Since we discussed joint prophylaxis for our dental patients last week, a number of you have asked us about taking antibiotics for your heart condition. Things have changed in the last ten years or so, so we thought to get everyone up to date. The good news is that the guidelines have gotten much clearer the past several years, and many people no longer need prophylaxis.
What’s the Big Deal?
The underlying concern is that certain dental procedures can cause a small amount of bleeding, and that this could open an avenue for mouth bacteria to get into the bloodstream and potentially cause damage. The idea for the use of antibiotics is that if the antibiotics are already present in the bloodstream at a high enough concentration when bacteria enter, they will destroy the bacteria and prevent complications.
Historically, antibiotics have been given for a very wide range of conditions, even without sound scientific rationale. Over the past 10-15 years, as the problems of bacterial resistance and overuse of antibiotics have come to the surface, as well as increasing awareness of the allergic risk of some antibiotics, these recommendations have been updated to target the patients most at risk for complications.
OK, Who is At Risk?
In the patient with cardiac disease, the concern has been that bacteria floating in the bloodstream could attach themselves to the valves of the heart (almost like barnacles on ships), especially if there is already a problem with the valves that prevents normal smooth blow flow. This could build up, altering blood flow and causing an infection of the actual heart, called infective endocarditis. Complications of this infection can include heart attack, stroke, or even death.
What Signs & Symptoms are There?
In infective endocarditis of the heart caused by dental bacteria, there is often a slow subtle onset. The most common sign is a fever, often anywhere from a couple of days to a couple weeks. You may also experience a cough, joint pain, diarrhea and trouble breathing. Occasionally you may see red streaks under the fingernails or on the soles of the feet. It is not uncommon, however, to not recognize anything at all beyond a vague fever.
How Do we Diagnose This?
The most important method of diagnosing infective endocarditis is with blood cultures (finding the bacteria in your blood). Other criteria are necessary, such as an echocardiograph (ultrasound of the heart), to look for bacterial buildup, along with certain other signs and symptoms.
How Is This Treated?
When a diagnosis of infective endocarditis of the heart is made, treatment is centered largely around IV antibiotics (directly into the blood stream), often for 4 or more weeks. This will often be done with the help of an infectious disease doctor, along with a cardiologist. Treatment can become more complex if any complications of endocarditis are evident, such as a heart attack, heart failure, or a stroke.
So, Who Needs Prophylaxis Now?
The American Dental Association, along with the American Heart Association, updated their recommendations for routine prophylaxis against infective endocarditis. Currently, patients with prosthetic valves, previous infections and certain specific congenital disorders are required to take prophylaxis. Many patients are no longer affected, such as patients with mitral valve prolapse or mitral valve prolapse with regurgitation. We have found that the risk of infection is actually lower than the risk associated with taking the antibiotics. We have also found that only a handful of cases of infective endocarditis is actually caused by oral bacteria yearly.
As far as what procedures require prophylaxis, the answer is that anything that can cause any bleeding at all. So, for instance, you’ll want to take your medicine prior to a cleaning or root canal, or a surgical procedure such as an extraction, dental implant, or gum surgery. However, for routine fillings, impressions and x-rays, prophylaxis is not needed. You’ll want to talk with us to make sure to get the correct recommendations.
What Can I Do?
The best way to minimize risk of getting endocarditis, or having your mouth be the source of infection elsewhere in your body is to maximize the health of your mouth. Make sure you are routinely brushing and flossing, at least twice daily. Make sure you see us for regular checkups twice yearly, or more frequently if you have gum disease.
If you currently take antibiotics prior to routine dental care, and have not reviewed your reasons with us and your physician for several years, you may want to bring this up with us prior to your next appointment. You may no longer need to take medication.
If there have been major changes to your health, and you are concerned that you may require medication, please feel free to contact us and also review with your physician.
Working together, we can make sure to follow the latest recommendations and keep you safe.
Drs. Beninato and Patsi