Sir, The recent Recommendations on Dental Aspects of Endocarditis Prophylaxis from the British Cardiac Society (BCS) and the Royal College of Physicians (RCP)1 give us great cause for concern. They differ significantly from previous international and national guidance in that they increase the necessity to prescribe antibiotic prophylaxis.

The document1 advises the use of prophylaxis for a variety of routine restorative dental procedures. In addition the cohort of 'high risk' patients has been greatly increased. Intravenous (IV) antibiotics are deemed necessary for patients who have a prosthetic heart valve or have mitral valve prolapse with regurgitation or thickened valve leaflets. This potential increase in the number of administrations of antibiotics is surprising when scientific opinion2 suggests that current regimes for antibiotic prophylaxis are considered to be unnecessarily stringent.

Recommendations have to be based on the best documentary evidence available and should be capable of realistic implementation. With time the recommendations will inevitably be tested in a court of law and upheld as best practice. Many of the recommendations made by the BCS/RCP are unsupported by clear documentary evidence and are confusing. The IV regimes have an increased complexity that is unjustified. In particular a fundamental assumption is made that the generation of a bacteraemia by a dental procedure is always associated with a risk of infective endocarditis (IE), thankfully this is not a fact. A bacteraemia is implicated as a risk factor if it has been shown that it can be associated with IE. It is generally accepted that dental surgery and scaling can cause IE. Many of the procedures, however, advocated by the BCS/RCP as requiring prophylaxis have not been reported as causing infective endocarditis. In particular placement of a rubber dam, matrix band and wedge placement and retraction cord placement.

The BCS/RCP document also unnecessarily perpetuates the use of IV prophylaxis for certain risk groups. In the USA the use of oral antibiotic prophylaxis has been shown to be effective, even in high-risk groups3. The use of oral antibiotics in high-risk groups has not been associated with an increase in the number of cases of IE following dental procedures. In the USA the administration of IV antibiotic prophylaxis has been reserved for use only in patients who cannot take oral medication. The use of IV antibiotic prophylaxis presents a barrier to patient care in dentistry and also carries inherent risks. Further discussion is therefore, required, about the BCS/RCP recommendations. Liverpool University Dental Hospital will not be adopting these recommendations until the issues raised in this letter have been addressed. We will therefore continue to follow the guidance given in the DPF (2002-4) based on the original BSAC recommendations.

We feel that the BCS/RCP recommendations need urgent revision if they are to stand up to scientific scrutiny and not to lead to an unnecessary increase in the use of antibiotics.