Crystal clear?

Hugh Harvie provides some clarity on the NICE guidance covering the use of antibiotics in patients at risk of infective endocarditis [Feature article from Summons Summer 08]

FROM the number of telephone contacts and emails from dentists to the MDDUS it is clear that there is considerable confusion and uncertainty about the National Institute for Health and Clinical Excellence (NICE) guidelines on Prophylaxis against infective endocarditis. Perhaps it is the wording or the presentation that has led to this confusion among both dentists and patients.

The advice to regard “people with the following cardiac conditions as being at risk of developing infective endocarditis” tends to reinforce the previously accepted doctrine (at least in the minds of dentists) that certain groups of patients are at risk of developing endocarditis and antibiotics should be given!

The groups identified as ‘at risk’ include those with the following conditions:

  • acquired valvular disease with stenosis or regurgitation
  • valve replacement
  • structural congenital heart disease including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defects or fully repaired patent ductus arteriosus, and closure devices judged to be endothelialised
  • hypertrophic cardiomyopathy
  • previous infective endocarditis.

All of the above ring alarm bells for dentists who have been indoctrinated to prescribe antibiotics for such conditions! Having rung the alarm bells the guidance then goes on to give advice on “When to offer prophylaxis” under the sub-heading of “Do not offer antibiotic prophylaxis…” The situations where antibiotic prophylaxis is no longer considered necessary are then listed and the most significant to dentists is “to people undergoing dental procedures”.

There it is…crystal clear…no antibiotic prophylaxis for dental procedures. Also, the guidance confirms that it is no longer necessary to offer chlorhexidine mouthwash as a prophylaxis.

Finally, the guidance offers advice on managing infection and emphasises the importance of the following:

  • investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce the risk of endocarditis developing
  • offer an antibiotic that covers organisms that cause infective endocarditis if a person at risk of infective endocarditis is receiving antimicrobial therapy because they are undergoing a gastrointestinal or genitourinary procedure at a site where there is a suspected infection.

So what does the dentist do?

These guidelines make it clear that there is now no longer any requirement or recommendation to prescribe antibiotic prophylaxis for dental treatment. Dentists should adhere to the guidelines as follows:

  • Carry out a thorough patient examination including an assessment of the medical history.
  • Where the medical history indicates that the patient is in an ‘At Risk’ category then the patient should be advised on the NICE guidelines and informed that antibiotic prophylaxis is no longer considered necessary for dental procedures.
  • If a patient is unhappy or concerned about the advice being given then the patient should be advised to discuss matters with the GP or consultant managing his or her care. If the GP or consultant confirms that antibiotics are required then the prescribing should be done by them. The dentist’s role is to provide information on the treatment to be undertaken and to explain, if required, the NICE guidelines in relation to dental procedures.

The patient record should record all necessary clinical information and note the discussions/advice given to the patient.

The guidelines do remind dentists of the need to investigate and treat promptly any episodes of infection in people at risk of infective endocarditis to reduce that risk. In other words a dentist must effectively manage the presenting dental condition promptly and effectively.

Mr Hugh Harvie is a dento-legal adviser at the MDDUS