102. Premedication: What Every Hygienist Should Know

Premedication can feel confusing, especially when guidelines have changed and every office seems to handle things a little differently. That’s why I’m so excited to welcome Sue Scherer, RDH, BS to the podcast to help break this topic down in a way that actually makes sense.

Sue is the Education and Professional Relations Manager for Water Pik and has been a dental hygienist for over 20 years, with experience as a clinician, instructor, CE speaker, and author. She’s passionate about helping dental professionals understand the science behind the guidelines, especially when it comes to topics that often bring confusion to patient care.

In this episode, we talk through who truly needs premedication, which medical conditions qualify, what procedures require it, and how to confidently verify everything before treatment. Sue shares practical insights and real-world clarity that hygienists can take straight into practice.

If you’re a student, new grad, or practicing hygienist who has ever second-guessed whether a patient really needs premedication, this conversation will help you feel more confident asking questions, verifying information, and protecting both your patients and your license.

Disclaimer: This conversation was originally recorded in September 2025 and reflects guidelines available at that time. This episode is for educational purposes only and is not a substitute for professional clinical judgment or current guidelines. Always follow the most up-to-date recommendations from your supervising dentist, physician, and professional organizations when making clinical decisions.

ADA Premedicaiton Guidelines

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Transcript

SPEAKER_00 0:08

Hey Bristles, welcome back to the Brush with Brit Podcast where we make prevention actually make sense. Welcome back to the Brush with Brit Podcast. Sue, so happy to have you here. Hi, Britt. It's great to see you. You know, I took your pre-medication course and even in dental hygiene school, of course, they went over pre-med. And yet I feel like a lot of us are still very confused most of the time when it comes to pre-medication. So I would just like to start today by talking about what is pre-medication and why do we need it in dentistry?

SPEAKER_01 0:45

This is the topic that causes the most, probably one of the topics that causes the most confusion in our profession. And that is because changes have occurred over time, but the significant changes, it's been a really long time. But antibiotic prophylaxis was first utilized in the 1940s for the prevention of infective endocarditis. So it was streptococcal infective endocarditis. And it is an older practice that was done when they were trying to just protect people as best as they knew how at the time. So the original groups of patients were those that were thought to be predisposed to infective endocarditis. So they had different cardiac concerns that they were trying to prevent from becoming a bigger issue. And so what we do now is we provide patients with antibiotic prophylaxis for the prevention of infective endocarditis as one of the historical groups. What the other group is historically are patients with prosthetic joints. So those are the two groups of patients that we pre-medicate for. So let's talk first about infective endocarditis because the pre-medication has been done because the thought is when you have introduced any manipulation of the gingival tissue. So that could be chewing, that could be brushing, it could be flossing, water flossing, and it could be a dental cleaning. That has the potential to introduce any bacteria that's in the mouth into the bloodstream. Now, for most of us, we have these amazing immune systems that rapidly remove any bacteria that are introduced into the bloodstream. So there are no issues. But for some patients, they have high-risk conditions that if that bacteria is present for a long enough amount of time and a high enough amount of bacteria, then they're at risk for infective endocarditis. Now I say that bacteremia could lead to infective endocarditis, but it's like, how healthy is the patient and what would happen if they developed infective endocarditis. And there's a small subset of patients that, if they were to develop infective endocarditis, it would be life-threatening for them. For most people, if they developed infective endocarditis, they could receive medical treatment to heal from that. But we want to be aware of these patients that are at really high risk if they were to develop infective endocarditis. And that's sort of, I think, where the blurred line has become, right? People are just like, oh, let's just give a premedication to protect our patients. But that's not always the best course of action. When we give our patients antibiotics, the benefit, it has to outweigh the risk. So what are some of the risks? So patients can have an anaphylactic reaction. So a patient with an allergy, think about a patient with an allergy to penicillin. If the patient has an anaphylactic reaction, that has a high risk of death. Then there's a lot of other reactions that are not so great. Effects like gastric upsets. How many times have you had a patient sit in the chair? You ask them, did you take your premedication? And they're like, oh yep, I took those horse pills, I took all four, and my stomach is already turning upside down. Another, you know, potential adverse effect. What else? RASH. There are all kinds of effects, but the greatest concern is that we have seen a growing antibiotic resistance worldwide. And that is from the overuse and the misuse of antibiotics. So we really want to reserve antibiotic prophylaxis when we know it has a direct purpose. So active infection. If a patient has an active infection that requires antibiotics, then we want to be able to utilize them. But if we're taking antibiotics just preemptively to hopefully prevent something, then the patient is being introduced to these little increments of antibiotics that over time might not be able to work as well for them. And they start to learn the bacteria and they morph and the bacteria morph and so that the antibiotics can't attack them anymore. So that that was a really big loaded answer to your question of why do we do antibiotic prophylaxis? But we do it for those patients that are at highest risk. So if they were to develop infective endocarditis, we would potentially prevent that from happening for them because they it's going to be much harder to treat that patient if they develop infective endocarditis.

SPEAKER_00 5:18

So basically what you're saying is when we go in and clean the teeth, bacteria is entering into the bloodstream and could potentially cause infective endocarditis. And so we're giving them antibiotics before the cleaning to hopefully the idea is to prevent that from happening. Yes. Thank you. When we were talking about antibiotic resistance, I mean, if you think about a patient that's coming in every three months and you have that mindset of, oh, let's just do it to hopefully prevent something, you could be giving them antibiotics up to four times a year, which could be quite a bit. Yes.

SPEAKER_01 5:52

And if if you think about that for a prolonged number of years over their lifetime, when they really don't need that antibiotic, we're doing more harm than good. So I always say, like, I really don't like that, oh, better safe than sorry. I've definitely heard dental professionals say that. Oh, like, well, you're better off safe than sorry. No, if that patient doesn't fall into the categories that are high risk for adverse outcomes of infective endocarditis, then we don't want that better safe than sorry. Because if they don't fall into those categories, then we know if they were to unfortunately develop endocarditis, we could treat those patients, right? They don't have a high risk of mortality. So we want to reserve it for when they really need it, when they have an active infection. Antibiotics don't work if there's not an active infection. I remember when my kids were little, they would be home from school sick. And I'd kind of be like, oh, you kind of hope it was like strep or an ear infection, because you knew if your child went to the pediatrician and it was an infection that they'd give an antibiotic and in 24 hours, you know, they're gonna be back to school and feeling better. But it was like dreaded when they were like, oh, it's viral, just ride it out because the antibiotics won't, it's not gonna benefit them. This is a little bit different, but again, we want to reserve those antibiotics only when they're absolutely necessary so they work when we need them to. This is a pretty wild statistic from the CDC. There are 35,000 deaths per year because of antibiotic resistance. That's really big number to me. And that's in the United States. I want to know that if I need the antibiotics to work, that they're gonna work, not just that, oh, better safe than sorry, to just take it in case that's not beneficial to our patients. But we definitely may have some patients that are high risk for adverse outcomes and they fall into categories that have been laid out for us by the American Heart Association, by the American Dental Association. They had a scientific council that joined together and they reviewed all of their research on infective endocarditis and who really determined who really should be taking a pre-medication because it reduces the bacterial load in the bloodstream because their bodies don't have those amazing immune systems to fight off any potential introduction of bacteria during a dental cleaning. Those groups are the ones that we need to be watching out for.

SPEAKER_00 8:13

So maybe we'll review what groups those are and then we'll save joint replacements for after that. Sure.

SPEAKER_01 8:22

Yeah, let's stick to let's stick to this group. So, right, so again, historically, antibiotic prophylaxis started for patients who are high risk for developing infective endocarditis. So since 2007, we have premedicated for four groups that fall into a high risk of cardiac concern. So the first group are patients that have prosthetic cardiac valves, and they have any prosthetic material used for cardiac valve repair. And then patients who have implantable cardiac devices. So these are things like a transcatheter aortic valve implantation. So I think sometimes that can be confused. Um, you know, we're not cardiologists, that's not our specialty. So sometimes I think we hear pacemaker, defibrillator, and people start to think, like, oh, well, do those patients need to be premedicated? No, because typically, like your pacemaker defibrillator, it's in the chest cavity, it's not in the aortic valve. So there are a few different types of devices that are actually implanted into the heart itself. And so something like that, that aortic valve. And if someone's not sure, right, the patient says, I had surgery on my heart, I had this repaired, I had this placed. If you're not certain, then follow up with the cardiologist and get confirmation on that. So your patients that have a history of infective endocarditis need to be a pre-med for life. Um, obviously, that makes them much higher risk. Um, and we want to be protecting these patients. This is where our medical history review is so important. Asking our patients, have you been hospitalized recently? Um, the last time I saw you was this date, have you been hospitalized since? Really, really important questions because that's going to reveal this. If we are vague in our questions and ask patients, are you taking any medication, any changes in your medical history? There's a potential that that could be skipped without diving a little bit deeper into those questions.

SPEAKER_00 10:30

Absolutely. I've noticed that many times where you really have to start asking, have you had any strokes or heart attacks? Have you had any surgeries? The other day I had a patient, no, I haven't had any changes. I lean them back, check on a lesion that we spoke about in the past, and they said, Oh, yes, I actually that's that's diagnosed as basal cell carcinoma. And I said, Oh, that's that's you know, that's a change in your in your medical health. I need to make sure we document that. And of course, we went over everything, but you really have to be specific because some things just don't come to mind when we're talking to our patients.

SPEAKER_01 11:03

They don't. And if if it was a previous infective endocarditis case, they might think, oh, I was treated, I'm not hospitalized, I'm going about, I'm living my life. Um, I worked in an office where that happened. We ended up finding out that the patient had been seen and didn't disclose that they had had infective endocarditis. But the wife had come in and the hygienist was then talking with the wife, and she was kind of exhausted because the partner had been hospitalized and it had been a long, you know, six months or what I don't remember exactly what the timeline was, but she'd kind of been through it because her, you know, her spouse had been so sick, but the spouse didn't disclose that because in their mind they were better. So yeah, so it's so important that we that we dive deep into those medical history reviews.

SPEAKER_00 11:52

So we have our prosthetic cardiac valves and implants, previous endocarditis. And what is our third category?

SPEAKER_01 12:01

The third category is congenital heart disease, but this just really has two subcategories. So it's patients that have unrepaired cyanotic congenital heart disease, and this can include what's called palliative shunts and conduits. And then if the patient has had a repaired congenital heart defect and it has any type of residual shunt or valvular regurgitation, um and this would be at the site where the surgery was. So it used to be that with congenital heart disease, we would premedicate for mitral valve prolapse and heart murmurs, but all of that has been gone since 2007. That was a significant change. I had been practicing for dental hygiene for six years at that point. And the number of patients this reduced that did not need to pre-medicate anymore was tremendous. And now, when you look at the research that has been done, the most recent research talks about since we made those changes in 2007, we have not had any increase in the cases of infective endocarditis for these patients that are considered high risk, which is amazing. But we reduced the number of patients that were pre uh pre-medicating by 80%. 80% with that change. So that's incredible. So you think about all those people, all the those years that were taking premedication that it wasn't a benefit and now they no longer take it. And guess what? We see no harm. So that's tremendous. And to me, that speaks such volumes about that whole better safe than sorry mentality, where we really should not be premedicating unless it's absolutely going to benefit the patient. And so that's our group three. Our last group are cardiac transplant recipients who have valvular regurgitation. And this is due to a structurally abnormal valve. I get the question a lot about organ transplants, and typically solid organ transplants do not require antibiotic prophylaxis. They may require a waiting period for treatment, but they they do not require a premedication. So in this specific case, they address cardiac transplant recipients, and the indicator would be that they have this valvular regurgitation after the surgery.

SPEAKER_00 14:27

I think one of the good things too to mention is that, you know, you went through that initial change when they took away the uh mitrovalve prolapse from the list. And so when I was in school, they were still talking about the joint replacements. And so I think it's good just to mention to stay open-minded and learn about what the current research is and be open to the changes because sometimes I feel like we can get kind of stuck in what we have learned in the past. So, leading us to joint replacements, where do we stand on that?

SPEAKER_01 14:58

So I think this causes more confusion than our patients that are at high risk for infective endocarditis. And that has a lot to do with over time, the way things were changed. Um, so we're gonna talk about what's current and what's recommended. The American Academy of Orthopedic Surgeons recommends that in general, patients who are having invasive dental procedures do not premedicate. And the reason is that the evidence, the scientific evidence, is lacking to support a connection between invasive dental procedures and prosthetic joint infections. So the purpose of where premedication for joint replacement surgeries began back in the um 70s. So what happened in the United States, just a little history lesson to help understand it all. In the 60s, we started seeing successful joint replacement surgeries taking place in the United States. And you saw this widespread success across our country. And with that, right, you have a new surgery, a new procedure comes the potential for infection. And so they began seeing prosthetic joint infections, and there became this hypothesized mechanism of infection, and that was that there was transient bacteria introduced during an invasive dental procedure that could seed the prosthetic joint and cause a prosthetic joint infection. And so, again, the key word to that is that it was a hypothesized mechanism of action, and it's never been definitively proven. So there's a lot of research out there that actually shows there's no connection. A great research study was done in England. And in England, they don't premedicate at all for prosthetic joints. And what they did was they looked at patients who had those high-risk categories and had prosthetic joints, and they looked at their correlation between dental visits, and they could not find any. And it's incredible. So this country that doesn't pre-medicate for that, they're like, no, people are still having prosthetic joint infections, but there's no correlation to dental treatment because we don't premedicate anyone for this and they couldn't find a correlation. It is most likely when a patient has a prosthetic joint infection, there is a connection at the time of surgery. So the joint becomes contaminated during surgery. And so you see these early cases, early iphyprosthetic joint infection. So that's considered to take place within like the first three months. So that research study from England looked at people three months and later, and they still couldn't find a correlation. So in the United States, right, we had this success of joint replacements and the concern for the orthopedic surgeons that if my patient is having an invasive dental procedure, I don't want that to lead to the potential of an infection. But again, hypothesized and so it began that they recommended it for every patient who had an artificial joint. And when they began looking at the research, so that was the 70s, so in 2014, they changed that recommendation that it should not be just anyone who has had a joint, a joint replacement. They did a lot of extensive research research, a lot of different cases looking at patients' A1C levels and looking at are they immunocompromised and what makes them at risk for prosthetic joint infection. And they did all these different categories. Um, I can't, I apologize because I can't remember the number. I want to say it was like 28 different categories, and they ranked them should this require premedication, and it came down to very few. Um, and the two groups that would be recommended for antibiotic prophylaxis that have a prosthetic joint are those who have a history of any type of medical concern that was related to the prosthetic joint. So if they've already had an infection of the joint, so it might have been like that early prosthetic joint infection, or they had some other kind of medical complication related to the joint. Those are the patients that should be pre-medicating. Otherwise, the American Academy of Orthopedic Surgeons does not recommend it for anyone. And I just I think it would be helpful to share that what uh the definition of an invasive dental procedure is. So that would be anything where you manipulate the gingival tissue, um, any perforation of the mucosa, any um the periapical region of the tooth as well. Those are all considered invasive dental procedures. So that would be what we would be premedicating. Anyone that falls into either those four categories or those two small categories for joint replacements.

SPEAKER_00 19:42

Is that including non-surgical periodontal therapy? Yes. Yes.

SPEAKER_01 19:48

Yeah, because you're still manipulating the gingival tissue for that. So yes, definitely. Pretty much anything a dental hygienist does is going to be invasive. I unless it's like coronal polishing. I don't think I have ever had any patient, adult patient, that would just need coronal polishing.

SPEAKER_00 20:04

So it went from being pre-medicated for life for joint replacements. Did it it then change to for two years after uh the surgery?

SPEAKER_01 20:14

No. Nope. So there is a timeline as far as a wait period after the surgery. So the um AAOS does recommend that there be a three-month wait period, unless there is an absolute emergency. Otherwise, they do recommend that that you wait for invasive dental procedures. But the timeline of two years, sometimes you hear a doctor says six months. Um, and by doctor, I should clarify that I mean the orthopedic surgeon, right? I think that's something we all encounter in clinical practice is like Dr. Jones says two years, Dr. Smith says six months, Dr. Allen says for life. Um, but those are not in alignment with what the American American Academy of Orthopedic Surgeons says. They do not put a timeline on the guidelines. So essentially, once they are past that three months of healing, if they don't have a history of high risk for the previous infection of the joint or a medical complication due to the joint replacement surgery, then there should be no timeline.

SPEAKER_00 21:17

So, what would be the best way to go about it? Like, let's say you have a new patient come come in, they've had a joint replacement, and maybe you work with a dentist that is still pre-medicating for joint replacements. Like, what would be the best way to make sure you're you're staying up to date with what's current and how to maybe get get that to change?

SPEAKER_01 21:37

So I'm gonna say, I'm gonna back up and share one thing related to that question. The American Dental Association has a statement about premedication for joint replacements. And in the cases where it's deemed necessary, it should be the orthopedic surgeon that is writing the prescription, not the dentist. That is their surgical procedure. That is their patient and that is their recommendation. So the dentist should not be the one writing that prescription. And that is really important because I think then we start putting that back on that association, right? The or that profession is what I really should say. We put it back on the orthopedic profession, like this is your responsibility. Like you need to know your regulations and you need to appropriately prescribe for your patients. Don't put that on us, right? Um, so with that, I think if you're in an office where the doctor is of the mindset better safe than sorry, I do have a resource. There's a self-study. I can share that link that Britt you could share out with the podcast so that anyone can take that and they can encourage their team to maybe all complete the self-study. It has all of the current regulations and it goes into the science on a deeper level. It goes over the regimens for prescribing. Again, for joint replacements, we really don't want to be the ones prescribing, but you may have those high-risk categories for infective endocarditis. And talk about it as a team. You know, we've changed so many things in the way we go about dentistry. This needs to be up to date as well. And there is a reason that the recommendations and the guideline has been changed. And that's because we know better. The science is now there to show us that it is not better safe than sorry. We have a really serious concern worldwide with antibiotic resistance, right? So we need to be mindful of that. And we know there's no scientific evidence supporting antibiotic prophylaxis to prevent a prosthetic joint infection. So we we really want to um push back. And I think the easiest thing to say is what we know now, the science tells us now. We are so fortunate to have this evidence that shows us that this is not the way we should be practicing.

SPEAKER_00 23:59

Sure, it makes some providers feel a little bit better because sometimes you go through a whole appointment and then somebody tells you, Oh, I had a joint replacement six months ago, and your heart drops, and you're like, Oh my gosh, were they supposed to be pre-medicated?

SPEAKER_01 24:13

So I will say the current guidelines do address people that inadvertently do not take their premedication. So the guideline specifically says if the premedication was inadvertently administered, that it can be administered for up to two hours after the procedure. So in that case, if that pops up and the team really can't determine, perhaps, you know, the doctor then writes a prescription for that one time. No refills, one time. I need you to go to a pharmacy, fill this immediately, and take that. Um, you know, I know a lot of offices keep antibiotics in the office as well. So maybe they choose to administer in the office. We would need to be the prescribing doctor on um, you know, that day and and all of that. But that is an that is an option too. But the majority of patients that have prosthetic joints, they are not going to be indicated for pre-medication. So in those scenarios, when that pops up, I mean, that is like the worst thing when a patient tells you that information after. Despite doing all the things right, despite asking the questions, they still don't disclose. And it's just that is the worst feeling.

SPEAKER_00 25:24

Hey friends, quick little break here. If you're enjoying this conversation and you'd love to bring Brush with Brit to your next event or your school, I'm now booking speaking events and meet and greets for next year. And I would love to add your location to the list. You can learn more at brushwithbrit.com. And if you're a student, definitely click the For Students tab. That's where you're gonna find resources, career tips, and tools to help you thrive in your new role as a dental hygienist. Now let's get back to the show. I know that this isn't pre-medication, but do you know the waiting period for when you have a patient that maybe has like a stroke or a heart attack? Because sometimes those cases come up too.

SPEAKER_01 26:02

I was reading a little bit about that recently, and those are six, those are six months generally. And a lot of times patients don't even realize that they're not clear for treatment. So if the patient was to come in and that is the case, they share that information as you review their medical history. You can use that time to make the phone call, do education, maybe update radiographs if needed, because those are not invasive. Do as much as you possibly can for that patient and then see them for any type of invasive procedure at another time when they're post-recovery, I guess would be the right way to say that.

SPEAKER_00 26:37

And for all the other categories that are not the joint replacements, who would be the prescribing doctor for those antibiotics? Could that then be the dentist, or are we still trying to get that to be the other doctor, whoever the patient's doctor is?

SPEAKER_01 26:54

So those patients that are high risk for infective endocarditis, um, the it's definitely a bit more clear-cut. Um, no one specifically addresses that. The ADA doesn't specifically address it. And I think it's because the categories seem to be so much more clear and cause a lot less confusion. That's just me making an educated guess. But I I think it would be if the doc the dentist knows that the patient is in one of those high risk categories, I think it would be acceptable for them to write the prescription. But it's that group is not specifically addressed just the pro just for the prosthetic joints, which is interesting. And I think that has a lot to do with being aware that there's definitely a lot of surgeons that are not necessarily on board with their association and the recommendations coming from their association.

SPEAKER_00 27:44

Well, thank you so much for all of this information. I feel like it's incredibly helpful. Do you have anything else that you want to add before we end? There are some great resources from the CDC.

SPEAKER_01 27:55

When you just simply Google CDC and antibiotic prophylaxis recommendations, they have some really great resources, and I'm happy to share those links with you so we can provide those to the listeners. But those resources are things like a little chairside guide that you can have that helps you to know yes, this patient presents an antibiotics not as a prophylaxis, but antibiotics, you know, would be appropriate for this patient because maybe they have swelling or they have a fever. So that goes along with antibiotic stewardship, not the antibiotic prophylaxis piece. But then they also have some guidance for prosthetic joints and I think it's mostly for prosthetic joints, because again, most confusion surrounding that. Um but I think that's helpful as a team to review those materials so that you can be delivering the same message to your patients and having the same is similar verbiage. It shouldn't be the same verbiage because everybody's different. I'm not going to present the way you're going to present, right? But to be on the same page and really sticking to that, what we know now is that the the benefit of, you know, having good oral health has it's so it's it's much greater for reducing your risk of infective endocarditis if you're a really good brusher and you're a really good flosser than if we were to give you antibiotics before your cleaning twice a year. You know, being able to say that to patients, I think is tremendous. So really they emphasize that good oral health as more important and access to dental care. So we get that opportunity to share those. But again, sorry, I went down a bunny trail, but like the CDC, great for some of those resources. The ADA has information on their website that is open and accessible for any dental professional to look at. You don't have to be a member to see that, what the current guidelines are. Um, the American Heart Association scientific statement from 2021 is the big detail of information that I shared today. So if I perhaps missed something in this conversation, that's a great resource. A little bit more depth and science in that for anybody that likes that. And then the self-study that I had created is really a great way, I think, for a dental team to pre, you know, like do that ahead of time and then everybody meet for a huddle or a team meeting and go through that, get your CE credits for free on that. And, you know, and then everybody, it sets everybody up for success in guiding the patients towards change that's going to benefit them in their and their health in the long run.

SPEAKER_00 30:33

I love that. Thank you so much. And I feel like that is a really good conversation piece that you mentioned because patients might be like, well, if I'm brushing and flossing my teeth at home, aren't I introducing bacteria into the bloodstream? So can't that cause infective endocarditis? And so I think that's a great highlight to be like, hey, if you keep your mouth really, really clean, you're decreasing your risks even more. And it's very important for you to have your daily routine down and also come in for your routine visit. So I think that's a a great highlight of pre-medication that you don't always think about mentioning that. So yeah, definitely. Well, thank you so much, Sue. I appreciate all your knowledge. And of course, everybody go take her course and get up to speed with it. And if we can get more offices to get on board with the current regulations, then the better our patients will be. So thank you. All right, everybody. Until next time, this is the Brush with Brit Podcast.