Views on Antibiotic prophylaxis before surgery or a dental procedure

Hi there

I just wondered your views and experiences on using antibiotics before surgery or dental procedure as a precaution to prevent bacterial infections with PMs to reduce risk of infective endocarditis? 

With my PM op they used antibiotics, with my loop recorder insertion they didn't. I've been told by a dentist that it's not normally recommended for teeth extractions, root canal, filing teeth to create space (part of orthodontic treatment) etc, but the hospital (cardio physiologist) today said they would recommend using antibiotics for those procedures. 

My medtronic leadless (Micra) PM handbook says to consider using Antibiotic prophylaxis before dental procedures for prevention of endocarditis due to the lack of human expereince with the PM. 

Also does dental cleaning/scaling come into this? Seems minor procedure but with similar risks?

Interesting topic with lots of conflicting guidelines it seems 

Would love to hear others experiences





by AgentX86 - 2020-07-07 14:24:15

Ask your cardiologist or EP (every time). That's what they're there for. 

That said, I've been told not to take antibiotics before all dental procedures, even extraction. Same for anticoagulants. The dentists and oral surgeons will ask the question,  however.


by Tracey_E - 2020-07-07 14:48:46

Surgery, it depends on the doctor and the procedure.

Dental, ADA and AHA stopped recommending antibiotics before dental procedures more than 10 years ago for pacemakers. It's still recommended for some heart conditions such as replacement valves. The micra is new so maybe the rules are different. The way I read that, they don't know so they are saying you might want to do it just in case, sounds very cya to me. It's unlikely you are going to find many dentists with more than minimal experience with micras so you'll want to go by what the manufacturer recommends.

Just for the fun of it, I'm gonna text my dentist (he is a friend)

Cleaning is a dental procedure. Any time they are working in the mouth there is a risk of bleeding and mouth bacteria getting in the blood stream. 



by Gemita - 2020-07-07 16:30:04

Hello Claire,

I believe it has to be assessed on a case by case basis.  After having four root canals treated I developed arrhythmias and several leaky heart valves.  My cardiologist advised 3g Amoxycillin 1 hr before any future dental work to protect against infective endocarditis.

I believe too it so depends on a patient's other health conditions, a weakened immune system for instance, where they might benefit from antibiotic protection.  But where do you start and stop?  Even brushing our teeth can release harmful bacteria into the blood stream and should we all consume a daily antibiotic - of course not.

My dentist by the way said a protective antibiotic was not really necessary for me before most dental procedures, so who do I believe.  Good dental hygiene and a healthy lifestyle is probably the best solution

Antibiotics for dental work

by LondonAndy - 2020-07-08 03:18:43

Here in the UK my dentist is not in favour of antibiotics for when I have minor dental work such as cleaning, even though I have both a pacemaker and a replacement mechanical aortic valve, on the basis that this is unnecessary and adds to our growing problem as a society of bateria becoming resistant to the drugs.  I go for cleaning every three months (pandemics permitting), and have done for the last 5 years without issue.

It depends on your personal circumstances

by crustyg - 2020-07-08 05:59:40

The UK NICE guidelines from March 2008 said not to use antimicrobial prophylaxis routinely even for patients at risk of developing infective endocarditis, but had to be updated in the light of research showing that the incidence of infective endocarditis had increased following this guideline advice.  Association in time doesn't equal a causal relationship, but it's a worry.  All good cardiac services now routinely check nasal and groin swabs for Staph aureus (methicillin sensitive or resistant) and won't allow Staph carriers into their suites except as emergencies, and routinely give flucloxacillin cover for invasive procedures to patients who had previously been shown to be Staph carriers - 20% are persistent carriers, and a further 60% are intermittent carriers!

I wouldn't use any dentist who was prepared to sacrifice *my* life on the altar of their personal beliefs about society-wide usage/abuse of antimicrobials.  Nice folk but they aren't doctors, whatever they might choose to call themselves.  I accept that there is a growing problem of multi-drug resistant bacteria, but this is as much to do with plasmid transference in Gram-negative bacteria and historical use of antimicrobials as growth promoters in animal husbandry as it is a reflection of generalised overusage of antimicrobials in humans.

UK NICE really don't know.  Their guidelines, based on a society-based approach is linked, in time, to an increase of serious problems for which there is evidence - not a lot of really good quality evidence, but more evidence than they used for their 2008 recommendation.  But they can't bring themselves to accept that they got it wrong and plead for a controlled trial in the latest update (2016) - if such a trial could ever get through an Ethics review.

Cover for tooth cleaning/scaling - IMHO, not needed.  Cover for extraction, root canal treatment - IMHO a definite YES.  The more risk factors you have (rheumatic fever damage, metal heart valve, previous Micra embedded in heart muscle, HOCM, etc., the more emphatic *I* would be about wanting cover for invasive dentistry.

Thank you crustyg

by Gemita - 2020-07-08 08:58:46

I shall make sure hubby is covered for implant surgery in two weeks time!  He has enough going on without risking a further infection.  He will have two implants (or preparation for implants) and has been asked to allow up to 2 hrs in the dentist's chair.

Agree 100% Crustyg

by _Claire_ - 2020-07-09 11:51:23

Thank you all. Crustyg I completely agree after doing a bit of research on this issue. I am very firmly not willing to be a good samaritan contributing to the reduction of antibiotic overuse in society by risking my life and my little boys future unnecessarily. I rang the hospital (physiologist techs) expecting them to say it's not necessary (after I read the NICE guidelines) and surprisingly (after the tech checked with a colleague) they said absolutely YES I should receive antibiotics with a micra pacemaker (they didn't give a list but said "things like extractions, root canals" etc). I guess from a cost perspective, if one survives endocarditis, it must cost them a fortune to replace the whole pacemaker device and put the patient at such risk, which could be avoided with a cheap preventative antibiotic treatment. In my case I don’t know what the risks of extracting a Micra are, especially down the line if it’s embedded in the heart muscle and was infected :/


Gemita - Dental hygiene

by _Claire_ - 2020-07-09 12:01:51

Yes agree completely Gemita that impeccable dental hygiene is crucial :) It is very hard to assess the risk when like you said even brushing can cause bleeding and therefore the risks we're concerned about here :/

How were your arrhythmias and leaky heart valves related to the dental work? How did you know? I'm only asking because I developed a pounding pulse in my neck (now awaiting an echo to check my valves) and I looked back through my diary and had visited the dentist several days prior to becoming very unwell with high fever, chills, sore throat, muscle pain. That's when my pounding neck symptom started. I had antibiotics. The neck problem seemed to improve but came back and I still have it. I never made the link at the time to dental procedures. It's something I've only just recently become aware of. I wish they'd told me this more clearly so at the very least when I became ill I could have make that link to tell the GP. 



Dental Hygiene

by Gemita - 2020-07-09 15:22:20

Hello Claire,

Hope you are doing well with that little device of yours and paving the way for us all to follow you one day.

Yes I had a bad experience at the dentist about six years ago when this all started.  I have always been so boringly thorough in cleaning my teeth (flossing, interdental brushes, electric toothbrush) and yet one day on visiting the dentist I had tooth upon tooth of tooth decay and my dentist couldn’t understand why it was suddenly happening or what was causing it.  I developed four abscesses upper left and I was in such pain.  My dentist carried out root canal treatment in all but one of the teeth, which had a very difficult root anatomy (lots of intricate curves) which he just couldn’t get around to thoroughly clean and eliminate all signs of infection.  I had to go to a private practice in Harley Street to have root canal treatment but it was long and complex and expensive.  They warned me that it might not work and I might still need to have the tooth out.   The tooth was saved but at great cost and in hindsight I wish I had had the tooth extracted.

Shortly after treatment was completed I developed a fever, with an extremely high temperature.  I had periods of breathlessness for the first time in my life and couldn’t swallow properly.  My neck felt swollen and painful.  My blood pressure became unstable and so did my heart rate and I developed arrhythmias.  My GP listened to my chest and heard a significant heart murmur, he questioned heart failure symptoms which frightened the life out of me.  I had an echocardiogram and saw a cardiologist and three leaky valves were diagnosed.  Both GP and cardiologist felt the oral abscesses had caused systemic infection.

I have to say Claire heart wise I have never really recovered from my struggles with those abscesses. My dentist and GP now believe the sudden decay was caused by a “dry mouth” from Sjogren’s Syndrome, an autoimmune condition.

I’ve had endocarditis - get antibiotic cover

by Blairhm - 2020-07-14 07:27:47

In 2009 I got very very sick over a period of a few months. Initially I had a series of fevers and thought I had the flu, but it was very strange, exhausting and drawn out, with no respiratory symptoms.
 I was seeing my doctor as often as I felt able to justify, and he seemed kind of sceptical, getting blood tests, samples of all kinds. I am pretty sure he had me tested for things I would never have dreamed of, including syphillis and AIDS.
I was losing weight and barely able to think, with constant headaches. I got to the point that my bedtime routine was - I would put a towel on the bed, lie down and when it was soaked with sweat, replace it and repeat. I was having mini blackout episodes, tunnel vision and periods of a weird sense of mental dislocation. It was frightening.
Finally small subcutaneous bleeds appeared in my feet and fingers, and my doctor sent me to hospital feeling very pleased with himself for having diagnosed subacute bacterial endocarditis. This was simply and quickly confirmed by a blood culture - one test my doctor had never had done.
I was then in hospital for 2 weeks on intravenous antibiotics, being warned that at any moment heart surgery might be needed.
Instead I was sent home and I continued administering IV antibiotics through a PIC for 6 more weeks. 
It took at least 18 months before I could exert myself to anywhere near the levels I had before endocarditis. It probably true to say I have never quite felt the same since that illness.
It's not clear how I got it. My bicuspid aortic valve was suspected as the site of infection, but never confirmed. Possibly from flossing, or a wisdom tooth that used to periodically break the gum then heal over again.
So now 11 years later I have a mechanical aortic valve and a pacemaker.
I would get antibiotic cover for dental work, no hesitation. Endocarditis is seriously bad news.

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