Antimicrobial therapy should not be initiated for the treatment of undefined febrile illnesses unless the patient s condition (eg, sepsis) warrants it (Class III; Level of Evidence C). Dental Management A large, prospective study demonstrated a strong associa- tion between 3 indexes of oral hygiene and gingival disease and the incidence of bacteremia from IE-related species.327 Poor oral hygiene results in gingivitis, which often leads to periodontitis, and it is likely that these 2 periodontal dis- eases are associated with community-acquired IE. Current evidence suggests that poor oral hygiene and periodon- tal diseases, not dental office procedures, are likely to be responsible for the vast majority of cases of IE that originate in the mouth.328 Regardless of the source of infection, inpatients with IE should be thoroughly evaluated by a dentist familiar with the potential role of the mouth in these cases. The optimal timing for this evaluation may be after the patient s cardiac status has stabilized and early enough that all invasive dental procedures can be accomplished during intravenous antibiotic therapy. The clinical examination should rule out periodontal inflammation and pocketing around the teeth and caries that will eventually result in pulpal infection. A full series of intra- oral radiographs is required for the identification of caries and periodontal disease (eg, bone loss, tooth fractures). All of this is aimed at reducing the incidence and magnitude of bactere- mia from any manipulation of the gingival tissues, including normal daily events such as brushing teeth and chewing food. Treatment invariably involves a thorough dental cleaning by a hygienist who will review with patients the importance of maintaining scrupulous oral hygiene. Dental disease is almost entirely preventable if patients are compliant with 4 measures. 