Premedication in Dentistry

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


PREMEDICATION AND CO-INFECTION

Co-Infection is treated one of two ways:
I: 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


II: 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

WHEN TO GIVE

CONDITIONS THAT REQUIRE PREMEDICATION

I) CARDIAC CONDITIONS

1) Prosthetic heart valves
2) Past history of bacterial endocarditis
3) Unreparied/ Incompletely repaired congenital heart disease
4) Completely repaired congential heart defect with prosthetic material or device for first 6 months after the procedure
5)Cardiac transplant patients who develop heart valve associated problems

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
The patient with an AV graft should always be premedicated prior to dentistry

b)Peritoneal dialysis: Premedication prophylaxis per say is not needed
However in some cases if there is an indwelling catheter premed is required


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 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

a) Atrial Septal defect/ Ventricular septal defect
b) Hypertrophic cardiomayopathy
c) Mitral Valve prolape with/ without regurgitation
d) Rheumatic Heart Disease
e) Calcified Aortic Stenosis
f) Coronory Artery Bypass Graft
g) Severe anaemia, hyperthyroidism,
h) Pacemakers or defibrillators
i) Mature AV fistulas for hemodialysis

Premedication 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. Patients 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.