Update on Antibiotics Prior to Dental Procedures

Wilderness dentistry is an art form, often improvised and rarely practiced in an optimal setting. Most health care professionals are not trained in dentistry and are therefore forced to improvise when faced with an injured or lost tooth, gum infection, lost crown, or other dental emergency. Furthermore, most first aid kits are not supplied with proper tools for managing dental problems unless a traveler has had the foresight to carry the necessary supplies and learn how to use them properly.

One traditional concept in dentistry has been that certain antibiotic coverage is necessary for persons with certain structural heart problems prior to certain dental manipulations. I was taught this in medical school, and dogma about this has not
changed until just recently. The American Heart Association (AHA) has released new recommendations that state that the use of antibiotics prior to dental procedures is rarely needed. This information is applicable to the wilderness as well as the urban setting.

The update states that giving antibiotics to patients prior to dental procedures is unlikely to prevent many cases of infective endocarditis [inflammation of the lining of the heart and its valves].

A specially appointed writing group sponsored by the AHA was created because of its collective expertise in prevention and treatment of infective endocarditis. This group, along with members representing the American Dental Association, the Infectious Diseases Society of America, and the American Academy of Pediatrics, concluded that the use of prophylactic (preventive) antibiotics should be restricted to patients at risk for infection, such as those with artificial heart valves or certain congenital heart defects.

According to the writing group, and as reported by Julie McKeel of the Duke Clinical Research Institute, antibiotic use should be reserved only for those people who would have the worst outcomes if they get infective endocarditis. The writing group concluded that "random bacteremia" (showers of bacteria released into the blood stream) resulting from routine daily activities, such as chewing food or tooth brushing, is far more likely to cause infective endocarditis than is bacteremia secondary to dental procedures. They did not, however, recommend that people take antibiotics whenever they eat or brush their teeth.

So, preventive antibiotics are now recommended for high-risk persons in which there will be manipulation of gum tissue, creation of cuts or perforations inside the mouth, or extensive dental worth around the periapical (near the base of the root) region of teeth. Such "high-risk" patients include recipients of heart transplants who have developed heart valve problems, as well as persons with:

• Prior infective endocarditis (infection of the heart valves)

• Artificial heart valves

• Unrepaired cyanotic ("blue coloration") congenital heart defects, including life-preserving shunts and conduits

• Congenital heart defects completely repaired with artificial material or a device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

• Repaired congenital defects with residual defects at the site or adjacent to the site of an artificial patch or prosthetic device

Preventive antibiotics are no longer advised for persons with unrepaired "natural" mitral and aortic valve disease, rheumatic heart disease, or structural disorders like ventricular or atrial septal defects or hypertrophic cardiomyopathy (thickened heart wall muscle).

It is unlikely that lay persons will make the decision about when to apply these rules, but they are an important example of current information that needs to be disseminated to physicians so that they can provide good advice to people with disabilities who might venture into the wilderness.

image courtesy of www.clinica-dental-estrella

Tags: dental procedures, antibiotics, cardiac, prophylaxis, physician, health, wilderness medicine, outdoor medicine, healthline

Labels: antibiotics, dentistry, prophylaxis

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