Oral Health Topics
Antibiotic prophylaxis recommendations exist for two groups of patients:
- those with heart conditions that may predispose them to infective endocarditis
- those who have a prosthetic joints and may be at risk for developing hematogenous infections at the site of the prosthetic.
Prevention of Infective Endocarditis (IE)
With input from the ADA, the American Heart Association (AHA) released guidelines for the prevention of infective endocarditis in 2007.
The current guidelines support premedication for a smaller group of patients than previous versions. This change was based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. Concern about the development of drug-resistant bacteria also was a factor.
Also, the data are mixed as to whether prophylactic antibiotics taken before a dental procedure prevent IE. The guidelines note that people who are at risk for IE are regularly exposed to oral bacteria during basic daily activities such as brushing or flossing.
The current guidelines state that use of preventive antibiotics before certain dental procedures is reasonable for patients with:
- prosthetic cardiac valve or prosthetic material used for cardiac valve repair
- a history of infective endocarditis
- a cardiac transplant that develops cardiac valvulopathy
- the following congenital (present from birth) heart disease:a
- unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedureb
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device (that inhibit endothelialization)
a Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of congenital heart disease.
b Prophylaxis is reasonable because endothelialization of a prosthetic material occurs within six months after the procedure.
Prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
Additional considerations about IE antibiotic prophylaxis
Sometimes patients forget to premedicate before their appointments. The recommendation is that the antibiotic be given before the procedure. This is important because it allows the antibiotic to reach adequate blood levels. However, the guidelines to prevent infective endocarditis state:
“If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure.”
Another concern that dentists have expressed involves patients who require prophylaxis but are already taking antibiotics for another condition. In these cases, the guidelines for infective endocarditis recommend that the dentist select an antibiotic from a different class than the one the patient is already taking. For example, if the patient is taking amoxicillin, the dentist should select clindamycin, azithromycin or clarithromycin for prophylaxis.
Other patient groups also may merit special consideration, which is discussed fully in the guidelines.
In 2014, The Lancet published a study out of the United Kingdom that presented new evidence on the correlation between antibiotic prophylaxis and IE.c At this time, the ADA recommends that dentists continue to use the AHA guidelines discussed above. Dental professionals should periodically visit the ADA websites for updates on this issue.
c Dayer MJ, Jones S, Prendergast B, et al. Incidence of infective endocarditis in England, 2000-13: a secular trend, interrupted time-series analysis. The Lancet, published online 18 November 2014. Accessed January 6, 2014.
Additional resources for AHA Guidelines
Prevention of Prosthetic Joint Infection
In 2014, the ADA Council on Scientific Affairs assembled an expert panel to update and clarify the clinical recommendations found in the 2012 evidence-based guideline, Prevention of Orthopaedic Implant Infection in Patients Undergoing Dental Procedures.
As was found in 2012, the 2014 updated systematic review found no association between dental procedures and prosthetic joint infections. Based on this review, the 2014 Panel concluded that prophylactic antibiotics given prior to dental procedures are not recommended for patients with prosthetic joint implants.
The ADA encourages dental professionals to review the full 2014 guideline and take this recommendation into account, consult with the patient's orthopedic surgeon as needed, and consider the patient's specific needs and preferences when planning treatment.
General Information About Antibiotic Prophylaxis