Maintaining good oral health is an important part of living well with aortic disease. Regular visits to the dentist and dental hygienist help prevent gum disease. For most people, dental treatment is routine and uncomplicated. However, some patients who have undergone complex aortic surgery may require additional precautions before certain dental procedures.
One of the most important considerations is the risk of infective endocarditis (IE). Although uncommon, this serious infection can develop when bacteria enter the bloodstream and attach to damaged heart tissue, prosthetic heart valves or implanted vascular material. For patients who have undergone aortic surgery, understanding this risk is an important part of long-term care.
James’ story highlights why greater awareness is needed. His family have chosen to share their experience in the hope that other patients will ask questions about their individual risk before dental treatment. They hope to encourage these conversations, helping to ensure that every patient receives care tailored to their individual medical history, surgical history and level of risk.
Understanding Infective Endocarditis and Antibiotic Prophylaxis
Our mouths naturally contain millions of bacteria. Most are harmless and form part of the normal balance within the mouth. During some dental procedures, particularly those involving the gums or tissues around the teeth, small amounts of bacteria can enter the bloodstream. This is known as bacteraemia.
In healthy people, these bacteria are usually removed quickly by the immune system. Occasionally, they can attach to damaged heart tissue or artificial material inside the heart and blood vessels. When this happens, they may cause infective endocarditis.
Infective endocarditis is an infection of the inner lining of the heart or heart valves. It is a rare condition, but it can become life-threatening if it is not recognised and treated quickly. The infection may damage heart valves, spread to surrounding tissue and lead to complications such as heart failure, stroke or sepsis.
One way of reducing this risk in selected patients is antibiotic prophylaxis.
Prophylaxis simply means taking medicine to prevent an illness before it occurs. Antibiotic prophylaxis involves taking antibiotics before certain dental procedures to reduce the chance of bacteria causing infective endocarditis.
It is important to understand that not every patient living with aortic disease requires antibiotic prophylaxis.
Current American and European guidelines on aortic dissection do not recommend routine antibiotics for everyone who has experienced a dissection. Instead, recommendations are based on a patient’s individual medical history and the type of surgery they have undergone.
Patients who may require additional consideration include those with:
- A prosthetic heart valve, including a mechanical valve
- A previous episode of infective endocarditis
- Valve repair using prosthetic material
- A vascular graft or endovascular stent graft following aortic surgery
European vascular surgery guidance advises that antibiotic prophylaxis should be considered for patients with vascular grafts undergoing dental procedures involving manipulation of the gums or oral tissues. International heart valve guidelines also recommend prophylaxis for patients with prosthetic heart valves and other high-risk cardiac conditions.
Guidance does differ between countries. For example, NICE does not recommend routine antibiotic prophylaxis for all patients in England and Wales, while Scottish guidance recommends antibiotics for patients with prosthetic heart valves. Despite these differences, one principle remains consistent across all guidance. Decisions should be made through shared decision-making between the patient and their specialist team.
Patients should ask their cardiologist or cardiac surgeon whether antibiotic prophylaxis applies to them. They should request this advice in writing and share it with their dentist or hygienist before treatment. It is also important to tell dental professionals about any allergy to antibiotics, particularly penicillin.
Whether antibiotics are appropriate depends on multiple factors. This is why patients should have an open conversation with their cardiologist or cardiac surgeon well before dental treatment.
Ask your specialist:
- Do I need antibiotic prophylaxis before dental treatment?
- Which dental procedures require it?
- Can I have this advice in writing?
- Should my dentist contact my specialist team if they are unsure?
Having written advice makes it easier for dentists and hygienists to follow the agreed treatment plan.
James’ Story: A Tragic Loss and the Need for Awareness
James Williams was 50 years old. He lived in Hove with his partner and worked as a recruiter for a care agency. He loved running, fitness, travelling and live music. He enjoyed spending time with family and friends and was known for his sense of humour and his positive outlook on life. He was also a devoted father to his daughter.
In January 2023, James was sitting at work when, without warning, he suffered a type A aortic dissection. He had no previous symptoms. He was taken to hospital and underwent emergency open-heart surgery. Surgeons repaired his aortic valve and saved his life.
James recovered remarkably well. Within months he had returned to exercise and was beginning to enjoy everyday life again.
Later that year, a routine scan revealed that his repaired valve had failed. James faced another major operation. This time he travelled to St Bart’s Hospital in London for complex aortic surgery. His ascending aorta was replaced using a Frozen Elephant Trunk (FET) procedure, and he received a mechanical heart valve.
The surgery was successful, although James experienced a spinal stroke during the operation. Once again, he approached rehabilitation with determination. Over the following months he worked hard to regain his mobility. He returned to fitness classes, started playing golf again and bought a home with his partner. In January 2026, a routine scan showed that everything was progressing well. It felt as though life was finally moving forward.
On 3 February, James attended his routine six-month appointment with his dental hygienist. He had seen the same clinician for several years and his medical history had been updated regularly. His previous heart surgeries and mechanical valve were well documented.
Around ten days later, James became unwell. He developed a high temperature and low blood pressure. At first, the symptoms appeared similar to a viral illness. As the days passed, he did not improve. After contacting NHS 111, he attended hospital and was admitted with sepsis.
James spent nine days receiving intravenous antibiotics and intensive treatment. Further investigations showed extensive infection affecting his heart and reconstructed aorta. Surgeons attempted a third open-heart operation, but the infection had caused severe damage to the tissues surrounding his prosthetic valve and repaired aorta. Despite every effort, James died in March this year.
His family cannot prove the exact source of the infection. However, his treating team believed infective endocarditis following recent dental treatment was a possible explanation. They were also surprised to learn that James had not been advised to discuss antibiotic prophylaxis before treatment following his valve replacement.
For James’ partner Claire, the greatest sadness is that after surviving two major heart operations and months of rehabilitation, they were unaware that infective endocarditis was something they needed to consider. She hopes that by sharing James’ story, other patients will receive clear advice about their individual level of risk before undergoing dental treatment, feel empowered to ask their consultant whether antibiotic prophylaxis is appropriate, and advocate for their own care.
