BruceBlaus, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons
The disruption of the dental mucosa can lead to transient bacteremia (the presence of bacteria in the bloodstream). In turn, bacteremia increases the risk of developing infective endocarditis, an infection of the inner tissue of the heart, usually affecting the heart valves along with other biofilm-associated infections. Infective endocarditis can be challenging to treat and often leads to severe complications (Hollingshead, CM et al., 2023).
Viable bacteria may enter the bloodstream during minor dental procedures, infections, and simple daily tasks like tooth brushing. Typically, the immune system clears these bacteria from the blood. However, transient bacteremia can lead to infection and sepsis when immune responses are inadequate or ineffective, particularly in individuals with conditions like rheumatic heart disease, repaired congenital heart disease in which palliative shunts or conduits were used, a history of infective endocarditis, prosthetic heart valves, an unrepaired cyanotic congenital heart disease, complete repair or heart transplant with subsequent valvulopathy, or chronic healthcare exposure are some of those who are most at risk (Hollingshead, CM et al., 2023).
Most patients diagnosed with infective endocarditis typically present with a low-grade persistent fever without any obvious cause, with or without a heart murmur. Infective endocarditis is diagnosed using the Modified Duke Criteria, which involves an echocardiogram to detect vegetation and positive blood cultures. The three most common organisms that cause infective endocarditis are Staphylococci, Streptococci, and Enterococci. If left untreated, Infective Endocarditis is usually fatal. Empiric treatment often includes vancomycin and ceftriaxone, while definitive treatment and duration of therapy for infective endocarditis depends on the pathogen, the type of infected valve (native or prosthetic), and the susceptibility test results (Hollingshead, CM et al., 2023).
For high-risk patients undergoing an invasive dental procedure involving gingival or apical manipulation or oral mucosa perforation, it is advisable to administer a single dose of antibiotic prophylaxis thirty to sixty minutes before the invasive dental procedure. Adults receive 2g of amoxicillin orally, while pediatric patients receive 50mg/kg. For those allergic to penicillin or ampicillin, alternatives include single doses of cephalexin 2 g, doxycycline 100 mg, or azithromycin 500 mg (McCartney, C. et al., 2023). Patients who cannot take oral medications may be prescribed 2g of ampicillin intravenously or intramuscularly or 1g of cefazolin intramuscularly or intravenously and dose-adjusted to 50mg/kg in pediatric patients (Hollingshead, CM et al., 2023).
In clinical practice, exceptional circumstances may arise. For instance, a different drug class should be selected if a patient is already on an antibiotic recommended for infective endocarditis prophylaxis. Also, if a patient takes oral penicillin for other reasons, they may likely have viridans group streptococci in their oral cavity, which are relatively resistant to beta-lactams. In such cases, clindamycin, azithromycin, or clarithromycin is recommended for prophylaxis. For patients on long-term parenteral antibiotics for infective endocarditis, the dental procedure should be scheduled thirty to sixty minutes after administering the antibiotic (Wilson W et al. 2008).
Due to the low incidence of dental-related infective endocarditis, guideline-adherent antimicrobial prescribing should be limited to patients at the highest risk (Habib G. et al., 2009). Practitioners should prescribe antibiotics only when necessary, ensuring accurate diagnoses and appropriate drug, dose, and duration.
References
Cindy McCartney, Thomas Crilley and Steven Gordon. Getting to the root of the problem: Should my patients receive antibiotics before dental procedures to prevent infective endocarditis? Cleveland Clinic Journal of Medicine August 2023, 90 (8) 465-467; DOI: https://doi.org/10.3949/ccjm.90a.22091
Hollingshead CM, Brizuela M. Antibiotic Prophylaxis in Dental and Oral Surgery Practice. [Updated 2023 Mar 19]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK587360/
Habib G, Hoen B, Tornos P, Thuny F, Prendergast B, Vilacosta I, et al. Guidelines on the prevention, diagnosis, and treatment of infective endocarditis (new version 2009): the Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). Endorsed by the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) and the International Society of Chemotherapy (ISC) for Infection and Cancer. Eur Heart J 2009;30:2369-413.
Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2008;139 Suppl:3S-24S Assessed and Endorsed by the MedReport Medical Review Board
Comments