Fewer Heart Patients Required to Take Antibiotics Before Dental Procedures
American Heart Association, American Dental Association Introduce New Guidelines
Based on a review of new and existing scientific evidence, most dental patients with heart disease do not need antibiotics before dental procedures
to prevent infective endocarditis (IE), a rare, but life-threatening heart infection.
According to revised guidelines from the American Heart Association (AHA) with input from the American Dental Association (ADA), antibiotics are now
only recommended for patients at greatest risk of negative outcomes from IE including those with artificial heart valves or certain congenital heart
conditions, heart transplant recipients who develop cardiac valve problems, recipients of an artificial patch to repair a congenital heart defect within
the past six months and patients with a history of IE.
The AHA's latest guidelines were published in its scientific journal, Circulation, in April. The Guidelines apply to a range of medical and dental
procedures. The ADA is publishing those portions of the new guidelines relevant to dentistry on its website (www.ada.org) today and in the June
issue of the Journal of the American Dental Association (JADA).
For decades, the AHA recommended that patients with certain heart conditions take antibiotics shortly before dental treatment. This was done with the
belief that antibiotics would prevent IE, previously referred to as bacterial endocarditis. IE is an infection of the heart's inner lining or
valves, which results when bacteria enter the bloodstream and travel to the heart. Bacteria are normally found in various sites of the body including
on the skin and in the mouth.
The ADA participated in the development of the new guidelines and has approved those portions relevant to dentistry. The guidelines are also
endorsed by the Infectious Diseases Society of America and by the Pediatric Infectious Diseases Society.
The new guidelines are based on a growing body of scientific evidence that shows the risks of taking preventive antibiotics outweigh the benefits for
most patients. The risks include adverse reactions to antibiotics that range from mild to potentially severe and, in rare cases, death. Inappropriate use
of antibiotics can also lead to the development of drug-resistant bacteria.
Scientists also found no compelling evidence that taking antibiotics prior to a dental procedure prevents IE in patients who are at risk of developing
a heart infection. Their hearts are already often exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities
such as brushing or flossing. The new guidelines are based on a comprehensive review of published studies that suggests IE is more likely to
occur as a result of these everyday activities than from a dental procedure.
The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with mitral
valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis, or congenital heart conditions such as ventricular septal
defect, atrial septal defect and hypertrophic cardiomyopathy.
The new recommendations apply to many dental procedures, including teeth cleaning and extractions.
The guidelines emphasize that maintaining optimal oral health and practicing daily oral hygiene are more important in reducing the risk of IE than taking
preventive antibiotics before a dental visit.
For more information, please visit ada.org.
FOR RELEASE
4 p.m. EDT, Thursday
April 19, 2007
American Heart Association scientific statement Most patients don't need antibiotics before dental procedures to prevent infective endocarditis
DALLAS, April 20 - Taking a precautionary antibiotic before a trip to the dentist isn't necessary for most people, and in fact, might create more harm
than good, according to updated recommendations from the American Heart Association.
The guidelines, published in Circulation: Journal of the American Heart Association, are based on a growing body of scientific evidence
weighing the effectiveness of antibiotics against possible risks. The updated recommendations say that only people who are at the greatest risk of
bad outcomes from infective endocarditis (IE) - an infection of the heart's inner lining or the heart valves - should receive short-term preventive
antibiotics before common, routine dental procedures. This includes people with artificial heart valves, a history of previous endocarditis, certain
serious congenital heart conditions, and heart transplants patients who develop a problem with a heart valve.
For decades, doctors have given short-term antibiotics prior to a dental procedure to many patients with the belief the drugs would prevent
IE. As a result, patients with any kind of heart abnormality from mild, symptomless forms of mitral valve prolapse (MVP) to serious congenital birth
defects have been instructed to take an antibiotic prior to dental work, even teeth cleaning.
However, the drugs carry risks, including fatal allergic reactions and possibly making the bacteria that cause IE to become resistant to
antibiotics. Although allergic reactions are minimal, new evidence shows the risks outweigh the benefits for most patients receiving these
antibiotics.
"We've concluded that if giving prophylactic antibiotics prior to a dental procedure works at all - and there's no evidence that it does work -
we should reserve that preventive treatment only for those people who would have the worst outcomes if they get IE. That's a profound change from
previous recommendations," said Walter R. Wilson, M.D., a professor of medicine at the Mayo Clinic in Rochester, Minn., and chair of the writing
group.
The new recommendations apply to such common dental procedures as teeth cleaning and extractions. They are based on a comprehensive review of
published studies that suggests IE is more likely to occur from bacteria that enter the bloodstream as a result of everyday activities than from a
dental procedure.
The statement cites a 1999 study estimating that tooth brushing twice a day for a year carried a 154,000 times greater risk of exposure to blood-borne
bacteria than a single tooth extraction,
-more-
the dental procedure reported to be the most likely to cause a bacterial infection. The writing group found no compelling evidence that antibiotic
prophylaxis prior to a dental procedure prevents IE in individuals who are at risk of developing this infection.
"In fact, maintaining good oral health and hygiene appears to be more protective than prophylactic antibiotics," Wilson said. "This changes
the whole philosophy of how we have constructed these recommendations for the last 50 years. Rather than based on the risk of getting IE, they're
based on the risk of which patients would have the worst outcome from the infection."
Wilson said it's difficult to estimate the number of people affected by the new guidelines. Measurements of the prevalence of mitral valve
prolapse range from less than 2 percent to almost 20 percent of the population.
According to American College of Cardiology/American Heart Association guidelines for the management of patients with valvular heart
disease, when using current echocardiographic criteria for diagnosing MVP, the prevalence is 1 percent to 2.5 percent of the population. Even this
estimate means millions of people have been taking antibiotics prior to dental procedures.
Patients at the greatest danger of bad outcomes from IE and for whom preventive antibiotics prior to a dental procedure are worth the risks
include those with:
.. artificial heart valves
.. a history of having had IE
.. certain specific, serious congenital (present from birth) heart conditions, including unrepaired or incompletely repaired cyanotic congenital
heart disease, including those with palliative shunts and conduits a completely repaired congenital heart defect with prosthetic
material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure any repaired congenital heart
defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device .. a cardiac transplant which develops a problem
in a heart valve. "Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease,"
the statement said.
"These new recommendations are a major change that has evolved over nearly 50 years," said Michael Gewitz, M.D., chair of the AHA Rheumatic
Fever, Endocarditis and Kawasaki Disease Committee, a co-author of the guidelines and professor of pediatrics at New York Medical College and
Physician-in-Chief for Maria Fareri Children's Hospital at Westchester Medical Center in Valhalla, N.Y. "Over this time, patients with common
heart conditions were told they needed to take antibiotics prior to a dental procedure. Now, they'll be told they no longer need them. This will likely
cause anxiety and concern in patients and health care providers." Gewitz says this is especially true for the millions of people,
young and old, affected with congenital heart diseases. "There is likely to be some confusion until dentists and primary care doctors, and even
specialists, all hear about these changes and get used to them," he said. "Since patients with congenital heart disease can have complicated
circumstances, even after surgical or other treatment, families and primary care doctors should check with their cardiologist if there is any question
at all as to which category best fits the individual patient."
-more-
He added that patients and their families should ask careful questions of their providers anytime antibiotics are suggested before a
medical or dental procedure. They should also be aware that overuse of antibiotics many times can lead to a worse outcome than if they were not
used at all.
Wilson acknowledged that patients and health care professionals may take awhile to get used to the new guidelines. Many dentists and physicians
are used to prescribing the drugs to any patient with any possibility of a heart abnormality, no matter how slight. Likewise, many patients are used
to taking the antibiotics, which provide a sense of security, he said. The guidelines say patients who have taken prophylactic antibiotics
routinely in the past but no longer need them include people with:
.. mitral valve prolapse
.. rheumatic heart disease
.. bicuspid valve disease
.. calcified aortic stenosis
.. congenital heart conditions such as ventricular septal defect,
atrial septal defect and hypertrophic cardiomyopathy.
"These patients still have a lifelong risk of IE," Wilson said.
"We're just saying that the risk is much greater from a random blood-borne bacterial infection resulting from everyday activities than from a dental or
medical procedure."
The guidelines also do not recommend any prophylactic antibiotics to prevent IE for common gastrointestinal procedures or procedures on the
urinary tract. This holds true even for patients with the highest risk of bad outcomes from IE,
