Advice for cardiology and cardiac surgery teams

The National Institute for Health and Care Excellence (NICE) Clinical Guideline 64 (CG64) Prophylaxis against infective endocarditis’ ²¹ states:

‘Antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures’.

NICE recognises that there is a sub-group of individuals at high risk of infective endocarditis (IE) who may benefit from antibiotic prophylaxis when undergoing dental procedures.

NICE CG64 directs users to this SDCEP implementation advice for information on antibiotic prophylaxis for people at high risk of infective endocarditis undergoing dental procedures.

Refer to Introduction for more information.

Patients at risk of infective endocarditis

The 2023 European Society of Cardiology (ESC) guideline¹⁹ identifies several categories of high risk patients for whom antibiotic prophylaxis is recommended or should be considered.

The ESC guideline also lists a group of moderate risk patients for whom antibiotic prophylaxis is not recommended.

Refer to Patients at risk of infective endocarditis for more information on these patient groups.

Prevention of infective endocarditis

All patients at high risk and moderate risk of infective endocarditis should be given clear and consistent information about prevention of infective endocarditis and reducing poorer outcomes, including:

the importance of maintaining good oral health
symptoms that may indicate infective endocarditis and when to seek expert advice
the risks of undergoing invasive procedures, including non-medical procedures such as body piercing or tattooing.

Refer to Prevention of infective endocarditis for more information.

'At-risk' dental procedures

Not all dental procedures in patients at high risk of infective endocarditis require antibiotic cover. Antibiotic prophylaxis is recommended for extractions and oral surgery procedures and should be considered for dental procedures that involve manipulation of the gingival or periapical region of the teeth.

Refer to 'At risk' dental procedures for more information on these recommendations and the dental procedures that fall into each of these groups.

Dental teams will make a shared decision on antibiotic prophylaxis with the patient, that involves:

consideration of the IE risk associated with the dental procedure
the potential benefits and harms of antibiotic prophylaxis
the patient's oral health status
the patient's values and preferences

For further explanation of the dental terms used in this implementation advice, see Glossary of dental terms.

What should cardiology and cardiac surgery teams do?

To support the implementation of CG64, it would be helpful for cardiology and cardiac surgery teams to discuss antibiotic prophylaxis against infective endocarditis with their patients and make a shared decision on whether this is required for dental treatment.

Note that if dental teams are unable to identify whether a patient has a high risk or moderate risk of infective endocarditis, they are advised to contact the patient’s cardiology or cardiac surgery team to confirm the nature of the patient’s cardiac condition and whether antibiotic prophylaxis is recommended prior to ‘at-risk’ dental procedures.

In addition, some patients with a moderate risk cardiac condition, for whom antibiotic prophylaxis is not recommended, may request antibiotic prophylaxis and their dentist may contact you for advice.

For all patients at high risk or moderate risk of infective endocarditis:

Discuss the risk of infective endocarditis with the patient while they are in your direct care to make a shared-decision about whether antibiotic prophylaxis prior to dental treatment is right for them.

Highlight the importance of maintaining good oral health, the symptoms that may indicate infective endocarditis and when patients should seek expert advice (refer to Prevention of infective endocarditis for more information)

Advise the patient to tell their dentist about their heart condition and any discussion that they have had with you about antibiotic prophylaxis.

It may be helpful to include this information, including your shared decision about antibiotic prophylaxis, in a written form, either as a letter or an alert card (refer to Supporting tools for examples). This may be sufficient to allow the patient’s dental team to carry out dental treatment without needing to contact you for advice.

A leaflet which provides dental advice for patients at increased risk of infective endocarditis is available (see Patient information).