Dentists need to look after your heart, too
OVER the past decade, a silent and deadly bug has been infecting rising numbers of people in the UK. Since 2009, annual cases of infective endocarditis — an infection of the heart which kills more than a third of those affected within a year — have risen by 86 per cent.
And experts fear official guidance is depriving those most in danger — the million or so Britons with defective or artificial heart valves — of the drugs that could protect them and even save their lives.
Infective endocarditis occurs when bacteria from bleeding gums, skin infections or even catheters inserted as part of a procedure, get into the bloodstream and travel to the heart. The bacteria, the most common of which is Staphylococcus aureus, found on the skin, then slowly attack the heart.
Early symptoms are flu-like but, left untreated, the damage to the heart can cause heart failure and stroke. But what could be causing this year-on-year increase?
Scientists say Britain’s ageing population is probably a factor: older hearts are less able to withstand destructive bacteria. Doctors may also be getting better at recognising the condition.
But there is also a theory that it is a consequence of rules introduced in 2008 by the National Institute for Health and Care Excellence (NICE), the NHS spending watchdog, that barred the routine preventative use of antibiotics for patients most at risk of infective endocarditis when they had a dental appointment.
In roughly a third of infections, the bacteria are thought to get into the bloodstream from the mouth, perhaps as a result of poor dental hygiene or due to accidental bleeds during routine dental procedures.
On reaching the heart, the bacteria destroy the valves. They can also trigger strokes, as fragments of diseased tissue break free and clog up blood vessels to the brain.
While the risks of infection during dental work were very low, dentists used to give the drugs routinely to certain patients. A single dose of antibiotics for those at high risk (a group that includes at least a million people born with defective heart valves and 100,000 with artificial valves) would be enough to prevent any problem. However, NICE ruled there was insufficient clinical evidence to support antibiotic use when science was — and still is —grappling with the problem of drug resistance. But research published in The Lancet in April suggests some patients may have paid a high price for that decision.
Experts at Sheffield university studied data on infection rates and found that between 1998 and 2009 — before the NICE ruling — about 27 in every million people got infective endocarditis. By 2019, this had risen to 50 people per million, almost all in high-risk groups.
Yet in the u.S. and other parts of Europe, where antibiotics are still given out by dentists, cases have remained comparatively stable.
research leader Dr Martin Thornhill says: ‘We cannot be sure what part the NICE recommendation played in the large increase here but it is very worrying.’
NICE reviewed its decision in 2015 and opted to stick with the ban but two years later it backtracked, saying antibiotics should not ‘routinely’ be prescribed but could be used at the discretion of the dentist. However, Dr Thornhill fears this amendment has gone largely unnoticed.
A 2017 review by the Scottish Dental Clinical Effectiveness Programme endorsed the NICE guidance but added that ‘a very small number of patients’ may be considered for antibiotics, such as those who have previously had infective endocarditis and also have artificial valves.
Dr Mark Dayer, a consultant cardiologist at Taunton and Somerset NHS Trust, says: ‘NICE changed its guidance in 2008… now there are lots of newly graduated dentists who know nothing about it.
‘I get a lot of letters from them asking if they should be giving antibiotics. I usually say yes, if it’s for a high-risk patient. ’
NICE said: ‘The increase in infective endocarditis could be due to a number of factors ... what seems clear is there is no link between the i ncrease and the 2008 NICE guidance.’