The pressure of premeds

Aug. 1, 2003
Every hygienist has experienced the patient who had forgotten his or her antibiotic coverage before a preventive visit.

By Shirley Gutkowski

Every hygienist has experienced the patient who had forgotten his or her antibiotic coverage before a preventive visit. It usually comes to light with a playful bat to the head as the patient realizes that the task completely escaped them as they prepared for the appointment. Hygienists face this problem almost weekly, in addition to issues of blood pressure.

"Oh, it's just a little murmur," they'll say. "The doctor hardly mentions it anymore." The hygienist cringes as the words escape the patient's mouth. If there is an office policy concerning premedication, then the sequence of events is already laid out. The patient either gets sent home without treatment or someone from the office calls the physician to verify the patient's "slight murmur" story.

Either way, the appointment is a bust. Someone is sitting on hold while the physician on the other end of the line is located. The chart must come up from medical central file storage, the physician then makes a determination, and the nurse relays the information to the dental office personnel. On a good day, the scenario can't last less than 20 minutes.

A number of years ago, I developed a fax sheet to send to physicians' offices. If a patient forgot to take pre-procedural antibiotics, we explained the situation to the patient, and then set the patient up with another appointment. The hygiene staff made use of the time by filling out the form, and faxing it off to the physician's office to fax back to us with the requested information. It took, at most, two days for the entire transaction. No sweat, no stress — just two days.

You may be able to shorten the time span on the form, if needed. It is a simple form and most offices can put together something similar. State what will be done to the patient and what your concerns are, such as bacteremia and stress. The form must have the patient's signature, allowing your office access to the information. This method is possibly more legal than a phone conversation, since everything is in written form and includes the physician's signature.

If the office doesn't have a protocol, the doctor may encourage the hygiene staff to go ahead and clean the teeth — just don't draw too much blood. (This scenario has been noted in many dental list serves. Do I hear the sound of teeth going on edge?) How safe is it to go ahead and clean someone's teeth under these circumstances? The American Heart Association (AHA) has modified their guidelines, most recently in 2000. Mitral valve prolapse (MVP) is in the moderate risk category. The new guidelines explain that not all MVP cases need premedication, only those with regurgitation.

Every now and then, talk starts up about eliminating premedication altogether. These conversations are stimulated by discussions of resistant bacteria caused by antibiotic overuse. However, today, there is no change in the basic need for premedication in any risky patients with procedural exposure. If your patient forgot to premedicate, you can not treat the patient and then administer antibiotics within two hours after the procedure. (The two-hour window study was done on animals only.) Also, the usual time needed for peak antibiotic level (with amoxicillin) is still one hour.

Here is a bit of news some don't know. If the person is already taking antibiotics for another condition, the AHA recommends taking a different antibiotic for premedication. The dose of the current medication should not be doubled; another antibiotic altogether should be recommended. If there are any questions about what antibiotic is needed, these questions should be addressed on the form that is faxed to the physician's office.

Under usual conditions, hygienists like to do as they were taught. Studies prove that obvious long-term consequences can occur with murmurs that can be directly attributed to a dental appointment. Hygienists are comfortable rescheduling anyone who forgot his or her premeds.

Oral health care providers cannot be accountable for an undiagnosed or hidden heart valve problem; however, they can be accountable for undetected high blood pressure. Some say that taking blood pressure, as part of the dental hygiene experience, is a new standard of care. They consider blood pressure readings a safety standard that must be followed and fit into a treatment plan sequence; if not at each appointment, at least within a one-year time span. Hygienists can delegate this task if time becomes an issue. The office manager or other staff member could take care of that small task, if need be. Taking a blood pressure is a relatively simple, noninvasive task.

Unquestionably, blood pressures should be taken before extractions. It is also a good idea to take blood pressures before injecting any local anesthetics, administering nitrous oxide, or placing a risky patient in a stressful situation (which would include most dental hygiene procedures).

An oral health care provider who chooses to use epinephrine-free anesthetic is still increasing the amount of endogenous epinephrine in the body. As we all know, the body makes epinephrine on its own during stressful times. A situation such as dental pain, or perceived dental pain, can stimulate the body to produce this hormone. Remember this from physiology courses? The stress response is a generalized, non-specific pattern of neural and hormonal reactions to any situation that threatens homeostasis. Not giving proper anesthetic, such as those containing epinephrine for its safety, increased duration, and heavenly hemostatic control, causes the body stress, affecting more than blood pressure.

Careful injection technique certainly decreases the amount of circulatory epinephrine. Even if incorrectly injected, the amount of epinephrine is much less than what the body would produce on its own if profound anesthesia is not achieved.

Enter the American Society of Anesthesiology (ASA) classifications, an underused barometer of overall patient health. Anesthesiologists can have a very fleeting, intimate relationship with patients, and need to understand their overall health in seconds. They must have a quick, general sense of how a person will react to the drugs they will administer — drugs that virtually bring a person to the brink of death, where patients teeter for a time. After the surgery, the anesthesiologist must bring them back to finish leading their lives. In 1941, the society established this general guide as an assessment tool for quickly calculating the odds of survival.

We don't use this classification system for medical risk much in dentistry. But we should. Some dental offices may have vague references to these classifications; others may actually use them daily. Almost all dental hygiene programs now teach these classifications. The table above describes the ASA classifications.

It used to be that most of the patients we saw in our practice of oral health care were within the ASA I classification: normal healthy individuals. Now the tendency is for ASA II, with an increased number of ASA III patients, even in a general dentistry practice. Specialty practices —such as periodontal, geriatric, endodontic and oral surgery — will have more patients with ASA III classification levels, and sometimes have patients at the ASA IV level (emergency care only). Examples of class IV patients include those with uncontrolled high blood glucose or uncontrolled high blood pressure. An untreated heart valve with regurgitation would also fit into the class IV category.

At a blood pressure of perhaps 165/100, it is dangerous to inject the patient with an anesthetic solution with 1:100,000 epinephrine. As discussed above, it would also be dangerous to inject this person with an anesthetic without epinephrine. At a blood pressure of 165/100, the patient is classified as an ASA III and should be referred to their physician before anything other than emergency treatment is attempted. Remember, dental hygiene treatment is elective treatment! Along with all of the other health issues of this patient, the person's own body will supply epinephrine, not exactly the same as for our purposes, but certainly enough to make potential trouble.

Not many people die, or even arrest in the dental chair. The chances are slim that an emergency will take place. Estimates from the mid-1980s were that every dental office would have one dire emergency within its walls once during its time span of operation. The courts take a dim view of care providers who gamble with others' safety. Establishing an ASA protocol in an office will substantially increase awareness of all care providers in the dental office.

All offices could have this discussion in a staff meeting. Guidelines can be established for nearly any medical history presentation. It is important to note that the ASA level can change over time. For example, a healthy pregnancy is generally considered to be ASA II, even though a pregnancy is a transient condition.

More than one medical condition and the extent that a condition is controlled can elevate the overall ASA level. A controlled, type 2 diabetic is ASA II; an uncontrolled type 2 diabetic is an ASA III. A controlled type 1 diabetic is an ASA III; while an uncontrolled one is an ASA IV. However, an uncontrolled diabetic with high blood pressure could notch the patient to an even higher ASA, possibly to an ASA IV. A notation in the corner of the health history as to the patient's ASA classification could be an alert much more telling than a general "Medical Alert" sticker, and it will still be within privacy regulations.

American Society of Anesthesiologists' Physical Status Classification

I Normal healthy individual
II Patient with mild to moderate systemic disease
III Patient with severe systemic disease that limits activity but is not incapacitating
IV Patient with severe systemic disease that limits activity and is a constant threat to life
V Moribund patient not expected to survive 24 hours with or without an operation
VI Clinically dead patient being maintained for harvesting of organs

Author's note: A very special and heartfelt thanks to Margaret Fehrenbach for her valuable input into this edition of Thinking Sharply.

• American Heart Association,, Accessed on June 16, 2003.
• American Society of Anesthesiologists, 2002/9_02/vent_0902.htm, Accessed on June 16, 2003.
• Sherwood L: Human Physiology from Cells to Systems. 4th Ed., Brooks/Cole, 2001.
• Malamed SR: Handbook of Local Anesthesia. 4th Ed., Mosby-Year Book, Inc., 1997.
• Margaret Fehrenbach, RDH, MS,, Accessed on June 16, 2003.

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Shirley Gutkowski, RDH, BSDH, has been a full time practicing dental hygienist in Madison, Wis., since 1986. Ms. Gutkowski is published in print and on Internet sites, and speaks to groups through Cross Links Presentations. She can be contacted at [email protected].