INDICATIONS FOR PROPHYLACTIC ANTIBIOTICS

 by:Joseph W. Costa, Jr., D.M.D., and Dale Potter, D.D.S.

For what cardiac conditions is prophylaxis for endocarditis recommended in patients receiving dental care?

High- Risk Category
• Prosthetic cardiac valves, including both bioprosthetic and homograft valves
• Previous bacterial endocarditis
• Complex cyanotic congenital heart disease (e.g., single ventricle states, transposition of the great arteries, tetralogy of Fallot)
• Surgically constructed systemic pulmonary shunts or conduits




Moderate-Risk Category
• Most congenital cardiac malformations other than above and below (see next question)
• Acquired valvular dysfunction (e.g., rheumatic heart disease)

• Hypertrophic cardiomyopathy
• Mitral valve prolapse with valvular regurgitation and/or thickened leaflets

What cardiac conditions do not require endocarditis prophylaxis? Negligible-risk category (no higher than the general population)
• Isolated secundum atrial septal defect
• Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 months)
• Previous coronary artery bypass graft surgery
• Mitral valve prolapse without valvular regurgitation
• Physiologic, functional, or innocent heart murmurs
• Previous Kawasaki disease without valvular regurgitation
• Previous rheumatic fever without valvular regurgitation
• Cardiac pacemakers (intravascular and epicardial) and implanted
defibrillators

What are the antibiotics and dosages recommended by the American Heart Association (AHA) for prevention of endocarditis from dental procedures?The AHA updates its recommendations every few years to reflect new findings. The dentist has an obligation to be aware of the latest recommendations. The patient’s well-being is the dentist’s responsibility. Even if a physician recommends an alternative prophylactic regimen, the dentist is liable if the patient
develops endocarditis and the latest AHA recommendations were not followed.

Standard regimen
Amoxicillin, 2.0 gm orally 1 hr before procedure
For patients allergic to amoxicillin and penicillin
Clindamycin, 600 mg orally 1 hr before procedure or
Cephalexin* or cefadroxil,* 2.0 gm orally 1 hr before procedure or
Azithromycin or clarithromycin, 500 mg orally 1 hr before procedure
Patients unable to take oral medications
Ampicillin, intravenous or intramuscular administration of 2 gm 30 mm
before procedure
For patients allergic to ampicillin, amoxicillin, and penicillin
Clindamycin, intravenous administration of 600 mg 30 mm before procedure
or Cefazolin,* intravenous or intramuscular administration of 1.0 gm within
30 mm before procedure
* Cephalosporins should not be used in patients with immediate-type
hypersensitivity reaction (urticaria, angioedema. or anaphylaxis) to penicillins.

For what dental procedures is antibiotic premedication recommended in patients identified as being at risk for endocarditis?• Dental extractions
•Periodontal procedures including surgery, scaling and root planing,
probing, and recall maintenance
• Dental implant placement and reimplantation of avulsed teeth
• Endodontic (root canal) instrumentation or surgery only beyond the apex
• Subgingival placement of antibiotic fibers or strips
• Initial placement of orthodontic bands but not brackets
• Intraligamentary local anesthetic injections
• Prophylactic cleaning of teeth or implants if bleeding is anticipated
Dajani AS, et a!: Prevention of bacterial endocarditis: Recommendations by the American Heart
Association. JAMA 277:1794-1801, 1997. 

For what dental procedures is antibiotic premedication not
recommended in patients identified as being at risk for endocarditis?•Restorative dentistry (including restoration of

TREATMENT PLANNING AND ORAL DIAGNOSIS

by : Stephen T. Sonis, D.M.D., D.M.Sc.

What are the objectives of pretreatment evaluation of a patient?
1. Establishment of a diagnosis
2. Determination of underlying medical conditions that may modify the oral
condition or the patient’s ability to tolerate treatment
3. Discovery of concomitant illnesses
4. Prevention of medical emergencies associated with dental treatment
5. Establishment of rapport with the patient

What are the essential elements of a patient history?1. Chief complaint
2. History of the present illness (HPI)
3. Past medical history
4. Social history
5. Family history
6. Review of systems
7. Dental history

Define the chief complaint.
The chief complaint is the reason that the patient seeks care, as described
in the patient’s own words

What is the history of the present illness?
The HPI is a chronologic description of the patient’s symptoms and should
include information about duration, location, character, and previous treatment.

What elements need to be included in the medical history?
• Current status of the patient’s general health
• Hospitalizations
• Medications
• Allergies 

What areas are routinely investigated in the social history?
• Present and past occupations
• Occupational hazards
• Smoking, alcohol or drug use
• Marital status

Why is the family history of interest to the dentist?
The family history often provides information about diseases of genetic
origin or diseases that have a familial tendency. Examples include clotting
disorders, atherosclerotic heart disease, psychiatric diseases, and diabetes
mellitus.

How is the medical history most often obtained?
The medical history is obtained with a written questionnaire supplemented
by a verbal history. The verbal history is imperative, because patients may leave
out or misinterpret questions on the written form. For example,