darby chp13 pt 4

Prophylactic Antibiotic Premedication

• AHA guidelines recommend prophylactic antibiotic premedication before dental procedures for patients with:

  • Prosthetic cardiac valves or prosthetic material used for cardiac valve repair (including annuloplasty rings, chords, or clips).
  • Previous, relapse, or recurrent infective endocarditis (IE).
  • Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits.
  • Congenital heart defects that have been completely repaired with prosthetic material or a device within the last 6 months (endothelialization requires 6 months).
  • Repaired congenital heart disease with residual defects at or adjacent to a prosthetic patch or device.
  • Recipients of cardiac transplantation who develop cardiac valvulopathy.

• Preventive measures involve administering prophylactic antibiotic premedication one-half to 1 hour before dental procedures to avoid bacteremia and infection.

• If the antibiotic dose is missed, it can be administered up to 2 hours after the procedure.

• Some facilities maintain a supply of antibiotics for immediate use when indicated.

• The rationale for prophylactic antibiotic premedication to prevent transient bacteremia from developing into IE is controversial.

• Bacteremia is detectable after dental procedures and during daily activities like tooth brushing and chewing.

• The risk of contracting IE from dental procedures versus routine oral activities is not precisely known.

• The standard prophylactic antibiotic premedication regimen recommended by the AHA is referenced in Table 13.4.

• Patients currently taking antibiotics should receive an antibiotic from a different class.

  • Example: A patient taking amoxicillin for another reason who normally takes it for IE prophylaxis should receive azithromycin, doxycycline, or cephalexin.
  • Alternatively, the dental procedure can be delayed for 10 days after completing amoxicillin therapy, followed by a one-time dose of amoxicillin before the dental procedure.
  • This 10-day period allows for reestablishment of usual oral flora.

• Current ADA guidelines no longer recommend clindamycin for dental prophylaxis or therapeutic use in penicillin-allergic patients due to more frequent and serious adverse reactions.

• Clindamycin can cause Clostridioides difficile (C. difficile), a bacterial infection inducing diarrhea and colitis.

• Premedication guidelines are continuously reviewed and updated on the ADA Premedication webpage.

• A complete drug history should be recorded, including prescribed antibiotics, doses, and administration times, to ensure the antibiotic is taken within 2 hours of the appointment.

• Patient education is crucial regarding the need for prophylactic antibiotic premedication for certain medical conditions.

• Table 13.5 summarizes considerations for prescribing prophylactic antibiotic premedication.

Prophylactic Antibiotic Premedication Tables

• TABLE 13.4 Prophylactic Antibiotic Premedication for a Dental Procedure (Single Dose 30 to 60 Minutes Before the Procedure)

  • Situation

    • Adults
      • Children
        • Agent

  • Oral

    • Amoxicillin
      • 2g
        • 50 mg/kg

  • Unable to take an oral medication

    • Ampicillin
      • 2g IV/IM
        • 50 mg/kg IV/IM

  • Allergic to penicillin or ampicillin and able to take an oral medication

    • Cephalexin

      • 2g
        • 50 mg/kg

    • Azithromycin or Clarithromycin

      • 500 mg
        • 15 mg/kg

  • Allergic to penicillin or ampicillin and unable to take an oral medication

    • Cefazolin or Ceftriaxone
      • 1g IV/IM
        • 50 mg/kg IV/IM

• Cephalosporins should not be taken by a person with a history of anaphylaxis, angioedema, or urticaria with penicillin or ampicillin.

• IM, Intramuscular; IV, intravenous.

• Data from Prevention of infective endocarditis: guidelines from the American Heart Association.

• TABLE 13.5 Considerations for Prescribing a Prophylactic Antibiotic Premedication

  • Management of Individuals Who Are at High Risk
    • Use prophylactic antibiotics during the perioperative period (30 minutes to 1 hour before treatment) or within 2 hours after the appointment.
    • Establish and maintain optimal oral health.
    • Schedule appointments 10 days apart for procedures requiring antibiotic prophylaxis.
    • Administer an alternative prophylactic antibiotic therapy when:
      • (a) Procedures are less than 9 days apart; or
      • (b) The patient is currently taking antibiotics for another reason.
    • Combine prophylaxis with other dental procedures during premedicated time frames.
    • Encourage full or partial denture wearers to have periodic oral examinations and return to their provider if discomfort develops.
  • Management Rationale
    • Use these measures to prevent infective endocarditis.
    • Use these measures to prevent infective endocarditis and to improve the patient's oral health literacy.
    • Reduce the emergence of resistant microorganisms. Allow for the repopulation of antibiotic-susceptible flora.
    • Reduce the emergence of resistant microorganisms.
    • Reduce the emergence of resistant microorganisms by reducing the number of premedicated dental visits.
    • Ill-fitting removable oral prostheses can cause tissue ulceration with concomitant bacteremia of oral origin.

Data from American Dental Association: 2017 Oral Health Topics: Antibiotic prophylaxis prior to dental procedures.

Patient Scenario: Mrs. Smith

• Patient Profile: Mrs. Smith, a 52-year-old woman referred for a periodontal evaluation.

• Chief Complaint: Facial swelling and gingival pain in the lower right quadrant.

• Dental History: Avoided dental care for over 15 years until recently developed facial swelling, pain, and a low-grade fever, leading to an emergency department visit.

  • Prescribed antibiotics and pain medication for 1 week, referred to a general dentist.
  • Rescheduled initial evaluation several times due to work and reluctance.
  • One month since the ED visit, pain and swelling are gradually returning; arrives with apprehension.

• Health History:

  • History of depression, hypertension, and type 2 diabetes.
  • Depression managed with Zoloft (sertraline hydrochloride, 25 mg once daily).
  • Hypertension controlled with Accupril (angiotensin-converting enzyme inhibitor), also slowing kidney damage from diabetes.
  • Type 2 diabetes controlled by daily insulin and diet.
  • Compliant with medications, regular physician visits.
  • Cannot recall recent HbA1c test level or any hypoglycemic episodes.
  • Vital signs within normal limits.
  • Notes unpleasant experiences in the dental office, probable cause for dental anxiety.

• Social History: Married with two grown children, works as an executive secretary.

• Extraoral Examination: All findings within normal limits.

• Supplemental Notes:

  • Arrives 30 minutes late for a 4:00 PM appointment.
  • At 4:35 PM, the dental hygienist escorts her to the treatment room to review health and dental history.
  • Appears anxious, clutching purse and speaking rapidly.
  • Health history is reviewed, vital signs measured, and no changes recorded.

Questions for Assessing Mrs. Smith:

1. What are Mrs. Smith's concerns for the dental visit? How would you prioritize her concerns with her dental needs?
2. What behavior modifications for the management of dental anxiety are warranted?
3. What questions should the dental hygienist ask Mrs. Smith regarding her medical conditions and medications to prevent a medical emergency?
4. What is Mrs. Smith's American Society of Anesthesiologists (ASA) classification and the protocol associated with this classification?
5. Does Mrs. Smith require prophylactic antibiotic premedication?
6. Due to Mrs. Smith's medical conditions, is a physician's consultation necessary before initiating treatment?
7. How would Mrs. Smith's medical conditions or medications alter the scheduling of her dental appointments and procedures (e.g., appointment time, meals)?
8. Due to Mrs. Smith's medical conditions, are any modifications to the selection or dose of the local anesthetic agent necessary (e.g., type of local anesthetic agent, cardiac dose)?

Treatments and Conditions Not Requiring Prophylactic Antibiotic Premedication

• Prophylactic antibiotic premedication is not recommended for:

  • Exposing dental radiographs.
  • Initiating fluoride treatments.
  • Placing removable prosthodontic appliances.
  • Operative restorative dentistry (with or without retraction cord, rubber dams, postoperative suture removal, impressions).
  • Adjusting or placing orthodontic appliances and brackets.
  • Shedding of primary teeth.
  • Bleeding from trauma to lips or oral mucosa.

• Awareness of adverse events from misuse and overuse of antibiotics promotes careful consideration when prescribing prophylactic antibiotic premedication.

• The AAOS and the ADA do not recommend prophylactic antibiotic premedication for patients with prosthetic joint implants.

• The AHA and the ACC agree that maintaining good oral hygiene is crucial for patients with prosthetic joints.

• Antibiotic prophylaxis is unwarranted in patients who have undergone surgical interventions such as:

  • Stem cell transplant
  • Organ transplant
  • Ventriculoarterial and ventriculoperitoneal shunts
  • Nonvascular devices including indwelling vascular catheters (e.g., central lines)
  • Cardiovascular implantable electronic devices (CIEDS)
  • Breast augmentation
  • Penile implants
    • Unless predisposed to infection; consult physician for antibiotics.

• Observed for patients with:

  • Immunocompromised
  • Immunosuppressed
  • Inflammatory arthropathies (e.g., rheumatoid arthritis, systemic lupus erythematosus)
  • Drug-induced immunosuppression
  • Radiation-induced immunosuppression
  • Comorbidities (e.g., previous prosthetic joint infections, malnourishment, hemophilia, HIV infection, type 1 diabetes, and malignancy).
  • See Box 13.3.

Physician Consultation and Referral

• Consult the physician of record if the patient reveals a condition that may jeopardize safety during dental care.

• Medical consultations are initiated for:

  • Conditions needing prophylactic antibiotic premedication.
  • Suspicion of undiagnosed or uncontrolled medical conditions.
  • Abnormal vital signs (see Chapter 14).
  • Precautionary treatment modifications (e.g., local anesthetics with reduced levels of vasoconstrictor).
  • Person taking anticoagulant or blood-thinning medication (e.g., warfarin [Coumadin]).

• Patients are referred for medical evaluation when:

  • A nonurgent but potentially undiagnosed condition is suspected (e.g., hypertension or diabetes).
  • Needed laboratory test results are not available (e.g., blood test for bleeding risk when warfarin is taken) (see Chapter 15).

• Urgent consultation is indicated if the client reveals a condition that precludes dental hygiene care or needs prompt dental or medical attention.

• Consultations should be documented, followed by a written consultation form.

• Request the physician to send information electronically.

• Obtain consent for information release before the request per HIPAA regulations.

• Document to whom the medical request was sent and the reason for the request.

• Information obtained from the patient's physician should be placed in the patient's dental record.

• A formal written request for medical consultation is the preferred procedure for medical-legal documentation.

• Consent may also be needed for medical clearance before initiating dental care.

Referral

• Initiate patient referrals for medical evaluations of an undiagnosed condition (e.g., signs and symptoms of diabetes mellitus), for reassessment of a condition (e.g., high blood pressure), or for laboratory tests to determine health status before treatment (e.g., blood test to eliminate risks of excessive bleeding due to medications, chemotherapy, risk of infection).

• Patients must understand the importance of maintaining communication between medical and dental providers to reduce risks and avoid emergency situations in the dental office.

• Box 13.4 provides additional information for patient education.

Patient Education Tips

• Educate patients regarding:
  • Predispositions for medical emergencies occurring in the dental setting from information obtained in the patients' health history (e.g., counseling patients with diabetes mellitus to eat after taking medication before their dental appointment)
  • Need for medical consultation before initiating dental procedures to avoid risks and emergency situations.
  • Administration of prophylactic antibiotic premedication for certain medical conditions before initiating dental hygiene procedures.
  • Importance of regular oral examinations to reduce the severity of oral disease and decrease the costs of oral care.
  • Legal justification for dental-related activities, including an explanation of the issues of standards of care, scope of practice, and duty to the patient.
  • Need to maintain accurate records of patient care to protect against health risks.

Key Concepts

• The health history is a legal document containing protected information regarding the patient's health status.

• The dental hygienist-patient partnership is a patient-centered relationship based on trust and dedicated to the patient's overall well-being.

• The patient completes the written health history questionnaire during the first visit. The dental hygienist reviews, discusses, and verifies the information during the patient interview. At subsequent appointments, the health history is updated, and changes are investigated and documented in writing or electronically.

• The dental hygienist builds rapport during the health history interview by applying patient-centered interviewing techniques such as open-ended questioning, active listening and responding, and excellent verbal and non-verbal communication skills.

• The ASA physical status classification system categorizes patients who are medically "at risk" and determines the probability of medical emergencies in the dental setting. Only patients in the ASA I through III classifications should receive elective oral care.

• Stress reduction protocols can minimize the risk of medical emergencies and create a satisfactory experience for the anxious patient.

• Medical references, such as the Physician's Desk Reference (PDR), Mosby's Dental Drug Reference, the Drug Information Handbook for Dentistry, and the Merck Manual of Diagnosis and Therapy, are available to identify drug actions, interactions, contraindications, adverse reactions, oral health implication, and information on diseases.

• Infective endocarditis (IE) can be a life-threatening condition. Routine dental procedures including prophylaxis and administration of local anesthesia may place patients with certain heart conditions at risk for IE. Only patients at the highest risk for complications from IE should receive prophylactic antibiotic premedication before dental hygiene procedures.

• Patients with prosthetic joints or orthopedic implants do not require prophylactic antibiotics before dental procedures.

• The selection of prophylactic antibiotics is based on recommended guidelines, concurrently prescribed antibiotic agents, and patient tolerance of the medication.

• A patient may have an undiagnosed disease that can be recognized by a comprehensive health history review and observation of signs and reported symptoms. The health history review and physical assessment are monitors of a patient's health and risk status.