Table 8: Dental Procedures That May Carry a Higher Bacteremic Risk Incidence Dental Procedure Higher incidence* • Dental extractions.
• Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/strips, scaling and root planing, probing, recall maintenance. • Dental implant placement and replantation of avulsed teeth. • Endodontic (root canal) instrumentation or surgery only beyond the apex.
• Initial placement of orthodontic bands but not brackets. • Intraligamentary and intraosseous local anesthetic injections. • Prophylactic cleaning of teeth or implants where bleeding is anticipated. • Restorative dentistry (operative and prosthodontic) with/without retraction cord.*** • Local anesthetic injections (non-intraligamentary and non-intraosseous). • Intracanal endodontic treatment; post placement and buildup. • Placement of rubber dam. • Postoperative suture removal. • Placement of removable prosthodontic/orthodontic appliances. • Taking of oral impressions. • Fluoride treatments. • Taking of oral radiographs. • Orthodontic appliance adjustment.
Lower incidence**
* Prophylaxis should be considered for patients with total joint replacement who meet the criteria in Table 7. No other patients with orthopedic implants should be considered for antibiotic prophylaxis prior to dental treatment/procedure. **Prophylaxis not indicated although clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding. *** Includes restoration of carious (decayed) or missing teeth. Note . Adapted from “Antibiotic Prophylaxis for Dental Patients With Total Joint Replacements,” by the American Dental Association and American Academy of Orthopedic Surgeons, 2003, Journal of the American Dental Association, 134 (7), 895-899.
Antibiotic prophylaxis for immunocompromised patients Numerous medical conditions are associated with suppression of the immune system, either directly from an underlying disease (e.g., diabetes, cancer, hemodialysis, organ transplantation) or from medications used to manage these diseases (e.g., insulin, chemotherapy, prednisone, anti- rejection medications). A primary concern for an immunocompromised patient is the risk of poor wound healing and systemic involvement from an orofacial infection. Therefore, consideration for appropriate antibiotics is vital to enhance healing of an orofacial infection and to avoid a systemic infection that could lead to a necrotizing fasciitis in the case of a fragile diabetic (Camino Junior, Naclerio- Homem, Cabral, & Luz, 2014; Lockhart et al., 2019). In addition to treatment of active infections, prophylactic antibiotics prior to invasive dental procedures have been suggested for cardiac and orthopedic patients with numerous medical conditions in which patients may not be able to mount an appropriate immune system response (e.g., diabetes, cancer, hemodialysis, organ transplantation patients). The use of appropriate antibiotics for the treatment of an oral infection is vital, particularly in immunocompromised patients with cancer. The timing of dental treatment is complicated in patients being treated with cytotoxic cancer therapy because the definitive treatment (e.g., endodontic therapy, extraction) should be timed prior to chemotherapy-induced neutropenia (low white blood cell count generally defined as 1,700 or fewer neutrophils per microliter of blood) or after the white blood cell counts (WBCs) return to an appropriate level. The development of an orofacial infection during chemotherapy-induced neutropenia is uncommon, which may be partly related to a decreased inflammatory response from deficient WBCs. Use of antibiotics and a delay of definitive dental treatment until WBCs increase is a rational treatment plan for patients with cancer and the associated chemotherapy-associated neutropenia.
Topical antibiotics such as chlorhexidine 0.12% solution (swish and expectorate 10 mL twice daily) are appropriate for localized gingival disease during neutropenia. Practitioners should be cautious, however, that despite the ubiquity of chlorhexidine, dental products containing this agent can cause various hypersensitivity reactions that range in severity from type IV, delayed hypersensitivity (usually manifesting as urticaria and dermatitis or fixed drug eruptions), to type I, which has serious and life-threatening consequences (immediate hypersensitivity and anaphylaxis) (Donaldson & Goodchild, 2019). The use of broad-spectrum antibiotics is also appropriate for the treatment of active orofacial infections in neutropenic patients. The antibiotic regimen should be based on appropriate susceptibility of bacterial isolates as identified through the culturing of draining pus. Outpatient cancer patients or patients without severe neutropenia may respond well to oral antibiotics such as penicillin VK, amoxicillin, clindamycin, azithromycin, tetracycline, or amoxicillin with the β -lactamase inhibitor clavulanate. The use of antibiotics for prophylaxis prior to an invasive dental procedure has been suggested for immunocompromised patients with a variety of conditions, including those with cancer and the associated neutropenia, patients with end-stage renal disease treated with hemodialysis, patients who have undergone organ transplant, and poorly-controlled diabetics. The evidence to support the practice of routine antibiotic prophylaxis prior to invasive dental procedures in these populations continues to evolve, however, and decisions to prescribe are often based on medicolegal concerns rather than literary evidence, which remains poor (Lockhart, Hanson, Ristic, Menezes, & Baddour, 2013; Lockhart et al., 2019; Lodi G, et al., 2021). For these reasons, dental prescribers need to understand that the negative consequences of repeated antibiotic use – such as increased antibiotic resistance, costs, and potential allergic reactions – must always be weighed against the perceived benefit of infection prevention, and that they should therefore practice only evidence-based dentistry.
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