This document summarizes guidelines for antibiotic prophylaxis for infective endocarditis and prosthetic joints. It recommends prophylaxis for certain high-risk cardiac conditions when undergoing dental procedures, including prosthetic cardiac valves or congenital heart disease. It also recommends prophylaxis for joint replacement patients undergoing dental work, including those who are immunocompromised or have certain medical conditions. The document reviews recommended antibiotic regimens for these patients and exceptions where prophylaxis is not needed.

1. Presented By: Stephanie Chahrouk

2. I-Antibiotic Prophylaxis for infective endocarditis and prosthetic
Joints
“Cardiac Conditions Associatedwiththe HighestRisk of AdverseOutcome from
Endocarditis for Which Prophylaxis withDental ProceduresIs Recommended:
 “Exceptfor the conditionslistedabove,antibioticprophylaxisisnolonger recommendedforany
otherformof CHD.
 Prophylaxisisrecommendedbecauseendothelializationof prostheticmaterial occurswithin6
monthsafterthe procedure”
Prosthetic cardiac valve
Previous IE
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 6 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)
Cardiac transplantation recipients who develop cardiac valvulopathy”

3. “Dental Procedures for which Endocarditis Prophylaxis is
Recommended for Patients
“Patients at Potential IncreasedRisk of Hematogenous Total Joint Infection
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 noninfected 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"
Immunocompromised/immunosuppressed patients
• Inflammatory arthropathies: rheumatoid arthritis, systemic lupus erythematosus
• Disease-, drug-, or radiation-induced immunosuppression
Other
• patients Insulin-dependent (type 1) diabetes
• First 2 years following joint placement
• Previous prosthetic joint infections
• Malnourishment
• Hemophilia”

4. “Suggested Antibiotic Prophylaxis Regimens for Orthopedic
Joint Patients
• cephalexin, cephradine, or amoxicillin 2 g orally 1 hour prior to dental procedure
Patients not allergic to penici llin:
• cefazolin or ampicillin
• Cefazolin 1 g or ampicillin 2 g IM or IV 1 hour prior to the procedure
Patients not allergic to penicillin and unable to take oral
medications:
• clindamycin
• 600 mg orally 1 hour prior to the dental procedure
Patients allergic to penicillin:
• clindamycin
• 600 mg IV 1 hour prior to the procedure”
Patients allergic to penicillin and unable to take oral
medications:

5. II- Medications for Oral Lesions
A- Ulcerations
“Recurrent Aphthous Stomatitis
•to reduce pain
•decrease the size andhealingtime of the lesionswithtopical medication.
The goal of the managementof recurrentaphthousstomatitis(RAS) ischiefly:
•analgesics(see Table 17) and
•corticosteroids(Table26).
•Injectable corticosteroidsare alsoreferredtoasintralesional corticosteroids(Table27) and
are useful forlarge andpainful lesions.
These drugsare generallyplacedintotwocategories:
In severe minorRASormajorRAS, use of systemicdrugsmaybe consideredtopreventlesion
formationorat leasttoreduce the numberof lesions.
•short coursesandare reserved
•severe outbreaksorafterulcershave notrespondedtoregularuse of topical orinjectable
drugs
Systemiccorticosteroidsare usuallyprescribedin:
!! Continuoususe of systemiccorticosteroidscanlead tothe developmentof significantside
effectsandshouldbe avoidedinmanaginglocalizeddiseasessuchasRAS.
Drugs forpreventive therapyinclude:
colchicine
pentoxifylline
•Thalidomidehassevere sideeffects:
•deforming birth defects, and must only be reserved for the most severe cases, which do not
respondtoany othertherapy.
•In severe cases, azathioprine can also be used as an adjunct to systemic corticosteroid
therapy”
thalidomide

6. B- “Behçet’s Syndrome
The treatmentof Behçet’ssyndrome issimilartothe treatmentof severe ormajorRAS.
Topical corticosteroidsare usedtomanage oral lesions.
•Colchicine
•pentoxifylline
•thalidomide
•dapsone
To treat mucocutaneouslesionsandsystemicmanifestationsof the disease:
Immunosuppressive drugssuchasazathioprine are usedtomanage severe cases"

7. C- Vesiculobullous Conditions
“Pemphigus Vulgaris
The principal treatmentforpemphigusvulgarisissystemiccorticosteroidsatdoses
of 1 to 2 mg/kg/d
•azathioprine
•mycophenolatemofetil
•cyclophosphamide
Adjuvanttherapyisfrequentlyrequiredwithimmunosuppressivedrugs,suchas
to reduce corticosteroiddosagesand
to reduce mortalityfromthe side effectsof systemiccorticosteroids.94
Maintenance of remissioncanoftenbe achievedwithtopical corticosteroids
allowingreductionof systemicdrugs.
Isolatedlesionscanbe treatedwithinjectable corticosteroids”

10. III- Antiviral Medications
 “Herpes simplex virus 1 (HSV-1), an
alphaherpesvirus, is a large DNA virus that
causes primary herpetic gingivostomatitis,
mucocutaneous orofacial disease, and ocular
disease”.
 “Recrudescent HSV-1 in immunocompromised
patients (eg, HIV+, AIDS) and those undergoing
cytoreductive therapy or those on immunosuppressive drugs (especially after organ
transplantation) may develop anywhere in the oral cavity as single or multiple
ulcers.”
 “Oral recrudescent HSV is dangerous in immunocompromised patients as it may
lead to HSV viremia and life-threatening disseminated disease and, requires
aggressive therapy”
 “Recurrent herpes labialis Infectivity is highest within the first 24 hours of the
appearance of lesions, with 80% of vesicles and 34% of ulcer/crust lesions yielding
positive HSV cultures are very short-lived (unless the patient is
immunocompromised), the treatment window using topical antivirals”

12. “Acyclovir
 ACV is a synthetic acyclic analogue of 2p-
deoxyguanosine
 inhibitory activity against HSV-1 and other herpes
viruses.
 Topical ACV
o Due to poor penetration,
o 5 or 10% ACV in an ointment base has not been demonstrated to be efficacious
for treating RHL in healthy patients.
 Orally Administered ACV
o 200 to 400 mg five times a day will shorten healing time,
o suppress delayed lesions,
o reduce lesion size and duration of pain,
o diminish viral shedding”
“Valacyclovir
 Valacyclovir is the l-valyl ester and prodrug of ACV
 It is well absorbed after oral administration.
 The rapid and almost complete conversion (99%) to ACV in the GI
tract and liver”
“Penciclovir
 Penciclovir is an acyclic nucleo has specific action against
virally infected cells and has a prolonged half-life in HSV-
infected cells,
 allows for less frequent dosing.
 for IV and topical use.side analogue similar to ACV.”
“Docosanol
 n-Docosanol is a saturated 22-carbon alcohol that
 inhibits HSV replication by interfering with early intracellular
events surrounding viral entry into target cells.
 Its mechanism of action is still poorly understood”

13. “Famciclovir
 is a diacetyl-6-deoxy analogue and prodrug of
penciclovir.
 It is rapidly absorbed after oral administration
 metabolized by deacetylation in the GI tract, blood, and
liver to penciclovir.”
III- Anti-Fungal Drugs
“Oral candidiasis has
 three commonoral variants:
o pseudomembraneouscandidiasis,
o erythematouscandidiasis,
o angularcheilitis
 Andseveral lesscommonvariants:
o hyperplasticcandidiasis,
o lineargingival erythemaassociatedwithHIV
infection
 Oral fungal infectionscanmanifestinup to60% of healthy
persons.
 more commonin immunocompromised patientswhereoral-pharyngeal candidiasiscanleadto
life-threateningsystemicdissemination ->whichsubstantiatesthe aggressive treatmentand
prophylaxisof thisinfection.”

15. Source: Burket's Oral Medicine 11th Ed - gr.dentistbd.com