Quality Resource Guide

Contemporary Approaches to Antibiotic Prophylaxis 2nd Edition

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Rationale for Antibiotic

Prophylaxis in Dentistry

A dentist is often faced with the decision whether

to use antibiotics prior to dental procedures to

prevent a distant site infection (DSI). The rationale

for use is based in biologic plausibility as bacteria

from the mouth have been implicated in severe

infections in other parts of the body, specifically in

cardiac valves and prosthetic joints. Studies over

the years have used bacteremia as a surrogate

risk factor for developing DSI.

Of concern is

that transient bacteremia has been proven to

occur after normal physiologic activities, such as

eating. However, this bacteremia will usually clear

quickly after the activity.

Likewise, tooth-brushing

results in transient bacteremia in many cases.

The risk of transient bacteremia during certain

dental procedures is also very likely.

Lockhart

et al in 2008 studied bacteremia associated

with tooth brushing and dental extraction and

noted that although amoxicillin had a significant

impact on bacteremia resulting from a single-tooth

extraction, given the greater frequency for oral

hygiene, tooth brushing may be a greater threat

for individuals at risk for infective endocarditis

(IE).

In another study, he noted that oral hygiene

and gingival disease indexes were associated

significantly with IE-related bacteremia after

tooth brushing.

In this study, participants with

mean plaque and calculus scores of 2 or greater

were at a 3.78- and 4.43-fold increased risk of

developing bacteremia, respectively. Furthermore,

the presence of generalized bleeding after tooth

brushing was associated with an almost eightfold

increase in risk of developing bacteremia.

Since bacteremia has been suggested as a

flawed surrogate for risk of DSI,

and antibiotics

have both individual and societal side effects,

especially when used repeatedly (as in antibiotic

prophylaxis),

serious questions remain:

Introduction

With life expectancy in the United States on the

rise, patients with complex medical problems will

continue to require dental care. It is estimated

that the number of patients 65 years and older

will rise to 94.6 million by the year 2060, while

those over the age of 85 will increase to over

19 million.

Forty percent of these patients will

have chronic conditions, including heart disease

and arthritis, that limit daily activities.

Many

of these patients will be prescribed multiple

medications to treat their ailments.

Dental

treatment has become increasingly complex,

often requiring multiple appointments of long

duration. Today’s dentist will be required to have

significant medical training in order to serve the

growing needs of the population. Dentists will

need to recognize deviations from normal health

that may alter dental treatment, including the

decision to use prophylactic antibiotics. Since

antibiotic use is associated with risks of allergy

and opportunistic infections , societal risk of

resistance, antimicrobial stewardship is critical.

However, there are various clinical situations

when prophylactic antibiotics may be appropriately

used prior to dental treatment. For example,

practitioners will consider administering antibiotic

prophylaxis if their patients are significantly

immunosuppressed or severely neutropenic.

4,5

There are also times when the dentist will need

to make informed decisions regarding the risk

of dental procedures for a patient without using

prophylactic antibiotics versus the risk of using an

antibiotic prophylactically, and identify the need

for medical consultation when the underlying

conditions are unclear.

The scope of this Quality Resource Guide will

include the consideration of using antibiotic

prophylaxis in patients with cardiac valvular

disease and with prosthetic joints.

•

Does dental treatment-induced bacteremia

cause distant site infections?

•

If so which patients are at greatest risk?

•

Does antibiotic prophylaxis prevent these

bacteremic events?

•

What is the risk / benefit ratio in using

antibiotic prophylaxis?

Although medical consultation is a means

for obtaining the necessary information to

make decisions and render treatment, it does

not exonerate dentists from responsibility

Since dentists remain legally accountable for the

care they provide, an evidence-based approach

should guide care.

So, dentists are often faced with the important

question: is antibiotic prophylaxis necessary for

my patient?

Prevention of Endocarditis

Guidelines from the

American Heart Association

Infective Endocarditis (IE) is a microbial infection

of the heart valves or endocardium.

It is important

for dentists to recognize patients at risk for IE.

Current data indicates the incidence of IE ranges

from 1.5 to 11.6 cases per 100,000 persons per

year.

IE is more common in men with a mean

age of diagnosis of 60.8 years old.

Endocarditis

has become more common in the elderly with

50% of all cases occurring in patients over 50.

It has been suggested that this trend maybe due

to an aging population, increased prevalence

of cardiac valvular disease or an increasing

population having in-dwelling devices.

12,13

Infective

endocarditis is commonly divided into native

valve endocarditis (NVE) and prosthetic valve

endocarditis (PVE). NVE can be subdivided into

acute and subacute categories while PVE could

be divided into early and late varieties. Acute