Table 2: Antibiotic Regimens for a Dental Procedure Regimen: Single Dose 30 to 60 Minutes Before Procedure Situation Agent Adults Children Oral Amoxicillin 2 g 50 mg/kg Unable to take oral medication Ampicillin OR 2 g IM or IV 50 mg/kg IM or IV Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV Allergic to penicillin or ampicillindoral Cephalexin* OR 2 g 50 mg/kg Azithromycin or clarithromycin OR Azithromycin or clarithromycin OR 15 mg/kg Doxycycline 100 mg <45 kg, 2.2 mg/kg >45 kg, 100 mg
Allergic to penicillin or ampicillin and unable to take oral medication
Cefazolin or ceftriaxone†
1 g IM or IV
50 mg/kg IM or IV
Clindamycin is no longer recommended for antibiotic prophylaxis for a dental procedure. IM indicates intramuscular; and IV indicates intravenous. * Or other first- or second-generation oral cephalosporin in equivalent adult or pediatric dosing. † Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticarial with penicillin or ampicillin. Note . Data from Wilson WR, Gewitz M, Lockhart PB, et al.; on behalf of the American Heart Association Young Hearts Rheumatic Fever, Endocarditis and Kawasaki Disease Committee of the Council on Lifelong Congenital Heart Disease and Heart Health in the Young; Council on Cardiovascular and Stroke Nursing; and the Council on Quality of Care and Outcomes Research. Prevention of viridans group streptococcal infective endocarditis: A scientific statement from the American Heart Association. Circulation , 2021, 143:e963ee978.
of poor oral hygiene and gingival disease than in a healthy environment. In fact, people with generalized bleeding after toothbrushing had an eightfold increase in the development of bacteremia. This suggests that maintaining the health of the gingival tissues may decrease the risks of developing IE. Before beginning any course of treatment for the patient with a CHD, a consultation should be arranged with the patient’s cardiologist. It is important to ask direct questions about the type of CHD, the type of medical and surgical management, adverse outcomes, and specific recommendations that the cardiologist may have (Al- Mohaissen et al., 2022). The oral healthcare provider should review the latest lab work from the patient’s physician or cardiologist and discuss the results with them. Patients with prosthetic heart valves may be on warfarin (Coumadin, Jantoven) for anticoagulation purposes. In this case, an international normalized ratio (INR), a blood test evaluating the ratio of measured prothrombin time and normal prothrombin time, taken within the past 3 months, should be on file. A recent study found that an INR of less than 3 demonstrated an insignificant risk for postextraction bleeding (Iwata et al., 2022). For patients on antiplatelet medications such as clopidogrel (Plavix), which is rarely used in the pediatric population, a bleeding time test would be indicated. As with the unaffected patient, treatment of dental emergencies, including pain and swelling, should be attended to promptly. It is especially important, however, that the oral healthcare provider be aware of the additional needs of a patient with a CHD. By remaining vigilant regarding the patient’s overall health, current disease status, and oral health needs, the dental professional can see that the patient with a CHD receives safe and effective care in the typical dental office setting.
In addition to the AHA guideline changes, a 2022 Cochrane review of antibiotic use in dentistry to prevent IE concluded that at this time, it is not possible to determine whether the benefits outweigh the risks (Rutherford et al., 2022). The American Academy of Pediatric Dentistry has also created guidelines to assist practitioners when making decisions on antibiotic prophylaxis use in at-risk patients. These guidelines reflect 2021 AHA recommendations and defer to AHA’s expertise, recommending conservative use of antibiotics to minimize the development of antibiotic resistance (AAPD, 2022d). Patient history is an important part of the assessment of the child with a CHD. Thorough discussion with the patient’s caregiver regarding dietary and hygiene habits is helpful when creating a treatment plan for long-term oral health. Although corrective treatments such as direct and indirect restorations, scaling and root planing, and extractions are important to eradicate active dental disease, it is long-term oral health maintenance that will help prevent IE in the future. Several risk or pathologic factors may be present in the caries risk assessment of patients with cardiac anomalies. For example, the patient may be taking several doses of a sugar-sweetened medication daily, may be prevented from maintaining adequate oral hygiene by frequent hospitalizations, or may not have access to fluoridated community water. Reviewing potential risk factors and increasing protective factors can help reduce the long-term risk for developing caries, thereby reducing the risk of IE for the CHD patient. Research strongly indicates that patients with good oral hygiene develop less bacteremia than those with poor oral hygiene. According to a study by Lockhart and colleagues (2023), there is a significantly greater risk of developing measurable bacteremia after daily brushing in the presence
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