Professional Documents
Culture Documents
Adopted
1990
Revised
1991, 1997, 1999, 2002, 2005, 2007, 2008, 2011, 2014
The significant reasons for the revision include1,2: hygiene practices to reduce gingivitis as part of the prophylactic
IE is much more likely to result from frequent exposure regimen.1,2,11,12 These patients and/or parents need to be
to random bacteremias associated with daily activities educated and motivated to maintain personal oral hygiene
than from bacteremia caused by a dental, GI tract, or GU through daily plaque removal, including flossing.1,2 Greater
tract procedure.1 (Daily activities would include tooth- emphasis should be placed on improved access to dental care
brushing, flossing, chewing, using toothpicks, using water and oral health in patients with underlying cardiac conditions
irrigation devices, and other activities.) at high risk for IE and less focus on a dental procedure and
Prophylaxis may prevent an exceedingly small number antibiotic coverage.1,2,10-12 Professional prevention strategies
of cases of IE, if any, in individuals who undergo a should be based upon the individuals assessed risk for caries
dental, GI tract, or GU tract procedure. and periodontal disease.
The risk of antibiotic-associated adverse events exceeds Specific recommendations from the 2007 AHA guideline
the benefit, if any, from prophylactic antibiotic therapy. on prevention of IE are included in the following tables.
Maintenance of optimal oral health and hygiene may re- The AHA recommends antibiotic prophylaxis only for those
duce the incidence of bacteremia from daily activities whose underlying cardiac conditions are associated with the
and is more important than prophylactic antibiotics for highest risk of adverse outcome 1,2 (see Table 1). Such
a dental procedure to reduce the risk of IE.1 conditions include prosthetic heart valves or prosthetic material
The 2007 AHA revision was intended to clarify when anti- used for cardiac valve repair, a previous history of IE, un-
biotic prophylaxis is/is not recommended and to provide repaired or incompletely repaired cyanotic congenital heart
more uniform global recommendations. Major changes from disease (CHD) including palliative shunts and conduits, com-
the 1997 version1,2,8 include: pletely repaired congenital heart defect with prosthetic material
The Committee concluded that only an extremely small or device (whether placed by surgery or by catheter intervention)
number of cases of infective endocarditis might be pre- during the first six months after the procedure, and repaired
vented by antibiotic prophylaxis for dental procedures even CHD with residual defects at the site or adjacent to the site of a
if such prophylactic therapy were 100 percent effective. prosthetic patch or device, and cardiac transplantation recipients
Infective endocarditis prophylaxis for dental procedures who develop cardiac valvulopathy such as valve regurgitation
is reasonable only for patients with underlying cardiac due to a structurally abnormal valve.1,2,14 After the 2007 AHA
conditions associated with the highest risk of adverse revised guidelines were published, there were concerns by
outcome from infective endocarditis. healthcare providers that there may be an increase in cases of
For patients with these underlying cardiac conditions, viridans group streptococci IE due to the decrease in the numbers
prophylaxis is reasonable for all dental procedures that of patients requiring antibiotic prophylactic coverage for dental
involve manipulation of gingival tissue or the periapical procedures. 15 A population based review of definitive and
region of teeth or perforation of the oral mucosa. possible cases of IE demonstrated no observed increase in
Prophylaxis is not recommended based solely on an viridans group streptococci IE after publication of the 2007
increased lifetime risk of acquisition of infective endo- AHA endocarditis prevention guidelines. 15 In addition to
carditis.1 those diagnoses listed in the AHA guidelines, patients with a
reported history of injection drug use may be considered at
Recommendations risk for developing IE in the absence of cardiac anomalies. 13
The conservative use of antibiotics is indicated to minimize the Although quite rare, complications from intraoral tongue
risk of developing resistance to current antibiotic regimens.1-4,7,8 piercing can include IE among patients with a pre-existing
Given the increasing number of organisms that have developed cardiac valvular condition and/or history of injection drug
resistance to current antibiotic regimens, as well as the poten- use. 16-18 Consultation with the patients physician may be
tial for an adverse anaphylactic reaction to the drug admin- necessary to determine susceptibility to bacteremia-induced
istered, it is best to be judicious in the use of antibiotics infections.
for the prevention of IE1,2 and other distant-site infections.9 Antibiotics are recommended for all dental procedures that
involve manipulation of gingival tissue or the periapical region
Patients with cardiac conditions of teeth or perforation of the oral mucosa for cardiac patients
Dental practitioners should consider prophylactic measures to with the highest risk1,2 (see Table 1 and 2). Specific antibiotic
minimize the risk of IE in patients with underlying cardiac regimens can be found in Table 3. Practitioners and patients/
conditions. The risk of developing IE can arise from a combi- parents can review the entire AHA guidelines in the AHA
nation of high-risk patients and dental procedures. However, Circulation Journal archives, http://circ.ahajournals.org/
at-risk patients with poor oral hygiene and gingival bleeding cgi/content/full/116/15/1736 for additional background
after routine activities (eg, toothbrushing) also have shown an information as well as discussion of special circumstances
increased potential for developing complications of IE.1,2,12,13 (eg, patients already receiving antibiotic therapy, patients on
It, therefore, is recommended to encourage daily good oral anticoagulant therapy).
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous infective endocarditis
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 six 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)
* Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.
Prophylaxis is reasonable because endothelialization of prosthetic material occurs within six months after the procedure.
Reprinted with permission. Circulation. 2007;116:1736-1754. 2007, American Heart Association, Inc.2
All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or
perforation of the oral mucosa**
* The following procedures and events do not need 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, and bleeding from trauma to the lips or oral mucosa.
Reprinted with permission. Circulation. 2007;116:1736-1754. 2007, American Heart Association, Inc.2
Ampicillin 2 g IM or IV 50 mg/kg IM or IV
Unable to take oral medication OR
Cefazolin or ceftriaxone 1 g IM or IV 50 mg/kg IM or IV
Cephalexin* 2g 50 mg/kg
Allergic to penicillins or OR
ampicillinoral Clindamycin 600 mg 20 mg/kg
OR
Azithromycin or clarithromycin 500 mg 15 mg/kg
Reprinted with permission. Circulation. 2007;116:1736-1754. 2007, American Heart Association, Inc.2
Table 4. AAOS/ADA PREVENTION OF ORTHOPAEDIC IMPLANT INFECTION CLINICAL PRACTICE GUIDELINE PROTOCOL
RECOMMENDATIONS 3,4
Recommendation 1
The practitioner might consider discontinuing the practice of routinely prescribing prophylactic antibiotics for patients with hip and knee
prosthetic joint implants undergoing dental procedures.
Grade of Recommendation: Limited
A Limited recommendation means the quality of the supporting evidence that exists is unconvincing, or that well-conducted studies show
little clear advantage to one approach versus another. Practitioners should be cautious in deciding whether to follow a recommendation classified
as Limited, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a sub-
stantial influencing role.
Recommendation 2
We are unable to recommend for or against the use of topical oral antimicrobials in patients with prosthetic joint implants or other ortho-
paedic implants undergoing dental procedures.
Grade of Recommendation: Inconclusive
An Inconclusive recommendation means that there is a lack of compelling evidence resulting in an unclear balance between potential benefits
and potential harm. Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Inconclusive and
should exercise judgment and be alert to future publications that clarify existing evidence for determining balance of benefits versus potential
harm. Patient preference should have a substantial influencing role.
Recommendation 3
In the absence of reliable evidence linking poor oral health to prosthetic joint infection, it is the opinion of the work group that patients with
prosthetic joint implants or other orthopaedic implants maintain appropriate oral hygiene.
Grade of Recommendation: Consensus
A Consensus recommendation means that expert opinion supports the guideline recommendation even though there is no available evidence that
meets inclusion criteria. Practitioners should be flexible in deciding whether to follow a recommendation classified as Consensus, although they
may set boundaries on alternatives. Patient preference should have a substantial influencing role.
Reprinted with permission from the American Academy of Orthopaedic Surgeons and the American Dental Association: Prevention of Orthopaedic
Implant Infection in Patients Undergoing Dental Procedures Clinical Practice Guideline; 2012.
Patients with compromised immunity Patients with shunts, indwelling vascular catheters, or
Patients with a compromised immune system may not be able medical devices
to tolerate a transient bacteremia following invasive dental The AHA recommends that antibiotic prophylaxis for non-
procedures.10 These non-cardiac factors can place a patient valvular devices, including indwelling vascular catheters (eg,
with compromised immunity at risk for distant-site infection central lines) and cardiovascular implantable electronic devices
from a dental procedure.10 This category includes, but is not (CIED), is indicated only at the time of placement of these
limited to, patients with the following medical conditions10: devices in order to prevent surgical site infection. 10,23-25 The
1. Immunosuppression secondary to: AHA found no convincing evidence that microorganisms
a. human immunodeficiency virus (HIV); associated with dental procedures cause infection of CIED and
b. severe combined immunodeficiency (SCIDS); nonvalvular devices at any time after implantation.10,23-25 The
c. neutropenia; infections occurring after device implantation most often are
d. cancer chemotherapy; and caused by Staphylococcus aureus and coagulase negative staphyl-
e. hematopoietic stem cell or solid organ transplantation. ococci or other microorganisms that are non-oral in origin
2. Head and neck radiotherapy. but are associated with surgical implantation or other active
3. Autoimmune disease (eg, juvenile arthritis, systemic lupus infections. 24-26 The AHA further states that immunosup-
erythematosus). pression is not an independent risk factor for nonvalvular
4. Sickle cell anemia.19 device infections; immunocompromised hosts who have those
5. Asplenism or status post splenectomy. devices should receive antibiotic prophylaxis as advocated
6. Chronic steroid usage. for immunocompetent hosts. 10,23-25 Consultation with the
7. Diabetes. childs physician is recommended for management of patients
8. Bisphosphenate therapy.20,21 with nonvalvular devices.
Consultation with the childs physician is recommended for Ventriculoatrial (VA), ventriculocardiac (VC), or ventri-
management of patients with a compromised immune system. culovenus (VV) shunts for hydrocephalus are at risk of
Discussion of antibiotic prophylaxis for patients undergoing bacteremia-induced infections due to their vascular access. 10,23
chemotherapy, irradiation, and hematopoietic cell transplant- In contrast, ventriculoperitoneal (VP) shunts do not involve
ation appears in a separate AAPD guideline.22 any vascular structures and, consequently, do not require
11. Lockhart PB, Brennan MT, Thornhill M, et al. Poor oral 22. American Academy of Pediatric Dentistry. Guideline on
hygiene as a risk factor for infective endocarditis related dental management of pediatric patients receiving che-
bacteremia. J Am Dent Assoc 2009;140(10):1238-44. motherapy, hematopoietic cell transplantation, and/or
12. Lockhart PB, Brennan MT, Sasser HC, Fox PC, Paster BJ, radiation. Pediatr Dent 2014;36(special issue):293-301.
Bahrani-Mougeot FK. Bacteremia associated with tooth- 23. Baddour LM, Bettman MA, Bolger AF, Bolger A, Ferrieri
brushing and dental extraction. Circulation 2008;117 P. Nonvalvular cardiovascular device-related infections.
(24):3118-25. Circulation 2003;108(16):2015-31.
13. Taubert KA, Gewitz MH. Infective endocarditis. In: 24. Baddour LM, Epstein AE, Erickson CC, et al. Update on
Mossand Adams Heart Disease in Infants, Children, and cardiovascular implantable electronic device infections
Adolescents: Including the Fetus and Young Adult, 7th and their management. Circulation 2010;121(3):458-77.
ed. Moss AJ, ed. Wolters Kluwer Health/Lippincott Will- 25. Baddour LM, Epstein AE, Erickson CC, et al on behalf
iams & Wilkins Philadelphia, Pa; 2008:1299-311. of the American Heart Association Rheumatic Fever,
14. Nishimura, RA, Carabello, BA, Faxon, DP, et al. ACC/ Endocarditis, and Kawasaki Disease Committee of the
AHA 2008 Guideline Update on Valvular Heart Disease: Council on Cardiovascular Disease in the Young; Council
Focused Update on Infective Endocarditis: A Report of on Cardiovascular Surgery and Anesthesia; Council on
the American College of Cardiology/American Heart Cardiovascular Nursing; Council on Clinical Cardiology;
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by the Society of Cardiovascular Anesthesiologists, So- Outcomes Research. A summary of the update on cardio-
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887-96. 26. Hong CHL, Allred R, Napenas JJ, Brennan MT, Baddour
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Incidence of infective endocarditis caused by viridans cedures to prevent indwelling venous catheter-related in-
group streptococci before and after publication of the fections. Am J Med 2010;123(12):1128-33.
2007 American Heart Associations Endocarditis Pre- 27. Aminoshariae A, Kulild J. Premedication of patients
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