Antibiotic prophylaxis with amoxicillin to prevent infective endocarditis in periodontitis patients reconsidered: a narrative review

OBJECTIVES: To discuss first, the adequacy of the antibiotic prophylaxis regimen currently recommended for the prevention of infective endocarditis in periodontitis patients,and second, preventive measures to decrease the rate of bacteraemia after periodontal treatment. MATERIALS AND METHODS: A bibliographic literature search identifying clinical trials between January 1990 and January 2021, focusing on microorganisms in bacteraemia after periodontal treatment and bacteria in infective endocarditis, was performed. Two reviewers independently identified and screened the literature by systematically searching in Medline/Premedline, EMBASE and Cochrane Library. RESULTS: Two hundred and seventy articles were identified,of which twenty-three met the inclusion criteria. Bacteraemia rates after periodontal treatment ranged from10-94% in the investigated patients. Mainly oral pathogens related to infective endocarditis, such as viridans group streptococci (up to 70%) and HACEK group pathogens (e.g., Aggregatibacter actinomycetemcomitans), were detected. But typical oral and periodontopathogenic species, such as Porphyromonas spp. (P.s gingivalis) (up to 50%), Actinomyces spp. (up to 30%) and Fusobacterium spp. (up to 30%), which do not usually cause infective endocarditis, were also found. Infective endocarditis episodes that might have been in association with a dental treatment were mainly caused by viridans group streptococci. Prophylactic measures like rinse application of chlorhexidine, povidone-iodine or essential oils,diode laser or systemic antibiotic prescription were described as decreasing the bacteraemia rate after periodontal interventions to 5-70%. CONCLUSION: The currently recommended systemic antibiotic prophylaxis with amoxicillin before periodontal treatment in high-risk cardiovascular patients still covers the most common oral bacteria causing infective endocarditis, namely viridans group streptococci, and therefore seems adequate in this context. Since bacteraemia, not infective endocarditis, is the endpoint in most studies, the causality between bacteraemia after periodontal treatments and infective endocarditis remains difficult to elucidate. Until more evidence is available regarding this, adherence to current guidelines for antibiotic prophylaxis inpatients at high risk for infective endocarditis undergoing periodontal treatment remains recommended.