A very common reason why I get referred patients is those who are at higher risk of Infective Endocarditis (IE) and need dental treatment, or have been admitted to hospital with this serious condition and require a dental check or a dental cause for the disease ruled out. So what is IE and how does it affect dental care?
What is Infective Endocarditis?
Infective Endocarditis (IE) is an infection of the inner lining (the endothelium) of the heart - most commonly the heart valves. It has a high mortality rate (40% at 5 years), and is therefore very serious. In 80% of cases, the cause is bacterial, but it can also be fungal or viral.
Some patients are at higher risk of IE, and we hear about it a lot within dentistry. This is because for bacterial causes of IE, caused by a bacteraemia (i.e. bacteria in the blood stream), the bacteraemia can be from a dental infection or dental treatment.
What happens in those patients who are at higher risk of IE, is that when the bacteria are circulating in the blood around the heart and the heart valves, they attach to the valves (which is much easier if the valves are damaged, artificial or their is turbulent blood flow in the area) and make plaques called vegetations which damage the valves.
Therefore some patients with certain conditions are in the special consideration group where the SDCEP guidance recommends antibiotic cover prior to invasive dental treatments. See the table below of patients who are at higher risk of IE, and those who require cover.
If cover is recommended, advice from a patient's cardiologist is prudent, but usual regimes to be taken 30-60 mins prior to procedure (which have be recently updated are:
- 2g amoxicillin (although it is acceptable and usual practice to prescribe 3g as the sachets of 2g are not readily available in the UK)
- 2g cephalexin if penicillin-allergic. This used to be 600mg clindamycin, but recent paper has updated recommendations to the SDCEP guidance.
Invasive dental treatment includes any of the following treatments:
- Placement of matrix bands
- Extractions
- Root canal treatment prior to apical stop establishment
- Subgingival scaling and root planing
- Placement of rubber dam clamp
- Subgingival restorations including extra-coronal restorations
- Preformed metal crowns used in deciduous teeth
- Full periodontal pocketing charting
- Incision and drainage of dental abscesses
- Surgery including a mucoperiosteal flap or incision
- Placement of dental implants including TADs or mini-implants
- Uncovering implant substructures
For patients who are not only in the special consideration group, but who are at higher risk of IE, it is very important to educate the patient about their risk and how they can lower it by ensuring they are maintaining their oral health. A bacteraemia can be caused from just chewing or brushing teeth in patients with periodontal disease! There are excellent patient information leaflets provided as part of the SDCEP guidance.
If you are also treating these patients, even if you do cover their treatment with antibiotics, you should still warn them of potential signs of IE so they can quickly act if they do develop - i.e. go straight to A&E! Signs and symptoms of IE include:
- Malaise
- Fever
- Chills
- Fatigue
- Aching joints
- Night sweats
- Shortness of breath
- Swelling in the ankles, finger joints, legs or belly
- Splint haemorrhages in the finger nails
- Cough
- Petechiae in the skin
- Weight loss
- Confusion
When we see patients in the hospital with IE, they will be having treatment for the condition, which can either be medical management (i.e. antimicrobials) or surgical management (repair or replacement of the valve or damaged lining). They will have had blood cultures to find out what the causative organism of the IE is. Streptococci can sometimes can be the causative organism from a dental origin.
If you are unsure whether a patient requires cover or what cover to give, it is best to contact their cardiologist for confirmation; they will be more useful usually than a GP.
There are various conflicting guidelines globally about antibiotic cover prior to dental procedures, most famously the NICE guideline that it is not routinely given prior. This is not that helpful in the day to day practice of a working dentist, therefore I would recommend reading this recent paper in the BDJ alongside SDCEP for guidance that is relevant in the UK.
Have to treated patients who are at risk of IE? Please leave your thoughts in the comments below.
