1. Oral Maxillofacial Surg Clin N Am 14 (2002) 231 – 240
Antibiotic prophylaxis in dentoalveolar surgery
Michael G. Savage, DDS
Division of Oral Surgery, Department of Surgical Dentistry, University of Colorado School of Dentistry,
4200 East Ninth Avenue, Campus Box C-284, Denver, CO 80262, USA
Antibiotic prophylaxis in dentoalveolar surgery ditis, but has spread to include patients at risk of
developing infections of prosthetic joints, those with
In England during the 1930s, it became evident that depressed immune systems from a variety of causes,
bacteremia from dental procedures could cause the those with synthetic implants of various kinds, and to
distant infection of bacterial endocarditis [1,2]. With prevent postoperative infection in a variety of patients
the onset of the antibiotic era, health care providers undergoing intraoral procedures. Failure to provide
assumed that if antibiotics could cure an infection, they prophylaxis when a distant or significant postoper-
may also be able to prevent them. Work began more ative infection occurs has become a major source of
than 40 years ago to investigate how antibiotics may be malpractice lawsuits across the country [5]. Since
able to prevent potentially devastating infections such there are far more attorneys than dentists in the
as bacterial endocarditis. Therefore, the concept of United States, antibiotics are often readily prescribed
using antibiotics as a prophylactic measure to prevent with a lack of true medical indication.
infection from dentally induced bacteremia has existed For some conditions (bacterial endocarditis and
since at least 1955 [3]. patients with prosthetic joint replacements), there are
Distant infections resulting from seeding of bac- consensus guidelines published by reputable organiza-
teria caused by dental manipulations have been a tions. The dentist must be aware of these well-known
matter of controversy. Indeed, the incidence of bac- conditions and guidelines. For other conditions, the
teremia with dental treatment (including surgical indications and literature are conflicting or unclear. In
procedures) is not vastly different from the bactere- addition, the dental practitioner who consults with the
mia that can be generated by chewing and by home patient’s physician for guidance may receive inad-
oral hygiene procedures. In addition, the net benefit equate, conflicting, or widely varying protocols [6].
of antibiotic prophylaxis is hard to quantify because The purpose of this article is to review current
only a few of the many patients who are given medical and dental literature and attempt to arrive
prophylactic antibiotics may actually benefit from at a rational guideline for the use of antibiotic
them. This fact must be weighed against the poten- prophylaxis in dentoalveolar surgery. Those condi-
tially adverse side effects of the antibiotics them- tions and procedures not requiring the use of anti-
selves (allergy, toxicity, superinfection, and selection biotics will also be discussed. Finally, there is a
of resistant organisms) [4]. Nevertheless, the empiric brief discussion concerning the global overuse of
use of antibiotic prophylaxis for dental procedures, antibiotics and its consequences.
especially surgical procedures, has become a well-
established practice among dental professionals. This
practice began for prevention of bacterial endocar- Conditions requiring antibiotic prophylaxis
Bacterial endocarditis
E-mail address: michael.savage@uchsc.edu The first American Heart Association (AHA) rec-
(M.G. Savage). ommendations for antibiotic prophylaxis to prevent
1042-3699/02/$ – see front matter D 2002, Elsevier Science (USA). All rights reserved.
PII: S 1 0 4 2 - 3 6 9 9 ( 0 2 ) 0 0 0 0 5 - 5

2. 232 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240
bacterial endocarditis were published in 1955 [5]. The latest AHA recommendations [7] focus on
Since that time, those recommendations have been those conditions known to have moderate and high
modified a number of times, the last time in 1997. This risk of endocarditis in patients undergoing oral pro-
most recent consensus panel had two participating cedures (Table 1). Compared to previous recommen-
dentists, T.J. Pallasch, and T.W. Gage. This inclusion dations, there has been substantial reduction in the
of more dentists on the ad hoc writing panel, at least in number of conditions for which antibiotics are rec-
part, led to a more ‘‘user-friendly’’ set of guidelines for ommended. Those conditions for which the risk is
the use of antibiotics in conditions that might lead to minimal or negligible are well specified. The dental
bacterial endocarditis. The newest guidelines elimina- practitioner has less need to rely on medical providers
ted most needs for parenteral administration and sec- who may not know or understand the recommenda-
ond follow-up doses, and they clarified the conditions tions and base their recommendations on anecdotal
for which antibiotics were and were not necessary. evidence. Hence, there is less chance that the dental
Infective endocarditis is a relatively uncommon but provider will be forced to accept responsibility for
life-threatening disease. It is defined as an exudative giving antibiotics to inappropriate patients.
and proliferative alteration of the endocardium, char- The change in acceptable antibiotic regimens is
acterized by growth of vegetations on the surface or welcome (Table 2). Amoxicillin, which attains higher
within the endocardium. These vegetations consist of blood levels than penicillin and lasts for hours, is the
bacterially colonized fibrin and platelet masses. The principal antibiotic for nonallergic patients [12]. Clin-
platelet and fibrin masses are known as nonbacterial damycin, clairithromycin, and azithromycin are good
thrombotic endocarditis and are caused by turbulent choices in severely allergic patients because they work
blood flow or foreign bodies within the heart. Bacteria along entirely separate pathways and have acceptable
from a bacteremia from any source colonize these levels of side effects. The cephalosporin alternatives
sterile masses and cause the infection in endocarditis
[6]. There is substantial morbidity and mortality for its
victims despite the advanced ability to diagnose and Table 1
wide availability of antibiotics [7]. Prevention of this Cardiac conditions associated with endocarditis
life-threatening disease is, therefore, highly desirable. Endocarditis prophylaxis recommended
The clinical presentation of endocarditis may be Prosthetic cardiac valves, including bioprosthetic and
slow in onset and reveal classic Oslerian symptoms: homograft valves
bacteremia, valvulitis, peripheral emboli, and immu- Previous bacterial endocarditis
nologic vascular phenomena. These latter signs are Complex cyanotic congenital heart disease(eg, single
more typical of subacute infective endocarditis. Acute ventricle states, transposition of the great arteries,
infective endocarditis usually develops so rapidly that tetralogy of Fallot) and any other congenital
the immunologic vascular phenomena do not have malformation other than those listed below
Surgically constructed systemic pulmonary shunts or
time to occur [8]. Not all bacteria have the ability to
conduits
colonize the sterile thrombi, nor do all invasive
Acquired valvular dysfuntion (eg, rheumatic heart disease)
procedures cause bacteremias that last long enough Hypertrophic cardiomyopathy
or carry a large enough inoculum of bacteria to cause Mitral valve prolapse with valvular regurgitation and/or
an infection of endocarditis. Indeed, most cases of thickened leaflets
endocarditis caused by oral flora are not attributable to
a dental invasive procedure [4,7,9]. There has been Endocarditis prophylaxis not recommended
some progress lately with a well-designed population- Isolated secundum atrial septal defect
based case-control study from B.L. Strom et al and Surgically repaired atrial septal defect, ventricular septal
others. This study makes a case that prophylactic defect, patent ductus arteriosus (> 6 mo)
Previous coronary artery bypass graft (CABG)
antibiotics should be used for only two populations,
Mitral valve prolapse without regurgitation
patients with a previous episode of endocarditis and
Functional or innocent heart murmurs
those with a prosthetic heart valve. Furthermore, the Previous Kawasaki disease without valvular dysfunction
only procedures to require antibiotics should be Previous rheumatic fever without valvular dysfunction
restricted to extractions, gingival surgery, and impac- Cardiac pacemakers (intravascular and epicardial) and
tions [5,10]. This new information is intriguing and implanted defibrillators
may well join other studies in a significant change (Adapted from Dajani AS, Taubert KA, Wilson W, et al.
from the AHA. The AHA has acknowledged this Prevention of bacterial endocarditis: recommendations by
information, but they continue to stand behind the the American Heart Association. JAMA 1997;277:1795;
current recommendations published in 1997 [11]. with permission.)

3. M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 233
Table 2
Prophylactic regimens for dental and oral procedures
Situation Agent Regimena
Standard general prophylaxis Amoxicillin Adults: 2.0 g
Children: 50 mg/kg
1 h before procedure
Unable to take oral medications Ampicillin Adults: 2.0 g
Children: 50 mg/kg
IM or IV within 30
min of procedure
Allergy to penicillin Clindamycin Adults: 600 mg
Children: 20 mg/kg
1 h before procedure
or
Cephalexin t or Adults: 2.0 g
cephadroxil t Children: 50 mg/kg
1 h before procedure
or
Azithromycin or Adults: 500 mg
clairithromycin Children: 15 mg/kg
1 h before procedure
Allergy to penicillin and unable Clindamycin Adults: 600 mg
to take oral medications Children: 20 mg/kg
IV 30 min
before procedure
or
Cefazolin t Adults: 1.0 g
Children: 25 mg/kg
IM or IV 30 min
before procedure
t Cephalosporins should not be used in individuals with immediate-type hypersensitivity reaction (urticaria, angioedema, or
anaphylaxis) to penicillins.
(Adapted from Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis: recommendations by the American
Heart Association. JAMA 1997;277:1798; with permission.)
a
Total children’s dose should not exceed adult dose.
are meant only for those patients who have not had osseous injection technique (available from at least
Ig-E – mediated immediate reactions with penicillin or three manufacturers) should warrant the same pre-
amoxicillin. It should be remembered that erythromy- cautions. The American Dental Association (ADA)
cin is still acceptable if it has been used successfully in emphasizes that ‘‘these recommendations are not
the past with individual patients [7]. intended as the standard of care, and practitioners
The 1997 AHA recommendations also identify should use their own clinical judgement in individual
those procedures likely to cause clinically significant cases or special circumstances’’ [13].
bacteremias (Table 3). Again, delineating the specific
procedures is a welcome and appropriate change from Special circumstances
previous recommendations, but these are not all-
encompassing. For example, there is no recommen- Patients already on antibiotics
dation for antibiotics when performing intracanal Patients often present on chronic daily doses of a
endodontic therapy, but there is a recommendation drug (eg, penicillin) for secondary prevention of
for prophylaxis when performing endodontic therapy endocarditis. They may also be on a drug that is the
beyond the apex. Since the dentist may not be able to same or similar to what would be used for prophy-
contain the endodontic treatment within the canal, the laxis, but are under therapy for an infection elsewhere
use of prophylaxis is indicated in high-risk patients. in the body. In these cases, one should change to
Likewise, there is a recommendation for prophylaxis another family of antibiotics (Table 2) and prescribe
when performing intraligamental injections. An intra- the normal dose for that family of drugs.

4. 234 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240
Table 3 had to pick a number, it would therefore seem prudent
Dental procedures and endocarditis prophylaxis to consider redosing if treatment will be delayed
Endocarditis prophylaxis recommendeda beyond 4 hours.
Extractions and other open oral surgical and endodontic
surgical procedures Unanticipated indications
All periodontal surgery, scaling, root planing, probing, It is possible that the dentist may have started a
and recall maintenance procedure for which antibiotic prophylaxis is not
Dental implant placement and reimplantation of avulsed
indicated, but then finds an indication. In a situation
teeth
where the dentist has initiated intracanal endodontics,
Endodontic instrumentation beyond apex
Subgingival placement of antibiotic fibers, strips, or but a perforation develops with bleeding, the AHA/
polymers ADA recommends administering the dose of anti-
Placement of orthodontic bands (but not acid etch brackets) biotics at that time. This necessitates the dentist to
Intraligamentary and intraosseous local anesthetic have an office supply of at least amoxicillin and
injections clindamycin for patient use.
Hygiene procedures on teeth or implants where bleeding
is anticipated Patients who have taken appetite suppressants
Endocarditis prophylaxis not recommended
There is a subset of the above group of patients
Restorative dentistry and prosthodontics with or without
whose potential for endocarditis has surfaced since
retraction cordb
Local anesthetic injections other than those listed above 1997. This group consists of patients who have taken
Intracanal endodontic treatments, including post and core the drugs fenfluramine (Pondimin) or dexfenflur-
Placement of rubber dam amine (Redux). Another drug, phentermine (Apidex,
Postoperative suture removal Fastin, or Ionamin), had often been combined with
Placement of any removable appliance fenfluramine in ‘‘fen-phen,’’ but is not implicated in
Impressions the clinical problem [16]. Initial concern linking
Fluoride treatments valvular heart disease with the use of fenfluramine/
Radiographs phentermine was generated by a report in the New
Orthodontic appliance adjustment
England Journal of Medicine (vol. 337, August 28,
Shedding of primary teeth
1997). This led to voluntary withdrawal of Redux and
Adapted from JAMA 1997;277:1797; with permission. Pondimin from the market by Wyeth-Ayerst Labora-
a
Prophylaxis recommended for patients with endocar-
tories in September 1997, a move praised by the AHA
ditis risk conditions.
b [17]. Interim guidelines for managing these patients
Clinical judgment may indicate antibiotic use in
selected circumstances that may create significant bleeding. were issued in November 1997 [18] and were
endorsed by the American Heart Association with a
media advisory soon after [19].
The guidelines issued from the US Department of
Patients on anticoagulants Health and Human Services (DHHS) recommended
Do not administer intramuscular injections of the following:
antibiotics to patients on heparin or coumarin deriv-
atives because they may form a hematoma or have 1. All people exposed to these drugs should
severe ecchymosis. Use an intravenous or oral route. undergo a medical history and cardiovascu-
lar examination.
Delay in treatment 2. An echocardiogram should be performed on all
There are times when patients will take the pre- people who exhibit cardiopulmonary signs and
scribed prophylaxis regimen as directed, but for some symptoms of cardiac valvulopathy
reason cannot be treated at the time anticipated. How 3. An echocardiogram is strongly recommended
long is acceptable before redosing? There is no con- for all people exposed to these drugs for any
sensus answer. We do know that amoxicillin maintains period of time, regardless of cardiopulmonary
a prolonged serum inhibitory activity of 6 to 14 hours signs or symptoms, if the patient was to have an
against most oral streptococci [14]. Peak serum levels invasive procedure for which they would have
of amoxicillin occur 1 hour after ingestion. Serum been given antibiotic prophylaxis, according to
levels of oral clindamycin occur slightly more rapidly the 1997 guidelines.
and remain for 3 hours [15]. Amoxicillin retains 4. For emergency procedures where cardiac
microbial killing power for several hours [14]. If one examination cannot be performed, empiric

5. M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 235
antibiotic prophylaxis according to the 1997 1997 with a joint advisory statement from the Amer-
guidelines should be performed. ican Academy of Orthopaedic Surgeons (AAOS) and
the American Dental Association. The ADA and the
Medical and dental literature point out some AAOS convened an expert panel of dentists, ortho-
problems with the guidelines above [16,20,21]. There pedic surgeons, and infectious disease specialists who
were no consistent physical examination criteria, a performed a thorough review of all available literature
wide range of true valvulopathies were found, there and data to determine the need for antibiotic prophy-
was a wide range in the length of time the drugs were laxis to prevent hematogenous prosthetic joint infec-
taken, and there was controversy regarding whether tions in dental patients who have undergone TJA
or not valvulopathy would regress over time. As a [27]. The panel outlined consensus recommendations
result, there is disagreement as to the true severity of that simplified the target population and regimens to
the problem; some authorities agree with the DHHS be used. These recommendations, though not com-
guidelines and others see less of a problem. pletely accepted by all orthopedic surgeons [28,29],
An additional problem, primary pulmonary hyper- at least created an area of agreement between dentists
tension, has a long clinical ‘‘tail’’ and has been and a national orthopedic group (Table 4). The
largely overlooked. This problem is rare in the specific joints replaced are not delineated with any
general population, but its frequency is 10 times differentiation; therefore, it is assumed that a total hip
greater in a population taking appetite suppressants replacement should be treated the same as a digit
and 20 times greater when the appetite suppressant is replacement. The recommendations targeted those
taken for more than 3 months [16]. The diagnosis is populations at most risk to have a hematogenous total
often delayed 1 to 2 years after symptom onset, and joint infection: immunocompromised/suppressed
people with the disorder have a median survival of 2 patients; those with inflammatory arthropathies (eg,
to 3 years from symptom onset [22,23]. rheumatoid arthritis); insulin-dependent diabetics;
For the dental practitioner, it would seem prudent those with previous episode of infected joint; mal-
to refer all these patients to a physician for a cardi- nourished persons; hemophiliacs; and those within
ovascular examination. It would also be prudent to be 2 years of their joint replacement, regardless of health
specific regarding your concerns and include a set of (Table 4).
the DHHS guidelines or refer the physician to the
appropriate AHA web site [24] that would have a
complete set of past advisories and recommendations. Table 4
Prophylaxis for patients with total prosthetic joint
replacement
Patients with prosthetic joint replacement
Patients at potentially increased risk of hematogenous
Before 1997, dental providers faced a conundrum joint infection
Immunocompromised and immunosuppressed patients,
with patients who had undergone total joint arthro-
including those with conditions caused by disease,
plasty (TJA). The vast majority of orthopedic sur-
drug, or radiation
geons favored antibiotic prophylaxis before dental Inflammatory arthropathies, including rheumatoid
treatment for all TJA patients under all circumstances, arthritis and systemic lupus erythematosus
even though they recognized that a consistent rela- Insulin-dependent (type I) diabetes
tionship between dentally induced bacteremia and First 2 y after total prosthetic joint replacement
prosthetic joint infections had not been established Previous prosthetic joint infection
[4]. Othopedic surgery authorities themselves admit Malnourishment
that orthopedic surgeons are among the heaviest users Hemophilia
of prophylactic antibiotics [25]. Nevertheless, a pros- Procedures likely to cause hematogenous joint infection in
the patients listed above
thetic joint infection can be devastating, can occur
Same as those in endocarditis (Table 3)
from a variety of sources other than dental, and can
Procedures less likely to cause hematogenous joint infection
occur long after the supposed insult, making cause Same as those in endocarditis (Table 3)
and effect difficult to prove. Antibiotic protocols Suggested antibiotic regimens to use in the patients listed
recommended by orthopedic surgeon colleagues var- above
ied widely and occasionally had no rationale against Same as those in endocarditis a(Table 2)
oral microbes. A study performed in 1990 concluded a
AAOS/ADA regimen places cephalexin and cephra-
that it cost $480,000 in antibiotics to prevent one case dine ahead of amoxicillin in suggested regimens and does
of prosthetic joint infection [26]. An attempt to not mention azithromycin or clairithromycin in suggested
eliminate this overuse controversy was made in regimens for penicillin allergic patients.

6. 236 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240
The recommendations then specified those proce- should be consulted regarding the timing and need for
dures likely to cause a higher incidence of bacteremia anticoagulation control before any extensive surgery
and those procedures less likely to cause bacteremia. [53]. Peritoneal dialysis requires no antibiotic pro-
Those procedures are identical to those specified in phylaxis [34].
the AHA bacterial endocarditis recommendations. Shunts are placed in patients with hydrocephaly to
Likewise, the recommended antibiotic protocols were relieve the pressure of cerebrospinal fluid buildup on
virtually identical to those recommended by the AHA the brain. Shunts placed for treatment of hydrocephaly
for endocarditis. Some authorities take special pains are of two types, ventriculo-peritoneal (VP) and ven-
to point out that the risk of causing a hematogenous triculo-atrial (VA). Infection of VA shunts is devastat-
spread of infection is higher when dealing with gross ing and carries a mortality of 40%. These patients
infection at the procedure site, such as a severe dental should receive prophylactic antibiotics [35,36]. VP
abscess or when procedures take longer than 45 shunts carry no higher risk of infection from dental
minutes [29,30]. sources and therefore require no antibiotics
Patients with plates, screws and pins: These Indwelling catheters may be present for a variety
patients require no prophylaxis. The recommenda- of reasons, usually to deliver long-term intravenous
tions point out that the dentist may be presented with drugs for chemotherapy or to treat infection.
a patient carrying recommendations from their ortho- Unless the terminal end is near the right side of
pedist which are inconsistent with these guidelines. the heart, no prophylaxis should be necessary [37].
This may result from unfamiliarity with the guide- Pacemakers and implanted defibrillators may
lines, or perhaps the patient has an overriding concern or may not be intracardiac. They can become
unknown to the dentist. Consultation is urged to come infected, but most infections culture out Staphylo-
to an agreement between the providers. If a disagree- coccu aureus, not viridans species [4]. The AHA does
ment still occurs, the dentist may proceed with the not recommend antibiotic prophylaxis before dental
recommendations of the orthopedic surgeon despite treatment for these patients [7].
the disagreement, proceed with the procedure without Patients who have undergone heart transplant
antibiotics, or place the burden of prescription for the do not, per se, require prophylactic antibiotics. They
antibiotics on the orthopedic provider. Best clinical are, however, prone to cardiac valvular dysfunction
judgement is always appropriate. The total replace- and are typically on multiple immunosuppressant
ment of temporomandibular joints (TTMJR) is not drugs. Consultation is warranted and they may
specifically addressed nor excluded in these recom- require antibiotic prophylaxis if a valvular abnormal-
mendations. The late infection of a TTMJR is exceed- ity exists [4].
ingly rare [31,32]. There is simply not enough data on Intracardiovascular artery stents, prosthetic ar-
which to base a sound recommendation. The very tery grafts, angioplasty procedures, and coronary
cautious practitioner may consider prophylaxis for artery bypass grafts (CABG) are performed for
that group of patients who fall under the AAOS/ patients with atherosclerotic cardiovascular disease
ADA guidelines only. and/or angina. Prophylactic antibiotic coverage for
these patients is a controversial area, and some feel
Shunts, catheters, and implanted materials that the requirement for antibiotic prophylaxis hinges
on the amount of epithelialization that will take place
Patients with surgically constructed shunts for after the procedure is performed. Most infections take
hemodialysis are at somewhat increased risk for place within 6 months of surgery, but oral flora are
infection, both locally and as a cause for endocarditis. rarely implicated [37,38]. Nevertheless, an infected
Moreover, if an infection occurs in these patients graft or stent is devastating. There is no consensus,
undergoing dialysis, the downside is devastating. but a recommendation cited by several authors is
Antibiotic prophylaxis for these patients, if under- that prophylaxis should be considered only within
going invasive dentoalveolar procedures, is appropri- the first 6 weeks after surgery. Endotheialization
ate. AHA recommendations are probably adequate of the stent occurs during this time period. Anti-
even though there is no consensus. The extent and biotics are not needed after 6 weeks, except possibly
length of surgery may induce stress and, because of for very large aortic grafts. Consultation is advised
anticoagulation, may result in significant bleeding. for these patients.
Many penicillin-type drugs are metabolized through Patients with penile implants or other cosmetic
the kidneys, so consultation with the nephrologist is or functional implanted materials do not require
warranted if therapy beyond a single dose is consid- prophylactic antibiotics before invasive dental treat-
ered to treat infection. Regardless, the nephrologist ment [6].

7. M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 237
Immunocompromised patients population. Most of these infections are not related to
the mouth, and the population most at risk are those
This group of patients includes those with neu- at two years or less post-splenectomy and children
tropenia for any reason, insulin-dependent diabetes, under 5 years old [4,38,41]. Therefore, routine pro-
and asplenia. There have been no long-term, con- phylaxis for these patients is not recommended, but
trolled studies that have looked at infection rates in consultation is warranted for these latter two groups
dental patients with various levels of neutropenia and antibiotic prophylaxis may be necessary. These
[38]. Nevertheless, threat of infection exists and patients also require consideration for pneumococcal
morbidity increases as the leukocyte count drops. vaccine from their physicians [41,42].
Regimens of antibiotics have been suggested for
patients with leukocyte levels of 3500/mm3, 2000/ Risk of brain abscess
mm3, and 1000/mm3 [39]. Difficulties arise as the
oral flora changes in patients on chemotherapy. Several recent high-profile lawsuits have resulted
Whereas the AHA recommendations are fine for most from patients who had minor infections or invasive
patients, they may not be the best choices for neu- dentoalveolar surgery and then suffered brain ab-
tropenic patients. Again, no controlled studies exist to scesses that cultured out oral flora. There are areas
provide the best regimen. Best recommendations of the country where experienced, board-certified
appear to define neutropenia as 1000/mm3 and to oral and maxillofacial surgeons who fear this liti-
treat patients only on a nonelective (emergency) gation are providing prophylactic antibiotics for
basis. The AHA regimen or a recommended regimen patients who require extractions or significant inva-
by consultation with the patient’s hematologist or sive surgery. In an elegant review of the literature and
infectious disease specialist is appropriate [4,37,38]. through the use of sound logic, Pallasch argues
Patients who are HIV positive are not at greater vigorously against this practice [4]. He makes the
risk than non-HIV positive patients, provided that case that the incidence, etiology, and clinical course
they currently have a satisfactory white blood cell of brain abscesses indicate that the association with
count. They should not receive antibiotic prophylaxis previous therapy is too small and the risk from the
for dental procedures unless they fall into another antibiotic is too great to warrant routine antibiotic
category that does require antibiotic prophylaxis. In prophylaxis for these patients. He argues that one
addition, there is an additional risk of selecting million people would have to receive prophylactic
antibiotic-resistant strains or causing fungal over- antibiotics in an attempt to save the theoretical less
growth [4,36 – 38]. than one person in that million from having a brain
Prophylactic antibiotics are not necessary for most abscess. Even assuming that a correct antibiotic is
diabetic patients undergoing dentoalveolar surgery. chosen for this unknown pathogen, there is an
Most authors agree that insulin-dependent diabetic unfavorable risk-to-benefit ratio. The death rate from
patients or non – insulin-dependent diabetics under anaphylaxis for the antibiotic would essentially be
good control are at no greater risk than other patients higher than the rate of brain abscess occurrence.
who are also undergoing minor but invasive surgical There would be a net loss of life from use of anti-
procedures [4,38 – 40]. Unless they are poorly con- biotics in this attempt at prevention [4].
trolled, non – insulin-dependent diabetics are usually
not candidates for prophylaxis. If either population is Routine antibiotic prophylaxis in oral and
well controlled, prophylactic antibiotics should be maxillofacial surgery
used only in situations where prophylactic antibiotics
would be used for nondiabetic patients. A diabetic with Antibiotics are commonly administered prophy-
an infection should receive appropriate antibiotics, lactically for major oral and maxillofacial surgery,
and a poorly controlled diabetic should also be referred such as temporomandibular joint surgery, orthog-
for stabilization. If emergency dentoalveolar surgery is nathic procedures, and repair of facial trauma with
required on a poorly controlled diabetic, then prophy- contamination. There is evidence that this is a sound
laxis is indicated, as well as consultation with the practice, though there is no need to continue the
patient’s endocrinologist. With no specific regimen antibiotics beyond the perioperative period [43]. On
established, the AHA recommendations would suffice. the other hand, oral and maxillofacial surgeons com-
The question of prophylactic antibiotics in monly prescribe antibiotics to ‘‘prevent’’ postopera-
patients who have undergone splenectomy is also tive infections in patients who are not at risk for
controversial. It is true that infections in post-splenec- serious infections from bacteremia and for relatively
tomy patients occur at a rate far above the normal minor dentoalveolar procedures. In these scenarios,

8. 238 M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240
there are many areas of disagreement and failure to Although he recommends penicillin for noncompro-
adhere to basic principles [4,32,36,44]. In many mised patients, it seems to me, in the interest of
cases, the antibiotic is given after the procedure as simplification, that the AHA regimen would supply
the patient is walking out the door. This violates the similar efficacy and be easier to remember. Topazian
well-substantiated principle that antibiotics need to be recommends a first-generation cephalosporin (cepha-
given before a procedure, not after, and sufficiently in lexin) or the combination of amoxicillin/clavulanate
advance to obtain a high blood level [4]. This for sinus grafting (see Table 5).
prophylaxis should ideally take place 2 hours before The question then arises for prophylactic antibiotic
the incision if given orally, or immediately before use specifically for third molar surgery. Piecuch,
surgery if given intravenously [45]. Arzadon, and Lieblich looked at this question in
Strictly speaking, surgical antibiotic prophylaxis is 1995 [47]. They offered that oral surgeons prescribe
indicated only (1) to prevent contamination of a sterile antibiotics in third molar surgery for five reasons: (1)
area, (2) where infection is unlikely but associated to treat an active infection, (2) as prophylaxis in
with significant morbidity, (3) in procedures with high medically compromised patients, (3) patient or family
rates of infection, and (4) during implantation of demand, (4) prevailing standard of care in community,
prosthetic material [4,36]. For antibiotics to be effec- and (5) risk of infection is high. They reviewed
tive, they must be given in high doses and aimed at a literature for and against use of antibiotics in third
specific pathogen or group of pathogens. They need molar surgery and then interjected their own ret-
not be continued after the procedure [46]. With the rospective study of 2134 patients with 6713 third
exception of implant placement, most dentoalveolar molar extractions. They answered the above justifica-
oral surgery procedures do not qualify for prophylactic tions and recommended that antibiotic prophylaxis be
antibiotics using the above criteria. The subject of justified only for full bony and partial bony impac-
prophylaxis for implant and bone graft surgery is tions. In all other classes and positions of impacted
another topic worth its own article. There are no third molars, prophylaxis provided no statistical
published studies comparing one agent to another or improvement over no antibiotic prophylaxis. They
the length of time of administration of one agent also revealed, however, that tetracycline placed in
versus another. There are many technique articles in the extraction site was just as efficacious as systemic
print recommending prophylaxis, but drugs vary from antibiotics. This practice will continue to incite contro-
penicillin to Augmentin to clindamycin, and length of versy and study. Indeed, a recently published double-
time of administration varies from perioperative only blind placebo control study appears to refute the above
to 2 weeks. A well-cited and thoughtful chapter by recommendations. This otherwise well-designed study
Topazian does specifically address this question [30]. suffered from a low number of subjects (151) and the
Table 5
‘‘Bottom line’’ recommendations for antibiotic prophylaxis
Condition Prophylaxis warranted? Regimen
Heart conditions Possibly (see Table 1) AHA (Table 2)
Total prosthetic Joint replacement Probably not (see Table 4) AHA
Vascular shunt for hemodialysis Yes AHA
Ventriculoatrial shunt for hydrocephaly Yes AHA
Vascular grafts No unless large or 6 months AHA
Other cosmetic or functional implants No
Immunocompromised Possibly. Consult if 1000 wbc/mm3
HIV positive No
Insulin-dependent diabetic No, unless poor control then AHA
Splenectomy No, unless spleen removed Consult
less than 6 mo before
or 5 y old then
Risk of brain abscess No
Routine oral surgery procedures No
Third molar surgery No, except possibly partial bony No established regimen
or full bony impactions
Implants, endosseous, bone grafts, Yes (immediate perioperative AHA (consider cephlosporin
extensive membrane use period only) for sinus lift)

9. M.G. Savage / Oral Maxillofacial Surg Clin N Am 14 (2002) 231–240 239
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