Reviewed by Emily Henderson,
B.Sc.Apr 15 2021
Maintenance of good oral health is more important than use of
antibiotics in dental procedures for some heart patients to prevent a heart
infection caused by bacteria around the teeth, according to a new American
Heart Association (AHA) scientific statement published today in the
association's flagship journal, Circulation.
Infective endocarditis (IE), also called bacterial endocarditis,
is a heart infection caused by bacteria that enter the bloodstream and settle
in the heart lining, a heart valve or a blood vessel. It is uncommon, but
people with heart valve disease or previous valve surgery, congenital heart
disease or recurrent infective endocarditis have a greater risk of
complications if they develop IE. Intravenous drug use also increases risk for
IE. Viridans group streptococcal infective endocarditis (VGS IE) is caused by
bacteria that collect in plaque on the tooth surface and cause inflammation and
swelling of the gums. There's been concern that certain dental procedures may
increase the risk of developing VGS IE in vulnerable patients.
The new guidance affirms previous recommendations that only four
categories of heart patients should be prescribed antibiotics prior to certain
dental procedures to prevent VGS IE due to their higher risk for complications
from the infection:
·
those with prosthetic
heart valves or prosthetic material used for valve repair;
·
those who have had a
previous case of infective endocarditis;
·
adults and children
with congenital heart disease; or
·
people who have
undergone a heart transplant.
Scientific data since
the 2007 AHA guidelines support the view that limited use of preventive
antibiotics for dental procedures hasn't increased cases of endocarditis and is
an important step at combating antibiotic overuse in the population." Walter R. Wilson, M.D., chair of the
statement writing group and a consultant for the Division of Infectious
Diseases, Department of Internal Medicine at Mayo Clinic in Rochester, Minn.
It has been over a decade since recommendations for preventing
infective endocarditis were updated amid concerns of antibiotic resistance due
to overprescribing. The American Heart Association's 2007 guidelines, which
presented the biggest shift in recommendations from the Association on the
prevention of infective endocarditis in more than 50 years, more tightly
defined which patients should receive preventive antibiotics before certain
dental procedures to the four high-risk categories. This change resulted in
about 90% fewer patients requiring antibiotics.
The scientific statement writing group reviewed data on VGS IE
since the 2007 guidelines to determine if the guidelines had been accepted and
followed, whether cases of and mortality due to VGS IE have increased or
decreased, and if the guidance might need to be adjusted.
The writing committee reports their extensive review of related
research found:
·
There was good general
awareness of the changes in the 2007 guidelines, however, adherence to the
guidelines was variable. There was about a 20% overall reduction in prescribing
preventive antibiotics among high-risk patients, a 64% decrease among
moderate-risk patients, and a 52% decrease in those patients at low- or
unknown-risk.
·
In a survey of 5,500
dentists in the U.S., 70% reported prescribing preventive antibiotics to
patients even though the guidelines no longer recommend it, and this was most
often for patients with mitral valve prolapse and five other cardiac
conditions. The dentists reported that about 60% of the time the antibiotic
regimen was recommended by the patient's physician, and 1/3 of the time was
according to patient preference.
·
Since the stricter
2007 antibiotic guidelines, there is no convincing evidence of an increase in
cases of VGS IE or increased mortality due to VGS IE.
·
The writing group
supports the 2007 recommendation that only the highest risk groups of patients
receive antibiotics prior to certain dental procedures to help prevent VGS IE.
·
In the presence of
poor oral hygiene and gingival disease, VGS IE is far more likely to develop
from bacteria attributable to routine daily activities such as toothbrushing
than from a dental procedure.
·
Maintenance of good
oral hygiene and regular access to dental care are considered as important in
preventing VGS IE as taking antibiotics before certain dental procedures.
·
It is important to
connect patients with services to facilitate access to dental care and
assistance with insurance for dental coverage, especially in those patients at
high risk for VGS IE.
·
It is still
appropriate to follow the recommendation to use preventive antibiotics with
high-risk patients undergoing dental procedures that involve manipulation of
the gum tissue or infected areas of the teeth, or perforation of the membrane
lining the mouth.
The scientific statement was prepared by the volunteer writing
committee on behalf of the American Heart Association's Young Hearts Rheumatic
Fever, Endocarditis and Kawasaki Disease Committee; the Council on Lifelong
Congenital Heart Disease and Heart Health in the Young; the Council on
Cardiovascular and Stroke Nursing; and the Council on Quality of Care and
Outcomes Research.
Source: American Heart Association
Journal reference: Wilson, W.R., et al. (2021) Prevention of
Viridans Group Streptococcal Infective Endocarditis: A Scientific Statement
From the American Heart Association. Circulation. doi.org/10.1161/CIR.0000000000000969.
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