I read with great interest the ADA Legal Division’s September JADA article, "A Legal Perspective on Antibiotic Prophylaxis." This statement is intended to serve as a companion to the July JADA update of the July 1997 JADA advisory statement of the American Dental Association and the American Academy of Orthopaedic Surgeons, "Antibiotic Prophylaxis for Dental Patients With Total Joint Replacements."
The Legal Division’s report succinctly and correctly represents the dilemma many dentists encounter in practice, when the published guidelines suggest against the need for antibiotic premedication prior to dental treatment, and the patient’s physician recommends antibiotic coverage.
Certainly, this is a "no-win" situation for the dentist. On the one hand, the dentist is held professionally and legally accountable for his or her treatment decisions. On the other hand, the dentist does not want to be placed in an adversarial relationship with the patient’s physician. Unfortunately, this also becomes a problem for the patient, because he or she is potentially placed in a situation of choosing between the advice of dentist and of physician.
I have practiced oral medicine for over 20 years in military, academic and private-practice settings. Clinical judgment disagreements regarding antibiotic premedication are frequently encountered in practice, and can be handled in a professional, nonconfrontational way.
I personally call the patient’s physician and relate the dental treatment that is anticipated for the patient. I then inform the physician that the current guidelines of the American Academy of Orthopaedic Surgeons and the ADA advise against the routine administration of antibiotics in patients who are otherwise healthy, not immunocompromised and without a history of previous prosthetic joint infection. Finally, I offer to send a facsimile copy of the current guidelines to the physician for his or her review.
The physician then can advise me if there are any medical circumstances particular to the patient that might warrant antibiotic premedication. If there are no medical conditions, as outlined in the guidelines, that indicate the need for antibiotic prophylaxis, I reiterate my position that antibiotic premedication is not indicated for the patient.
If the physician still insists on having the patient premedicated prior to dental treatment, I suggest that I will be most pleased to have the patient contact the physician for any antibiotic regimen the physician chooses to prescribe. In this way, the dentist is not placed in a position of having his or her treatment decisions compromised. The physician can prescribe any antibiotic he or she feels is indicated and the patient is not caught in the middle. I should add that, frequently, the patient will report to me at a subsequent visit that the physician read the guidelines I sent to him or her and determined that no antibiotics were indicated prior to dental treatment.
