Who requires endocarditis prophylaxis for dental procedures?

From the Guidelines

Endocarditis prophylaxis for dental procedures is recommended only for patients at highest risk of adverse outcomes from infective endocarditis, including those with prosthetic cardiac valves or prosthetic material used for valve repair, previous infective endocarditis, certain congenital heart diseases, and cardiac transplant recipients who develop cardiac valvulopathy. These high-risk individuals should receive prophylaxis for dental procedures that involve manipulation of gingival tissue, perforation of oral mucosa, or procedures involving the periapical region of teeth, as stated in the guidelines by the American College of Cardiology and American Heart Association 1. The standard prophylactic regimen is amoxicillin 2g orally taken as a single dose 30-60 minutes before the procedure. For patients allergic to penicillin, alternatives include clindamycin 600mg, azithromycin or clarithromycin 500mg, or cephalexin 2g (if not severely allergic) 1.

Some key points to consider:

• Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis 1.
• Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo GU or GI tract procedures 1.
• Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis 1.
• The risk of antibiotic-associated adverse effects exceeds the benefit (if any) from prophylactic antibiotic therapy 1.

High-risk patients who should receive prophylaxis include:

• Patients with prosthetic cardiac valve or prosthetic material used for cardiac valve repair
• Patients with previous infective endocarditis
• Patients with CHD, including unrepaired cyanotic CHD, completely repaired congenital heart defect with prosthetic material, and repaired CHD with residual defects
• Cardiac transplant recipients with valve regurgitation due to a structurally abnormal valve

Prophylaxis is specifically indicated for dental procedures involving:

• Manipulation of gingival tissue
• Perforation of oral mucosa
• Procedures involving the periapical region of teeth

This recommendation is based on the understanding that bacteremia from dental procedures can lead to bacterial colonization of damaged or abnormal heart valves, potentially causing life-threatening endocarditis in these high-risk patients.

From the Research

Patients Requiring Endocarditis Prophylaxis

• Patients with prosthetic heart valves, including mechanical and bioprosthetic valves, require antibiotic prophylaxis before certain dental and surgical procedures to prevent endocarditis 2.
• Patients with complex congenital heart diseases, intravenous drug abusers, and patients with chronic renal failure under hemodialysis are also considered high-risk subjects for infective endocarditis and may require endocarditis prophylaxis 3.
• Cardiac implantable electronic devices (CIED) infective endocarditis is a life-threatening complication, and patients with CIEDs may require antibiotic prophylaxis before certain procedures 4.
• Patients with a history of infective endocarditis, or those with certain types of prosthetic valves or cardiac devices, may also require endocarditis prophylaxis before dental procedures 5.

Dental Procedures Requiring Endocarditis Prophylaxis

• Certain dental procedures, such as those involving manipulation of gingival tissue, periapical region of teeth, or perforation of the oral mucosa, may require antibiotic prophylaxis for high-risk patients 2.
• The specific dental procedures that require endocarditis prophylaxis may vary depending on the individual patient's risk factors and medical history 3, 4, 5.