The New Endocarditis Guideline: Which Dental Procedures Merit Prophylaxis?

It’s the dentist’s call.

The updated 2007 American Heart Association recommendations for endocarditis prophylaxis will dramatically reduce the number of patients with cardiac conditions for whom prophylactic antibiotics will be prescribed (Journal Watch Jun 12 2007). In a departure from the earlier guideline, the writers did not include a list of specific dental procedures for which prophylaxis is recommended. This change prompted one of my internal medicine colleagues to ask this question: "When patients call and ask us whether they need prophylaxis before upcoming dental visits, how do we decide?"

Her question arose because the 1997 version of the guideline included a table listing 8 specific dental procedures for which prophylaxis was indicated and 11 for which prophylaxis was unnecessary. In contrast, the new guideline eliminates the detailed listing and simply notes that, for patients with the designated cardiac conditions, prophylaxis "is reasonable for ... all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa." A footnote lists a few procedures that do not require prophylaxis (e.g., dental x-rays, adjustment of orthodontic appliances), but no detailed list is included of those procedures that do require it.

I asked Peter Lockhart, DDS, who is Chair of Oral Medicine at Carolinas Medical Center in Charlotte, North Carolina, and a member of the committee that wrote the new recommendations, to comment on this issue. Dr. Lockhart pointed out that "the primary care physician’s responsibility is to determine whether the patient has one of the four qualifying cardiac conditions. If the patient has one of those conditions, it’s the dentist’s responsibility — not the physician’s — to determine whether the upcoming dental procedure warrants prophylaxis." Whether or not a dental procedure will involve substantial gingival manipulation can vary according to clinical circumstances during a given dental encounter. Data on the incidence, duration, and magnitude of bacteremia from the many invasive dental procedures don’t tell us which (if any) procedures are more or less likely to cause endocarditis. Hence, those who wrote the 2007 revision considered a specific black-and-white list of procedures (as provided in the 1997 guideline) as too rigid.

So, when your patient with a prosthetic heart valve calls and asks you — the primary care physician — whether he’ll need prophylaxis for an upcoming dental visit, instruct him to ask his dentist (and, of course, explain why you’re deferring to the dentist). Dentists are aware of the changes in the guideline and should not resist assuming this responsibility. In fact, the American Heart Association guideline was reprinted in a supplement to the January 2008 issue of the Journal of the American Dental Association.

— Allan S. Brett, MD

Published in Journal Watch General Medicine February 28, 2008