Good dental health trumps antibiotics for heart infection

By Theresa Pablos, DrBicuspid.com editor in chief

April 20, 2021 -- When it comes to preventing a type of heart infection caused by oral bacteria, good dental health is better than antibiotics, according to a landmark American Heart Association (AHA) statement published on April 15 in the journal Circulation.

In the statement, the committee reviewed the evidence around the AHA's watershed 2007 guidelines that recommended dentists limit antibiotic prophylaxis (AP) to only four types of patients. In its new review, the AHA writing committee found the scientific evidence supported limited use of AP and reaffirmed the importance of good dental health for preventing infective endocarditis (IE).

"Scientific data since the 2007 AHA guidelines support the view that limited use of preventive antibiotics for dental procedures hasn't increased cases of endocarditis and is an important step at combating antibiotic overuse in the population," stated Dr. Walter Wilson, chair of the statement writing group, in a press release.

When the AHA changed its AP recommendations in 2007, the number of patients who qualified for AP before a dental procedure dropped by about 90%, the authors wrote. At the time, some healthcare professionals saw the change as controversial, and it is still debated to this day.

The new review sought to better understand some of the long-term implications of the decision to limit the use of AP to patients with the following qualifications:

  1. Prosthetic cardiac valve or prosthetic material used for cardiac valve repair or other implantable cardiac devices, such as transcatheter aortic valve implantation
  2. Previous, relapse, or recurrent IE
  3. Congenital heart disease
  4. Cardiac transplant recipients

The AHA writing group included experts from a variety of medical specialties, including members of the ADA and the American Academy of Pediatrics. After searching the scientific literature, the group found "no convincing evidence" that limiting AP use caused an increase in viridans group streptococcal (VGS) IE.

"Randomized controlled studies are necessary to resolve the issue of the efficacy of AP in preventing VGS IE," the committee wrote. "Until such studies are published, our extensive review suggests that after more than a decade since implementation, the 2007 guidelines adequately provide VGS IE AP for those patients with the highest risk of adverse outcome."

The committee also noted that dentists showed good awareness but variable compliance with the 2007 recommendations. In multiple studies, the vast majority of dentists said they were satisfied with the guidelines, and that reflected in the data, which showed a significant drop in the use of AP before dental procedures. But a minority of dentists still prescribed AP for moderate-risk patients, and some did not prescribe AP for high-risk patients at all, the committee noted.

Additionally, the statement reaffirmed the importance of good dental health in preventing IE. Maintaining good oral health in at-risk patients has a major effect on preventing the spread of bacteria during routine oral healthcare, such as toothbrushing, the authors noted.

"Because routine daily activities result in transient VGS bacteremia at a much higher frequency than a single dental procedure, optimizing oral health has a major impact on preventing VGS IE," they wrote.


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