Course Overview

In 2007 the American Heart Association (AHA) updated their guidelines for the use antibiotic prophylaxis (AP) only for patients at the highest risk of adverse outcomes should they acquire viridans group streptococcal infective endocarditis (VGS IE). This eliminated many patients who had previously been recommended to use AP, including patients with mitral valve prolapse and heart murmurs. Since that time there has been no evidence that this reduction in AP use has led to an increase in cases of VGS IE in patients undergoing invasive dental procedures (IDPs).

2021 American Heart Association Scientific Statement on the Prevention of Viridans Group Streptococcal Infective Endocarditis.(1)

CONCLUSION:
On the basis of a review of the available evidence, there are no recommended changes to the 2007 VGS IE prevention guidelines. We continue to recommend VGS IE prophylaxis only for categories of patients at highest risk for adverse outcome while emphasizing the critical role of good oral health and regular access to dental care for all.

 Antibiotic Prophylaxis Recommended for Patients With: (1)

• Prosthetic cardiac valve or material
• Presence of cardiac prosthetic valve
• Transcatheter implantation of prosthetic valves
• Cardiac valve repair with devices, including annuloplasty, rings, or clips
• Left ventricular assist devices or implantable heart
• Previous, relapse, or recurrent IE

CONGENITAL HEART DISEASE (CHD)

•  Unrepaired cyanotic congenital CHD, including palliative shunts and conduits.
• Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by transcatheter during the first 6 mo after the procedure
• Repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device
• Surgical or transcatheter pulmonary artery valve or conduit placement such as Melody valve and Contegra conduit
• Cardiac transplant recipients who develop cardiac valvulopathy

CONDITIONS WHERE AP IS NOT RECOMMENDED

• Implantable electronic devices such as a pacemaker or similar devices
• Septal defect closure devices when complete closure is achieved
• Peripheral vascular grafts and patches, including those used for hemodialysis
• Coronary artery stents or other vascular stents
• CNS ventriculoatrial shunts
• Vena cava filters
• Pledgets

Antibiotic Prophylaxis Regimens to be taken 30-60 minutes prior to appointment:

• Amoxicillin 2g
• Allergy to Penicillin …. -Cephalexin (Keflex) 2g or:
  -Azithromycin 500mg
  -Clarithromycin 500mg
  -Doxycycline 100mg

NO CLINDAMYCIN

• If a patient inadvertently does not take AP, it can be administered up to 2 hours after the appointment, however the efficacy is not the same as having taken it prior to the appointment.
•  If a patient has been on a therapeutic course of antibiotics prior to the need for AP it is recommended to change the class of antibiotics.
• 21% of patients prior to any AP are colonized with amoxicillin-resistant VGS which increased to 31% after a single dose of
  Amoxicillin and persisted for 24d.
• When Amoxicillin is given for weekly intervals, resistant VGS increased significantly and persisted for 4-7 weeks.
• It is advisable to consider an alternative regimen for repeated dental procedures or intervals of 4 weeks between appointments.
• Antibiotic prophylaxis is not recommended for any dental work done as a clearance prior to valve replacement
• Bioprosthetic/Tissue valves (Porcine or Pig valves) are considered “prosthetic” although not mechanical and require AP as they are at higher risk of VGS IE than mechanical prosthetic valves. (2,3)
  

  Recent studies confirming AP is beneficial prior to invasive dental procedures only for patients at the highest risk of adverse outcomes from VGS IE:

• Thornhill American College of Cardiology Study: (4)
  Looked at nearly 8M patients in US where medical, dental and pharmacy records were available to determine the risk of IE following an IDP, and by how much AP can reduce the risk. The study confirmed a strong association between IDP and IE (particularly extractions and surgical procedures) and the relationship was strongest within 30d of the ID, meaning most IE cases occurred within 30d of the procedure. The odds of IE in high risk patients were dramatically higher following extractions (9x) and other oral surgical procedures (20x). In high risk patients, AP was linked with a significant reduction in IE for extractions and other surgical procedures, but showed no benefit for other invasive dental procedures (scaling) or for moderate or low risk patients.
• Thornhill Oral Diseases Study: (5)
  Was an identical study to J. Am Coll of Cardiology Aug 2022 study. The study looked at 1.8M Medicaid patients where medical, dental and prescription data was available. It identified an increased IE incidence within 30d of invasive dental procedures, particularly extractions and oral surgery, and showed Medicaid patients were 4x more likely to acquire VGS IE than commercially insured patients. It also showed that AP significantly reduced IE incidence following invasive dental procedures.
• Lockhart Triple O study: (6)
  Studied patients admitted to hospital for IE and did a dental exam within 24 hours of diagnosis. The study identified 62 cases of IE and compared them to outpatients with heart valve disease but without IE ( 119 controls). The case patients (IE) had 53% greater dental calculus index and 26% greater dental plaque index than controls (those without IE). The cases had fewer dentist or hygiene visits, fewer dental visits in the 12 weeks prior to IE diagnosis and were more likely to have never seen a dentist. Common oral bacteria were identified from blood cultures in 44% of IE case patients. The author’s conclusion was that poor oral hygiene should be considered a risk factor for IE and improving oral hygiene should be
  encouraged for patients at risk of IE.

SUMMARY:

• Good oral health and oral hygiene lowers the risk of daily bacteremia, thus lowering the risk of needing an IDP, and lowers procedure related bacteremia, lowering the risk of IE.
• There are two dental issues that put patients at risk of VGS IE: POOR ORAL HYGIENE AND INVASIVE DENTAL PROCEDURES.
• An emphasis should be placed on improved oral hygiene to lower the risk from routine daily activity induced bacteremia.
• For those at highest risk of VGS IE, Antibiotic Prophylaxis should be used for any procedure that requires gingival
  manipulation.

(1). Wilson WR, Gewitz M, Lockhart PB, et al. Prevention of viridans group streptococcal infective endocarditis: a scientific statement from the American Heart Association. Circulation. 2021;143(20):e963-e978. doi:10.1161/CIR.0000000000000969.
(2). Anantha-Narayanan M., et al., Endocarditis risk with bioprosthetic and mechanical valves: systematic review and meta-analysis. BMJ Heart 2020;106, 1378-9.
(3) Ostergard L., et al., Incidence and factors associated with infective endocarditis in patients undergoing left-sided heart valve replacement. Eur Heart J. 2018 Jul 21;39(28)2668-75.
(4). Thornhill M., et al., Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures. J Am Coll of Cardiol; Aug 2022.
(5). Thornhill M., et al., Endocarditis, invasive dental procedures, and antibiotic prophylaxis efficacy in US Medicaid patients. Oral Diseases. April 2023.
(6). Lockhart PB, Chu V, Zhao J, et al. Oral Hygiene and Infective Endocarditis: A Case Control Study. Oral Surg Oral Med Oral Pathol Oral Radiol . Published online March 2023:SS2212440323000755. doi:10.1016/j.oooo.2023.02.020

Dr. Tom Paumier

A 1987 cum laude graduate of the Ohio State University College of Dentistry, completed a general practice residency at St. Elizabeth Medical Center in Youngstown, Ohio. He has been in private practice in Canton, Ohio, since 1988. Dr. Paumier is on the faculty of the Mercy Medical Center GPR in Canton and is a fellow in the International College of Dentists and American College of Dentists. He was a member of the American Dental Association Council on Scientific Affairs’ Expert Panel on Prosthetic Joint Prophylaxis and the ADA/American Academy of Orthopaedic Surgeons’ Expert Panel for Prosthetic Joint Prophylaxis Appropriate Use Criteria. He also serves on the ADA Expert Panel for Antibiotic Therapeutics. He is a past president of the Ohio Dental Association.       

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