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SPECIAL CONSIDERATIONS

Dental

It has been well established that during certain types of dental work, patients may be at increased risk of bacteremia during the dental work.¹ This is the rational for the American Heart Association’s 2007 endocarditis guidelines to recommend that patients who are high risk for endocarditis, receive antibiotic prophylaxis, during certain types of dental procedures.² For certain high risk patients, prophylaxis is reasonable for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

PPN’s expert committee members have experienced that PANS/PANDAS patients may have exacerbations of their symptoms after dental work, which involves manipulation of the gingival tissue, pericoronal regions of the teeth or perforation of oral tissue as well procedures such as extraction, cleaning, fillings, and oral surgery. Although the exact mechanisms are not known, this bacteremia may stimulate an immune response which is responsible for worsening clinical status.

Therefore, patients may benefit from antibiotic prophylaxis starting the day before, until 4-7 days after the procedure. The dosing to prevent PANS/PANDAS exacerbation is higher than that used for endocarditis prophylaxis for dental procedures and should be at least equivalent to the dosing for therapeutic strep pharyngitis.

¹CDC Guidelines for Infection Control in Dental Health-Care Settings — 2003 
²(2007) Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group. Circulation 116:1736–1754
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Probiotic

In order to maintain a proper balance in the microbiome while a PANS/PANDAS patient is undergoing antibiotic therapy or prophylaxis, the providers caring for PANS/PANDAS patients should consider multi-strain probiotics. Probiotics are available in colony forming units (“CFU’s) and the correct CFU dosage for children and adults must be considered as part of the therapy.
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