everything you want to know about premedication and the new american heart association guidelines...
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Everything You Want To Know Everything You Want To Know About Premedication and the About Premedication and the
New American Heart New American Heart Association GuidelinesAssociation Guidelines
WDHA Presentation/ January 10th 2008Kelly Anderson RDH, MHS
Topics to be discussed……Topics to be discussed……History of the premedication
guidelinesDefinition, incidence, and
characteristics of bacterial endocarditis
Controversy surrounding the old guidelines/ benefits of the new guidelines
Differences between the old and the new guidelines
Premedication for other dental/dental hygiene patients
History of AHA GuidelinesHistory of AHA GuidelinesAmerican Heart Association has
made recommendations for more than 50 years
Updated in 1960, 1965, 1972 (ADA endorsed), 1977, 1984, 1990
Most recent was 1997- grouped patients into high, moderate and low risk groups
Rationale for RevisionsRationale for RevisionsQuality of evidence for IE
prophylaxis was based on a few cases- not enough evidence!
Infective EndoInfective Endocarditiscarditis/ / EndEndarteritisarteritis A microbial infection most often in
proximity to congenital or acquired heart defect◦endocarditis- infection of the heart valves or
endocardium◦endarteritis- infection of major vessels leading
into and out of the heart
IncidenceIncidence
In general population not known◦Less than 1% of the population (estimated)
◦4,000 to 15,000 cases of IE occurring in the U.S. per year
Other Considerations: Other Considerations: IncidenceIncidenceDoes not appear to be decreasing with
use of prophylactic antibiotics
60 to 80% of the cases present in patients with some type of predisposing heart or arteriole disease
Fewer than 1 in 5 cases are associated with medical or dental procedures
Important!!!Undiagnosed or untreated IE◦mortality rate of 100%
EtiologyEtiologyBacteria
Streptococcus- Sub acuteStaphylococcus Aureus- acuteOrder of events:1. Bacteremia introduced in blood
stream2. Infects damaged endocardium near
high flow area such as the heart or prosthetic joints
80% of the cases
CARDIAC LESIONCARDIAC LESION
Symptoms and Signs/ Symptoms and Signs/ Occurrence: IEOccurrence: IE
Signs Signs &Symptoms&Symptoms– WeaknessWeakness– Unexplained Unexplained
feverfever– Weight lossWeight loss– FatigueFatigue– Chest painChest pain– Cardiac Cardiac
murmurmurmur
Sub acute: StrepSub acute: Strep– Progresses over a Progresses over a
period of weeks to period of weeks to monthsmonths
AcuteAcute– Develops over a Develops over a
period of days to 1 period of days to 1 weekweek
– Complications Complications develop quickly develop quickly and can lead to and can lead to death is 6 weeksdeath is 6 weeks
Pathophysiology/Pathophysiology/ComplicationComplication
Treated IE patients ◦hospital stay ranges from 4-6 wks◦increases the risk for reinfection, congestive heart failure, renal disease, scarred valve
◦mortality rate for treated patients is 10-70%
◦mortality rate for untreated patients is 100%
Signs and Symptoms of Signs and Symptoms of Dental Dental Induced Induced IIEE
Appear within 2 wk of medical of dental procedure and may lead to death within 6 weeks
Sub-acute IE is caused most often by Alpha-Hemolytic Streptococci (the most common found in dental induced bacteremias)
At risk….without exposure to medical or dental procedures*◦elderly◦patients with valvular prosthesis◦IV drug users*Other bacteria may be the causative agent in these high risk patients
Potential Problems with Potential Problems with Dental Care-Frequency of Dental Care-Frequency of Bacteremia Bacteremia
Procedures and Risks for
bacteremia:perio surgery 36-88%perio scaling 8-80%prophy (polishing) 0-40%toothbrushing 0-40%chewing 7-50%
Antibiotic Prophylaxis may Antibiotic Prophylaxis may prevent endocarditis by:prevent endocarditis by:
Killing or damaging the bacteriaDecreasing bacterial adherence
to irregular heart surfacesThis is controversial! There are
no controlled studies on the efficacy of antibiotic prophylaxis
Controversy Over Antibiotic Controversy Over Antibiotic Prophylaxis for Dental ProceduresProphylaxis for Dental Procedures
◦Rareness of disease following medical/dental procedures
◦If dental treatment causes 1% of IE in the U.S, the overall risk is 1 case of IE per 14 million dental procedures
◦Evidence linking IE and dental procedures is not conclusive
◦Incidence of anaphylactic type of reaction to antibiotic is 400-800 deaths per year in the U.S. after the use of penicillin
◦Bacterial resistance becoming a problem
Risks Risks OOutweigh the utweigh the BenefitsBenefits for for Premedication for Low-Moderate Premedication for Low-Moderate
Risk PatientsRisk Patients
Antibiotics not needed for individuals with low or moderate risk for BE
Absolutely necessary for high risk patients
WHY NEW GUIDELINES?WHY NEW GUIDELINES?IE is much more likely to result from
frequent exposure to random bacteremias associated with daily activities
Prophylaxis may prevent an exceedingly small number of cases of IE, if any
The risk of antibiotic-associated adverse events exceed the benefit, if any, from prophylactic antibiotic therapy
Maintenance of optimal health and hygiene may reduce the incidence of bacteremia and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
NEW GUIDELINES:NEW GUIDELINES:AHAAHA Considers Considers High RiskHigh Risk
Individuals-Individuals-Premedication Indicated Premedication Indicated
Prosthetic cardiac valve: mechanical or tissue
Previous history of infective endocarditis
Congenital Heart Disease which is unrepaired
Congenital heart defects repaired during the first six months after surgery
Cardiac Transplant with cardiac complications
CONSIDERED MODERATE RISK CONSIDERED MODERATE RISK INDIVIDUALS- INDIVIDUALS- Premedication NOT Premedication NOT
Indicated Now Indicated NowMitral Valve Prolapse with or without
regurgitation Pathological/Organic heart murmurPrevious rheumatic fever with or without
valvular dysfunctionPrevious Kawaskasi disease with or
without valvular dysfunctionSystemic Lupus Erythematosis (1/4 of
these patients have cardiac involvement)Rheumatoid Arthritis with cardiac
involvementOther acquired valvular dysfunction
CONSIDERED MODERATE RISK CONSIDERED MODERATE RISK INDIVIDUALS- INDIVIDUALS- Premedication NOT Premedication NOT
Indicated Indicated Now Now (cont.)(cont.)
Previous coronary bypass graft surgery
Coronary artery stentsHeart transplants patient without
complicationsCardiac pacemakers Implanted defibrillators
Antibiotic Prophylaxis Regimen Antibiotic Prophylaxis Regimen Following current loading guidelines:
► 30-60 minutes before procedure
► Next 1 to 2 hours is the best coverage of antibiotics
► Ideally give subsequent loads of antibiotics 9 to 14 days after initial treatment to allow the oral flora to return to normal
The dose can be given 2 hours after the procedure if it was accidentally not given
Patients already receiving Patients already receiving Antibiotics Antibiotics
Select an antibiotic from a different class rather than increase dosage of current antibiotic to minimize resistance
Example: If patient is already
taking amoxicillin, use
clindamycin.
AMERICAN HEART ASSOCIATION AMERICAN HEART ASSOCIATION RECCOMENDATION- RECCOMENDATION- new guidelinesnew guidelines
Adults Amoxicillin 2 grams orally (500 X
4 tablets), 30-60 minutes before appointment
Children Amoxicillin 50mg/kg. orally, 30-
60 minutes before appointment
Situation Antibiotic Agent Regimen *
Standard Prophylaxis Amoxicillin Adults: 2.0 g. Children : 50 mg / kgOrally 30-60 minutes before procedure
Unable to take oral medication
Ampicillin Adults: 2.0 g IM or IVChildren: 50 mg / kg IM or IVwithin 30-60 minutes before procedure
Allergic to Penicillin Clindamycin Adults: 600 mgChildren: 20 mg / kgOrally 30-60 minutes before procedure
** Cephalexin or cefadroxil Adults: 2.0 gChildren: 50 mg / kg Orally 30-60 minutes before procedure
Azithromycin or clarithromycin
Adults: 500 mg Children: 15 mg / kg orally 30-60 minutes before procedure
Allergic to Penicillin and unable to take Oral Medications
Clindamycin Adults: 600 mgChildren: 20 mg / kg IV 30-60 minutes before procedure
Cefazolin Adults: 1.0 gChildren: 25 mg / kg IM or IVwithin 30-60 minutes before procedure
* Total children’s dose should not exceed adult dose** Cephalosporin's should not be used in individuals with immediate-type hypersensitivity reaction to penicillins
PROCEDURES TO GIVE PROCEDURES TO GIVE ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXISProbingRecall maintenance Cleaning of the teethSubgingival fiber placementExtractionScaling and Root Planing
PROCEDURES PROCEDURES NOTNOT NEEDING NEEDING ANTIBIOTIC PROPHYLAXISANTIBIOTIC PROPHYLAXISRestorative dentistry with or
without cordLocal anesthetic (non-PDL)Root canal therapy (not beyond
apex)ImpressionsSuture removalPlacement of the rubber dam
MYTHS/MISBELIEFS MYTHS/MISBELIEFS Most physicians and dentists are
aware and comply with the AHA guidelines
Most cases of IE or oral origin are produced by dental procedures
AHA regimens give total protection against developing endocarditis after dental procedures
Antibiotics should be given for any procedure that causes bleeding
If a patient is already on antibiotic therapy for another infection, the patient is covered
Additional Conditions Additional Conditions Requiring PremedicationRequiring Premedication
End Stage Renal Disease/Renal dialysis patients
Prosthetic joint repairCerebrospinal fluid shuntsChemotherapy patientsHIV patientsSickle Cell patientsHemophiliacs
ESRDESRDHemodialysis:Hemodialysis: Premedication Premedication
needed to prevent Endarteritis needed to prevent Endarteritis
Fistula -- native artery and vein joined to create high flow system. Best long term outcome, but take awhile to matureAV Graft -- artificial (Gortex) placed in a “U” or “straight” formation between artery and vein. Easy to place, can be used early, but many problems.
•Access through vascular means
Central Catheter -- placed for urgent dialysis (temporary) or no other options (permanent). Most prone for infection
ESRD: ESRD: No premedication neededNo premedication needed
Peritoneal Dialysis --CCPD & Peritoneal Dialysis --CCPD & CAPDCAPD
• 10% of dialysis patients
• Done at home
• CCPD -- cycler, at night
• CAPD -- 4-5 bags/day
• Installation of hypertonic solution (glucose) intraabdominal to draw off toxins & fluid
• Reduced risk of infection unless direct contamination (peritonitis)
• No heparin
Dental/Dental Hygiene Dental/Dental Hygiene Modifications for ESRD Modifications for ESRD
PatientsPatientsConsultation with nephrologists advisable for premedication considerations
Blood pressure taken on the arm without the shunt/fistula
Scheduling dental hygiene care the day after dialysis- heparin concerns
Determining risk for increased bleeding; may need INR time, platelet count
Prosthetic Joint: ADVISORY Prosthetic Joint: ADVISORY STATEMENTSTATEMENT
Made by the ADA and American Academy of Orthopedic Surgeons in 1997:
1.Scientific evidence does not support the need for antibiotic prophylaxis for dental procedures
2.It is also not indicated for pins, screws, plates or total hip replacement
3.It is only indicated for high risk patients
PROSTHETIC JOINT PROSTHETIC JOINT HIGH RISK HIGH RISK PATIENTSPATIENTS
►Immunocompromised or suppressed patients:
rheumatoid arthritis, systemic lupus, drug or
radiation induced immunosuppression
► Insulin-dependent diabetes (Type 1 diabetes)
► First 2 years after joint replacement
► Previous prosthetic joint infection
► Malnourishment
► Hemophilia
NEUROLOGICAL DISORDERS/ NEUROLOGICAL DISORDERS/ CEREBROSPINAL FLUID SHUNTSCEREBROSPINAL FLUID SHUNTSHydrocephalus is a condition in which
fluid accumulates in the brainNecessitates a shunt to drain fluid75,000 placed each year in the U.S.Only the ventriculoatrial shunt is at
risk from infection from invasive dental procedures so premedication is indicated with current AHA regimen
Consultation with medical doctor needed before dental hygiene treatment
With the Ventriculoperitneal shunt in place, cerebrospinal fluid flows into the ventricular (collection) catheter and down the exit catheter, which shunts the fluid into the peritoneal cavity.
page url:http://www.cinn.org/cr-articles/CR-nph.html
A small catheter is passed into a ventricle of the brain. A pump is attached to the catheter to keep the fluid away from the brain. Another catheter is attached to the pump and tunneled under the skin, behind the ear, down the neck and chest and into the peritoneal cavity (abdominal cavity). The CSF is absorbed in the peritoneal cavity.
Prevention of Prevention of ComplicationsComplicationsDuringDuring ChemotherapyChemotherapyConsult with oncologist for any procedureIf dental procedure is indicated, schedule
appointment either a day or several days before chemo treatment when levels of WBC are high
If invasive procedures:◦ Antibiotic prophylaxis-for central venous
catheters or ports- AHA guidelines/consult oncologist
◦ Postpone treatment if WBC/neutrophil count less than 1,000 cells/mm3
◦ Platelet replacement if platelet count is below 50,000/mm3 -for urgent care
http://orbit.unh.edu/cancer/PORTA1.jpg
Indwelling cathetersIndwelling catheters
Treatment Plan Modification Treatment Plan Modification for Cancer Patientsfor Cancer PatientsEstablish a schedule for dental
hygiene and dental treatment to begin at least 14 days before cancer treatment begins
Only emergency dental care during chemotherapy based on prognosis of underlying disease
With special considerations, patients who are in remission can receive most indicated dental treatment
Questions to ask the oncologist Questions to ask the oncologist during during chemotherapychemotherapyWhat is the patient’s complete blood
count including neutrophil and platelet counts?
Are adequate clotting factors present to prevent bleeding?
Does the patient have a central venous catheter? Pre-medication indicated?
What is the scheduled sequence of cancer treatments?
HIV Patient Considerations HIV Patient Considerations PremedicationPremedication
Premedication indicated when:
► Neutrophils drop below 500 cells/mm³
► Not based on CD4 count anymore- CD4 is an indicator for oral lesions
Viral load is considered as well as neutrophil level
High viral load indicates the patient’s drug therapy is not effective and level of transmission
TREATMENT: Anti- fungalsLocal/Topical Applications► Clotrimazole (Mycelex)
► Nysatin
Erythematous Candidiasis
Copyright © 1996-2000 David Reznik, D.D.S. All Rights Reserved.
Hairy Leukoplakia/ Epstein-Barr Hairy Leukoplakia/ Epstein-Barr Virus Virus
Treatment: ► For cosmetic
purpose only
► Acyclovir
Copyright © 1997 Cesar A. Migliorati, DDS MS Oral Medicine Specialist, All Rights Reserved.
Kaposi’s SarcomaKaposi’s Sarcoma
Treatment:
►Radiation►Chemotherapy►Cure rates vary from 30-50%
DermAtlas, Johns Hopkins University
Human Papillomavirus Human Papillomavirus Lesions/ HPVLesions/ HPV
Treatment:
► Surgical or Laser excision
► Recurrence is common
Sickle Cell PatientsSickle Cell PatientsProphylactic antibiotics to
prevent any infection from dental procedures because they are highly susceptible to infection
Treatment Plan Modifications Treatment Plan Modifications for Sickle Cell Patientsfor Sickle Cell Patients
Consult physician for premedication guidelines
Routine dental care during non-crisis periodShort, non-stressful appointmentsProphylactic antibiotics to prevent any
infection from dental procedures because they are highly susceptible to infection
Avoid low concentration of oxygen with Nitrous Oxide- use 50% oxygen
Avoid infection◦ If it occurs, treat in aggressive manner◦ Pain control with acetaminophen is small
doses
Hemophiliacs/ InfusionHemophiliacs/ InfusionThe factor replacement is
called infusion performed by:◦patient◦or care giver◦Patients who infuse at
home do it on an average of every 2-4 months
Young patients with an early history of bleeding:◦have an “intra-venous
port-a-cath” ◦surgically placed for
ease of the infusion process
Dental Management of Serious Bleeding Dental Management of Serious Bleeding DisorderDisorder
Consult, consult, consult physician before dental treatment.
Establish PT,PTT or INR time before invasive procedures.
Patients at risk can experience spontaneous bleeding with minor trauma to oral tissues
Be careful when inserting x-rays No block anesthesia given unless replacement factors
have been givenConservative periodontal procedures can be done
without replacement therapyAspirin and NSAIDs should not be used for pain reliefPatients with serious bleeding problems need
hospitalized for dental treatmentPre-medication usually indicated for hemophilia Replacement factor DDAVP/EACA can be given when
anticipating bleeding prior to appointment
SourcesSourcesLittle JW, Falace D, Miller C,
Rhodus N. Dental Management of the Medically Compromised Patient, Sixth edition: Mosby 2002.
Prevention of Infective Endocarditis;
2007 American Heart Association; http://circ.ahajournals.org/cgi/content/full/116/15/1736