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Endocarditis is a rare, life-threatening bacterial inflammation of the lining
of the heart muscle and its valves. Although endocarditis can occur in anyone,
it is more common in people who have heart valve disease, have had heart valve
replacement surgery, have a congenital heart defect, have had recent heart
surgery or who are IV drug abusers.
Dental procedures can trigger endocarditis, especially in susceptible
individuals. Bacteria found in tooth plaque are the source of the inflammation
of the heart muscle lining and valves. More specifically, what happens is that
bacteria in plaque build up and cause gingivitis, which if left untreated,
proceeds to periodontitis. The gums become inflamed (red and swollen) and often
easily bleed during tooth brushing, flossing, or certain dental procedures. When
gums bleed, the bacteria enter the bloodstream and potentially infect other
areas of the body – in this case —the inner lining of the heart and its
valves.
To prevent the development of endocarditis, a single dose of an antibiotic
– usually given about 1 hour prior to certain dental treatments – is
recommended in certain patients with cardiovascular conditions.
Patients with what types of cardiovascular conditions should receive
pretreatment with antibiotics?
The American Heart Association and the American Dental Association recommend
that antibiotics be given prior to dental treatment in patients:
- Who have artificial heart valves
- Who have mitral valve prolapse with
valvular regurgitation and/or thickened leaflets
- Who have had previous bacterial
endocarditis
- Who have a surgically constructed
systemic pulmonary shunt
- Who have congenital (born with) heart
defects
- Who have acquired heart valve disease
(for example, from rheumatic heart disease)
- Who have hypertrophic cardiomyopathy
(a disease resulting in the enlargement and thickening of certain areas of the
heart muscle itself)
Are antibiotics recommended for all dental procedures in patients with the
above cardiovascular problems?
Antibiotic pretreatment is recommended for the dental procedures most likely
to cause significant bleeding to the extent that oral bacteria could be
released into the bloodstream. These procedures include:
- Tooth extraction
- Implant placement
- Reimplantation of natural teeth (for
example, that get knocked out)
- Periodontal procedures (including
surgery, scaling and root planing; for more on this topic see the document,
Treating Gum Disease
- Endodontic surgery (surgeries
involving the inside of the tooth – the human dental pulp or the nerve) and
use of instruments in such surgery that extends beyond the very bottom of the
root of the tooth
- Initial placement of orthodontic
bands (but not brackets)
- Intraligamentary local anesthetic
injections
- Subgingival placement of antibiotic
fibers or strips
- Professional cleaning of teeth or
implants if bleeding is anticipated
- Incision and drainage of infected
oral tissues
Antibiotic pretreatment is also recommended for patients undergoing
tonsillectomy and adenoidectomy (removal of the tonsils and adenoids,
respectively).
Dental procedures that have low potential to cause bleeding are considered
low risk for the development of infective endocarditis. Antibiotics are NOT
recommended for these procedures:
- Taking x-rays
- Taking oral impressions
- Fluoride treatments
- Restorative dentistry (such as
placement of fillings)
- Placement of a rubber dam
- Orthodontic appliance adjustment
- Placement of removable orthodontic/prosthodontic
appliances
- Shedding of primary (baby) teeth
- Postoperative suture removal
- Intracanal endodontic treatment
(post-placement and build-up)
- Local anesthetic injections
(specifically nonintraligamentary)
If endocarditis were to possibly develop following a dental procedure, what
signs and symptoms should I be aware of?
Call your dentist or doctor if you experience unexplained fever, night
chills, weakness, muscle pain (myalgia), joint pain (arthralgia), sluggishness
(lethargy) or malaise (general ill feeling), or have any unusual symptoms. Keep
in mind that receipt of the antibiotic significantly lowers the chance that
endocarditis won’t occur, but it does not absolutely guarantee that
endocarditis won’t occur. Also keep in mind that most cases of
procedure-related endocarditis develop 2 weeks or sooner after the procedure. So
if you experience any of these symptoms beyond this time "window," it
is not very likely that you have endocarditis, though it’s always wise to
check with your doctor or dentist if you have any concerns.
Is there anything else I can do to lower my risk for bacterial
endocarditis?
- Tell your dentist if your health
status has changed since your last visit. In particular, let your dentist know
if you’ve undergone heart surgery or vascular surgery within the past 6
months or have been diagnosed with other heart conditions.
- Make sure your dentist has a complete
list of the names and dosages of all medications – both prescription and
over-the-counter – that you are taking.
- Make sure your dentist has the names
and phone numbers of all of your physicians. Your dentist may want to consult
with your doctor regarding your dental plan of care and specific medication
choices.
- Practice good oral hygiene. Brush
your teeth at least twice a day; floss at least once daily.
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