Patients undergoing dental procedures beyond routine cleaning or fillings are often prescribed precautionary antibiotics if they have had any number of surgical procedures. These might include knee or hip replacement, arterial stent insertion or pacemaker implantation. The logic is that bacteria from the oral cavity, whether ordinary mucosal flora or arising from an abscess can enter the bloodstream through the oral vasculature and colonize susceptible structures like valve replacements, stents and the like. Administration of antibiotics helps prevent this sort of colonization.

The relationship between dental work and infection is somewhat paradoxical. While invasive dental work increases the likelihood of infection of implanted devices, frequent hygiene and scaling/root planing procedures were shown to actually decrease the frequency of infection for patients who had received total knee arthroplasty by around 20%. Clearly a balance exists between procedures that maintain oral health and those that temporarily expose the bloodstream to bacteria, although necessary for overall oral health.

However, trends in antibiotic resistance have escalated, with regulatory bodies advising clinicians to avoid any unnecessary usage of antibiotics. This represents somewhat of a dilemma for doctors looking to reduce the risk of patient harm and guard themselves from malpractice lawsuits arising from infections. Many patients expect to be prescribed antibiotics for a toothache even though they are unlikely to lessen the pain. So where are prophylactic antibiotics most indicated?

The answer, as posited by the journal Therapeutics and Clinical Risk Management, is "only when there is an acute and obvious infection in the oral cavity." The risk of secondary infection, even for "highly predisposed" patients has been found to be very low. According to this journal, only the following conditions inherently necessitate antibiotics: facial cellulitis, lateral periodontal abscess, pericoronitis, and necrotizing ulcerative gingivitis. Other conditions with severe or atypical presentations may also require antibiotics at the discretion of the clinician.

Choosing an antibiotic:
A good short-course oral antibiotic should have the following qualities: easy penetration into tissues, activity against non-dividing bacteria, and rapid onset of action. Amoxicillin and metronidazole are preferred for these reasons. Choosing the wrong antibiotic could have serious implications. Clostridium difficile infections are on the rise, induced by an antibiotic purge of the "good" bacteria in the gut.

Sources:
Enzler, M. J., Berbari, E., & Osmon, D. R. (2011). Antimicrobial Prophylaxis in Adults. Mayo Clinic Proceedings, 86(7), 686-701. doi:10.4065/mcp.2011.0012

Gopalakrishnan, P. P., Shukla, S. K., & Tak, T. (2009). Infective Endocarditis: Rationale for Revised Guidelines for Antibiotic Prophylaxis. Clinical Medicine & Research, 7(3), 63-68. doi:10.3121/cmr.2009.848

Disclaimer

The information contained in this, or any case study post in Incisor should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 106 Lenora Street, Seattle, WA 98121. Please print a copy of this posting and include it with your question or request.

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The information contained in this, or any case study post in Incisor, should never be considered a proper replacement for necessary training and/or education regarding adult oral conscious sedation. Regulations regarding sedation vary by state. This is an educational and informational piece. DOCS Education accepts no liability whatsoever for any damages resulting from any direct or indirect recipient's use of or failure to use any of the information contained herein. DOCS Education would be happy to answer any questions or concerns mailed to us at 3250 Airport Way S, Suite 701 | Seattle, WA 98134. Please print a copy of this posting and include it with your question or request.
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