A Bionic *** !

[Woodbutcher]

Phew, that took some reading ! Thank you Lyn.
So... Here's the thing. Whether or not one has Antibiotic cover, it would seem you have the same risk of becoming infected with Endocarditis from a dental treatment ? If it's just been given for the past 50 yrs to set the patients mind at rest then surely they should have recommended a nice slice of sponge cake or something in the first place and not a nasty drug that could really be useful to you one day, thus maybe rendering it useless from over exposure to it !? I have a tooth that will have to be extracted at some point and now it's become one more thing to worry about !

 

[Adrienne]

To quote a part of what Lynlw said:

"...the use of antibiotic prophylaxis has relied heavily on extrapolation from animal models of the disease (Pallasch 2003) and the applicability of these models to people has been questioned. With a rare but serious condition such as IE it is difficult to plan and execute research using experimental study designs. Consequently, the evidence available in this area is limited, being drawn chiefly from observational (case–control) studies."

I definitely understand why they wouldn't want to experiment with humans on something like IE. However, if they have in fact done experiments on animals which have shown that those animals are at least partly protected by PA, in my mind it seems logical that it would help humans too. I realize that there are differences in whatever animals they use and us, but there are a lot of similarities too.

 

[Lynlw]

To quote a part of what Lynlw said:

"...the use of antibiotic prophylaxis has relied heavily on extrapolation from animal models of the disease (Pallasch 2003) and the applicability of these models to people has been questioned. With a rare but serious condition such as IE it is difficult to plan and execute research using experimental study designs. Consequently, the evidence available in this area is limited, being drawn chiefly from observational (case–control) studies."

I definitely understand why they wouldn't want to experiment with humans on something like IE. However, if they have in fact done experiments on animals which have shown that those animals are at least partly protected by PA, in my mind it seems logical that it would help humans too. I realize that there are differences in whatever animals they use and us, but there are a lot of similarities too.

Its hard to prove people at risk didn't get BE because they took PA before dentist, but I did find this interesting altho small study on pubmed from Germany in 2000 (old guidelines were inplace at the time)

http://www.ncbi.nlm.nih.gov/pubmed/...nel.Pubmed_DefaultReportPanel.Pubmed_RVDocSum
Severe complications caused by inattention to endocarditis prevention during dental procedures in adults with congenital heart abnormalities][Article in German]
Vogel M, Knirsch W, Lange PE.
BACKGROUND AND OBJECTIVE: Despite new guidelines on antibiotic prophylaxis to prevent bacterial endocarditis there is still confusion about the forms of dental procedures requiring antibiotic prophylaxis. Aim of this study was to determine the incidence of bacterial endocarditis following dental procedures in adults with congenital heart disease during a one-year period, and to assess connections with prophylaxis. PATIENTS AND METHODS: The case notes of all adults with congenital heart disease (CHD) treated in hospital during a one year period were analyzed retrospectively to identify cases of endocarditis, and all adults with CHD admitted to hospital for other reasons than endocarditis were interviewed about their knowledge of antibiotic prophylaxis against bacterial endocarditis. RESULTS: Among the 456 adults with CHD 351 (78%) knew about the need for antibiotic prophylaxis against bacterial endocarditis. Three patients developed endocarditis, in each case after a visit to the dentist. The disease started 11-16 days after dental descaling had been performed without antibiotic covering, one patient developing a brain abscess. The patients had to be treated in the hospital for 42-49 days. Despite presentation by the patient of a leaflet with recommendations for prophylaxis, the dentist refused to give antibiotics. CONCLUSIONS: Knowledge of adults with CHD is satisfactory but can still be improved. Even more important is better training of dentists who treat patients with CHD with special emphasis on the specific procedures including dental descaling, which require antibiotic prophylaxis

ps don't worry I am not going to post each study as I find them

 

[bit of a chicken]

At my last visit to hygienist I did not take antibiotic cover, which seemed a little bizarre to me at the time, given that on previous appointments they would not even treat you unless they actually witnessed your consumption of the antibiotic.
I took the advice of the hygienist as she seemed adamant... Bearing in mind I have taken antibiotics my entire life up until that point. It does make you wonder at it all. I have a hazy morphine induced recollection of having IV antibiotics immediately after childbirth, slowly pumped into your vien...urgh!At that time, and some years ago now, this was on the recommendation of the cardiologist ?! The thing is ...I have wondered at the potential infection you could provoke below the gum by flossing , or some of those scary dental objects you can buy in boots, with no a b cover, in your bathroom at home ?!
I personally am happy to go without and would not worry about it...stands to logic NHS would not promote a guideline that leaves them open to every heart patient suing once that contract BE ?

 

[bit of a chicken]

P .S .Lynlw....love the long and boring....still comprehending it !!

 

[Nupur]

My cardio and GP will NOT give me anti biotics for dental app, the surgeon I consulted with cautioned me that although he thinks I have a few years before surgery, avoid endocarditis at all costs, and therefore premedicate despite the change in policy, because BE would hasten surgery for sure, and kill the chance of repair. The dentist gave me a prescription. She wanted to be safe.

It was disconcerting that most people who got endocarditis got it from unknown source rather than dental procedure (for which they were pre-medicating). As Adrienne replied to my other thread about flu-like symptoms without flu, we should be cautious even if we premedicate.

 

[Adrienne]

My cardio and GP will NOT give me anti biotics for dental app, the surgeon I consulted with cautioned me that although he thinks I have a few years before surgery, avoid endocarditis at all costs, and therefore premedicate despite the change in policy, because BE would hasten surgery for sure, and kill the chance of repair. The dentist gave me a prescription. She wanted to be safe.

It was disconcerting that most people who got endocarditis got it from unknown source rather than dental procedure (for which they were pre-medicating). As Adrienne replied to my other thread about flu-like symptoms without flu, we should be cautious even if we premedicate.

If your cardio and GP will not give you antibiotics, yet your surgeon said to premedicate, what do you do?

By the way, I feel extremely fortunate to have had a surgeon who was able to do a much more complicated MV repair despite the previous endocarditis. I am sure that most surgeons would have replaced the valve.

 

[Duff Man]

I had one of few cleanings without antibiotic pre-med a couple weeks ago. I'd be lying if I said I wasn't just a tiny bit nervous. Alas, I lived to tell about it!

If I had a prosthetic valve already, I don't think I'd risk it. It just makes sense to use premeds in that case, in my opinion.

 

[ponygirlmom]

When I visited the dentist six months ago, I learned that the dangerous procedures are the ones that involve bleeding. Therefore, drilling and filling is safe, and cleaning is not. (I guess that novicain injection sites are not cause for concern.)

That said, I think my dentist and cardiologist still recommend antibiotics for dental procedures.

 

[SMS]

Words,Words,Words. All I know is I had a leaky mitral valve and was told I no longer needed antibiotic treatment for my cleanings. The first time I didn't take them, well, read my signature. Proof positive? no, but mighty suspicious.

 

[Kathy McCain]

Justin,
You know the old saying. I would rather be safe, than sorry! It's a certain bacteria, that causes endocarditis. If you are not alergic to any type of antibiotic, it's much better to take, than not to. My dentist ALWAYS prescribes amoxicillan. I am having a colonoscopy next month, and it's no longer in the protocol. Both my GI dr, and cardiologist okayed my prescription.

From what I understand, it can take up to several weeks, to see symptoms. Fever, chills. You can look it up on the net.

 

[Woodbutcher]

Of course it's better to be safe than sorry, but it seem it may not be the safe option, and there lies the problem ? Correct me if I'm wrong, but I was advised that every time one takes a sachet of Amoxicillan so our bodies can build up an immunity against it,
so one day when you most definately do need an antibiotic it may longer work ? also the more we use it the more likely we'd have an anaphylactic shock ?
So, whilst I agree that it's better to be safe than sorry, in this instance not only is proven it's likely not to do anything anyway but the safety net has some pretty huge holes it ?

 

[tobagotwo]

I would have to agree with you in terms of what you've gleaned from the thread. Fortunately, if you've had antibiotics before, but were unknowingly working up to an allergic reaction, it's likely you would have a less violent episode with it first that would tip you off, rather than slipping suddenly into anaphylaxis. Yes, as you note, it is also likely to lessen that antibiotic's effectiveness for you in the future (maybe even that whole class of antibiotics).

I stopped taking prophylactic antibiotics four years ago after I had a short run of premedicated dental visits that culminated in developing an inability to digest dairy products. It took two months with probiotics before I could stop taking lactase. I have no idea what other damage it may or may not have done. There was already a protest movement underway in dentistry and cardiology about the use of prophylactic antibiotics, which led to the AHA study.

The contents of the AHA/ACC study are available for purchase, and a very short version of the analysis is free. It's really pretty cut-and-dried. The current AHA/ACC recommendations are a compromise loosely based on, not a final result of the study.

I have read where IE was blamed on dental visits from a year or more before and from two weeks before. I have also read about people who got it even though they had premedicated, and then came up with very complicated theories to explain how it might have happened anyway. However, it seems that if the IE is from mouth bacteria, it's more likely that a casual gum injury during eating or brushing was responsible than a dental visit. It's just the way it is.

The dentist is far more apt to be a good guy in this, by helping you keep your gums healthy, than a bad guy. To be blunt, unless you have a specific condition, if your gums bleed much during cleanings, you're likely not flossing correctly or you're not getting them cleaned often enough. Taking care of that would likely go a much longer way toward reducing your risk of IE than any other, single act.

Infective endocarditis is a devastating and life-threatening disease, with a shocking fatality rate of about 20%. It ruins valves and damages hearts for many who live through it. There is no way to make light of the seriousness of this disease. And it's true that people who've had it before are more susceptible to it. And those fresh from surgery with as-yet unhealed endothelium (like me) are more susceptible to it.

But the level of risk really has nothing to do with it. "Better safe than sorry" only works if there's a "safe" thing to do. Prophylactic antibiotic use doesn't seem to provide safety from IE, nor does it seem to be entirely harmless on its own.

Each person needs to decide for himself how this does or should affect him. Some people will never be comfortable with this idea, or will refuse to believe it. Some have been waiting for it. For the time being at least, both options are available, although it's less easy to obtain antibiotics in the UK, and less easy to deal with dentists when avoiding premedication in the US.

Good luck to each of us with his choice.

Best wishes,

 

[sue943]

NICE or not my hospital dentist prescribes antibiotics for me with the blessing of the cardiologist who said if a patient such as me requests antibiotic cover and knows the guidelines and knows it might not be effective then to prescribe.

 

[Woodbutcher]

Here's the latest thoughts of the day ... I think it was "BIt of a chicken" who mentioned flossing ? Well, that's a really good point because flossing can and does sometimes make your gums bleed so flossing is putting yourself at a high risk. Another thing, today I was told by somebody with a heart condition that he's been advised not to eat things like toast or Bagette which can often send a sharp edge or corner into your gum where it meets your tooth thus damaging it ?

 

[Kathy McCain]

Justin,

That is the extreme. I really do not give that much of a thought! What can you do, stop eating? I have always pre-medicated. Even before my surgery. I have NEVER had an adverse reaction, so far. Evidently, anitbiotics still do the job, when I really need them to. My cardio told me, if it were him, he would probably request the antibiotics.

Now, if it where me, I would insist on it. As a matter of fact, that's exactly what I did, when I had a consultation with my GI dr. He said, "no problem".

Good luck, Justin!

 

[Bryan B]

Well folks I've had endocarditis (although my infectious disease doc said it occurred due to chronic bacterial bronchitis, not dental work) and the overall mortality rate runs somewhere around 25%. So even though the odds of getting endocarditis from dental work are very low, the odds of DYING if you do get endocarditis go up significantly. That old saying that an ounce of prevention is worth a pound of cure comes to mind. And I honestly don't think taking 2 Grams of Amoxicillin twice a year (maybe more if you need extra work done on your teeth) is going to lead to a resistance to bacteria normally treated with this class of antibiotic. However if you get endocarditis you are going to be receiving powerful antibiotics for weeks (in my case 7 weeks). I was on Rocephin 2GM IV dailly (ceftriaxone) which is a third-generation broad spectrum cephalosporin. Now I would hate my body to become resistant to this type of antibiotic because that would seriously limit my future treatment options for infections.

I will take the antibiotics before dental work or any invasive test (conlonoscopy, endoscopy, TEE, etc.) even if there is only a 0.01% chance it will help prevent endocarditis. My reasoning is that there is at least that high of a chance that sterile equipment used by a dentist or medical professional may be contaminated. As the old saying goes, chit happens. And I say this even though I realize that I expose myself to bacteria on a regular basis by poking my gum with a fork or a tortilla chip and regularly get scrapes or small cuts that could allow bacteria into my bloodstream.

That is one of the reasons I opted for the Ross Procedure as I would still have a native aortic valve, just without the messed up leaflets caused by my VSD prolapsing them for years and years. That's also why I will be opting for a valve sparing David Procedure to repair my aortic root if my surgeon still thinks it's a viable option after my next echo in a couple of months. Right now he has given me a guesstimate that there is a 70% chance he will be able to do this, but like with the Ross Procedure he will have to make the final determination once he gets in there.

 

[Lynlw]

MORE long and boring

MORE long and boring

Of course it's better to be safe than sorry, but it seem it may not be the safe option, and there lies the problem ? Correct me if I'm wrong, but I was advised that every time one takes a sachet of Amoxicillan so our bodies can build up an immunity against it,
so one day when you most definately do need an antibiotic it may longer work ? also the more we use it the more likely we'd have an anaphylactic shock ?
So, whilst I agree that it's better to be safe than sorry, in this instance not only is proven it's likely not to do anything anyway but the safety net has some pretty huge holes it ?

I don't know that is has been Proven it's not likely to help anyway. There are alot of ways you chance getting BE just by living life, brushing and flossing ect and having certain dental work seems to be one of the things that raises your chances of getting BE. I've read about 60-70 % of the cases were caused other ways than the dentist, so about 1/3 are. I never personal read of/heard anyone claiming they got it from going to the dentist a year or more before, I have heard of people getting it in 1-2 months after the dentist, (well they were DXD in that time frame, alot of them had the symptoms and went to the docs a couple times before they did blood cultures)The problem is since BE can be so deadly, they have never done a study where they give 1/2 the people the PA and the other half (with the same heart issues) none and see what happens and I'm not sure they could get many people to be in the trial. Most things I read, including the NICE, say it DOES help a small percent, but NICE took cost effectiveness into account and that's why they came up with different guidelines than all the other international ORGs, apparently they feel since it only helps such a small percentage it isn't worth the cost.(plus the problems associated with antibiotics, both reactions or the growing problem with resistent bacteria) I guess we will know more in 5 years since basically the UK stopped giving them to everyone, wether they are in the high risk group or better phrase they are in the group that IF they got BE it would cost the most damage. So it will be interesting to see if the cases of BE increase in the UK compared to all the countries that still recomend it for the highest risk people. It sort of is a BIG random trial, (but the people might not know they are guinie pigs)IF you look on pubmed,google ect you can find a couple studies that would appear to say it DOES help, most involve looking back at a time frame of records , (of course you can probably find studies showing either side, but I haven't found any studies that say is definateley does not help anyone) like the study I posted in #41. or this (which IS from 90, but I don't think that matters that much in this case, since new technology ect doesn't change anything)
Imperiale TF, Horwitz RI.
Department of Medicine, Yale University School of Medicine, New Haven, Connecticut.
PURPOSE: Despite the American Heart Association's (AHA) recommendations for antibiotic prophylaxis to prevent infective endocarditis, no controlled clinical evidence exists for the effectiveness of this intervention. The purpose of this case-control study was to determine whether antibiotic prophylaxis for a dental procedure reduces the risk of infective endocarditis in persons with high-risk cardiac lesions. PATIENTS AND METHODS: Cases consisted of eight subjects with high-risk lesions (six mitral, one aortic, one uncorrected tetralogy) whose first-time, native-valve infective endocarditis occurred within 12 weeks of a dental procedure and was diagnosed between 1980 and 1986. For each case subject, three control subjects were chosen from patients who underwent echocardiographic evaluation between 1980 and 1986, and who were matched for the specific high-risk lesion and age. Use of antibiotic prophylaxis, which was determined by interviews with patients and supplemented by the dentists, was defined as antibiotic taken both before and after the dental procedure. RESULTS: Antibiotic prophylaxis was used by only one of eight (13%) case subjects compared with 15 of 24 (63%) control subjects, for an odds ratio of 0.09, which is clinically impressive (indicating 91% protective efficacy) and statistically significant (p = 0.025). CONCLUSION: Although this report does not specifically assess the value of antibiotic prophylaxis for the current AHA recommendations, the use of antibiotic prophylaxis in persons with high-risk cardiac lesions is supported by the magnitude of protective efficacy observed in this study.
PMID: 2301438 [PubMed - indexed for MEDLINE http://www.ncbi.nlm.nih.gov/pubmed/2301438?ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&linkpos=5&log$=relatedarticles&logdbfrom=pubmed

 

[tobagotwo]

Just a word of caution regarding pulling every tiny study from PubMed. They may not actually represent what they appear to.

If you read the way this case study was set up, the eight manually chosen cases who had IE (one of whom did use prophylactic antibiotics) were manually matched with another group of 24 who specifically did not get endocaditis (over a third of whom did not take antibiotics) who were individually cherry-picked from hundreds of cases.

Only 32 people total, each manually chosen. It would be very difficult to see the validity of this method, and how there could not be concern that the outcome could be gerrymandered for the results that the writer desired. This looks very much like a Yale med student's thesis, intended to come out the way the supervisory counsellor expected it to. Being in Yale has its perks, including getting published.

Nor does this hold a candle to over 50 years' worth of data involving thousands of cases and numerous studies which were handled as they appeared, rather than carefully chosen and constructed to a model that bears no statistical validity. When you cherry-pick your subjects from a large field, you eliminate the integrity of the sample.

While most of what has been presented has been both interesting and informative, this one paper absolutely fails to impress.

Best wishes,

 

[Herburban1]

I had mitral repair with a annuplasty ring and was told I need the antibiotics for any invasive procedure.