Dental Pre medication

For many years, the American Heart Association (AHA) recommended that patients with certain heart conditions take antibiotics (pre-med) right before dental treatment. This was done because they believed that antibiotics would prevent bacterial endocarditis (now called infective endocarditis (IE)). When bacteria enter the bloodstream and travel to the heart the heart’s inner lining or valves, they may lodge there causing an infection (infective endocarditis, IE). Bacteria normally are found in various sites of the body, but especially in the mouth.

The AHA’s latest guidelines were published in April 2007. The good news: the AHA recommends that most of these patients no longer need short-term antibiotics as a preventive measure before their dental treatment.

In conjunction with the American Dental Association, the AHA developed the new guidelines and approved those portions relevant to dentistry. The Infectious Diseases Society of America and the Pediatric Infectious Diseases Society endorsed the guidelines.
Scientific evidence now shows the risks of taking preventive antibiotics significantly outweighs the benefits for most patients. Adverse reactions to antibiotics range from mild to severe cases is the most significant risk, while inappropriate and over use of antibiotics can lead to the development of drug-resistant bacteria.
Scientists have found no compelling evidence that taking antibiotics prior to a dental procedure prevents IE in patients who are at risk of developing a heart infection. For most people, their hearts already are exposed to bacteria from the mouth, which can enter their bloodstream during basic daily activities such as eating, talking, brushing and/or flossing. The new guidelines are based on a comprehensive review of published studies that suggests IE is more likely to occur as a result of these everyday activities than from a dental procedure.

The guidelines say many patients who have taken prophylactic antibiotics routinely in the past no longer need them. These include people with:
• mitral valve prolapse
• rheumatic heart disease
• bicuspid valve disease
• calcified aortic stenosis
• congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection.

Preventive antibiotics prior to a dental procedure are advised for patients with:
1. artificial heart valves
2. a history of infective endocarditis
3. certain specific, serious congenital heart conditions, including

- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
-a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
-any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

4. a cardiac transplant that develops a problem in a heart valve.

The new recommendations apply to many dental procedures, including teeth cleaning and extractions. Patients with congenital heart disease can have complicated circumstances. They should check with their cardiologist if there is any question at all as to the category that best fits their needs.
Patients and their families should also ask their medical health care providers careful questions anytime antibiotics are suggested before a medical or dental procedure.
The AHA guidelines emphasize that maintaining optimal oral health and practicing daily oral hygiene are more important in reducing the risk of IE than taking preventive antibiotics before a dental visit.

by Dr. Gregory C. Dilger - July 30, 2009

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