Sir, the editorial by Martin on antibiotic prophylaxis for the prevention of infective endocarditis (IE) in patients with cardiac disease undergoing dental procedures reflects poorly on the dental profession.1

It reveals an ignorance of this devastating condition and an inability to learn from previous experience. Moreover, it is disappointing that he prefers to turn to laboratory specialists for advice on antibiotic prophylaxis for patients at risk of IE2 rather than accept the recommendations of the experienced body of cardiologists and cardiac surgeons in the UK, Europe and the USA.3,4,5 To say that the link between IE and dentistry is tenuous and much over-emphasised is naïve, untrue and mischievously misleading. The comments that dentists 'do things to prevent IE because of emotion rather than science' suggests a poor understanding of the pathogenesis of IE and a major underestimate of the intelligence of dentists in clinical practice in the UK. Furthermore, his statement that the sensible dental practitioner who gives prophylaxis in those 'at-risk' patients is 'largely based on the fear of medicolegal action' is an insult to such professionals.

If Martin was aware of the potentially lethal consequences that occur as a result of the vasculitic and embolic complications of IE, he perhaps would not be dismissive of the need to protect those patients at risk who put their trusts in our professionalism and expertise. Although the extracardiac complications involving the kidneys, gastrointestinal and central nervous systems are very serious, the cardiac complications are particularly life-threatening because of their local destructive effects. Valvular destruction causing severe aortic or mitral regurgitation and cardiac failure, aortic root abscesses, myocarditis and cardiac abscesses, false aneurysms and fistula formation between cardiac chambers and aorta are difficult to treat and carry a poor prognosis despite surgical intervention.

Patients who develop IE go quickly from being healthy to becoming very sick and require intensive intravenous antibiotic therapy for a prolonged period in hospital. Much of this time will be in an intensive care unit especially when major organ involvement occurs. Unfortunately, a large number of patients will require cardiac surgery to replace a valve(s), repair a fistula, resect an aneurysm or replace the aortic root and surgery frequently carries a high post-operative morbidity and mortality despite using powerful parenteral antibiotics in large doses for a prolonged period in-hospital. Patients with prosthetic valve IE are more difficult to treat than those with infection on native valves, usually require further cardiac surgery to remove the infected prosthesis and have the highest morbidity and mortality. IE is still associated with a mortality rate of 30% despite antibiotic treatment and surgery.

Because IE is still such a life-threatening condition, every effort to prevent it should be made. Greater awareness of the seriousness of the condition and vigilance to try and prevent it is required rather than the rationing of antibiotic prophylaxis for convenience sake. Bacteraemia is usually a prerequisite for the development of IE and patients with certain cardiac abnormalities appear to be more likely to develop infected vegetations on or close to the anatomical defect. In such 'at-risk' patients, antibiotic prophylaxis should be given to try and deal with the bacteraemia created by whatever instrumentation that is responsible. It is irrational and reckless in our view not to give antibiotic prophylaxis to, for example, patients who have mitral valve prolapse and regurgitation or a bicuspid aortic valve and who are undergoing dental work. The recommendations by BSAC are woefully inadequate, were not created as a result of consultation with the British Cardiac Society and are at odds with the national and international guidelines on antibiotic prophylaxis for the prevention of IE.

Martin's editorial is entitled 'victory for science and common sense'. The science of pathology has clearly demonstrated the mechanism of the formation of vegetations in IE and yet he chooses to ignore it presumably because a randomised clinical trial has not been published which shows benefit in favour of those receiving prophylaxis over those not given preprocedural antibiotics. This is unlikely to happen because of the unethical nature of the research. As for common sense, this is sadly lacking in this editorial and in the BSAC recommendations but hopefully will be shown by the majority of dentists in the UK who will follow the UK/European Society of Cardiology/American Heart Association & American College of Cardiology Guidelines and continue to provide antibiotic prophylaxis for all their patients deemed to be at risk of IE because of existing cardiac pathology.