GRADE Rating:

Commentary

The role of AP in preventing IE following IDPs remains debated [1, 2, 3]. This systematic review and meta-analysis by Sperotto et al. [4] explore whether AP reduces IE risk in different patient groups.

This study is particularly relevant in the UK, where NICE recommends against routine AP for dental procedures [5], contrasting with American Heart Association (AHA) and European Society of Cardiology (ESC) guidance supporting AP for high-risk patients [6, 7]. With IE incidence rising, UK dentists must balance patient safety and antimicrobial stewardship. This commentary explores implications for dental professionals.

Context and controversy

IE is a rare but serious condition, often caused by viridians group streptococci entering the bloodstream [8, 9, 10]. Dental procedures disrupting oral tissues can cause transient bacteraemia, potentially contributing to IE in susceptible individuals.

Before 2008, UK guidance aligned with AHA and ESC recommendations, routinely prescribing AP to at-risk patients [6, 7]. NICE changed this in 2008, recommending against routine AP due to insufficient evidence of benefit, antimicrobial resistance concerns, and potential risks such as anaphylaxis [5]. Some studies suggest increased IE incidence following this change [11,12,13]; others do not [14,15,16].

This study [4] adds to the debate, with findings supporting AP use in high-risk patients, but not in moderate- or low-risk groups. However, inconsistent time-trend data and lack of randomised trials mean uncertainty remains.

Strengths and limitations of the study

This study’s strengths include a large dataset and structured quality assessments. Meta-analysis of case-crossover and cohort studies strengthens the argument that AP reduces IE risk in high-risk patients.

However, observational studies are prone to confounding, and RCTs are unlikely in this field and so establishment of a direct causal link remains challenging. Time-trend findings were inconsistent, possibly reflecting differences in healthcare systems, populations, guideline adherence, or IE causative organisms [16, 17]. Other factors like improved diagnostics, increased prosthetic heart valve use, and an ageing population may also influence IE trends independently of AP practices.

Clinical implications for UK dentists

In October 2024, NICE issued “Exceptional surveillance of prophylaxis against infective endocarditis,” [18] which reviewed existing evidence, including Sperotto et al. [4]. It concluded that robust research is lacking but limited findings indicate invasive dental treatments might contribute to a small proportion of IE in high-risk individuals. NICE CG64 guidance remained unchanged but now signposts SDCEP implementation advice to help clarify those patients that require special consideration for antibiotic prophylaxis [19]. SDCEP is currently reviewing its own guidance.

Considering current evidence dentists should:

  1. 1.

    Identify patients at increased risk and differentiate those requiring special consideration

    While NICE guidance does not recommend routine AP, it allows for individual clinical judgment. SDCEP [19] advises increased-risk patients include those with:

    • Heart disease that has developed over time, involving stenosis or regurgitation

    • Hypertrophic cardiomyopathy

    • History of IE

    • Certain structural heart defects (excluding isolated or fully repaired cases)

    • Valve replacements

    Within this group, a subset requires special consideration, including:

    • Prosthetic heart valves, including transcatheter valves, or prosthetic material used in valve repair

    • History of Previous IE

    • Certain types of congenital heart disease

    • Cardiac transplant recipients with valvulopathy

    Care for these patients should involve their cardiologist or relevant medical specialist if IDPs are planned.

  2. 2.

    Understand which procedures are invasive

    AP is considered for procedures likely to cause significant bacteraemia, including [19]:

    • Extractions

    • Periodontal surgery or subgingival scaling

    • Implant placement

    • Endodontic treatment before apical stop establishment

    • Any mucosal incision

    Procedures like supragingival restorations, BPE, scaling above the gumline, orthodontics, and radiographs are non-invasive and do not require AP [19].

  3. 3.

    Communicate effectively with medical colleagues

    UK guidance differs from other countries, so clear communication is essential. If a cardiologist recommends AP, dentists should document and respect this if appropriate. Patients should be fully informed of the risks and benefits when AP is considered [19].

  4. 4.

    Promote antimicrobial stewardship and educate patients

Dentists must minimise unnecessary antibiotic use to combat resistance and adverse effects. When AP isn’t indicated, patients should be encouraged to maintain good oral hygiene and understand IE signs and symptoms.

Conclusion

For UK dentists, the study highlights the importance of adhering to NICE guidelines alongside SDCEP implementation advice while considering individual patient circumstances. Clinicians should be confident in avoiding unnecessary AP prescriptions but remain open to case-by-case decision-making in collaboration with patients and medical colleagues.

While the debate over AP in dentistry continues, this study is a valuable addition to the evidence base for clinical decision-making.