Questions and Answers about your Pre medication:

·     Do you (Dr. Dilger) need to confer with my physician before doing dentistry, according to the guidelines?

·     What if I want the pre medication even though it is no longer recommended? 

·    Do murmurs or mitral valve prolapse still require coverage? 

·    Do patients with stents require coverage? 

·    Is pre medication recommended for all patients with heart valve replacements, whether prosthetic, human or porcine? 

·     I forgot to pre medicate. What do I do? 

·    I am allergic to penicillin. What options do I have for pre medication? 

·    I just had heart surgery. Does I require coverage? 

·    Do I need antibiotic prophylaxis if I have taken phen-fen? 

·    I am already taking antibiotics. How does that affect me? 

·    Do the AHA updates affect the recommendations for joint replacements?

Do you (Dr. Dilger) need to confer with my physician before doing dentistry, according to the guidelines?

The courts recognize that each independent professional is responsible for his or her own treatment decisions. However, the professional goal is consensus among the professionals involved. To this end we will always consult with your physician. Back to Top

What if I want the pre medication even though it is no longer recommended?

I am not obligated to render treatment that I deem not to be in the patient’s best interest, simply because the patient requests it. The American Heart Association (AHA) guidelines are the standard of care in dentistry. Back to Top

Do murmurs or mitral valve prolapse still require coverage?

Heart murmurs are caused by a large number of conditions. Some can be due to mitral valve prolapse (MVP). The 2007 AHA Infective Endocarditis Guidelines specifically no longer recommend that patients with MVP be pre medicated, whether or not they have regurgitation or thickened valve leaflets, nor does it recommend pre medicating for heart murmurs.

The report says, “MVP is the most common underlying condition that predisposes to acquisition of [infective endocarditis] IE in the Western world; however the absolute incidence of IE is extremely low for the entire population with MVP, and is not usually associated with a grave outcome. Thus, IE prophylaxis is no longer recommended for this group.” Back to Top

Do patients with stents require coverage?

According to the American Heart Association Scientific Statement, antibiotic prophylaxis after stent placement is not recommended for patients who undergo dental procedures. Back to Top

Is pre medication recommended for all patients with heart valve replacements, whether prosthetic, human or porcine?

Yes. Back to Top

I forgot to pre medicate. What do I do?

According to the guidelines, the antibiotic should be given in a single dose 30 to 60 minutes before treatment. This time period is recommended so that there will be high blood levels of antibiotic at the time bacteraemia occurs. The report adds that if the antibiotic inadvertently (AHA italicized) is not administered, the dosage may be given up to 2 hours after the procedure. However, it is important to note that the recommendation is to give the antibiotics 30-60 minutes before treatment. The Safeway pharmacy is next door, and you can fill the prescription and take it right before your appointment, or we can reschedule you. Back to Top

I am allergic to penicillin. What options do I have for pre medication?

For individuals who are allergic to penicillins or amoxicillin, the guidelines recommend use of cephalexin or another first-generation oral cephalosporin*, clindamycin, azithromycin or clarithromycin. Back to Top

I just had heart surgery. Does I require coverage?

Patients who have had surgery for placement of prosthetic heart valves or prosthetic intravascular or intracardiac materials are at risk for the development of an infection and should be given pre medication. There is no evidence that patients who have had coronary artery by pass graft surgery are at increased risk of infective endocarditis (IE), and therefore, these patients do not require pre medication. There are insufficient data to support specific recommendations for patients who have undergone heart transplantation. The guidelines suggest that IE prophylaxis for transplant recipients who develop cardiac valvulopathy may be reasonable. Back to Top

Do I need antibiotic prophylaxis if I have taken phen-fen?

Individuals who have taken the appetite suppressant phen-fen (phentermine and fenfluramine) do not require antibiotic prophylaxis based solely on a history of using this drug combination. The 2007 American Heart Association (AHA) guidelines no longer recommend antibiotic prophylaxis in patients with a number of heart conditions, including mitral valve regurgitation. Back to Top

I am already taking antibiotics. How does that affect me?

If you are already receiving antibiotic therapy with a medication that is also recommended for infective endocarditis (IE) prophylaxis, the guidelines state that it is prudent to select an antibiotic from another class rather than to increase the dose of the currently administered antibiotic. For example, if you are already taking amoxicillin, we would select clindamycin, azithromycin, or clarithromycin for IE prophylaxis. Back to Top

Do the AHA updates affect the recommendations for joint replacements?

No. For recommendations on antibiotic prophylaxis for patients with total joint replacements see pre-med guidelines.  Back to Top

by Dr. Gregory C. Dilger - July 30, 2009

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