Pacific Coast Society of Orthodontists Bulletin Fall 2017 - 24

Let's Talk About That

provide antibiotic prophylaxis to a teenage
patient with a history of heart problems who
developed bacterial endocarditis while wearing
braces. The result of the infection was devastating: one of the patient's heart valves had to be
replaced; a 4x5cm portion of her aorta was
replaced with a Teflon patch; she was placed on
lifetime blood thinners; and she was advised
never to bear children due to the risk of hemorrhage. Expert witnesses were on both sides of
the fence. One pediatric cardiologist testified
that he recommends that his patients not
undergo full bonded orthodontic treatment. The
orthodontist settled out of court for a substantial
sum. It seems the recommendations from the
American Heart Association are constantly
changing. Where are we today in regards to
endocarditis prophylaxis in orthodontics?
JZ: Infective endocarditis prophylaxis in the U.S.
hasn't changed since the last 2007 AHA recommendation; new AHA recommendations are usually written every 10 years.4 There are only four
medical indications, associated with the most
morbidity and mortality, for which antibiotics are
recommended for infective endocarditis prophylaxis: 1) previous endocarditis; 2) prosthetic cardiac valve or prosthetic valve repair; 3) cardiac
transplant that develops valvular disease; and
4) congenital heart disease (CDH) with cyanosis
(if CDH is completely surgically repaired, prophylaxis can stop after six months).
Dental procedural indications for antibiotic prophylaxis are: 1) perforation of oral mucosa;
2) manipulation of gingival tissue or periapical
region of teeth. (Manipulation is defined as
affecting, changing, or skillfully treating by
hand.) The AHA recommends antibiotic prophylaxis for band placement; I would add recementing and removal of bands since subgingival
scaling is needed to remove cement. If orthodontic procedures perforate tissue or manipulate

(affect or change) gingival tissue, then antibiotic
prophylaxis should also be used. In my practice, I
interpret endocarditis prophylaxis to be recommended for band separation, periodontal probing, and TAD placement or removal. However,
antibiotic prophylaxis is not recommended by
the AHA for routine placement or adjustment of
brackets and removable appliances.
The antibiotic prophylaxis recommendation for
adults is amoxicillin 2000mg; the child dose is
50mg/kg, up to 2000mg. Amoxicillin is available
in 250mg chewable tablets for those patients
who are unable to swallow capsules. For those
allergic to penicillin, give azithromycin 500mg;
the child dose is 15mg/kg, up to 500mg or clindamycin 600mg; the child dose is 20mg/kg, up
to 600mg. Antibiotics should be taken orally
30 to 60 min prior to an orthodontic procedure.
Verify (with an adult guardian for children) and
chart that antibiotic prophylaxis has been taken
before the procedure is started. If antibiotic prophylaxis was forgotten, and the procedure has
started, the antibiotic should be given immediately, up to two hours after the procedure. All
experts agree that chronic bacteremia should be
decreased; therefore impeccable oral hygiene
should be continually stressed.
PT: One of the most common concerns that
potential new patients express is the discomfort
and pain associated with treatment. What are
the indications for pain meds, and which agents,
in what doses do you recommended (if any)?
JZ: I usually advise patients to take the over-thecounter (OTC) pain reliever that has worked well
for them in the past. However, the large Oxford
acute pain studies compared effectiveness of
pain relievers after third molar extractions.5
Acetaminophen - 650mg for teens and women;
1000mg for large men; 10-15mg/kg, up to teen
dose, for children - every six hours prn is a mild
pain reliever. Ibuprofen - 400mg for teens and

PCSO Bulletin  Fall 2017

Table of Contents for the Digital Edition of Pacific Coast Society of Orthodontists Bulletin Fall 2017