What do do when ALL your doctors have a differant opinion on pre-medication after OHS

[jake]

So here is the deal......

I have been putting off pulling of a pair of wisdom teeth for the last year because of fear of infection after a repair of my ascending aorta 18 months ago. I still have my bi-cusped aortic valve and before OHS to repair my aorta, I never pre-medicated. The surgeon deemed my bi-cusped to be more than adequate and likely able to last a lifetime, or at least longer than a Pig or cow valve. With than said, the issue of pre-medication is now becoming a real issue for me at the dentist office.

There is so much debate, grey area, lack of consensus, whatever you want to call it, about pre-medication for folks who have had aortic repairs WITHOUT mechanical valves. Everyone has a different opinion and there don’t seem to be current guidelines.

The surgeon says "pre-medication for life" and the cardiologist says "pre-medication for at least the first year as per AHA guidelines."
I can find absolutely no published pre-medication protocols for dental work on people with aortic repairs, only for valve replacements and bypass recipients. I’m not a pario patient and have great teeth and no gum disease and my wisdom teeth are not infected. My Wisdom tooth is just getting in the way of stuff and is uncomfortable and they need to come out.

Add to this that I have had to have a few routine dental procedures done because of a problem with a root canal over the last year, and have discovered that Amoxicillin simply does not agree with me and my Gastro tract. There was a time when my dentist had me going for evaluations to an endodontist for examination, re-treatment and more examination to the tune of like 4 pre-medications in a two week period to the tune of 2 grams (4 tabs) of Amoxicillin each visit. The result was almost 8 months of horrible reflux, gas and bloating!

Than the doctor says "lets change you to clindamician" a different pre-med, but the oral surgeon says that this stuff is REALLY hard on the gastro tract and wont sanction its use as an alternative for the extraction. He said that amoxicillin is the only stuff he will use for pre-medication, PERIOD! The oral surgeon refuses to consider any other pre-medication than Amoxicillin for the initial extraction. He says that he does not care what the doctor wants me to take AFTER the extraction, but before, 2 grams of amoxicillin or he won’t do the extraction. He states that gastro discomfort is one thing, but endocarditis is far more his concern and that gastro problems are a minor inconvenience. The Gastro doctor says to take prevacid with the amoxicillin to reduct the impact of the amoxicillin on my gastro tract. Now I am REALLY confused!!!!!!!

So I’m not looking for absolution but what does one do when everyone on your health care team is on a different page and the American Heart Association does not have any clear or current guidelines for us folks with aortic graft material 1+ year post operatively and have our native, all be it bi-cuspid, valves.

What am I looking for?

I am looking for anyone who has the same or a similar situation as I do. Not the dental problems, but hey, we ALL go to the dentist dont we? I cant be the first guy to run across a problem like this can I? What do you have to do when you need dental work? What do you understand your pre-medication responsibilities to be? I already know what the artificial valve folks have to do, that is spelled out very clearly, I am more interested in those who are, like me, in the gray area.

 

[Adrienne]

You could try taking probiotics once you finish the antibiotics. I have heard that people who previously had gastro problems with antibiotics were greatly relieved if they took probiotics.

 

[ElectLive]

You clearly have done some research, and as you've found, you are in a unique situation. Even for the more typical prosthetic valve situation, there may be fairly recently updated guidelines now (Prevention of Infective Endocarditis: Guidelines From the American Heart Association - 2007 and ACC/AHA 2008 Guideline Update on Valvular Heart Disease: Focused Update on Infective Endocarditis), but it is still not a resounding consensus. The guidelines even include a comment to individual practitioners to the effect of "ignore [the new guidelines] if you are more comfortable doing so". That's not word for word, but I'm not kidding, it's in there. So, what's left then, for patients like you, or anyone else in similar shoes, may be more interpretation and extrapolation, which could go in either direction depending who you ask, as you've found.

As you've probably already guessed, I don't have the personal experience of similar circumstances you are hoping for. Even if I did, though, it wouldn't be any more conclusive. But I do have one small suggestion. I would look to the list of Writing Committee members who put together the ACC/AHA guidelines and contact one or more about your case. They are supposed to be the absolute experts in this area, so if it were me, and I knew someone would be interpreting and extrapolating my well-being, I would want it to be an absolute expert in the field, someone most knowledgeable about all the clinical data, or lack thereof.

I'm treading dangerous water, here, but between the lines, your situation might actually be included in the guidelines, particularly the first one I mentioned, just not explicitly. There is a very in depth discussion of the formation of endocarditis and the interaction with a host of cardiac conditions and different types of prosthetic material. If endothelialization of the prosthetic material falls within a normal 6 month range, with no residual defect from the repair, then the guidelines say pre-medication not necessary. My layman's understanding of aneurysm repair would say this might just be the case. I'm certainly no expert, but as I said earlier, there are certainly those that are who you could try to contact.

I'm much more of a textbook case since I have a prosthetic valve, and by the way, valve type doesn't matter. My surgeon said I didn't need to pre-medicate, and my cardiologist says I should. The guidelines say I should. I trust my surgeon the most, though. So, what do I do? I'm sticking with the guidelines and will pre-medicate until they say not to. I'm not convinced it's helping, nor am I convinced it's hurting. It's just one of those things, you have to go one way or the other, so I'm going with the evolution of expert opinion.

I guess one bright spot to point out about all of this is that endocarditis risk is overall very low, and likely more so for a controlled dental procedure (for those with prosthetic valves, it's estimated to be 1 in 114,000)! One of the reasons there is such a "gray area" is that there is such a limited number of cases (clinical data) to evaluate. Best wishes!

 

[Garserin]

Jake,
I had valve-sparing aortic root replacement last year and my surgeon at Mayo wants me to pre-medicate for life with 2000mg of amoxicillin before dental procedures.

 

[ejc61]

I only had mitral valve repair and my surgeon, previous cardio,current cardio and even dentist said to premedicate with 2000 mg amoxicillin. It costs like $5.00. I wouldn't take the risk of not premedicating.

 

[Lynlw]

here's the aha card wih guidelines of different meds that are reccomend, (different oral, IV or Im for those wh cant take oral etc) if thed at helps http://www.heart.org/idc/groups/heart-public/@wcm/@hcm/documents/downloadable/ucm_307684.pdf

americanheart.org
Situation Agent
Regimen—Single Dose
30-60 minutes
before procedure
Adults Children
Oral Amoxicillin 2 g 50 mg/kg
Unable to
take oral
medication
Ampicillin OR 2 g IM or IV* 50 mg/kg IM
or IV
Cefazolin or
ceftriaxone 1 g IM or IV 50 mg/kg IM
or IV
Allergic to
penicillins or
ampicillin—
Oral regimen
Cephalexin**† 2 g 50 mg/kg
OR
Clindamycin 600 mg 20 mg/kg
OR
Azithromycin or
clarithromycin 500 mg 15 mg/kg
Allergic to
penicillins or
ampicillin and
unable to take
oral medication
Cefazolin or
ceftriaxone† 1 g IM or IV 50 mg/kg IM
or IV
OR
Clindamycin
600 mg IM
or IV
20 mg/kg IM
or IV
*IM—intramuscular; IV—intravenous
** Or other first or second generation oral cephalosporin in equivalent
adult or pediatric dosage.
† Cephalosporins should not be used in an individual with a history of
anaphylaxis, angioedema or urticaria with penicillins or ampicillin