The Committee on Rheumatic Fever, Endocarditis, and Kawasaki Disease of the American Heart Association issues detailed recommendations on the rationale, indications, and antimicrobial regimens for prevention of bacterial endocarditis for people at increased risk. The most recent recommendations were published in 2007.¹ The committee noted that recent data have cast doubt on the benefits of dental prophylaxis because bacteremia associated with most dental procedures represents only a fraction of the bacteremias that occur with daily living such as brushing teeth, chewing, and other oral hygiene measures. The committee has restricted recommendations for prophylaxis to a narrower group of individuals with cardiac abnormalities and for fewer procedures than in the past. While previous recommendations stressed prophylaxis for people undergoing procedures most likely to produce bacteremia, this revision stresses cardiac conditions in which an episode of infective endocarditis would have high risk of adverse outcome. Furthermore, prophylaxis is recommended only for certain dental procedures. Prophylaxis is no longer recommended solely to prevent endocarditis for procedures involving the respiratory, gastrointestinal and genitourinary tracts. The cardiac conditions and procedures for which endocarditis prophylaxis is recommended and specific prophylactic regimens, are shown below and in Table 5.3 . Health care professionals should consult the published recommendations for further details (http://circ.ahajournals.org/cgi/content/full/116/15/1736).

Table 5-3

Cardiac conditions associated with the highest risk of adverse outcome from endocarditis for which prophylaxis with dental procedures is reasonable include the following²:

• Prosthetic cardiac valve or prosthetic material used for repair of valve.


• Previous infective endocarditis.


• Congenital heart disease (CHD)²:
  
  • Unrepaired cyanotic CHD, including palliative shunts and conduits.
  
  
  • Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure.³
  
  
  • Repaired CHD with residual defect(s) at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).
  
  


• Cardiac transplantation with subsequent cardiac valvulopathy.

Dental procedures for which endocarditis prophylaxis is reasonable for patients listed above include the following:

• All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. The following procedures and events do not require prophylaxis: routine anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.