What are the reasons to premedicate before a dentist visit?

Reasons for Premedication Before Dental Visits

Antibiotic premedication before dental procedures is primarily indicated for specific high-risk cardiac conditions and rarely for other medical conditions, as routine premedication for most patients lacks evidence of benefit and carries risks of adverse events and antimicrobial resistance. 1, 2

High-Risk Cardiac Conditions Requiring Antibiotic Prophylaxis

Antibiotic prophylaxis is recommended for patients with:

• Prosthetic cardiac valves
• Previous history of infective endocarditis
• Unrepaired cyanotic congenital heart disease
• Completely repaired congenital heart disease with prosthetic material (for first 6 months after procedure)
• Cardiac transplant recipients with cardiac valvulopathy 2

These recommendations apply specifically to dental procedures involving:

• Manipulation of gingival tissue
• Procedures involving the periapical region of teeth
• Procedures involving perforation of oral mucosa 2

Prosthetic Joint Considerations

• Current evidence does not support routine antibiotic prophylaxis for patients with prosthetic joints
• The risk of taking antibiotics (20% chance of adverse events requiring medical attention) outweighs the benefit (<1% risk of prosthetic joint infection) 1
• Only approximately 12% of patients with prosthetic joints may require prophylaxis based on individual risk factors 1
• Antibiotic prophylaxis is not indicated for dental patients with pins, plates, or screws 3

Recommended Antibiotic Regimens (When Indicated)

For adults:

• First-line: Amoxicillin 2g orally 30-60 minutes before procedure
• For penicillin-allergic patients: Clindamycin 600mg or Azithromycin/Clarithromycin 500mg 2

For children:

• First-line: Amoxicillin 50mg/kg orally 30-60 minutes before procedure (not exceeding adult dose)
• For penicillin-allergic children: Clindamycin 20mg/kg or Azithromycin/Clarithromycin 15mg/kg 2

Premedication for Hypersensitivity Reactions

Premedication with antihistamines and/or glucocorticoids may be considered in specific situations:

• For patients with prior moderate to severe reactions to radiocontrast media (though evidence of benefit is limited) 1
• Not routinely recommended for patients with mild previous reactions to radiocontrast media 1
• May be beneficial for patients undergoing aeroallergen rush immunotherapy 1

Important Considerations and Caveats

• Maintaining optimal oral hygiene through proper brushing, flossing, and regular dental check-ups is more important than antibiotic prophylaxis for preventing infections 2
• The emerging trend in dentistry is to avoid prophylactic antibiotics unless clearly indicated due to concerns about antimicrobial resistance 4
• For patients on anticoagulation or antiplatelet therapy, these medications typically should not be suspended for common dental procedures 5
• Elective dental care should be avoided for six weeks after myocardial infarction or bare-metal stent placement, or for six months after drug-eluting stent placement 5
• Patients with a history of antiresorptive or antiangiogenic therapies should communicate this to their dentist 5

Decision Algorithm for Antibiotic Prophylaxis

1. Determine if patient has a high-risk cardiac condition (prosthetic valve, prior endocarditis, etc.)
2. If yes and procedure involves gingival manipulation or mucosal perforation → provide prophylaxis
3. For patients with prosthetic joints:
   • Most patients do not need prophylaxis
   • Consider only for severely immunocompromised patients or those identified by orthopedic surgeon as high-risk
4. For all other patients, antibiotic prophylaxis is generally not indicated

The evidence clearly demonstrates that the risks of inappropriate antibiotic use (resistance, adverse events) outweigh potential benefits in most dental patients, making selective and judicious use of prophylaxis the most appropriate approach.