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Dental Premedication 

New Guidelines from the America Heart Assn.

A Summary by Charles Wilson, DDS

[NOTE: Do not change your premedication until authorized to do so by your treating dentist or physician.]

The American Heart Assn. (AHA) released a major revision in June of 1997 to their guidelines for premedication to prevent bacterial endocarditis (BE). The changes are very significant to anyone who has to take premedication before dental appointments to prevent BE.

What is Bacterial Endocarditis (BE)? BE is a rare but potentially fatal infection of the heart’s valves or inner lining that can lead to irreversible damage. It is believed to be caused by the presence of certain types of damage to heart tissue from a variety of causes (the most well known is Rheumatic Heart Disease). It is normal for bacteria to occasionally travel through the blood stream – a phenomenon called "bacteremia". When a bacteremia occurs in most of us, we have no ill effects. But when a person who has this pre-existing heart damage has a bacteremia, it is possible for BE to develop. It is believed that the damaged areas in the heart (scar tissue on heart valves, malformed heart valves, etc.) provide "hiding places" for bacteria. The bacteria can grow in these areas because the white blood cells that would normally consume the bacteria are not able to get into these areas adequately.

How do antibiotics prevent BE? When certain antibiotics are taken as a premedication before the dental appointment, they weaken any bacteria that may enter the blood. The weakened bacteria are then destroyed by the white blood cells before they can infect the heart. Many years ago, the American Heart Assn. developed a recommended premedication procedure that became the standard for all dentists to use in treating these high-risk patients.

There are 2 reasons that motivated medical experts to update the AHA guidelines:

1. They want to limit premedication to only those conditions truly needing it.
2. They desire to limit the amount of antibiotic that needs to be taken.

Antibiotics are becoming less effective as they are overused. Antibiotic overuse also risks serious side effects that are unnecessary.

A panel of experts has spent much time reviewing recent knowledge, current studies and the latest statistical data. The panel has concluded the following basic principles:

1. Less antibiotic is necessary to protect you
2. Only the specific listed heart conditions need premedication
3. A greater effort has been made to clearly indicate which dental procedures do need premedication and which procedures do not so that the patient may avoid premedication whenever possible.

1) Less antibiotic is necessary to protect you.

I have listed below the AHA guidelines for medication. To summarize, it basically says that you can take less antibiotic before your dental visit and you do not take the follow up dose 6 hours later that was recommended in the past.

# Total children's dose should not exceed adult dose.

* Cephalosporins should not be used in individuals with immediate type hypersensitivity reaction (urticaria, angioedema, or anaphylaxis) to penicillins.

2) Only the specific listed heart conditions need premedication.  

Listed below are the specific heart conditions that do or do not require premedication. You will need you dentist or physician to help you determine which type you are before any decision can be made about your premedication.

HEART CONDITIONS FOR WHICH PROPHYLAXIS IS OR IS NOT RECOMMENDED:

Endocarditis Prophylaxis Recommended:

High Risk Category:

Prosthetic cardiac valves, including bioprosthetic and homograft valves

Previous bacterial endocarditis

Complex cyanotic congenital heart disease (e.g. single ventricle states,

transposition of the great arteries, tetralogy of Fallot)

Surgically constructed systemic pulmonary shunts or conduits

Moderate Risk Category

Most other congenital cardiac malformations (other than above and below)

Acquired valvar dysfunction (e.g., rheumatic heart disease)

Hypertrophic cardiomyopathy

Mitral valve prolapse with valvar regurgitation and/or thickened leaflets

Endocarditis Prophylaxis NOT Recommended:

Negligible Risk Category (No Greater Risk than the General Population):

Isolated secundum atrial septal defect

Surgical repair of atrial septal defect, ventricular septal defect, or patent ductus arteriosus (without residua beyond 6 mo)

Previous coronary artery bypass graft surgery

Mitral valve prolapse without valvar regurgitation

Physiologic, functional, or innocent heart murmurs

Previous Kawasaki disease without valvar dysfunction

Previous rheumatic fever without valvar dysfunction

Cardiac pacemakers (intravascular and epicardial) and implanted defibrillators

3) A greater effort has been made to clearly indicate which dental procedures do need premedication and which procedures do not so that the patient may avoid pre-medication whenever possible.  You will need your dentist to determine if you need pre-medication for your dental treatment.

DENTAL PROCEDURES FOR WHICH PROPHYLAXIS IS OR IS NOT RECOMMENDED:

Endocarditis Prophylaxis Recommended*:

Dental extraction

Periodontal procedures including surgery, scaling and root planing, probing, recall maintenance

Dental implant placement and reimplantation of avulsed teeth

Endodontic (root canal) instrumentation or surgery only beyond the apex

Subgingival placement of antibiotic fibers/strips

Initial placement of orthodontic bands but not brackets

Intraligamentary local anesthetic injections

Prophylactic cleaning of teeth or implants where bleeding is anticipated

Endocarditis Prophylaxis NOT Recommended:

Restorative dentistry (operative and prosthodontic) with/without retraction cord

Local anesthetic injections (nonintraligamentary)

Intracanal endodontic treatment; post placement and buildup

Placement of rubber dams

Postoperative suture removal

Placement of removable prosthodontic/orthodontic appliances

Taking of oral impressions

Fluoride treatments

Taking of oral radiographs

Orthodontic appliance adjustment

Shedding of primary teeth

* Prophylaxis is recommended for patients with high and moderate risk cardiac conditions.

^ This includes restoration of decayed teeth (filling cavities) and replacement of missing teeth

# Clinical judgment may indicate antibiotic use in selected circumstances that may create significant bleeding

* Remember that you should check with your dentist before changing your premedication *

These AHA Guidelines for BE Premedication are the joint effort of many medical and dental authorities. Their motive (and mine!) is to help you the patient enjoy safe dental treatment.  Please feel free to contact me if you have any questions.

Copyright © 2000
Last modified: March 01, 1999
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