How to prevent endocarditis?

[rakesh1167]

Hi,
I will be going through AVR within 6 months, have decided to go with mechanical valve(32 years old). I want to go with ON-X valve, but not sure if they do that in India. Contacted ON-X through message, but they are not replying. Any help here would be appreciated.

But more than surgery, it is the thought of endocarditis that is scaring me. I used to have bloody gums, then had 4 wisdom teeth extracted last year. It is much better now, but still now i get blood in gums during brushing of teeth occasionally(if i press it hard). I will go to dentist again to get couple more teeth extracted if required. But i have a feeling that occasional blood in gums can't be avoided.
What precautions do you take to avoid this disease? I know dental hygiene is required, but how exactly.
1) Rinse with Lysterine for 2 minutes before and after brush during morning and evening. Is this good enough to clean your teeth regularly.

How often do you guys go to dentist? Each trip to dentist carries risk of endocarditis(not to mention messed up INR due to antibiotics), but if you don't get it checked regularly enough then also there is a risk.
2)So what is the criteria to go to dentist?

3)How risky are normal cuts and bruises?

I have a feeling that this disease is going to kill me one day, they almost always cause emergency redo in case of mechanical valves.

 

[pellicle]

Hi

Hi,
.... I want to go with ON-X valve, but not sure if they do that in India. Contacted ON-X through message, but they are not replying. Any help here would be appreciated.

while On-X are well invested in advertising and marketing presence, to be honest there is very little to differentiate the major pyrolytic carbon valves. St Jude has an established track record and Medtronics too is good. Seriously one or the other each has advantages, all of which are miniscule.

But more than surgery, it is the thought of endocarditis that is scaring me.

its shouldn't its really an unlikely thing ... about 3%

but still now i get blood in gums during brushing of teeth occasionally(if i press it hard). I will go to dentist again to get couple more teeth extracted if required. But i have a feeling that occasional blood in gums can't be avoided.

firstly don't press hard. Go see a dentist or dental hygnist and get instructions on how to clean your teeth. Some people I have observed seem to be acting like a boilermaker scraping rust off a drum. First tip: use a toothbrush which is classified as soft.

1) Floss with Lysterine for 2 minutes before and after brush during morning and evening. Is this good enough to clean your teeths regularly.

yes, it is, that's the primary thing

How often do you guys go to dentist?

I go for cleans about every 6 months.

Each trip to dentist carries risk of endocarditis(not to mention messed up INR due to antibiotics

not if you take some antibiotics before the visit to the dentist. 1000mg of Amoxicillin 1 hour before is normal prevention

It will make no observable difference to your INR (so that's one more myth in the rubbish bin)

3)How risky are normal cuts and bruises?

absolutely insignificant

I have a feeling that this disease is going to kill me one day, they almost always cause emergency redo in case of mechanical valves.

unlikely to be an issue

http://www.jtcvsonline.org/article/S...035-8/abstract

Replacement valve endocarditis occurred in 3.7% of 2443 patients who underwent primary or redo aortic valve replacements...

http://www.clevelandclinicmeded.com/...-endocarditis/

...and occurs in 1% to 3% of patients after valvular heart surgery.

so as you will see that the incidence of endocarditis is uncommon.

deal with what is actually before you, do not imagine or conjure up potential threats. You'll be fine.

Most important it to properly deal with your INR which is not hard. I strongly urge you to get a Coaguchek (as you seem to live in India) as that's the best way to manage your INR.

My blog posts on that:
http://cjeastwd.blogspot.com/search/label/INR

Best Wishes

 

[rakesh1167]

Thanks pellicle for another informative post. Yes, i have been following your blog post and posts, and yes i will buy Coagucheck and planning to check INR weekly.
I want to do everything under my control to deal with current situation in a best possible way.

 

[pellicle]

Hi

Thanks pellicle for another informative post.

you are welcome. Glad to help make the transition to managing ones post-AVR life as smooth and unstressed as possible. I wish I could have been there for me back in 2011...

I want to do everything under my control to deal with current situation in a best possible way.

that's the spirit and that's the best course. In so many ways we are each our most important team member. The Health Professionals are of course critical at points, but it is in the good long term case management of the other things upon which hinge the best long term outcomes.

BTW, I usually take my warfarin in the evenings, and so if dentist appointments are more typical daytime events, the its well past the intake of antibiotics that I have my warfarin. This should minimise any potential for interaction. I personally have never noted any change in INR which is substantial or could be unambiguously attributed to the Antibiotics. Your experience may vary, but then thats why its good to have the INR measurement tools ... to know for ourselves rather than just speculate or guess.



PS: have a read of the GELIA study, as they suggest that all of the pyrolytic carbon valves are more or less equal in requirement of reduced AntiCoagulation Therapy INR targets. So while On-X have led this campaign I expect that we will see a trend downards in target INR for low risk patients (low risk means only on ACTherapy because of the valve).

we conclude that low-intensity anticoagulation with a target INR of 2.0 to 3.5 is safe for patients with SJM prostheses in the aortic position as well as the mitral position.

I wonder if this link will work?

 

[epstns]

Rakesh - my dentist takes a more conservative approach. I go in for dental cleaning 4 times/year. We have found that in my case, the biofilm (that drek that clings to your teeth) is just beginning to become an issue at 3 months, so I have it professionally removed 4 times a year. Each time, prior to cleaning, I take 600 mg of clindamycin, 1 hour prior to the appointment.

My point in sharing this detail is that there really is not a hard and fast "rule" about how often to have your teeth professionally cleaned. Each of us is different, and we must work with our dental professionals to determine what is right for us. The old "once a year" though, will not be enough once you are determined to be at risk of endocarditis (which, technically you are already due to advanced stenosis).

 

[AZ Don]

I don't have references handy but from reading about this it is my understanding that the risk at a dental visit is little more than the risk you have everyday (in both cases risk is low), and I think this is at least part of the reason antibiotics are not recommended for as many situations as they used to be. For example, the guidance used to be prophylactic antibiotics for those with BAV, but that was dropped from the guidance not so long ago. I think the risk comes from bleeding gums. The best way to deal with that is more frequent cleanings and/or a deeper cleaning. I go for cleanings every 3-4 months to stay on top of things. Less often and my gums get worse, but then I neglected them somewhat in my younger days and I think I'm paying the price for it now.

A possible way to reduce risk is Listerine before something that makes your gums bleed, whether that be a trip to the dentist or flossing at home. The idea being that the listerine kills the bacteria before it can get into the bloodstream.

 

[rakesh1167]

epstns I have regurgitation and not stenosis. But i think it would still put me at risk of endocarditis.

 

[rakesh1167]

AZ Don Even i ignored my gums in my younger days. It sucks when you have a valve disease(i came to know about it only 3 years back). I still have couple of months, so i will get them thoroughly cleaned and if need arises, get problematic ones extracted.

 

[epstns]

epstns I have regurgitation and not stenosis. But i think it would still put me at risk of endocarditis.

I believe that you are still in the group that is considered "higher risk" for endocarditis. I have been told that for various medical procedures (colonoscopy, biopsy, etc.) that any patient with coronary valve disease or a pacemaker, or even a prosthetic bone implant, joint or other "foreign" materials in or attached to their bodies is considered a risk for endocarditis. I've always felt that in this case, it is better to be safe than sorry. I guess the choice may vary depending upon the patient's age, though, as some docs may be concerned about the lifetime impacts of frequent antibiotic use.

 

[Eva]

I go to the dentist four times a year for same reasons Steve mentioned. So, your dentist should be able to advise you how often to see him.
I, too, was always worried about endocarditis after my surgery. But with time, I'm more relaxed and don't think about it. Of course, I'm cautious and when. In doubt I check with my doctor.

Good luck.

 

[Paleowoman]

I went to the dentist yesterday. There was the funniest picture on display at the surgery which I couldn't resist taking a photo of:

I think with the dental problems I've had most of this year, kissing a donkey might have been more effective than seeing a dentist LOL Besides, I love donkeys

 

[tom in MO]

My GP told me that there is not a documented cause/effect case of endocarditis being caused by dental procedures. This was about 10 years ago. My cardio said a similar thing about 3-5 years ago. Both said the link was primarily intellectual, i.e., the majority of bacteria that cause endocarditis are found in the mouth, hence your endocarditis could have been caused by bacteria from your mouth. That being said, they don't tell you to take antibiotics before flossing, which can get some blood.

Both doctors said good tooth care is wise. The last article I read about post-operative care for heart valve patients indicated normal dental cleaning with antibiotics, but for cavity filling antibiotics were not required, my dentist disagrees and wants me on antibiotics for fillings. It did not recommended anything more than "normal" care, which I believe per insurance is every 6 months. Personally, the antibiotics disrupt my gut, so I am happy not going more often.

I know that if your teeth are rotten you can aspirate the bacteria into your lungs, someone I know needed part of his lung removed due to an incurable infection caused by his bad teeth. THe infection can also go up into your ears, another person I know went deaf in one ear due to ignoring a tooth infection.

 

[pellicle]

the comparison between flossing and dental calculus removal often comes up. The amount of bleeding and druation of bleeding plus the breaking up of plaque (releasing more bacteria) in calculus removal is orders of magnitude greater than flossing. Even in this training video (not designed to scare you,so mild on the bleeding) you can see bleeding in the gums occurring.



I rarely have bleeding of the gums when I floss (technique is important, some people I have watched seem to want to shred their gums), but when I get a calculus removal they always have the sucking thing in there to remove the saliva and blood. If anyone gets bleeding anything like that for cleaning or their teeth then I suggest you need to see your dentist.

 

[rakesh1167]

pellicle we can use 'waterpik' for flossing. I think it won't cause blood in gums(not sure through). I have ordered one. I find traditional flossing cumbersome.

 

[Paleowoman]

My dentist always uses ultrasonic cleaning. I rarely get any bleeding at all, don't know whether that is because of the ultrasonic technique or because my gums are okay.

 

[AZ Don]

While not all experts will agree with the American Heart Association Guidelines, I think they are a good place to start. I believe the latest is from 2007:
http://circ.ahajournals.org/content/116/15/1736.full.pdf

The document includes a discussion of the history and evidence behind the recommendations. A couple key points from the document:

Table 2. Primary Reasons for Revision of the IE Prophylaxis Guidelines
IE is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure.

Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.

The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.

Table 3. Cardiac Conditions Associated With the Highest Risk of Adverse Outcome From Endocarditis for Which Prophylaxis With Dental Procedures Is Reasonable
Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
Previous IE
Congenital heart disease (CHD)*
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first 6 months after the procedure†
Repaired CHD with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device (which inhibit endothelialization)
Cardiac transplantation recipients who develop cardiac valvulopathy

 

[QuincyRunner]

I guess I was one of the "exceedingly small number of cases" since I developed endocarditis from a teeth cleaning without the benefit of prophylaxis while having an existing heart murmur. Obviously I have serious problems with the latest AHA guidelines, which I blame for my near death experience. That and the fact that my dental hygienist used a new procedure that day, which I have dubbed as sand blasting, rather than the traditional flossing method. I don't much care for all the talk about the over use of antibiotics. I for one will take them every chance I get from now on.

 

[epstns]

I can only wish, Anne. My dental hygienist is reluctant to use their ultra-sonic system because they were told that it may interfere with my pacemaker. So, we do the old "dig it out" routine each time.

Also, my dentist wants me to pre-medicate for any "invasive" procedure -- anything that could result in gum or tissue damage. Fortunately, since my valve surgery, that has only been for cleaning, since the 4X/year cleaning has helped me to avoid any other issues. The part of my insurance that covers my dental work is very flexible - no limitations on how often services are covered. After I (finally) retire, then I'm on my own for dental expenses.

 

[cldlhd]

I guess I was one of the "exceedingly small number of cases" since I developed endocarditis from a teeth cleaning without the benefit of prophylaxis while having an existing heart murmur. Obviously I have serious problems with the latest AHA guidelines, which I blame for my near death experience. That and the fact that my dental hygienist used a new procedure that day, which I have dubbed as sand blasting, rather than the traditional flossing method. I don't much care for all the talk about the over use of antibiotics. I for one will take them every chance I get from now on.

I'm in the middle. I don't like the overuse of antibiotics for things like colds or farm animals but I think the newer recommendations against using them for a dental prophylaxis is the medical community worrying about the big picture possibly at the expense of the individual. They say you don't need it because it's a hard sell to tell someone they may be risking infection and death in order to prevent a potential future problem. I'm slightly paranoid about IE this week because for the 1st time in a long time I had a swollen gum this week. I take good care of the choppers- floss and brush twice and use mouthwash about 3 to 4 times a day- but perhaps I was a tad aggressive with the floss. Thought about calling the Dr for some antibiotics but instead I've just been using some hydrogen peroxide in addition to the usual routine.

 

[carolinemc]

Rakesh, just also keep an eye on the gums for redness, irriatation or tenderness, then see the dentist before surgery, And I would ask the cardio or dentist about the bleeding gums, not usual for gums to bleed for any reason. Hugs for today.