Fall 2007 | Ports, Antibiotics, and Your Dentist / Jenny Massey

As an alternative to intravenously administering clotting factor, many adults and children with bleeding disorders have central venous access devices, such as a port-a-caths. A port-a-cath is a device that is surgically inserted into the upper chest area. The device consists of a reservoir called a portal that has a silicone bubble for needle insertion. The portal is attached to a plastic tube called a catheter. The catheter is inserted into a vein that leads to the heart, usually the jugular vein, subclavian vein, or superior vena cava. Externally, the port-a-cath appears as a quarter-size bump under the skin.

A port-a-cath is often suggested as an alternative to peripheral vein access in patients that require frequent infusions, long infusions, or have difficult veins. Since it is an internal device, swimming and bathing are not a problem. However, port-a-caths do run a risk of infection. Often, a dentist or physician will want their bleeding disorder patients with a central venous access device to receive antibiotics prior to beginning any dental work including oral surgeries, tooth extractions, fillings, and even general cleaning. The concern is over the possibility of bacteria entering the bloodstream and resulting in endocarditis, which means “infection of the heart.” This condition may also be referred to as Subacute Bacterial Endocarditis, or Infective Endocarditis. Endocarditis refers to an infection of the heart’s inner lining or valves.

With the risk of endocarditis, many health professionals will insist that antibiotics be used prior to dental work; however just as many will say that it is not necessary. Deciding whether to use antibiotics may be confusing. The decision to use these medications depends on a few key factors:

• Does the patient have any prior history of heart disease?
• What type of dental work is needed? Will there be a high risk of blood stream infection, for example, as when having a tooth pulled?
• Has the patient previously experienced a port infection?
• Is the patient prone to dental problems or poor dental hygiene?
• Does the patient have an allergy or resistance to antibiotics?
• Has the dental patient previously had a total joint replacement?

Why might antibiotics be necessary?
At any given time, the mouth is naturally full of germs and bacteria. If the tongue, gums, or other part of the mouth is cut or irritated, the area can become a source for infection to enter the bloodstream. Normally, the inside of the heart is smooth like glass. If bacteria enters the bloodstream, it can most often smoothly pass through the heart and continue through the blood stream until the spleen filters it out. However, in people with a port-a-cath, the bacteria may potentially find its way to the catheter as it enters the heart. The catheter could then become a place for bacteria to set up shop. Once the bacterium finds a home, it can multiply and cause an infection. Likewise, if the port becomes infected, the heart and bloodstream could follow suit and become infected as well.

An infection of the heart is very serious and can potentially be life threatening. It requires aggressive treatment with intravenous antibiotics for many weeks. Due to the seriousness of the potential exposure, many physicians and dentists insist that dental patients with venous access devices receive a prophylactic dose of antibiotics. The most common type of antibiotic used is Amoxicillin. A single dose taken an hour before the dental procedure is usually considered adequate.

The Medical and Scientific Advisory Council, also known as MASAC, recommends that a prophylactic dose of antibiotic be administered with dental procedures. (Recommendation 103 - May 19, 2001) MASAC is an international advisory council consisting of expert medical professionals specializing in bleeding disorders, infectious diseases, and blood safety. MASAC and the National Hemophilia Foundation Board of Directors set forth the recommendations for those in the bleeding disorder community.

Why might antibiotics not be necessary?
Controversially, many physicians believe that antibiotics should not be given freely due to the possible development of a resistance to antibiotics. In a patient with a port-a-cath that has no history of heart disease, the chances of an infection of the heart or port due to a dental procedure is small, thereby leading many professionals to say that antibiotics for dental procedures are unnecessary. In fact, the American Heart Association (AHA) set forth a guideline stating that many patients who have previously been advised to use a prophylactic dose of antibiotics prior to routine dental work do not gain any significant benefit from doing so. AHA now feels that often times, the risks of taking antibiotics outweigh the benefits. These risks include fatal allergic reactions or developing drug-resistance to the antibiotics, which would render them useless when they become truly necessary. The American Dental Association has since adopted AHA’s findings.

Especially since the possibility of infection is a major concern for children and adults with central venous access devices, understanding the risks involved with the dental procedure you are in need of is important. The decision of whether to use or to forego the use of antibiotics is one that should be made in conjunction with your dentist and physician. Encourage communication between the two healthcare providers. Your Hemophilia Treatment Center is also an excellent source of information and may provide you with additional information to assist you in making your decision.

References:

“What is the Medical and Scientific Advisory Council?” National Hemophilia Foundation. 2006. 11 August 2007 http://www.hemophilia.org/NHFWeb/MainPgs/MainNHF.aspx?menuid=57&contentid=335

The Council on Scientific Affairs of the American Dental Association, “Journal of the American Heart Association Circulation.” AHA Statement 04/19/2007. American Heart Association. April 19, 2007. 11 August 2007 http://www.americanheart.org/presenter.jhtml?identifier=3047083

“Antibiotics and Your Heart.” American Dental Association, 1995-2007 American Dental Association. 3/14/05. 11 August 2007 http://www.ada.org/public/topics/antibiotics.asp

“Antibiotics Not Advised Before Dental Work.” New York (Reuters Health). Reuters April 23, 2007. 11 August 2007 http://www.reuters.com/article/healthNews/idUSLAU37762220070423?feedType=RSS