The conservative use of antibiotics is indicated to minimize the risk of developing resistance to current antibiotic regimens. Given the increasing number of organisms that have developed resistance to current antibiotic regimens, it is best to be prudent in the use of antibiotics for the prevention of infective endocarditis (IE) and other conditions.
Patients with Cardiac Conditions
Dental practitioners should consider prophylactic measures to minimize the risk of IE in patients with underlying cardiac conditions. These patients and/or parents need to be educated and motivated to maintain personal oral hygiene through daily plaque removal, including flossing. 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. Professional prevention strategies should be based upon the individual's assessed risk for caries and periodontal disease.
Specific recommendations from the 2007 American Heart Association (AHA) guideline on prevention of IE are included in the tables below. The AHA recommends antibiotic prophylaxis only for those whose underlying cardiac conditions are associated with the highest risk of adverse outcome (see Table 1 below). Such conditions include prosthetic heart valves, previous history of IE, unrepaired cyanotic congenital heart disease (CHD), completely repaired congenital heart defect with prosthetic material or device during the first 6 months after the procedure, 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 valvulopathy. In addition to those diagnoses listed in the AHA guidelines, patients with a history of intravenous drug abuse may be at risk for developing bacterial endocarditis due to associated cardiac anomalies. 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 (see Table 2 below). Specific antibiotic regimens can be found in Table 3 in the original guideline document. Practitioners and patients/parents can review the entire AHA guidelines http://circ.ahajournals.org/cgi/reprint/CIRCULATIONAHA.106.183095 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. This category includes, but is not limited to, patients with the following conditions:
- Human immunodeficiency virus (HIV)
- Severe combined immunodeficiency (SCIDS)
- Neutropenia
- Immunosuppression
- Sickle cell anemia
- Status post splenectomy
- Chronic steroid usage
- Lupus erythematosus
- Diabetes
- Status post organ transplantation
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 American Academy of Pediatric Dentistry (AAPD) guideline (see the National Guideline Clearinghouse [NGC] summary Guideline on Dental Management of Pediatric Patients Receiving Chemotherapy, Hematopoietic Cell Transplantation, and/or Radiation).
Patients with Shunts, Indwelling Vascular Catheters, or Medical Devices
The AHA recommends that antibiotic prophylaxis for nonvalvular devices, including indwelling vascular catheters (central lines), is indicated only at the time of placement of these devices in order to prevent surgical site infection. The AHA found no convincing evidence that microorganisms associated with dental procedures cause infection of nonvalvular devices at any time after implantation. The infections occurring after device implantation most often are caused by staphylococci, Gram-negative bacteria, or other microorganisms associated with surgical implantation or other active infections. 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. Consultation with the child's physician is recommended for management of patients with nonvalvular devices.
Ventriculoatrial (VA) or ventriculovenous (VV) shunts for hydrocephalus are at risk of bacteremia-induced infections due to their vascular access. In contrast, ventriculoperitoneal (VP) shunts do not involve any vascular structures and, consequently, do not require antibiotic prophylaxis. Consultation with the child's physician is recommended for management of patients with vascular shunts.
The AAPD endorses the recommendations of the American Dental Association and the American Academy of Orthopedic Surgeons for management of patients with prosthetic joints. Antibiotic prophylaxis is not indicated for dental patients with pins, plates, and screws, nor is it indicated routinely for most dental patients with total joint replacements. Antibiotics may be considered when high-risk dental procedures (Table 2 below) are performed for patients within 2 years following implant surgery or for patients who have had previous joint infections. Consultation with the child's physician may be necessary for management of patients with other implanted devices (e.g., Harrington rods, external fixation devices).
| Table 1. Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis for which Prophylaxis with Dental Procedures Is Reasonable |
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Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis
Congenital heart disease (CHD)*
Unrepaired cyanotic 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 6 months after the procedure**
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy
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* 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.
Circulation 2007; 116:1745.
| Table 2. Dental Procedures for which Endocarditis Prophylaxis Is Reasonable for Patients in Table 1 |
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All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa*
* 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, shedding of deciduous teeth, and bleeding from trauma to the lips or oral mucosa.
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Circulation. 2007; 116:1746.
