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November 21, 2008

Dear Dianne,

My question concerns antibiotic protocol. A patient divulged while conversing with the dentist that she had a total hip replacement in August 2007. She was not aware of a need to be covered with antibiotic therapy before her appointment. My employer gave her 2 grams of amoxicillin at that time and said to "give it up after a year or so," meaning antibiotics will not be necessary in the future. He also told me to document in the chart, just not in too much detail. I'm afraid my license is at stake here. What should I do?
Worried in Washington

Dear Worried,

In April 2007, the American Heart Association published new premedication guidelines related to dental procedures and at-risk patients. The committee scoured the literature worldwide in an effort to find one shred of evidence that premedicating with antibiotics prior to dental procedures would prevent bacterial endocarditis. As it turned out, they found zero evidence that preventive antibiotics benefitted patients in preventing endocarditis. The consensus was this: dental procedures do not increase the risk of endocarditis for at-risk patients, as many events of everyday living can cause bacteremias, such as defecation, skin abrasions, toothbrushing, flossing, and using a toothpick. In light of this knowledge, it makes no sense to mandate preventive antibiotics.

However, the committee did not discontinue premedication across the board. There are still a few extremely high risk or immunocompromised patients who are indicated for premedication.

The American Academy of Orthopaedic Surgeons also issued some updated guidelines. I urge you to read the entire document. Here are two excerpts from their Web site at http://www.aaos.org/about/papers/advistmt/1014.asp.

"An expert panel of dentists, orthopaedic surgeons, and infectious disease specialists, convened by the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons (AAOS), performed a thorough review of all available data to determine the need for antibiotic prophylaxis to prevent hematogenous prosthetic joint infections in dental patients who have undergone total joint arthroplasties. The result is this report, which has been adopted by both organizations as an advisory statement. 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 who may be at potential increased risk of hematogenous total joint infection."

And,
"Presently, no scientific evidence supports the position that antibiotic prophylaxis to prevent hematogenous infections is required prior to dental treatment in patients with total joint prostheses. The risk/benefit and cost/effectiveness ratios fail to justify the administration of routine antibiotic prophylaxis. The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms, and mechanisms of infection are all different."

After this statement, they do mention that some people "may" be considered for premedication within two years postsurgery, those who have had previous joint infections, and certain debilitated and immunocompromised patients. The AAOS even said that the dentist may want to consult the patient's physician.

"After this consultation, the dentist may decide to follow the physician's recommendation, or, if in the dentist's professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis. The dentist is ultimately responsible for making treatment recommendations for his/her patients based on the dentist's professional judgment."

The AAOS understands that many variables can exist regarding patients and their supposed risk, and dentists should have some discretion in decision-making regarding premedication. The committee also understands that physicians are not always on the same page regarding the matter of premedication, and the dentist has a right to direct physicians to the official document published by the AAOS. The dentist is ultimately responsible for decisions regarding patient care when the patient is actively being treated in the dental office.

It would have been more desirable if the committee had said point blank, "No premedication is ever necessary for dental procedures," as there were some on the committee who felt this way. Use of the word "may" leaves all of us to wonder which way to proceed.

The driving force behind the change to premedication guidelines is the serious problem of bacterial resistance to antibiotics. One doctor on the AHA committee shared with me that he feels that antibiotics have been misused far too long in this country, which is part of the reason we have so much bacterial resistance today. Surely you have heard of methicillin-resistant Staphylococcus aureus (MRSA), C. difficile (a resistant intestinal pathogen), Acinetobacter (can be carried on the skin), or Pseudomonas aeruginosa (can cause severe infections of the bloodstream).

You may not know that hospital-acquired infections killed more than 90,000 people in 2006, which is more than double the number of people killed in automobile accidents, and they add $5 billion to our health-care costs each year. The CDC says more than 70% of the estimated 2 million annual hospital infections are caused by superbugs — bacteria that are resistant to antibiotics.

Additionally, the pathogens that cause the number two sexually transmitted disease, gonorrhea, have become resistant to the traditionally administered antibiotics, fluoroquinolones (Ciprofloxacin). We now have only one antibiotic to treat gonorrhea — cephalosporins — which are only available in injection form at present. Years ago, we successfully treated gonorrhea with penicillin, but resistance developed over time to that drug.

Another real danger for anyone taking an antibiotic is the possibility of an untoward antibiotic reaction. People who have taken many antibiotics throughout their lifetimes are certainly more at risk for an allergic reaction than others. My advice for all dental clinicians is that they cease prescribing antibiotics for premedication reasons — period. If a physician wants a patient premedicated for some physical condition, then that physician should prescribe the antibiotics and thereby assume the risk associated with antibiotic reactions. Dentists should only prescribe antibiotics for dental conditions that warrant an antibiotic.

Since the patient was still within the two-year time limit, one course of action would have been for someone to call the patient's physician and inquire if premedication was indicated for this particular patient. Then proceed at the physician's direction. Who knows? The physician may have recommended no antibiotics were needed. However, the dentist did what he felt was in the patient's best interest and is therefore ultimately responsible. As for the chart notes, I can only speculate what was meant by "not too much detail," but he probably felt that the issue need not be blown out of proportion. You should always write your chart notes accurately and thoroughly and refrain from writing your opinion. Stick to the facts.

Best wishes,
Dianne

About the Author

Dianne Glasscoe-Watterson, 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-Watterson for speaking or consulting, call (301) 874-5240 or e-mail dglasscoe@northstate.net. Visit her Web site at www.professionaldentalmgmt.com.

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