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Schematic diagram for prescribing antibiotics for oral infections



Patient presents to clinic with pain




S/S of oral infection No S/S of oral infection



Antibiotic prescription Continue to monitor



Patient not allergic to penicillin Patient allergic to penicillin



Patient taking tetracycline

Pen V (500 mg) – 30 Clindamycin (300 mg) - 30

2 tabs to start, then q6h X 7 days 2 tabs to start, then q6h X 7d

Be aware of PMC!

or

Infection does not respond to Pen V

Within 48 hours Azithromycin (250 mg) - 4

Once daily for 3-4 days



Augmentin (875 mg) – 10 or

2 tabs to start, then q12h X 4 days

Ketek (800 mg) - 1

or One tab for 1 day

Not yet formulary item

Pen V (500 mg) + Flagyl (500mg)-28

Q6h X 7 days or

Be aware of alcohol!

Cephalexin (500) - 30

Infection does not respond to either regimen 2 tabs to start, then q6h X7d


or
Amoxicillin (500) – 32



2 tabs to start, then tid X 10d

B.19 EXTRACTED TEETH
PURPOSE
To establish a policy for the disposal of teeth and soft tissue following dental treatment.
PROCEDURE
All patients will be offered the opportunity to keep their extracted teeth or oral tissue removed during a dental surgery (if the tooth or tissue is not being analyzed for pathology, See Policy B.22). If a patient wishes to save an extracted tooth it will be cleaned and surface-disinfected with an EPA-registered hospital disinfectant with intermediate-level activity and placed in a water-resistant bag or other suitable container.
Disposal

All oral hard and soft tissues shall be disposed of according to guidelines established by the Centers for Disease Control and prevention, and comply with regulations set forth by OSHA and the Environmental Protection Agency.


Extracted teeth that are being discarded are subject to the containerization and labeling provisions outlined by OSHA's bloodborne pathogens standard. OSHA considers extracted teeth to be potentially infectious material that should be disposed in medical waste containers. Extracted teeth sent to a dental laboratory for shade or size comparisons should be cleaned, surface-disinfected with an EPA-registered hospital disinfectant with intermediate-level activity (i.e., tuberculocidal claim), and transported in a manner consistent with OSHA regulations. However, extracted teeth can be returned to patients on request, at which time provisions of the standard no longer apply. Extracted teeth containing dental amalgam should be placed in the “Contact Scrap Amalgam” container, which will be sent to an amalgam recycler.

Teeth saved for educational purposes

Extracted teeth are occasionally collected for use in pre-clinical educational training. Written consent from the patient shall be obtained for teeth collected for use in training or research. These teeth should be cleaned of visible blood and gross debris and maintained in a hydrated state in a well-constructed closed container during transport. The container should be labeled with the biohazard symbol. Because these teeth will be autoclaved before clinical exercises or study, use of the most economical storage solution (e.g., water or saline) is practical. Liquid chemical germicides can also be used but do not reliably disinfect both external surface and interior pulp tissue. Before being used in an educational setting, the teeth should be heat-sterilized to allow safe handling. Microbial growth can be eliminated by using an autoclave cycle for 40 minutes.

B.20 HYPERTENSION SCREENING AND TREATMENT GUIDELINES

PURPOSE


According to ADA recommendations, “BP [blood pressure] readings should be taken for all new patients and for all recall patients on at least an annual basis. People who have hypertension should have BP assessed at each visit in which significant dental procedures are accomplished”. (JADA, 2004;135: 576-584) The purpose of this policy is to establish protocols for monitoring blood pressure for dental patients in accordance with American Dental Association recommendations.

PROCEDURE

Blood pressure will be taken [state method such as: using an automated blood pressure monitor] on all new patients and for all recall patients on at least an annual basis. People who have hypertension will have BP assessed at each visit in which significant dental procedures are accomplished.


    1. Blood pressure will be recorded on the [appropriate form] or progress note in the chart.

    2. Referral:

      1. Emergency Treatment: Patients with Systolic over 180 and/or diastolic over 100 should have pain controlled with local anesthesia (without vasoconstrictor). If BP does not improve, call the [appropriate referral site] or the patient’s physician for a consultation. Following emergency dental treatment, the patient should be referred to [appropriate referral site] for evaluation.

      2. Routine care (elective dental treatment, patient is not in pain): Patients with systolic over 180 and/or diastolic over 100, call the [appropriate referral site] clinic or the patient’s physician for a consultation. Appropriate dental care will be rendered according to physician’s recommendations.

      3. Any patient with systolic over 200 and/or diastolic over 110 should be referred immediately to the[appropriate referral site]. (Dental provider should first call [referral site] for a phone consult and to advise the [referral site] a patient is being referred.)

      4. Alternatively the dental provider may consult with the patient’s physician regarding need for treatment and/or dental considerations

B.21 PREMEDICATION TO PREVENT INFECTIVE ENDOCARDITIS


PURPOSE
The purpose of this policy is to set guidelines for premedicating dental patients to prevent Infective Endocarditis (IE) that may result from dental treatment. The policy adheres to the 2007 recommendations by the American Heart Association (AHA) and is endorsed by the American Dental Association. Primary reasons for revising IE Prophylaxis guidelines are:

  • IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, Gastro Intestinal (GI) tract or Gastro Urinary (GU) tract procedure.

  • Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.

  • The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

  • Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

PROCEDURE

The 2007 AHA guidelines say patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people with:


  • mitral valve prolapse

  • rheumatic heart disease

  • bicuspid valve disease

  • calcified aortic stenosis

  • congenital heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy.

(The new guidelines are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection.)
Procedures:


  1. All dental patients or parent/guardian of dental patients will complete and sign a written medical history annually. The medical history will be reviewed at each appointment and updated as needed.




  1. Patients with the following conditions will receive preventive antibiotics prior to a dental procedure that requires antibiotic prophylaxis: (see item #3):

    1. artificial heart valves

    2. a history of infective endocarditis

    3. certain specific, serious congenital (present from birth) heart conditions, including

      1. unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits

      2. a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

      3. any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

    4. a cardiac transplant that develops a problem in a heart valve.




  1. Dental Procedures that require antibiotic prophylaxis:

All dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa *

*The following procedures and events do not need prophylaxis: routine anesthetic injections through noninfected tissue, taking dental radiographs, placement of removable prosthodontic or orthodontic appliances, adjustment of orthodontic appliances, placement of orthodontic brackets, shedding of deciduous teeth and bleeding from trauma to the lips or oral mucosa.



  1. Premedication Regimen for Dental patients who meet the criteria listed in item #2:




Situation

Agent

Regimen- Single dose 30-60

minutes before procedure




Adults

Children

Oral

Amoxicillin


2 gm

50 mg/kg


Unable to take oral medication

Ampicillin

OR

Cefazolin or ceftriaxone

2 g IM or IV*
1 g IM or IV

50 mg/kg IM or IV
50 mg/kg IM or IV


Allergic to penicillins or ampicillin

Oral

Cephalexin** +

OR

Clindamycin

OR

Azithromycin or

clarithromycin

2 g
600 mg
500 mg

50 mg/kg
20 mg/kg
15 mg/kg

Allergic to penicillins or ampicillin AND unable to take oral medication

Cefazolin or ceftriaxone

OR

Clindamycin

1 g IM or IV

600 mg IM or IV

50 mg/kg IM or IV

20 mg/kg IM or IV

* IM–intramuscular; IV–intravenous.

** or other first or second generation oral cephalosporin in equivalent adult or pediatric dosage.

+ Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin




  1. An antibiotic for prophylaxis should be administered in a single dose before the procedure. If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to 2 hours after the procedure. However, administration of the dosage after the procedure should be considered only when the patient did not receive the pre-procedural dose.




  1. If a patient is already receiving chronic antibiotic therapy with an antibiotic that is also

recommended for IE prophylaxis for a dental procedure, whenever possible an antibiotic from a different class will be used rather than to increase the dosage of the current antibiotic.


  1. Patients with congenital heart disease can have complicated circumstances. Prior beginning to any dental treatment requiring antibiotic prophylaxis, the dental provider should check with the patient’s cardiologist or primary care provider to determine antibiotic prophylaxis needs or other considerations pertaining to dental treatment or progression of oral disease.


B.22 PREMEDICATION FOR PATIENTS WITH COMPLETE JOINT REPLACEMENT
PURPOSE

The purpose of this policy is to set guidelines for premedicating dental patients to prevent joint infection that may result from dental treatment that may cause bacteremia.


Note: The American Academy of Orthopaedic Surgeons and the Association of Oral and Maxillofacial Surgeons differ in their recommendation for antibiotic prophylaxis for patients with total joint replacement. The dental chief should consider each protocol, and in consultation with the facility’s medical staff, determine which protocol to follow.
POLICY #1: American Academy of Orthopaedic Surgeons

This facility adheres to the American Academy of Orthopaedic Surgeons guidelines for premedication of patient with total joint replacement. http://www.aaos.org/about/papers/advistmt/1033.asp

According to the AAOS 2010 Information Statement and Clinical Guidelines:
“More than 1,000,000 total joint arthroplasties are performed annually in the United States, of which approximately 7 percent are revision procedures. Deep infections of total joint replacements usually result in failure of the initial operation and the need for extensive revision, treatment and cost. Due to the use of perioperative antibiotic prophylaxis and other technical advances, deep infection occurring in the immediate postoperative period resulting from intraoperative contamination has been markedly reduced in the past 20 years.

Bacteremia from a variety of sources can cause hematogenous seeding of bacteria onto joint implants, both in the early postoperative period and for many years following implantation.2 In addition, bacteremia may occur in the course of normal daily life3-5 and concurrently with dental, urologic and other surgical and medical procedures. The analogy of late prosthetic joint infections with infective endocarditis is invalid as the anatomy, blood supply, microorganisms and mechanisms of infection are all different.

It is likely that bacteremia associated with acute infection in the oral cavity,skin, respiratory, gastrointestinal and urogenital systems and/or other sites can and do cause late implant infection. Practitioners should maintain a high index of suspicion for any change or unusual signs and symptoms (e.g. pain, swelling, fever, joint warm to touch) in patients with total joint prostheses. Any patient with an acute prosthetic joint infection should be vigorously treated with elimination of the source of the infection and appropriate therapeutic antibiotics.

Patients with joint replacements who are having invasive procedures or who have other infections are at increased risk of hematogenous seeding of their prosthesis. Antibiotic prophylaxis may be considered, for those patients who have had previous prosthetic joint infections, and for those with other conditions that may predispose the patient to infection (Table 1). 8,10-16 There is evidence that some immunocompromised patients with total joint replacements may be at higher risk for hematogenous infections.10-18 However, patients with pins, plates and screws, or other orthopaedic hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms.



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.

Table 1. Patients at Potential Increased Risk of Hematogenous Total Joint Infection8,10-16,18

  • All patients with prosthetic joint replacement

  • Immunocompromised/immunosuppressed patients

  • Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus erythematosus)

  • Drug-induced immunosuppression

  • Radiation-induced immunosuppression

  • Patients with co-morbidities (e.g.: diabetes, obesity, HIV, smoking)

  • Previous prosthetic joint infections

  • Malnourishment

  • Hemophilia

  • HIV infection

  • Insulin-dependent (Type 1) diabetes

  • Malignancy

  • Megaprostheses

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the basis of its activity against endogenous flora that would likely to be encountered from any secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia, an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that an effective tissue concentration is present at the time of instrumentation or incision in order to protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current prophylactic antibiotic recommendations for these different procedures are listed in Table 2. 19

Occasionally, a patient with a joint prosthesis may present to a given clinician with a recommendation from his/her orthopaedic surgeon that is not consistent with these recommendations. This could be due to lack of familiarity with the recommendations or to special considerations about the patient's medical condition which are not known to either the clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the orthopaedic surgeon to determine if there are any special considerations that might affect the clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these recommendations with the physician, if appropriate. After this consultation, the clinician may decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis.”

Prophylactic antibiotics prior to any procedure that may cause bacteremia are chosen on the basis of its activity against endogenous flora that would likely to be encountered from any secondary other source of bacteremia, its toxicity, and its cost. In order to prevent bacteremia, an appropriate dose of a prophylactic antibiotic should be given prior to the procedure so that an effective tissue concentration is present at the time of instrumentation or incision in order to protect the patient’s prosthetic joint from a bacteremia induced periprosthetic sepsis. Current prophylactic antibiotic recommendations for these different procedures are listed in Table 2. 19

Occasionally, a patient with a joint prosthesis may present to a given clinician with a recommendation from his/her orthopaedic surgeon that is not consistent with these recommendations. This could be due to lack of familiarity with the recommendations or to special considerations about the patient's medical condition which are not known to either the clinician or orthopaedic surgeon. In this situation, the clinician is encouraged to consult with the orthopaedic surgeon to determine if there are any special considerations that might affect the clinician’s decision on whether or not to pre-medicate, and may wish to share a copy of these recommendations with the physician, if appropriate. After this consultation, the clinician may decide to follow the orthopaedic surgeon’s recommendation, or, if in the clinician’s professional judgment, antibiotic prophylaxis is not indicated, may decide to proceed without antibiotic prophylaxis.



Table 2.



POLICY #2: American Dental Association and Association of Oral and Maxillofacial Surgeons

This facility adheres to the American Dental Association (ADA) and Association of Oral and Maxillofacial Surgeons (AAOMS) guidelines for premedication of patient with total joint replacement. The [Facility] dental clinic will follow the ADA and AAOMS Advisory Statement and use the following clinical guidelines to determine the need for, drugs, and regimens of antibiotic prophylaxis for patients with total joint replacement.


According to the ADA and AAOMS 2003 Advisory Statement: “There is limited evidence that some immunocompromised patients with total joint replacements (Table 1) may be at

higher risk of experiencing hematogenous infections.12,16-23 Antibiotic prophylaxis for such patients undergoing dental procedures with a higher bacteremic risk (as defined in Table 2) should be considered using an empirical regimen (Table 3). In addition, antibiotic prophylaxis may be considered when the higher-risk dental procedures (again, as defined in Table 2) are performed on dental patients within two years post–implant surgery,3 on those who have had previous prosthetic joint infections and on those with some other conditions” JADA, Vol. 134, July 2003 p 895

(Table 1).

PATIENTS AT POTENTIAL INCREASED RISK OF EXPERIENCING HEMOTOGENOUS TOTAL JOINT INFECTION*

PATIENT TYPE

CONDITION PLACING PATIENT AT RISK

All patients during first two years following

joint replacement



N/A†

Immunocompromised/immunosuppressed

patients


Inflammatory arthropathies such as rheumatoid arthritis, systemic

lupus erythematosus

Drug- or radiation-induced immunosuppression


Patients with comorbidities‡

Previous prosthetic joint infections

Malnourishment

Hemophilia

HIV infection

Insulin-dependent (type 1) diabetes

Malignancy



* Based on Ching and colleagues,12 Brause,16 Murray and colleagues,17 Poss and colleagues,18 Jacobson and colleagues,19 Johnson and Bannister,20 Jacobson and colleagues21 and Berbari and colleagues.22

† N/A: Not applicable.

‡ Conditions shown for patients in this category are examples only; there may be additional conditions that place such patients at risk of experiencing hematogenous total joint infection.


Table 2


INCIDENCE STRATIFICATION OF BACTEREMIC DENTAL PROCEDURES

Incidence

Dental Procedure

Higher Incidence*

Dental extractions

Periodontal procedures, including surgery, subgingival placement of antibiotic fibers/strips,

scaling and root planing, probing, recall maintenance

Dental implant placement and replantation of avulsed teeth

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

Initial placement of orthodontic bands but not brackets

Intraligamentary and intraosseous local anesthetic injections

Prophylactic cleaning of teeth or implants where bleeding is anticipated



Lower Incidence

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

Local anesthetic injections (nonintraligamentary and nonintraosseous)

Intracanal endodontic treatment; post placement and buildup

Placement of rubber dam

Postoperative suture removal

Placement of removable prosthodontic/orthodontic appliances

Taking of oral impressions

Fluoride treatments

Taking of oral radiographs

Orthodontic appliance adjustment



* Adapted with permission of the publisher from Dajani AS, Taubert KA, Wilson W, et al.23

† Prophylaxis should be considered for patients with total joint replacement who meet the criteria in Table 1. No other patients with orthopedic

implants should be considered for antibiotic prophylaxis prior to dental treatment/procedures.

‡ Prophylaxis not indicated.

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

¶ Includes restoration of carious (decayed) or missing teeth.


Table 3


SUGGESTED ANTIBIOTIC PROPHYLACXIS REGIMENS.*

Patient Type

Suggested Drug

Regimen

Patients not allergic to penicillin

Cephalexin, cephradine or

amoxicillin



2 grams orally 1 hour prior to dental procedure

Patients not allergic to penicillin and

unable to take oral medications



Cefazolin or ampicillin

Cefazolin 1 g or ampicillin 2 g intramuscularly or

intravenously 1 hour prior to the dental procedure



Patients allergic to penicillin

Clindamycin

600 milligrams orally 1 hour prior to the dental

procedure



Patients allergic to penicillin and unable

to take oral medications



Clindamycin

600 mg intravenously 1 hour prior to the dental

procedure*



* No second doses are recommended for any of these dosing regimens.

B.23 MEDICAL EMERGENCIES IN THE DENTAL CLINIC

PURPOSE


Patients in the dental clinic should be protected while receiving dental care in the [Facility] dental clinic. To insure their safety, a policy will be in place to insure quick and efficient response to any emergency arising in the dental clinic.

PROCEDURE

Dental providers should be aware that urgent or emergent medical and dental situations might arise in their clinics. It is their responsibility to ensure that they themselves and their dental staffs are well prepared to cope efficiently, quickly, and appropriately on such occasions. Preparation and training must take place well in advance so that when action is needed in potentially life threatening situations appropriate action will be taken.

Training
Basic Life Support (BLS)
All dental staff will maintain certification in Basic Life Support (BLS). Certification may be sponsored by either the American Heart Association or the American Red Cross. When a patient, visitor or other individual is observed in distress, staff will respond according to current BLS recommendations. [Insert other specific requirements for emergency response]


In-Service Training

Annually the emergency response plan and staff assignments listed below will be held for all dental staff. In-service training will be provided as needed to review appropriate responses to medical emergencies including but not limited to: seizures, syncope (fainting), hyperventilation, cardiac and respiratory distress, chest pain, drug related emergencies, allergic or toxic reaction, asthma, insulin shock, diabetic coma or airway obstruction.


Emergency Response Plan
Staff Assignments
In case of a medical emergency in the dental clinic, staff assignments are as follows:

[Describe clinic specific procedures for response to medical emergencies]

Example:

1. Provider treating the patient with the medical emergency will stay with the patient and call for help. The provider will monitor the patient’s vital signs and maintain airway, support breathing and monitor circulation until medical assistance arrives.

2. The nearest dental assistant will get the oxygen tank and set it up for the provider to administer oxygen to the patient.

3. The receptionist or nearest dental assistant will phone for help.


Equipment and Medications

Equipment for providing supplemental oxygen to hypoxic patients should be available in all dental clinics. This equipment should provide capabilities for forced respiration through the use of an Ambu bag and a face mask that can produce an air tight seal around the patient's nose and mouth. An Ambu bag is ideal for such purposes. Oxygen and ambu-bags are located [state location]

Automated External Defibrillators (AED) will be available, in good repair, and maintained ready for use. Automated External Defibrillators are located [state location]



[The Council on Scientific Affairs of the American Dental Association recommends that each dental office examine local needs and determine appropriate emergency kit needs. Kit contents should be based on individual practitioner training and requirements.

Dental staff may elect to keep emergency drugs, or to defer to medical staff for emergency services. Select the procedures that best serve the facility. Some State Practice Acts specify required equipment or drugs be available to the dental staff. Check the appropriate State Dental Practice act for requirements]

Emergency Drugs (For those clinics that elect to maintain an Emergency Drug Kit)

Emergency medications will be checked monthly for expiration and a log will be maintained of Emergency Kit monitoring. Expired drugs will be replaced at least 2 months prior to the expiration date. Annually, the dental staff will have an in-service on all emergency kit drugs, dosage, and administration.

The dental emergency kit will include:


  1. Positive pressure oxygen

  2. Ambu bag

  3. Sphygmomanometer and Stethoscope

  4. Benadryl 50 mg/ml injectable

  5. Tubex Hypodermic Syringe

  6. 5% Dextrose

  7. Butterfly I V set

  8. Epinephrine 1:1000 Tubex x 2

  9. Glucose

Option for Dental Clinics that defer to Medical Department for Emergency Services

Emergency Kit without Emergency Drugs

The dental clinic will maintain an emergency kit containing an Epi pen and a source of glucose. No emergency drugs will be kept in the dental clinic. In case of an emergency, the dental staff will notify the medical department or call Emergency Services for medical support.

The dental emergency kit will contain:

1. Positive pressure oxygen

2. Ambu-bag

3. Epi pen

4. Glucose

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