Antibiotic Prophylaxis in Dentistry

What Is Antibiotic Prophylaxis?

The use of certain antibiotics before a dental treatment or any surgery to prevent post-surgical bacterial infection is called antibiotic prophylaxis. The guidelines for using antibiotics as prevention have undergone various changes in the last 10 years because of increased resistance of bacteria to antibiotics (antibiotic resistance), changes in bacteria, and improved diagnostic tests to detect infections.

But, antibiotic prophylaxis is still prescribed for people who have a high risk of bacterial infection before the following procedures:

1. Head and neck cancer surgeries.

2. C-sections (Cesarean).

3. Implanting a pacemaker or defibrillator.

4. Surgeries of the gastrointestinal tract.

5. Heart surgeries, like valve replacement, heart transplant, etc.

In dentistry, the following two groups of patients were given antibiotic prophylaxis prior to certain procedures historically:

1. Patients with heart conditions, which predisposed them to infective endocarditis.

2. Patients with a prosthetic joint, who were said to be at risk of infection of the prosthetic joint.

But, these are old recommendations, and currently, only a few dental procedures for a small group of patients require antibiotic prophylaxis.

In 2015, ADA (American Dental Association) clinical practice guidelines revoked the use of prophylactic antibiotics for patients with prosthetic joints to prevent prosthetic joint infection. For patients undergoing invasive dental procedures and have a history of joint replacement surgery complication, prophylactic antibiotics should be considered after consultation with an orthopedic surgeon. For heart patients, antibiotic prophylaxis is needed only for a few patients with the highest risk of infective endocarditis following dental procedures.

What Are the Drugs Commonly Used for Antibiotic Prophylaxis?

Your dentist will commonly prescribe Penicillin-type antibiotics, such as Amoxicillin and Ampicillin. If you are allergic to Penicillin, then Cephalosporins like Cefazolin and Cefuroxime might be prescribed.

Antibiotic Prophylaxis for Patients With Prosthetic Joints:

Bacteraemia, the spread of infection to the blood, due to dental procedures, increases the risk of prosthetic joint infection. This is why antibiotic prophylaxis was prescribed for such patients in the past. As there is a lack of evidence for oral Streptococcus bacteria resulting in prosthetic joint infection, this practice is not followed any longer. This was after they determined that the rate for prosthetic joints is around 1.5 %, and the main organism responsible is Staphylococcus, which commonly causes skin infections. But, some orthopedic surgeons used to advise patients to take antibiotics prior to all dental visits. But in 2012, after a study showed that dental treatments do not increase the risk of subsequent prosthetic joint infection, and antibiotic prophylaxis does not really reduce the risk of joint infection, practitioners were advised against prescribing prophylactic antibiotics for patients who had hip and knee prosthetic joint implants and wanted to get dental procedures done.

Nowadays, as the risks of side effects outweigh the benefits of prophylaxis, antibiotics are no longer recommended. Only if the patient has a recent history of prosthetic infection, and if the orthopedic surgeon thinks antibiotics are needed, they are prescribed before dental procedures.

Antibiotic Prophylaxis for Heart Patients:

Patients with certain heart conditions are at risk of developing infective endocarditis, a rare but potentially fatal complication of bacteremia. It is the infection of the heart valves or the inner lining of the heart chambers (endocardium). Viridans Streptococci, Staphylococcus aureus, and Enterococcus bacteria are commonly responsible for infective endocarditis. The less common causes include infection with Enterococcus, Haemophilus species, Eikenella corrodens, and Kingella species.

The following guidelines were issued by the American Heart Association (AHA) for the prevention of infective endocarditis and to avoid antibiotic resistance:

1. Daily activities like toothbrushing, chewing, using a toothpick, and water flossing are more likely to cause bacteremia when compared to dental treatments.

2. Prophylactic antibiotics only seem to prevent very few numbers of IE cases in those who undergo dental treatments.

3. The side effects of administering antibiotics are more than the benefits.

4. Maintaining optimal oral health and hygiene is more likely to reduce the incidence of bacteremia due to daily activities than prophylactic antibiotics.

As of now, the AHA recommends antibiotic prophylaxis for the following heart patients before a dental procedure:

1. Prosthetic heart valves.

2. A history of infective endocarditis.

3. Congenital heart defect (CHD).

4. Unrepaired cyanotic congenital heart diseases, which includes palliative shunts and conduits.

5. Repaired congenital heart defect with prosthetic material or device, in the first six months after the surgery.

6. Persisting leaks or abnormal blood flow present adjacent or at the site of repaired congenital heart defects.

7. Heart implant patients that develop heart valve problems.

Patients who fall under that above list should be prescribed prophylactic antibiotics before all dental treatments that require manipulating the gums or the region surrounding the tooth (periapical area) or incision in the oral mucosa. Prophylaxis is not needed while taking dental x-rays, placing removable orthodontic or prosthodontic appliances, placing braces, adjusting braces, and bleeding due to injury to the lips or mucosa.

Antibiotic Prophylaxis for Immunocompromised Patients:

People with a compromised immune system are also at risk of developing infections due to bacteremia. Some immunocompromised patients might need antibiotics before any dental procedures to minimize the risk of infections. The dentist should consult the patient's general physician. Take an informed decision to prescribe prophylactic antibiotics to patients with the following conditions:

1. Human immunodeficiency virus (HIV) infection.

2. Severe combined immunodeficiency (SCIDS).

3. Neutropenia.

4. Undergoing chemotherapy for cancer.

5. After organ transplantation.

6. History of radiotherapy to the head and neck.

7. Autoimmune diseases, such as lupus and juvenile arthritis.

8. Sickle cell anemia.

9. Uncontrolled diabetes.

Antibiotic Prophylaxis Regimen:

Antibiotics are commonly administered an hour before the dental procedure.

Side Effects of Antibiotic Prophylaxis:

Indiscriminate and overuse of antibiotics has resulted in antibiotic-resistant bacteria, also called superbugs. Some of the common superbugs include MRSA (methicillin-resistant Staphylococcus aureus), Clostridium difficile, and bacteria that result in multidrug-resistant tuberculosis (MDR-TB). Infections with these superbugs are severe and challenging to treat.

Always watch out for fever, pain, pus discharge, and abscess from the extraction or dental procedure site. These are signs of infection. Call your dentist immediately if you have these symptoms. For more information, consult a dentist online now.