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Antibiotics before dental procedures for endocarditis prophylaxis: back to the future
  1. GARY D WEBB, The Bitove Family Professor of Adult Congenital Heart Disease
  1. Mount Sinai Hospital
  2. 600 University Avenue
  3. Toronto, Ontario M2R 3S1
  4. Canada
  6. Toronto Congenital Cardiac Centre for Adults
  7. 200 Elizabeth Street
  8. Toronto, Ontario M5G 2C4
  9. Canada

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Infective endocarditis (IE) is a rare infection of the endocardial surface, with an incidence of approximately 4 per 100 000 person-years. Uniformly fatal in the pre-antimicrobial era, the mortality from IE remains high (∼20%). Before the introduction of antibiotics, dentists were called upon to prevent IE in persons with valvar lesions by helping to maintain good oral health. Over the past 60 years, however, antibiotic prophylaxis has been seen as protective, and dental care as potentially hazardous to patients at risk of IE. This view is erroneous, and likely harmful. A call to refocus our energies back on maintaining good oral health is long overdue.

Dental procedures and endocarditis

The relation between oral microbial flora and infective endocarditis was recognised early in the 20th century. With knowledge that disruption of infected oral mucosal barriers results in bacteraemia, medical wisdom in the first half of the 20th century taught that patients at risk of IE “should take all precautions to prevent infections of the teeth . . . and should have existing foci of infection removed.”1 Beginning in the 1930s, though, an expanding body of literature began to document bacteraemia after a wide variety of dental “procedures” in uninfected mouths, including such seemingly benign activities as whistling, brushing teeth, and chewing.

Following several case reports of IE preceded by dental extractions, Northrop and …

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