“Did you take your premedication?”
I hear these words almost every day. Someone on my amazing and responsible team is either reminding a patient to take their premedication or asking them at the appointment if they did remember. They’ve gotten really good at it because we’ve been doing it as long as I’ve been a dentist. Dentists have been acting as if dental procedures are inherently risky for developing heart problems or artificial joint infections in certain patient populations. It’s time to set the record straight.
Infective endocarditis is a scary sounding condition. It happens when bacteria get into the bloodstream and end up infecting the lining of the heart, a heart valve or even a blood vessel. It’s a very uncommon infection. People who have certain heart conditions are clearly at greater risk than the rest of the population. But the one thing everyone seems to know is that dental treatment is almost always the cause. We know this because the mouth is full of bacteria, and dentists and hygienists cause bleeding with their treatment. So bacteria is definitely going to enter the bloodstream if you have dental treatment and if you are at greater risk for infective endocarditis, you better look out.
So what have we done for dental patients with these heart conditions? We preventively treat them with antibiotics. A LOT of antibiotics. We used to give them doses of antibiotics days before and after dental treatment. But then later we dropped the dosage down to an hour before and several hours after. And now, we just give it an hour before.
But it’s O.K. Because we have solid evidence that our intervention prevents infective endocarditis at these levels, so it is worth doing, right? Well. Not really. The American Heart Association has continued to change its guidelines for premedication to the point where we only rarely premedicate patients with certain very serious heart conditions. For instance, we premedicate people who have had a previous case of infective endocarditis. Also folks with prosthetic heart valves and a few other rare congenital heart problems.
One of the more bizarre aspects of our tendency to premedicate our patients is the assumption that dental procedures in particular cause a great risk of bacteria entering the bloodstream. If you’ve ever bitten your tongue, flossed a little too hard or bitten down on a Dorito in the wrong way and caused a wound in your mouth, you’ve had an “event” that cause bacteria to enter the bloodstream. But you don’t see us lobbying Frito Lay to start lacing their corn chips with amoxicillin! The evidence for dental procedures causing infective endocarditis has always been a little thin. Patients treated for endocarditis (yes, thank goodness it’s very treatable) are always asked if they’ve had recent dental treatment. Some patients may have, so it was assumed that the dental treatment caused the infection. What I really want to know is if cardiologists are screening for nacho chips or beef jerky.
The American Heart Association continued to evaluate the evidence for taking a large dose of antibiotics prior to dental treatment and found little to no proof that the antibiotics prevented infective endocarditis. For that I say “three cheers for the AHA!” Many dentists and patients don’t think much about the megadose of antibiotics that their patients were routinely taking prior to routine dental treatments. What many don’t consider is that a hypersensitivity (allergic) reaction to antibiotics can happen at any time. Just because you aren’t allergic to amoxicillin now doesn’t mean you’ll alway s tolerate it. In fact, the more often you have to take it, the more chances you have to develop hypersensitivity to it. What I’m saying is even though taking antibiotics is common place for most people, there is still a risk involved. In fact, the AHA weighed the risk of taking a prophylactic dose of antibiotics agains the risk of developing infective endocarditis and determined that the risk was only worthwhile in a very select number of patients.
The AHA did what so many doctors, dentists and patients are unwilling or unable to do. They evaluated the evidence and changed their recommendations! Here at Mead Family Dental we follow the 2007 AHA guidelines for the very few patients that require premedication for a heart condition. A few patients who have been premedicating for a long time, find the change disconcerting. They assume that what they’ve been doing all along was correct and that the new recommendations are putting them at risk. However, most of these patients are tickled at the idea of not dealing with this premedication regimen.
A more complicated and less well defined problem is the risk of infection of artificial joints. I will tackle this problem the sequel to this post: “My surgeon told me to premedicate for life.”
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