premedication

[uptowngirl]

Hi,  thank you for taking my question.  I am a female,early 40's, history of MVP (moderate), mild MR, redundant leaflets per echo and TEE.
I've always premedicated before dental procedures.  Tomorrow I am having endodontic treatment on a bicuspid.  When I asked if I need to premedicate, the endodontist said to check with my cardio because he thought the guidelines from the Heart association have changed. The nurse at the cardio office said according to my chart I need to premedicate.  I was unable to speak to the Dr.  

My question is:  Have the guidelines for premedication changed and when was this? Also, what is the antibiotic of choice to use if I am allergic to pennicillen?  I've tried Clindamycin, but have difficulty tolerating it.

Thank you for your time.

Uptowngirl

[loveympw]

If a dental patient who requires premedication before dental prophylaxis presents without taking it the required one hour before, are we still o.k. to give it to them just before the start of the appointment? I understand that there may be a guideline of a 2 hour window where the antibiotic can be administered and be considered effective. I am particularly concerned with MVP(regurgitating). Our employer would prefer not to have to rebook the patient.Are we in compliance? Is this 2 hour window valid? There is some doubt on the part of the hygiene staff and yet I have read that it is o.k. Thanks.

[brcdmd]

The AHA guidelines have not changed the last few years regarding prophylaxis.  Conditions listed for which prophylaxis is recommended include prosthetic heart valves, mitral valve prolapse with valvular regurgitation, previous hx of endocarditis, surgically constructed pulmonary shunts, acquired valvar dysfunction, hypertrophic cardiomyopathy, and some congenital cardiac malformations.  Prophylaxis is not recommended for previous bypass surgery, MVP without regurgitation, or innocent heart murmurs.  Moreover, the procedure itself may or may not require prophylaxis.  For example, if you have MVP with regurgitation and you have an app't for a simple filling, premed is not recommended.  Procedures that DO req. premed include extractions, periodontal procedures in which significant bleeding may occur, implant placement, endodontic treatment or surgery, placement of ortho bands, intraligamentary injections (your dentist knows what this is...it is not your typical injection).  As an aside, if you have had prosthetic joint replacement surgery, premed is recommended for the first two years following surgery to prevent joint infection.

As a dentist, I follow these guidelines strictly, unless superceded by a physician.  In the event that their recommendations do not coincide with the AHA recommendations, I will alert them to this.  Sometimes they still want their patients to premed, and in that case we do, but the bottom line is this:  you have just as much of a chance at having an adverse reaction to the antibiotic as you do having the antibiotic do you any good at all.  Not to mention, microbial resistance to antibiotics is always a concern.  You should not just use them to use them.

I have not looked, but the ADA website should have the latest recommendations online.  Look there for a full listing of the drugs of choice and specific conditions and procedures involved.  Amox 2g 1 hr pripr to visit is the gold standard as previously stated...but there are several acceptable regimines.  

[biker1]

What is the current list of ailments that need premed before dental care?

[karie]

I had this exact question. I took medication before all dental visits due to MVP guidelines and then my EP Cardiologist 3 years ago said guidelines changed and my heart murmurs, pvc', pac's were not an issue. The echocardiogram looked fine and I would see him yearly but no need to pre-med. Then I had extensive dental work, bleeding and issue and then my pvc's,pac's increased and have for a couple years now. My fear was that I was not being and continue not to protect myself enough. I respect the M.D.'s opinion but what concretely shows we have a healthy heart and dental work did not or will not cause further issues.

[Gaspipe]

Premedication for dental work is to prevent SBE and would not do anything to prevent arrthymia.

[uptowngirl]

Already checked. I could not find anything more current than 2002.  I'll wait for the Dr. response, I know they are on the cutting edge at the Cleveland Clinic. Thanks.

[Gaspipe]

Your answer can be found on the web site of the American Heart Association

[CCF-M.D.-MJM]

Hi Uptowngirl,

I would still premedicate for an endodontic procedure.

The first choice is still amoxicillin.  If you cannot take amoxicillin, alternatives are clindamycin, azithromycin, or clarithromycin, with cefadroxil or cephalexin also possible for patients who have not had immediate-type hypersensitivity reactions (urticaria, angioedema, or anaphylaxis) to penicillin.

I am actually not sure when the new guidelines were published.

Good luck with your procedure!