10 QUESTIONS AND ANSWERS ABOUT USE OF ANTIBIOTIC PROPHYLAXIS IN DENTISTRY

1. For what cardiac conditions is prophylaxis for endocarditis recommended in patients receiving dental care?

High-risk category

• Prosthetic cardiac valves, including both bioprosthetic and homograft valves

• Previous bacterial endocarditis

• Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot)

• Surgically constructed systemic pulmonary shunts or conduits Moderate-risk category

• Most congenital cardiac malformations other than above and below (see next question)

• Acquired valvular dysfunction (e.g., rheumatic heart disease)

• Hypertrophic cardiomyopathy

• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets

2. What cardiac conditions do not require endocarditis prophylaxis? Negligible-risk category (no higher than the general population)

• Isolated secundum atrial septal defect

• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months)

• Previous coronary artery bypass graft surgery

• Mitral valve prolapse without valvular regurgitation

• Physiologic, functional, or innocent heart murmurs

• Previous Kawasaki disease without valvular regurgitation

• Previous rheumatic fever without valvular regurgitation

• Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

3. What are the antibiotics and dosages recommended by the  American Heart Association (AHA) for prevention of endocarditis from dental procedures?

The AHA updates its recommendations every few years to reflect new findings. The dentist has an obligation to be aware of the latest recommendations.

The patient’s well-being is the dentist’s responsibility. Even if a physician recommends an alternative prophylactic regimen, the dentist is liable if the patient develops endocarditis and the latest AHA recommendations were not followed.

Standard regimen

Amoxicillin, 2.0 gm orally 1 hr before procedure

For patients allergic to amoxicillin and penicillin

Clindamycin, 600 mg orally 1 hr before procedure or

Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure or

Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure

 Patients unable to take oral medications

Ampicillin, intravenous or intramuscular administration of 2 gm 30 mm before procedure

 For patients allergic to ampicillin, amoxicillin, and penicillin 

Clindamycin, intravenous administration of 600 mg 30 mm before procedure  or Cefazolin,* intravenous or intramuscular administration of 1.0 gm within 30 mm before procedure

* Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria, angioedema. or anaphylaxis) to penicillins.

4. For what dental procedures is antibiotic premedication recommended in patients identified as being at risk for endocarditis?

• Dental extractions

•Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance

• Dental implant placement and reimplantation of avulsed teeth

• Endodontic (root canal) instrumentation or surgery only beyond the apex

• Subgingival placement of antibiotic fibers or strips

• Initial placement of orthodontic bands but not brackets

• Intraligamentary local anesthetic injections

• Prophylactic cleaning of teeth or implants if bleeding is anticipated

5. For what dental procedures is antibiotic premedication not recommended in patients identified as being at risk for endocarditis?

•Restorative dentistry (including restoration of carious teeth and prosthodontic replacement of teeth) with or without retraction cord (clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding)

• Local anesthetic injections (nonintraligamentary)

• Intracanal endodontic treatment (after placement and build-up)

• Placement of rubber dams

• Postoperative suture removal

• Placement of removable prosthodontic or orthodontic appliances

• Making of impressions

• Fluoride treatments

• Intraoral radiographs

• Orthodontic appliance adjustment

• Shedding of primary teeth

6. Should a patient who has had a coronary bypass operation be placed on prophylactic antibiotics before dental treatment?

No evidence indicates that coronary artery bypass graft surgery introduces a risk for endocarditis. Therefore, antibiotic prophylaxis is not needed.

7. What precautions should you take when treating a patient with a central line such as a Hickman or Portacath?

Patients with central venous access are usually receiving intensive antibiotic therapy, chemotherapy, or nutritional support. It is imperative to consult with the patient’s physician before performing any  dental procedures. If it is determined that the dental procedure is necessary, the patient should receive antibiotic prophylaxis to protect the central venous access line from infection secondary to transient bacteremias. The same antibiotic regimen recommended for the prevention of endocarditis should be prescribed.

8. Should a patient with a prosthetic joint be placed on prophylactic antibiotics before dental treatment?

Case studies support the hematogenous seeding of prosthetic joints. However, it is questionable whether organisms from the oral cavity are a source for late deep infections of prosthetic joints. The decision whether to premedicate should be determined by the dentist’s clinical judgment in consultation with the patient’s physician or orthopedic surgeon. Patients considered at high risk for developing a late infection of a prosthetic joint should be premedicated. Such patients can be grouped based on predisposing systemic conditions, issues associated with joint prostheses, or presence of acute infection at sites distant to the joint prosthesis.

High-risk Patients with Total Joint Replacements

Predisposing systemic conditions

Rheumatoid arthritis                                    

Insulin-dependent diabetes mellitus

Systemic lupus erythematosus                                                          

Hemophilia

Disease-, drug-, or radiation-induced immunosuppression           

Malnourishment

Issues associated with joint prostheses

First 2 years after joint replacement         

Loose prosthesis

History of replacement of prosthesis     

History of previous infection of prosthesis

Acute infection located at distant sites: skin, oral cavity, other

9. What are the antibiotics and dosages recommended by the American Dental Association and the American Academy of Orthopaedic Surgeons to prevent late joint infections in patients considered to be at high risk?

Standard regimen

Cephalexin* or cephradine* or amoxicillin, 2 gm orally 1 hr before procedure

 For patients allergic to amoxicillin and penicillin

Clindamycin, 600 mg orally 1 hr before procedure

Patients unable to take oral medications

Cefazolin,* intravenous or intramuscular administration of 1.0 gm 1 hr before procedure or

Ampicillin, intravenous or intramuscular administration of 2.0 gm 1 hr before procedure

For patients allergic to ampicillin, amoxicillin, and penicillin

Clindamycin, intravenous or intramuscular administration of 600 mg 1 hr before procedure

* Cephalosporins should not be used in patients  with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.

10.Is it necessary to prescribe prophylactic antibiotics for a patient on renal dialysis?

Patients on dialysis with arteriovenous (AV) shunts should be premedicated before any dental treatment that has  the potential of producing a transient bacteremia. The dosages for antibiotic coverage are as follows:

Standard regimen

Amoxicillin, 2.0 gm orally 1 hr before procedure

For patients allergic to amoxicillin and penicillin

Clindamycin, 600 mg orally 1 hr before procedure or

Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure

Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure

Patients unable to take oral medications

Ampicillin, intravenous or intramuscular administration 2.0 gm within 30 mm before procedure

For patients allergic to ampicillin, anioxicillin, and penicillin

Clindamycin, intravenous administration of 600 mg within 30 mm before procedure or

Cefazolin,* intravenous or intramuscular administration of 1.0 gm within 30 mm before procedure

* Cephalosporins should not be used in patients  with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.