dental extractions etc. in patient with valvular heart disease, septal defect, patent ductus, or history of endocarditis

Last edited 09/2022 and last reviewed 09/2022

  • NICE suggest that healthcare professionals should regard people with the following cardiac conditions as being at risk of developing infective endocarditis:

    • acquired valvular heart disease with stenosis or regurgitation

    • valve replacement

    • structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus
      arteriosus, and closure devices that are judged to be endothelialised

    • previous infective endocarditis

    • hypertrophic cardiomyopathy

  • NICE have also given guidance concerning use of antibiotic prophylaxis against infective endocarditis
    • antibiotic prophylaxis against infective endocarditis is not recommended routinely:
      • for people undergoing dental procedures
      • for people undergoing non-dental procedures at the following sites :
        • upper and lower gastrointestinal tract
        • genitourinary tract; this includes urological, gynaecological and obstetric procedures, and childbirth
        • upper and lower respiratory tract; this includes ear, nose and throat procedures and bronchoscopy o chlorhexidine mouthwash should not be offered as prophylaxis against infective endocarditis to people at risk of infective endocarditis undergoing dental procedures
    • infection
      • any episodes of infection in people at risk of infective endocarditis should be investigated and treated promptly to reduce the risk of endocarditis developing
      • if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection, the person should receive an antibiotic that covers organisms that cause infective endocarditis

A systematic review about antibiotics to prevent complications following tooth extractions concluded(2):

  • low-certainty evidence that prophylactic antibiotics may reduce the risk of infection and dry socket following third molar extraction when compared to placebo, and very low-certainty evidence of no increase in the risk of adverse effects
  • on average, treating 19 healthy patients with prophylactic antibiotics may stop one person from getting an infection
  • unclear whether the evidence in this review is generalisable to patients with concomitant illnesses or patients at a higher risk of infection
  • due to the increasing prevalence of bacteria that are resistant to antibiotic treatment, clinicians should evaluate if and when to prescribe prophylactic antibiotic therapy before a dental extraction for each patient on the basis of the patient's clinical conditions (healthy or affected by systemic pathology) and level of risk from infective complications
  • immunocompromised patients, in particular,indeed anindividualised approach in consultation with their treating medical specialist

Antibiotic Prophylaxis Against Infective Endocarditis Before Invasive Dental Procedures (IDPs) (3)

  • study evidence showed that there was a significant temporal association between IDPs (particularly extractions and oral-surgical procedures) and subsequent IE (infective endocarditis) in high-IE-risk individuals, and a significant association between AP (antibiotic prophylaxis) use and reduced IE incidence following these procedures
  • authors concluded that these data support the American Heart Association, and other, recommendations that those at high IE risk should receive AP before IDP