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| JADA, Vol. 128, August 1997 The new American Heart Association, or AHA, recommendations for the prevention of bacterial endocarditis represent a substantial departure from past guidelines. The new recommendations reflect a better understanding of the disease and its potential prevention. Major changes involve the indications for prophylaxis, antibiotic choice and dosing, ancillary procedures that may reduce bacteremic risk, a detailed discussion of mitral valve prolapse and greater attention to the medicolegal aspects of endocarditis. Previously, antibiotic prophylaxis was suggested for dental procedures associated with any amount of bleeding. Now, only those that are associated with significant bleeding are recommended for prophylaxis as dictated by clinical judgement. This allows for a substantial number of dental procedures to be eliminated from the prophylaxis recommendation. A table is provided that delineates dental treatment procedures into those that may be associated with significant bleeding and those that pose negligible or no bacteremic risk. Recommended antibiotic regimens now consist of a single dose; no second dose is recommended. If the clinical decision is made not to premedicate and significant unanticipated bleeding occurs, the dental professional may then begin the antibiotic and continue the procedure. A gentle prerinse with chlorhexidine can be employed, but gingival (subgingival) irrigation is not recommended due to conflicting data on efficacy in bacteremia reduction, the lack of data establishing that gingival irrigation will reduce endocarditis, its own potential for causing bacteremias and the lack of any stanardized regimen. It is recommended that all identified at risk patients be strongly encouraged to maintain good oral health via professional and home care and plaque control procedures. This is particularly true for patients prior to cardiovascular surgical procedures. It is acknowledged that plaque control may induce bacteremias, but with much less or negligible risk as compared to a mouth with ongoing inflamation. The recommendations identify at-risk patients both medically and dentally. Importantly, the medicolegal aspects of bacterial endocarditis are thoroughly addressed in the new recommendations, particularly regarding causation. The incubation period for most cases of endocarditis is defined, as are several factors that must be considered before attempting to attribute cause and affect to a given invasive procedure. It is asknowledged that most endocarditis is not associated with invasive procedures and that professional dental care is responsible for only a small percentage of endocarditis cases. However , antibiotic prophylaxis is still recommended prior to dental procedures associated with significant bleeding in high- and moderate-risk patients who are at a much greater risk of endocarditis than the general population. These recommendations are not intended as the standard of care, and practitioners should use their own clinical judgement in individual cases or special circumstances. The new AHA recommendations for the prevention of bacterial endocarditis better define at-risk patients and the dental procedures to be covered by antibiotic prophylaxis. As a result, these new recommendations should aid in both patient and practitioner compliance and diminish the adverse effects of prophylaxis, including its role in promoting the development of bacterial antibiotic resistance. |
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