Prophylactic Antibiotic Coverage (PAC):  Do you need to premedicate with an antibiotic for a dental appointment due to a heart condition or a prosthetic joint?

            This is truly one of the most debated issues in dentistry today.  The most current recommendations by the American Dental Association (ADA) are based upon their research and recommendations along with those of the American Heart Association (AHA) and the American Academy of Orthopedic Surgeons (AAOS).  Some susceptible patients need to take antibiotics before certain dental procedures because bacteria can enter the bloodstream through wounds in the mouth during the procedure and find their way to vulnerable organs and joints.  In the past, there were much broader recommendations that covered more people.  However, further studies have shown that many conditions do not benefit from PAC and that the risks outweigh the rewards.  Even for patients who have more susceptible conditions, PAC is only recommended when dental procedures involve manipulation of the gum tissue or periapical region of the teeth, or perforation of the oral mucosa.

            The AHA’s current guidelines recommend PAC for patients with:

1. a prosthetic cardiac valve or a cardiac valve repaired with a prosthetic material
2. a history of infective endocarditis (a type of heart infection)
3. a cardiac transplant that develops cardiac valvulopathy
4. certain congenital heart conditions including unrepaired cyanotic congenital heart disease, a completely repaired congenital heart defect with a prosthetic material or device during the first six months after the procedure, and any repaired congenital heart defect with a residual defect.

Note that PAC is no longer recommended for any other form of congenital heart disease, including mitral valve prolapse.

            The AAOS’s most recent guidelines no longer recommend PAC for the majority of patients who have had joint replacements (such as a knee or hip) because it has found no association between the dental procedures and prosthetic joint infections.  One exception would be a patient who is highly immunosuppressed.  However, the ADA recommends consulting with the patient’s orthopedic surgeon and considering the patient’s specific needs and preferences when planning treatment.

            The newest guidelines support stopping the widespread overuse of antibiotics.  The CDC recently reported that about 50% of all antibiotic prescriptions written in the outpatient setting are unnecessary!  The CDC also reports that more than 5 antibiotic prescriptions are written each year for every 6 people in the US!  Antibiotics can be very helpful in treating or preventing bacterial infections, but they have no effect on viral infections.  In addition, they can cause diarrhea, stomach pain, and serious and even fatal allergic reactions.  Overuse of antibiotics can also increase a patient’s risk of developing Clostridium difficile colitis (a serious infection and inflammation of the large intestine) and breed antibiotic-resistant bacteria such as Staphylococcus aureus (MRSA) and Streptococcus pneumonia.  These are major public health concerns.

            In addition, prescribing antibiotics should not be a substitute for definitive dental treatment such as root canal therapy or oral surgery.  Consult with your dentist and physicians to see what is most appropriate for your individual circumstances.  As my patient, I would be happy to help guide you in your care.

                                                                                    Dr Swain