may be of greatest concern. Further complicating the issue is the ongoing emergence of resistant bacterial pathogens created by the indiscriminate use of antibiotics, the costs to the healthcare system, the small risk of fatal allergic reactions, and the reported low compliance rate on the part of physicians and OHCPs with respect to these guidelines. Clearly what drives the prescribing of prophylactic antibiotics in dentistry is a combination of the AHA guidelines, long-standing dogma, practice habits, and medicolegal considerations. The latest AHA recommendations for the dental management of patients with cardiac abnormalities were published in 2007 (Wilson et al., 2007). These guidelines define patients at risk (Table 5), and the appropriate antibiotic regimen they should
receive for prophylaxis (Table 6). The dental procedures most likely to put patients at risk include all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. In contrast, the following procedures and events do not require prophylaxis: ● Routine anesthetic injections through non-infected tissue. ● Taking dental radiographs. ● Placement of removable prosthodontic or orthodontic appliances. ● Adjustment of orthodontic appliances. ● Placement of orthodontic brackets. ● Shedding of deciduous teeth. ● Bleeding from trauma to the lips or oral mucosa.
Table 5: Cardiac Conditions Associated with the Highest Risk of Adverse Outcome from Endocarditis • Prosthetic cardiac valve. • Previous IE. • 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. * Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD. ** Prophylaxis is recommended because endothelialization of prosthetic material occurs within 6 months after the procedure. Note . Adapted from “Prevention of Infectious Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group,” by W. Wilson, K. A. Taubert, M. Gewitz, P. B. Lockhart, L. M. Baddour, M. Levison, … D. T. Durack, 2007, Circulation, 116( 15), 1736-1754. Table 6: AHA Antibiotic Regimens for Endocarditis Prophylaxis Single Dose 30-60 Minutes Prior to Procedure Situation Antibiotic Adults Children Oral Amoxicillin 2 gm 50 mg/kg
Ampicillin or
2 g IM or IV*
50 mg/kg IM or IV
Unable to take oral medication
Cefazolin or Ceftriaxone
1 g IM or IV
50 mg/kg IM or IV
Cephalexin**†
2 g
50 mg/kg
Allergic to penicillin but able to tolerate oral therapy
Clindamycin
600 mg
20 mg/kg
Azithromycin or Clarithromycin
500 mg
15 mg/kg
Allergic to penicillin and unable to take oral medication
Cefazolin or Ceftriaxone†
1 g IM or IV
50 mg/kg IM or IV
Clindamycin
600 mg IM or IV
20 mg/kg IM or IV
* IM – intramuscular; IV – intravenous. ** Or other first or second-generation oral cephalosporin in equivalent adult or pediatric dosage.
† Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins. Note . Adapted from “Prevention of Infectious Endocarditis: Guidelines From the American Heart Association: A Guideline From the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group,” by W. Wilson, K. A. Taubert, M. Gewitz, P. B. Lockhart, L. M. Baddour, M. Levison, … D. T. Durack, 2007, Circulation, 116(15), 1736-1754.
However, intraligamentary and intraosseous anesthetic injections do require antibiotic prophylaxis. The AHA does not recommend secondary antibiotic prophylaxis for patients with nonvalvular cardiovascular devices (i.e., a pacemaker implantation) who are undergoing dental, respiratory, gastrointestinal, or genitourinary procedures (Baddour et al., 2011). When there is any doubt as to whether antibiotic prophylaxis is necessary on any given patient, it is always best to consult with the patient’s physician prior to initiating any invasive dental treatment.
Regardless of the clarity of the most recent guidelines on the appropriate prescribing of antibiotic prophylaxis for cardiac patients at risk (Wilson, et al., 2007), thirteen years later Thornhill et al. still found current practice to be inconsistent (Thornhill, et al. 2020). In fact, their study identi ed substantial underprescribing of antibiotic prophylaxis in patients at high risk of developing infective endocarditis complications undergoing invasive dental procedures, as well as a number of different prescribing strategies to provide antibiotic prophylaxis, some of which were not consistent with modern antibiotic stewardship recommendations.
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