Antibiotic Prophylaxis

WHAT TO GIVE:

Amoxicillin
Adults: 2.0 g PO (oral), 1 h before procedure
Children*: 50 mg/kg PO, 1 h before procedure

Non-Penicillin allergic patients unable to take Oral Medications:
Ampicillin:
Adults: 2.0 g IM or IV 30 minutes before the procedure
Children: 50 mg/kg IM or IV 30 minutes before the procedure

Cefazolin or Ceftriaxone:
Adults: 1 g IM or IV 30 minutes before the procedure.
Children: 50 mg/kg IM or IV 30 minutes before the procedure

*Total children’s dose should not exceed adult dose

Clindamycin :
Adults: 600 mg PO (oral), 1 h before the procedure
Children: 20 mg/kg PO 1 h before the procedure

Cephalexin (Keflex)
Adults: 2.0 g oral 1 h before the procedure
Children: 50 mg/kg oral 1 h before the procedure

Azithromycin (Zithromax) or Clarithromycin (Biaxin):
Adults: 500 mg oral 1 h before the procedure
Children: 15 mg/kg oral 1 h before the procedure

**Avoid Cephalosporins with immediate-type hypersensitivity/acute anaphylaxis to Penicillin


To avoid Strep. Viridans resistance to the Premed. antibiotic: Keep an interval of 7 days between successive appointments when using the same antibiotic for premedication


Prophylaxis and co-infection
 1. Use the same antibiotic for premedication and treatment of infection
Example:
Premed: 2.0 g Amox. P.O 1 h prior to treatment
Infection Rx: Then start Amox. 250 / 500 mg 6 hours LATER, prescribing
250 / 500 mg Amox. q.i.d for 5-7 days

NOTE:
Avoid Amoxicillin as premed during appointments for the following 2-3 weeks

2. Use a different antibiotic for premedication and the treatment of infection
Example:
Premed: 2.0 g Amoxicillin PO 1 h prior to treatment
Infection Rx: Then start Clindamycin 150/300mg PO 6 hours AFTER intake of 2.0 g Amoxicillin prescribing Clindamycin 150/300 mg tid x 5- 7 days

NOTE:
No change in the premed. antibiotic needed for subsequent dental visits


CONDITIONS THAT REQUIRE PREMEDICATION

I) CARDIAC CONDITIONS

Cardiac Conditions Associated with Highest Risk of Adverse Outcome from Endocarditis                for which Prophylaxis with Dental Procedures is Recommended.

1. Prosthetic cardiac valve 2. Previous endocarditis 3. Congenital heart disease* Unrepaired cyanotic CHD, including palliative shunts and conduits Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure† Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization) 4.  Cardiac transplantation recipients who develop cardiac valvulopathy

II) NON CARDIAC CONDITIONS

a) Hemodialysis
Premedicate patient with intravenous catheter
AV fistula does not require premedication for invasive dental procedures.However always confirm with patient’s MD prior to dentistry.Occasionally premedication may be needed with a “young” or newly forming fistula if the patient has severe periodontal infection
A patient with an AV graft should always be premedicated prior to dentistry

b)Peritoneal dialysis: Check with physician.

c)Cirrhosis: Premedicate a cirrhotic patient presenting with ascites to prevent bacterial growth

d)Chemotherapy Vascular Access: Patients with infuse port or Hickman catheter line requires premedication prior to dental treatment

e)Prosthetic Joints: Premedication is needed for the first 2 years for all patients.

Premedicate joint prosthesis beyond the first two years in pts with:
Immune deficiency: DM, HIV/AIDS, chemotherapy, radiotherapy or malignancy
Chronic joint diseases caused by RA/osteoarthritis/Lupus arthritis
Patient with multiple joint prosthesis
Past history of joint prosthesis infection
Congenital bleeding disorders: Hemophilias/VWD
Chronic skin disease with open sores due to Psoriasis/eczema: Distant infection
Severe periodontal disease: This is a local source of infection

f) Neutropenia: Moderate neutropenic patient gets premedication prophylaxis for all dental procedures.
Mild neutropenic patient gets premedication prophylaxis for major procedures only

These are based on the Absolute Neutrophil Count (ANC) levels:
i) 0-500 Neutrophils/mm3:
This range identifies severe Neutropenia
Increased/severe risk for life threatening infections exists with this range

ii) 500-1,000 Neutrophils/mm3:
This range identifies moderate Neutropenia
Moderate risk of infection exists with this range

iii) 1000-1,500 Neutrophils/mm3:
This range identifies mild Neutropenia
Mild risk of infection exists with this range

CONDITIONS THAT DO NOT REQUIRE PREMEDICATION
-Atrial Septal defect/ Ventricular septal defect
-Hypertrophic cardiomyopathy
-Mitral Valve prolapse with/ without regurgitation
-Rheumatic Heart Disease
-Calcified Aortic Stenosis
-Coronary Artery Bypass Graft
-Severe anemia, hyperthyroidism,
-Pacemakers or defibrillators
-Mature AV fistulas for hemodialysis

Prophylaxis in patients already receiving antibiotics.

If a patient is already receiving chronic antibiotic therapy with an antibiotic that is also recommended for IE prophylaxis for a dental procedure, it is prudent to select an antibiotic from a different class rather than to increase the dosage of the current antibiotic. Eg. Patient's who take an oral penicillin for secondary prevention of rheumatic fever or for other purposes are likely to have viridans group streptococci in their oral cavity that are relatively resistant to penicillin or amoxicillin. In such cases, the provider should select either clindamycin, azithromycin or clarithromycin for IE prophylaxis for a dental procedure. Because of possible cross-resistance of viridans group streptococci with cephalosporins, this class of antibiotics should be avoided. If possible, it would be preferable to delay a dental procedure until at least 10 days after completion of the antibiotic therapy. This may allow time for the usual oral flora to be re-established.

Allergies in Dentistry

Allergies in Dentistry

Sulpha Allergy: "Sulfa allergy" is a term used to describe adverse drug reactions to sulfonamides, a group of drugs that includes those with and without antibiotic characteristics. Avoid Celecoxib!

b) Sulphite/bisulphite Allergy: All dental local anesthetics that contain epinephrine contain metabisulfite which is an antioxidant to prevent breakdown of epi.

Sulfites are added to injectable epinephrine (such as in the Epi-Pen) to prevent browning, which decreases the effectiveness of the drug. However, epinephrine has not been reported to cause adverse reactions in people with sulfite allergy, and should not be withheld in an allergic emergency. Injectable epinephrine may prove life saving in people with sulfite allergy experiencing anaphylaxis.

Patients who are allergic to sulpha are not allergic to bisulphites and vice-versa. It is safe to give epi containing local anesthetics with sulpha allergy

c)Penicillin : Allergic to Penicillin means allergy to all members of penicillin family. If its a simple rash type of reaction then we can use cephalosporins but in case of severe anaphylaxis type reaction even cephalosporins are contraindicated. Even for rash type reactions it is advisable not to give cephalosporins because of other choice available at disposal.

d)Codeine : A patient allergic to codeine is usually allergic to morphine due to cross reactivity. Before giving out prescription make sure you not only ask "Are you allergic to codeine/morphine but ask have you taken codeine/morphine before" ?

e)Local Anesthetics: Allery to amide anesthetics is very rare. Allergy to one amide does not contraindicate the use of other amides. There is definite cross reactivity with ester anesthetics ie allergy to one ester anesthetic means allergy to all ester anesthetics

f) Latex Allergy: Children with spina bifida are at extraordinary high risk of latex hypersensitivity.

Screening: Have you experienced hives, wheezing, rashes, coughing, or difficulty in breathing when handling items like balloons and rubber balls?”

“Have you experienced any of these symptoms after contact with medical or dental products like rubber gloves or dental dams?”
“Have you ever worked in a health care setting? In the rubber industry?”

Dental Management: There are two main sources of latex exposure to our patients. The primary source is latex gloves. The practitioner must wear nonlatex gloves for the latex-sensitive patient. The second source is aerosolized latex. Latex proteins adhere to the cornstarch powder added by manufacturers to assist in donning and removal. It is a common misconception that it is the powder to which a person is allergic; rather, it is the protein sticking to the powder.

Each time powdered gloves are used, latex is introduced into the air, where it can remain up to 12 hours.(14) This “latex dust” acts as a sensitizing aeroallergen, and in sensitive people has caused serious, asthmatic life-threatening reactions. Therefore, merely wearing nonlatex gloves while treating an allergic patient may be an inadequate precaution when powdered latex gloves are being used elsewhere in the office.

If there is any question of safety, it is often advisable to have an allergic patient come to your office and simply sit in your waiting room. If there is any risk, it may be prudent to refer the patient to a latex-safe office.

For the latex-allergic patient, the following are recommended:

the patient should be the first patient of the day (low “latex dust”);
no direct contact with latex is allowed;
nonlatex substitutes for patient care must be used: prophy cups, dental dam, N20 mask, etc.;
latex in the room must be ALARA (As Low As Reasonably Achievable);
any latex items that cannot be removed must be covered;
the room should be close to the entrance (in case of emergency);
personnel setting up the room must wear nonlatex gloves;
instruments must be handled only with nonlatex gloves;
lab work must be handled with nonlatex gloves and thoroughly rinsed before placement;
multi-dose glass vials of anesthetic or glass ampules should be used;
if the patient is taking beta blockers, a medical consult must be done (these drugs interfere with the medications needed to resuscitate a patient should an emergency arise);
use nonlatex blood pressure cuffs;
wear minimal perfume and aftershave;
gutta percha has a potential for cross-allergencity (an alternative is Ketac-Endo fill).

Original Author for latex topic By Lawrence D. Duffield, DDS
Journal of the Michigan Dental Association
June 1998 href="http://www.latexallergylinks.org/MDA.html">http://www.latexallergylinks.org/MDA.html

Periapical Radiography: Bisecting Angle Technique

• Alternative to paralleling technique
• Not as accurate:
• Prone to more distortion than paralleling technique
• Must use BSA technique if anatomically difficult to position film in parallel alignment:
  
  • Shallow palate 
  • Shallow floor of mouth
    
    Two differences between BSA and paralleling techniques:
    
  • Film placed as close as possible to crown of tooth, so film is NOT parallel to long axis – tilts at an angle from tooth.
  • Vertical angle of central ray perpendicular to line that bisects angle between long axis of tooth and film.
    
    

    

    If vertical angle is aligned perpendicular to bisecting
    line, the tooth is projected on the film with minimal
    distortion, although it is usually more distorted than
    it would appear on a paralleling periapical radiograph

    
    

    
    

    
    All other aspects of BSA technique are the same as paralleling:

    • Horizontal angulation
    • Film positioning in arch
    • Alignment of central ray to cover film