Endocarditis and bicuspid valve

[jadams]

Hi All,

Went to see my dentist who recommended to take all 4 wisdom teeth out. I have a bicuspid aortic valve and I am planning to have my aortic valve surgery in April. Based on your experience (if any) is it better to do the extractions now or do it after the surgery? Also, would you suggest maintaining the wisdom teeth using fillings or get them extracted? Read a lot about IE (endo) and just want to make a right decision.

Also, does Bicuspid valve expose you to higher risk for Endocarditis after invasive dental work even with antibiotics cover? Anyone has any experience or know of anyone that had Endocarditis with a bicuspid valve and was it due to any dental work after taking the prophylactic antibiotics?

Thanks very much

 

[pellicle]

Hi

extractions are regarded as less of a problem than dental cleans. Imagine that your teeth are covered in a film of bacteria (but your gums not so much, then look at that as scraping the old paint off a bunch of chairs in your living room vs just picking them up and taking them outside.

does Bicuspid valve expose you to higher risk for Endocarditis after invasive dental work

to the best of my understanding the most important aspect is if you've had your valve operated on or not. There's nothing in your bio (except a rather useless point of your birthday being the same as racehorses, a year would help, the date of the month is irrelevant). However what's there implies you've had AVR (so clearing that up would help).

If you have not had surgery then you are less exposed to the higher risk of endo and are about par with the general population. This is because your endothelial lining in the heart has not been cut (and therefore have scar tissue).

even with antibiotics cover?

I've not read any studies but it would seem to me that as long as you have the cover at the right timing pre the appointment (half life of amoxicillin is short) you'll have the best chance of anyone of not getting (what is really quite rare).

If I were you I'd take the cover anyway.

Best Wishes

 

[MdaPA]

Went to see my dentist who recommended to take all 4 wisdom teeth out.

Did your dentist say why? i.e. are they causing a problem or expected to in near future?

 

[jadams]

Hi

extractions are regarded as less of a problem than dental cleans. Imagine that your teeth are covered in a film of bacteria (but your gums not so much, then look at that as scraping the old paint off a bunch of chairs in your living room vs just picking them up and taking them outside.


to the best of my understanding the most important aspect is if you've had your valve operated on or not. There's nothing in your bio (except a rather useless point of your birthday being the same as racehorses, a year would help, the date of the month is irrelevant). However what's there implies you've had AVR (so clearing that up would help).

If you have not had surgery then you are less exposed to the higher risk of endo and are about par with the general population. This is because your endothelial lining in the heart has not been cut (and therefore have scar tissue).



I've not read any studies but it would seem to me that as long as you have the cover at the right timing pre the appointment (half life of amoxicillin is short) you'll have the best chance of anyone of not getting (what is really quite rare).

If I were you I'd take the cover anyway.

Best Wishes

Thanks Pellicle for your response. Sorry I am new to this so wasn't able to establish my profile correctly. I am 42 years old. Haven't had any surgery yet but it will be in April due to aortic valve regurgitation.

I am going to take the cover as you suggested. The treatment plan comprises of cleaning first, an implant and 4 wisdom teeth extractions in this order. I wanted to ensure i am doing everything to cover all my basis.

 

[jadams]

Did your dentist say why? i.e. are they causing a problem or expected to in near future?

Hi MdaPA,

Yes, there are some carries and he thinks to get them out now before they cause issues after the surgery. For most folks wisdom teeth causes issues since they are not well maintained due to their positioning and they are just extra teeth that doesn't assist in chewing or anything else. Hope this helps.

 

[MdaPA]

Yes, there are some carries and he thinks to get them out now before they cause issues after the surgery.

Normally, dental clearance is required prior to OHS so you should get any recommended dental work completed sooner rather than later.

 

[hostapasta]

Hi All,

Went to see my dentist who recommended to take all 4 wisdom teeth out. I have a bicuspid aortic valve and I am planning to have my aortic valve surgery in April. Based on your experience (if any) is it better to do the extractions now or do it after the surgery? Also, would you suggest maintaining the wisdom teeth using fillings or get them extracted? Read a lot about IE (endo) and just want to make a right decision.

Also, does Bicuspid valve expose you to higher risk for Endocarditis after invasive dental work even with antibiotics cover? Anyone has any experience or know of anyone that had Endocarditis with a bicuspid valve and was it due to any dental work after taking the prophylactic antibiotics?

Thanks very much

FWIW, I was just at the dentist last week. OHS with a bicuspid replaced early September. Surgery had me not have a scheduled cleaning before and made me hold off for (90?) days afterwards.
Cleaning was only interesting in that (I took my 4 amoxy pills an hour before) my dentist is dental faculty at our university. He was telling me the history of how doctors used to write full regiments of antibiotics for just about anything pre-dental. He said there was a real rebellion from the dental world and they've cut it down a good bit. He won't write the prescription as he doesn't want to be liable.

He said all the surgeons for hip/knee replacements now are all writing antibiotic scripts, even though the ADA (american dental association) and the AMA (american medical association) have put out guidelines that it's not needed at all. As pellicle pointed out, the risk is very low for an infection.

This just reminded me of a microcosm of the ebb and flow, and slow reaction time, of the various medical disciplines and advancements. (slow advancing, on our personal time scale, is still better than a good bleeding and the doctor tasting your urine for a diagnosis .

 

[pellicle]

Good morning and welcome to the forum btw ... didn't pay attention to that detail last night

.. I am 42 years old.

handy to know (although not so much for this topic)

Haven't had any surgery yet but it will be in April due to aortic valve regurgitation.

Right ... that makes the difference, but in this particular case not so much because you haven't had surgery. I asked because your "about" (bio) is where people (should) go to when answering questions (because everyone can't know all the things about each person like they know themselves). Currently your "about" seems to suggest you've already had AVR.

Surgery: AVR

Anyway, good luck with that in April

I am going to take the cover as you suggested. The treatment plan comprises of cleaning first, an implant and 4 wisdom teeth extractions in this order. I wanted to ensure i am doing everything to cover all my basis.

so yes, with such a situation I'd suggest that the likelihood of you having calcification (which provides nooks an crannies for a happy little planktonic bacteria to settle down and become sessile and grow a great little colony.

Such a thing could exactly set you up for endo after your surgery, and it may indeed go unnoticed prior to surgery without (say) CRP and/or white blood cell tests to identify any elevated situations implying (not identifying) a (possible) infection.

So by all means take that cover 1 hour prior to the procedure.

2mg

I note a total absence of questions about valve choice, which I'm taking to mean that you are across that and comfortable with your choice. I applaud that.

Best Wishes

 

[jadams]

Good morning and welcome to the forum btw ... didn't pay attention to that detail last night


handy to know (although not so much for this topic)


Right ... that makes the difference, but in this particular case not so much because you haven't had surgery. I asked because your "about" (bio) is where people (should) go to when answering questions (because everyone can't know all the things about each person like they know themselves). Currently your "about" seems to suggest you've already had AVR.

Surgery: AVR

Anyway, good luck with that in April



so yes, with such a situation I'd suggest that the likelihood of you having calcification (which provides nooks an crannies for a happy little planktonic bacteria to settle down and become sessile and grow a great little colony.

Such a thing could exactly set you up for endo after your surgery, and it may indeed go unnoticed prior to surgery without (say) CRP and/or white blood cell tests to identify any elevated situations implying (not identifying) a (possible) infection.

So by all means take that cover 1 hour prior to the procedure.

2mg

I note a total absence of questions about valve choice, which I'm taking to mean that you are across that and comfortable with your choice. I applaud that.

Best Wishes

This is scary. So you are suggesting even with the cover I may get infected and wouldn't know? In this case it can harm the replaced valve as well.

I was told Endo usually impact in the first 2 weeks of any dental procedure and was hoping i have enough time between getting the dental work and the surgery to know any symptoms.

 

[pellicle]

Hmm

This is scary.

not sure how I communicated so "badly" that you got this take, I suspect you're conflating some things.

So, lets look at condoms ... timing when you wear it is important. Same with taking oral antibiotics as a prophylaxis is timing.

The half life is short ... TAKE IT AS DIRECTED

So you are suggesting even with the cover I may get infected and wouldn't know?

No, I'm saying that if you didn't take it and you got infected you may not know it ... BUT YOU ARE TAKING IT right?

In this case it can harm the replaced valve as well.

yes, IF YOU GOT ENDO FROM NOT TAKING then it MIGHT RESULT in you having an undiagnosed case .. FROM NOT TAKING IT

I was told Endo usually impact in the first 2 weeks of any dental procedure

That might be, but it might also be longer ... infections can be strange and unexpected things.

and was hoping i have enough time between getting the dental work and the surgery to know any symptoms.

just take the stuff as directed ... not 3 hours before, not 2 hours after.

Just like a condom ... put it on before so that it covers you for the action.

absorption is rapid

Absorption: Amoxicillin exhibits stability in the presence of gastric acid and is rapidly absorbed after oral administration, with average peak blood levels typically reached within 1 to 2 hours.

Elimination: Amoxicillin has an approximate half-life of 61.3 minutes, and about 60% of the administered dose is excreted in the urine within 6 to 8 hours.

So just take exactly it as directed.

PS: I think I get it ...
here I was evaluating what MIGHT happen IF YOU DIDN'T TAKE IT because for BAV (not having had any OHS) its normally not given, and because you are having surgery (...I assume that...) you're being directed to take it as a prophylaxis (precaution). So I mused:

so yes, with such a situation I'd suggest that the likelihood of you having calcification (which provides nooks an crannies for a happy little planktonic bacteria to settle down and become sessile and grow a great little colony.

the reason why you'd take it ...

Such a thing could exactly set you up for endo after your surgery, and it may indeed go unnoticed prior to surgery without (say) CRP and/or white blood cell tests to identify any elevated situations implying (not identifying) a (possible) infection.

So by all means take that cover 1 hour prior to the procedure.

but in the end i was back to assuming you were going to take it.

HTH

 

[jadams]

Hmm



not sure how I communicated so "badly" that you got this take, I suspect you're conflating some things.

So, lets look at condoms ... timing when you wear it is important. Same with taking oral antibiotics as a prophylaxis is timing.

The half life is short ... TAKE IT AS DIRECTED


No, I'm saying that if you didn't take it and you got infected you may not know it ... BUT YOU ARE TAKING IT right?



yes, IF YOU GOT ENDO FROM NOT TAKING then it MIGHT RESULT in you having an undiagnosed case .. FROM NOT TAKING IT


That might be, but it might also be longer ... infections can be strange and unexpected things.



just take the stuff as directed ... not 3 hours before, not 2 hours after.

Just like a condom ... put it on before so that it covers you for the action.

absorption is rapid

Absorption: Amoxicillin exhibits stability in the presence of gastric acid and is rapidly absorbed after oral administration, with average peak blood levels typically reached within 1 to 2 hours.

Elimination: Amoxicillin has an approximate half-life of 61.3 minutes, and about 60% of the administered dose is excreted in the urine within 6 to 8 hours.

So just take exactly it as directed.

PS: I think I get it ...
here I was evaluating what MIGHT happen IF YOU DIDN'T TAKE IT because for BAV (not having had any OHS) its normally not given, and because you are having surgery (...I assume that...) you're being directed to take it as a prophylaxis (precaution). So I mused:


the reason why you'd take it ...


but in the end i was back to assuming you were going to take it.

HTH

Thanks so much for clarification

Yes taking care of this stuff tomorrow with the administration of 2g Amoxicillin an hr before the dental work.

Appreciate you taking the time to explain in such detail.

 

[pellicle]

Thanks so much for clarification

yeah, sorry about the confusion; definitely guilty of not making clear what was going on in my head.

Best wishes

 

[dornole]

Having just had valve replacement- yes there is a dental clearance. I had a loose tooth and was required to have it removed prior to surgery (this was about 2-3 weeks before). They also told me no dental work for at least 3 months after. So if you’re doing it I would get it done asap and give yourself time to recover before you need the heart surgery.

 

[Chuck C]

Hi and welcome to the forum.

is it better to do the extractions now or do it after the surgery?

It sounds like you are getting your dental procedure today and have already decided to get the dental work done before surgery. In my view, you are making the correct decision, as it is better to get the dental work done prior and give time for things to heal up before getting valve surgery. The period following surgery is probably the time when you are at greatest risk, given the nice home for bacteria created as the sutures heal. I was told that I should wait at least 3 months after valve surgery before getting any dental work or cleaning, and best to get both work and cleaning done prior to surgery, which I did.

Also, does Bicuspid valve expose you to higher risk for Endocarditis after invasive dental work even with antibiotics cover?

It appears that you are pre-medicating with 2,000mg of amoxicillin. This is exactly what I would do, and this is exactly what I did, in fact, do. You and your dentist have already made the decision to pre-medicate, but I'll add some comments here for the benefit of others who might stumble upon this thread in the future.

Before 2007, it was standard procedure to pre-medicate with 2,000mg of amoxicillin about 1 hour prior to any dental work or cleaning for both 1)patients with valve disease who had not yet had surgery and 2) patients who had already had their valve surgery and now have a prosthetic heart valve. This was in the ADA guidelines. But, guidelines often change and in the new 2007/2008 guidelines this was modified. The new 2007/2008 guidelines recommended that pre surgery patients with valve disease no longer take amoxicillin prior to dental work/cleanings, but they continued to recommend that patients premedicate with 2,000mg of amoxicillin if they were post surgery and had a prosthetic valve prior to dental work/cleanings. An important nuance: their reasoning was not because it was believed that there was no benefit to pre-medicating for these pre-surgery patients, but that there was not sufficient evidence that the benefit outweighed the negative to society of over prescribing anti-biotics, which many believed, perhaps with good reason, was a growing problem. But, that does not mean it was settled and it is not- there are two camps currently regarding the premedication of pre-surgery valve disease patients.

Although the risk of endocarditis is higher for post surgery patients with prosthetic valves compared to pre-surgery patients with valve disease, those who are pre-surgery are still at significantly greater risk for endocarditis than the general public when undergoing dental work. So, many dentists and cardiologists still recommend anti-biotics prior to dental work, even if the valve disease patient is pre-surgery. My dentist is in this camp. Once I was diagnosed with aortic stenosis, he had me pre-medicate with amoxicillin prior to each cleaning or other dental procedure, although we did have a discussion about the guidelines and he indicated that if I preferred to follow the guidelines and not pre-medicate that it would be my choice. As far as how much the antibiotics did to lower my risk of contracting endo at that time, we just don't have the data to say with any precision. However, the very minimal downside risk of taking one dose of amoxicillin would almost certainly be worth the potential of preventing endocarditis in the mind of my dentist and, from what I understand, many cardiologists. I share this view, and thus would fully endorse the decision of you and your dentist to pre-medicate with antibiotics prior to this procedure.

With that, wishing you the very best of luck with today's dental extractions and with your upcoming valve surgery in April.

 

[danielwoz]

Hi All,

Went to see my dentist who recommended to take all 4 wisdom teeth out. I have a bicuspid aortic valve and I am planning to have my aortic valve surgery in April. Based on your experience (if any) is it better to do the extractions now or do it after the surgery? Also, would you suggest maintaining the wisdom teeth using fillings or get them extracted? Read a lot about IE (endo) and just want to make a right decision.

Also, does Bicuspid valve expose you to higher risk for Endocarditis after invasive dental work even with antibiotics cover? Anyone has any experience or know of anyone that had Endocarditis with a bicuspid valve and was it due to any dental work after taking the prophylactic antibiotics?

Thanks very much

Scarred tissue is much more likely to get infected hence the best practice of anti biotic cover for post valve replacement surgical patients. I think your dentist is right if there's anything you can do pre-op that is *reasonably* predictable, get it done.

Saying that, I'd guess/bet/suggest the health outcome percentage changes are A. Hard to prove, B. Single digit percentages.

Don't think there's anything to lose in trusting your dentist opinion though. Maybe some money?

 

[Chuck C]

Don't think there's anything to lose in trusting your dentist opinion though. Maybe some money?

Amoxicillin is super cheap. I recently picked up 30 tablets at Costco. The price at Costco was $8.97 (no insurance adjustment). That's only 30 cents per 500mg tablet. So, a 2,000mg dose prior to my cleaning last week was only about $1.20.

 

[Chuck C]

Relative to this discussion, this 2023 review is worth a read.
They present data suggesting that pre surgery BAV(biscuspid aortic valve) and MVP(mitral valve prolapse) patients are at high risk of developing endocarditis. They recommend that the guidelines be changed back to pre 2008 guidelines (or pre 2015 guidelines in EU) for said BAV and MVP patients. The pre 2008 guidelines (in the US) recommended prophylactic antibiotics (AP) for BAV and MVP patients. Currently, the guidelines recommend prophylactic antibiotics only for high risk patients, such as post surgery patients with prosthetic valves, but not for moderate risk patients, which would be presurgery BAV and MVP individuals, based on current classifications of risk. The authors recommend reclassifying BAV and MVP patients from moderate risk to high risk and resume premedication for these individuals. Clearly, many dentists and cardiologists are already doing this, including the dentist of the OP and my dentist.

Recent infective endocarditis research findings suggest dentists prescribe prophylactic antibiotics for patients having abicuspid aortic valve or mitral valve prolapse

"Conclusions: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the “high risk”category so that AP are recognized as being needed prior to provision of HRDP."

https://www.medicinaoral.com/medoralfree01/aop/25984.pdf

 

[pellicle]

Hey Chuck

Recent infective endocarditis research findings suggest dentists prescribe prophylactic antibiotics for patients having abicuspid aortic valve or mitral valve prolapse

"Conclusions: Patients having either a BAV or MVP are at significant risk of developing IE and suffering serious sequelae including death. The ESC guidelines must reclassify these specific cardiac anomalies into the “high risk”category so that AP are recognized as being needed prior to provision of HRDP."

this is really good to read as it backs up my conjecture here ... what I said above and some emphasis:

so yes, with such a situation [having a diagnosis of BAV] I'd suggest that the likelihood of you having calcification (which provides nooks an crannies for a happy little planktonic bacteria to settle down and become sessile and grow a great little colony.

Such a thing could exactly set you up for endo after your surgery [if it was done just prior to surgery], and it may indeed go unnoticed prior to surgery without (say) CRP and/or white blood cell tests to identify any elevated situations implying (not identifying) a (possible) infection.

So by all means take that cover 1 hour prior to the procedure.

In the above I was speaking generally

This study also perhaps (in the light of my above conjecture being correct) that Endo (and other blood infections) occurs not only because the (endo) patient had a bacteria "pulse" go through their blood, but also posessed some defect in their endothelia such as:

• arterial plaques
• valve surface calcification
• scar tissue in an artery or vein

Perhaps this is well known ... dunno

 

[dornole]

I mean, with rheumatic heart disease (which I have) the valves are severely scarred and gnarly. Def seems like a risk.