New Premedication Guidelines

By Dianne D. Glasscoe, RDH, BS

Dear Dianne,
Now that the American Heart Association has issued new guidelines for premedication and dentistry, our practice is trying to implement the new protocol. However, we have some patients who still insist on premedicating when, according to the AHA, the need no longer exists. How can we relate the new information and allay their fears without upsetting our patients?
– Worried Hygienist

Dear Worried,

Thanks for asking this question, because many of your peers have the same concerns. The fact is, we are creatures of habit, and old habits are hard to change.

The new guidelines should be seen as great news to all those people who previously had to pre-medicate, but now do not need pre-medication as their condition does not warrant it under the new guidelines that were handed down in April, 2007. Nevertheless, some people feel a false sense of security in taking antibiotics before their appointments.

Further, some clinicians are also resistant to change. Shortly after the new guidelines were issued, I was talking with a hygienist about the great news that many of our patients will not need to premedicate in the future. Her reply shocked me. “That’s fine, but I’m not changing anything. I don’t want to be responsible for a patient dying!”

Over time, the trend has been to eliminate various subsets of patients from premedication mandates every time the AHA updates the guidelines. The last update was in 1997, and there were two distinct changes: 1) patients with artificial joints that were problem-free for two years were excluded from pre-medication, and 2) patients with mitral valve prolapse without regurgitation were excluded.

We have known for several years that dental procedures do not increase the risk for infective endocarditis. Dr. Brian Strom, MD, MPH, chair of biostatistics and epidemiology at the University of Pennsylvania, published in 1998 that, in a case-controlled study that compared the relationship between previous dental work performed on 273 adults with infective endocarditis and a control group of equal size, dental procedures were not risk factors for endocarditis. “There is no need for prophylaxis for dental work,” said Strom. His reasoning was that at-risk people acquire bacteremias from many daily living activities, such as defecation, skin abrasions, tooth brushing and flossing, and dental procedures do not increase that risk. He further stated that there is no rationale behind thinking that risk is confined to dental procedures.

The ever-increasing problem of resistant organisms in our environment has fueled the change to the guidelines. Dr. Strom said he feels health-care professionals have misused antibiotics for too long, and we are to blame for the today’s prevalent problem of antibiotic resistance. We have disease-producing organisms that are now resistant to every known antibiotic!

My neighbor is a good example of this. She had surgery in 2005. She came through fine and was progressing normally until she developed an infection. The infecting organism was identified as methicillin-resistant Staphylococcus aureus (MRSA), which she acquired in the hospital. Medical personnel gave her the “big gun” antibiotics, but nothing stopped the infection. Within days it spread to her brain, and she lapsed into a coma. She died 30 days after surgery. She is just one example.

According to the CDC, more people died of MRSA than in car accidents in 2006. There were over 90,000 deaths documented from MRSA, which is more than double the number of people who died in car accidents. The CDC states that over 70 percent of hospital infections came from “superbugs,” which are defined as organisms resistant to the antibiotics typically used to treat them.

Gonorrhea, which is the second most common sexually transmitted disease, has become so resistant to fluoroquinolones, such as Cipro, that the CDC issued a new directive informing health-care professionals to stop prescribing it to treat gonorrhea. There is currently only one class of antibiotics that can effectively treat gonorrhea, and that is cephalosporins. The problem is that we do not currently have a pill form of cephalosporins, only injection.

Antibiotic resistance is a serious problem. No one should be indiscriminately taking an antibiotic that is not warranted through evidence-based studies.

You need to become thoroughly familiar with the new guidelines, which can be downloaded from the ADA Web site at http://www.ada.org/prof/resources/topics/infective_endocarditis.asp.

The guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with:

  1. mitral valve prolapse
  2. rheumatic heart disease
  3. bicuspid valve disease
  4. calcified aortic stenosis
  5. congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy

    The new guidelines are aimed at patients who have the greatest danger of a bad outcome if they develop a heart infection.

    Preventive antibiotics prior to a dental procedure are advised for patients with:

    • artificial heart valves
    • a history of infective endocarditis
    • certain specific, serious congenital (present from birth) heart conditions, including

    > unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
    > a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or catheter intervention, during the first six months after the procedure
    > any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

    • a cardiac transplant that develops a problem in a heart valve

    Incidentally, the guidelines did not change for joint/orthopedic patients. Those guidelines can be obtained at http://www.aaos.org/about/papers/advistmt/1014.asp. The panel’s conclusion: Antibiotic prophylaxis is not indicated for dental patients with pins, plates and screws, nor is it routinely indicated for most dental patients with total joint replacements. However, it is advisable to consider premedication in a small number of patients (Table 1) who may be at potentially increased risk of hematogenous total joint infection. (AAOS.org).

    When talking to patients, it’s important to stress the seriousness of antibiotic resistance and the necessity of curbing indiscriminate antibiotic use. You can allay your patients’ fears by informing them that the AHA committee worked for several years to conclude that taking antibiotics preventively is actually more dangerous than any perceived risk of developing infective endocarditis from a dental procedure. According to ADA.org, “The guidelines are based on a growing body of scientific evidence that shows the risks of taking preventive antibiotics outweigh the benefits for most patients. The risks include adverse reactions to antibiotics that range from mild to potentially severe and, in very rare cases, death. Inappropriate use of antibiotics can also lead to the development of drug-resistant bacteria.”

    Some offices have made copies of the new guidelines to give to patients who formerly required pre-medication. Unfortunately, some physicians are not up-to-date with the new guidelines. I have heard of some dental offices calling the patient’s physician to ask about the need for pre-medication. I believe dental professionals are capable and competent to interpret the new guidelines, and a call to the physician should be made only if the clinician is not clear about the patient’s medical history. I recommend that any patient who still falls under the new premedication guideline obtain his/her antibiotics from the physician.

    For most practices, there will be only a small number of people who will still require antibiotic prophylaxis. That’s good news for our patients and us!
    Best wishes,
    Dianne

    About the Author

    Dianne D. Glasscoe, RDH, BS, is a professional speaker, writer, and consultant to dental practices across the United States. She is CEO of Professional Dental Management, based in Frederick, Md. To contact Glasscoe for speaking or consulting, call (301) 874-5240 or e-mail dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.


    Table 1

    Patients at Potential Increased Risk of Hematogenous Total Joint Infection

    A. All patients during the first two years after prosthetic joint replacement

    B. Immunocompromised/immunosuppressed patients
    • Inflammatory arthropathies
    (e.g., rheumatoid arthritis, systemic lupus erythematosus)
    • Drug-induced immunosuppression
    • Radiation-induced immunosuppression

    C. Patients with co-morbidities, e.g.,
    • Previous prosthetic joint infections
    • Malnourishment
    • Hemophilia
    • HIV infection
    • Insulin-dependent (Type 1) diabetes
    • Malignancy

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