Endocarditis is a rare, life-threatening bacterial inflammation of the lining of the heart muscle and its valves. Although endocarditis can occur in anyone, it is more common in people who have heart valve disease, have had heart valve replacement surgery, have a congenital heart defect, have had recent heart surgery or who are IV drug abusers.
Dental procedures can trigger endocarditis, especially in susceptible individuals. Bacteria found in tooth plaque are the source of the inflammation of the heart muscle lining and valves. More specifically, what happens is that bacteria in plaque build up and cause gingivitis, which if left untreated, proceeds to periodontitis. The gums become inflamed (red and swollen) and often easily bleed during tooth brushing, flossing, or certain dental procedures. When gums bleed, the bacteria enter the bloodstream and potentially infect other areas of the body – in this case —the inner lining of the heart and its valves.
To prevent the development of endocarditis, a single dose of an antibiotic – usually given about 1 hour prior to certain dental treatments – is recommended in certain patients with cardiovascular conditions.
Patients with what types of cardiovascular conditions should receive pretreatment with antibiotics?
The American Heart Association and the American Dental Association recommend that antibiotics be given prior to dental treatment in patients:
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Who have artificial heart valves
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Who have mitral valve prolapse with valvular regurgitation and/or thickened leaflets
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Who have had previous bacterial endocarditis
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Who have a surgically constructed systemic pulmonary shunt
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Who have congenital (present at birth) heart defects
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Who have acquired heart valve disease (for example, from rheumatic heart disease)
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Who have hypertrophic cardiomyopathy (a disease resulting in the enlargement and thickening of certain areas of the heart muscle itself)
Are antibiotics recommended for all dental procedures in patients with the above cardiovascular problems?
Antibiotic pretreatment is recommended for the dental procedures most likely to cause
significant
bleeding to the extent that oral bacteria could be released into the bloodstream. These procedures include:
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Tooth extraction
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Implant placement
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Reimplantation of natural teeth (for example, for teeth that get knocked out)
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Periodontal procedures (including surgery, scaling and root planing)
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Endodontic surgery (surgeries involving the inside of the tooth – the human dental pulp or the nerve) and use of instruments in such surgery that extends beyond the very bottom of the root of the tooth
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Initial placement of orthodontic bands (but not brackets)
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Intraligamentary local anesthetic injections
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Subgingival placement of antibiotic fibers or strips
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Professional cleaning of teeth or implants if bleeding is anticipated
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Incision and drainage of infected oral tissues
Antibiotic pretreatment is also recommended for patients undergoing tonsillectomy and adenoidectomy (removal of the tonsils and adenoids, respectively).
Dental procedures that have low potential to cause bleeding are considered low risk for the development of infective endocarditis. Antibiotics are NOT recommended for these procedures:
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Taking x-rays
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Taking oral impressions
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Fluoride treatments
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Restorative dentistry (such as placement of fillings)
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Placement of a rubber dam
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Orthodontic appliance adjustment
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Placement of removable orthodontic/prosthodontic appliances
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Shedding of primary (baby) teeth
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Postoperative suture removal
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Intracanal endodontic treatment (post-placement and build-up)
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Local anesthetic injections (specifically nonintraligamentary)
If endocarditis were to possibly develop following a dental procedure, what signs and symptoms should I be aware of?
Call your dentist or doctor if you experience unexplained fever, night chills, weakness, muscle pain (myalgia), joint pain (arthralgia), sluggishness (lethargy) or malaise (general ill feeling), or have any unusual symptoms. Keep in mind that receipt of the antibiotic significantly lowers the chance that endocarditis won’t occur, but it does not absolutely guarantee that endocarditis won’t occur. Also keep in mind that most cases of procedure-related endocarditis develop 2 weeks or sooner after the procedure. So if you experience any of these symptoms beyond this time "window," it is not very likely that you have endocarditis, though it’s always wise to check with your doctor or dentist if you have any concerns.
Is there anything else I can do to lower my risk for bacterial endocarditis?
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Tell your dentist if your health status has changed since your last visit. In particular, let your dentist know if you’ve undergone heart surgery or vascular surgery within the past 6 months or have been diagnosed with other heart conditions.
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Make sure your dentist has a complete list of the names and dosages of all medications – both prescription and over-the-counter – that you are taking.
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Make sure your dentist has the names and phone numbers of all of your physicians. Your dentist may want to consult with your doctor regarding your dental plan of care and specific medication choices.
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Practice good oral hygiene. Brush your teeth at least twice a day; floss at least once daily.
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This information is provided by the Cleveland Clinic and is not intended to replace the medical advice of your doctor or health care provider. Please consult your health care provider for advice about a specific medical condition. This document was last reviewed on: 11/20/2003
