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July 12, 2008

By Carol Tekavec CDA RDH

According to the Journal of the American Dental Association, Special Supplement, January 2008, the reasons for the drastic changes in the American Heart Association guidelines for the prevention of infective endocarditis were based on the findings of a writing group that reviewed all related information over a three-year period. According to the AHA, the writing group determined that about 90% of people who were previously considered to be at risk of developing endocarditis after dental treatment are no longer of concern.

For decades, antibiotic premedication was recommended to reduce the chance of spreading infection from mouth bacteria released during dental treatment. New evidence shows that in many situations premedication may not be necessary.

In the Clinician's Report, February 2008, published by the CR Foundation, Dr. Gordon Christensen listed a few important points for dentists, taken from the AHA information. These points include:

• For the most part, there are no benefits to antibiotic premedication.

• A few patients with underlying cardiac conditions with a very high risk of infective endocarditis are still recommended to be premedicated.

• The best prevention for infective endocarditis is adequate home care and a healthy mouth, which decreases chronic oral bacteremias.

• Random bacteremias are more likely to result from tooth brushing or chewing than from dental procedures.

Practically speaking, under the new guidelines, patients who were used to taking antibiotics prior to treatment will not understand why it may no longer be recommended. Patients for whom premedication is still suggested will want you to explain why.

The American Dental Association Division of Legal Affairs, in their recent article, "An updated legal perspective on antibiotic prophylaxis" (J Am Dent Association, Vol. 139 Special Supplement), states that the new AHA guidelines will "likely be cited as some evidence of the standard of care in malpractice litigation." So, what happens if a patient wants to continue taking prophylactic premedication? What if a patient's physician recommends premedication that is contradictory to what the AHA guidelines suggest? What are the situations where premedication is still recommended? What about other situations, such as autoimmune diseases and prosthetic joints?

The ADA Division of Legal Affairs points out that "the answer may lie in informed consent." Current thinking on the consent process indicates that all pertinent issues surrounding treatment or medications should be addressed in straightforward terminology and as simply as possible, so that a patient can make an educated decision on what happens to his/her body. For antibiotics taken prior to treatment to prevent infections, a consent form should include situations where antibiotics are no longer recommended (including mitral valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis, and most congenital heart conditions).

The four situations where antibiotics are still recommended should also be listed (artificial heart valves, a history of infective endocarditis, certain congenital heart conditions, and cardiac transplant). In addition, there are 12 other conditions previously linked to possible infections after dental treatment that should be addressed. These include prosthetic joints, organ transplants, indwelling catheters, and autoimmune diseases. In point of fact, The Oral Care Report, 2008, Volume 18, Number 1, recently published information stating that an expert panel, which included dentists, orthopedic surgeons, and infectious disease specialists, concluded that "prophylactic therapy is still advised in patients at high risk of hematogenous total joint infection."

The ADA Division of Legal Affairs states the following: "The dentist and not the patient ultimately is responsible for patient treatment. The dentist, therefore, is not obligated to perform a treatment he or she does not believe to be in the best interests of the patient." Informed consent can facilitate patients' understanding and comprehension of their "best interests."

If prophylactic antibiotics are determined by the dentist to be appropriate for a patient, the specific AHA recommended medications may be different from what a dentist had previously used. For nonallergic individuals, amoxicillin, 2 grams, 30 to 60 minutes before a dental procedure is still on the AHA list. For patients allergic to penicillin or IM or IV ampicillin, cephalexin, clindamycin, or azithromycin may be used. Prescribing information, the legal affairs article, and the AHA recommendations can be found on the ADA.org Web site.

Interested dentists or staff may find out more information about a "stand-alone" informed consent form that addresses all of the issues mentioned in this article by going to my Web site at www.steppingstonestosuccess.com. My form addresses the AHA guidelines in accepted consent format, uses simple language patients can understand, and is all presented on a single sheet.

Reasons to have a copy of a patient-signed consent form in the patient's chart include: it simplifies the discussion, focuses attention on the topics that need to be covered, and documents that the patient has read, understood, and signed off on what has been presented. Dentists and staff may also devise their own consent form(s) or simply document their discussion with the patient and/or any other pertinent persons, such as the patient's physician, in the chart progress notes.

Carol Tekavec, CDA, RDH, is the president of Stepping Stones to Success and a practicing dental hygienist. She is the author of six patient education brochures and a series of informed consent forms. She is also the author of the "Dental Insurance Coding Handbook." Contact her at (800) 548-2164 or visit www.steppingstonestosuccess.com.

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