Fewer heart patients need antibiotics before dental procedures to prevent infective endocarditis

Based on a review of new and existing scientific evidence, most dental patients with heart disease do not need antibiotics before dental procedures to prevent infective endocarditis (IE), a rare, but life-threatening heart infection.

According to revised guidelines from the American Heart Association (AHA) with input from the American Dental Association (ADA), antibiotics are now only recommended for patients at greatest risk of negative outcomes from IE including those with artificial heart valves or certain congenital heart conditions, heart transplant recipients who develop cardiac valve problems, recipients of an artificial patch to repair a congenital heart defect within the past six months and patients with a history of IE.

The AHA's latest guidelines were published in its scientific journal, Circulation, in April. The Guidelines apply to a range of medical and dental procedures. The ADA is publishing those portions of the new guidelines relevant to dentistry on its Web site (www.ada.org/goto/endocarditis) today and in the June issue of the Journal of the American Dental Association (JADA).

For decades, the AHA recommended that patients with certain heart conditions take antibiotics shortly before dental treatment. This was done with the belief that antibiotics would prevent IE, previously referred to as bacterial endocarditis. IE is an infection of the heart's inner lining or valves, which results when bacteria enter the bloodstream and travel to the heart. Bacteria are normally found in various sites of the body including on the skin and in the mouth.

The ADA participated in the development of the new guidelines and has approved those portions relevant to dentistry. The guidelines are also endorsed by the Infectious Diseases Society of America and by the Pediatric Infectious Diseases Society.

The new guidelines are based on a growing body of scientific evidence that shows the risks of taking preventive antibiotics outweigh the benefits for most patients. The risks include adverse reactions to antibiotics that range from mild to potentially severe and, in rare cases, death. Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria.

Scientists also found no compelling evidence that taking antibiotics prior to a dental procedure prevents IE in patients who are at risk of developing a heart infection. Their hearts are already often exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as brushing or flossing. The new guidelines are based on a comprehensive review of published studies that suggests IE is more likely to occur as a result of these everyday activities than from a dental procedure.

The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with mitral valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis, or congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

The new recommendations apply to many dental procedures, including teeth cleaning and extractions. The guidelines emphasize that maintaining optimal oral health and practicing daily oral hygiene are more important in reducing the risk of IE than taking preventive antibiotics before a dental visit.