CDA Essentials 2018 • Volume 5 • Issue 1

26 | 2018 | Issue 1 I ssues and P eople According to guidance from the American Heart Association 7 (AHA) and CDA, 8 only those at greatest risk of developing infective endocarditis should receive short-term preventive antibiotics before routine dental procedures. This includes people with (1) prosthetic cardiac valve or prosthetic material used for cardiac valve repair, (2) a history of infective endocarditis, (3) certain specific, serious congenital heart conditions (see CDA Position on Prevention of Infective Endocarditis for these specific conditions), and (4) a cardiac transplant that develops a problem in a heart valve. Responses to questions about which specific medical conditions require antibiotics to prevent infective endocarditis suggest that survey respondents were not aware of the AHA and CDA guidance on this issue. Thirteen percent of respondents were not prescribing antibiotics for patients with previous infective endocarditis, and 19% of respondents were not prescribing antibiotics for patients with a prosthetic heart valve. However, there are also signs of overprescribing: over 20% reported that patients with rheumatic fever with mitral regurgitation, organ transplant, mitral valve prolapse, or total joint prosthesis required prophylactic antibiotics for prevention of infective endocarditis. Almost 20% reported that patients with a myocardial infarction within the past six months required antibiotic prophylaxis. ◗� Discrepancies among dentists about which dental procedures require antibiotic prophylaxis for the prevention of infective endocarditis For patients at high risk of developing infective endocarditis, only certain dental procedures— those that involve “manipulation of gingival tissues or the periapical region of a tooth and…those procedures that perforate the oral mucosa” 7 —require prophylactic antibiotics, while the need for antibiotic prophylaxis for other procedures are left up to the clinical judgment of the dentist, according to the 2007 AHA guidelines. 7 The survey results revealed some uncertainty among respondents about which procedures require antibiotic prophylaxis for patients at risk of developing infective endocarditis and show some evidence of underprescribing. For example, not all respondents reported that dental implants (71%) and periodontal surgery (78%) require antibiotic prophylaxis. There were also some examples of overprescribing; some respondents believe antibiotic prophylaxis is required for dental procedures that do not require it, such as anesthetic injections through non-infected tissue (12%). ◗� Discrepancies among dentists about which signs and symptoms require therapeutic antibiotics Therapeutic antibiotics for specific signs and symptoms associated with dental conditions are only required if there are signs of spreading infection, patient malaise, elevation in temperature or lymphadenitis. 5 However, 60% of dentists who participated in the survey said they would prescribe antibiotics for localized, fluctuant swelling, and 20% would prescribe antibiotics for pain associated with a dental condition; in both cases, antibiotics are contraindicated. ◗� Discrepancies among dentists about which dental conditions require therapeutic antibiotics Dentists do not need to prescribe antibiotics for dental conditions if there are no signs of systemic infection and diffuse swelling. 5 However, over 50% of dentists surveyed reported they would prescribe antibiotics to patients presenting with pericoronitis, which is only indicated in select scenarios, such as accompaniment of suppuration or for patients with high risk of infection. Some also responded that they would provide therapeutic antibiotics for conditions where they aren’t indicated, such as for healthy patients with acute periapical infection before drainage (66%), acute ulcerative gingivitis (43%), acute periapical infection after drainage (41%), acute irreversible pulpitis (20%), and dry socket (18%). ◗� Dentists prescribing amoxicillin in patients with penicillin allergies For patients with known allergies to penicillin, the primary choice of antibiotic was clindamycin (>80%), although 2% still chose amoxicillin, even though it is contraindicated The survey results revealed some uncertainty among respondents about which procedures require antibiotic prophylaxis for patients at risk of developing infective endocarditis and show some evidence of underprescribing.