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Antibiotic Prophylaxis for Dental Patients at Risk for Infection

Purpose

The American Academy of Pediatric Dentistry (AAPD) recognizes that numerous medical conditions predispose patients to bacteremia-induced infections. Because it is not possible to predict when a susceptible patient will develop an infection, prophylactic antibiotics are recommended when these patients undergo procedures that are at risk for producing bacteremia. These recommendations are intended to help practitioners make decisions regarding antibiotic prophylaxis for dental patients at risk.

Methods

Recommendations on antiobiotic prophylaxis for dental patients at risk for infection were developed by the Clinical Affairs Committee and adopted in 1990. This document is a revision of the previous version, last revised in 2011, and based on a review of current dental and medical literature pertaining to post procedural bacteremia-induced infections. This revision included database searches using key terms: infective endocarditis (IE), bacteremia, antibiotic prophylaxis, and dental infection. Articles were evaluated by title and/or abstract and relevance to dental care for children, adolescents, and those with special health care needs. Thirty-one citations were chosen from this method and from references within selected articles. When data did not appear sufficient or were inconclusive, recommendations were based upon expert and/ or consensus opinion by experienced researchers and clinicians. In addition, “Prevention of infective endocarditis: Guidelines from the American Heart Association”1,2 and “Prevention of orthopedic implant infection in patients undergoing dental procedures: Guidelines from the American Academy of Orthopedic Surgeons (AAOS) and American Dental Association (ADA)”3,4 were reviewed. 

Background

Bacteremia, bacteria in the bloodstream, is anticipated following invasive dental procedures.5,6  Infective endocarditis is an uncommon but life-threatening complication resulting from bacteremia. The incidence of infections such as IE ranges from 5.0 to 7.9 per 100,000 person-years with a significant increasing trend among women.7  Only a limited number of bacterial species have been implicated in resultant postoperative infections. Viridans group streptococci, Staphylococcus aureus, enterococcus, pseudomonas, serratia, and candida are some of the microorganisms implicated with IE.1,2  The vast majority of cases of IE caused by oral microflora can result from bacteremia associated with routine daily activities such as toothbrushing, flossing, and chewing.1,2  However, antibiotic prophylaxis is recommended with certain dental procedures.1,2,5,6  An effective antibiotic regimen should be directed against the most likely infecting organism, with antibiotics administered shortly before the procedure. When procedures involve infected tissues or are performed on a patient with a compromised host response, additional doses or a prescribed postoperative regimen of antibiotics may be necessary.

Antibiotic usage may result in the development of resistant organisms.1,2,5,6,8,9  Utilization of antibiotic prophylaxis for patients at risk does not provide absolute prevention of infection. Post-procedural symptoms of acute infection (e.g., fever, malaise, weakness, lethargy) may indicate antibiotic failure and need for further medical evaluation.

The decision to use antibiotic prophylaxis should be made on an individual basis. Some medical conditions that may predispose patients to post-procedural infections are discussed below. This is not intended to be an exhaustive list; rather, the categorization should help practitioners identify children who may be at increased risk. If a patient reports a syndrome or medical condition with which the practitioner is not familiar, it is appropriate to contact the child’s physician to determine susceptibility to bacteremia-induced infections.

In 2007, the American Heart Association (AHA) released its newly revised guidelines for the prevention of IE and reducing the risk for producing resistant strains of bacteria.1,2  The AAPD, acknowledging the AHA’s expertise and efforts to produce evidenced-based recommendations, continues to endorse the AHA guideline for antibiotic prophylaxis, titled Prevention of Infective Endocarditis.

The significant reasons for the revision include1,2: 

  • “IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure.”1 (Daily activities would include toothbrushing, flossing, chewing, using toothpicks, using water irrigation devices, and other activities.) 
  • “Prophylaxis may prevent an exceedingly small number of cases of IE if any, in individuals who undergo a dental, GI tract, or GU tract procedure. 
  •  The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.
  • Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.”1  

The 2007 AHA revision was intended to clarify when antibiotic prophylaxis is/is not recommended and to provide more uniform global recommendations. Major changes from the 1997 version1,2,8 include:

  • “The Committee concluded that only an extremely small number of cases of infective endocarditis might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. 
  • Infective endocarditis prophylaxis for dental procedures is reasonable only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from infective endocarditis. 
  • For patients with these underlying cardiac conditions, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
  • Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of infective endocarditis.”1 

Recommendations

The conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens.1-4,7,8  Given the increasing number of organisms that have developed resistance to current antibiotic regimens, as well as the potential for an adverse anaphylactic reaction to the drug administered, it is best to be judicious in the use of antibiotics for the prevention of IE1,2 and other distant-site infections.9

Patients with cardiac conditions
 Dental practitioners should consider prophylactic measures to minimize the risk of IE in patients with underlying cardiac conditions. The risk of developing IE can arise from a combination of high-risk patients and dental procedures. However, at-risk patients with poor oral hygiene and gingival bleeding after routine activities (e.g., toothbrushing) also have shown an increased potential for developing complications of IE.1,2,12,13  It, therefore, is recommended to encourage daily good oral hygiene practices to reduce gingivitis as part of the prophylactic regimen.1,2,11,12  These patients and/or parents need to be educated and motivated to maintain personal oral hygiene through daily plaque removal, including flossing.1,2 Greater emphasis should be placed on improved access to dental care and oral health in patients with underlying cardiac conditions at high risk for IE and less focus on a dental procedure and antibiotic coverage.1,2,10-12  Professional prevention strategies should be based upon the individual’s assessed risk for caries and periodontal disease.

Specific recommendations from the 2007 AHA guideline on prevention of IE are included in the following tables. The AHA recommends antibiotic prophylaxis only for those whose underlying cardiac conditions are associated with the highest risk of adverse outcome1,2 (see Table 1). Such conditions include prosthetic heart valves or prosthetic material used for cardiac valve repair, a previous history of IE unrepaired or incompletely repaired cyanotic congenital heart disease (CHD) including palliative shunts and conduits, 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 procedure, and repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or device, and cardiac transplantation recipients who develop cardiac valvulopathy such as valve regurgitation due to a structurally abnormal valve.1,2,14 After the 2007 AHA revised guidelines were published, there were concerns by healthcare providers that there may be an increase in cases of viridans group streptococci IE due to the decrease in the numbers of patients requiring antibiotic prophylactic coverage for dental procedures.15  A population based review of definitive and possible cases of IE demonstrated no observed increase in viridans group streptococci IE after publication of the 2007 AHA endocarditis prevention guidelines.15  In addition to those diagnoses listed in the AHA guidelines, patients with a reported history of injection drug use may be considered at risk for developing IE in the absence of cardiac anomalies.13  Although quite rare, complications from intraoral tongue piercing can include IE among patients with a pre-existing cardiac valvular condition and/or history of injection drug use.16-18 Consultation with the patient’s physician may be necessary to determine susceptibility to bacteremia-induced infections.

Antibiotics are recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa for cardiac patients with the highest risk1,2 (see Table 1 and 2). Specific antibiotic regimens can be found in Table 3. Practitioners and patients/parents can review the entire AHA guidelines in the AHA Circulation archives, “http://circ.ahajournals.org/cgi/ content/full/116/15/1736” for additional background information as well as discussion of special circumstances (e.g., patients already receiving antibiotic therapy, patients on anticoagulant therapy).

Patients with compromised immunity
Patients with a compromised immune system may not be able to tolerate a transient bacteremia following invasive dental procedures.10  These non-cardiac factors can place a patient with compromised immunity at risk for distant-site infection from a dental procedure.10  This category includes, but is not limited to, patients with the following medical conditions10:

  1. Immunosuppression secondary to:
    a. human immunodeficiency virus (HIV);
    b. severe combined immunodeficiency (SCIDS);
    c. neutropenia;
    d. cancer chemotherapy; and
    e. hematopoietic stem cell or solid organ transplantation.
  2. Head and neck radiotherapy.
  3. Autoimmune disease (e.g., juvenile arthritis, systemic lupus erythematosus).
  4. Sickle cell anemia.19 
  5. Asplenism or status post splenectomy. 
  6. Chronic steroid usage. 
  7. Diabetes.
  8. Bisphosphenate therapy.20,21

Consultation with the child’s physician is recommended for management of patients with a compromised immune system. Discussion of antibiotic prophylaxis for patients undergoing chemotherapy, irradiation, and hematopoietic cell transplantation appears in a separate AAPD guideline.22

Patients with shunts, indwelling vascular catheters, or medical devices
 The AHA recommends that antibiotic prophylaxis for nonvalvular devices, including indwelling vascular catheters (e.g., central lines) and cardiovascular implantable electronic devices (CIED), is indicated only at the time of placement of these devices in order to prevent surgical site infection.10,23-25  The AHA found no convincing evidence that microorganisms associated with dental procedures cause infection of CIED and nonvalvular devices at any time after implantation.10,23-25  The infections occurring after device implantation most often are caused by Staphylococcus aureus and coagulase negative staphylococci or other microorganisms that are non-oral in origin but are associated with surgical implantation or other active infections.24-26  The AHA further states that immunosuppression is not an independent risk factor for nonvalvular device infections; immunocompromised hosts who have those devices should receive antibiotic prophylaxis as advocated for immunocompetent hosts.10,23-25  Consultation with the child’s physician is recommended for management of patients with nonvalvular devices.

Ventriculoatrial (VA), ventriculocardiac (VC), or ventriculovenus (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections due to their vascular access.10,23  In contrast, ventriculoperitoneal (VP) shunts do not involve any vascular structures and, consequently, do not require antibiotic prophylaxis.10,23 Consultation with the child’s physician is recommended for management of patients with vascular shunts.

Patients with prosthetic joints
 For patients with a history of total joint arthroplasty, deep hematogenous infections can lead to life threatening complications such as a loss of the prosthetic joint or even increased morbidity and mortality.27,28  A 2012 information statement published by the AAOS recommends that dentists consider antibiotic prophylaxis for at-risk joint replacement patients who are undergoing an invasive procedure.28  Patients with an increased risk of hematogenous total joint infection are all patients with a prosthetic joint replacement, previous prosthetic joint infection, inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus), megaprosthesis, hemophilia, malnourishment, and compromised immunity (see examples in previous section).28  However, AAOS states that clinical judgment must consider the potential benefit of antibiotic prophylaxis versus the risks of adverse reactions for each patient.3,4,28  The AAPD recognizes recommendations from AAOS and the ADA with regards to antibiotic prophylaxis for patients with joint replacement. A joint collaboration of the AAOS and the ADA developed evidence based recommendations on antibiotic prophylaxis for patients at a high risk for implant infection undergoing dental procedures (Table 4).3,4,28

Currently, the AAPD endorses the 2012 recommendations of the ADA and the AAOS for management of patients with prosthetic joints.3,4,28  Antibiotic prophylaxis has not shown a significant reduction in the risk of developing joint infections subsequent to dental procedures.27,29  Therefore, antibiotic prophylaxis is not indicated for dental patients with pins, plates, screws, or other hardware that is not within a synovial joint nor is it indicated routinely for most dental patients with total joint replacements.28,30

Consultation with the child’s physician may be necessary for management of at-risk patients as well as patients with other implanted devices (e.g., Harrington rods, external fixation devices).10,27-30

Acceptance by dental practitioners of AHA guidelines for antibiotic prophylaxis
 The revised 2007 AHA guidelines provided a significant reduction in patients requiring antibiotic prophylaxis prior to invasive dental procedures. In a survey sent to U.S. dentists, 71 percent of the respondents reported they were satisfied with the current guidelines.31  The survey also demonstrated that 70 percent of the dentists reported a majority of patients previously receiving antibiotic prophylaxis no longer required prophylaxis.31  However, the same percentage of respondents also indicated that a significant number of these patients were still receiving antibiotic prophylaxis regardless of the AHA revised guidelines.31

References

  1. Wilson W, Taubert KA, Gevitz M, et al. 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 Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. J Am Dent Assoc 2007;138(6):739-45, 747-60. Erratum in: J Am Dent Assoc 2008;139(3):253.
  2. Wilson W, Taubert KA, Gevitz M, et al. 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 Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 2007;116(15):1736-54. E-published April 19, 2007. Erratum in: Circulation 2007;116(15):e376-e7. 
  3. Watters W, Rethman MP, Hanson NB, et al. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg 2013;21(3):180-9. 
  4. American Academy of Orthopedic Surgeons, American Dental Association. Guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg 2013;95(8):745-7.
  5. Lockhart PB, Brennan MT, Kent ML, Norton JH, Weinrib DA. Impact of amoxicillin prophylaxis on the incidence, nature, and duration of bacteremia in children after intubation and dental procedures. Circulation 2004;109(23):2878-84.
  6. Roberts GJ, Jaffrey EC, Spract DA, Petrie A, Greville C, Wilson M. Duration, prevalence and intensity of bacteremia after dental extractions in children. Heart 2006;92(9):1274-7.
  7. de Sa DD, Tleyieh IM, Anavekar NS, et al. Epidemiological trends of infective endocarditis: A populationbased study in Olmsted County, Minnesota. Mayo Clin Proc 2010;85(5):422-6. Erratum in: Mayo Clin Proc 2010;85(8):722.
  8. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: Recommendations by the American Heart Association. JAMA 1997;227(22):1794-801. 
  9. Centers for Disease Control and Prevention. Antibiotic/ Antimicrobial resistance. About antimicrobial resistance: A brief overview. Available at: “http://www.cdc.gov/drugresistance/about.html”. Accessed August 20, 2014. 
  10.  Lockhart PB, Loven B, Brennan MT, Baddour LM, Levinson M. The evidence base for the efficiency of antibiotic prophylaxis in dental practice. J Am Dent Assoc 2007;138(4):458-74.
  11. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral hygiene as a risk factor for infective endocarditis related bacteremia. J Am Dent Assoc 2009;140(10):1238-44. 
  12. Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK. Bacteremia associated with toothbrushing and dental extraction. Circulation 2008;117(24):3118-25.
  13. Taubert KA, Gewitz MH. Infective endocarditis. In: Moss AJ, ed. Mossand Adam’s Heart Disease in Infants, Children, and Adolescents: Including the Fetus and Young Adult, 7th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins Philadelphia, Pa.; 2008:1299-311.
  14. Nishimura, RA, Carabello, BA, Faxon, DP, et al. ACC/ AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines: Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008;118:887-96. 
  15. DeSimone, DC, Tleyjeh, IM, Correa de Sa, DD, et al. Incidence of infective endocarditis caused by viridans group streptococci before and after publication of the 2007 American Heart Association’s Endocarditis Prevention Guidelines. Circulation 2012;126:60-4.
  16. Lick SD, Edozie SN, Woodside KJ, Conti VR. Streptococcus viridans endocarditis from tongue piercing. J Emerg Med 2005;29(1):57-9.
  17. Akhondi H, Rahimi AR. Haemophilus aphrophilus endocarditis after tongue piercing. Emerg Infect Dis 2002;8(8):850-1. 
  18. Tronel H, Chaudemanche H, Pechier N, Doutrelant L, Hoen B. Endocarditis due to Neisseria mucosa after tongue piercing. Clin Microbiol Infect 2001;7:275–6. 
  19. Tate AR, Norris CK, Minniti CP. Antibiotic prophylaxis for children with sickle cell disease: A survey of pediatric dentistry residency program directors and pediatric hematologists. Pediatr Dent 2006;28(3):332-5.
  20. Montefusco V, Gay F, Spina F, et al. Antibiotic prophylaxis before dental procedures may reduce the incidence of osteonecrosis of the jaw in patients with multiple myeloma treated with bisphosphonates. Leuk Lymphoma 2008;49(11):2156-62. 
  21. Rogers SN, Hung J, Barber AJ, Lowe D. A survey of consultant members of the British Association of Oral and Maxillofacial Surgeons regarding bisphosphonateinduced osteonecrosis of the jaws. Br J Oral Maxillofac Surg 2009;47(8):598-601.
  22. American Academy of Pediatric Dentistry. Guideline on dental management of pediatric patients receiving chemotherapy, hematopoietic cell transplantation, and/or radiation. Pediatr Dent 2014;36(special issue):293-301. 
  23. Baddour LM, Bettman MA, Bolger AF, Bolger A, Ferrieri P. Nonvalvular cardiovascular device-related infections. Circulation 2003;108(16):2015-31.
  24. Baddour LM, Epstein AE, Erickson CC, et al. Update on cardiovascular implantable electronic device infections and their management. Circulation 2010;121(3):458-77.
  25. Baddour LM, Epstein AE, Erickson CC, et al. on behalf of the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young; Council on Cardiovascular Surgery and Anesthesia; Council on Cardiovascular Nursing; Council on Clinical Cardiology; and the Interdisciplinary Council on Quality of Care and Outcomes Research. A summary of the update on cardiovascular implantable electronic device infections and their management. J Am Dent Assoc 2011;142(2):159-65.
  26. Hong CHL, Allred R, Napenas JJ, Brennan MT, Baddour LM, Lockhart PB. Antibiotic prophylaxis for dental procedures to prevent indwelling venous catheter-related infections. Am J Med 2010;123(12):1128-33.
  27. Aminoshariae A, Kulild J. Premedication of patients undergoing dental procedures causing bacteremia after total joint arthroplasty. J Endod 2010;36(6):974-7. 
  28. American Academy of Orthopaedic Surgeons. Information statement: Guideline on prevention of orthopaedic implant infection in patients undergoing dental procedures. Available at: “http://www.aaos.org/about/papers/advis.asp”. Accessed August 20, 2014.
  29. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: A hospital-based prospective case-control study. Clin Infect Dis 2010;50(1):8-16. Erratum in: Clin Infect Dis 2010;50(6):944.
  30. Little JW, Jacobson JJ, Lockhart PB, American Academy of Oral Medicine. The dental treatment of patients with joint replacements: A position paper from the American Academy of Oral Medicine. J Am Dent Assoc 2010;141 (6):667-71. 
  31. Lockhart PB, Hanson NB, Ristic H, Menezes AR, Baddour L. Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis. J Am Dent Assoc 2013;144(9):1030-5.