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Practice Uncertainties

Do patients at risk of infective endocarditis need antibiotics before dental procedures?

BMJ 2017; 358 doi: https://doi.org/10.1136/bmj.j3942 (Published 07 September 2017) Cite this as: BMJ 2017;358:j3942
cropped thumbnail of infographic

Infographic available

Click here for a patient information leaflet on infective endocarditis, summarising common symptoms.
  1. Thomas J Cahill, cardiology specialist registrar1,
  2. Mark Dayer, consultant cardiologist2,
  3. Bernard Prendergast, consultant cardiologist3,
  4. Martin Thornhill, professor of translational research in dentistry4
  1. 1Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
  2. 2Department of cardiology, Taunton and Somerset NHS Foundation Trust, Musgrove Park, Taunton, UK
  3. 3Department of cardiology, Guy’s and St Thomas’ Hospitals NHS Foundation Trust, London, UK
  4. 4Department of oral and maxillofacial medicine, surgery & pathology, University of Sheffield School of Clinical Dentistry, Sheffield, UK
  1. Correspondence to M Thornhill m.thornhill{at}sheffield.ac.uk

What you need to know

  • Patients with prosthetic heart valves, previous infective endocarditis, and some types of congenital heart disease are at highest risk of infective endocarditis

  • Invasive dental procedures cause bacteraemia, which can be complicated by infective endocarditis in those at increased risk of the disease

  • Antibiotic prophylaxis reduces the incidence of bacteraemia, but high level studies confirming that this reduces the incidence of infective endocarditis are lacking

  • Warn high risk patients undergoing high risk dental interventions of the risk of infective endocarditis. Offer these patients antibiotic prophylaxis, and discuss with them the risks and benefits of this option

  • Where patients are at moderate risk, encourage preventative measures, such as maintaining good oral hygiene and infection control, and discourage tattooing or piercing

Infective endocarditis is a life threatening disease with 30% one year mortality1 that affects 3-10 per 100 000 population per year—the average general practitioner will see one case every 20 years.2 Infective endocarditis occurs when bacteria enter the bloodstream through the mouth, gut, or skin, and replicate within the heart to form a “vegetation,” which is usually adherent to one of the valves (fig 1⇓, fig 2⇓). Specific patient subgroups are at increased risk of infective endocarditis as a result of damaged cardiac endothelium, abnormal blood flow, intracardiac prosthetic material, immunosuppression, or recurrent bacteraemia (box 1).3 4

Fig 1 Pathogenesis of infective endocarditis

Fig 2 Infective endocarditis. Vegetation can be seen on the mitral valve (arrow)

Box 1: Risk factors for infective endocarditis

Cardiac

  • Prosthetic heart valve*

  • Previous infective endocarditis*

  • Congenital heart disease* †

  • Rheumatic heart disease

  • Degenerative valve disease

  • Cardiac transplant with valvulopathy

  • Implantable electronic cardiac device (pacemaker or defibrillator)

  • Hypertrophic cardiomyopathy

Non-cardiac

  • Haemodialysis

  • Diabetes mellitus

  • Injected drug use

  • Indwelling venous catheters

  • Immunosuppression

  • Poor oral hygiene

  • *at highest risk

  • †see specific subgroups in fig 3

Streptococci which colonise the mouth are the causative organism in …

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