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  • The Internet Journal of Dental Science
  • Volume 7
  • Number 2

Original Article

Antimicrobial prophylaxis against infective endocarditis for dental procedure. - A brief commentary

O Cavezzi Junior

Citation

O Cavezzi Junior. Antimicrobial prophylaxis against infective endocarditis for dental procedure. - A brief commentary. The Internet Journal of Dental Science. 2008 Volume 7 Number 2.

Abstract
 

For over a half century, guidelines for the prevention of infective endocarditis (IE) have recommended antibiotic prophylaxis for certain patients receiving dental care. Much emphasis has been attributed historically on the baseless concept that dental procedures are main cause of cases of IE and dentistry carried the blame for induce endocarditis without much supporting evidence.

In 2007, the American Heart Association (AHA) and British Society for Antimicrobial Chemotherapy (BSAC) updated the recommendations for IE prophylaxis before dental procedures and those recommendations are clearly evidence-based 9 . The dental treatment is a very rarely cause of IE and antibiotic prophylaxis do not give assurances as preventive. So, the value of antibiotic prophylaxis in prevention of IE has been questioned for over 20 years 3 .

In reviewing the literature 2 , we did not find support that antibiotic prophylaxis actually prevents endocarditis from dental procedure only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedure. There is increasing evidence that spontaneous bacteremia are more likely to cause IE in at risk patients than specific episodes of dental treatment 568 . The majority of infective endocarditis cases caused by oral bacteria result from chewing, flossing, tooth brushing and others daily activities, and the presence of dental disease may increase the risk of bacteremia associated with these daily events 8 . Anyway the role of dental procedures in the production of infective endocarditis has probably been overestimated in relation to oral health condition thus more attention should be given to the importance of good oral hygiene and control of dental biofilm in the prevention of IE. In short, the care of the oral health must be the first step in the prevention of infective endocarditis from dental origin than antibiotic prophylaxis.

Almost a year after the issued of new recommendations for prevention of IE, we still seeing most patients and health care professionals resistant to adopt this new recommendations and persisting to prescribe antibiotic prophylaxis when the need no longer exists. Only a few patients will be elected to receive antibiotic prophylaxis according to the AHA and BSAC, thus only employ in the very highest risk patients 8 . (Tables 1, 2, 3)

The prescription of antibiotics carries the risk for both, patient and community, through the undesirable effects and the fact of introducing microorganisms mutants or genetically transfer the microbial resistance, respectively.

The scientific community has focused the link between the overuse of antibiotics and the increasing prevalence of the drug resistant organisms 14710 .

This concern is overt when evaluating ambulatory patients wich receiving short courses of antibiotics and they became an important reservoir of resistant microorganisms 7 . Antibiotic resistance is a serious incident and capable to be prevented through common sense and clinical judgment. Health care professionals have misused antibiotics for too long and carry the blame of antibiotic resistance. The risks associated with widespread antibiotic use and lack of efficacy data take us back to rethink our practice

The new guidelines should be seen as great progress based on evidence that currently exists and must be followed until more evidence arise. We need further debate, especially as there are increasing environmental concerns over the misuse of antibiotics. We are now experiencing a shift thus we need time to change this scenario.

Figure 1
Table 1

* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

† Prophylaxis is recommended because endothelialization of prosphetic material occurs within 6 months after the procedure.

Figure 2
Table 2

Figure 3
Table 3

* IM indicates intramuscular; IV, intravenous.

** Or other fi rst-or second-generation oral cephalosporin in equivalent adult or pediatric dosage.

† Cephalosporings should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with

penicillins or ampicillin.

References

1. Al-Haroni M. Bacterial resistance and the dental professionals' role to halt the problem. J Dent 2008;36(2):95-103.
2. Cavezzi Junior O, Zanatto ARL. Endocardite infecciosa: odontologia baseada em evidência. Odontol Clín Científ. 2003;2(2):85-94.
3. Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol 1984;54(7):797-801.
4. Haas DA, Epstein JB, Eggert FM. Antimicrobial resistance: dentistry's role. J Can Dent Assoc 1998;64(7):496-502.
5. Lacassin F, Hoen B, Leport C, Selton-Suty C, Delahaye F, Goulet V, et al. Procedures associated with infective endocarditis in adults. A case control study. Eur Heart J 1995;16(12):1968-74.
6. Strom BL, Abrutyn E, Berlin JA, Kinman JL, Feldman RS, Stolley PD, et al. Dental and cardiac risk factors for infective endocarditis. A population-based, case-control study. Ann Intern Med 1998;129(10):761-9.
7. Teng LJ, Hsueh PR, Chen YC, Ho SW, Luh KT. Antimicrobial susceptibility of viridans group streptococci in Taiwan with an emphasis on the high rates of resistance to penicillin and macrolides in Streptococcus oralis. J Antimicrob Chemother 1998;41(6):621-7.
8. van der Meer JT, Thompson J, Valkenburg HA, Michel MF. Epidemiology of bacterial endocarditis in The Netherlands. . Arch Intern Med 1992;152(9):1863-73.
9. Wilson W, Taubert KA, Gewitz M, Lockhart PB, Baddour LM, Levison M, et al. Prevention of Infective Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):1736-54.
10. Younessi OJ, Walker DM, Ellis P, Dwyer DE. Fatal Staphylococcus aureus infective endocarditis: the dental implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;85(2):168-72.

Author Information

Orlando Cavezzi Junior, DDS, Private Practice

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