Dental work and prophylaxis question

[Happy Camper]

Hi everyone,

I'm 33 years old and had open heart surgery two years ago, August of 2018 due to a bicuspid aortic valve and an aortic aneurysm measuring 6 cm.

I was fitted with an On-X valve and the aneurysm was repaired.

Intros aside, I finally went for a dental checkup recently and was told I would need a cleaning due to heavy buildup of calculus which has always been a problem for me.

I set up everything with my dentist and he said I should take the antibiotic prophylaxis 6 hours before the procedure (2g of Amoxicilin) because according to him the concentration will then be highest. I followed his instruction and now I am worried that I maybe screwed up by listening to him. Also, the procedure went a bit rough and I still have some slight bleeding a day later.

Should I have taken the antibiotics as the usual instructions go, 1 hour before the procedure? I guess I just need someone to tell me I am not going to get endocarditis because of this.

This is my first time dealing with this stuff since my heart surgery and my stress levels are going through the roof.

 

[Warrick]

I think the risk of endo from a dental cleaning is very small to start with for valvers and non valvers alike, I believe the recomendations for dental premedding for heart patients were relaxed/changed/found to be unnessary a few years back and valvers are about the only ones recomended for the dentist and even then its not followed in every country.
My script instructions before the dentist are take one hour before.
I think you will be fine and you’ve perhaps googled endo symptoms already so know what to look for so are already a step ahead, don’t stress, I have a bit of bleeding sometimes when flossing so theres only so many bases you can cover.

 

[pellicle]

I agree with @Warrick I never even heard of it till later in life when a dentist went spakko over my not having had antibiotics. That was some time after my second surgery and in my 30's.

Since then I've had antibiotic cover because it kept the dentists happy (I'm Australian).

. I followed his instruction and now I am worried that I maybe screwed up by listening to him. Also, the procedure went a bit rough and I still have some slight bleeding a day later.

I doubt its significant about the antibiotics, but I'd be checking up on the bleeding. what's your INR at the moment?

 

[Happy Camper]

I think the risk of endo from a dental cleaning is very small to start with for valvers and non valvers alike, I believe the recomendations for dental premedding for heart patients were relaxed/changed/found to be unnessary a few years back and valvers are about the only ones recomended for the dentist and even then its not followed in every country.
My script instructions before the dentist are take one hour before.
I think you will be fine and you’ve perhaps googled endo symptoms already so know what to look for so are already a step ahead, don’t stress, I have a bit of bleeding sometimes when flossing so theres only so many bases you can cover.

Thanks for the reassurance. I guess the worry and stress just get the better of me in these situations.

I doubt its significant about the antibiotics, but I'd be checking up on the bleeding. what's your INR at the moment?

It's mostly subsided now. There was just this one persistent spot that wouldn't quit, but now there's a clot over it so I guess it should be fine.
My last INR was 2.26

 

[spartangator]

Sorry about the stress over all this. Glad things are arriving at a reasonable place.
It's taxing sometimes, isn't it, the things we get hung up on post-surgery? I've had this experience, too, for what it's worth.

 

[Astro]

After having my AVR last year, I used prophylactic antibiotics when I went to the dentist. It made me and the dentist feel better. However, does it really make sense? Do we take antibiotics every time when we brush our teeth? Brushing teeth causes bacteria to be released into our blood stream and potentially land on our valve. While I will continue to take antibiotics before seeing dentists, the risk must be quite low if no antibiotics are used.

I agree that normally antibiotics are taken 1 hour before the procedure to achieve the highest blood levels at the time of the procedure. At 6 hours there would still be some antibiotic left in the blood stream so it is more protection than no dose.
"Detectable serum levels are observed up to 8 hours after an orally administered dose of amoxicillin", source: Amoxil (Amoxicillin): Uses, Dosage, Side Effects, Interactions, Warning

 

[dick0236]

Hi Happy Camper! Welcome to this forum. You can learn a lot here.

The jury seems to still be out on the need for antibiotics prior to dental work. I prefer to take an antibiotic before I have ANY invasive dental work (fillings, cleaning, etc).

 

[Happy Camper]

Sorry about the stress over all this. Glad things are arriving at a reasonable place.
It's taxing sometimes, isn't it, the things we get hung up on post-surgery? I've had this experience, too, for what it's worth.

It is. It's very taxing. And knowing other people go through the same things makes it a little bit easier.

After having my AVR last year, I used prophylactic antibiotics when I went to the dentist. It made me and the dentist feel better. However, does it really make sense? Do we take antibiotics every time when we brush our teeth? Brushing teeth causes bacteria to be released into our blood stream and potentially land on our valve. While I will continue to take antibiotics before seeing dentists, the risk must be quite low if no antibiotics are used.

I agree that normally antibiotics are taken 1 hour before the procedure to achieve the highest blood levels at the time of the procedure. At 6 hours there would still be some antibiotic left in the blood stream so it is more protection than no dose.
"Detectable serum levels are observed up to 8 hours after an orally administered dose of amoxicillin", source: Amoxil (Amoxicillin): Uses, Dosage, Side Effects, Interactions, Warning

I've always assumed the gums actually need to be bleeding for it to be possible. But who knows. Ultimately it's better to be safe and take precautions that can be taken then try to fix it later. Just reading some of the symptoms of endocarditis makes me queasy.

And thanks for that quote. It does make me feel a bit better to know that the antibiotics were still effective, at least according to the specs.

Hi Happy Camper! Welcome to this forum. You can learn a lot here.

The jury seems to still be out on the need for antibiotics prior to dental work. I prefer to take an antibiotic before I have ANY invasive dental work (fillings, cleaning, etc).

Thanks!
It was a great source of information and comfort two years ago when I was mentally preparing for my operation, but I was content with just lurking back then.

 

[pellicle]

Thanks for the reassurance. I guess the worry and stress just get the better of me in these situations.

no problem ... its always the unknown that erodes our confidence.

I'm glad to read your bleed has stopped. If I may, you don't really need to count 2 decimal places for INR because it really is a rubbery figure. so 2.3 is plenty. As to why it is rubbery for a start the R is Ratio and the N is Normalised, so an INR of 1 is baselined on a large sample of peoples "un-anti-coagulated" clotting times. So if you have a naturally lower "normal" then you'll be over anti-coagulated (a bit) and if you have a naturally higher "normal" then you'll be under-anticoagulated (a bit).

This fact is often ignored by the OCD patients who obsess about numbers (not saying you are one), and has on occasion (with those On-X valvers who obsess about keeping INR low) led to harm. Here is one such thread:
https://www.valvereplacement.org/threads/failure-of-onx-valve-and-problems-with-lowering-inr.878615/

Best wishes

 

[kevanndo]

My daughter, who received a mechanical mitral valve at 9 years of age, has had braces twice since her replacement. With all that orthodontic work, she has never taken antibiotics prior to the treatments. She does take 2000mg of amoxycillin 1 hour prior to each dental cleaning, but her dentist/orthodontist has told me that while it makes the cardiologists feel better, it's not generally the position of the ADA that antibiotics are even needed. As mentioned above, we don't use antibiotics every time we release bacteria and possibly cause bleeding when brushing or flossing. Additionally, several years ago my daughter had two baby teeth pulled that were firmly entrenched in her gums, and the oral surgeon simply required that her INR be below 3.0 for the procedure. Even though her INR was 2.9 the morning of the procedure, she had no bleeding at all.

 

[Happy Camper]

My daughter, who received a mechanical mitral valve at 9 years of age, has had braces twice since her replacement. With all that orthodontic work, she has never taken antibiotics prior to the treatments. She does take 2000mg of amoxycillin 1 hour prior to each dental cleaning, but her dentist/orthodontist has told me that while it makes the cardiologists feel better, it's not generally the position of the ADA that antibiotics are even needed. As mentioned above, we don't use antibiotics every time we release bacteria and possibly cause bleeding when brushing or flossing. Additionally, several years ago my daughter had two baby teeth pulled that were firmly entrenched in her gums, and the oral surgeon simply required that her INR be below 3.0 for the procedure. Even though her INR was 2.9 the morning of the procedure, she had no bleeding at all.

Glad it went well. Sometimes reading the guidelines on prophylaxis etc. gives me a dreadful feeling that it's a 100% chance that I will get endocarditis if I don't do this and this... of course it's not that simple.

 

[Warrick]

Yep, I know a local guy who got endo due to his teeth and now has a mechanical valve, he’s intellectualy handicapped and his teeth must have been absolutely shot and uncared for as they ripped them all out rather than risk a reoccurrance.

Ive also read of people getting endo from mosquito bites and we don’t premed for those

 

[tom in MO]

If you want reassurance, ask your cardiologist.

For the future, my cardio and dentist says to take the 2-g right before the procedure. The most current treatment guidelines I've read says for a mechanical valve in the aortic position that's the way to go. If you handle amoxicillin, they can use another antibiotic. I'd check with my cardio rather than a dentist on these types of things. If you get bleeding after the cleaning next time you might want to check with the cardio if you should continue on the antibiotics.

As an aside, I've never had that type of bleeding after a "heavy cleaning" and I have plaque problems as well. You might want to find a new dentist. That level of bleeding from a cleaning doesn't seem right.