Update on antibiotic prophylaxis and infective endocarditis

Much separates the UK for the USA.

An ocean, obviously.

And language - ‘Two nations divided by a common language’- a comment variously attributed to George Bernard Shaw or possibly Oscar Wilde or even Winston Churchill. 

I mean, who knew that the exhaust pipe on your car is a muffler and the bonnet is a hood? Chips/crisps, fries/chips, pants/trousers, jelly/jam – the opportunities for misunderstanding are endless.

When it comes to the differences in advice with regard to management of patients at risk of infective endocarditis (IE), the chasm between the UK and the USA is very wide indeed.

The American Heart Association (AHA) continues to recommend that antibiotic prophylaxis (AP) is given to those undergoing invasive dental procedures (IDP) and at risk of IE.

Those at increased risk of developing IE include people with

  • acquired valvular heart disease with stenosis or regurgitation
  • hypertrophic cardiomyopathy
  • previous infective endocarditis
  • structural congenital heart disease, including surgically corrected or palliated structural conditions, but excluding isolated atrial septal defect, fully repaired ventricular septal defect or fully repaired patent ductus arteriosus, and closure devices that are judged to be endothelialised
  • valve replacement

IDPs which should be covered by AP are defined as

  • extractions and other surgical interventions such as biopsies, implant placement and periodontal surgery
  • scaling and root planning
  • endodontic treatment

The European Society of Cardiology (ESC) recommends that AP is restricted to those at highest risk of IE.

However, in the UK, since 2008, the National Institute for Health and Care Excellence (NICE) guidance has stated that “antibiotic prophylaxis against infective endocarditis is not recommended routinely for people undergoing dental procedures.”

The evidence for the use of AP before IDP’s appears to be lacking and causal links with bacteraemia’s from tooth brushing have been suggested. Despite research published in 2013 which found an increase in IE in the UK followed a decrease in AP prescriptions subsequent to the issue of the 2008 guidelines, the NICE recommendations have largely remained unchanged since then.

However, a recent paper in the Journal of the American College of Cardiology, by Martin Thornhill of Sheffield University and colleagues, provides evidence that an association between IDP’s and the development of IE in at risk individuals. Using diagnostic, treatment and hospital admission coding from almost 8 million case records, it was found that the chances of acquiring IE following extractions or other oral surgical procedures were significantly increased for those at high risk. Where AP was provided (in 32% of cases) there was a significantly reduced risk of acquiring IE. The low rate of compliance with the AHA advice about AP is possibly explained by a lack of understanding of the guidance or a belief that AP is the responsibility of the cardiologist, not the dentist.

The authors suggest that their findings “provide evidence to support the current AHA and ESC recommendations that those at highest risk of IE should receive AP before IDPs”, implying that the current NICE guidance is out of date.

NICE guidance to UK dentists continues to be that AP is not routinely recommended and that

“Healthcare professionals should offer people at increased risk of infective endocarditis clear and consistent information about prevention, including:

  • the benefits and risks of antibiotic prophylaxis, and an explanation of why antibiotic prophylaxis is no longer routinely recommended
  • the importance of maintaining good oral health
  • symptoms that may indicate infective endocarditis and when to seek expert advice
  • the risks of undergoing invasive procedures, including non‑medical procedures such as body piercing or tattooing.”

So - watch out for new guidance soon!

But for TMD, there’s a bridge over the pond!

The regular reader of this blog (there’s probably only one, I’m a born pessimist) may recall that the first in the series, back in January, discussed the management of tempero-mandibular disorders (TMD) and asked to whom patients should be referred. Given its links to other chronic pain conditions, a multi-disciplinary approach to care and management seemed appropriate.

And here’s a move towards that. A recent paper in the British Dental Journal – A commentary on Tempero-mandibular disorders: priorities for research and care – bridging from the US to the UK (Durham,J, Greene,C and Ohrbach,R) reviews work from the US indicating that ‘the current dental-focussed treatments for TMD must be re-conceptualised toward a multi-disciplinary, inter-professional team approach, involving specialists within the broader healthcare community.’ International co-operation to create registers to gather data on patients’ health and treatments should provide sufficiently large datasets to allow the development of clinical guidelines for patient care. Centres of excellence for treatment are proposed for treatment of TMD s and management of oro-facial pain. Already in the UK, a National Orofacial Pain Alliance has been set up, drawing together the expertise of oral surgeons and clinical psychologists.

So, as we move into fall, perhaps we can take a rain check on our dental differences with the USA, and wait to see how NICE has gotten on with some new guidance.

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Health and Financial Costs of Antibiotic Resistance

Health and Financial Costs of Antibiotic Resistance

In May 2015, the World Health Assembly endorsed a global action plan to tackle antimicrobial resistance, including antibiotic resistance, the most urgent drug resistant trend.


The World Health Organisation (WHO) defines antibiotic resistance as “resistance of a microorganism to an antimicrobial drug that was originally effective for treatment of infections caused by it.1” They go on further to say it is a “natural phenomenon” and that the misuse and overuse of the medication accelerates this worldwide problem. The effect of this “ticking time bomb” is felt across the health of the global population and worldwide healthcare budgets.


The meeting in May created five strategic objectives to tackle the issue including increasing awareness and understanding, reducing the incidence of infection and developing the economic case for sustainable investment2. A survey carried out by the WHO a month earlier found that of 133 participating countries, only 34 had a comprehensive national plan to fight resistance to antibiotics. It discussed how management of the situation was paramount but due to inadequate laboratory capacity, infrastructure and data management practice, trends and outbreaks were poorly detected and monitored. Importantly, many countries had no stringent guidelines on the prescription of antibiotics, which could result in overuse and misuse by prescribers.


Excess Expenditure

There is not only the effect this issue has on the health of the global population, but also the impact it has on a country’s economy. Drug-resistant infections could kill an extra 10 million people across the world every year by 2050 if they are not treated successfully. By this date they could also cost the world around $100 trillion in lost output2. Health expenditure in most countries is rising steeply already and resistance to antibiotics is going to contribute significantly in the near future. Excess costs associated with the resistance are due to longer hospitalisation, delayed therapy, higher morbidity rates, the necessity for surgery and the need to use more expensive antibiotics3.


Jim O’Neill, an economist leading a review into antimicrobial resistance for the UK government, estimated that $37 billion is needed over the next 10 years to spur the pharmaceutical industry into developing innovations in this troublesome segment. He went on further to say that this was a “modest sum” compared to the cost of not doing anything. During the 1990’s, pharmaceutical companies withdrew from investing in this kind of research due to a high uncertainty around what the final market potential would be, and still the pipeline does not look particularly robust. Also, antibiotics work so fast and so well that they provide relatively weak returns for high investment. Companies prefer to channel their funds towards the treatment of chronic illnesses, such as diabetes, as drug treatment for this type of disease will be taken for longer periods of time; usually for the rest of the patient’s life.


Prevention Strategies

This naturally occurring threat is not going to be eradicated without preventative measures being implemented globally. In one research paper on the subject, Sipahi suggests that the following strategies should be followed:

-       Optimal use of existing antimicrobial agents

-       Where possible, use alternative therapies

-       Increase immunity

-       Educate healthcare professionals

-       Regulations and policies

-       Stringent infection control protocols3.


There are scientists working to develop new drugs able to combat bacteria that are resistant to antibiotics. One of the more recent discoveries reported in The Guardian earlier this year has been hailed as a “game changer” and is called teixobactin. It can kill a wide range of bacteria, including Methicillin-resistant Staphylococcus aureus (MRSA). Teixobactin works by blocking the capacity of resistant bacteria to build cell walls, therefore making it almost impossible for bacteria to develop resistance4. It is, of course, still early days.


Alternatives to Antibiotics

The alternative is to use drugs and therapies that do not contain antibiotics, yet are as effective in the results that they deliver. PerioChip® is a non-antibiotic solution and can therefore be used in the longer term. It is designed for use in conjunction with traditional treatment to suppress bacterial flora in periodontal pockets of 5mm or more. It contains 2.5 mg of Chlorhexidine Digluconate and is recommended for first line treatment of periodontal pocketing. Results from clinical studies show a pocket reduction of more than 2mm in almost three quarters of patients when placed every three months5.


Antibiotic resistance is a looming problem that all governments and healthcare professionals around the world need to take responsibility for. With alternatives to antibiotics available that can be used in dental treatment plans, dental practitioners need to carefully consider what they prescribe and ensure they are doing what they can.


To order PerioChip® or for further information Freephone 0800 013 2333 or email This email address is being protected from spambots. You need JavaScript enabled to view it.



Summary of product link;


Abbreviated Prescribing Information

PerioChip® 2.5mg Dental Insert (Chlorhexidine digluconate)

For full prescribing information, including side effects, precautions and contraindications, see Summary of Product Characteristics (SmPC).

Presentation: Dental insert: bullet shaped orange brown containing Chlorhexidine digluconate 2.5mg.

Indications: PerioChip® is an adjunctive antimicrobial treatment for moderate to severe chronic periodontal disease in adults with pocketing, combined with Root Surface Debridement (RSD). Not indicated in children and adolescents.

Dosage and Administration: One PerioChip® is inserted into a periodontal pocket with a probing pocket depth of ?5mm. Retreatment with PerioChip® following mechanical plaque removal at 3 month intervals may provide additional benefit if pocket depth remains ?5mm. For details see SmPC. Removal is unnecessary as PerioChip® biodegrades.

Contraindications: Hypersensitivity to Chlorhexidine digluconate or excipients.

Precautions: Allergic reactions have occurred but are rare.

Interactions: Avoid nystatin: antagonistic of Chlorhexidine. Chlorhexidine is incompatible with anionic agents present in some toothpastes and with dietary sucrose, but there is no significant impact on the efficacy of PerioChip®.

Undesirable effects: During the first few days after insertion, transient pain or discomfort of gums or teeth; redness and/or swelling of the gums.

Overdose: Not reported

Pregnancy/ Lactation: Controlled studies in pregnant women have not been conducted, so weigh expected benefits against possible foetal risks: caution in nursing mothers (see SmPC).

NHS list price: £207.20

Legal category: P, Product Licence Number: PL 14017/0035

MA holder: Full prescribing information is available on request from Dexcel Pharma Ltd, 7 Sopwith Way, Drayton Fields Industrial Estate, Daventry, Northants, NN11 8PB.

Adverse events should be reported. Reporting forms and information can be found at

Adverse events should also be reported to:

Dexcel Pharma Ltd on 01748 828784


1. Fact Sheet No194, WHO


3. Sipahi OR. Economics of antibiotic resistance. Expert Rev Anti Infect Ther. 2008 Aug;6(4):523-39. doi: 10.1586/14787210.6.4.523.

4. The Guardian, 7th January 2015

5. Soslkolne W.A et al. Probing depth changes following 2 years of periodontal maintenance therapy including adjunctive controlled-release of chlorhexidine. JOP 2003;74:420-427

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