Prevention of infective endocarditis in at-risk patients: how should dentists proceed in 2024?

Abstract

National Institute for Health and Care Excellence (NICE) guidelines are ambiguous over the need for patients at increased risk of infective endocarditis (IE) to receive antibiotic prophylaxis (AP) prior to invasive dental procedures (IDPs), and this has caused confusion for patients and dentists alike. Moreover, the current law on consent requires clinicians to ensure that patients are made aware of any material risk they might be exposed to by any proposed dental treatment and what can be done to ameliorate this risk, so that the patient can decide for themselves how they wish to proceed. The aim of this article is to provide dentists with the latest information on the IE-risk posed by IDPs to different patient populations (the general population and those defined as being at moderate or high risk of IE), and data on the effectiveness of AP in reducing the IE risk in these populations. This provides the information dentists need to facilitate the informed consent discussions they are legally required to have with patients at increased risk of IE about the risks posed by IDPs and how this can be minimised. The article also provides practical information and advice for dentists on how to manage patients at increased IE risk who present for dental treatment.

Fig. 1

Algorithm for the management of infective endocarditis

Fig. 2

Diagram to facilitate explanation of the effect of AP in reducing the risk of IE following IDPs performed in high-risk patients. Each stack contains 1,000 yellow blocks representing 1,000 high-risk individuals undergoing IDPs (of all types), dental extractions or oral surgical procedures. Red blocks represent the number of individuals within each 1,000 population who would develop IE following the procedure in the absence of antibiotic cover (AP) (upper row). Blue blocks represent the number of individuals within each 1,000 population that would develop IE if each received AP before the procedure (lower row). Note: the incidence of IE following invasive dental procedures covered by AP is less than 1:1,000 (three in 10,000). The risk of a non-fatal adverse reaction following AP is even lower still (two in 100,000) and too small to feature in this figure. Data shown here are derived from a US study of patients with employer-provided medical/dental insurance cover. A similar study in Medicaid patients found generally higher values and it is therefore possible that the values shown are under-estimated for some patient groups. However, AP was equally effective in reducing the incidence of IE in both studies

Appendix 1 Patient information leaflet. Heart image courtesy of iStock, credit: sajithsaam