Infective endocarditis risk

BACKGROUND

A 58-year-old retired teacher, Mr G, attends his dental surgery with severe pain in a lower right molar. Dr C examines the tooth and finds gingival swelling around LR8. A periapical radiograph reveals significant root decay and Dr C advises extraction.

It is noted in Mr G’s records that two years previously he had heart valve replacement surgery. A further review is booked for the following day and Dr C emails MDDUS for advice on guidelines for antibiotic prophylaxis prior to the carrying out the procedure. He asks whether antibiotic prophylaxis is required and should he request that the patient's cardiologist or his GP prescribe the antibiotics.

ANALYSIS/OUTCOME

An MDDUS dental adviser responds via email. He reminds Dr C that in 2008 the National Institute for Health and Care Excellence (NICE) issued Clinical Guideline 64 (CG64) on Prophylaxis against infective endocarditis, which stated that antibiotic prophylaxis against infective endocarditis is not recommended for patients with predisposing cardiac conditions undergoing dental procedures. However, in 2016 NICE amended the guideline using the word “routinely”, stating: “Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures”.

Following this change, the Scottish Dental Clinical Effectiveness Programme (SDCEP) convened a short-life working group to develop advice for the dental team to help clarify and facilitate the implementation of this amended NICE guideline. The SDCEP implementation advice sets out clearly how risk in this circumstance should be assessed and which prophylactic drugs should be used, and offers guidance on obtaining valid consent with reference to the landmark legal case of Montgomery v Lanarkshire Health Board on decision making and consent.

The SDCEP advice states that the vast majority of patients at increased risk of infective endocarditis should not be prescribed prophylactic antibiotics but a "very small number of patients" should be considered in consultation with their cardiologist or cardiac surgeon. These include patients with a prosthetic heart valve or prior endocarditis, and the advice would apply only for those undergoing “invasive dental procedures”, such as dental extractions, subgingival scaling or dental implant procedures.

The MDDUS adviser provides a link the SDCEP document and advises Dr C to liaise with Mr G's cardiologist and any other appropriate medical professional in relation to the extraction and necessity of antibiotic prophylaxis. This would allow Dr C to prescribe the most appropriate medication and monitor the treatment. A clear audit trail would then exist demonstrating engagement with other professionals and with Mr G, acting in his best interests at all times.