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Re: MVP/dental

Posted by mattdds on May 18, 2003, at 22:56:04

In reply to Re: MVP/dental » mattdds, posted by Snoozy on May 18, 2003, at 21:47:19

Snoozy,

Great question. I see this at least once a week in the clinic at my school. There is indeed, a slight increase in incident of a severe, fulminating, and sometimes fatal infection called subacute bacterial endocarditis (SBE) after invasive dental procedures in people with *regurgitant* MVP. This infection is caused by colonization of Streptococcus organisms on the mitral valve. When it occurs, it is life-threatening! So these people need antibiotic prophylaxis. AB prophylaxis is typically 2 grams of amoxicillin in people who aren't allergic to it, or 600 mg of Cleocin (clindamycin) in people who have a penicillin allergy. Either one is taken 1 hour before an invasive procedure.

However, it is important to consult with a cardiologist, because some people with certain types of MVP don't need antibiotic prophylaxis. There are different types of MVP, as you may know. Some people with more severe MVP have actual regurgitation of blood back into the atrium of the heart. In others with mild MVP, it is merely the prolapsing of the valve backward (bending back) into the atrium, with no regurgitation of the blood.

As of now, the American Heart Association recommends that only people with MVP *WITH* regurgitation have antibiotic prophylaxis.

It is funny you bring this topic up, because I have a patient who has MVP *without* regurgitation (I personally talked to his cardiologist to make sure), and he still insists on AB prophylaxis. This is unnecessary and poses risks of its own (e.g. acute doses of AB's encourage resistant strains of bacteria, or anaphalaxis because of Type I hypersensitivity). He gets mad when I don't write the prescription, and somehow gets his own (he told me)!

Also, not all procedures need AB prophylaxis, even in people with regurgitant MVP. Only procedures that are expected to cause significant bacteremia (bacteria in the blood) require AB's. These would be things like a deep periodontal scaling and root planing, extractions. Simple fillings do not require AB's.

Keep in mind that SBE is extremely rare, even in people with regurgitant MVP. Some have even argued that AB prophylaxis *increases* mortality because of the increase in penicillin allergy and death due to anaphalaxis! Other things also cause bacteremia, e.g. brushing your teeth, chewing, etc. I get the feeling in a lot of cases it is more of a medicolegal issue than anything, and that AB's are over/mis-used in dentistry. So this is kind of a cloudy issue, but we are pretty sure that people with regurgitant MVP do benefit from AB prophylaxis before invasive dental procedures.

Hope this helps!

Matt


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