What to Know About Dental Antibiotic Prophylaxis Dosage
Source: Debbie Goff Pharm D, Julie E Mangino MD, the Ohio State University Wexner Medical Center
Don’t Use Clindamycin
The American Dental Association and American Heart Association no longer recommend the antibiotic clindamycin for dental prophylaxis or therapeutic use.
It has a black box warning for C. difficile diarrhea because the risk is high and there have been dental lawsuits.
What Should You Use Instead?
Your options include:
1. Give azithromycin 500 mg PO or IV one time (prophylaxis), then 250 mg once daily for four days (therapeutic). Don’t give for more than five days because five days’ dosage has the effectiveness of 10 days’ dosage.
2. Prescribe doxycycline 100 mg PO or IV one time (prophylaxis), then 100 mg BID for five days (therapeutic).
3. Give cephalexin 2 grams PO one time for prophylaxis (but not if there’s a history of anaphylaxis or hives).
Longer Use of Antibiotics Doesn’t Equal Better Care
Use shorter courses (three to five days), not seven to 10 days. No current dental data supports that seven to 10 days gives better outcomes.
Every additional day increases the risk of antibiotic resistance and C. difficile diarrhea.
Prescriptions for more than five days should be the exception, not the rule.
Should You Prescribe Antibiotics for Pain and Swelling?
The JADA Nov 2019 ADA guideline on antibiotic use for pain and swelling says that:
If patients have pain only, don’t prescribe antibiotics.
If they have pain and swelling, prescribe amoxicillin 500 mg TID for three to five days. Reevaluate in three days with a phone call. Instruct patients to stop using antibiotics 24 hours after their symptoms resolve.
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Amoxicillin Is Recommended
Amoxicillin 500 mg TID or 875 mg BID is the first line antibiotic for all dental procedures. It is better tolerated than penicillin and BID/TID dosing has better compliance than QID.
If amoxicillin fails, add metronidazole 500 mg TID or switch to Augmentin (amoxicillin/clavulanate) 875 mg BID.
Other Dental Antibiotic Prophylaxis Dosage Recommendations
Patients should never take metronidazole (Flagyl) 500 mg TID alone. It only offers anaerobic coverage and no oral strep coverage. It can cause peripheral neuropathy, likely related to duration.
Penicillin-allergic patients can take azithromycin 500 mg day one, then 250 mg daily for four days (Zpac) or 500 mg daily for three days. Do not prescribe for more than five days. It can cause arrhythmia, which is potentially fatal.
Cephalexin (Keflex) 500 mg q eight hours is not a first-line antibiotic unless the patient has a penicillin (non-anaphylaxis or hives) allergy.
Do not use ciprofloxacin, levofloxacin, moxifloxacin because of four black box warnings for tendon ruptures/tendinitis, peripheral neuropathy, CNS effects and exacerbation of myasthenia gravis, and aortic aneurysm/dissection.
Antibiotic Prophylaxis for Patients with Infective Endocarditis (IE)
Patients with a previous episode of IE or who have prosthetic valves/materials must receive antibiotic prophylaxis. Certain patients with congenital heart disease and/or cardiac transplant recipients likely need antibiotic prophylaxis. Discuss this with the cardiologist.
Review your screening forms to make sure you ask whether your patient has a history of IE. A recent lawsuit stated that on a patient’s medical history form “next to heart disease, she checked yes and wrote in ‘IE.'” Dental staff didn’t recognize the term IE and cleaned her teeth without antibiotic prophylaxis. She developed IE and she sued the dentist.
Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements
The 2020 ADA/AAOS guide states after one year, prophylaxis is rarely needed. Less than 10% of prosthetic joint infections are caused by oral strep species.
The American Academy of Orthopedic Surgeons provides a care decision-making tree to determine whether a patient needs prophylactic antibiotics.
Many orthopedic surgeons still recommend lifelong antibiotic prophylaxis before dental work, and this is not correct. Your responsibility is to inform your patients of the updated ADA/AAOS information.
The ADA advises that the orthopedic surgeon should write the prescription.