Antibiotic Prophylaxis
Before some dental treatments, patients who have certain heart conditions and those with artificial joints take antibiotics. These people may be at risk of developing an infection in the heart or at the site of the artificial joint, respectively. Antibiotics reduce this risk. This is called antibiotic prophylaxis (pronounced pro-fuh-lax-iss).
When treating patients with heart conditions, dentists follow guidelines developed by the American Heart Association (AHA), with input from the ADA. For patients who have total joint replacements, they refer to guidelines developed by the American Academy of Orthopedic Surgeons (AAOS).
Dental procedures
Antibiotic prophylaxis guidelines exist for two groups of patients:
- those with heart conditions that may predispose them to infective endocarditis; and
- those who have a total joint replacement and may be at risk for developing hematogenous infections at the site of the prosthetic.
Prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
Guidelines for People with Heart Conditions
The AHA guidelines are meant to reduce the risk of infective endocarditis (pronounced end-o-car-die-tiss). Infective endocarditis (IE) is an infection of the lining inside the heart or the heart valves.
In the past, a number of heart conditions were thought to put patients at risk for IE. When writing the new guidelines, the AHA looked at published research and other scientific articles. They found that fewer conditions were associated with IE. As a result, a smaller group of patients needs to premedicate before dental treatments.
The current prophylactic antibiotic recommendation for infective endocarditis is 2 gm. of Cephalexin or Amoxicillin or 600mg. of Clinamycin 1 hour prior to a dental procedure.
Why did the guidelines change?
After looking at the published scientific reports and articles, the AHA concluded that:
- the risks of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. Adverse reactions can range from mild (rashes) to severe (breathing problems that could result in death).
- when all the study results were looked at together, it wasn’t clear that premedication prevented IE.
- bacteria from the mouth can enter the bloodstream during daily activities like brushing or cleaning between the teeth. Once in the bloodstream, it can travel to the heart. People at risk of infection might be more likely to develop IE from these activities than after a dental treatment.
Also, bacteria that cause infections can become resistant to antibiotics if those drugs are used too often. Because of this, doctors try to limit the use of antibiotics.
Patient selection
The current guidelines recommend use of preventive antibiotics before certain dental procedures for people with:
- artificial heart valves
- a history of infective endocarditis
- a cardiac transplant that develops a heart valve problem
- the following congenital (present from birth) heart conditions:*
- 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 intervention, 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 a prosthetic device.
People who took prophylactic antibiotics in the past but no longer need them include those with:
- mitral valve prolapse
- rheumatic heart disease
- bicuspid valve disease
- calcified aortic stenosis
- congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.
Talk to Dr. Sugar about how these guidelines might apply to you.
Additional resources
- American Heart Association downloadable wallet card (available in English and Spanish)
- For the Dental Patient: Antibiotics and Your Heart
Guidelines for People with Total Joint Replacements
Guidelines from the AAOS are meant to reduce the risk of infections at the site of an artificial joint. They apply to people who have total joint replacements. Patients who have pins, plates or other orthopedic hardware are not affected.
AAOS recommends that all patients who have total joint replacements should take antibiotics before certain types of dental procedures.
Antibiotic prophylaxis guidelines for patients who have a total joint replacement were updated by the American Academy of Orthopedic Surgeons (AAOS) in 2009. You can access the updated AAOS Information Statement at www.aaos.org/about/papers/advistmt/1033.asp
The current AAOS information statement recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia (bacteria in the blood stream). The current prophylactic antibiotic recommendation is 2 gm. of Cephalexin, Cephrahadine, or Amoxicillin 1 hour prior to a dental procedure.
The following procedures could have a higher incidence of bacteremia: dental extractions; periodontal procedures, including surgery, subgingival placement of antiobiotic fibers/strips, scaling and root planing, probing, recall maintenance; dental implant placement and replantation of avulsed teeth; endodontic (root canal) instrumentation or surgery only beyond the apex; initial placement of orthodontic bands but not brackets; intraligamentary and intraosseous local anesthetic injections; prophylactic cleaning of teeth or implants where bleeding is anticipated.
The current statement notes that "patients with pins, plates and screws, or other [orthopedic] hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms."
Please note: The ADA does not provide specific answers to individual questions about fees, dental problems, conditions, diagnoses, treatments or proposed treatments, or requests for research. Information about dental referrals, complaints and a variety of dental procedures may be found on ADA.org.If you have any questions about these guidelines, please contact Dr. Sugar at 717 235 3837 or the ADA Division of Science via e-mail or by calling 312-440-2878.