Last year I wrote an article about dental antibiotic prophylaxis, which talked about why dentists prescribe antibiotics for their patients to take before many dental procedures.

In that post I mentioned that anybody who has a joint replacement is supposed to get antibiotics prescribed to them before certain dental procedures.  The reason for this is that there are millions of bacteria in our mouth that may enter our bloodstream during certain dental procedures.  When an artifical joint gets infected, it normally is considered a failure.

Since antibiotics are very cheap and they can help prevent the infection of an artificial joint, it seems like a no-brainer to give antibiotics to patients before invasive dental procedures so that the catastrophic loss of an artificial joint can be avoided.

However, there really isn’t conclusive evidence that antibiotics prevent joint infections in the average healthy person.  That is why, in the American Dental Association’s original 1997 guidelines on dental antibiotic prophylaxis for joint replacements, and in the 2003 guidelines, the ADA stated, “Antibiotic prophylaxis is not routinely indicated for most dental patients with total joint replacements.”

However, a few years later, the ADA reversed its position and stated that everyone who had an artificial joint replacement needed to take antibiotics before invasive dental procedures regardless of whether or not that person was even at a high risk for developing an infection.  Those were the current guidelines when I wrote my post on dental antibiotic prophylaxis last year.  However, I also mentioned that the ADA was looking into the issue and would likely issue some new guidelines this year.

New Dental Antibiotic Prophylaxis Recommendations for Patients With Total Joint Replacements

The ADA has since turned away from its aggressive approach of recommending that everyone with a total joint replacement get antibiotics before invasive dental work.

Last year I mentioned that the ADA had formed a task force to research the literature and form new guidelines on the decision of how to give antibiotic prophylaxis to patients who had undergone total joint replacement.  The ADA has since removed the recommendation from their website that all patients with joint replacements be premedicated with antibiotics before dental work.  They have now posted the following recommendation (I bolded the main points):

“The American Dental Association and the American Academy of Orthopedic Surgeons (AAOS) are currently in the process of developing evidence-based clinical guidelines on the topic of antibiotic prophylaxis for patients with orthopedic implants undergoing dental procedures. The ADA and AAOS do not have a joint recommendation at this time. There are differing opinions on the need for antibiotic prophylaxis. These opinions/statements are presented below to assist the dentist in making informed decisions about the prescription of antibiotics. The ADA believes that the professional goal should be consensus among the dentist and physician, which is the expressed goal being pursued in the ongoing ADA/AAOS project.”

Basically, the ADA is stating that the dentist and physician should weigh the benefits/risks to each patient and then assess how likely it is that a given patient would develop an infection in an artificial joint.  If they determine that the risk is high enough, then antibiotics should be given before invasive dental procedures.  If the risk of infection to the joint replacement is extremely low, then antibiotics before dental work probably are not needed.

Antibiotics Are No Longer Necessary for All Patients with Joint Replacements Before Dental Work

Basically, the new guidelines (or lack of guidelines) mean that not all patients with artificial joint replacements need to get premedicated with antibiotics before invasive dental work.

I think that this is a good thing.  Many times dentists had to premedicate patients when there was hardly any risk at all of infection.  In very healthy patients, this meant that dentists were prescribing tons of unnecessary antibiotics.

I do think that many dentists and physicians will continue to prescribe antibiotics because it is the “safe” thing to do legally.  Even though lots of antibiotics may not be in the patients best interest, it is the best way for physicians and dentist to cover themselves legally.  For example, a dentist might end up in court for failing to prescribe antibiotics when it was probably needed, but a dentist would likely never end up in court for unnecessarily prescribing excessive antibiotics to patients.

What Do You Think?

Do you have a joint replacement?  Do you think that antibiotics are really necessary before invasive dental work?  Do you have any questions or concerns about taking antibiotics before dental work?  I’d love to hear what you have to say in the comments section below.  Thanks for reading!

During my first few weeks as a student-dentist in the clinic at dental school, I had a new patient assigned to me.  She arrived late, and we were both in a hurry to get the oral examination and treatment planning finished so we could start working on her teeth.

Without going into too much detail, she had a history of heart problems as a child.  After mentally running through the guidelines for determining which patients need antibiotics, I didn’t think she needed to be premedicated.  I went ahead and did a screening procedure to check the health of her gums which made her bleed slightly.  When the dentist in charge came to review what I had done, he told me that this patient should have been premedicated with antibiotics for the procedure.  He had me immediately go over to the appropriate department and get 2 grams of amoxicillin for my patient.

I explained everything to the patient and she was very understandable.  However, with her particular condition, I still didn’t think she needed to take the antibiotics.   But I did what my professor told me to do.

At the end of the appointment, I told my professor that I felt like an idiot.

He replied, “You should.”  Then he told me that it wasn’t a big deal because her condition wasn’t too risky, and since we got her the antibiotics within two hours of the procedure, no harm was done.

As it turns out, my patient did not need the antibiotics that we gave her (according to the 2007 American Heart Association guidelines).  However, she would have needed them according to the old guidelines, which is probably what my professor had memorized.

All in all, it ended up being a good learning experience for me.  I learned to double-check with my dental professors about pre-medication before doing gingival/gum screenings.  I also learned the importance of not rushing, even if a patient is in a hurry.   As a health professional, I am responsible for ensuring that things are done properly so that the patient receives proper treatment..

After thoroughly researching this subject, I decided to share my findings about antibiotic pre-medication.  This is often called antibiotic prophylaxis; prophylaxis is defined as protective or preventive treatment.

Why Do Some Dental Patients Need Antibiotic Prophylaxis?

We have billions of bacteria living on and inside our body.  However, our blood is usually kept free of bacteria as a result of our hard-working immune system.  If bacteria enters our bloodstream, it is known as a bacteremia.

When a dentist extracts a decayed tooth that is infected with millions of bacteria, some of those bacteria could enter the bloodstream.

So, let’s say that a patient needs a tooth extracted and he just had a plastic heart valve inserted into his heart.  The bacteria in that patient’s mouth have the ability to attach to the plastic heart valve in that person’s heart.  This could lead to a very serious condition known as infective endocarditis.

After seeing the patient I mentioned above, I went online to research which exact conditions require premedication.  I have summarized the information I gathered below.

6 Conditions For Which Antibiotic Pre-Medication Might Be Necessary

The heading to this section says “might be necessary” because the necessity for antibiotic pre-medication depends on which procedure is being performed.  In the next section, you’ll find a list of the dental procedures that do not require an antibiotic prophylaxis before visiting your dentist.

Heart Conditions

1 – Prosthetic Cardiac valve or prosthetic material used for cardiac valve repair.

2 – Previous case of infective endocarditis.

3 – If the patient has had congenital heart disease AND any of the following apply:

• The patient has unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
• The patient has a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during hte first six months after the procedure. Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the procedure.
• Repaired congenital heart disease  with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization).

4 – Cardiac transplantation recepients who develop cardiac valvulopathy.

Those are the only heart conditions that require antibiotic premedication.  For your information, endothelialization refers to the tissue layer of the heart growing over the prosthetic material that was implanted.  The bacteria are easily able to colonize a prosthetic device in the heart.  Once the natural heart tissue grows back, there is no need to premedicate.

Prosthetic Joint Conditions

5 – Prosthetic Joints

Patients with prosthetic joints are at an increased risk of developing an infection.  If you have an artificial joint and it becomes infected with bacteria, it is very difficult for your body to fight off that infection due to a lack of blood vessels supplying the artificial joint.

The American Academy of Orthopaedic Surgeons recommends that “all patients with prosthetic joint replacement” receive antibiotic prophylaxis before an invasive dental procedure.

However, only patients with total joint replacements need to be premedicated.  “Patients with pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms.” (Source, AAOS)

Note that these guidelines regarding total joint replacement will probably change within the next one to two years.  The American Dental Association has stated the following:

In collaboration with the ADA, the AAOS has assembled a work group to develop evidence-based clinical guidelines on the topic of antibiotic prophylaxis for patients with total joint replacements undergoing dental procedures. It is possible that the recommendations will change following an evidence-based review of this topic beginning in 2010 and extending through 2011. Therefore, you are encouraged to check the ADA Web site for the most current information.

I would expect that the guidelines will be more relaxed when it comes to premedicating those with total joint replacements.  In the past, dentists only premedicated for total joint replacements if it had been replaced within the last few years.

Immune Conditions

6 – Compromised Immunity.  If you have a compromised immune system, it may be harder for your body to fight off bacteremia caused by a dental procedure.  I made the following list of conditions that may qualify for antibiotic premedication before an invasive dental procedure from three papers: a paper by the American Academy of Pediatric Dentistry entitled, Guideline on antibiotic prophylaxis for dental patients at risk for infection; Antibiotic prophylaxis in dentistry: an update from the Academy of General Dentistry; and Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements published by the American Academy of Orthopaedic Surgeons.

• Human Immunodeficiency Virus (HIV)
• Severe Combined Immunodeficiency (SCIDS)
• Neutropenia
• Immunosuppression (Drug-induced, radiation-induced, or any other type)
• Sickle Cell Anemia
• Within six months of a splenectomy (more studies needed)
• Chronic Steroid Usage
• Lupus Erythematosus or Rheumatoid Arthritis
• Sickle Cell Anemia
• Poorly-controlled Type I Diabetes
• After an Organ Transplant if organ is being rejected, functioning poorly, or there is abnormally high immunosuppression.

You may not necessarily need an antibiotic premedication if you have any of the above conditions.  Your dentist and primary care physician (PCP) are qualified to understand your unique situation and determine whether or not you need to be premedicated with antibiotics before invasive dental procedures.

Antibiotic Premedication Is Only Necessary for Certain Dental Procedures

If you have a condition above that requires antibiotic prophylactic premedication, you don’t necessarily need to take antibiotics before going to the dentist.  It all depends on what procedure you are having done at the dental office.

You only need to take an antibiotic premedication if the dentist will be doing a procedure that involves “manipulation of the gingival tissue or the periapical region of teeth or perforation of the oral mucosa.” (AHA guidelines)  The American Academy of Orthopaedic Surgeons came out with a more specific list in their guidelines from 2003, but did not include it in their most recent update.

Here’s the list from the American Academy of Orthopaedic Surgeons of dental procedures where antibiotic premedication is required:

• Dental extractions (removing a tooth or teeth)
• Periodontal procedures including:
  • Periodontal surgery (gum surgery)
  • Subgingival (below the gumline) placement of antibiotic fibers/strips
  • Scaling and root planing (a deep cleaning of the root surface of the teeth)
  • Periodontal probing (measuring the pocket between your tooth and gums)
  • Periodontal recall maintenance (a thorough examination of the gums with the possibility of additional cleaning needed)
• Placement of dental implants
• Endodontic instrumentation (root canal) or surgery that goes beyond the apex (end of the tooth root)
• Initial placement of orthodontic bands (but not brackets – see below on list of procedures not requiring antibiotic premedication)
• Intraligamentary (in the ligament) and intraosseous (in the bone) local anesthetic injections (but not routine anesthetic injections – see below)
• Dental cleaning of teeth or implants where bleeding is anticipated.

Here’s a list from the Amerian Heart Association of dental procedures that do NOT require antibiotic premedication:

• Routine anesthetic injections through non-infected tissue (routine “numbing” done before a procedure)
• Taking dental X-Rays
• Placement of removable prosthodontic appliances (dentures, removable partial dentures, etc.)
• Placement of removable orthodontic appliances (retainers, etc.)
• Adjustment of orthodontic appliances (tightening braces, adjusting palatal expanders, etc.)
• Placement of orthodontic brackets (for braces)
• Loss of a baby tooth
• Bleeding from trauma to the lips or oral mucosa (mucosa is the lining of the mouth, such as the inside of the lips, cheeks, etc.)

What Antibiotic Will My Dentist Prescribe for Premedication?

The current guidelines state that a single dose of antibiotics should be given 30 to 60 minutes before the dentist performs the procedure.

If you can take pills, then the dentist will prescribe 2 grams of amoxicillin for adults or for children 50 mg/kg, not to exceed 2 grams.

If you’re allergic to the penicillin family of medications, then the dentist can prescribe any of the following antibiotics:

• Cephalexin – 2 grams for adults or 50mg/kg in kids.
  • Or another first or second-generation oral cephalosprin in equivalent adult or child dosage (i.e. – Cephradine.)
• Clindamycin – 600 mg for adults or 20mg/kg in children.
• Azithromycin – 500 mg for adults or 15 mg/kg in children.
• Clarithromycin – 500 mg for adults or 15 mg/kg in children.

If You Can’t Take Pills

If you have difficulty swallowing pills, your dentist will provide the antibiotic through an IV or an injection.  There are many antibiotics available for this purpose, such as ampicillin, cefazolin, ceftriaxone, cefazolin, and clindamycin.

Conclusion

Do you have any questions on antibiotic premedication and dentistry?  Please leave them below in the comments!

I do plan on adding a follow-up article regarding the effectiveness of antibiotic premedication in the prevention of bacteremias and infections.  I’ll put a link here when I get it written.  Thanks for reading!

References and Extras

Antibiotic Prophylaxis in Dentistry: An Update from the Academy of General Dentistry

A printable, informative wallet card from the American Heart Association regarding antibiotic premedication (PDF file)

Antibiotic prophylaxis information from the American Dental Association

Reprinted American Heart Association information on antibiotic prophylaxis courtesy of the American Dental Association

Official guidelines on Antibiotic Prophylaxis for complete joint replacement from the American Academy of Orthopaedic Surgeons