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Medically Compromised Patient Care

Course Number: 628

Antibiotic Prophylaxis

Bacteremia is induced during any dental procedure that involves gingival manipulation, perforation of oral mucosa, or manipulation of the periapical regions of the teeth. This includes procedures such as probing, scaling and root planing, etc. For example, orthodontic bands are often placed subgingivally, which causes bacteremia and would require antibiotic premedication for certain medically compromised individuals. However, the placement of brackets alone would not require premedication due to the supragingival location of the brackets (Figure 1).

ce628 - Images - Figure 1

Figure 1. Subgingival orthodontic band and supragingival orthodontic bracket.

Bacteremia can cause infections (both orally and systemically) and antibiotics are needed to treat those infections. However, there is concern that when antibiotics are used too often, it can lead to adverse events, such as Type 1 allergic reactions to penicillin and antibiotic resistance. Antibiotic resistance does not discriminate and can occur in all ages and geographic locations. Misuse of antibiotics is accelerating the process of antibiotic resistance and is becoming a serious public health concern. As a result, more infections are becoming harder to treat, due to the reduced effectiveness of the antibiotics that are available. This leads to an increase in hospital stays, medical costs, and ultimately to increased mortality.6 According to the CDC, antibiotic resistance is currently one of the greatest public health challenges that exists. In the U.S., approximately 2.8 million people acquire antibiotic-resistant infections each year and 35,000 die from them.7

According to the American Dental Association (ADA), current guidelines support premedication for a small subset of patients, because scientific evidence has confirmed that the risks of adverse reactions outweigh the benefits for patients who were eligible under the previous guidelines. There was also concern about the development of drug-resistant bacteria, thus new guidelines were created and continue to be updated with the latest update in 2021.8 Table 1 provides examples of procedures that would require antibiotic premedication when indicated and those procedures that are acceptable to perform without antibiotic premed.

Table 1. Antibiotic Premedication Treatment Examples 1
These cases DO need antibiotic premed if there is manipulation of gingival tissue or periapical region of teeth, or perforation of oral mucosa, such as:These procedures are ok to perform WITHOUT antibiotic premed:
  • Biopsies
  • Suture removal
  • Placement of ortho bands
  • Root planing
  • Adult prophy
  • Filling or root canal
  • Injections through PDL (intraligamentary and intraosseous)
  • Routine anesthetic injections (nerve blocks and supraperiosteal) through non-infected tissue
  • Taking radiographs
  • Placement of removable appliances
  • Adjusting ortho appliances & placing orthodontic brackets
  • Shedding deciduous teeth