The American Dental Association (ADA) has recently updated guidelines for patients who require antibiotic coverage prior to certain dental treatment.
Compared with previous recommendations, there are currently relatively few patient subpopulations for whom antibiotic prophylaxis may be indicated prior to certain dental procedures. This is based on a review of scientific evidence, which showed that the risk of adverse reactions to antibiotics generally outweighs the benefits of prophylaxis for many patients who would have been considered eligible for prophylaxis in previous versions of the guidelines. Concern about the development of drug-resistant bacteria also was a factor.
Key points in the updated ADA antibiotic stewardship recommendations:
- In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior to dental procedures to prevent prosthetic joint infection.
- For infective endocarditis prophylaxis, American Heart Association guidelines (updated in 2021) support premedication for a relatively small subset of patients i.e only indicated for patients at the highest risk of infective endocarditis.
- For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.
- With the exception of the AHA/ACC guidelines regarding prevention of infective endocarditis, there is no general guidance or recommendation to provide antibiotics as a prophylactic measure prior to dental procedures except for specific individuals with extenuating circumstances, where the determination and prescription are made by the patient’s surgeon or other treating physician.
- Cyanotic congenital heart disease (birth defects with oxygen levels lower than normal), that has not been fully repaired, including children who have had surgical shunts and conduits.
- A congenital heart defect that's been completely repaired with prosthetic material or a device for the first six months after the repair procedure.
- Repaired congenital heart disease with residual defects, such as persisting leaks or abnormal flow at or adjacent to a prosthetic patch or prosthetic device.
Additional Considerations About Infective Endocarditis Antibiotic Prophylaxis (When Indicated):
- Clindamycin is no longer preferred as an oral or parenteral alternative to amoxicillin or ampicillin in individuals with allergies. Instead, cephalexin (or other first- or second-generation cephalosporins), azithromycin, clarithromycin, or doxycycline be used as alternatives for patients who can take oral antibiotics. Cefazolin or ceftriaxone can be used otherwise.
- If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure.
- If patients require prophylaxis but are already taking antibiotics for another condition, select an antibiotic from a different class than the one the patient is already taking.
Additionally, the ADA developed guidelines for the management of dental pain and intra-oral swelling that largely recommended against the use of antibiotics for the treatment of infections without systemic involvement, favoring dental intervention in immunocompetent patients.