Is endocarditis prophylaxis for dental procedures necessary?

OBJECTIVES: Our purpose is to address whether antimicrobial prophylaxis is necessary before certain dental procedures for patients at increased risk for acquiring infective endocarditis (IE).
METHODS: We reviewed recommendations for IE prophylaxis made by the American Heart Association (AHA) from 1995 to the present time. We also compared and contrasted the current recommendations from the AHA, European Society of Cardiology (ESC), United Kingdom's National Institute for Health and Care Excellence (NICE) and a consortium of French organisations. We further reviewed recent papers that have observed the incidence of IE since these current recommendations were published.
RESULTS: Beginning in the 1990s, questions were raised about the advisability of using antimicrobial prophylaxis before certain dental procedures to prevent IE. Various groups in Europe and the US were increasingly aware that there were not any clinical trials showing the effectiveness, or lack thereof, of such prophylaxis. In the early to mid-2000s, the AHA, ESC and French consortium published guidelines recommending restriction of prophylaxis before dental procedures to patients with highest risk for developing IE and/or the highest risk for an adverse outcome from IE. The NICE guidelines eliminated recommendations for prophylaxis before dental procedures. Studies published after these changes were instituted have generally shown that the incidence of IE has not changed, although two recent reports have observed some increased incidence (but not necessarily related to an antecedent dental procedure).
CONCLUSION: A multi-national randomised controlled clinical trial that would include individuals from both developed and developing countries around the world is needed to ultimately define whether there is a role for antibiotic prophylaxis administered before certain dental procedures to prevent IE.