Pure Dental Arts Antibiotic Prophylaxis Protocol Before Dental Appointment
Historically, AP has been recommended for two types of patients: 1) those with heart conditions which may predispose them to heart infections (also called infective endocarditis), 2) those with prosthetic joints who may be at high risk of developing blood infections at the site of the prosthetic.
As of today, when compared to the above (outdated) recommendations, there are currently few patients who will actually need AP.
Between 2012-2015, the American Dental Association (ADA) conducted a study, and found that there was no association between prosthetic joint infections and dental procedures. Therefore, as of 2015 the ADA has concluded that “In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infections.”
Under the new guidelines, we also have to take into account the patient’s overall health, i.e. have they had infections of their prosthetics before? Are they immunocompromised or in poor health? Even then, the recommendation for AP is a gray area, and as dentists we will have to do our due diligence by consulting with the patient’s physicians. Furthermore, in cases where AP is deemed necessary, it would be most appropriate for the patient’s orthopedic surgeon to be the one who recommends and writes the prescription for AP.
What are the current guidelines for giving AP to prevent heart infections (infective endocarditis)? The joint statement from the ADA and the American Heart Association (AHA) is as follows: AP is recommended “only for…patients at highest risk of adverse outcome.” Therefore, these current guidelines tell us that AP is only needed for a relatively small number of patients. Especially because recent scientific studies show that the risk of a bad reaction to AP generally outweigh the benefits of it for many patients who would have been considered eligible for AP based on the old guidelines (those guidelines are above).
In fact, indiscriminate use of AP may result in the development of drug-resistant bacteria. Furthermore, the data was inconclusive with respect to whether or not AP before a dental procedure will actually prevent a heart infection. Ironically enough, the current guidelines from the ADA and AHA actually state that the best way to prevent a heart infection is not necessarily AP, but maintaining optimal oral health through regular professional dental care and use of appropriate dental cleaning devices!
So what kind of patients may actually need AP in order to prevent a heart infection? The following is a list of patient conditions that MAY warrant it:
- prosthetic cardiac valves, including transcatheter-implanted prostheses and homografts
- prosthetic material used for cardiac valve repair, such as annuloplasty rings and chords
- a history of infective endocarditis
- a cardiac transplant with valve regurgitation due to a structurally abnormal valve
- the following congenital (present from birth) heart disease
- unrepaired cyanotic congenital heart disease, including palliative shunts and conduits
- any repaired congenital heart defect with residual shunts or valvular regurgitation at the site of or adjacent to the site of a prosthetic patch or a prosthetic device
Scientists theorize that heart infections may be more common in those who have received heart transplants (due to their immunocompromised state), with the risk being greatest within the first 6 months of receiving the heart transplant.
For Pediatric patients, AP is only recommended for the following conditions:
- Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had surgical shunts and conduits.
- A congenital heart defect that’s been completely repaired with prosthetic material or a device for the first six months after the repair procedure.
- Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.
Assuming that AP is needed, what dental procedures actually warrant prior AP? Pretty much any procedures that involve manipulation of gum tissue or the root tips of the teeth, or perforation of the oral soft tissues. For example, deep cleanings, extractions, root canals, anesthetic injections, etc.
What kind of antibiotics do we give for AP? Typically amoxicillin and ampicillin. In patients who are allergic to the preceding, we will give cephalexin, azithromycin (sometimes given as a “Z pack when used in a non AP context), clarithromycin, or doxycycline. Sometimes, patients may forget to take their AP prior to their dental appointment. In such a case, we should provide AP to be taken prior to the procedure. But what if we forget? The current guideline states that we can give the AP for up to 2 hours after the procedure. What if a patient has consecutive appointments? We would give them AP prior to the dental procedure on day 1, and for day 2 give the same dose of AP prior to that day’s dental procedure.
That about sums it up for antibiotic prophylaxis before dental procedure as of 2022. Of course, these guidelines are subject to change as scientific discoveries are continuously being made, but as your local Seattle Dentist you can be rest assured that we will always stay on top of it!
1) Antibiotic Prophylaxis Prior to Dental Procedures https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/antibiotic-prophylaxis
2) AHA Scientific Statement:Prevention of Viridans Group Streptococcal Infective Endocarditis. “Circulation.” Walter R Wilson MD, Michael Gewitz MD, Peter B. Lockhart DDS, Et Al.
3) The Use of Prophylactic Antibiotics Prior To Dental Procedures In Patients with Prosthetic Joints. “JADA.” Thomas B. Sollecito DMD, Eliot Abt DMD, Et. Al.