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Israeli dentists should be aware that in the United Kingdom there has been a change in the recommendations for prescribing antibiotic cover for patients at risk of bacterial endocarditis (infective endocarditis). These recommendations can be cited in court in the event of a patient holding a dentist liable for having acquired IE.
It is now not recommended that all patients with heart problems receive antibiotics before dental treatment. Those who do require cover are those who have the following conditions:
- An isolated atrial septal defect;
- A fully repaired ventricular septal defect; or
- A fully repaired patent ductus arteriosus and closure devices that are judged to be endothelialised.
The National Institute for Health and Clinical Excellence (NICE) has issued clinical guidelines (17.03.08) on antibiotic prophylaxis against infective endocarditis (IE).
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In a significant change to current clinical practice, the guidelines recommend that antibiotics to prevent IE should not be given to adults and children with structural cardiac defects at risk of IE who are undergoing dental and a number of non-dental interventional procedures.
IE is an inflammation of the inner lining of the heart, particularly affecting the heart valves, caused by bacterial or other infection. It may arise following bacteraemia in patients who have certain pre-existing heart conditions (see list below). Although IE is a rare condition, with fewer than 10 people in every 100,000 developing it each year, it can be life-threatening. It has been accepted clinical practice to use preventive (prophylactic) antibiotics before dental and some non-dental procedures in people who are considered to be at risk of IE. However, the effectiveness of this treatment in humans has never been properly investigated and clinical practice has been dictated by clinical guidelines based on expert opinion.
The 2008 NICE guidelines are based on the best available published evidence and a consensus of multidisciplinary, expert opinion within the Guideline Development Group (GDG). The guidelines conclude that there is no consistent association between interventional procedures, dental or non-dental, and the development of IE and that the clinical effectiveness of antibiotic prophylaxis is not proven. The evidence also suggests that antibiotic prophylaxis against IE for dental procedures is not cost effective and may lead to a greater number of deaths through fatal anaphylactic reactions than not using preventive antibiotics.
The guidelines list a group of people with particular cardiac conditions as being at risk of developing IE. The conditions listed are;
- acquired valvular heart disease with stenosis or regurgitation valve replacement;
- structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised;
- previous IE;
- hypertrophic cardiomyopathy.
However, the risk assessment accepted by NICE suggests that there is no need to offer antibiotics (to prevent IE) to the group of patients listed above for any of the following procedures:
- a dental procedure;
- an obstetric or gynaecological procedure, or childbirth;
- a procedure on the bladder or urine system;
- a procedure on the gullet, stomach or intestines;
- a procedure on the airways, including ear, nose and throat and bronchoscopy.
Because patients at risk of IE can be vulnerable in other aspects of their everyday life, dentists and other healthcare professionals can still help by offering people at risk of IE clear and consistent information about prevention, including:
- an explanation of why antibiotic prophylaxis is no longer routinely recommended the importance of maintaining good oral health;
- symptoms that may indicate IE and when to seek expert advice the risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.
Additionally, the guidelines mention the need to investigate and treat promptly any episodes of infection in people at risk of IE to reduce the risk of endocarditis developing.
Dental Protection is not an arbiter of clinical opinion but we recognise that this change will raise concerns both with practitioners and patients. Therefore members are welcome to contact us to discuss any issues arising from the new guideline.
We would further recommend that if there is any doubt regarding a particular patient the General Physician or Cardiologist should be consulted.