When to Use Prophylaxis for Dental Procedures
The guidelines (2007), published in Circulation: Journal of the American Heart Association, are based on a growing body of scientific evidence that shows that, for most people, the risks of taking prophylaxis antibiotics for certain procedures outweigh the benefits. These guidelines represent a major change in philosophy.
The new guidelines show taking preventive antibiotics is not necessary for most people and, in fact, might create more harm than good. Unnecessary use of antibiotics could cause allergic reactions and dangerous antibiotic resistance.
Only the people at greatest risk of bad outcomes from infective endocarditis — an infection of the heart's inner lining or the heart valves — should receive short-term preventive antibiotics before common, routine dental and medical procedures.
Patients at the greatest danger of bad outcomes from IE and for whom preventive antibiotics are worth the risks include those with:
- artificial heart valves
- a history of having had IE
- certain specific, serious congenital (present from birth) heart conditions, including:
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter interventions, during the first six months after the procedure**
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or prosthetic device
- a cardiac transplant which develops a problem in a heart valve.
Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
** Prophylaxis is reasonable because endothelialization of prosthetic material occurs within 6 months after the procedure.
Endocarditis prophylaxis is recommended for these groups for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. This includes procedures such as biopsies, suture removal, and placement of orthodontic bands
The following procedures and events do not need prophylaxis:
- routine anesthetic injections through noninfected tissue
- taking dental radiographs
- placement of removable prosthodontic or orthodontic appliances
- adjustment of orthodontic appliances
- placement of orthodontic brackets
- non-dental procedures: shedding of deciduous teeth, bleeding from trauma to the lips or oral mucosa.
Antibiotic Regimens
- administer a single dose 30-60 min before the procedure
- prophylactic antimicrobial therapy should be directed against viridans group streptococci.
- If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. However, administration of the dosage after the procedure should be considered only when the patient did not receive the pre-procedure dose.
- Some patients who are scheduled for an invasive procedure may have a coincidental endocarditis. The presence of fever or other manifestations of systemic infection should alert the provider to the possibility of IE. In these circumstances, it is important to obtain blood cultures and other relevant tests before administration of antibiotics intended to prevent IE. Failure to do so may result in delay in diagnosis or treatment of a concomitant case of IE.
- In Table 5, amoxicillin is the preferred choice for oral therapy because it is well absorbed in the GI tract and provides high and sustained serum concentrations.
- if allergic to penicillins or amoxicillin, the use of cephalexin or another first-generation oral cephalosporin, clindamycin, azithromycin, or clarithromycin is recommended. Even though cephalexin was less active against viridans group streptococci than other first-generation oral cephalosporins in 1 study,136 cephalexin is included in Table 5. No data show superiority of 1 oral cephalosporin over another for prevention of IE, and generic cephalexin is widely available and relatively inexpensive. Because of possible cross-reactions, a cephalosporin should not be administered to patients with a history of anaphylaxis, angioedema, or urticaria after treatment with any form of penicillin, including ampicillin or amoxicillin.
- Patients who are unable to tolerate an oral antibiotic may be treated with ampicillin, ceftriaxone, or cefazolin administered intramuscularly or intravenously.
- For ampicillin-allergic patients who are unable to tolerate an oral agent, therapy is recommended with parenteral cefazolin, ceftriaxone, or clindamycin.
Source: Circulation. 2007;116:1736-1754.
Prevention of Infective Endocarditis
Guidelines From the American Heart Association
A Guideline From the American Heart Association Rheumatic Fever,
Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular
Disease in the Young, and the Council on Clinical Cardiology, Council on
Cardiovascular Surgery and Anesthesia, and the Quality of Care and
Outcomes Research Interdisciplinary Working Group
http://circ.ahajournals.org/cgi/content/full/116/15/1736