Antibiotics & Dentistry

antibiMany of you take an antibiotic prior to dental treatment. The purpose is to use an antibiotic prior to an infection to prevent an infection. It may be because of a mitral valve prolapse, certain types of implants, a joint replacement, or a heart murmur cause by a roughened heart valve. Antibiotic prophylaxis began initially to prevent bacterial endocarditis. Endocarditis is the collection and colonization of bacteria in the heart muscle. This leads to inflammation and deformation of the heart and is a life-threatening condition.

The American Heart Association published its first guidelines in 1955. Since then the guidelines have been modified several times. Each revision has tried to make the antibiotic regime simpler to increase patient compliance. The revisions also attempt to consider the fact that many bacteria present can eventually become resistant to the antibiotic therapy.

The guidelines for antibiotic prophylaxis was updated in 1990 and most recently in 1997. Before we review the most recent guidelines, as they relate to dentistry, please remember this. The original decision to use antibiotics to prevent infection was based on the assumption that if antibiotics are effective in treating an infection, they should be able to prevent them. Any studies to support this premise were done strictly in the laboratory and the primary mechanism for the prevention of endocarditis is not known.

The AHA guidelines are followed by most practitioners, but it is not unusual to find certain changes in dosages or medications made by particular doctors.

Antibiotic prophylaxis is RECOMMENDED for the following:

High-risk category

Prosthetic cardiac valves,including 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 other congenital cardiac malformations (other than above and below)
Acquired valvar dysfunction (e.g., rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Antibiotic prophylaxis is NOT RECOMMENDED for the following:

Negligible-risk category (no greater risk than the general population)

Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation
Physiologic, functional, or innocent heart murmurs
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

FOR HIGH & MODERATE RISK PATIENTS
Antibiotic prophylaxis is recommended for the following dental procedures:

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 where bleeding is anticipated

FOR HIGH & MODERATE RISK PATIENTS
Antibiotic prophylaxis is not recommended for the following dental procedures

Restorative dentistry (operative and prosthodontic) with or without retraction cord
Local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; post placement and buildup
Placement of rubber dams, postoperative suture removal, taking of oral impressions, and fluoride treatments
Placement of removable prosthodontic or orthodontic appliances and orthodontic appliance adjustment
Taking of oral radiographs
Shedding of primary teeth

RELATED NEWS ITEMS

Treating Gum Disease with Antibiotics – Oct 18, 1999 (Ivanhoe)
Misuse, Overuse and Underuse of Antibiotics – Jul 12, 2000 (ABC News)