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antibiotics CE article | 13 roots 4 2016 fections from occurring. Orofacial infections do not “rebound” if the source of the infection is properly eradicated. Most orofacial infections persist for two tosevendays,andoftenless.Patientsplacedonanti- biotic therapy for an orofacial infection should be clinicallyevaluatedonadailybasis.Whenthereissuf- ficient clinical evidence that the patient’s host de- fenseshaveregainedcontroloftheinfectionandthat the infection is resolving or resolved, the antibiotic therapy should be terminated. Antibiotic prophylaxis for medically at-risk patients Antibiotic prophylaxis is the administration of antibiotics to patients without evidence of infection to prevent bacterial colonization and reduce subse- quent postoperative or post-treatment complica- tions. The only established use of antibiotic prophy- laxis in dentistry is in the attempt to reduce the potential consequences of bacteremias induced by dentaltreatmentincertainmedicallyat-riskpatients. The principle indication for antibiotic prophylaxis for dentalpatientsisthepreventionofinfectiveendocar- ditis during specified dental treatment of patients who also have specific medical conditions. Contro- versialindicationsincludedentalpatientswithortho- pedic prosthetic devices, indwelling catheters and impaired (immunosuppressed) host defenses. Dental patients presenting for treatment with im- paired host defenses (chemotherapy, organ trans- plant or tissue graft recipient, insulin-dependent diabetes,alcoholics)orpatientswithindwellingcath- eters (hemodialysis) may benefit from antibiotic prophylaxis if their white cell count is below 2,500 (normal = 4,000–11,000). It is not currently recom- mendedthatpatientswithAIDS receive routine anti- biotic prophylaxis prior to dental treatment. The op- portunistic pathogens common to this disorder are not susceptible to routine prophylactic antibiotics and such a practice may result in the development of antibiotic-resistant microorganisms, thereby result- ing in a serious superinfection.3 Antibiotic prophylaxis for prevention of infective endocarditis The American Heart Association has published guidelinesforthepreventionofIEinmedicallyat-risk patients for more than 50 years. The most recent guidelines,publishedinApril2007,representasignif- icant change from the previous guidelines.17 One of thestatedreasonsforthedevelopmentofthecurrent revised guidelines was that the risk of antibiotic-as- sociated adverse events exceeds the benefit, if any, fromprophylactictherapy(Table1).Itiswellaccepted that the risk for developing bacterial resistant strains to the antibiotic drug used is considered an anti biotic-associated adverse event. The majority of published studies regarding IE be- ing caused by oral bacteria have focused on dental procedures. Although the infective dose required to causeIEinhumansisunknown,thenumberofmicro- organisms present in the blood following a dental procedureislow.Ithaslongbeenassumedthatdental procedures may cause IE in patients with underlying cardiac risk factors and that antibiotic prophylaxis iseffective.However,scientificproofislackingtosup- port this assumption. Cases of IE caused by oral bac- teria probably result more from exposures to low in- ocula of bacteria in the bloodstream that result from routinedailyactivities(brushingandflossing)andnot from a dental procedure.17 The 2007 AHA report regarding prevention of IE concludes: “If prophylaxis is effective, such therapy shouldberestrictedtothosepatientswiththehighest risk of adverse outcomes from IE and who would de- rive the greatest benefit from prevention. In patients with underlying cardiac conditions associated with thehighestriskofadverseoutcomesfromIE,prophy- laxis for some dental procedures is reasonable, even though we acknowledge that its effectiveness is un- known.”17 Therefore, the 2007 AHA guidelines suggest that antibiotic prophylaxis should be considered for pa- tientspresentingfortreatmentwiththecardiaccon- ditions identified in Table 2, and who are undergoing any dental procedure that involves the gingival tis- suesorperiapicalregionofatoothandforthosepro- cedures that perforate the oral mucosa. This would include procedures such as biopsies, suture removal, placement of orthodontic bands, and intraligamen- tary and intraosseous local anesthetic injections, but it does not include routine local anesthetic injections through non infected tissue (Table 3). Dental Procedures for Which Antibiotic Prophylaxis is Reasonable – Dental extractions – Periodontal procedures,including surgery,subgingival placement of antibiotic fibers/ strips,scaling and root planing,proving,recall maintenance – Dental implant placement – Replantation of avulsed teeth – Endodontic (root canal) instrumentation only if beyond the root apex and endodontic surgery – Initial placement of orthodontic bands (not brackets) – Intraligamentary and intraosseous local anesthetic injections – Postoperative suture removal (in selected circumstances that may create significant bleeding) – Prophylactic cleaning of teeth or implants where bleeding is anticipated Table 3 42016