Sir, the Scottish Dental Clinical Effectiveness Programme (SDCEP) are to be congratulated for their advice concerning the implementation of NICE guideline CG64 – prophylaxis to prevent endocarditis1 and for obtaining the endorsement of NICE, the British Cardiovascular Society and the Royal Colleges. This should help ensure that the advice is implemented UK-wide.

Dentists should now:

(A) Make specific patient groups aware of their increased risk of infective endocarditis (IE)

(B) Discuss the advantages and potential drawbacks of antibiotic prophylaxis (AP)

(C) Liaise with cardiologists/cardiac surgeons as appropriate

(D) Allow the patient to make the ultimate decision whether or not AP will be used.

This is a significant departure from the NICE 2008 recommendation against antibiotic AP.2 It essentially mirrors guidelines from the European Society of Cardiology (ESC)3 and the American Heart Association (AHA)4 and is in keeping with the legal precedent provided by Montgomery.5

However, we have some reservations. SDCEP adopted the ESC and AHA definition of invasive dental procedures, ie procedures requiring manipulation of the gingival or periapical region of the teeth or perforation of the oral mucosa. In their consultation document, they gave the same list of exceptions as ESC/AHA.

In their published advice, however, BPE screening and supragingival scale and polish have been inexplicably added as examples of 'non-invasive procedures'. This is of considerable concern.

BPE screening involves periodontal-probing of all teeth to identify the deepest pocket in each sextant. Several studies have shown that periodontal probing can cause significant bacteraemia with organisms that cause IE.

Most supragingival calculus accumulates at the gingival margin and causes gingival inflammation. Instrumentation to remove this often results in gingival manipulation and bleeding.

Numerous studies have shown that scaling (including supragingival scaling and polishing) can cause significant bacteraemia with IE-related organisms. We are unaware of evidence demonstrating the safety of these procedures and dentists and hygienists following ESC and AHA guidelines normally provide AP cover for these procedures (as did UK dentists prior to the 2008 NICE guidelines).

We agree with SDCEP that patients at 'increased risk' of IE should have this level of risk explained to them. However, the illustrative figure provided by SDCEP (1/10,000/year) relates to the general population and is much lower than the actual level for those at increased (34/10,000/year) or high-risk (50/10,000/year) – called the 'special consideration sub-group' by SDCEP – as shown in a recent study referenced within the SDCEP document.6

It would be misleading, therefore, to use a Figure 30-50 times too low to illustrate the level of risk for these patients. Similarly, whilst SDCEP described the 'special consideration sub-group' as representing a small fraction of those at 'increased-risk', the same study identified 365,875 individuals at 'increased-risk' in England (2000-2008) with 96,021 (26%) in the 'special consideration sub-group'.6

Furthermore, the number at high-risk is growing inexorably as those at moderate-risk undergo cardiac interventions that convert them into high-risk ('special consideration sub-group') cases.

We hope these issues are quickly addressed so that clinicians can confidently adopt the SDCEP advice nationwide.