Need+for+Prophylactic+Premedication

**1. Premedication with prophylactic antibiotics has been proven to cause an increase in bacterial resistances.** Patients from moderate to high risk require premedication and are prescribed antibiotics such as amoxicillin. Appropritate appointment intervals of 10-14 days should be established in an attemp to reduce the risk of acquiring a resistant to bacteria. If the patient is unable to meet the 10-14 day interval an alternative antibiotic regimen should be prescribed. In one study it was concluded that 53.3% of staphylocci and 16.7% of the streptococci were resistant to amoxicillin; 23.3% of the streptococci were resistant to azithromycin; and 26.7% to clindamycin. Bacteria resistance is an adverse reaction to antibiotics and more research is needed to prove if the risk outweigh the benefits. MC#3

Patients with certain heart conditions as well as joint replacements are said to benefit from an antibiotic premedication treatment prior to dental treatment. For many years researchers have been studying the need for antibiotic prophylaxis in dentistry. Through the research there has been no evidence that shows the need for antibiotic premedication prior to a dental treatment.
 * 2. Efficacy of antibiotic premedication in dental work. LM # 11**

Infective Endocarditis is an infection of the endocardial surface of the heart, which may include one or more heart valves. Dental Hygienist’s should take preventative measures in order to reduce patients at risk of developing infective Endocarditis such as carefully reviewing medical histories to determine if the patient is at risk of IE, demonstrate oral hygiene methods that will improve their gingival health and minimize bacteria, and implement current antibiotic pre-medication regimens during periodontal treatment. In addition when treating a patient who is susceptible to IE clinicians should try to reduce the number of visits and allow at least 7 days between each visit.
 * 3. Pretreatment Chlorhexidine rinses significantly reduce the presence of bacteria and reduces the chances of developing I.E. RK 7**

In the past, a number of heart conditions were thought to put patients at risk for IE. When writing the new recommendations, the AHA looked at published research and other scientific articles. They found that fewer conditions were associated with IE. As a result, a smaller group of patients needs to premedicate before dental treatments


 * High risk patients ** include those who have prosthetic heart valves, a previous history of endocarditis, congenital heart disease, or surgically constructed systemic pulmonary shunts or conduits.
 * Moderate risk patients ** include those with acquired valvar dysfunction (eg, due to rheumatic heart disease or collagen vascular disease) and hypertropic cardiomyopathy. Mitral valve prolapse is common and the need for prophylaxis for this condition is controversial.


 * High risk procedures include: ** dental extractions, periodontal procedures, dental implant or insertion of teeth that were knocked out, some root canal procedures, initial placement of orthodontic bands (not brackets), certain specialized local anesthesia injections, regular dental cleanings (if bleeding is anticipated).

The current regimen is: Two grams of amoxicillin, one hour prior to treatment with no follow-up dosage required. Clindamycin, cephalexin, cefadroxil, azithronycin or clarithromycin as also suggested alternative.

Research shows that the use of pretreatment Chlorhexidine rinses significantly reduce the presence of bacteria and reduce a patient’s chances of developing infective endocarditis. In the study, effects of chlorhexidine mouthwash on the risk of postextraction bacteremia, one-hundred and six patients were randomly divided into a control group and a chlorhexidine group. Prior to the procedure the chlorhexidine group rinsed for 30 seconds. A baseline blood sample was then taken from each group and repeated 30 seconds, 15 minutes, and 1 hour after the procedure. Upon the completion of the procedure the first reading for the occurance of bacteremia for the control group was 96% and the chlorhexidine group was 79%, after 15 minutes the control groups was 64% and the chlorhexidine groups was 30%, and 1 hour following the procedure the control groups was 20% and the chlorhexidine groups was 2%. This study showed a reduction in the presence of bacteria present in the blood after the completion of a dental procedure with the chlorhexidine group and supports the use of pretreatment rinses.

In conclusion, taking premedication on a regular basis may reduce the patient’s resistance to the antibiotic and the AHA guidelines emphasize that maintaining optimal oral health and practicing daily oral hygiene are more important in reducing the risk of IE than taking preventive antibiotics before a dental visit. So it is our job to provide all patients with effective individualized oral hygiene methods for each specific case. One aid that can be easily implemented is the use of oral rinses prior to treatment. Pretreatment Chlorhexidine rinses are recommended before all procedures in order to reduce the presence of bacteria on the mucosal surfaces. The use of pretreatment oral rinses can reduce a patients chances of induced transient bacteremia due to bleeding during a dental procedure, which in turn will reduce the patients chances of developing Infective Endocarditis.

Tomas, I, Alvarez, M, Limeres, J, & Tomas, M. (2007). Effect of a chlorhexidine mouthwash on the risk of postextraction bacteremia. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/17464918

The main treatment considerations with patients that have had a prosthetic joint replacement is that they premedicate prior to their dental treatment to prevent any prosthetic joint infections. However there is no scientific evidence that indicates that prophylactic antibiotics prevents late prosthetic joint infections that would occur from dental treatment. Therefore the American Dental Association, American Academy of Orthopedic Surgeons, American Academy of Oral Medicine, and British Society for Antimicrobial Chemotherapy have all agreed that a routine premedication is not necessary for all patients that have had a prosthetic joint replacement. However premedication is indicated for most patient that have had a joint replacement with in the last two years because they are considered "high risk", including those who have previously had a prosthetic joint infection. There are several preventative measures that dental professional should follow to reduce the risk of bacterimia. A thorough medical history review should be done to determine the patient's current and history status to see if there is a need for and premedication and providing patients good oral hygiene and educating them on the importance of it.
 * 4. Premedication prior to dental treatment may be considered for some patients with prosthetic joint replacements. GE6**


 * 5. As a healthcare provider it is critical to be able to identify the conditions that may require prophylactic medication. MW19**

There are certain conditions which require prophylactic premedication prior to dental treatment in order to reduce the risk of bacteremia in patients. Carranza mentions specifically patients with a history of infective endocarditis as well as patients with total joint replacements. These conditions place the patient at a greater risk for acquiring complications associated with dental work. This is because bacteria is introduced into the blood stream, and in these patients there is a chance the bacteria may accumulate on the roughened heart walls in the case of I.E., or on the artificial material in the case of a joint replacement, leading to infection. Other conditions that may require premedication could include cases in which the immune system is compromised. While it is the doctor's decision whether or not to pre-medicate, the hygienist must be acutely aware of these conditions to bring it to the doctor's attention in case something is overlooked.

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As a dental hygienist it is important for us to have an understanding of our patients health. Effective communication with the patient's physician will enable us to fulfill the physician's request and provide safe treatment for our patients. Medical consultations will often be needed to determine what dosage and regimen the physician will want the patient to follow or if prophylaxis is need at all. This consultation should be sent to the physician who is an expert of the said condition, such as the cardiologist for IE.=====

7. There is no evidence for the need for antibiotic prophylaxis, consultation with the orthopedic surgeon before dental treatment is recommended. AP12
Although there is little evidence demonstrating the need for AP, it is best to consult with the patient's orthopedic surgeon to ensure the safety of the patient. This is especially if the are in the high risk category which would make them prone to an infection.

8. 50% of adult patients with Down syndrome develop Mitral Valve Prolapse. An echocardiagraphy must be performed to evaluate whether or not this condition has developed. For our patients with Down syndrome a medical consult should be obtained prior to dental treatment in order to determine if the patient requires prophlactic antiobiotics. MT18


 * 9. The dental field is very much concerned of preventing infective endocarditis because dental procedures involves bleeding that could initiate bacteremia. Therefore, the American Heart Association have recommendations for antibiotic prophylaxis regimen for dental procedures that have significant bleeding, perio surgery, and scaling and root planning. According to Carranza, bacteremia can also occur even in the abscence of dental procedures. Poor oral hygiene and periodontal inflammation can also cause bacteremia. As healthcare providers, it is our obligation to educate our patients in assisting with reducing the microbial oral activity, decrease inflammtion and bacteremia. LL#9.**

Chung, M. (2009). Prescription of antibiotics for prophylaxis to prevent bacterial endocarditis. The Journal of the American Dental Association, 140(8), Retrieved from http://jada.ada.org /cgi/content/full/140/8/1025
 * 10. To prevent infective endocarditis, the American Heart Association recommends premedication prior to dental treatment for at risk patients, however other research states that antibiotic premedication may not be necessary. TL #8**

The need for a prophylactic premedication depends on the patient’s medical history. If at any point there is a questionable susceptibility the Dentist should consult with the physician to determine treatment. There are numerous organisms that can cause IE such as //S viridians. E. Corrodens, A. a, Capnocytophaga and lactobacillus//. If a patient is currently on a antibiotic regiment the Dr may need to Rx a supplemental regiment to reduce A.a bacteria that is resistant to penicillin. Knowing the type of medication the pt may be on can determine the prophylactic regiment that is prescribed by the doctor.
 * 11. Need for prophylactic premedication****. SR14**

Some studies have reported reduced post-op complications including reduced pain and inflammation, when antibiotics are given before surgery and continued for 4 to 7 days following.
 * 12. For patients who are not medically compromised, the value of administering antibiotics routinely for periodontal surgery has not been clearly demonstrated. CE5**