Heart associations update oral health guidelines for premedication
The American College of Cardiology (ACC) and the American Heart Association (AHA) have jointly updated practice guidelines for important cardiovascular diseases and procedures.
The guidelines attempt to deal with general issues of treatment of patients with heart valve disorders, such as evaluation of patients with heart murmurs, prevention and treatment of endocarditis, management of valve disease in pregnancy, and treatment of patients with concomitant coronary artery disease (CAD), as well as more specialized issues that pertain to specific valve lesions. The guidelines focus primarily on valvular heart disease in the adult, with a separate section dealing with specific recommendations for valve disorders in adolescents and young adults.
It is worth noting that the last rationale for the revisions is an enormous take-home message to our patients. It further reinforces the importance of efficient and effective daily self-care practice and regular hygiene management visits.
The rationale reads: "Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis."Below is an excerpt from the ACC/AHA PRACTICE GUIDELINE and click here to be linked to the entire document.
Section 2.3 Endocarditis and Rheumatic Fever Prophylaxis (UPDATED). This updated section deals exclusively with the changes in recommendations for antibiotic prophylaxis against infective endocarditis in patients with valvular heart disease. Treatment considerations in patients with congenital heart disease (CHD) or implanted cardiac devices are reviewed in detail in other publications (1071), and the upcoming ACC/AHA guideline for the management of adult patients with CHD (1072). For an in-depth review of the rationale for the recommended changes in the approach to patients with valvular heart disease, the reader is referred to the AHA guidelines on prevention of infective endocarditis, published online April 2007 (1070).
(Table 5 of the 2006 Valvular Heart Disease Guideline [1068] is now obsolete.)
Infective endocarditis is a serious illness associated with significant morbidity and mortality. Its prevention by the appropriate administration of antibiotics before a procedure expected to produce bacteremia merits serious consideration. Experimental studies have suggested that endothelial damage leads to platelet and fibrin deposition and the formation of nonbacterial thrombotic endocardial lesions. In the presence of bacteremia, organisms may adhere to these lesions and multiply within the platelet-fibrin complex, leading to an infective vegetation. Valvular and congenital abnormalities, especially those associated with high velocity jets, can result in endothelial damage, platelet fibrin deposition, and a predisposition to bacterial colonization. Since 1955, the AHA has made recommendations for prevention of infective endocarditis with antimicrobial prophylaxis before specific dental, gastrointestinal (GI), and genitourinary (GU) procedures in patients at risk for its development. However, many authorities and societies, as well as the conclusions of published studies, have questioned the efficacy of antimicrobial prophylaxis in most situations.
On the basis of these concerns, a writing group was appointed by the AHA for their expertise in prevention and treatment of infective endocarditis, with liaison members representing the American Dental Association, the Infectious Disease Society of America, and the American Academy of Pediatrics. The writing group reviewed the relevant literature regarding procedure-related bacteremia and infective endocarditis, in vitro susceptibility data of the most common organisms that cause infective endocarditis, results of prophylactic studies of animal models of infective endocarditis, and both retrospective and prospective studies of prevention of infective endocarditis. As a result, major changes were made in the recommendations for prophylaxis against infective endocarditis.
The major changes in the updated recommendations included the following:
• The committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective.
• Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis.
• For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of either gingival tissue or the periapical region of teeth or perforation of oral mucosa.
• Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis.
• Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo GU or GI tract procedure.
The rationale for these revisions is based on the following:
• Infective endocarditis is more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU procedure;
• Prophylaxis may prevent an exceedingly small number of cases of infective endocarditis (if any) in individuals who undergo a dental, GI tract, or GU procedure;
• The risk of antibiotic associated adverse effects exceeds the benefit (if any) from prophylactic antibiotic therapy;
• Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of infective endocarditis.
(Table 8 of the 2006 Valvular Heart Disease Guidelines [1068] is now obsolete.)
