Premedication conundrum

BY DIANNE GLASSCOE WATTERSON, RDH, BS, MBA

Dear Dianne:

Recently, a patient came in for his prophy. He had his right hip replaced eight years ago and has had no problems. However, he had not premedicated prior to his visit, and I was afraid to treat him. As I understand it, any patient who has had a full joint replacement is supposed to premedicate with antibiotics prior to dental treatment.

The doctor felt that I was overreacting, especially since this patient has not been premedicating and has had no problems. Are we not supposed to follow the guidelines that have been established by the American Association of Orthopedic Surgeons for patients with joint replacements? I really need an answer, because I want to be prepared when situations like this come up in the future.

Abbey, RDH

Dear Abbey:

The current guidelines from the AASO on premedication for patients with joint replacements are controversial, to say the least. Prior to 2009, their guidelines recommended premedication before dental procedures that were likely to cause bacteremias within the first two years following placement. Beyond that, no premedication was recommended. Then, in 2009, the AAOS issued new guidelines that recommended lifetime premedication, not just the first two years following placement.

This new recommendation caused considerable uproar within both the dental and orthopedic communities. There are many who feel that there is no scientific basis for premedication antibiotics, except in particular cases, such as if the patient is severely immunocompromised/immunosuppressed, has had a previous joint infection, debilitated individuals, or patients with diabetes. Indiscriminate antibiotic usage over the years has led to a host of pathogens that have become resistant to antibiotics, and requiring more antibiotic usage when it may be of no benefit only exacerbates the problem of antibiotic resistance.

Another problem with antibiotic usage is the potential for untoward reactions, particularly with individuals who have had much antibiotic exposure throughout their lifetimes. Think of all those individuals with mitral valve prolapse who formerly premedicated every time they came for their dental appointments over and over again through the years. Increased exposure to antibiotics heightens their potential for an untoward reaction or even death from anaphylaxis. These are real issues today.

The information statement on the AAOS website (aaos.org) uses vague wording in its recommendation. One statement, for example, says this:

"Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for joint replacement patients with one or more of the following risk factors prior to any invasive procedure that may cause bacteremia."

The word "consider" suggests that the treating dentist should think about premedication for the patient with a joint replacement. It seems to say that the decision is up to the dentist. However, many dentists are uncomfortable making that decision. After all, the dentist is not the one who performed the arthroplasty.

Another interesting yet disturbing statement on the AAOS website is this one:

"This statement provides recommendations to supplement practitioners in their clinical judgment regarding antibiotic prophylaxis for patients with a joint prosthesis. It is not intended as the standard of care nor as a substitute for clinical judgment as it is impossible to make recommendations for all conceivable clinical situations in which bacteremias may occur. The treating clinician is ultimately responsible for making treatment recommendations for his/her patients based on the clinician's professional judgment."

This statement seems to be an attempt to transfer responsibility and ultimately leaves the dentist in the dark. The legal ramifications are unclear, since they state that their guideline is not given as the "standard of care."

So what happens if a dentist decides that premedication is not warranted, but the patient develops an infected joint after dental care? Or what if the treating dentist prescribes a premedication antibiotic and the patient has a serious or fatal reaction? At this point, I'm not sure anyone knows for sure how this would play out in a court of law.

I find it interesting that of the 19 reference articles listed at the conclusion of the AAOS information statement, 12 were written prior to 1990. The oldest reference is from 1976. I believe it is fair to say that 20 years ago we did not have the problem of antibiotic resistance that we see today. We need more current information to guide decision-making in light of the emergence of superbugs and resistance.

From a risk management standpoint, it seems prudent to me that we in dentistry should remove ourselves from the premedication business. If a patient has a medical condition that has been diagnosed and treated by a physician, and that physician wants the patient to be premedicated with antibiotics prior to dental care, then that physician should assume the liability risk that is inherent with antibiotics and provide the antibiotic prescription for the patient. We in dentistry should provide antibiotics for dental reasons, such as dental infections.

Practice guidelines are written by a panel of experts on a particular subject that outlines the current best practice to inform health care professionals and patients in making clinical decisions. Based on the level of disagreement among clinicians in the AAOS and the medical/dental community at large, we are likely to see a modified directive in the near future regarding premedication for joint replacement patients. Stay tuned.

In the case you outlined, the patient had no problems or obvious risk factors related to his joint replacement over a period of eight years. There was nothing to indicate that he would be at risk if he received dental care. His six-year history of care without premedication and with no untoward effects seems proof enough that additional antibiotics are unnecessary and unwarranted. Why start premedicating this patient now after all these years? Why risk an untoward reaction? Why risk the potential for antibiotic resistance?

The doctor is ultimately responsible for the treatment provided for his/her patients. In light of all the circumstances, I have to agree with the doctor on this one. You may feel that you had the patient's best interest at heart, but consider the ramifications to the patient if he is denied preventive care that he needs to stay healthy. It is entirely possible that his pattern of frequent preventive oral care is part of the reason he has had no problems with infections of his artificial joint. Regular professional preventive care is important to helping patients maintain good overall health.

Early identification of patients who may or may not need premedication is a key component in avoiding situations like this. If this patient had been identified two business days ahead of his appointment, his physician could have been notified of the impending appointment and consulted as to the need for premedication. Whatever the physician's decision, his office should fax his directives on his letterhead stationery to your office for the inclusion in the patient chart. If the physician desires the patient to premedicate, then the physician should provide the prescription and the patient should be notified to proceed with obtaining the antibiotics. I suggest you and your employer have a discussion about this issue so patients won't be unpleasantly surprised like this in the future. RDH

All the best,
Dianne