Doctor Information

Antibiotic Prophylactic Regimens for Certain Dental Procedures and Certain Medical Conditions:

The American Heart Association, or AHA, and the American Dental Association recently changed their recommended protocols for antibiotic prophylaxis against bacterial endocarditis.  A new recommendation also has been issued by the ADA and the American Academy of Orthopedic Surgeons, or AAOS, against routine antibiotic prophylaxis in patients with prosthetic joint replacements, except if it has been less than 2 years since placement of the prosthetic joint,  of if there has been recent joint infections, or if there has been a recent joint infection.

Susceptible Patients in High Risk Category:

     - Valvular Heart Disease
     - Previous Endocarditis
     - Surgical Pulmonary Shunts
     - Mitral Valve Prolapse with Regurgitation
     - Prosthetic Heart Valves
     - Vascular Grafts less than 6 months in place
     - Orthopedic Prostheses less than 2 years in place, or with recent infection, or in patient with immune
        compromise
     - Renal Hemodialysis with Atrio-Venous Shut
     - Hydrocephalus with AV Shunt
     - Immune Compromised patients may be considered for Prophylaxis in certain invasive procedures (surgery)

Standard Prophylaxis AHA, AAOS and ADA

Amoxicillin:
     Adults, 2.0 grams, (4 x 500 mg tablets);
     Children, 50 milligrams/kilogram
     Orally one hour before procedure

IF Allergic to Penicillin

Clindamycin:
     Adults, 600mg (4 x 150mg or 2 x 300 mg capsules);
     Children, 20 mg/kg
     Orally one hour before procedure
Cephalexin or Cefadrozil:
     Adults, 2.0 g (4 x 500 mg tablets);
     Children, 50 mg/kg
     Orally one hour before procedure
     Cephalosporins should not be used in patients with immediate-type hypersensitivity reaction (urticaria,
          angioedema or anaphylaxis) to penicillin.
Azithromycin or Clarithromycin:
     Adults, 500 mg (one tablet);
     Children, 15 mg/kg
     Orally one hour before procedure

Total Children's dose should not exceed adult dose.
     IM:  Intramuscular;  IV:  Intravenous.

If the patient cannot take oral medication, your surgeon or physician will recommend the proper IV regimen for you.  Patients prepared for General Anesthesia are to have nothing by mouth the morning of and prior to surgery, and medications will be given in the IV.

Reprinted with the permission of the Journal of the American Medical Association from Dajani and colleagues.

Bisphosphonate Medications and Bisphosphonate induced Osteonecrosis of Jaw.

Osteoporosis and other medical conditions are often treated with medications to limit bone resorption.  Bisphosphonate medications stop the osteoclasts from resorbing bone, and thus regeneration of new bone is also interrupted.  Injury of bone when a patient is taking these medications may not heal, and remain exposed through out life.  This is only a problem of alveolar bone or of deeper jaw bone due to extension from the alveolus.

Oral Medications
Etidronate (Didronel)  -- Paget Disease
Tilubronate (Skelid) --    Paget Disease
Alendronate (Fosamax)  -- Osteoporosis
Residronate (Actonel)    --  Osteoporosis
Ibandronate (Boniva)      -- Osteoporosis

IV Medications
Pamidronate (Aredia)   -- Bone Metastases
Zoledronate )Zometa)   -- Bone Metastases

Prevention is best achieved by taking care of all invasive type dental treatment prior to use of these medications.  After 6 months of IV Aredia or Zometa, extractions, periodontal surgery, implants and such are to be avoided if at all possible

After 2 years of oral medication such as Fosamax, there is increased risk of non-healing exposed bone.  After 5 years of oral medication the risk increases significantly.

Treatment generally involves Antibiotics and Chlorhexidene Oral Rinse.

Penicillin, 2 gm per day, is the main antibiotic.  Levofloxacin 500 mg once daily or Azithromycin 500 mg daily can be used in cases of penicillin allergy.  Clindamycin is NOT recommended for BONJ.

Chlorhexidene 0.12% should be used 3 times daily.

Stage 1 BONJ is non-painful but has exposed jaw bone, and is treated with Chlorhexidene rinse 3 times daily

Stage 2 BONJ is painful without clinical infection or fistula.  Tx includes antibiotics until pain subsides and infection controlled.

Stage 3 BONJ has pain, infection, fistula or fracture.  Tx may require long term, or for life, antibiotics.

Debridement or attempts to remove the exposed bone is discouraged.  Aggressive treatment will likely only extend the problem to more areas of bone.

Referral to an Oral and Maxillofacial surgeon familiar with this problem is indicated.