Understanding Antibiotic Prophylaxis for Infective Endocarditis in Dentistry

Infective endocarditis (IE) is a rare but severe infection affecting the heart’s inner lining, particularly the valves. Despite its low incidence (fewer than 1 case per 10,000 annually), IE has high mortality and morbidity rates, with approximately 30% of cases being fatal and around half requiring corrective cardiac surgery. While certain cardiac conditions predispose individuals to IE, about 50% of cases occur in those without known cardiac disease.

Recent evidence indicates that everyday activities like tooth brushing, rather than dental procedures, are more significant contributors to IE, prompting a reassessment of the role of antibiotic prophylaxis (ABP).

Historical Context and NICE Guidelines

• Pre-2008: ABP was routinely recommended for at-risk patients undergoing invasive dental procedures.
• 2008: NICE issued Guideline 64, advising against ABP for dental procedures, citing weak evidence of its efficacy and concerns about adverse drug reactions.
• 2015: A thorough review confirmed insufficient evidence to support ABP, maintaining the guidance against routine use.
• 2016: The term "routinely" was added to clarify that ABP may still be considered for specific cases, requiring professional judgement and patient consultation.
• 2018: SCDEP provided clarification on which cardiac conditions were "Increased Risk".
• 2024: Pressure brought onto NICE from a Sheffield research study

more…

Challenges and Clarifications
The revised guidelines left key questions unanswered, such as which patients warrant non-routine management and the appropriate ABP regimens for dentistry. This ambiguity created variability in implementation, leading the Scottish Dental Clinical Effectiveness Programme (SDCEP) to develop implementation advice.

Current Recommendations

• Routine ABP is not recommended for most dental patients.
• A small subset of high-risk patients may need special consideration, requiring consultation with their cardiologist.
• Dentists must ensure patients understand the risks, benefits, and alternatives during discussions, documenting decisions carefully in clinical records.

We will cover the "Increased Risk" cardiac conditions later in the course.