Oral Maxillofacial Surg Clin N Am 14 (2002) 231 240

Antibiotic prophylaxis in dentoalveolar surgery

Michael G. Savage, DDS
Division of Oral Surgery, Department of Surgical Dentistry, University of Colorado School of Dentistry, 4200 East Ninth Avenue, Campus Box C-284, Denver, CO 80262, USA

Antibiotic prophylaxis in dentoalveolar surgery In England during the 1930s, it became evident that bacteremia from dental procedures could cause the distant infection of bacterial endocarditis [1,2]. With the onset of the antibiotic era, health care providers assumed that if antibiotics could cure an infection, they may also be able to prevent them. Work began more than 40 years ago to investigate how antibiotics may be able to prevent potentially devastating infections such as bacterial endocarditis. Therefore, the concept of using antibiotics as a prophylactic measure to prevent infection from dentally induced bacteremia has existed since at least 1955 [3]. Distant infections resulting from seeding of bacteria caused by dental manipulations have been a matter of controversy. Indeed, the incidence of bacteremia with dental treatment (including surgical procedures) is not vastly different from the bacteremia that can be generated by chewing and by home oral hygiene procedures. In addition, the net benefit of antibiotic prophylaxis is hard to quantify because only a few of the many patients who are given prophylactic antibiotics may actually benefit from them. This fact must be weighed against the potentially adverse side effects of the antibiotics themselves (allergy, toxicity, superinfection, and selection of resistant organisms) [4]. Nevertheless, the empiric use of antibiotic prophylaxis for dental procedures, especially surgical procedures, has become a wellestablished practice among dental professionals. This practice began for prevention of bacterial endocar-

ditis, but has spread to include patients at risk of developing infections of prosthetic joints, those with depressed immune systems from a variety of causes, those with synthetic implants of various kinds, and to prevent postoperative infection in a variety of patients undergoing intraoral procedures. Failure to provide prophylaxis when a distant or significant postoperative infection occurs has become a major source of malpractice lawsuits across the country [5]. Since there are far more attorneys than dentists in the United States, antibiotics are often readily prescribed with a lack of true medical indication. For some conditions (bacterial endocarditis and patients with prosthetic joint replacements), there are consensus guidelines published by reputable organizations. The dentist must be aware of these well-known conditions and guidelines. For other conditions, the indications and literature are conflicting or unclear. In addition, the dental practitioner who consults with the patients physician for guidance may receive inadequate, conflicting, or widely varying protocols [6]. The purpose of this article is to review current medical and dental literature and attempt to arrive at a rational guideline for the use of antibiotic prophylaxis in dentoalveolar surgery. Those conditions and procedures not requiring the use of antibiotics will also be discussed. Finally, there is a brief discussion concerning the global overuse of antibiotics and its consequences.

Conditions requiring antibiotic prophylaxis Bacterial endocarditis

E-mail address: michael.savage@uchsc.edu (M.G. Savage).

The first American Heart Association (AHA) recommendations for antibiotic prophylaxis to prevent

1042-3699/02/$ see front matter D 2002, Elsevier Science (USA). All rights reserved. PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 5 - 5

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bacterial endocarditis were published in 1955 [5]. Since that time, those recommendations have been modified a number of times, the last time in 1997. This most recent consensus panel had two participating dentists, T.J. Pallasch, and T.W. Gage. This inclusion of more dentists on the ad hoc writing panel, at least in part, led to a more user-friendly set of guidelines for the use of antibiotics in conditions that might lead to bacterial endocarditis. The newest guidelines eliminated most needs for parenteral administration and second follow-up doses, and they clarified the conditions for which antibiotics were and were not necessary. Infective endocarditis is a relatively uncommon but life-threatening disease. It is defined as an exudative and proliferative alteration of the endocardium, characterized by growth of vegetations on the surface or within the endocardium. These vegetations consist of bacterially colonized fibrin and platelet masses. The platelet and fibrin masses are known as nonbacterial thrombotic endocarditis and are caused by turbulent blood flow or foreign bodies within the heart. Bacteria from a bacteremia from any source colonize these sterile masses and cause the infection in endocarditis [6]. There is substantial morbidity and mortality for its victims despite the advanced ability to diagnose and wide availability of antibiotics [7]. Prevention of this life-threatening disease is, therefore, highly desirable. The clinical presentation of endocarditis may be slow in onset and reveal classic Oslerian symptoms: bacteremia, valvulitis, peripheral emboli, and immunologic vascular phenomena. These latter signs are more typical of subacute infective endocarditis. Acute infective endocarditis usually develops so rapidly that the immunologic vascular phenomena do not have time to occur [8]. Not all bacteria have the ability to colonize the sterile thrombi, nor do all invasive procedures cause bacteremias that last long enough or carry a large enough inoculum of bacteria to cause an infection of endocarditis. Indeed, most cases of endocarditis caused by oral flora are not attributable to a dental invasive procedure [4,7,9]. There has been some progress lately with a well-designed populationbased case-control study from B.L. Strom et al and others. This study makes a case that prophylactic antibiotics should be used for only two populations, patients with a previous episode of endocarditis and those with a prosthetic heart valve. Furthermore, the only procedures to require antibiotics should be restricted to extractions, gingival surgery, and impactions [5,10]. This new information is intriguing and may well join other studies in a significant change from the AHA. The AHA has acknowledged this information, but they continue to stand behind the current recommendations published in 1997 [11].

The latest AHA recommendations [7] focus on those conditions known to have moderate and high risk of endocarditis in patients undergoing oral procedures (Table 1). Compared to previous recommendations, there has been substantial reduction in the number of conditions for which antibiotics are recommended. Those conditions for which the risk is minimal or negligible are well specified. The dental practitioner has less need to rely on medical providers who may not know or understand the recommendations and base their recommendations on anecdotal evidence. Hence, there is less chance that the dental provider will be forced to accept responsibility for giving antibiotics to inappropriate patients. The change in acceptable antibiotic regimens is welcome (Table 2). Amoxicillin, which attains higher blood levels than penicillin and lasts for hours, is the principal antibiotic for nonallergic patients [12]. Clindamycin, clairithromycin, and azithromycin are good choices in severely allergic patients because they work along entirely separate pathways and have acceptable levels of side effects. The cephalosporin alternatives

Table 1 Cardiac conditions associated with endocarditis Endocarditis prophylaxis recommended Prosthetic cardiac valves, including bioprosthetic and homograft valves Previous bacterial endocarditis Complex cyanotic congenital heart disease(eg, single ventricle states, transposition of the great arteries, tetralogy of Fallot) and any other congenital malformation other than those listed below Surgically constructed systemic pulmonary shunts or conduits Acquired valvular dysfuntion (eg, rheumatic heart disease) Hypertrophic cardiomyopathy Mitral valve prolapse with valvular regurgitation and/or thickened leaflets Endocarditis prophylaxis not recommended Isolated secundum atrial septal defect Surgically repaired atrial septal defect, ventricular septal defect, patent ductus arteriosus (> 6 mo) Previous coronary artery bypass graft (CABG) Mitral valve prolapse without regurgitation Functional or innocent heart murmurs Previous Kawasaki disease without valvular dysfunction Previous rheumatic fever without valvular dysfunction Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators (Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1795; with permission.)

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231240 Table 2 Prophylactic regimens for dental and oral procedures Situation Standard general prophylaxis Agent Amoxicillin Regimena

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Unable to take oral medications

Ampicillin

Allergy to penicillin

Clindamycin

Adults: 2.0 g Children: 50 mg/kg 1 h before procedure Adults: 2.0 g Children: 50 mg/kg IM or IV within 30 min of procedure Adults: 600 mg Children: 20 mg/kg 1 h before procedure Adults: 2.0 g Children: 50 mg/kg 1 h before procedure Adults: 500 mg Children: 15 mg/kg 1 h before procedure Adults: 600 mg Children: 20 mg/kg IV 30 min before procedure Adults: 1.0 g Children: 25 mg/kg IM or IV 30 min before procedure

or Cephalexin t or cephadroxil t or Azithromycin or clairithromycin Allergy to penicillin and unable to take oral medications Clindamycin

or Cefazolin t

t Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins. (Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277:1798; with permission.) a Total childrens dose should not exceed adult dose.

are meant only for those patients who have not had Ig-E mediated immediate reactions with penicillin or amoxicillin. It should be remembered that erythromycin is still acceptable if it has been used successfully in the past with individual patients [7]. The 1997 AHA recommendations also identify those procedures likely to cause clinically significant bacteremias (Table 3). Again, delineating the specific procedures is a welcome and appropriate change from previous recommendations, but these are not allencompassing. For example, there is no recommendation for antibiotics when performing intracanal endodontic therapy, but there is a recommendation for prophylaxis when performing endodontic therapy beyond the apex. Since the dentist may not be able to contain the endodontic treatment within the canal, the use of prophylaxis is indicated in high-risk patients. Likewise, there is a recommendation for prophylaxis when performing intraligamental injections. An intra-

osseous injection technique (available from at least three manufacturers) should warrant the same precautions. The American Dental Association (ADA) emphasizes that these recommendations are not intended as the standard of care, and practitioners should use their own clinical judgement in individual cases or special circumstances [13]. Special circumstances Patients already on antibiotics Patients often present on chronic daily doses of a drug (eg, penicillin) for secondary prevention of endocarditis. They may also be on a drug that is the same or similar to what would be used for prophylaxis, but are under therapy for an infection elsewhere in the body. In these cases, one should change to another family of antibiotics (Table 2) and prescribe the normal dose for that family of drugs.

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Table 3 Dental procedures and endocarditis prophylaxis Endocarditis prophylaxis recommendeda Extractions and other open oral surgical and endodontic surgical procedures All periodontal surgery, scaling, root planing, probing, and recall maintenance Dental implant placement and reimplantation of avulsed teeth Endodontic instrumentation beyond apex Subgingival placement of antibiotic fibers, strips, or polymers Placement of orthodontic bands (but not acid etch brackets) Intraligamentary and intraosseous local anesthetic injections Hygiene procedures on teeth or implants where bleeding is anticipated Endocarditis prophylaxis not recommended Restorative dentistry and prosthodontics with or without retraction cordb Local anesthetic injections other than those listed above Intracanal endodontic treatments, including post and core Placement of rubber dam Postoperative suture removal Placement of any removable appliance Impressions Fluoride treatments Radiographs Orthodontic appliance adjustment Shedding of primary teeth Adapted from JAMA 1997;277:1797; with permission. a Prophylaxis recommended for patients with endocarditis risk conditions. b Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding.

had to pick a number, it would therefore seem prudent to consider redosing if treatment will be delayed beyond 4 hours. Unanticipated indications It is possible that the dentist may have started a procedure for which antibiotic prophylaxis is not indicated, but then finds an indication. In a situation where the dentist has initiated intracanal endodontics, but a perforation develops with bleeding, the AHA/ ADA recommends administering the dose of antibiotics at that time. This necessitates the dentist to have an office supply of at least amoxicillin and clindamycin for patient use. Patients who have taken appetite suppressants There is a subset of the above group of patients whose potential for endocarditis has surfaced since 1997. This group consists of patients who have taken the drugs fenfluramine (Pondimin) or dexfenfluramine (Redux). Another drug, phentermine (Apidex, Fastin, or Ionamin), had often been combined with fenfluramine in fen-phen, but is not implicated in the clinical problem [16]. Initial concern linking valvular heart disease with the use of fenfluramine/ phentermine was generated by a report in the New England Journal of Medicine (vol. 337, August 28, 1997). This led to voluntary withdrawal of Redux and Pondimin from the market by Wyeth-Ayerst Laboratories in September 1997, a move praised by the AHA [17]. Interim guidelines for managing these patients were issued in November 1997 [18] and were endorsed by the American Heart Association with a media advisory soon after [19]. The guidelines issued from the US Department of Health and Human Services (DHHS) recommended the following: 1. All people exposed to these drugs should undergo a medical history and cardiovascular examination. 2. An echocardiogram should be performed on all people who exhibit cardiopulmonary signs and symptoms of cardiac valvulopathy 3. An echocardiogram is strongly recommended for all people exposed to these drugs for any period of time, regardless of cardiopulmonary signs or symptoms, if the patient was to have an invasive procedure for which they would have been given antibiotic prophylaxis, according to the 1997 guidelines. 4. For emergency procedures where cardiac examination cannot be performed, empiric

Patients on anticoagulants Do not administer intramuscular injections of antibiotics to patients on heparin or coumarin derivatives because they may form a hematoma or have severe ecchymosis. Use an intravenous or oral route. Delay in treatment There are times when patients will take the prescribed prophylaxis regimen as directed, but for some reason cannot be treated at the time anticipated. How long is acceptable before redosing? There is no consensus answer. We do know that amoxicillin maintains a prolonged serum inhibitory activity of 6 to 14 hours against most oral streptococci [14]. Peak serum levels of amoxicillin occur  1 hour after ingestion. Serum levels of oral clindamycin occur slightly more rapidly and remain for  3 hours [15]. Amoxicillin retains microbial killing power for several hours [14]. If one

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antibiotic prophylaxis according to the 1997 guidelines should be performed. Medical and dental literature point out some problems with the guidelines above [16,20,21]. There were no consistent physical examination criteria, a wide range of true valvulopathies were found, there was a wide range in the length of time the drugs were taken, and there was controversy regarding whether or not valvulopathy would regress over time. As a result, there is disagreement as to the true severity of the problem; some authorities agree with the DHHS guidelines and others see less of a problem. An additional problem, primary pulmonary hypertension, has a long clinical tail and has been largely overlooked. This problem is rare in the general population, but its frequency is 10 times greater in a population taking appetite suppressants and 20 times greater when the appetite suppressant is taken for more than 3 months [16]. The diagnosis is often delayed 1 to 2 years after symptom onset, and people with the disorder have a median survival of 2 to 3 years from symptom onset [22,23]. For the dental practitioner, it would seem prudent to refer all these patients to a physician for a cardiovascular examination. It would also be prudent to be specific regarding your concerns and include a set of the DHHS guidelines or refer the physician to the appropriate AHA web site [24] that would have a complete set of past advisories and recommendations. Patients with prosthetic joint replacement Before 1997, dental providers faced a conundrum with patients who had undergone total joint arthroplasty (TJA). The vast majority of orthopedic surgeons favored antibiotic prophylaxis before dental treatment for all TJA patients under all circumstances, even though they recognized that a consistent relationship between dentally induced bacteremia and prosthetic joint infections had not been established [4]. Othopedic surgery authorities themselves admit that orthopedic surgeons are among the heaviest users of prophylactic antibiotics [25]. Nevertheless, a prosthetic joint infection can be devastating, can occur from a variety of sources other than dental, and can occur long after the supposed insult, making cause and effect difficult to prove. Antibiotic protocols recommended by orthopedic surgeon colleagues varied widely and occasionally had no rationale against oral microbes. A study performed in 1990 concluded that it cost $480,000 in antibiotics to prevent one case of prosthetic joint infection [26]. An attempt to eliminate this overuse controversy was made in

1997 with a joint advisory statement from the American Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. The ADA and the AAOS convened an expert panel of dentists, orthopedic surgeons, and infectious disease specialists who performed a thorough review of all available literature and data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone TJA [27]. The panel outlined consensus recommendations that simplified the target population and regimens to be used. These recommendations, though not completely accepted by all orthopedic surgeons [28,29], at least created an area of agreement between dentists and a national orthopedic group (Table 4). The specific joints replaced are not delineated with any differentiation; therefore, it is assumed that a total hip replacement should be treated the same as a digit replacement. The recommendations targeted those populations at most risk to have a hematogenous total joint infection: immunocompromised/suppressed patients; those with inflammatory arthropathies (eg, rheumatoid arthritis); insulin-dependent diabetics; those with previous episode of infected joint; malnourished persons; hemophiliacs; and those within 2 years of their joint replacement, regardless of health (Table 4).

Table 4 Prophylaxis for patients with total prosthetic joint replacement Patients at potentially increased risk of hematogenous joint infection Immunocompromised and immunosuppressed patients, including those with conditions caused by disease, drug, or radiation Inflammatory arthropathies, including rheumatoid arthritis and systemic lupus erythematosus Insulin-dependent (type I) diabetes First 2 y after total prosthetic joint replacement Previous prosthetic joint infection Malnourishment Hemophilia Procedures likely to cause hematogenous joint infection in the patients listed above Same as those in endocarditis (Table 3) Procedures less likely to cause hematogenous joint infection Same as those in endocarditis (Table 3) Suggested antibiotic regimens to use in the patients listed above Same as those in endocarditis a(Table 2) AAOS/ADA regimen places cephalexin and cephradine ahead of amoxicillin in suggested regimens and does not mention azithromycin or clairithromycin in suggested regimens for penicillin allergic patients.
a

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The recommendations then specified those procedures likely to cause a higher incidence of bacteremia and those procedures less likely to cause bacteremia. Those procedures are identical to those specified in the AHA bacterial endocarditis recommendations. Likewise, the recommended antibiotic protocols were virtually identical to those recommended by the AHA for endocarditis. Some authorities take special pains to point out that the risk of causing a hematogenous spread of infection is higher when dealing with gross infection at the procedure site, such as a severe dental abscess or when procedures take longer than 45 minutes [29,30]. Patients with plates, screws and pins: These patients require no prophylaxis. The recommendations point out that the dentist may be presented with a patient carrying recommendations from their orthopedist which are inconsistent with these guidelines. This may result from unfamiliarity with the guidelines, or perhaps the patient has an overriding concern unknown to the dentist. Consultation is urged to come to an agreement between the providers. If a disagreement still occurs, the dentist may proceed with the recommendations of the orthopedic surgeon despite the disagreement, proceed with the procedure without antibiotics, or place the burden of prescription for the antibiotics on the orthopedic provider. Best clinical judgement is always appropriate. The total replacement of temporomandibular joints (TTMJR) is not specifically addressed nor excluded in these recommendations. The late infection of a TTMJR is exceedingly rare [31,32]. There is simply not enough data on which to base a sound recommendation. The very cautious practitioner may consider prophylaxis for that group of patients who fall under the AAOS/ ADA guidelines only. Shunts, catheters, and implanted materials Patients with surgically constructed shunts for hemodialysis are at somewhat increased risk for infection, both locally and as a cause for endocarditis. Moreover, if an infection occurs in these patients undergoing dialysis, the downside is devastating. Antibiotic prophylaxis for these patients, if undergoing invasive dentoalveolar procedures, is appropriate. AHA recommendations are probably adequate even though there is no consensus. The extent and length of surgery may induce stress and, because of anticoagulation, may result in significant bleeding. Many penicillin-type drugs are metabolized through the kidneys, so consultation with the nephrologist is warranted if therapy beyond a single dose is considered to treat infection. Regardless, the nephrologist

should be consulted regarding the timing and need for anticoagulation control before any extensive surgery [53]. Peritoneal dialysis requires no antibiotic prophylaxis [34]. Shunts are placed in patients with hydrocephaly to relieve the pressure of cerebrospinal fluid buildup on the brain. Shunts placed for treatment of hydrocephaly are of two types, ventriculo-peritoneal (VP) and ventriculo-atrial (VA). Infection of VA shunts is devastating and carries a mortality of 40%. These patients should receive prophylactic antibiotics [35,36]. VP shunts carry no higher risk of infection from dental sources and therefore require no antibiotics Indwelling catheters may be present for a variety of reasons, usually to deliver long-term intravenous drugs for chemotherapy or to treat infection. Unless the terminal end is near the right side of the heart, no prophylaxis should be necessary [37]. Pacemakers and implanted defibrillators may or may not be intracardiac. They can become infected, but most infections culture out Staphylococcu aureus, not viridans species [4]. The AHA does not recommend antibiotic prophylaxis before dental treatment for these patients [7]. Patients who have undergone heart transplant do not, per se, require prophylactic antibiotics. They are, however, prone to cardiac valvular dysfunction and are typically on multiple immunosuppressant drugs. Consultation is warranted and they may require antibiotic prophylaxis if a valvular abnormality exists [4]. Intracardiovascular artery stents, prosthetic artery grafts, angioplasty procedures, and coronary artery bypass grafts (CABG) are performed for patients with atherosclerotic cardiovascular disease and/or angina. Prophylactic antibiotic coverage for these patients is a controversial area, and some feel that the requirement for antibiotic prophylaxis hinges on the amount of epithelialization that will take place after the procedure is performed. Most infections take place within 6 months of surgery, but oral flora are rarely implicated [37,38]. Nevertheless, an infected graft or stent is devastating. There is no consensus, but a recommendation cited by several authors is that prophylaxis should be considered only within the first 6 weeks after surgery. Endotheialization of the stent occurs during this time period. Antibiotics are not needed after 6 weeks, except possibly for very large aortic grafts. Consultation is advised for these patients. Patients with penile implants or other cosmetic or functional implanted materials do not require prophylactic antibiotics before invasive dental treatment [6].

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Immunocompromised patients This group of patients includes those with neutropenia for any reason, insulin-dependent diabetes, and asplenia. There have been no long-term, controlled studies that have looked at infection rates in dental patients with various levels of neutropenia [38]. Nevertheless, threat of infection exists and morbidity increases as the leukocyte count drops. Regimens of antibiotics have been suggested for patients with leukocyte levels of 3500/mm3, 2000/ mm3, and 1000/mm3 [39]. Difficulties arise as the oral flora changes in patients on chemotherapy. Whereas the AHA recommendations are fine for most patients, they may not be the best choices for neutropenic patients. Again, no controlled studies exist to provide the best regimen. Best recommendations appear to define neutropenia as 1000/mm3 and to treat patients only on a nonelective (emergency) basis. The AHA regimen or a recommended regimen by consultation with the patients hematologist or infectious disease specialist is appropriate [4,37,38]. Patients who are HIV positive are not at greater risk than non-HIV positive patients, provided that they currently have a satisfactory white blood cell count. They should not receive antibiotic prophylaxis for dental procedures unless they fall into another category that does require antibiotic prophylaxis. In addition, there is an additional risk of selecting antibiotic-resistant strains or causing fungal overgrowth [4,36 38]. Prophylactic antibiotics are not necessary for most diabetic patients undergoing dentoalveolar surgery. Most authors agree that insulin-dependent diabetic patients or non insulin-dependent diabetics under good control are at no greater risk than other patients who are also undergoing minor but invasive surgical procedures [4,38 40]. Unless they are poorly controlled, non insulin-dependent diabetics are usually not candidates for prophylaxis. If either population is well controlled, prophylactic antibiotics should be used only in situations where prophylactic antibiotics would be used for nondiabetic patients. A diabetic with an infection should receive appropriate antibiotics, and a poorly controlled diabetic should also be referred for stabilization. If emergency dentoalveolar surgery is required on a poorly controlled diabetic, then prophylaxis is indicated, as well as consultation with the patients endocrinologist. With no specific regimen established, the AHA recommendations would suffice. The question of prophylactic antibiotics in patients who have undergone splenectomy is also controversial. It is true that infections in post-splenectomy patients occur at a rate far above the normal

population. Most of these infections are not related to the mouth, and the population most at risk are those at two years or less post-splenectomy and children under 5 years old [4,38,41]. Therefore, routine prophylaxis for these patients is not recommended, but consultation is warranted for these latter two groups and antibiotic prophylaxis may be necessary. These patients also require consideration for pneumococcal vaccine from their physicians [41,42]. Risk of brain abscess Several recent high-profile lawsuits have resulted from patients who had minor infections or invasive dentoalveolar surgery and then suffered brain abscesses that cultured out oral flora. There are areas of the country where experienced, board-certified oral and maxillofacial surgeons who fear this litigation are providing prophylactic antibiotics for patients who require extractions or significant invasive surgery. In an elegant review of the literature and through the use of sound logic, Pallasch argues vigorously against this practice [4]. He makes the case that the incidence, etiology, and clinical course of brain abscesses indicate that the association with previous therapy is too small and the risk from the antibiotic is too great to warrant routine antibiotic prophylaxis for these patients. He argues that one million people would have to receive prophylactic antibiotics in an attempt to save the theoretical less than one person in that million from having a brain abscess. Even assuming that a correct antibiotic is chosen for this unknown pathogen, there is an unfavorable risk-to-benefit ratio. The death rate from anaphylaxis for the antibiotic would essentially be higher than the rate of brain abscess occurrence. There would be a net loss of life from use of antibiotics in this attempt at prevention [4]. Routine antibiotic prophylaxis in oral and maxillofacial surgery Antibiotics are commonly administered prophylactically for major oral and maxillofacial surgery, such as temporomandibular joint surgery, orthognathic procedures, and repair of facial trauma with contamination. There is evidence that this is a sound practice, though there is no need to continue the antibiotics beyond the perioperative period [43]. On the other hand, oral and maxillofacial surgeons commonly prescribe antibiotics to prevent postoperative infections in patients who are not at risk for serious infections from bacteremia and for relatively minor dentoalveolar procedures. In these scenarios,

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there are many areas of disagreement and failure to adhere to basic principles [4,32,36,44]. In many cases, the antibiotic is given after the procedure as the patient is walking out the door. This violates the well-substantiated principle that antibiotics need to be given before a procedure, not after, and sufficiently in advance to obtain a high blood level [4]. This prophylaxis should ideally take place 2 hours before the incision if given orally, or immediately before surgery if given intravenously [45]. Strictly speaking, surgical antibiotic prophylaxis is indicated only (1) to prevent contamination of a sterile area, (2) where infection is unlikely but associated with significant morbidity, (3) in procedures with high rates of infection, and (4) during implantation of prosthetic material [4,36]. For antibiotics to be effective, they must be given in high doses and aimed at a specific pathogen or group of pathogens. They need not be continued after the procedure [46]. With the exception of implant placement, most dentoalveolar oral surgery procedures do not qualify for prophylactic antibiotics using the above criteria. The subject of prophylaxis for implant and bone graft surgery is another topic worth its own article. There are no published studies comparing one agent to another or the length of time of administration of one agent versus another. There are many technique articles in print recommending prophylaxis, but drugs vary from penicillin to Augmentin to clindamycin, and length of time of administration varies from perioperative only to 2 weeks. A well-cited and thoughtful chapter by Topazian does specifically address this question [30].

Although he recommends penicillin for noncompromised patients, it seems to me, in the interest of simplification, that the AHA regimen would supply similar efficacy and be easier to remember. Topazian recommends a first-generation cephalosporin (cephalexin) or the combination of amoxicillin/clavulanate for sinus grafting (see Table 5). The question then arises for prophylactic antibiotic use specifically for third molar surgery. Piecuch, Arzadon, and Lieblich looked at this question in 1995 [47]. They offered that oral surgeons prescribe antibiotics in third molar surgery for five reasons: (1) to treat an active infection, (2) as prophylaxis in medically compromised patients, (3) patient or family demand, (4) prevailing standard of care in community, and (5) risk of infection is high. They reviewed literature for and against use of antibiotics in third molar surgery and then interjected their own retrospective study of 2134 patients with 6713 third molar extractions. They answered the above justifications and recommended that antibiotic prophylaxis be justified only for full bony and partial bony impactions. In all other classes and positions of impacted third molars, prophylaxis provided no statistical improvement over no antibiotic prophylaxis. They also revealed, however, that tetracycline placed in the extraction site was just as efficacious as systemic antibiotics. This practice will continue to incite controversy and study. Indeed, a recently published doubleblind placebo control study appears to refute the above recommendations. This otherwise well-designed study suffered from a low number of subjects (151) and the

Table 5 Bottom line recommendations for antibiotic prophylaxis Condition Heart conditions Total prosthetic Joint replacement Vascular shunt for hemodialysis Ventriculoatrial shunt for hydrocephaly Vascular grafts Other cosmetic or functional implants Immunocompromised HIV positive Insulin-dependent diabetic Splenectomy Prophylaxis warranted? Possibly (see Table 1) Probably not (see Table 4) Yes Yes No unless large or >6 months No Possibly. Consult if < 1000 wbc/mm3 No No, unless poor control then No, unless spleen removed less than 6 mo before or < 5 y old then No No No, except possibly partial bony or full bony impactions Yes (immediate perioperative period only) Regimen AHA (Table 2) AHA AHA AHA AHA

AHA Consult

Risk of brain abscess Routine oral surgery procedures Third molar surgery Implants, endosseous, bone grafts, extensive membrane use

No established regimen AHA (consider cephlosporin for sinus lift)

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fact that a prophylactic drug effective only against anaerobes was used [48]. Until similar studies are performed with higher numbers of subjects and drugs that are effective across the spectrum of oral pathogens, the practice of third molar prophylaxis will continue to be partly based on empiricism [33]. Patterns of use in prophylaxis There is no question that one of the problems with the use of antibiotics for prophylaxis is lack of knowledge and inconsistency among providers. This is true in this country and elsewhere [48]. Practitioners prescribe prophylactic antibiotics incorrectly for patients that require them and inappropriately for patients who do not require them. This occurs not only in private practices, but also in schools of dentistry, where one would hope the focus would be on accurate and appropriate prophylactic antibiotic use [49]. Antibiotics have been used as drugs of fear [50] to prevent lawsuits, to please patients or families, and to cover for errors of omission or commission [51]. This leads to overuse of these agents, and overuse of these agents leads to unnecessary growth of resistant strains of organisms. In the past, research and development from the drug industry has kept up with yet other new and more powerful agents for practitioners to use. To recoup the high cost of development, the drug industry encouraged providers to use the newest agents. Between the rising costs of development and the continued ability of the microbes to keep ahead of the curve by mutation, however, this is a no-win situation [51]. We are running out of arrows in the quiver. There are reports of vancomycinand methicillin-resistant S. aureus, dubbed the andromeda strain. In central Africa, some strains of shigella are no longer sensitive to quinolone antibiotics and, unable to treat recent outbreaks, thousands have died. S. pneumoniae resistant to penicillin have passed resistant genes to the previously susceptible S. viridans species [52]. The only sound solution is to use them less. As infectious disease specialist Norman Simmons, MD has stated, We screwed up, and we ought to say so and apologize. Doctors were handed the wonderful gift of antibiotics but are destroying them through indiscriminate use. We dont need another committee. We know what to do, we should use them less. This article attempts to assemble the available literature to delineate those medical conditions and dentoalveolar procedures that would require the use of antibiotic prophylaxis (Table 5). It also aims to eliminate some of the overuse of antibiotics used by surgeons in inappropriate circumstances.

References
[1] Okell CC, Elliott SD. Bacteraemia and oral sepsis: with special reference to etiology of subacute endocarditis. Lancet 1935;2:869 72. [2] Rushton MA. Subacute bacterial endocarditis following extraction of teeth and tonsils. Guys Hosp Rep 1930;80:39 44. [3] Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis through Control of Streptococcal Infection. Prevention of rheumatic fever and bacterial endocarditis through control of streptococcal infection. Circulation 1955;11:317 20. [4] Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontology 2000; 10:107 38. [5] Strom BL, Abrutyn E, Berlin JA, et al. Dental and cardiac risk factors for infective endocarditis. Ann Int Med 1998;129:761 9. [6] Tong DC, Rothwell BR. Antibiotic prophylaxis in dentistry: a review and practice recommendations. JADA 2000;131:366 74. [7] Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association. JAMA 1997;277: 1794 801. [8] Bayer AS, Bolger AF, Taubert KA, et al. Diagnosis and management of infective endocarditis and its complications. Circulation 1998;98:2936 48. [9] Guntheroth WG. How important are dental procedures as a cause of infective endocarditis? Am J Cardiol 1984;54:797 801. [10] Durack DT. Antibiotics for prevention of endocarditis during dentistry: time to scale back? Ann Int Med 1998;129:829 31. [11] Pallasch TJ. Dental treatment and bacterial endocarditis. J Calif Dent Assoc 1999;27:282 3. [12] Dajani AS, Bawdon RE, Berry MC. Oral amoxicillin as prophylaxis for endocarditis: what is the optimal dose? Clin Infect Dis 1994;18:157 60. [13] Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American Heart Association (sidebar by ADA Council on Scientific Affairs). JADA 1997;128:1142 51. [14] Fluckiger U, Franciolo P, Blaser J, et al. Role of amoxicillin serum levels for successful prophylaxis of experimental endocarditis due to tolerant streptococci. J Infect Dis 1994;169:397 400. [15] Burnham TH, editor. Drug facts and comparisons. St. Louis: Facts and Comparisons; 2000. p. 1217, 1316. [16] Pallasch TJ. Current status of fenfluramine/dexfenfluramine-induced cardiac valvulopathy. J Calif Dent Assoc 1999;27:400 4. [17] American Heart Association. American Heart Association comment on Redux and Pondimin [science advisory]. September 15, 1997. [18] Centers for Disease Control and Prevention. Cardiac valvulopathy associated with exposure to fenfluramine or dexfenfluramine. 1997; U.S. Department of Health

240

M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231240 and Human Services Interim Public Health Recommendation, November MMWR 46; 45:1061 6. American Heart Association. American Heart Association supports interim guidelines for managing patients who have taken appetite suppressants [media advisory]. November 13, 1997. Pallasch TJ. Antimicrobials and periodontal disease: quo vadis? [guest editorial]. Int J. Perio Restor Dent 1998;18:212 3. Devereaux RB. Appetite suppressants and valvular heart disease [editorial]. N Engl J Med 1998;339: 765 7. Abenheim L, Moride Y, et al. Appetite-suppressant drugs and the risk of primary pulmonary hypertension. N Engl J Med 1996;335:609 16. Gaine SP, Rubin LJ. Primary pulmonary hypertension. Lancet 1998;352:719 25. American Heart Association. Science advisories. Available at: http://americanheart.org/Whats_News/ AHA_Science_Advisories/. Accessed March 1, 2000. American Academy of Orthopaedic Surgeons Advisory Statement. The use of prophylactic antibiotics in orthopaedic medicine and the emergence of vancomycin-resistant bacteria. Available at: http://www.aaos. org/wordhtml/papers/advistmt/vancomycin.htm. Accessed March 17, 2001. Jacobson JJ, Schweitzer S, DePorter DJ, et al. Antibiotic prophylaxis for dental patients with joint prostheses? A decision analysis. Int J Technol Assess Health Care 1990;6:569 87. American Dental Association/American Academy of Orthopedic Surgeons Advisory Statement. Antibiotic prophylaxis for dental patients with total joint replacements. JADA 1997;128:1004 8. Waldman BJ, Mont MA, Hungerford DS. Total knee arthroplasty infections associated with dental procedures. Clin Orthoped & Rel Res. 1997;343:164 72. Laporte DM, Waldman BJ, Mont MA, et al. Infections associated with dental procedures in total hip arthroplasty. J Bone Joint Surg 1999;81:56 9. Topazian RG. The basis of antibiotic prophylaxis. In: Worthington P, Branemark PI, editors. Advanced Osseointegration surgery. Chicago: Quintessence Publishing Co.; 1992. p. 57 66. Nawrocki JH, Ziccardi V, Sotereanos GC. Infection of a prosthetic temporomandibular joint in an intravenous drug abuser. J Oral Maxillofac Surg 1991;49:1339 40. Eppley BL, Delfino JJ. Use of prophylactic antibiotics in temporomandibular joint surgery. J Oral Maxillofac Surg 1991;43:675 9. Sekhar CH, Narayanan V, Baig MF. Role of antimicrobials in third molar surgery: prospective, double-blind, randomized, placebo-controlled clinical study. Br J Oral Maxillofac Surg 2001;39:134 7. Derossi S, Glick M. Dental considerations for the patient with renal disease receiving hemodialysis. JADA 1996;127:211 9. Zentner J, Gilsback J, Felder T. Antibiotic prophylaxis in cerebrospinal fluid shunting: a prospective randomized trial in 129 patients. Neurosurg Rev 1995;18: 169 72. Pallasch TJ. Antibiotic prophylaxis: the clinical significance of its recent evolution. J Calif Dent Assoc 1997; 25:619 32. Pallasch TJ, Expert addresses fen-phen, CDA Update 9, #12, 2, 15. Hall EH, Sherman RG, Emmons WW, et al, Antibacterial prophylaxis. Dent Clin North Amer 1994;38: 707 717. Alexander RE. Routine prophylactic antibiotic use in diabetic dental patients. J Calif Dent Assoc 1999;27: 611 8. Rothstein JP. The care of dental patients with diabetes mellitus, part I. Dent Today 2001;20:72 7. Westerman E. Postsplenectomy sepsis and antibiotic prophylaxis before dental work. Am J Infect Control 1991;19:254 5. White KS, Covington D, Churchill P, et al. Patient awareness of health precautions after splenectomy. Am J Infect Control 1991;19:36 41. Aijderveld SA, Smeele LE, Kostense PJ, et al. Preoperative antibiotic prophylaxis in orthognathic surgery: a randomized, double-blind and placebo-controlled clinical study. J Oral Maxillofac Surg 1999;57:1403 6 [discussion, 1406 7]. Singer AJ, Hollander JE, Quinn JV. Evaluation and management of traumatic lacerations. N Eng J Med 1997;337:1142 8. Classen DC, Evans RS, Pestotnik SL, et al. The timing of prophylactic administration of antibiotics and the risk of surgical-wound infection. N Engl J Med 1992; 326:281 6. Peterson LJ. Principles and management of odontogenic infections. In: Peterson LJ, Tucker MR, Ellis E, Hupp JR, editors. Contemporary oral and maxillofacial surgery. 3rd edition. St. Louis: Mosby; 1998. p. 392 417. Piecuch JF, Arzadon J, Lieblich SE. Prophylactic antibiotics for third molar surgery: a supportive opinion. J Oral Maxillofac Surg 1995;53:53 60. Palmer NA, Pealing R, Ireland RS, et al. A study of prophylactic antibiotic prescribing in National Health Service general dental practice in England. Br Dent J 2000;189:43 6. Johnson TE, Froeschle ML, Lange BM. Management of patients needing antibiotic prophylaxis in a dental education setting, J Dent Ed 2000;64:276 82. Kunin CA. Editorial response: antibiotic armageddon. Clin Infect Dis 1997;25:240 1. Pallasch TJ. Chemotherapy metastasis resistance revisited. J Calif Dent Assoc 2000;28:183 233. Pallasch TJ. A critical appraisal of antibiotic prophylaxis. Int Dent J 1989;39:183 96. Silverstein KE, Adams MC, Fonseca RJ. Evaluation and management of the renal failure and dialysis patient. In: Ogle OE, editor. Management of medical problems. OMFS Clinics of NA, 1998. vol. 10, p. 417 427.

[19]

[36]

[37] [38]

[20]

[21]

[39]

[22]

[40] [41]

[23] [24]

[42]

[25]

[43]

[26]

[44]

[45]

[27]

[46]

[28]

[29]

[47]

[30]

[48]

[31]

[49]

[32]

[50] [51] [52] [53]

[33]

[34]

[35]