Practice Management – The Premedication Predicament

Question: I recently had a patient with a history of a heart murmur who had not taken his premedication upon arriving for his dental hygiene appointment. The office had no antibiotic available so a prescription was called into the pharmacy. I was told to proceed with the appointment because the antibiotic can be given post-treatment. What is the standard for premedication?

Managing patients who may need antibiotic coverage to avoid bacterial endocarditis is not always black and white. Although endocarditis is not common, it is a life-threatening illness, estimated to occur in approximately 17,000-25,000 total cases per year.1 Bacteremia can also cause complications with joint replacements.2 Because dental hygienists are licensed oral health care professionals, we must take responsibility for those patients under our care. In addition to ethical and legal concerns in this area, the risk of bacteremia is far more substantial in a mouth with ongoing inflammation than in one that is healthy.3

AHA Guidelines

In 1997, the American Heart Association (AHA) revised the recommendations for prophylactic antibiotic coverage for the prevention of bacterial endocarditis (Figure 1).4 With each revision, the approach has become more conservative, targeting a more at-risk population. For example, the 1955 guidelines included a full 5-day antibiotic regimen. The 1997 guidelines reduced the dose of antibiotic administered and eliminated the previously recommended follow-up dose.

Also in 1997, the American Dental Association and the American Academy of Orthopaedic Surgeons published an advisory statement on “Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements.” In 2003, the statement was updated to note that antibiotic prophylaxis is “not indicated for patients with pins, plates, or screws, nor is it routinely indicated for most dental patients with total joint replacements.”2

Currently, antibiotic prophylaxis for at-risk patients is recommended for dental and oral procedures likely to cause bacteremia. According to the AHA, it is recommended for procedures “associated with significant bleeding from hard or soft tissues, periodontal surgery, scaling and professional teeth cleaning.” In addition, patients who have experienced total joint replacement should be covered with antibiotic prophylaxis for 2 years postsurgery.2,4

Compliance Issues

Even though these guidelines exist and each dental practice has ready access to them, questions and controversies still arise on how to comply. Sometimes there is an initial question on whether the patient even needs premedication. The patient may indicate that he had a heart murmur as a child or that his previous dentist told him he did or did not need to take precautions. Medical history must be updated at EVERY appointment. If there is any question regarding the current status of the patient or if he or she requires premedication, the patient’s physician should be consulted. Some patients may need further medical testing to determine if they need the premedication. With the emergence of resistant organisms, the unnecessary prescription of antibiotics should be avoided. However, a patient’s health must not be jeopardized by a busy schedule or the absence of an office protocol.

Many patients do not realize the importance of a dental scaling and that it can produce a potentially life threatening condition. Good communication skills are essential. When the physician is contacted and a premedication decision is made, a letter should be faxed to the practice and placed in the chart for future reference. In addition, thorough documentation should be included in the progress notes.

Liability

What if the patient indicates that he or she will sign a release form and not hold the hygienist legally responsible should a problem develop? What if the employer demands the hygienist proceed with the appointment without premedication? The AHA guidelines are recommendations for proper care; they are not law. However, if complications arise with a patient-regardless of a signed release form-the patient or the patient’s family can still sue the dentist and dental hygienist. Health care providers are not obligated to provide treatment that is not in the patient’s best interest. Hygienists must convey that they do not want to risk their professional license and that it is not in the patient’s best interest to proceed with treatment in the absence of the recommended antibiotic premedication.

Administering Premedication

Confusion also exists on when the medication can be taken and when treatment can be started. Some believe the treatment can begin in less than the recommended hour as outlined by the AHA. While other treatments can begin before the full hour, eg, an extraoral exam or oral health care instructions, intraoral treatment should not be initiated until the full hour has passed.

What if treatment has begun and the hygienist realizes the patient needed premedication? According to George Blakey, DDS, assistant professor in the Department of Oral and Maxillofacial Surgery at the University of North Carolina School of Dentistry, Chapel Hill,”Give the patient the medication as soon as you realize it is needed. The bacteremia has already been induced so there is no need to stop treatment at this point. However, the provider should document the incident and make sure the patient is premedicated at the next appointment unless his/her medical situation changes.”

Joint Replacement

Recently, changes have been made to the recommendations for joint replacement premedication.2 Hygienists need to find out exactly which medication the physician wants administered to the patient. Blakey points out, “The problem is that there is no consensus on how to premedicate for joint replacement. If a room full of orthopedic surgeons got together, even if they agreed that premedication is needed, they would probably not agree on which drug and for how long. In the situation of joint replacement, physicians are concerned with the patient developing a staphylococcus infection. Therefore, they may not want the AHA recommended premedication at all. So, the physician should determine exactly which premedication should be used and for what time period for the specific patient.”

The liaison between you and the physician is vital in determining if the patient really needs premedication. Many physicians do not understand dental procedures. Be very specific about the dental procedure that is to be performed on the patient and the amount of bleeding that may be involved.

While the topic of premedication remains controversial, the AHA guidelines should be followed until future, more conservative revisions are endorsed. Offices with a definitive policy regarding antibiotic prophylaxis are likely more efficient, have less tension, and attract more compliant patients.

Disclaimer

Information in this article should not be interpreted as legal advice. Since each state is different, practitioners are advised to seek personal legal representation in their legal jurisdiction.

References

1. Palmer P. Intent to prevent: antibiotic prophylaxis in oral health care. Access. 2004;4:12-18.
2. American Dental Association, American Academy of Orthopedic Surgeons. Antibiotic prophylaxis for dental patients with total joint replacements. J Am Dent Assoc. 2003;134:895-898.
3. Pallasch TJ, Slots J. Antibiotic prophylaxis and the medically compromised patient. Periodontol 2000. 1996;10:107-138.
4. Dajani AS, Taubert KA, Wilson W, et al. Prevention of bacterial endocarditis. Recommendations by the American Heart Association. JAMA. 1997;277:1794-1801.