Patients die needlessly every year because vulnerable Britons with heart problems are not given antibiotics when they go to the dentist, doctors say.
Nearly 400,000 people in Britain are at high risk of developing life-threatening infective endocarditis every time they receive dental treatment, doctors say. The condition kills 30% of patients within a year.
A refusal to approve antibiotic prophylaxis (AP) in such cases means that up to 261 people a year will develop the disease and up to 78 people will die from it, they add. That policy may have caused up to 2,010 deaths over the past 16 years, it is claimed.
That danger has arisen because the National Institute for Health and Care Excellence (Nice) does not follow international good medical practice and does not tell dentists to give at-risk patients antibiotics before extracting a tooth, performing a root canal or even setting tartar deleted. experts claim.
The doctors – including a professor of dentistry, two leading cardiologists and a professor of infectious diseases – did so expressed their concerns in the medical journal The Lancet. In it, they urge Nice to reconsider its approach to saving lives, citing crucial evidence that has emerged since the regulator last examined the issue in 2015 showing that antibiotics are “safe, cost-effective and be effective”.
Infective endocarditis (IE) is an infection of the inner lining of the heart and the valves that separate each of the four chambers of the heart. In about 30%-40% of cases, it is caused by bacteria in the mouth entering the bloodstream as a result of poor oral hygiene or invasive dental treatments. The bacteria can then inflame damaged heart valves and also artificial heart valves.
An estimated 397,000 Britons are at risk of developing the condition as a direct result of undergoing dental treatment, because they have had a congenital heart condition or have previously been treated for a heart condition, for example by implanting a pacemaker or ventricular assist device.
Patients are being put at risk because Nice’s position conflicts with the European Society of Cardiology and the American Heart Association, both of which say high-risk patients should be given antibiotics before dental treatment, the doctors claim.
The medicines regulator used to support that approach. But in 2008 she changed her position and said this had to stop because there was insufficient evidence and she was concerned about possible side effects, such as the risk of fatal consequences. anaphylaxisoutweighed the potential benefits.
In the joint op-ed in the Lancet Regional Health – Europe, the doctors say the switch has led to “a significant increase in IE incidence”. As a result, an additional 35 people receive IP every month, according to evidence published by the Lancet in 2015.
Data showing the number of dental procedures requiring antibiotics to be given to prevent one case of IE “suggests that 41-261 cases (including 12-78 deaths) could be prevented in Britain each year”.
Switching to dentists routinely administering antibiotics to high-risk patients when treating them would be cost-effective for the NHS, even if it prevented just 1.4 cases of IE per year, they argue.
The doctors say: “Therefore, reintroducing AP for high-risk individuals undergoing invasive dental procedures would not only prevent serious illness and save lives, it would also result in significant savings for the UK National Health Service.”
Nice’s 2008 move to oppose antibiotics may have led to as many as 6,700 additional cases of IE and 2,010 deaths from it over the 16 subsequent years, according to Martin Thornhill, co-author of the paper and professor of translational research at the dentistry at New York University. University of Sheffield.
His co-authors include Prof. Bernard Prendergast, a consultant cardiologist at Guy’s and St Thomas’ NHS Trust in London, Ireland-based consultant cardiologist Mark Dayer, and Larry Baddour, a professor of infectious diseases at Mayo Clinic Hospital in the U.S.
Unusually, the article was also co-authored by a long-suffering advocate, Ash Frisby. Her husband, Myles, was at high risk for IE because he had a prosthetic heart valve fitted when he underwent dental scaling in October 2014 – without receiving antibiotics. He developed IE shortly afterwards and died two months later in December 2014. His symptoms were initially mistaken for influenza.
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Thornhill said: “By the time the diagnosis was made, the damage to the heart valves was so severe that he died shortly after admission to hospital and the diagnosis of IE.
“In most other countries, where antibiotic prophylaxis is recommended for at-risk patients undergoing invasive dental procedures, Myles would likely have received AP coverage for the dental scaling and this would likely have prevented him from developing IE.”
Baddour said: “We are concerned that there are high-risk individuals in the UK who are at risk of infective endocarditis related to invasive dental procedures without antibiotic prophylaxis.
“We believe that a re-evaluation of (Nice’s) position is necessary in high-risk individuals undergoing invasive dental procedures who require antibiotic prophylaxis.”
Prendergast said that although Nice had softened its guidelines somewhat in 2015, it had “failed to respond to the accumulating evidence supporting the use of antibiotic prophylaxis in patients at high risk of IE undergoing specific high-risk procedures, including invasive dental procedures”.
Nice’s position has “caused significant confusion” among both doctors and dentists treating at-risk patients about whether to administer antibiotics, he added.
The drug watchdog has dismissed the doctors’ concerns.
“Nice rejects the claim that patients are suffering harm as a result of our guidance,” a spokesperson said.
“The guideline says that antibiotic prophylaxis against infective endocarditis is not routinely recommended for people undergoing dental procedures. However, healthcare professionals should use their clinical judgment in implementing recommendations, taking into account the individual’s circumstances, needs and preferences.
“Our surveillance team will this year review the current evidence regarding prophylaxis against infective endocarditis and determine whether new information, studies or research would support the case for a further update of the existing Nice guidelines.”