possible under each cover but this has to be balanced against the stress of longer
appointments. If multiple appointments with prophylaxis are required, then 4 weeks
should be allowed between appointments when penicillin is used to allow penicillin-
resistant organisms to disappear from the oral flora though alternating with non-
penicillin antibiotics can circumvent this. Other problems may include prolonged
bleeding following scaling or surgical procedures due to thrombocytopenia and
anticoagulant medication. It is essential to check the platelet count and prothrombin
time if dental extractions are planned. The patient's prothrombin time is compared
with normal and called the international normalized ratio (INR). No child with
symptomatic cardiac problems should have any routine dental procedures until details
of the condition have been obtained and the patient's physician consulted.
Antibiotic prophylaxis
Antibiotic prophylaxis is necessary for most congenital cardiac malformations. The
cardiac conditions that require antibiotic prophylaxis for dental procedures are listed
in 1087HTable 16.2. Dento gingival manipulative procedures that are likely to induce an
increase in the level of bacteria in the blood require antibiotic prophylaxis to prevent
the development of endocarditis. The procedures are shown in 1088HTable 16.3. These
include extractions, scaling, surgery involving gingival tissues, and restorative
procedures where the gingival margins are likely to be traumatized either during
cavity preparation or during matrix band, wedge, or rubber dam placement.
Endodontic treatment should only be carried out on teeth where there is a very high
probability of success. This is usually confined to permanent incisor teeth with
straight canals and closed apices and is carried out as a single-visit procedure under
appropriate antibiotic cover.
Antibacterial prophylaxis recommendations are constantly updated (1089HTables 16.4 and
1090H16.5) and revised as new scientific evidence and drugs become available. The latest
British Cardiac Society guidelines and the British National Formulary should be
checked. The medication should be taken under supervision. There is still some
controversy over which conditions do or do not require prophylactic antibiotic
therapy. If any doubt exists then the paediatrician or cardiologist should be consulted
before invasive dental procedures are undertaken.
At the time of writing this new edition, the British Cardiac Society have published
new guidelines. These have not yet been widely adopted within the dental profession
and they differ from the current BNF (2004). Readers are advised to read the latest
editions of the BNF and to read the remainder of this section in that context.
There is a three-step approach to the use and choice of antibiotic prophylaxis.
- Assessment of cardiac risk (1091HTable 16.2)
- Antibiotic prophylaxis is required only in moderate or high risk.
- Assessment of the risk of significant bacteraemia associated with the dento-gingival
manipulative procedure (1092HTable 16.3)
- If the detail of the planned dental procedure involves a dento-gingival