The endocarditis guidance change that could expose you to negligence claims

Martin Thornhill explores the implications of recent changes to NICE guidelines around infective endocarditis prevention in dentistry – how should the workflow of dentists and the wider team change and what are the legal implications of not following guidance correctly?

UK guidance on antibiotic prophylaxis for dental procedures recently underwent its most significant change in nearly two decades, with high-risk patients now recommended for cover before extractions and oral surgery.

Martin Thornhill, emeritus professor of oral medicine at the University of Sheffield, explained why the guidance has changed and what these changes mean for the dental profession.

Why did the UK previously advise against the use of antibiotic prophylaxis for dental procedures?

The UK has been in a rather isolated position over the last 18 years. In 2008 the National Institutes for Health and Care Excellence (NICE) changed the guidance that was existent in the UK at the time to recommend against all use of antibiotic prophylaxis.

They did so for a couple of reasons. Firstly, there was no randomised controlled trial data to show that antibiotic prophylaxis was effective. Secondly, they were concerned about the possibility of adverse drug reactions with the antibiotics that were being used.

Any prescription carries a certain risk of an adverse reaction. However, the risk of a reaction to the most commonly prescribed antibiotic for antibiotic prophylaxis – which is a single, 2g or 3g dose of amoxicillin – is extremely low. The risk is certainly much lower than that posed by developing endocarditis in those people who are highly susceptible.

It’s important to stress that the vast majority of the population are not at any significant risk of developing endocarditis and don’t need antibiotic prophylaxis. People with certain cardiac conditions are the ones that antibiotic prophylaxis should be targeted at.

Every other guideline committee in the world has continued to recommend that antibiotic prophylaxis should be given before invasive dental procedures – particularly for patients at high risk of developing endocarditis.

Gradually, more and more researchers come along to provide evidence to support that. And so, the position of recommending against antibiotic prophylaxis has become more and more tenuous.

What prompted NICE to change its endocarditis prevention guidance?

There’s quite a lot of data which has developed over the last 20 years or so that demonstrates that at-risk patients are more likely to develop endocarditis if they have invasive dental procedures. Endocarditis is a serious infection of the heart valves which has a 30% mortality rate within the first year of diagnosis. Those who survive have long-term health problems and are put at even higher risk of developing endocarditis subsequently as a result.

In 2024, NICE had a look and decided not to completely review their guidance. However, they did change the wording of their guidance. Where they previously said that antibiotic prophylaxis was not recommended routinely for patients undergoing dental procedures, they added an extra instruction that dentists should look at the advice being published by the Scottish Dental Clinical Effectiveness Programme (SDCEP) for information about antibiotic prophylaxis when treating patients at high risk of endocarditis.

That was a big change, because SDCEP was effectively telling dentists to follow the guidelines that everyone else in Europe follows, which essentially say that these patients should be considered for antibiotic prophylaxis.

More recently, SDCEP has updated its advice, which has brought it into even closer alignment with what all the other major guideline committees say.

We went from a position where no antibiotic prophylaxis was recommended to it once again being recommended for all high risk patients undergoing extractions or oral surgery procedures. It should also be considered for patients undergoing any other at-risk dental procedure, which means any procedure involving manipulation of the gingival or periapal region of the teeth.

Which patients are considered high risk?

High risk patients include people who’ve had a previous episode of endocarditis, those who have any prosthetic heart valves or valve repairs, and patients with congenital heart disease problems that can cause cyanosis.

While the first two are quite easy to identify, congenital heart disorders may be slightly more difficult. That’s where it’s important that these patients are flagged up by their cardiologist.

It’s also important to be aware of patients who are at moderate risk of endocarditis, because although antibiotic prophylaxis isn’t recommended for them, they still need to be aware of the risk posed by having a dental procedure and what they can do to reduce that risk. This is generally improving oral hygiene, looking out for symptoms of endocarditis so that early action can be taken.

The other thing that has to be taken into consideration is the actual procedure. If it’s a simple oral examination, which doesn’t involve anything invasive at all, antibiotic prophylaxis may not be necessary. Any procedures that are likely to be invasive or involve manipulation of the gingival or the periapal region of the teeth should be considered at-risk.

How should antibiotic prophylaxis for dental procedures change your workflow?

Many older dentists are actually quite familiar with the updated guidance because it was common practice before 2008. In fact, the evidence shows that dentists were extremely good at identifying people at increased risk of endocarditis and providing antibiotic prophylaxis protection.

The problem we have now is that there is a generation of dentists who trained while antibiotic prophylaxis was not recommended, so they have no familiarity with it.

In terms of managing patients, most dental practices are very good at taking a medical history before they see patients to identify risk factors that they need to be aware of. Now, it becomes even more important that relevant cardiac history is taken to identify individuals who are at high risk of developing endocarditis.

A discussion should be had with the patient to explain the risk of the procedure, the risks and benefits of antibiotic prophylaxis, and then to come to a decision with the patient about whether to go ahead with it. A lot of these patients will be aware that they’re at-risk and will already be concerned. The important thing is to be balanced in the approach.

You should also plan when the procedure should occur carefully. If the patient wants antibiotic prophylaxis, you can issue a prescription or provide them with the antibiotics and ensure they’re taken properly. Usually the recommendation is that the antibiotics are taken 30 to 60 minutes before the procedure, and ideally that’s done in the reception or in the surgery if you have time.

What is the role of the wider dental team in endocarditis prevention?

This is undoubtedly a team-wide issue.

Dental hygienists and dental therapists will be carrying out invasive procedures on a regular basis, sometimes on patients who fall into this high or moderate risk category. By numbers, scaling procedures outnumber all other invasive dental procedures by a big margin. It’s critically important that dental care professionals are aware of the guidelines.

Dental nurses are in the position where they’re often flagging up the medical history of patients to dentists and other clinicians. They might also be more aware of a patient’s anxieties about this kind of issue, and therefore be in a better position to remind dentists that patients are at risk.

Receptionists also deal with the practice management side of it. Flags around endocarditis risk often come up when they’re booking patients in. They may need to be aware of this at the point of booking to allow time for further discussion or to administer the antibiotics before they go into the surgery.

Are there any legal implications to neglecting antibiotic prophylaxis guidance?

This has been a fraught area, to be quite honest, because of the guidance that NICE gave against the use of antibiotic prophylaxis. But that has clearly now changed to tell dentists that they should be giving out antibiotic prophylaxis for dental procedures where it’s appropriate.

If you were not to do that, it’s not an issue if you’ve discussed it with the patient and you’ve jointly come to a decision as to whether the patient wants antibiotic prophylaxis. Crucially, this should be recorded in the patient’s clinical notes.

Obviously, there is a risk if you don’t have or record the conversation, don’t give antibiotic prophylaxis, and the patient then goes on to develop endocarditis – particularly with a 30% mortality rate associated with it. Dentists could find themselves open to negligence claims, and such a claim has happened in the last two years.

Does anything else need to change to protect patients who are at risk of endocarditis?

The guidance is certainly in a much better place to protect patients now. The issue we’ve got is, first of all, educating the dental profession. Awareness is the most important factor in avoiding medico-legal situations or damage to patients.

It’s also important to be aware that there is a slight ambiguity. We still have NICE saying antibiotic prophylaxis is not routinely recommended but for high risk patients, look at this other advice. This is not a very clean situation. It would be so much easier if NICE had clearly recommended antibiotic prophylaxis itself, or perhaps better still, advised people to follow the European guidelines.

In the UK, most cardiologists and other hospital specialists use the European guidelines and will not be particularly familiar with the SDCEP advice, which is obviously written originally for Scottish dentists. Dentists in England, Wales and even Northern Ireland have often believed that this was advice for dentists in Scotland. NICE is making it clear now that the advice applies to all dentists across the UK.

This is a major step forward. We do have a lot more clarity than we once did, but it’s not perfect clarity.

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