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