Update on Dental Prophylaxis
The Latest Recommendations
by Tanya Feke, MD
Antibiotics have a role not only in treating infections but also in preventing them. But before you call your doctor to report a case of the sniffles, please know that there are specific indications for use of prophylactic antibiotics. These relate to dental procedures and invasive surgery.
Why Do We Need Dental Prophylaxis?
The mouth is filled with bacteria. Staphylococcus, streptococcus, lactobacillus, even Escherichia coli. I know the idea just makes you want to kiss the person sitting next to you, but these bacteria can wreak havoc if they travel outside of the oral cavity to other areas of the body, namely to the heart.
Infective endocarditis (IE) is a serious medical condition that occurs when a bacteria or virus infects the heart tissue. This results in inflammation and formation of vegetations (clumps of bacteria and/or cell debris) on the heart valves. These vegetations not only weaken the function of the heart valves but can also break loose to travel to other areas of the body. Complications of IE can be deadly ranging from heart failure to stroke to end-organ damage (kidneys, liver, extremities, etc).
AHA Guidelines for Dental Prophylaxis
For decades, the American Heart Association (AHA) had broad guidelines in place to minimize the risk for IE caused by oral bacterial flora that gets into the blood after dental procedures. These guidelines were updated in 2007 in response to increased antibiotic resistance and to the questionable benefit of dental prophylaxis given limited data. Dental prophylaxis was subsequently reduced to individuals with the highest cardiac risk.
Current cardiac conditions needing dental prophylaxis:
- Cardiac valve disease after a heart transplant
- Congenital heart disease – repaired with prosthetic material
- Cyanotic congenital heart disease
- Heart valve repair using prosthetic material
- History for IE
- Prosthetic heart valves
Cardiac conditions no longer needing dental prophylaxis:
- Acquired aortic valve disease (aortic regurgitation, aortic stenosis)
- Acquired mitral valve disease (mitral regurgitation, mitral stenosis, mitral valve prolapse)
- Bicuspid aortic valve
- Obstructive hypertrophic cardiomyopathy
Impact of AHA Guidelines on IE
Multiple population studies have since evaluated the effect of this policy change and show no evidence for increases in dental procedure induced IE despite a dramatic decrease in antibiotic use.
- A study performed at the Mayo Clinic compared data pre- and post- these antibiotic policy changes. Over 12 years, only 22 IE cases were identified, 19 of the cases occurred before antibiotic restriction and 3 of the cases after antibiotic restriction. Of the 3 cases, 2 of them had no reported dental work preceding their diagnosis of IE and the third had in fact received clindamycin prophylaxis.
- A study in France assessed 11 million individuals and found no significant change. in rates of IE. The number of patients with verified or suspected IE remained stable over time — 323 in 1991, 331 in 1999, and 339 in 2008.
Guidelines from Other Professional Organizations
The American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association (ADA) released a statement in December 2012 advising against dental prophylaxis for patients with joint replacements. They reported that data was insufficient to show a relationship between routine dental procedures and prosthetic joint infections.
For many patients, these policy changes will have a direct impact on their health care and a confusing one at that. Many no longer require antibiotics and this is a wonderful thing. The opportunity to reduce antibiotic resistance is paramount. Still, many patients will call their primary care providers looking for antibiotics and not all of those providers will be well versed in the latest recommendations.
Antibiotic Prophylaxis for Invasive Surgery
While there is limited need for dental prophylaxis, there may be indications for antibiotic prophylaxis for cases of invasive surgery. Of note, IE prophylaxis is not strongly recommended for respiratory tract procedures and not recommended at all for bronchoscopy, unless incision of the respiratory tract mucosa is intended. IE prophylaxis is also not recommended for GU (genitourinary) or GI (gastrointestinal) procedures. In appropriate cases, the surgeon will address the need for antibiotics with their patients during their pre-surgical consultation and provide IV antibiotics immediately prior to the procedure.