same dental procedure but have not been offered them now. Why has this changed?

In the past, guidelines recommended that people at risk of infective endocarditis were given prophylactic (preventative) antibiotics before certain procedures. The National Institute for Health and Clinical Excellence (NICE) has reviewed the evidence regarding infective endocarditis and concluded that prophylactic antibiotics are notrequired for dental procedures.

To understand why the guidelines have changed, it is helpful to know why antibiotics were recommended in the first place: Dental procedures (such as scaling or tooth extraction) disturb bacteria in the mouth and these bacteria can then enter the bloodstream. It was thought that the rise in the number of bacteria in the bloodstream (bacteraemia) that occurred following dental proceduresincreased the risk of getting endocarditis, and antibiotics were given to combat this rise.

NICE has found that the levels of bacteria in the bloodstream associated with dental procedures are no higher than those associated with toothbrushing. So, patients undergoing dental procedures are not at any greater risk of getting endocarditis than they are from brushing their teeth.The bacteria that enter the bloodstream are killed by the body’s immune system.

Antibiotics can cause side effects, some of which can be very serious, or even fatal. Taking antibiotics when they are not needed puts patients at unnecessary risk. Because antibiotics have not been shown to reduce the chance of getting endocarditis, and because dental procedures are no longer thought to be a cause of endocarditis, taking antibiotics before dental procedures is no longer recommended.

  • I’ve used a chlorhexidine mouthwash when I have had dental treatment in the past. Is this helpful?

Chlorhexidine mouthwash is not recommended to prevent infective endocarditis. It has not been shown toreduce the chance of getting endocarditis and, as explained above, dental procedures are no longer thought to be a cause of endocarditis.

  • Is there some written material (like a leaflet) about infective endocarditis that I can have?

The British Heart Foundation has information about infective endocarditis on its website. Go to the home page ( and type ‘endocarditis’ in the search box at the top of the screen.

  • What can I do to improve my oral health?

Keep your teeth and mouth clean with twice-daily toothbrushing. Visit your dentist for regular checkups and don't let any dental problems such as a dental abscess or gum disease go untreated.

  • What are the symptoms of infective endocarditis? What should I do if I think I have it?

Infective endocarditis is very rare.Symptoms are flu-like, and include fever, night sweats and chills, weakness and tiredness as well as breathlessness, weight loss and joint pain.It is very unlikely that you will ever suffer from endocarditis but if you are at risk (e.g. if you have a replacement heart valve, valvular heart disease or hypertrophic cardiomyopathy) and have flu-like symptoms for longer than a week you should see a GP.

  • What do I do if I think I have an infection?

Guidelines for the treatment of infections have not changed. If you think you have an infection, contact a healthcare professional (e.g. pharmacist, GP, dentist or optician) as you would normally.

NICE provides guidance for the NHS in England and Wales. Further information about NICE, its work and how it reaches decisions is available online at

Limitations

This document does not relate to the use of pre-procedural antibiotics to prevent infections other than infective endocarditis.

September 2011 – NICE Clinical Guideline 64 – Prophylaxis against infective endocarditis, is under review. If the review process results in alteration to the original advice this Q&A will be updated.

References

  1. Joint Formulary Committee. British National Formulary. 54th edition. London: British Medical Association and Royal Pharmaceutical Society of Great Britain; 2007. Chapter 5.1, Table 2: Summary of antibacterial prophylaxis (page 279).
  1. Ramsdale DR, Turner-Stokes L, Advisory Group of the British Cardiac Society Clinical Practice Committee, et al. Prophylaxis and treatment of infective endocarditis in adults: a concise guide. Clin Med 2004; 4: 545-550.
  1. Gould FK, Elliott TSJ, Foweraker J, et al. Guidelines for prevention of endocarditis: report of the Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006; 57: 1035-1042. Accessed on 7/9/2011 at:
  1. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis. March 2008 (NICE Clinical Guideline No.64). Accessed on 7/9/2011 at:

NICE full guideline pages)

NICE appendices to the full guideline pages)

  1. British National Formulary. Chapter 5.1 antibacterial drugs; Table 2 summary of antibacterial prophylaxis. Accessible online at
  1. National Institute for Health and Clinical Excellence. Understanding NICE guidance: information for people who use NHS services. Preventing infective endocarditis. Reference N1488. Accessed on 7/9/2011 at:
  1. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis. Quick reference guide. Reference N1487.Accessed on 7/9/2011at:
  1. British Heart Foundation. Information sheet IS27. Endocarditis (infective endocarditis). Accessed on 7/9/2011 at

Quality Assurance

Prepared by

Karoline Brennan, North West Medicines Information Centre, April 2008

Reviewed by

Karoline Brennan, North West Medicines Information Centre, August 2009

Christine Randall, North West Medicines Information Centre, September 2011

Checked by

Christine Randall, North West Medicines Information Centre, April 2008 and August 2009

Christine Proudlove, North West Medicines Information Centre, September 2011

Medicines Q&A 187.3 Date reviewed September 2011

Do patients undergoing dental procedures require antibiotic prophylaxis?

From the NHS Evidence website

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