Cahill TJ, Dayer M, Prendergast B, Thornhill M. BMJ 2017; 358: j3942

General dental practitioners of a certain age will recall routinely prescribing penicillin V (250 mg, qds, 5 days, 1 g stat) for any patient with a history of rheumatic fever, prior to any dental interventions which might cause a bacteraemia and consequently infective endocarditis. However, guidance from the National Institute for Health and Care Excellence (NICE) changed that routine in 2008. New guidelines stated that the use of antibiotic cover for such patients was unnecessary and unproven, and should consequently not be administered in the future. Despite that UK update, American and European cardiologists continue to recommend its use.

This current review suggests that it is still not known who is correct. It is acknowledged that invasive dental procedures cause a bacteraemia but that there is little evidence to show that these are a major cause of infective endocarditis. There is evidence to show that antibiotic prophylaxis will reduce the incidence of post-procedural bacteraemia but little evidence to suggest that this reduces the incidence of infective endocarditis. In addition, the risks of antibiotic prophylaxis include the possibility of contributing to antibiotic resistance and of an anaphylactic reaction.

The suggested response is to risk assess each patient. Those at high risk of infective endocarditis – those with 'prosthetic heart valves, previous infective endocarditis or certain types of congenital heart disease' – should be offered antibiotic prophylaxis after a discussion with the cardiologist, and an explanation of the risks and benefits if they are to undergo a high risk invasive dental procedure. A high risk invasive procedure is defined as one in which 'there is manipulation of the gingival or periapical region of the teeth' which includes extractions, scaling and root canal procedures but not injection of local anaesthetic.

When used, the recommended antibiotic prophylaxis is 3 g of oral amoxicillin 60 minutes prior the procedure, or 600 mg of clindamycin for those allergic to penicillin. Further suggested advice to the patient recognises the importance of excellent oral home care, regular dental follow up, the avoidance of tattoos and piercings and education regarding the symptoms of infective endocarditis.

The authors conclude by stating that the views expressed in the publication are their own and not necessarily those of the NHS or the Department of Health. The current NICE guidelines can be found at, in which the heart conditions which may require prophylaxis are specified in more detail.