Is antibiotic prophylaxis recommended for patients with rheumatic heart disease and mild mitral valve regurgitation (Mitral Regurgitation, MR) prior to an extensive dental cleaning procedure?

From the Guidelines

Antibiotic prophylaxis is not recommended for patients with rheumatic heart disease and mild mitral valve regurgitation before extensive dental cleaning procedures, unless they have certain high-risk cardiac conditions. The standard regimen, if prophylaxis is deemed necessary, is amoxicillin 2g orally taken as a single dose 30-60 minutes before the dental procedure 1. For patients allergic to penicillin, alternatives include clindamycin 600mg, azithromycin 500mg, or clarithromycin 500mg orally as a single dose. Prophylaxis is specifically indicated for patients with prosthetic heart valves, previous infective endocarditis, unrepaired cyanotic congenital heart disease, or completely repaired congenital heart defects with prosthetic material during the first six months after the procedure 1. However, for most patients with rheumatic heart disease and mild mitral valve regurgitation without these high-risk features, routine antibiotic prophylaxis is no longer recommended, as the risk of adverse effects from antibiotics outweighs the benefit in preventing infective endocarditis for most patients with valvular disease 1. Key points to consider include:

• The bacteremia caused by daily activities like brushing teeth is much more likely to cause endocarditis than the transient bacteremia from dental procedures 1
• The committee concluded that only an extremely small number of cases of infective endocarditis may be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective 1
• Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis 1

From the Research

Antibiotic Prophylaxis for Rheumatic Heart Disease

• Antibiotic prophylaxis is recommended for patients with rheumatic heart disease to prevent infective endocarditis, especially during dental procedures 2.
• The American Heart Association recommends antibiotic prophylaxis for patients with rheumatic heart disease who have a high risk of developing infective endocarditis, such as those with a history of infective endocarditis or with prosthetic heart valves 2.

Mild Mitral Valve Regurgitation

• Patients with mild mitral valve regurgitation may not require antibiotic prophylaxis for routine dental procedures, but it is recommended for those with a history of infective endocarditis or with prosthetic heart valves 3, 2.
• The decision to use antibiotic prophylaxis should be made on a case-by-case basis, taking into account the individual patient's risk factors and medical history 2.

Dental Procedures

• Extensive dental cleaning procedures may increase the risk of infective endocarditis in patients with rheumatic heart disease, especially if they have a history of infective endocarditis or prosthetic heart valves 2.
• Antibiotic prophylaxis is recommended for patients with rheumatic heart disease who undergo dental procedures that involve manipulation of the gingival tissue, periapical region of teeth, or perforation of the oral mucosa 2.