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Everything You Want To Know About Premedication and the New American Heart Association Guidelines WDHA Presentation/ January 10th 2008 Kelly Anderson RDH, MHS Topics to be discussed…… History of the premedication guidelines Definition, 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 Guidelines American 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 Revisions Quality of evidence for IE prophylaxis was based on a few cases- not enough evidence! Infective Endocarditis/ Endarteritis 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 Incidence 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: Incidence Does 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% Etiology Bacteria 80% of the Streptococcus- Sub acute cases Staphylococcus Aureus- acute Order of events: 1. Bacteremia introduced in blood stream 2. Infects damaged endocardium near high flow area such as the heart or prosthetic joints CARDIAC LESION Symptoms and Signs/ Occurrence: IE Signs &Symptoms – Weakness – Unexplained fever – Weight loss – Fatigue – Chest pain – Cardiac murmur Sub acute: Strep – Progresses over a period of weeks to months Acute – Develops over a period of days to 1 week – Complications develop quickly and can lead to death is 6 weeks Pathophysiology/Complication 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 1070% ◦ mortality rate for untreated patients is 100% Signs and Symptoms of Dental Induced IE 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 AlphaHemolytic 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 Dental Care-Frequency of 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 prevent endocarditis by: Killing or damaging the bacteria Decreasing bacterial adherence to irregular heart surfaces This is controversial! There are no controlled studies on the efficacy of antibiotic prophylaxis Controversy Over Antibiotic Prophylaxis 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 Outweigh the Benefits for Premedication for Low-Moderate Risk Patients Antibiotics not needed for individuals with low or moderate risk for BE Absolutely necessary for high risk patients 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:AHA Considers High Risk Individuals-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 INDIVIDUALS- Premedication NOT Indicated Now Mitral Valve Prolapse with or without regurgitation Pathological/Organic heart murmur Previous rheumatic fever with or without valvular dysfunction Previous Kawaskasi disease with or without valvular dysfunction Systemic Lupus Erythematosis (1/4 of these patients have cardiac involvement) Rheumatoid Arthritis with cardiac involvement Other acquired valvular dysfunction CONSIDERED MODERATE RISK INDIVIDUALS- Premedication NOT Indicated Now (cont.) Previous coronary bypass graft surgery Coronary artery stents Heart transplants patient without complications Cardiac pacemakers Implanted defibrillators 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 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 RECCOMENDATION- new 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 / kg Orally 30-60 minutes before procedure Unable to take oral medication Ampicillin Adults: 2.0 g IM or IV Children: 50 mg / kg IM or IV within 30-60 minutes before procedure Allergic to Penicillin Clindamycin Adults: 600 mg Children: 20 mg / kg Orally 30-60 minutes before procedure ** Cephalexin or cefadroxil Adults: 2.0 g Children: 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 Clindamycin Adults: 600 mg Children: 20 mg / kg IV 30-60 minutes before procedure Cefazolin Adults: 1.0 g Children: 25 mg / kg IM or IV within 30-60 minutes before procedure Allergic to Penicillin and unable to take Oral Medications * 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 ANTIBIOTIC PROPHYLAXIS Probing Recall maintenance Cleaning of the teeth Subgingival fiber placement Extraction Scaling and Root Planing PROCEDURES NOT NEEDING ANTIBIOTIC PROPHYLAXIS Restorative dentistry with or without cord Local anesthetic (non-PDL) Root canal therapy (not beyond apex) Impressions Suture removal Placement of the rubber dam 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 Requiring Premedication End Stage Renal Disease/Renal dialysis patients Prosthetic joint repair Cerebrospinal fluid shunts Chemotherapy patients HIV patients Sickle Cell patients Hemophiliacs ESRD Hemodialysis: Premedication needed to prevent Endarteritis Central Catheter -placed for urgent dialysis (temporary) or no other options (permanent). Most prone for infection •Access through vascular means Fistula -- native artery and vein joined to create high flow system. Best long term outcome, but take awhile to mature AV Graft -- artificial (Gortex) placed in a “U” or “straight” formation between artery and vein. Easy to place, can be used early, but many ESRD: No premedication needed Peritoneal Dialysis --CCPD & CAPD • 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 Modifications for ESRD Patients Consultation 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 STATEMENT 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 HIGH RISK PATIENTS ►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/ CEREBROSPINAL FLUID SHUNTS Hydrocephalus is a condition in which fluid accumulates in the brain Necessitates a shunt to drain fluid 75,000 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/crarticles/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 Complications During Chemotherapy Consult with oncologist for any procedure If 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 Indwelling catheters http://orbit.unh.edu/cancer/PO RTA1.jpg Treatment Plan Modification for Cancer Patients Establish 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 during chemotherapy What 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 Premedication 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 Erythematous Candidiasis TREATMENT: Antifungals Local/Topical Applications ► Clotrimazole (Mycelex) ► Nysatin Copyright © 1996-2000 David Reznik, D.D.S. All Rights Reserved. Hairy Leukoplakia/ Epstein-Barr Virus Treatment: ► For cosmetic purpose only ► Acyclovir Copyright © 1997 Cesar A. Migliorati, DDS MS Oral Medicine Specialist, All Rights Reserved. Kaposi’s Sarcoma Treatment: ►Radiation ►Chemotherapy ►Cure rates vary from 30-50% Human Papillomavirus Lesions/ HPV Treatment: ► Surgical or Laser excision ► Recurrence is common DermAtlas, Johns Hopkins University Sickle Cell Patients Prophylactic antibiotics to prevent any infection from dental procedures because they are highly susceptible to infection Treatment Plan Modifications for Sickle Cell Patients Consult physician for premedication guidelines Routine dental care during non-crisis period Short, non-stressful appointments Prophylactic antibiotics to prevent any infection from dental procedures because they are highly susceptible to infection Avoid low concentration of oxygen with Nitrous Oxideuse 50% oxygen Avoid infection ◦ If it occurs, treat in aggressive manner ◦ Pain control with acetaminophen is small doses Hemophiliacs/ Infusion The 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 porta-cath” ◦ surgically placed for ease of the infusion process Dental Management of Serious Bleeding Disorder 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 given Conservative periodontal procedures can be done without replacement therapy Aspirin and NSAIDs should not be used for pain relief Patients with serious bleeding problems need hospitalized for dental treatment Pre-medication usually indicated for hemophilia Replacement factor DDAVP/EACA can be given when anticipating bleeding prior to appointment Sources Little 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