Antibiotic Prophylaxis

Antibiotic prophylaxis guidance in the UK has recently been amended to recommend antibiotic cover for high-risk patients before subjecting them to any intrusive dental procedures, thereby reversing the guidance produced in 2008 which recommended against the use of all antibiotic prophylaxis. The advice is clearly contained in the European guidelines and in the Scottish Dental Clinical Effectiveness Programme (SDCEP) guidance.

The guidance is to protect patients at risk of endocarditis, which is a serious infection of the heart lining and of heart valves and which has a significant mortality rate. 

All those with a history of a previous episode of endocarditis, patients known to have congenital heart disorders and those who have prosthetic heart valves or previous valvular repairs fall into the group which should be identified and protected. Prophylaxis is not required for routine dental inspections and restorative procedures.

Intrusive dental procedures include, not only all oral surgical procedures but also any dental procedures causing trauma to the gingivae or to the periapical areas of teeth. 

Not only dentists, but also dental hygienists and therapists may undertake invasive scaling procedures and it is important that all clinical dental staff are aware of the guidance.

The antibiotic usually prescribed for prophylaxis is amoxicillin administered as a single 3 gm dose, normally thirty to sixty minutes before the procedure, and ideally provided and observed in the practice. For patients with a penicillin allergy, cephalexin or clarithromycin provide a suitable alternative. 

The use and appropriate documentation of antibiotic prophylaxis is essential in invasive dental procedures and should be explained and discussed with any at-risk patient and the details documented in the clinical record. If, for some reason, there is concern about diagnosis or the use of the prophylaxis, it is wise to seek the advice of the cardiologist providing the patient’s care before proceeding. A dentist who does not take appropriate steps to use prophylaxis in a vulnerable patient who subsequently develops endocarditis and who may actually die of the disease, will be vulnerable to an allegation of dental negligence resulting in a claim and possible referral to the regulator.

To keep safe, make appropriate enquiries of all patients about cardiac risks and ensure appropriate protection in any invasive procedures in those who are susceptible.

Dr Paul Lambden