Medicines Q&As
Q&A 187.3
Do patients undergoing dental procedures require endocarditis
prophylaxis?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals
Before using this Q&A, read the disclaimer at www.ukmi.nhs.uk/activities/medicinesQAs/default.asp
Date reviewed: September 2011
Summary
Antibiotic prophylaxis is not recommended for the prevention of infective endocarditis in patients
undergoing dental procedures.
Background
Infective endocarditis is an inflammation of the inner lining of the heart (endocardium), particularly
affecting the heart valves and caused mainly by bacterial infection. Patients with structural abnormalities
of the heart, hypertrophic cardiomyopathy, replacement heart valves or with a history of infective
endocarditis are considered to be at risk of developing infective endocarditis.
Traditionally, prophylactic antibiotics have been given to patients at risk of infective endocarditis before
undergoing dental procedures. Typically, three grams of oral amoxicillin would be taken one hour
beforehand. The rationale for using antibiotics was that dental procedures lead to increased numbers of
bacteria in the blood (bacteraemia) and it was assumed that bacteraemia was a key factor in the
development of infective endocarditis.
Prior to 2008 there were conflicting guidelines as to which patients and dental procedures warranted the
use of prophylactic antibiotics (1, 2, 3). This led to confusion for health professionals and patients. In
April 2008, the National Institute for Health and Clinical Excellence (NICE) issued definitive, evidencebased guidance on the prophylaxis of infective endocarditis (4). This guidance has been adopted
nationally and is reflected in the British National Formulary (5).
Answer
Antibiotic prophylaxis is not recommended for the prevention of infective endocarditis in adults or
children undergoing any dental procedure (4).
The basis for this recommendation is:
 There is no consistent association between dental procedures and an increased risk of infective
endocarditis;
 Bacteraemia associated with dental procedures is no greater than that from toothbrushing; Regular
toothbrushing almost certainly presents a greater risk of infective endocarditis than a single dental
procedure because of repetitive exposure to bacteraemia;
 Antibiotics are not proven to reduce the risk of infective endocarditis;
 Antibiotics are themselves not without risk and can cause fatal anaphylaxis.
Patients who previously received endocarditis prophylaxis for dental procedures will require a clear
explanation as to why prophylaxis is no longer recommended. A summary of the NICE guideline for
patients (6) and a ‘quick reference leaflet’ (7) are available online. Printed copies can be ordered from
NICE Publications via 0845 003 7783 or publications@nice.org.uk (quote reference numbers N1488
and N1487 when ordering the patient summary and quick reference leaflet, respectively).
NICE states that healthcare professionals should offer clear and consistent advice to patients on four
points, details of which are on page 2 of this document.
The NICE summary for patients (6) includes a list of questions that patients might ask their healthcare
team; answers are suggested on page 3 of this document.
From the NHS Evidence website www.evidence.nhs.uk
Advice for healthcare professionals to offer to patients
Patients at risk of infective endocarditis should be reassured that antibiotic prophylaxis is no
longer recommended and offered information regarding:

The benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic
prophylaxis is no longer recommended:
Patients at risk of infective endocarditis have traditionally received prophylactic antibiotics prior to
dental procedures. Procedures that disturb bacteria in the mouth increase the number of bacteria in
the blood (bacteraemia). High levels of bacteraemia have been shown (in animal models) to
increase the risk of infective endocarditis. On this basis, it was considered prudent to provide
antibiotic prophylaxis to reduce bacteraemia in patients considered to be at risk of infective
endocarditis. Over recent years, there have been conflicting guidelines as to which patients required
antibiotic prophylaxis and for which dental procedures.
NICE has reviewed the evidence regarding infective endocarditis and concluded that there is no
clear association between dental procedures and infective endocarditis. Evidence shows that levels
of bacteraemia associated with dental procedures are no greater than those associated with regular
toothbrushing. The risk of infective endocarditis is almost certainly greater from toothbrushing than
from a single dental procedure due to repeated exposure to bacteraemia with regular toothbrushing.
Antibiotic prophylaxis given before dental procedures has not been shown to eliminate bacteraemia
or to reduce the risk of infective endocarditis and is associated with risks of its own. Antibiotics can
cause adverse reactions including fatal anaphylaxis. Using antibiotics when not indicated puts
patients at risk from adverse effects and can increase bacterial resistance to antibiotics. For all these
reasons, antibiotic prophylaxis is no longer recommended for the prevention of infective endocarditis
in patients undergoing dental procedures.

The importance of maintaining good oral health:
Maintaining good oral health reduces the numbers of bacteria in the mouth and helps prevent tooth
decay and gum disease. Patients should be advised to keep their mouth and teeth clean with twicedaily toothbrushing, to have regular dental check-ups and not to let any dental problems such as
abscess or gum disease go untreated.

Symptoms that may indicate infective endocarditis and when to seek expert advice:
Infective endocarditis is rare and patients are unlikely to develop it. Early symptoms of infective
endocarditis are similar to flu-symptoms: fever, night sweats and chills, weakness and tiredness, and
also breathlessness, weight loss and joint pain. Patients at risk of infective endocarditis should be
advised to see a GP if they have such symptoms for longer than a week (8).

The risks of undergoing invasive procedures, including non-medical procedures such as
body piercing or tattooing:
Bacteraemia can develop following piercing or tattooing, particularly if non-sterile equipment or
techniques are involved. Patients at risk of infective endocarditis should be discouraged from having
procedures such as piercing or tattooing (8).
People with the following cardiac conditions are considered to be at risk of developing infective
endocarditis and would have received antibiotics for endocarditis prophylaxis in the past:





Previous infective endocarditis,
Replacement heart valve,
Structural congenital heart disease
(but not isolated atrial septal defect, fully repaired septal defect, fully repaired patent ductus
arteriosus or congenital heart disease repaired with closure devices that are judged to be
endothelialised),
Valvular heart disease with stenosis or regurgitation,
Hypertrophic cardiomyopathy.
Medicines Q&A 187.3 Date reviewed: September 2011
Do patients undergoing dental procedures require antibiotic prophylaxis?
From the NHS Evidence website www.evidence.nhs.uk
Questions patients may ask

In the past I have been given antibiotics to prevent infective endocarditis for the same dental
procedure but have not been offered them now. Why has this changed?
In the past, guidelines recommended that people at risk of infective endocarditis were given
prophylactic (preventative) antibiotics before certain procedures. The National Institute for Health
and Clinical Excellence (NICE) has reviewed the evidence regarding infective endocarditis and
concluded that prophylactic antibiotics are not required for dental procedures.
To understand why the guidelines have changed, it is helpful to know why antibiotics were
recommended in the first place: Dental procedures (such as scaling or tooth extraction) disturb
bacteria in the mouth and these bacteria can then enter the bloodstream. It was thought that the rise
in the number of bacteria in the bloodstream (bacteraemia) that occurred following dental procedures
increased the risk of getting endocarditis, and antibiotics were given to combat this rise.
NICE has found that the levels of bacteria in the bloodstream associated with dental procedures are
no higher than those associated with toothbrushing. So, patients undergoing dental procedures are
not at any greater risk of getting endocarditis than they are from brushing their teeth. The bacteria
that enter the bloodstream are killed by the body’s immune system.
Antibiotics can cause side effects, some of which can be very serious, or even fatal. Taking
antibiotics when they are not needed puts patients at unnecessary risk. Because antibiotics have not
been shown to reduce the chance of getting endocarditis, and because dental procedures are no
longer thought to be a cause of endocarditis, taking antibiotics before dental procedures is no longer
recommended.

I’ve used a chlorhexidine mouthwash when I have had dental treatment in the past. Is this
helpful?
Chlorhexidine mouthwash is not recommended to prevent infective endocarditis. It has not been
shown to reduce the chance of getting endocarditis and, as explained above, dental procedures are
no longer thought to be a cause of endocarditis.

Is there some written material (like a leaflet) about infective endocarditis that I can have?
The British Heart Foundation has information about infective endocarditis on its website. Go to the
home page (www.bhf.org.uk) and type ‘endocarditis’ in the search box at the top of the screen.

What can I do to improve my oral health?
Keep your teeth and mouth clean with twice-daily toothbrushing. Visit your dentist for regular
checkups and don't let any dental problems such as a dental abscess or gum disease go untreated.

What are the symptoms of infective endocarditis? What should I do if I think I have it?
Infective endocarditis is very rare. Symptoms are flu-like, and include fever, night sweats and chills,
weakness and tiredness as well as breathlessness, weight loss and joint pain. It is very unlikely that
you will ever suffer from endocarditis but if you are at risk (e.g. if you have a replacement heart
valve, valvular heart disease or hypertrophic cardiomyopathy) and have flu-like symptoms for longer
than a week you should see a GP.

What do I do if I think I have an infection?
Guidelines for the treatment of infections have not changed. If you think you have an infection,
contact a healthcare professional (e.g. pharmacist, GP, dentist or optician) as you would normally.
NICE provides guidance for the NHS in England and Wales. Further information about NICE, its work
and how it reaches decisions is available online at www.nice.org.uk/aboutguidance.
Medicines Q&A 187.3 Date reviewed September 2011
Do patients undergoing dental procedures require antibiotic prophylaxis?
From the NHS Evidence website www.evidence.nhs.uk
Limitations
This document does not relate to the use of pre-procedural antibiotics to prevent infections other than
infective endocarditis.
September 2011 – NICE Clinical Guideline 64 – Prophylaxis against infective endocarditis, is under
review. If the review process results in alteration to the original advice this Q&A will be updated.
References
1. Joint Formulary Committee. British National Formulary. 54th edition. London: British Medical
Association and Royal Pharmaceutical Society of Great Britain; 2007. Chapter 5.1, Table 2:
Summary of antibacterial prophylaxis (page 279).
2. Ramsdale DR, Turner-Stokes L, Advisory Group of the British Cardiac Society Clinical Practice
Committee, et al. Prophylaxis and treatment of infective endocarditis in adults: a concise guide. Clin
Med 2004; 4: 545-550.
3. Gould FK, Elliott TSJ, Foweraker J, et al. Guidelines for prevention of endocarditis: report of the
Working Party of the British Society for Antimicrobial Chemotherapy. J Antimicrob Chemother 2006;
57: 1035-1042. Accessed on 7/9/2011 at: http://jac.oxfordjournals.org/cgi/reprint/dkl121v1
4. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis.
March 2008 (NICE Clinical Guideline No.64). Accessed on 7/9/2011 at:
NICE full guideline www.nice.org.uk/nicemedia/pdf/CG64NICEguidance.pdf (107 pages)
NICE appendices to the full guideline www.nice.org.uk/nicemedia/pdf/CG64Appendices.pdf (270
pages)
5. British National Formulary. Chapter 5.1 antibacterial drugs; Table 2 summary of antibacterial
prophylaxis. Accessible online at www.bnf.org
6. National Institute for Health and Clinical Excellence. Understanding NICE guidance: information for
people who use NHS services. Preventing infective endocarditis. Reference N1488. Accessed on
7/9/2011 at: www.nice.org.uk/nicemedia/pdf/CG64UNG.pdf
7. National Institute for Health and Clinical Excellence. Prophylaxis against infective endocarditis.
Quick reference guide. Reference N1487. Accessed on 7/9/2011 at:
www.nice.org.uk/nicemedia/pdf/CG64PIEQRG.pdf
8. British Heart Foundation. Information sheet IS27. Endocarditis (infective endocarditis). Accessed on
7/9/2011 at www.bhf.org.uk/publications/view_publication.aspx?ps=1000858
Quality Assurance
Prepared by
Karoline Brennan, North West Medicines Information Centre, April 2008
Reviewed by
Karoline Brennan, North West Medicines Information Centre, August 2009
Christine Randall, North West Medicines Information Centre, September 2011
Checked by
Christine Randall, North West Medicines Information Centre, April 2008 and August 2009
Christine Proudlove, North West Medicines Information Centre, September 2011
Medicines Q&A 187.3 Date reviewed: September 2011
Do patients undergoing dental procedures require antibiotic prophylaxis?
From the NHS Evidence website www.evidence.nhs.uk