CARDIOVASCULAR JOURNAL OF AFRICA • Vol 23, No 6, July 2012
304
AFRICA
revises standard treatment guidelines for the public sector in
South Africa. The Adult Expert Review Group for the hospital
level reviewed the literature, including the above guidelines,
and acknowledged that clinicians would be concerned with
both the exclusion of RHD from the list of cardiac conditions
that required prophylaxis and with not giving an antibiotic prior
to dental extraction. The Review Group recommended the use
of antibiotics prior to certain dental procedures and included
acquired valvular heart disease with stenosis or regurgitation
as a cardiac condition that requires prophylaxis. Further debate
culminating in a concensus position on antibiotic prophyaxis in
developing countries is needed.
It should be noted, however, that antibiotic prophylaxis
no longer occupies centre stage in the prevention of IE. The
BSAC has endorsed the NICE guidelines.
24
The emphasis for
IE causation has shifted from procedure-related bacteraemia
to cumulative bacteraemia, i.e. infective endocarditis is more
likely to result from frequent exposure to random bacteraemias
associated with daily activities such as tooth brushing than with
a dental procedure.
3,4,18,20-23
Poor oral hygiene may increase the risk
of bacteraemia associated with these everyday procedures.
22,25
A number of authors have stressed good oral health as a far
more important preventative measure than chemoprophylaxis
against IE.
3,26-30
The BSAC stated that good oral hygiene is
probably the most important factor in reducing the risk of IE in
susceptible individuals, and access to high-quality dental care
should be facilitated.
21
The AHA has stated that the maintenance of optimal oral
health and hygiene may reduce the incidence of bacteraemia
from daily activities, and it is more important than prophylactic
antibiotics for dental procedures to reduce the risk of IE.
23
NICE has also placed emphasis on the importance of this
aspect of prophylaxis.
20
Improving oral hygiene and reducing or
eliminating gingivitis would reduce the incidence of bacteraemia
following tooth brushing and the need to extract teeth due to
periodontal disease and caries.
25
The accompanying study on the oral health status of patients
with severe RHD who were awaiting cardiac surgery revealed
that inadequate attention is being paid to the maintenance of
good oral health in these patients (page 336). It is very likely that
within the healthcare systems of developing countries, the oral
health of patients with less-severe RHD who are not attending
specialist cardiac facilities is also suboptimal. Also knowledge
regarding the need and measures for prevention of IE among
patients is insufficient.
31-35
Care of the oral health of patients at risk of developing IE
needs to be improved. Greater awareness of this problem among
cardiologists, cardiothoracic surgeons, physicians, paediatricians,
medical practitioners and dental surgeons is needed. The results
of the study by Bobhate and Pinto indicate that the majority
of oral lesions could have been prevented if patients had been
informed of the vital importance of preventative dentistry.
36
Therefore, advice on regular oral care and the maintenance of
oral health must be given to all patients at risk of developing IE
and their parents (in the case of children).
36
Furthermore, patients and parents of children need to be given
appropriate advice regarding antibiotic prophylaxis, including
informing their dentist that they have heart disease that may
require antibiotics, before dental procedures, particularly dental
extraction, can be done. Patients and parents of childrenwith RHD
also need advice on secondary prophylaxis of rheumatic fever.
At the time of diagnosis of a heart lesion that could predispose
to IE, a full oral examination, including dental radiography,
should be performed. Further examinations at frequent and
regular intervals will ensure early diagnosis and treatment of oral
lesions, and maintenance of good oral hygiene. It is advisable
to issue patients with a warning card on which their cardiac
condition, drug therapy, suggested prophylactic measures to
be taken before dental manipulations, and name, address and
telephone number of the attending doctor is recorded. A medical
history should be obtained from every patient before institution
of any dental treatment.
Co-operation between doctors and dental surgeons and their
support staff, e.g. oral hygienists, would ensure that the oral
health needs of every susceptible patient, including patient
education, can be catered for more adequately. Supplies such
as toothbrushes and toothpaste should be made available to
these patients. Social support, including social grants, could
assist patients in financial difficulty. The key to protection of
susceptible patients is improved oral health education, effective
preventative care, oral hygiene instruction and sensible treatment
planning. An oral hygienist should form part of the team that
cares for patients with RHD.
A number of surveys have revealed that doctors and dentists
are familiar with the concept of prophylaxis against IE, are
aware of the published recommendations and believe them to
be authoritative, yet prophylaxis is not used for many patients
for whom it is indicated, and specific recommendations and
regimens are not followed.
37-40
The medical and dental curricula
need to place appropriate emphasis on all aspects of prophylaxis,
including patient education, maintenance of good oral health and
antibiotic prophylaxis.
The prevention of IE has been neglected in the past and
does not solely concern antibiotic prophylaxis.
21
There should
be a shift in emphasis away from antibiotic prophylaxis prior
to dental procedure, towards a greater emphasis on improved
access to dental care and oral heath in patients with predisposing
cardiac conditions.
22
The first step in the prevention of IE in
developing countries would be to reduce the pool of patients
who are susceptible to this infection through implementation of
programmes to prevent rheumatic fever.
The second step would be the early identification of at-risk
patients, and prompt referral to oral health specialists, e.g. oral
hygienists, for comprehensive evaluation and treatment. The
third step would be to educate these patients and the parents of
children on the need for maintaining optimal oral health and
about antibiotic prophylaxis for IE. The fourth step would be to
integrate IE prophylaxis into rheumatic fever/rheumatic heart
disease prevention programmes and provide more holistic care
of patients with rheumatic heart disease.
Accordingly, a comprehensive prevention programme, which
incorporates the secondary prevention of rheumatic fever and
the prevention of IE, is urgently needed in developing countries.
Optimal oral healthcare, in conjunction with the judicious use
of antibiotic prophylaxis for prevention of IE, should serve to
reduce the significant morbidity and mortality associated with
this infection. It is hoped that the care of patients at risk of
developing infective endocarditis will thus be improved.
