CASE 2

Done By: - Elaf Ahmed Salah Fairouz Al-moghrabi Madhawy Fahad Maha Al-taifi Rafal Gumgumji Rahaf Mohammed Rasha Al-shehri Group 6

Outline : 1) ASA physical status classification system ( allocation + justification + examples) What is the ASA classification of this patient? 2) Indications for antibiotic prophylaxis prior to a dental procedure Does this patient need antibiotic prophylaxis? And if so, what protocol of prophylaxis will be used? 3) Dental procedures that require prophylaxis 4) Antibiotic prophylaxis regimens for a dental procedure 5) Antibiotic prophylaxis ( in patients with artificial joints)

1) ASA physical status classification system ( allocation + justification + examples)

ASA ClassificationDefinition Examples, including, but not limited to: ASA IA normal healthy person Healthy, non-smoking, no or minimal alcohol use

ASA ClassificationDefinitionExamples, including, but not limited to: ASA IIA patient with mild systemic disease Mild diseases only without substantive functional limitations. Examples: Current smoker Social alcohol drinker Pregnancy Obesity (30 < BMI < 40) Well-controlled DM /HTN Mild lung disease

ASA ClassificationDefinition Examples, including, but not limited to: ASA III A patient with severe systemic disease Substantive functional limitations; one or more moderate to severe diseases. Examples: Poorly controlled DM / HTN COPD Morbid obesity (BMI ≥ 40) Active hepatitis Alcohol dependence or abuse Implanted pacemaker

ASA ClassificationDefinitionExamples, including, but not limited to: ASA IIIA patient with severe systemic disease Continuation: Moderate reduction of ejection fraction ESRD undergoing regularly scheduled dialysis Premature infant PCA < 60 weeks History (>3 months) of MI CVA TIA CAD/stents

ASA ClassificationDefinitionExamples, including, but not limited to: ASA IV A patient with severe systemic disease that is a constant threat to life Examples: Recent (< 3 months ) MI, CVA, TIA, or CAD/stents Ongoing cardiac ischemia or severe valve dysfunction Severe reduction of ejection fraction Sepsis DIC ARD ESRD not undergoing regularly scheduled dialysis

ASA ClassificationDefinitionExamples, including, but not limited to: ASA V A moribund patient who is not expected to survive without the operation Examples: Ruptured abdominal / thoracic aneurysm Massive trauma Intracranial bleed with mass effect Ischemic bowel in the face of significant cardiac pathology or multiple organ/ system dysfunction

ASA ClassificationDefinition Examples, including, but not limited to: ASA VI A declared brain-dead patient whose organs are being removed for donor purposes

What is the ASA classification of this patient? A history of rheumatic fever should prompt the dentist to perform an in depth dialogue history for the presence of rheumatic heart disease (RHD). Depending on the severity of the disease and the presence of disability, RHD patients can be an ASA 2, 3, or 4 risk. Given the patient being discussed has had no history of complications from the disease after the initial exposure to it as a child, this patient would be classified as an ASA II patient.

2) Indications for antibiotic prophylaxis prior to a dental procedure

Previous guidelines

New guidelines

Does this patient need antibiotic prophylaxis? And if so, what is the protocol of prophylaxis to be used? The patient’s medical history of concern in this case is rheumatic fever that was acquired when she was a child. According to the old guidelines, the patient falls into the negligible risk category given she has developed no valvular dysfunction. The patient is thus not to be administrated any prophylactic antibiotics. If a more comprehensive medical history shows she has actually acquired valvular dysfunction, she would be eligible for antibiotic prophylaxis. According to the new guidelines, the patient is not to be administrated antibiotic prophylaxis either way. Thus, although controversy will definitely continue, no current evidence suggests that antibiotic prophylaxis will be of any benefit for this patient.

3) Dental procedures that require prophylaxis

4) Antibiotic prophylaxis regimens for a dental procedure

5) Antibiotic prophylaxis (in patients with artificial joints)

“Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia.” Feb.2009

References : Sollecito TP, Abt E, Lockhart PB, Truelove E, Paumier TM, Tracy SL et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. The Journal of the American Dental Association 2015; 146: 11–16.e8. Newman MG, Takei HH, Carranza FA, Klokkevold PR. Carranza’s clinical Periodontology expert consult: Text with continually updated online reference - 11th edition. 11th ed. Elsevier Science Health Science div: United States, Statement P, Map S, Terms. American society of Anesthesiologists - American society of Anesthesiologists (accessed 29 Feb2016). Association AD (accessed 29 Feb2016). Merlos A, Vinuesa T, Jané-Salas E, López-López J, Viñas M. Antimicrobial prophylaxis in dentistry. Journal of Global Antimicrobial Resistance 2014; 2: 232–238. Baltimore RS, Gewitz M, Baddour LM, Beerman LB, Jackson MA, Lockhart PB et al. Infective Endocarditis in childhood: 2015 update. Circulation 2015; 132: 1487–1515. EPSTEIN JB, CHONG S, LE ND. A SURVEY OF ANTIBIOTIC USE IN DENTISTRY. The Journal of the American Dental Association 2000; 131: 1600–1609. TONG DC, ROTHWELL BR. ANTIBIOTIC PROPHYLAXIS IN DENTISTRY: A REVIEW AND PRACTICE RECOMMENDATIONS. The Journal of the American Dental Association 2000; 131: 366–374. Uckay I, Pittet D, Bernard L, Lew D, Perrier A, Peter R. Antibiotic prophylaxis before invasive dental procedures in patients with arthroplasties of the hip and knee. Journal of Bone and Joint Surgery - British Volume 2008; 90-B: 833–838.

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