Where are the updated Prophylaxis Recommendations?


2TheApex:  AAE Guide RIGHT HERE!  ADA Guides here!

Key points to note:

Antibiotic inadvertently NOT administered pre-operatively can be given up to two hours following treatment.

If the patient is already taking an antibiotic, a different class antibiotic should be given for prophylaxis.  (Example: Patient already taking Penicillin for days is not good enough and should be given another class of antibiotic acceptable for prophylaxis, i.e. Clindamycin 600mg)

In general, NOT recommended for prosthetic joint implants unless specifically prescribed by the patient’s orthopedic surgeon.  Their surgeon should recommend the specific regimen and ideally write the RX for the patient when possible.

(image: Staph. Aureus)



Can you call in a RX containing Hydrocodone?

2TheApex:  Not any more (as of today)

Effective today any medication containing Hydrocodone is Reclassified as Schedule II.  Yes, Hydrocodone combined with Tylenol is now Schedule II.  (Click here for the DEA ruling on this) This means you CANNOT give an oral order for Hydrocodone.  The pharmacy will need a physical prescription brought in to the pharmacy.  Back to writing (or printing) and signing paper again.  No more phoning it in unless it’s an “emergency.”  Click below for the rules in our area.

Wisconsin           Minnesota         Iowa

Weekend pain control after October 6, 2014.  First determine the patients pain level and how they are currently trying to control it.  Sometimes patients are inadvertently doing things to make the pain worse. (Like placing ice on an swelling caused by infection)  Be sure they are taking OTC pain medications properly.  Taking 800 mg Ibuprofen every six hours with an Extra Strength Tylenol (500 mg) staggered between the Ibuprofen can manage most pain we encounter.

Other options:  Call in for Schedule III (Tylenol III) or call Hydrocodone in as an “emergency” and most states will allow you 7 days to get them a physical prescription.

Another medication that works well for dental pain is Ultram (Tramadol) Schedule IV

If you think the pain source is primarily inflammatory a Medrol dose pack can be very effective.

When prescribing, the patient’s heath history is paramount as well as current medications and allergies.  A proper diagnosis is always critical to managing a patient’s pain.

What do you plan to prescribe for a patient, if needed, after hours?

Is diagnosis more challenging with a patient taking Ibuprofen?

2TheApex: Yes!


If a patient has been taking Ibuprofen symptoms can be masked.  Read found palpation to be masked up to 40% of the time.  Cold response was masked 25% of the time.  Be sure and ask patients if they have been taking any NSAIDs and at what dosage prior to pulpal testing.  The bite stick test is one test that seems to be least affected by taking NSAIDs.  We encourage patients to cease taking any pain medication at least 6 hours prior to the appointment if it sounds like the diagnosis might be challenging.

Antibiotics for Endodontic infections


2TheApex:  Penicillin VK 500mg,  Disp. 30 Tabs  Take 2 stat then 1 QID until gone

Penicillin allergic Patient:  Clindamycin 300mg,  Disp. 30 Tabs  Take 2 stat then 1 QID until gone

If the patient taking Pen VK does not have a decrease in symptoms within 48 hours we add Metronidazole 500mg  Disp. 30 tabs taken QID until gone.

The reason for choosing Pen VK as the first line antibiotic lies in the fact that it will kill most bacteria in endodontic infections.  It is also a very narrow spectrum antibiotic thus it has very low side effects.  Baumgartner recommended Pen VK after his research published in 2003.  A medication that is well tolerated is more likely to be taken by the patient and the prescription completed.  It is also cheap.  Patient compliance should be considered.

Ideally, antibiotics should be limited to patients with malaise, fever, lymph node involvement, a suppressed or compromised immune system, cellulitis or a spreading infection, or a rapid onset of severe infection.  This supported by Matthews review of the literature.

Removal of the infection by complete debridement of the root canal system is a priority.  Incision for drainage is also considered for all moderate to severe infections with localized involvement.

When prescribing any medications the medical history is considered.  With a complicated medical history other antibiotics can always be considered.

-Pic is of Alexander Fleming, who is credited with discovering penicillin in 1928.