Heart Condition & Premed

Certain heart conditions are more often associated with endocarditis than others.

Infective Endocarditis

New guidelines for prevention of infective endocarditis were released by the American Heart Association April 19. The AHA and ADA now recommend that fewer dental patients with heart disease receive antibiotic prophylaxis before dental procedures to prevent the heart infection called infective endocarditis (IE). The guidelines were developed by a group appointed by the AHA that included experts in infectious disease and cardiology and members representing the ADA. The guidelines were endorsed by the Infectious Diseases Society of America and the Pediatric Infectious Diseases Society.

After reviewing relevant scientific literature from 1950-2006, the group concluded that bacteremia resulting from daily activities is much more likely to cause IE than bacteremia associated with a dental procedure. In addition, only an extremely small number of IE cases might be prevented by antibiotic prophylaxis, even if prophylaxis is 100% effective. Based on these conclusions, antibiotic prophylaxis is now recommended before dental procedures only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE, such as patients with artificial heart valves, a history of endocarditis, certain serious congenital heart conditions and heart transplant patients who develop a problem with a heart valve.

For more details see ADA.org

The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with:

	mitral valve prolapse
	rheumatic heart disease
	bicuspid valve disease
	calcified aortic stenosis
	congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection.

Preventive antibiotics prior to a dental procedure are advised for patients with:

artificial heart valves

a history of infective endocarditis

certain specific, serious congenital (present from birth) heart conditions, including

	unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
	a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
	any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

a cardiac transplant that develops a problem in a heart valve.

The new recommendations apply to many dental procedures, including teeth cleaning and extractions. Patients with congenital heart disease can have complicated circumstances. They should check with their cardiologist if there is any question at all as to the category that best fits their needs. ADA 5/07

To determined if an existing heart condition poses a risk you will be asked to complete health information. You will need to tell us if you have had:

	Heart surgery within the past six months
	Artificial heart valve
	Rheumatic fever
	Pacemaker
	Mitral valve prolaspe
	Previous bacterial endocarditis
	Pulmonary shunt
	Congenital heart defect
	Acquired valvular dysfunction
	Within six months of vascular surgery

The elderly are at higher risk. More than one half of the current cases of endocarditis occur in people 60 years of age and older with a mortality rate for this group as high as 70%.

Poor oral hygiene and periodontal (gum disease) or periapical infections increase your risk for endocarditis.

The American Hearth Association recommends antibacterial prophylaxis for at-risk individuals with any dental procedure that may cause bleeding such as the following procedures:

	Tooth extractions
	Periodontal surgery
	Scaling and root planing
	Probing
	Recall maintenance
	Dental implant placement
	Replantation of avulsed teeth
	Subgingival placement of antibiotic fiber or strips
	Initial placement of orthodontic bands (not brackets)
	Intraligamentary local anesthetic injections
	Cleaning of teeth or implants where bleeding is anticipated
	Endodontic surgery
	Instrumentation beyond the apex

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The current regimen is:

Two grams of amoxicillin, one hour prior to treatment with no follow-up dosage required.

Clindamycin, cephalexin, cefadroxil, azithronycin or clarithromycin as also suggested alternative

If you are allergic to Amoxicillin AND Clindamycin use Azithromycin or Clarithromycin 500mg 1 hour prior to procedure.

At our office we also reduce bacteremias by using an antiseptic mouthrinse for 30 seconds before any procedures are done.

The most effective reduction in bacteria in your mouth is accomplished by you. It is urgent that you improve your oral hygiene care in order to improve you oral health by:

Rinsing your mouth with an antiseptic mouthrinse like BreathRx or Perioguard to reduce the bacteria count in your mouth BEFORE you do the following:

Use a Waterpik irriagator on a daily basis.

Brushing at least twice a day for 2 minutes or more using a Sonicare toothbrush.

Flossing daily or using an automatic flosser.

All these will "stir up" the bacteria in your mouth, yet by using a consistent and regular self care maintenance routine along with frequent check-ups and professional cleanings will result in an overall reduction of oral bacteria to improve not only your oral health but your total well-being.

Antibiotics and You Heart ADA.org

The dental procedures can be found on the American Heart Association's website: www.americanheart.org.
AHA Prophylaxis Guidelines For Prevention Of Bacterial Endocardiditis

Source: American Dental Association

Resource: American Heart Association-Prevention of Bacterial Endocarditis and ADA Bacterial Endocarditis.

ADA PREMEDICATION Facts

New Recommendations from ADA 5/07

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