Antibiotic Prophylaxis Prior to Dental Treatment: Current Status

Ira Lamster DDS, MMSc

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Antibiotic Prophylaxis Prior to Dental Treatment: Current Status

There is a global crisis resulting from the overuse of antibiotics, leading to an increase in the number of bacterial species (strains) resistant to some or all antibiotics commonly used to treat infections. This has developed by a process of natural selection, as the historical overuse of these drugs has led to emergence of bacteria that can survive when antibiotics are used to treat infections that occur in a variety of clinical situations.

In response to this present and still expanding threat, major efforts are underway to reduce the use of antibiotics in all disciplines of healthcare, certainly including dentistry. These efforts take a number of forms, including reduction in the use of antibiotics in food production (specifically in animals to increase growth), elimination of the use of antibiotics when the underlying disease is either not associated with a bacterial infection (i.e. in pediatrics, elimination of antibiotic treatment when a viral cause of an upper respiratory infection is suspected), reduced usage when other approaches can address the problem (i.e. endodontic treatment that successfully treats a pulpal infection), as well as a reduction in the use of prophylactic antibiotics prior to a dental appointment (i.e. to prevent an infection following dental care). Several recent articles have reviewed the current protocols for antibiotic prophylaxis prior to dental treatment. This information is critically important for dentists and dental hygienists when advising certain patients how to prepare for their dental appointment.

A review by Goff and colleagues1Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of guidelines for dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections and need for dental stewardship. Clin Infect Dis 2019. examined the need for antibiotic prophylaxis prior to dental treatment for both prevention of infective endocarditis in patients with a history of cardiac disease, and prevention of infection of prosthetic joints. These clinical situations have traditionally been the two main indications for antibiotic prophylaxis in dentistry.

There is a lack of clarity regarding the need for antibiotic prophylaxis, which often results in confusion among the treating dentist, the patient’s physician and the patient. As reviewed by Goff et al1Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of guidelines for dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections and need for dental stewardship. Clin Infect Dis 2019., the original guidelines for prevention of infective endocarditis were published more than 65 years ago. The American Dental Association’s involvement began in 1972, with a significant change occurring in 1997 with the elimination of the post-procedural dose, but retention of the pre-procedural dose. However, the rationale for prophylaxis has been questioned since a bacteremia can be created following toothbrushing, and proper oral hygiene to reduce the oral microbial burden, performed daily, has been argued to be more important than antibiotic prophylaxis. Further, unnecessary ingestion of antibiotics can be associated with adverse events for both the patient and society.

Recent data illustrates the over-use of prophylactic antibiotics to prevent cardiac and prosthetic joint infections associated with dental treatment and argues for the drastic reduction of this practice. An analysis of data from commercial insurance carriers and Medicare examined data for a four-year period and included 168,420 dental visits for 91,438 patients. Based on current criteria, more than 80% of the prescriptions for prophylactic antibiotics were unnecessary2Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open 2019;2:e193909..

The situation with antibiotic prophylaxis to prevent prosthetic joint infections is particularly unsettled. Strong evidence argues against the widespread use of pre-procedural antibiotics to prevent joint infection following dental treatment. Decision modeling indicates that foregoing antibiotic prophylaxis was more cost effective than administration of these drugs for patients who had received total hip replacement3Skaar DD, Park T, Swiontkowski MF, Kuntz KM. Cost-effectiveness of antibiotic prophylaxis for dental patients with prosthetic joints: Comparisons of antibiotic regimens for patients with total hip arthroplasty. J Am Dent Assoc 2015;146:830-839.,4Sendi P, Uckay I, Suva D, Vogt M, Borens O, Clauss M. Antibiotic Prophylaxis During Dental Procedures in Patients with Prosthetic Joints. J Bone Jt Infect 2016;1:42-49.. In addition, epidemiological modelling indicated that the impact of adverse events associated with prophylactic antibiotic administration far exceed any benefit of using these drugs to prevent infection of the prosthesis. Orthopedic surgeons, however, continue to recommend antibiotic prophylaxis for patients who have received a prosthetic joint, and in some cases suggest that patients considered as being at high risk receive antibiotic prophylaxis for their entire lives. While a small percentage of patients (between 0.8 and 1.5%;5Beam E, Osmon D. Prosthetic Joint Infection Update. Infect Dis Clin North Am 2018;32:843-859.) with a joint prosthesis will experience an infection, and the consequences of that infection can be severe including need for placement of the prosthesis, the consequences of overprescribing antibiotics can also be detrimental. As an important example, super-infection with Clostridium difficile can occur with the administration of antibiotics. This infection is associated with significant morbidity and occasionally mortality. In the longer term, overuse of antibiotics is associated with development of resistant bacteria. Considering that joint replacement in the United States is a common surgical procedure (soon to approach one million per year), prophylaxes for all treated patients would be a gross overuse of antibiotics.

There are now a limited number of situations in which antibiotic prophylaxis to prevent infective endocarditis is still recommended. The current regimens are provided in Table 1. At present the current recommendations for antibiotic prophylaxis to prevent infective endocarditis for patients with a history of cardiac disease are as follows6Department of Scientific Information, ADA Science Institute. Antibiotic Prophylaxis Prior to Dental Procedures. American Dental Association. Retrieved from https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis on January 20, 2020..

  1. Prosthetic cardiac values, which include transcatheter-implanted prosthesis and homografts.
  2. Prosthetic material used for cardiac valve repair, i.e. annuloplasty rings and chords.
  3. A history of infectious endocarditis.
  4. A heart transplant, if there is valve regurgitation related to a structurally abnormal valve.
  5. A limited number of congenital heart disorders.
    1. unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
    2. any repaired congenital heart defect with residual shunts or vascular regurgitation at the site of or adjacent to a prosthetic patch or other prosthetic device.

To further define the congenital heart disorders requiring prophylaxis in children, it is recommended in the following conditions:

  1. Cyanotic congenital heart disease that has not been fully repaired, including the use of shunts and conduits.
  2. A congenital defect that is completely replaced with a prosthetic material or device, for six months following the procedure.
  3. Repaired congenital heart disease with residual defects (i.e. persistent leaks or abnormal flow at or near a prosthetic patch or device).

The current recommendations for antibiotic prophylaxis to prevent prosthetic joint infections are as follows7Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146:11-16 e18.:

  1. In general, for patients who have received prosthetic joints, prophylactic antibiotics are not recommended to prevent infections of the prosthetic joint.
  2. If a patient has a history of complications following joint replacement surgery, and the dental care will result in gingival manipulation or a mucosal incision, prophylactic antibiotics should be considered in consultation with both the patient and the patient’s orthopedist.
  3. If prophylactic antibiotics are felt to be indicated, the orthopedist should recommend the appropriate antibiotic regimen and if possible write the prescription.

The focus of the Goff et al1Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of guidelines for dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections and need for dental stewardship. Clin Infect Dis 2019. review is the importance of antibiotic stewardship programs. The intent is to develop a multidisciplinary program that promotes appropriate use of antimicrobial medications (generally antibiotics), with the goal of improving patient outcomes while reducing unnecessary use of these drugs. The examples provided focus on the use of antibiotic prophylaxis prior to dental treatment to prevent a prosthetic joint infection. A pharmacist and physician each with specialty training in infectious diseases were facilitators and included members of the local dental and orthopedic societies. A pretest/posttest format was used, and an informational lecture was presented, followed by evaluation of two cases. This exchange allowed a face-to-face interaction among providers, and the authors list many suggestions and advantages to this approach. Included here are the information provided by infectious disease specialists and, while the orthopedic surgeon ultimately determines the need for prophylaxis, collaboration between dentists and orthopedists will be promoted, including referral to the dentist to perform any necessary dental treatment prior to the joint replacment surgery. However, interprofessional communication is not easy to achieve. If communication is established, patients are better informed and will receive improved care as a result of the collaboration among their health care providers. The emphasis on the practice of “defensive medicine” will be reduced.

Other recent publications have addressed the question of antibiotic prophylaxis prior to dental treatment or oral surgery and are a reminder that the use of antibiotic prophylaxis is not restricted to dental patients with a cardiac condition or a prosthetic joint. Antibiotic prophylaxis is used to prevent post-surgical infection in orthognathic surgery. A complex systematic review concluded that the literature (including both previously published systematic reviews and original research) did not provide guidance as to which antibiotic and at what dosage should be used8Naimi-Akbar A, Hultin M, Klinge A, Klinge B, Tranaeus S, Lund B. Antibiotic prophylaxis in orthognathic surgery: A complex systematic review. PLoS One 2018;13:e0191161.. Prophylactic antibiotics have also been evaluated for their effect on implant outcomes. Two systematic reviews9Braun RS, Chambrone L, Khouly I. Prophylactic antibiotic regimens in dental implant failure: A systematic review and meta-analysis. J Am Dent Assoc 2019;150:e61-e91.,10Abd-Elwahab Radi I, Hassaan A. Which is the best antibiotic prophylaxis protocol to prevent early implant failures? Evid Based Dent 2019;20:105-106., including one with a meta-analysis,9Braun RS, Chambrone L, Khouly I. Prophylactic antibiotic regimens in dental implant failure: A systematic review and meta-analysis. J Am Dent Assoc 2019;150:e61-e91. have examined the available literature and concluded that the use of prophylactic antibiotics may reduce early implant failure. However, there is only limited data on which patients would benefit from this approach, and the indiscriminate use of antibiotics in all patients is not warranted. Further, there is evidence that a higher dose of amoxicillin than what is recommended for prevention of infective endocarditis or prosthetic joint infection (3 g vs. 2 g of amoxicillin) may be more effective in reducing implant complications10Abd-Elwahab Radi I, Hassaan A. Which is the best antibiotic prophylaxis protocol to prevent early implant failures? Evid Based Dent 2019;20:105-106.. Also related to dental implant outcomes, a complex systematic review evaluated the effect of antibiotic prophylaxis on bone augmentation surgery associated with early implant outcomes. No definite conclusions could be drawn11Klinge A, Khalil D, Klinge B, et al. Prophylactic antibiotics for staged bone augmentation in implant dentistry. Acta Odontol Scand 2020;78:64-73..

Conclusions:

  1. Over the past 20 years, the use of prophylactic antibiotics prior to dental care (specifically to prevent infective endocarditis) has been dramatically reduced, certainly contributing to a reduction in the unnecessary use of antibiotics at a time of great concern over development of antibiotic-resistant bacteria.
  2. Antibiotic prophylaxis is still often recommended for patients who are medically complex, with both advanced/congenital cardiac problems or a history of previous complications with a prosthetic joint, or who are compromised immunologically as a result of a chronic disease (i.e. poorly controlled diabetes). These individuals are very likely under the care of medical providers, and consultation with those providers may be desirable before determining the need for antibiotic prophylaxis. This type of interprofessional collaboration will benefit the patient and all involved providers. Data supporting the efficacy of prophylactic antibiotics for many of these subgroups, however, is lacking.
  3. It is incumbent upon the dentist to continue to consider antibiotic stewardship as among their primary responsibilities. Dentists have been estimated to account for 10% of the total number of antibiotic prescriptions in the United States12Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148:172-178 e171.. Appropriate and judicious use of these drugs for both treating oral/dental infections, and pre-medicating patients who may require prophylaxis due to an underlying disease or their medical history, is essential.
Table 1: Recommended Antibiotic Prophylaxis Regimen
No allergy to penicillin
Amoxicillin 2 g orally, 30-60 minutes before the procedure
Allergy to penicillin
Clindamycin 600 mg orally, 30-60 minutes before the procedure.

Acknowledgement: thanks are expressed to Dr. Peter Lockhart for reviewing this essay. Dr. Lockhart has provided a list of additional readings which are included after the reference list.

References

  • 1.Goff DA, Mangino JE, Glassman AH, Goff D, Larsen P, Scheetz R. Review of guidelines for dental antibiotic prophylaxis for prevention of endocarditis and prosthetic joint infections and need for dental stewardship. Clin Infect Dis 2019.
  • 2.Suda KJ, Calip GS, Zhou J, et al. Assessment of the appropriateness of antibiotic prescriptions for infection prophylaxis before dental procedures, 2011 to 2015. JAMA Netw Open 2019;2:e193909.
  • 3.Skaar DD, Park T, Swiontkowski MF, Kuntz KM. Cost-effectiveness of antibiotic prophylaxis for dental patients with prosthetic joints: Comparisons of antibiotic regimens for patients with total hip arthroplasty. J Am Dent Assoc 2015;146:830-839.
  • 4.Sendi P, Uckay I, Suva D, Vogt M, Borens O, Clauss M. Antibiotic Prophylaxis During Dental Procedures in Patients with Prosthetic Joints. J Bone Jt Infect 2016;1:42-49.
  • 5.Beam E, Osmon D. Prosthetic Joint Infection Update. Infect Dis Clin North Am 2018;32:843-859.
  • 6.Department of Scientific Information, ADA Science Institute. Antibiotic Prophylaxis Prior to Dental Procedures. American Dental Association. Retrieved from https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis on January 20, 2020.
  • 7.Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: Evidence-based clinical practice guideline for dental practitioners--a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc 2015;146:11-16 e18.
  • 8.Naimi-Akbar A, Hultin M, Klinge A, Klinge B, Tranaeus S, Lund B. Antibiotic prophylaxis in orthognathic surgery: A complex systematic review. PLoS One 2018;13:e0191161.
  • 9.Braun RS, Chambrone L, Khouly I. Prophylactic antibiotic regimens in dental implant failure: A systematic review and meta-analysis. J Am Dent Assoc 2019;150:e61-e91.
  • 10.Abd-Elwahab Radi I, Hassaan A. Which is the best antibiotic prophylaxis protocol to prevent early implant failures? Evid Based Dent 2019;20:105-106.
  • 11.Klinge A, Khalil D, Klinge B, et al. Prophylactic antibiotics for staged bone augmentation in implant dentistry. Acta Odontol Scand 2020;78:64-73.
  • 12.Roberts RM, Bartoces M, Thompson SE, Hicks LA. Antibiotic prescribing by general dentists in the United States, 2013. J Am Dent Assoc 2017;148:172-178 e171.

Additional readings:

  • Lockhart PB. The risk for endocarditis in dental practice. Periodontol 2000 2000;23:127-135
  • Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. J Am Dent Assoc 2007;138:458-474; quiz 534-455, 437.
  • Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, Bahrani-Mougeot FK. Bacteremia associated with toothbrushing and dental extraction. Circulation 2008;117:3118-3125.
  • Napenas JJ, Lockhart PB, Epstein JB. Comment on the 2009 American Academy of Orthopaedic Surgeons' information statement on antibiotic prophylaxis for bacteremia in patients with joint replacements. J Can Dent Assoc 2009;75:447-449.
  • Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral hygiene as a risk factor for infective endocarditis-related bacteremia. J Am Dent Assoc 2009;140:1238-1244.
  • Lockhart PB. Antibiotic prophylaxis for dental procedures: are we drilling in the wrong direction? Circulation 2012;126:11-12.
  • Lockhart PB. Antibiotic prophylaxis guidelines for prosthetic joints: much ado about nothing? Oral Surg Oral Med Oral Pathol Oral Radiol 2013;116:1-3.
  • Mougeot FK, Saunders SE, Brennan MT, Lockhart PB. Associations between bacteremia from oral sources and distant-site infections: tooth brushing versus single tooth extraction. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:430-435.
  • Thornhill MH, Dayer MJ, Prendergast B, Baddour LM, Jones S, Lockhart PB. Incidence and nature of adverse reactions to antibiotics used as endocarditis prophylaxis. J Antimicrob Chemother 2015;70:2382-2388.
  • Thornhill MH, Gibson TB, Cutler E, et al. Antibiotic Prophylaxis and Incidence of Endocarditis Before and After the 2007 AHA Recommendations. J Am Coll Cardiol 2018;72:2443-2454.
  • Thornhill MH, Dayer MJ, Durkin MJ, Lockhart PB, Baddour LM. Risk of Adverse Reactions to Oral Antibiotics Prescribed by Dentists. J Dent Res 2019;98:1081-1087.