Is mitral valve regurgitation an indication for prophylactic antibiotics during dental cleaning?

From the Guidelines

Mitral valve regurgitation alone is not an indication for prophylactic antibiotics before dental cleaning. According to the most recent guidelines, specifically the 2017 AHA/ACC focused update on valvular heart disease 1, prophylactic antibiotics are no longer recommended for most patients with valvular heart disease, including mitral regurgitation. The guidelines emphasize that the risk of adverse reactions to antibiotics outweighs the benefit in preventing endocarditis for most valve conditions.

Key Points to Consider

• The 2017 guidelines recommend prophylaxis against infective endocarditis for patients with prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts, prosthetic material used for cardiac valve repair, previous infective endocarditis, unrepaired cyanotic congenital heart disease or repaired congenital heart disease with residual shunts or valvular regurgitation, and cardiac transplant with valve regurgitation due to a structurally abnormal valve 1.
• Mitral valve regurgitation is not listed among the conditions for which prophylaxis is recommended, unless it is associated with a prosthetic valve or other high-risk conditions.
• Routine oral hygiene practices are considered more important for preventing bacteremia than prophylaxis for occasional dental procedures, as emphasized in the guidelines 1.
• If antibiotics are needed for patients at high risk, the standard regimen includes amoxicillin 2g orally taken 30-60 minutes before the dental procedure, with alternatives for patients allergic to penicillin being clindamycin 600mg, azithromycin 500mg, or clarithromycin 500mg.

Rationale for the Recommendation

The rationale behind limiting antibiotic prophylaxis is based on the lack of evidence supporting its efficacy in preventing infective endocarditis, coupled with the risks of anaphylaxis and increasing bacterial resistance to antimicrobials 1. The guidelines prioritize the maintenance of optimal oral health through regular professional dental care and the use of appropriate dental products to reduce potential sources of bacterial seeding 1.

Conclusion Not Required

As per the guidelines, the focus should be on maintaining good oral hygiene and only considering antibiotic prophylaxis for those with specific high-risk conditions, not mitral valve regurgitation alone.

From the Research

Mitral Valve Regurgitation and Prophylactic Antibiotics for Dental Cleaning

• The provided studies do not directly address the indication for prophylactic antibiotics for dental cleaning in patients with mitral valve regurgitation.
• However, studies 2, 3, 4 discuss the risk of bacterial endocarditis in patients with mitral valve prolapse, which may be relevant to mitral valve regurgitation.
• A study 4 suggests that antibiotic prophylaxis is unnecessary for the majority of patients with mitral valve prolapse, unless they have systolic murmurs.
• Another study 5 states that antibiotic prophylaxis for endocarditis is not required for routine dermatological surgery procedures, even in the presence of a pre-existing heart lesion, including mitral valve prolapse with regurgitation.
• A case study 6 presents a patient with acute mitral valve regurgitation secondary to papillary muscle rupture due to infective endocarditis, highlighting the importance of culture-guided prolonged antibiotic treatment in such cases.
• It is essential to note that the American Heart Association guidelines, although not directly cited in the provided studies, recommend antibiotic prophylaxis for patients with certain heart conditions, including mitral valve regurgitation, before undergoing dental procedures that may cause bleeding 2, 4.

Relevant Findings

• The risk of bacterial endocarditis in patients with mitral valve prolapse is small, with an estimated 14 cases per 100,000 adult patients with mitral valve prolapse developing endocarditis over a 1-year period 4.
• The use of antibiotic prophylaxis for dental procedures in patients with mitral valve prolapse has been controversial, with some studies suggesting that the risks of antibiotic prophylaxis may outweigh the benefits 2.
• The decision to use antibiotic prophylaxis for dental cleaning in patients with mitral valve regurgitation should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history.