A.M. Sklar, DDS - Premedication

Prevention of Bacterial Endocarditis
premed.htm
Recommendations by the American Heart Association

Disclaimer for patients: you MUST contact your physician or dentist to determine the correct risk factors and regimen to follow. This information is provided as a guide only!

Disclaimer for healthcare professionals: you MUST read and be familiar with the full text article (which was previously at http://www.americanheart.org/Scientific/statements/1997/079701.html but has moved and may still be web-searchable elsewhere) to utilize these recommendations accurately. This information is provided as a guide only!

Simple Version below:

Technical Version below:

Simple Version:

    These guidelines are updated from the 1990 recommendations, and can be found in these journals (Journal of the American Medical Association - June 11, 1997, Vol. 277, No. 22, 1794-1801; Circulation - July 1, 1997, Vol. 96:358-366; ADA News Daily - June 26, 1997; Journal of the American Dental Association - August 1, 1997, Vol. 128, 1142-1151) Reprints of the full article: Kathryn A. Taubert, Ph.D., Office of Science and Medicine, American Heart Association at http://www.americanheart.org , 7272 Greenville Ave., Dallas, TX 75231.

    Bacterial endocarditis is a life-threatening disease, yet most cases are not attributable to an invasive procedure. Medical and dental procedures are both discussed in the full article, but this guide deals only with the dental implications.

    Bacteria that get into the blood (bacteremia) commonly occurs during activities of daily living such as routine tooth brushing or chewing. With respect to endocarditis protection, significant bacteremias are only those caused by organisms commonly associated with endocarditis and attributable to identifiable procedures.

Poor dental hygiene and gum infections or infections around the roots of teeth may produce bacteremia even in the absence of dental procedures.
Home-use devices (toothbrush, floss, Water-Pik, etc.) pose far less risk of bacteremia in a healthy mouth than does ongoing oral inflammation.

Notable Changes

Initial amoxicillin dose reduced to 2.0 grams (from 3.0 grams).
Follow-up dose is no longer recommended.
Erythromycin is no longer recommended.

Other Notes

Orally administered antibiotics are still recommended to be taken 1 (one) hour before a dental procedure.
It is also noted in the article that experimental animal models suggest that antibiotics taken within 2 hours following the procedure will provide effective protection.
Antibiotics taken more than 4 hours after the procedure probably have no protective benefit.
The use of antibiotics to prevent infection of joint prostheses (which was originally at http://www.ada.org/adapco/jada/9707/pro-01.html but has since moves and may be web-searchable) during procedures that bacteria can potentially be introduced into the blood is not within the scope of issues addressed by the committee.
Patients who have successfully used erythromycin for prevention may choose to continue with this antibiotic (previous regimen).
Other medications that can be taken include: cephalexin, cefadroxil (these are cephalosporins and should not be taken by individuals who have immediate-type allergic reactions to penicillin); azithromycin, clarithromycin (these can be used by individuals allergic to penicillin, but are more expensive than the recommended alternative to amoxicillin which is clindamycin). Injectable medications also are available for those who cannot take oral medications.

Heart Conditions Requiring Antibiotics Before Dental Appointments

Prosthetic cardiac valves, including bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (e.g. single ventricle states, transposition of the great arteries, tetralogy of Fallot)
Surgically constructed systemic pulmonary shunts or conduits
Most other congenital cardiac malformations (other than above and below)
Acquired valvar dysfunction (e.g. rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets *

* See full article text for details

Heart Conditions That Do Not Require Antibiotics Before Dental Appointments

Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo.)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation*
Physiologic, functional, or innocent heart murmurs*
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

* See full article text for details

Dental Procedures, Antibiotics Recommended

Extractions
Fillings between teeth, at/below the gumline (bleeding usually expected)
Crowns (bleeding usually expected)
Routine cleanings, gum treatment including surgery, scaling and root planing, probing
Dental implant placement and reimplantation of avulsed teeth
Root canal or root canal surgery (if only inside the tooth, antibiotics not required, but often it goes outside the root tip)
Placement of antibiotic fibers or strips below the gumline
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Teeth or implant cleaning where bleeding is anticipated - all cleanings

Dental Procedures, Antibiotics Not Recommended

Fillings above the gumline, and not between teeth
local anesthetic injections (nonintraligamentary)
Placement of dentures (complete or partial) and orthodontic appliances
Taking oral impressions
Fluoride treatments
Taking of x-rays
Orthodontic appliance adjustment
Shedding of baby teeth

Recommended Antibiotic

Adults: Amoxicillin 2.0 grams (usually 4 - 500mg capsules), 1 hour before dental appointment.
Children: Amoxicillin 50 mg/kg, 1 hour before dental appointment - not to exceed total adult dose (40 kg or 88 lb. child).

Recommended Antibiotic, Allergic to Penicillin

Adults: Clindamycin 600 mg (usually 2 - 300mg capsules), 1 hour before dental appointment
Children: Clindamycin 20 mg/kg, 1 hour before dental procedure - not to exceed total adult dose (30 kg or 66 lb. child).

Special Situations and Circumstances - Check With Your Physician or Us

Patients Already Receiving Antibiotics
Procedures Involving Infected Tissues (e.g. incision and drainage)
Patients Who Receive Anticoagulants (regarding IM or IV prophylaxis)
Patients Who Undergo Cardiac Surgery (preoperative dental care)
Status Following Cardiovascular Procedures

Technical Version:

Excerpts and synopsis of the article:

The wording is often technical, and we apologize in advance; however, considering the nature of the material covered it is important to be exact.

These are the updated guidelines from the American Heart Association for antibiotic premedication for the prevention of bacterial endocarditis. These guidelines are updated from the 1990 recommendations, and can be found in these journals (Journal of the American Medical Association - June 11, 1997, Vol. 277, No. 22, 1794-1801; Circulation - July 1, 1997, Vol. 96:358-366; ADA News Daily - June 26, 1997; Journal of the American Dental Association - August 1, 1997, Vol. 128, 1142-1151) Reprints of the full article: Kathryn A. Taubert, Ph.D., Office of Science and Medicine, American Heart Association at http://www.americanheart.org, 7272 Greenville Ave., Dallas, TX 75231.

Factors for risk assessment:

the degree to which the patient's underlying condition creates a risk of endocarditis;
the apparent risk of bacteremia with the procedure (as defined in these recommendations);
the potential adverse reactions of the prophylactic antimicrobial agent to be used;
and the cost-benefit aspects of the recommended prophylactic regimen.

Cardiac Conditions Associated with Endocarditis

Antibiotic Prevention Recommended

High-risk category

Prosthetic cardiac valves, including bioprosthetic and homograft valves
Previous bacterial endocarditis
Complex cyanotic congenital heart disease (e.g. single ventricle states, transposition of the great arteries, tetralogy of Fallot)
Surgically constructed systemic pulmonary shunts or conduits

Moderate-risk category

Most other congenital cardiac malformations (other than above and below)
Acquired valvar dysfunction (e.g. rheumatic heart disease)
Hypertrophic cardiomyopathy
Mitral valve prolapse with valvar regurgitation and/or thickened leaflets*

Antibiotic Prevention Not Recommended

Negligible-risk category (no greater risk than the general population)

Isolated secundum atrial septal defect
Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo.)
Previous coronary artery bypass graft surgery
Mitral valve prolapse without valvar regurgitation*
Physiologic, functional, or innocent heart murmurs*
Previous Kawasaki disease without valvar dysfunction
Previous rheumatic fever without valvar dysfunction
Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

* See full article text for details

Bacteremia-Producing Procedures

Bacteremias commonly occur during activities of daily living such as routine tooth brushing or chewing. With respect to endocarditis prophylaxis, significant bacteremias are only those caused by organisms commonly associated with endocarditis and attributable to identifiable procedures.

Poor dental hygiene and periodontal or periapical infections may produce bacteremia even in the absence of dental procedures.
Home-use devices pose far less risk of bacteremia in a healthy mouth than does ongoing oral inflammation.

Dental Procedures and Endocarditis Prophylaxis

Antibiotic Prevention Recommended*

Dental extractions
Periodontal procedures including surgery, scaling and root planing, probing, and recall maintenance
Dental implant placement and reimplantation of avulsed teeth
Endodontic (root canal) instrumentation or surgery only beyond the apex
Subgingival placement of antibiotic fibers or strips
Initial placement of orthodontic bands but not brackets
Intraligamentary local anesthetic injections
Prophylactic cleaning of teeth or implants where bleeding is anticipated

Antibiotic Prevention Not Recommended

Restorative dentistry¶ (operative and prosthodontic) with or without retraction cord§
local anesthetic injections (nonintraligamentary)
Intracanal endodontic treatment; post placement and buildup
Placement of removable prosthodontic or orthodontic appliances
Taking oral impressions
Fluoride treatments
Taking of oral radiographs
Orthodontic appliance adjustment
Shedding of primary teeth

* Prophylaxis is recommended for patients with high- and moderate-risk cardiac conditions.
¶ This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth.
§ Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

Prophylactic Regimens

Orally administered antibiotics are recommended to be taken 1 (one) hour before a dental procedure.
It is also noted in the article that experimental animal models suggest that antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis.
Antibiotics administered more than 4 hours after the procedure probably have no prophylactic benefit.
The use of prophylactic antibiotics to prevent infection of joint prostheses (was at http://www.ada.org/adapco/jada/9707/pro-01.html) during potentially bacteremia-inducing procedures is not within the scope of issues addressed by the committee.
Practitioners who have successfully used erythromycin for prophylaxis in individual patients may choose to continue with this antibiotic (previous regimen).

Special Situations and Circumstances

Refer to the full text article for recommendations in specific instances:

Patients Already Receiving Antibiotics
Procedures Involving Infected Tissues (e.g. incision and drainage)
Patients Who Receive Anticoagulants (regarding IM or IV prophylaxis)
Patients Who Undergo Cardiac Surgery (preoperative dental care)
Status Following Cardiovascular Procedures

Dental Procedures and Endocarditis Prophylaxis
Situation	Agent	Regimen*
Standard general prophylaxis	Amoxicillin	Adults: 2.0 g; children: 50mg/kg orally 1 h before procedure
Unable to take oral medications	Ampicillin	Adults: 2.0 g intramuscularly (IM) or intravenously (IV); children: 50 mg/kg IM or IV within 30 min before procedure
Allergic to penicillin	Clindamycin or	Adults: 600 mg; children: 20 mg/kg orally 1 h before procedure
	Cephalexin¶ or cefadroxil¶ or	Adults: 2.0 g; children: 50 mg/kg orally 1 h before procedure
	Azithromycin§ or clarithromycin§	Adults: 500 mg; children 15 mg/kg orally 1 h before procedure
Allergic to penicillin and unable to take oral medications	Clindamycin or	Adults: 600 mg; children: 20 mg/kg IV within 30 min before procedure
Allergic to penicillin and unable to take oral medications	Cefazolin¶	Adults: 1.0 g; children 25 mg/kg IM or IV within 30 min before procedure
* Total children's dose should not exceed adult dose. ¶ Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins. § Azithromycin or clarithromycin are also acceptable alternative agents for the penicillin-allergic individual, although they are more expensive than the other regimens.

Andrew M. Sklar, DDS, PC
http://www.drsklar.com
Family and General Dentistry
4901 Seminary Road, Suite 120
Alexandria, VA 22311
Tel: 703-931-3141
Fax:703-845-1512
email: office@drsklar.com

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