Antibiotic prophylaxis in dentoalveolar surgery (1)
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, USAAntibiotic prophylaxis in dentoalveolar surgery ditis, but has spread to include patients at risk of developing infections of prosthetic joints, those with In England during the 1930s, it became evident that depressed immune systems from a variety of causes,bacteremia from dental procedures could cause the those with synthetic implants of various kinds, and todistant infection of bacterial endocarditis [1,2]. With prevent postoperative infection in a variety of patientsthe onset of the antibiotic era, health care providers undergoing intraoral procedures. Failure to provideassumed that if antibiotics could cure an infection, they prophylaxis when a distant or significant postoper-may also be able to prevent them. Work began more ative infection occurs has become a major source ofthan 40 years ago to investigate how antibiotics may be malpractice lawsuits across the country . Sinceable to prevent potentially devastating infections such there are far more attorneys than dentists in theas bacterial endocarditis. Therefore, the concept of United States, antibiotics are often readily prescribedusing antibiotics as a prophylactic measure to prevent with a lack of true medical indication.infection from dentally induced bacteremia has existed For some conditions (bacterial endocarditis andsince at least 1955 . patients with prosthetic joint replacements), there are Distant infections resulting from seeding of bac- consensus guidelines published by reputable organiza-teria caused by dental manipulations have been a tions. The dentist must be aware of these well-knownmatter of controversy. Indeed, the incidence of bac- conditions and guidelines. For other conditions, theteremia with dental treatment (including surgical indications and literature are conflicting or unclear. Inprocedures) is not vastly different from the bactere- addition, the dental practitioner who consults with themia that can be generated by chewing and by home patient’s physician for guidance may receive inad-oral hygiene procedures. In addition, the net benefit equate, conflicting, or widely varying protocols .of antibiotic prophylaxis is hard to quantify because The purpose of this article is to review currentonly a few of the many patients who are given medical and dental literature and attempt to arriveprophylactic antibiotics may actually benefit from at a rational guideline for the use of antibioticthem. This fact must be weighed against the poten- prophylaxis in dentoalveolar surgery. Those condi-tially adverse side effects of the antibiotics them- tions and procedures not requiring the use of anti-selves (allergy, toxicity, superinfection, and selection biotics will also be discussed. Finally, there is aof resistant organisms) . Nevertheless, the empiric brief discussion concerning the global overuse ofuse of antibiotic prophylaxis for dental procedures, antibiotics and its consequences.especially surgical procedures, has become a well-established practice among dental professionals. Thispractice began for prevention of bacterial endocar- Conditions requiring antibiotic prophylaxis Bacterial endocarditis E-mail address: firstname.lastname@example.org The first American Heart Association (AHA) rec-(M.G. Savage). ommendations for antibiotic prophylaxis to prevent1042-3699/02/$ – 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
232 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240bacterial endocarditis were published in 1955 . The latest AHA recommendations  focus onSince that time, those recommendations have been those conditions known to have moderate and highmodified a number of times, the last time in 1997. This risk of endocarditis in patients undergoing oral pro-most recent consensus panel had two participating cedures (Table 1). Compared to previous recommen-dentists, T.J. Pallasch, and T.W. Gage. This inclusion dations, there has been substantial reduction in theof more dentists on the ad hoc writing panel, at least in number of conditions for which antibiotics are rec-part, led to a more ‘‘user-friendly’’ set of guidelines for ommended. Those conditions for which the risk isthe use of antibiotics in conditions that might lead to minimal or negligible are well specified. The dentalbacterial endocarditis. The newest guidelines elimina- practitioner has less need to rely on medical providersted most needs for parenteral administration and sec- who may not know or understand the recommenda-ond follow-up doses, and they clarified the conditions tions and base their recommendations on anecdotalfor which antibiotics were and were not necessary. evidence. Hence, there is less chance that the dental Infective endocarditis is a relatively uncommon but provider will be forced to accept responsibility forlife-threatening disease. It is defined as an exudative giving antibiotics to inappropriate patients.and proliferative alteration of the endocardium, char- The change in acceptable antibiotic regimens isacterized by growth of vegetations on the surface or welcome (Table 2). Amoxicillin, which attains higherwithin the endocardium. These vegetations consist of blood levels than penicillin and lasts for hours, is thebacterially colonized fibrin and platelet masses. The principal antibiotic for nonallergic patients . Clin-platelet and fibrin masses are known as nonbacterial damycin, clairithromycin, and azithromycin are goodthrombotic endocarditis and are caused by turbulent choices in severely allergic patients because they workblood flow or foreign bodies within the heart. Bacteria along entirely separate pathways and have acceptablefrom a bacteremia from any source colonize these levels of side effects. The cephalosporin alternativessterile masses and cause the infection in endocarditis. There is substantial morbidity and mortality for itsvictims despite the advanced ability to diagnose and Table 1wide availability of antibiotics . Prevention of this Cardiac conditions associated with endocarditislife-threatening disease is, therefore, highly desirable. Endocarditis prophylaxis recommended The clinical presentation of endocarditis may be Prosthetic cardiac valves, including bioprosthetic andslow in onset and reveal classic Oslerian symptoms: homograft valvesbacteremia, valvulitis, peripheral emboli, and immu- Previous bacterial endocarditisnologic vascular phenomena. These latter signs are Complex cyanotic congenital heart disease(eg, singlemore typical of subacute infective endocarditis. Acute ventricle states, transposition of the great arteries,infective endocarditis usually develops so rapidly that tetralogy of Fallot) and any other congenitalthe immunologic vascular phenomena do not have malformation other than those listed below Surgically constructed systemic pulmonary shunts ortime to occur . Not all bacteria have the ability to conduitscolonize the sterile thrombi, nor do all invasive Acquired valvular dysfuntion (eg, rheumatic heart disease)procedures cause bacteremias that last long enough Hypertrophic cardiomyopathyor carry a large enough inoculum of bacteria to cause Mitral valve prolapse with valvular regurgitation and/oran infection of endocarditis. Indeed, most cases of thickened leafletsendocarditis caused by oral flora are not attributable toa dental invasive procedure [4,7,9]. There has been Endocarditis prophylaxis not recommendedsome progress lately with a well-designed population- Isolated secundum atrial septal defectbased case-control study from B.L. Strom et al and Surgically repaired atrial septal defect, ventricular septalothers. This study makes a case that prophylactic defect, patent ductus arteriosus (> 6 mo) Previous coronary artery bypass graft (CABG)antibiotics should be used for only two populations, Mitral valve prolapse without regurgitationpatients with a previous episode of endocarditis and Functional or innocent heart murmursthose with a prosthetic heart valve. Furthermore, the Previous Kawasaki disease without valvular dysfunctiononly procedures to require antibiotics should be Previous rheumatic fever without valvular dysfunctionrestricted to extractions, gingival surgery, and impac- Cardiac pacemakers (intravascular and epicardial) andtions [5,10]. This new information is intriguing and implanted defibrillatorsmay well join other studies in a significant change (Adapted from Dajani AS, Taubert KA, Wilson W, et al.from the AHA. The AHA has acknowledged this Prevention of bacterial endocarditis: recommendations byinformation, but they continue to stand behind the the American Heart Association. JAMA 1997;277:1795;current recommendations published in 1997 . with permission.)
M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 233Table 2Prophylactic regimens for dental and oral proceduresSituation Agent RegimenaStandard general prophylaxis Amoxicillin Adults: 2.0 g Children: 50 mg/kg 1 h before procedureUnable to take oral medications Ampicillin Adults: 2.0 g Children: 50 mg/kg IM or IV within 30 min of procedureAllergy to penicillin Clindamycin Adults: 600 mg Children: 20 mg/kg 1 h before procedureorCephalexin t or Adults: 2.0 gcephadroxil t Children: 50 mg/kg 1 h before procedureorAzithromycin or Adults: 500 mgclairithromycin Children: 15 mg/kg 1 h before procedureAllergy to penicillin and unable Clindamycin Adults: 600 mg to take oral medications Children: 20 mg/kg IV 30 min before procedure or Cefazolin t Adults: 1.0 g Children: 25 mg/kg IM or IV 30 min before proceduret Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, oranaphylaxis) to penicillins.(Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the AmericanHeart Association. JAMA 1997;277:1798; with permission.) a Total children’s dose should not exceed adult dose.are meant only for those patients who have not had osseous injection technique (available from at leastIg-E – mediated immediate reactions with penicillin or three manufacturers) should warrant the same pre-amoxicillin. It should be remembered that erythromy- cautions. The American Dental Association (ADA)cin is still acceptable if it has been used successfully in emphasizes that ‘‘these recommendations are notthe past with individual patients . intended as the standard of care, and practitioners The 1997 AHA recommendations also identify should use their own clinical judgement in individualthose procedures likely to cause clinically significant cases or special circumstances’’ .bacteremias (Table 3). Again, delineating the specificprocedures is a welcome and appropriate change from Special circumstancesprevious recommendations, but these are not all-encompassing. For example, there is no recommen- Patients already on antibioticsdation for antibiotics when performing intracanal Patients often present on chronic daily doses of aendodontic therapy, but there is a recommendation drug (eg, penicillin) for secondary prevention offor prophylaxis when performing endodontic therapy endocarditis. They may also be on a drug that is thebeyond the apex. Since the dentist may not be able to same or similar to what would be used for prophy-contain the endodontic treatment within the canal, the laxis, but are under therapy for an infection elsewhereuse of prophylaxis is indicated in high-risk patients. in the body. In these cases, one should change toLikewise, there is a recommendation for prophylaxis another family of antibiotics (Table 2) and prescribewhen performing intraligamental injections. An intra- the normal dose for that family of drugs.
234 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240Table 3 had to pick a number, it would therefore seem prudentDental procedures and endocarditis prophylaxis to consider redosing if treatment will be delayedEndocarditis prophylaxis recommendeda beyond 4 hours. Extractions and other open oral surgical and endodontic surgical procedures Unanticipated indications All periodontal surgery, scaling, root planing, probing, It is possible that the dentist may have started a and recall maintenance procedure for which antibiotic prophylaxis is not Dental implant placement and reimplantation of avulsed indicated, but then finds an indication. In a situation teeth where the dentist has initiated intracanal endodontics, Endodontic instrumentation beyond apex Subgingival placement of antibiotic fibers, strips, or but a perforation develops with bleeding, the AHA/ polymers ADA recommends administering the dose of anti- Placement of orthodontic bands (but not acid etch brackets) biotics at that time. This necessitates the dentist to Intraligamentary and intraosseous local anesthetic have an office supply of at least amoxicillin and injections clindamycin for patient use. Hygiene procedures on teeth or implants where bleeding is anticipated Patients who have taken appetite suppressantsEndocarditis prophylaxis not recommended There is a subset of the above group of patients Restorative dentistry and prosthodontics with or without whose potential for endocarditis has surfaced since retraction cordb Local anesthetic injections other than those listed above 1997. This group consists of patients who have taken Intracanal endodontic treatments, including post and core the drugs fenfluramine (Pondimin) or dexfenflur- Placement of rubber dam amine (Redux). Another drug, phentermine (Apidex, Postoperative suture removal Fastin, or Ionamin), had often been combined with Placement of any removable appliance fenfluramine in ‘‘fen-phen,’’ but is not implicated in Impressions the clinical problem . Initial concern linking Fluoride treatments valvular heart disease with the use of fenfluramine/ Radiographs phentermine was generated by a report in the New Orthodontic appliance adjustment England Journal of Medicine (vol. 337, August 28, Shedding of primary teeth 1997). This led to voluntary withdrawal of Redux andAdapted from JAMA 1997;277:1797; with permission. Pondimin from the market by Wyeth-Ayerst Labora- a Prophylaxis recommended for patients with endocar- tories in September 1997, a move praised by the AHAditis risk conditions. b . Interim guidelines for managing these patients Clinical judgment may indicate antibiotic use inselected circumstances that may create significant bleeding. were issued in November 1997  and were endorsed by the American Heart Association with a media advisory soon after . The guidelines issued from the US Department ofPatients on anticoagulants Health and Human Services (DHHS) recommended Do not administer intramuscular injections of the following:antibiotics to patients on heparin or coumarin deriv-atives because they may form a hematoma or have 1. All people exposed to these drugs shouldsevere ecchymosis. Use an intravenous or oral route. undergo a medical history and cardiovascu- lar examination.Delay in treatment 2. An echocardiogram should be performed on all There are times when patients will take the pre- people who exhibit cardiopulmonary signs andscribed prophylaxis regimen as directed, but for some symptoms of cardiac valvulopathyreason cannot be treated at the time anticipated. How 3. An echocardiogram is strongly recommendedlong is acceptable before redosing? There is no con- for all people exposed to these drugs for anysensus answer. We do know that amoxicillin maintains period of time, regardless of cardiopulmonarya prolonged serum inhibitory activity of 6 to 14 hours signs or symptoms, if the patient was to have anagainst most oral streptococci . Peak serum levels invasive procedure for which they would haveof amoxicillin occur 1 hour after ingestion. Serum been given antibiotic prophylaxis, according tolevels of oral clindamycin occur slightly more rapidly the 1997 guidelines.and remain for 3 hours . Amoxicillin retains 4. For emergency procedures where cardiacmicrobial killing power for several hours . If one examination cannot be performed, empiric
M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 235 antibiotic prophylaxis according to the 1997 1997 with a joint advisory statement from the Amer- guidelines should be performed. ican Academy of Orthopaedic Surgeons (AAOS) and the American Dental Association. The ADA and the Medical and dental literature point out some AAOS convened an expert panel of dentists, ortho-problems with the guidelines above [16,20,21]. There pedic surgeons, and infectious disease specialists whowere no consistent physical examination criteria, a performed a thorough review of all available literaturewide range of true valvulopathies were found, there and data to determine the need for antibiotic prophy-was a wide range in the length of time the drugs were laxis to prevent hematogenous prosthetic joint infec-taken, and there was controversy regarding whether tions in dental patients who have undergone TJAor not valvulopathy would regress over time. As a . The panel outlined consensus recommendationsresult, there is disagreement as to the true severity of that simplified the target population and regimens tothe problem; some authorities agree with the DHHS be used. These recommendations, though not com-guidelines and others see less of a problem. pletely accepted by all orthopedic surgeons [28,29], An additional problem, primary pulmonary hyper- at least created an area of agreement between dentiststension, has a long clinical ‘‘tail’’ and has been and a national orthopedic group (Table 4). Thelargely overlooked. This problem is rare in the specific joints replaced are not delineated with anygeneral population, but its frequency is 10 times differentiation; therefore, it is assumed that a total hipgreater in a population taking appetite suppressants replacement should be treated the same as a digitand 20 times greater when the appetite suppressant is replacement. The recommendations targeted thosetaken for more than 3 months . The diagnosis is populations at most risk to have a hematogenous totaloften delayed 1 to 2 years after symptom onset, and joint infection: immunocompromised/suppressedpeople with the disorder have a median survival of 2 patients; those with inflammatory arthropathies (eg,to 3 years from symptom onset [22,23]. rheumatoid arthritis); insulin-dependent diabetics; For the dental practitioner, it would seem prudent those with previous episode of infected joint; mal-to refer all these patients to a physician for a cardi- nourished persons; hemophiliacs; and those withinovascular examination. It would also be prudent to be 2 years of their joint replacement, regardless of healthspecific regarding your concerns and include a set of (Table 4).the DHHS guidelines or refer the physician to theappropriate AHA web site  that would have acomplete set of past advisories and recommendations. Table 4 Prophylaxis for patients with total prosthetic joint replacementPatients with prosthetic joint replacement Patients at potentially increased risk of hematogenous Before 1997, dental providers faced a conundrum joint infection Immunocompromised and immunosuppressed patients,with patients who had undergone total joint arthro- including those with conditions caused by disease,plasty (TJA). The vast majority of orthopedic sur- drug, or radiationgeons favored antibiotic prophylaxis before dental Inflammatory arthropathies, including rheumatoidtreatment for all TJA patients under all circumstances, arthritis and systemic lupus erythematosuseven though they recognized that a consistent rela- Insulin-dependent (type I) diabetestionship between dentally induced bacteremia and First 2 y after total prosthetic joint replacementprosthetic joint infections had not been established Previous prosthetic joint infection. Othopedic surgery authorities themselves admit Malnourishmentthat orthopedic surgeons are among the heaviest users Hemophiliaof prophylactic antibiotics . Nevertheless, a pros- Procedures likely to cause hematogenous joint infection in the patients listed abovethetic joint infection can be devastating, can occur Same as those in endocarditis (Table 3)from a variety of sources other than dental, and can Procedures less likely to cause hematogenous joint infectionoccur long after the supposed insult, making cause Same as those in endocarditis (Table 3)and effect difficult to prove. Antibiotic protocols Suggested antibiotic regimens to use in the patients listedrecommended by orthopedic surgeon colleagues var- aboveied widely and occasionally had no rationale against Same as those in endocarditis a(Table 2)oral microbes. A study performed in 1990 concluded a AAOS/ADA regimen places cephalexin and cephra-that it cost $480,000 in antibiotics to prevent one case dine ahead of amoxicillin in suggested regimens and doesof prosthetic joint infection . An attempt to not mention azithromycin or clairithromycin in suggestedeliminate this overuse controversy was made in regimens for penicillin allergic patients.
236 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 The recommendations then specified those proce- should be consulted regarding the timing and need fordures likely to cause a higher incidence of bacteremia anticoagulation control before any extensive surgeryand those procedures less likely to cause bacteremia. . Peritoneal dialysis requires no antibiotic pro-Those procedures are identical to those specified in phylaxis .the AHA bacterial endocarditis recommendations. Shunts are placed in patients with hydrocephaly toLikewise, the recommended antibiotic protocols were relieve the pressure of cerebrospinal fluid buildup onvirtually identical to those recommended by the AHA the brain. Shunts placed for treatment of hydrocephalyfor endocarditis. Some authorities take special pains are of two types, ventriculo-peritoneal (VP) and ven-to point out that the risk of causing a hematogenous triculo-atrial (VA). Infection of VA shunts is devastat-spread of infection is higher when dealing with gross ing and carries a mortality of 40%. These patientsinfection at the procedure site, such as a severe dental should receive prophylactic antibiotics [35,36]. VPabscess or when procedures take longer than 45 shunts carry no higher risk of infection from dentalminutes [29,30]. sources and therefore require no antibiotics Patients with plates, screws and pins: These Indwelling catheters may be present for a varietypatients require no prophylaxis. The recommenda- of reasons, usually to deliver long-term intravenoustions point out that the dentist may be presented with drugs for chemotherapy or to treat infection.a patient carrying recommendations from their ortho- Unless the terminal end is near the right side ofpedist which are inconsistent with these guidelines. the heart, no prophylaxis should be necessary .This may result from unfamiliarity with the guide- Pacemakers and implanted defibrillators maylines, or perhaps the patient has an overriding concern or may not be intracardiac. They can becomeunknown to the dentist. Consultation is urged to come infected, but most infections culture out Staphylo-to an agreement between the providers. If a disagree- coccu aureus, not viridans species . The AHA doesment still occurs, the dentist may proceed with the not recommend antibiotic prophylaxis before dentalrecommendations of the orthopedic surgeon despite treatment for these patients .the disagreement, proceed with the procedure without Patients who have undergone heart transplantantibiotics, or place the burden of prescription for the do not, per se, require prophylactic antibiotics. Theyantibiotics on the orthopedic provider. Best clinical are, however, prone to cardiac valvular dysfunctionjudgement is always appropriate. The total replace- and are typically on multiple immunosuppressantment of temporomandibular joints (TTMJR) is not drugs. Consultation is warranted and they mayspecifically addressed nor excluded in these recom- require antibiotic prophylaxis if a valvular abnormal-mendations. The late infection of a TTMJR is exceed- ity exists .ingly rare [31,32]. There is simply not enough data on Intracardiovascular artery stents, prosthetic ar-which to base a sound recommendation. The very tery grafts, angioplasty procedures, and coronarycautious practitioner may consider prophylaxis for artery bypass grafts (CABG) are performed forthat group of patients who fall under the AAOS/ patients with atherosclerotic cardiovascular diseaseADA guidelines only. and/or angina. Prophylactic antibiotic coverage for these patients is a controversial area, and some feelShunts, catheters, and implanted materials that the requirement for antibiotic prophylaxis hinges on the amount of epithelialization that will take place Patients with surgically constructed shunts for after the procedure is performed. Most infections takehemodialysis are at somewhat increased risk for place within 6 months of surgery, but oral flora areinfection, both locally and as a cause for endocarditis. rarely implicated [37,38]. Nevertheless, an infectedMoreover, if an infection occurs in these patients graft or stent is devastating. There is no consensus,undergoing dialysis, the downside is devastating. but a recommendation cited by several authors isAntibiotic prophylaxis for these patients, if under- that prophylaxis should be considered only withingoing invasive dentoalveolar procedures, is appropri- the first 6 weeks after surgery. Endotheializationate. AHA recommendations are probably adequate of the stent occurs during this time period. Anti-even though there is no consensus. The extent and biotics are not needed after 6 weeks, except possiblylength of surgery may induce stress and, because of for very large aortic grafts. Consultation is advisedanticoagulation, may result in significant bleeding. for these patients.Many penicillin-type drugs are metabolized through Patients with penile implants or other cosmeticthe kidneys, so consultation with the nephrologist is or functional implanted materials do not requirewarranted if therapy beyond a single dose is consid- prophylactic antibiotics before invasive dental treat-ered to treat infection. Regardless, the nephrologist ment .
M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 237Immunocompromised patients population. Most of these infections are not related to the mouth, and the population most at risk are those This group of patients includes those with neu- at two years or less post-splenectomy and childrentropenia for any reason, insulin-dependent diabetes, under 5 years old [4,38,41]. Therefore, routine pro-and asplenia. There have been no long-term, con- phylaxis for these patients is not recommended, buttrolled studies that have looked at infection rates in consultation is warranted for these latter two groupsdental patients with various levels of neutropenia and antibiotic prophylaxis may be necessary. These. Nevertheless, threat of infection exists and patients also require consideration for pneumococcalmorbidity increases as the leukocyte count drops. vaccine from their physicians [41,42].Regimens of antibiotics have been suggested forpatients with leukocyte levels of 3500/mm3, 2000/ Risk of brain abscessmm3, and 1000/mm3 . Difficulties arise as theoral flora changes in patients on chemotherapy. Several recent high-profile lawsuits have resultedWhereas the AHA recommendations are fine for most from patients who had minor infections or invasivepatients, they may not be the best choices for neu- dentoalveolar surgery and then suffered brain ab-tropenic patients. Again, no controlled studies exist to scesses that cultured out oral flora. There are areasprovide the best regimen. Best recommendations of the country where experienced, board-certifiedappear to define neutropenia as 1000/mm3 and to oral and maxillofacial surgeons who fear this liti-treat patients only on a nonelective (emergency) gation are providing prophylactic antibiotics forbasis. The AHA regimen or a recommended regimen patients who require extractions or significant inva-by consultation with the patient’s hematologist or sive surgery. In an elegant review of the literature andinfectious disease specialist is appropriate [4,37,38]. through the use of sound logic, Pallasch argues Patients who are HIV positive are not at greater vigorously against this practice . He makes therisk than non-HIV positive patients, provided that case that the incidence, etiology, and clinical coursethey currently have a satisfactory white blood cell of brain abscesses indicate that the association withcount. They should not receive antibiotic prophylaxis previous therapy is too small and the risk from thefor dental procedures unless they fall into another antibiotic is too great to warrant routine antibioticcategory that does require antibiotic prophylaxis. In prophylaxis for these patients. He argues that oneaddition, there is an additional risk of selecting million people would have to receive prophylacticantibiotic-resistant strains or causing fungal over- antibiotics in an attempt to save the theoretical lessgrowth [4,36 – 38]. than one person in that million from having a brain Prophylactic antibiotics are not necessary for most abscess. Even assuming that a correct antibiotic isdiabetic patients undergoing dentoalveolar surgery. chosen for this unknown pathogen, there is anMost authors agree that insulin-dependent diabetic unfavorable risk-to-benefit ratio. The death rate frompatients or non – insulin-dependent diabetics under anaphylaxis for the antibiotic would essentially begood control are at no greater risk than other patients higher than the rate of brain abscess occurrence.who are also undergoing minor but invasive surgical There would be a net loss of life from use of anti-procedures [4,38 – 40]. Unless they are poorly con- biotics in this attempt at prevention .trolled, non – insulin-dependent diabetics are usuallynot candidates for prophylaxis. If either population is Routine antibiotic prophylaxis in oral andwell controlled, prophylactic antibiotics should be maxillofacial surgeryused only in situations where prophylactic antibioticswould be used for nondiabetic patients. A diabetic with Antibiotics are commonly administered prophy-an infection should receive appropriate antibiotics, lactically for major oral and maxillofacial surgery,and a poorly controlled diabetic should also be referred such as temporomandibular joint surgery, orthog-for stabilization. If emergency dentoalveolar surgery is nathic procedures, and repair of facial trauma withrequired on a poorly controlled diabetic, then prophy- contamination. There is evidence that this is a soundlaxis is indicated, as well as consultation with the practice, though there is no need to continue thepatient’s endocrinologist. With no specific regimen antibiotics beyond the perioperative period . Onestablished, the AHA recommendations would suffice. the other hand, oral and maxillofacial surgeons com- The question of prophylactic antibiotics in monly prescribe antibiotics to ‘‘prevent’’ postopera-patients who have undergone splenectomy is also tive infections in patients who are not at risk forcontroversial. It is true that infections in post-splenec- serious infections from bacteremia and for relativelytomy patients occur at a rate far above the normal minor dentoalveolar procedures. In these scenarios,
238 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240there are many areas of disagreement and failure to Although he recommends penicillin for noncompro-adhere to basic principles [4,32,36,44]. In many mised patients, it seems to me, in the interest ofcases, the antibiotic is given after the procedure as simplification, that the AHA regimen would supplythe patient is walking out the door. This violates the similar efficacy and be easier to remember. Topazianwell-substantiated principle that antibiotics need to be recommends a first-generation cephalosporin (cepha-given before a procedure, not after, and sufficiently in lexin) or the combination of amoxicillin/clavulanateadvance to obtain a high blood level . This for sinus grafting (see Table 5).prophylaxis should ideally take place 2 hours before The question then arises for prophylactic antibioticthe incision if given orally, or immediately before use specifically for third molar surgery. Piecuch,surgery if given intravenously . Arzadon, and Lieblich looked at this question in Strictly speaking, surgical antibiotic prophylaxis is 1995 . They offered that oral surgeons prescribeindicated only (1) to prevent contamination of a sterile antibiotics in third molar surgery for five reasons: (1)area, (2) where infection is unlikely but associated to treat an active infection, (2) as prophylaxis inwith significant morbidity, (3) in procedures with high medically compromised patients, (3) patient or familyrates of infection, and (4) during implantation of demand, (4) prevailing standard of care in community,prosthetic material [4,36]. For antibiotics to be effec- and (5) risk of infection is high. They reviewedtive, they must be given in high doses and aimed at a literature for and against use of antibiotics in thirdspecific pathogen or group of pathogens. They need molar surgery and then interjected their own ret-not be continued after the procedure . With the rospective study of 2134 patients with 6713 thirdexception of implant placement, most dentoalveolar molar extractions. They answered the above justifica-oral surgery procedures do not qualify for prophylactic tions and recommended that antibiotic prophylaxis beantibiotics using the above criteria. The subject of justified only for full bony and partial bony impac-prophylaxis for implant and bone graft surgery is tions. In all other classes and positions of impactedanother topic worth its own article. There are no third molars, prophylaxis provided no statisticalpublished studies comparing one agent to another or improvement over no antibiotic prophylaxis. Theythe length of time of administration of one agent also revealed, however, that tetracycline placed inversus another. There are many technique articles in the extraction site was just as efficacious as systemicprint recommending prophylaxis, but drugs vary from antibiotics. This practice will continue to incite contro-penicillin to Augmentin to clindamycin, and length of versy and study. Indeed, a recently published double-time of administration varies from perioperative only blind placebo control study appears to refute the aboveto 2 weeks. A well-cited and thoughtful chapter by recommendations. This otherwise well-designed studyTopazian does specifically address this question . suffered from a low number of subjects (151) and theTable 5‘‘Bottom line’’ recommendations for antibiotic prophylaxisCondition Prophylaxis warranted? RegimenHeart conditions Possibly (see Table 1) AHA (Table 2)Total prosthetic Joint replacement Probably not (see Table 4) AHAVascular shunt for hemodialysis Yes AHAVentriculoatrial shunt for hydrocephaly Yes AHAVascular grafts No unless large or 6 months AHAOther cosmetic or functional implants NoImmunocompromised Possibly. Consult if 1000 wbc/mm3HIV positive NoInsulin-dependent diabetic No, unless poor control then AHASplenectomy No, unless spleen removed Consult less than 6 mo before or 5 y old thenRisk of brain abscess NoRoutine oral surgery procedures NoThird molar surgery No, except possibly partial bony No established regimen or full bony impactionsImplants, endosseous, bone grafts, Yes (immediate perioperative AHA (consider cephlosporin extensive membrane use period only) for sinus lift)
M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 239fact that a prophylactic drug effective only against Referencesanaerobes was used . Until similar studies areperformed with higher numbers of subjects and drugs  Okell CC, Elliott SD. Bacteraemia and oral sepsis:that are effective across the spectrum of oral patho- with special reference to etiology of subacute endocar-gens, the practice of third molar prophylaxis will ditis. Lancet 1935;2:869 – 72.continue to be partly based on empiricism .  Rushton MA. Subacute bacterial endocarditis follow- ing extraction of teeth and tonsils. Guys Hosp RepPatterns of use in prophylaxis 1930;80:39 – 44.  Committee on Prevention of Rheumatic Fever and Bacterial Endocarditis through Control of Streptococ- There is no question that one of the problems with cal Infection. 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