From the Guidelines
Antibiotic prophylaxis before dental procedures is currently not recommended for patients with most medical implants, including joint replacements, except for those with cardiac implants or conditions that carry the highest risk of adverse outcomes from infective endocarditis. The most recent and highest quality study, published in 2020 by the American Dental Association and the American Academy of Orthopedic Surgeons 1, suggests that antibiotic prophylaxis is not necessary for patients with prosthetic joint implants, unless they have a high risk of infection, such as those with compromised immune systems or a history of prosthetic joint infection. Some key points to consider include:
- The American Heart Association guidelines, published in 2020 2, recommend antibiotic prophylaxis before dental procedures for patients with prosthetic heart valves, a history of infective endocarditis, certain congenital heart defects, and cardiac transplants with valve abnormalities.
- The standard regimen for antibiotic prophylaxis is amoxicillin 2g orally 30-60 minutes before the dental procedure, with alternatives including clindamycin 600mg, azithromycin or clarithromycin 500mg, or cephalexin 2g for patients allergic to penicillin.
- The risks of routine antibiotic use, including allergic reactions and antibiotic resistance, may outweigh the benefits for most implants, as suggested by studies such as those by Berbari et al 1 and Skaar et al 1.
- Patients who receive unnecessary antibiotic prophylaxis can suffer significant morbidity, including disruptions to the gut microbiome, antibiotic resistance, and adverse drug reactions, as reported by studies such as those by Thornhill et al 1 and Swan et al 1. The current guidelines prioritize the prevention of infective endocarditis and prosthetic joint infections, while also considering the potential risks and benefits of antibiotic prophylaxis. Key considerations for dental procedures include:
- Manipulation of gingival tissue, manipulation of the periapical region of teeth, or perforation of the oral mucosa, which may increase the risk of infection.
- The use of antibiotic prophylaxis for patients with high-risk conditions, such as prosthetic heart valves or a history of infective endocarditis.
- The potential risks and benefits of antibiotic prophylaxis, including the risk of allergic reactions, antibiotic resistance, and adverse drug reactions.
From the Research
Medical Implants Requiring Pre-Treatment Antibiotics for Dental Work
- Prosthetic joints: + The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints is not recommended in general, as the current best evidence fails to demonstrate an association between dental procedures and prosthetic joint infection (PJI) 3, 4. + However, the practitioner and patient should consider possible clinical circumstances that may suggest the presence of a significant medical risk in providing dental care without antibiotic prophylaxis 3.
- Dental implants: + Systematic reviews support preprocedure antibiotics for all patients undergoing dental implants 5. + However, the majority of antibiotics were prescribed postprocedure, and dental stewardship efforts should ensure appropriate antibiotic timing, indication, and duration 5.
Other Considerations
- Patient-specific implants: + There is limited information available on the use of antibiotic prophylaxis for patient-specific implants in oral and maxillofacial surgery 6.
- Antibiotic prophylaxis guidelines: + Guidelines for antibiotics prior to dental procedures for patients with specific cardiac conditions and prosthetic joints have changed, reducing indications for antibiotic prophylaxis 5. + The guidelines identify physical conditions that place joint replacement patients at the highest risk for joint sepsis, and stratify dental procedures into higher-risk and lower-risk categories 7.