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, as well as the potential for an adverse anaphylactic reaction to the drug administered, it is best to be judicious in the use of antibiotics for the prevention of infective endocarditis (IE) and other distant-site infections.
Patients with Cardiac Conditions
Dental practitioners should consider prophylactic measures to minimize the risk of IE in patients with underlying cardiac conditions. The risk of developing IE can arise from a combination of high-risk patients and dental procedures. However, at-risk patients with poor oral hygiene and gingival bleeding after routine activities (e.g., toothbrushing) also have shown an increased potential for developing complications of IE. It, therefore, is recommended to encourage daily good oral hygiene practices to reduce gingivitis as part of the prophylactic regimen. 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 latest 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 or incompletely repaired 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 cardiac valvulopathy. In addition to those diagnoses listed in the AHA guidelines, patients with a reported history of injection drug use may be considered at risk for developing IE in the absence of cardiac anomalies. Although quite rare, complications from intraoral tongue piercing can include IE among patients with a pre-existing cardiac valvular condition and/or history of injection drug use. 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 in the AHA Circulation Journal archives, http://circ.ahajournals.org/cgi/content/full/116/15/1736 
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. These non-cardiac factors can place a patient with compromised immunity at risk for distant-site infection from a dental procedure. This category includes, but is not limited to, patients with the following medical conditions:
- Immunosuppression secondary to:
- Human immunodeficiency virus (HIV)
- Severe combined immunodeficiency (SCIDS)
- Neutropenia
- Cancer chemotherapy
- Hematopoietic stem cell or solid organ transplantation
- Head and neck radiotherapy
- Autoimmune disease (e.g., juvenile arthritis, systemic lupus erythematosus)
- Sickle cell anemia
- Asplenism or status post splenectomy
- Chronic steroid usage
- Diabetes
- Bisphosphonate therapy
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) and cardiovascular implantable electronic devices (CIED), 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 CIED and nonvalvular devices at any time after implantation. The infections occurring after device implantation most often are caused by Staphylococcus aureus and coagulase negative staphylococci or other microorganisms that are non-oral in origin but are 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), ventriculocardiac (VC), 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.
Patients with Prosthetic Joints
For patients with a history of total joint arthroplasty, deep hematogenous infections can lead to life threatening complications such as a loss of the prosthetic joint or even increased morbidity and mortality. A 2009 information statement published by the American Academy of Orthopaedic Surgeons (AAOS) recommends that dentists consider antibiotic prophylaxis for at-risk joint replacement patients who are undergoing an invasive procedure. Patients with an increased risk of hematogenous total joint infection are all patients with a prosthetic joint replacement, previous prosthetic joint infection, inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus), megaprosthesis, hemophilia, malnourishment, and compromised immunity (see examples above). However, AAOS states that clinical judgment must consider the potential benefit of antibiotic prophylaxis versus the risks of adverse reactions for each patient. The AAPD recognizes that there are varying recommendations from AAOS and the American Dental Association (ADA) with regards to antibiotic prophylaxis for patients with joint replacement. However, the AAOS is collaborating with the American Dental Association to develop evidence-based recommendations on antibiotic prophylaxis for patients at a high risk for hematogenous total joint infection.
Currently, the AAPD endorses the 2003 common recommendations of the ADA and the AAOS for management of patients with prosthetic joints. Antibiotic prophylaxis has not shown a significant reduction in the risk of developing joint infections subsequent to dental procedures. Therefore, antibiotic prophylaxis is not indicated for dental patients with pins, plates, screws, or other hardware that is not within a synovial joint nor is it indicated routinely for most dental patients with total joint replacements. Antibiotics may be considered when high-risk dental procedures (see Table 2 below) are performed for patients within 2 years following implant surgery, immunocompromised patients with total joint arthroplasty, or patients who have had previous joint infections.
Consultation with the child's physician may be necessary for management of at-risk patients as well as patients with other implanted devices (e.g., Harrington rods, external fixation devices). In addition, as consensus may change following this review, practitioners are encouraged to follow the literature for the most current information on antibiotic prophylaxis.
| 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.
