Do Patients with Solid Organ Transplants or Breast Implants Require Antibiotic Prophylaxis before Dental Treatment?

Human solid organ transplantation has evolved into a predictable therapeutic modality due to advances in medical and surgical care and improved understanding of the immune system. At its peak in 2007, the Canadian Organ Replacement Register documented 1042 organ donors (living and deceased) and 2127 completed organ transplants.¹ The overwhelming majority of donated organs were deceased donor kidneys.¹ Records from the United States show that, between 1999 and 2008, patient and graft survival improved for almost every organ type.²*

With the large number of people receiving organ transplants and those who have already received a transplant living longer, dental professionals will be providing oral health care to an increasing number of patients in this specific population. The question of administering antibiotic prophylaxis to these patients, as well as to patients with breast implants, before invasive dental treatment is addressed in this article.

Solid Organ Transplants

The oral health care provider plays an important role in overall management of the solid organ transplant patient. At many transplant centres, examination of both the hard and soft tissues of the oral cavity is often carried out by a dental professional to determine oral and dental health status before transplantation.³ As the patient's immune system is often significantly suppressed in the weeks to months following the transplant to prevent organ rejection, the risk of infection (viral, bacterial or fungal) is a concern and dental treatment during that time is recommended only on an emergency basis.^3,4 As the patient moves into the stable post-transplantation period, risk of infection generally decreases and oral health care may be sought more routinely.

Evidence supporting the use of antibiotic prophylaxis among patients with solid organ transplants before dental treatment is extremely limited.^3-6 In 2003, Guggenheimer and colleagues³ reported that postoperative guidelines for recipients of solid organ transplants frequently advise treatment with antibiotics before dental procedures, but there are no data from controlled clinical trials to support this recommendation, nor is a consensus evident. However, the authors state that because bacteremia arising from invasive dental procedures represents a significant risk in the immunocompromised patient, premedication is usually recommended.

In a 2005 survey of dental care protocols at organ transplant centres in the United States, 239 out of 294 centres (83%) reported recommending antibiotic prophylaxis for dental treatment following an organ transplant.⁷ However, because the overall response rate to this survey was only 38%, these results do not represent a consensus. The authors of the study reiterated that, at that time, there was no documentation of transient bacteremia from an invasive dental procedure posing another threat to the immunosuppressed organ transplant recipient.

In 2007, a systematic review by Lockhart and colleagues⁵ concluded that it is difficult to determine the likelihood that invasive dental procedures will cause morbidity or mortality in immunosuppressed patients and classified the finding as Class IIB (usefulness/efficacy less well-established by evidence/opinion) and Level C (based on expert opinion, case studies or standard of care).

In a recent article, Scully and colleagues⁸ recommend administering antibiotic prophylaxis to organ transplant patients before invasive dental procedures (particularly during the 6 months after transplantation) without citing evidence-based research to support their recommendation.

In 2007, the American Heart Association (AHA) published revised guidelines for the prevention of infective endocarditis using a stronger evidence-based approach. In relation to organ transplants, these guidelines recommend providing antibiotic prophylaxis before specific dental procedures in cardiac transplantation recipients with cardiac valvulopathy to prevent infective endocarditis.⁹ The guidelines have been endorsed by members of the Canadian Cardiovascular Society.¹⁰

Breast Implants

First described by Czerny in 1895, breast augmentation is now the most common cosmetic procedure among American women.¹¹ Infections after breast augmentation are relatively uncommon, with most occurring within the early postoperative period (i.e., 4 weeks).¹² Endogenous breast flora, such as Propionibacterium acnes and coagulase-negative Staphylococcus, have been implicated in the etiology of these types of infections.¹² Ellenbogen¹³ postulated a causal relation between dental prophylaxis and rapid breast encapsulation within weeks of the surgical procedure based on personal experience. Late infections (months to years after implantation) are even less common at a reported rate of 1:10 000.^12,14 Bacteremia, as a consequence of an invasive procedure or distant antecedent infection, is thought to cause seeding of the breast implant capsule or periprosthetic space.¹²

Few articles in the literature implicate bacteremia secondary to dental procedures as the etiology for late breast implant infection. In a survey, Brand¹⁴ found 2 cases of late infection thought to have originated after an episode of bacterial stomatitis and after extensive dental treatment. In both cases, the identified cause was Staphylococcus aureus, an organism considered part of normal oral microflora.¹⁵ S. aureus has been implicated as the most common microbiological agent responsible for periprosthetic breast implant infections.¹⁶ Hunter and colleagues¹⁷ reported a case in which a woman developed a late breast implant infection associated with Clostridium perfringens after completion of extensive dental therapy, including abscess drainage, endodontic treatment and crown placement. Most recently, Chang and colleagues¹² reported a late breast infection with coagulase-negative Staphylococcus and Streptococcus viridians, which developed after periodontal surgery to treat recurrent periodontitis.

Clinical Recommendations

Antibiotic Prophylaxis and Solid Organ Transplants

Based on current evidence-based research, we do not recommend routine administration of antibiotic prophylaxis to patients with solid organ transplants before invasive dental treatment.^5,18 Oral health care providers should discuss the patient's overall health status and planned dental procedures with the patient's physician or transplant surgeon or both, and the decision to administer antibiotic prophylaxis should be made on a case-by-case basis.^6,18 If antibiotic prophylaxis is recommended, the patient's physician should prescribe the medication (type, dose, instructions). Regarding patients with cardiac transplants, we recommend providing antibiotic prophylaxis to patients according to the 2007 AHA guidelines.^9,10

Antibiotic Prophylaxis and Breast Implants

Based on current evidence-based research and scant case reports, we do not recommend routine administration of antibiotic prophylaxis to patients with breast implants before invasive dental treatment.^6,18-20 However, patients with a history of complications after breast implant surgery, especially infection, may warrant antibiotic prophylaxis before invasive dental treatment, and this decision must be made in consultation with the patient's surgeon. If antibiotic prophylaxis is recommended, the patient's surgeon should prescribe the medication (type, dose, instructions).

*The data and analyses reported in the 2009 Annual Report of the U.S. Organ Procurement and Transplantation Network and the Scientific Registry of Transplant Recipients have been supplied by UNOS and Arbor Research under contract with HHS/HRSA. The authors alone are responsible for reporting and interpreting these data; the views expressed herein are those of the authors and not necessarily those of the U.S. Government.

THE AUTHORS

	Dr. Stoopler is an associate professor of oral medicine and director of the postdoctoral oral medicine program, department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.
	Dr. Sia is a resident in the department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.
	Dr. Kuperstein is an assistant professor of oral medicine and director of the oral diagnosis, emergency and radiology clinics, department of oral medicine, University of Pennsylvania School of Dental Medicine, Philadelphia, Pennsylvania.

Correspondence to: Dr. Eric T. Stoopler, University of Pennsylvania School of Dental Medicine, 240 South 40th Street, Philadelphia, PA  19104, USA. Email: ets@dental.upenn.edu

The authors have no declared financial interests.

This article has been peer reviewed.