The American Heart Association (AHA) has recently updated guidelines for Infective Endocarditis (IE) prevention for cardiac patients who are undergoing dental procedures.  This extensive report represents the findings of a 23 member panel of experts in IE and includes representatives from the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics.  This is the first update by the AHA on this subject since 1997.

After reviewing the scientific literature and input from international experts in IE, the AHA panel has concluded that very few cases of IE are actually caused by dental procedures and that most cases of IE which are caused by oral bacteria are probably due to routine daily activities such as toothbrushing or chewing food.  Furthermore, they concluded that only a small number of IE cases could be prevented by presurgical antibiotics even if 100% effective.  For these reasons, the AHA group recommends that emphasis be placed on preventive oral health care for cardiac patients with conditions which place them at high risk of contracting IE and the highest risk of poor outcomes from IE.

For which cardiac conditions is antibiotic prophylaxis still indicated prior to invasive dental procedures:
. Prosthetic heart valve patients
. Patients with previous IE
. Patients with certain congenital heart defects
. Patients with heart transplants who also have valvular disease

Which dental procedures require antibiotic prophylaxis for these "high risk" patients:
. Procedures which involve gingival manipulation
. Procedures which involve the periapical regions of teeth
. Procedures which involve perforation of the oral mucosa

Antibiotic injections through healthy tissue, dental radiograph exposure, placement / adjustment of removable prosthodontic or orthodontic appliances and shedding of deciduous teeth do not require antibiotic prophylaxis.

Have the recommended antibiotic regimes changed:
The antibiotic regimes are essentially unchanged from the 1997 guidelines.  Doses should be given 30-60 minutes prior to the procedure instead of 60 minutes prior to the procedure.

What does all of this mean for the dentist:
Dentists are now required to premedicate fewer cardiac patients with antibiotics prior to treatment.  Patients with the history of a heart murmur who do not have a prosthetic heart valve, heart transplant, previous IE or congenital heart defect do not require antibiotic prophylaxis.  When a patient meets the criteria requiring antibiotic prophylaxis, the drug can now be given in the office 30 minutes prior to the initiation of invasive treatment.

The entire report is available on the AHA website at: www.americanheart.org/presenter.jhtml?identifier=3004539.  I recommend that all dentists obtain a copy for future reference.

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