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Medical Forum / General / Dentistry / November 2005Hip replacement premed antibiotics
I came across someone who had hip replacements and the hygienist asked me about premed, stating that she thought that it should be done within 5 years of the surgery. I looked it up, seeing that it should be within 2 years of surgery, but could have sworn I've seen it to be within only ONE YEAR of the surgery. Was it ever one year and they changed it to 2 years? Also I'm seeing some say you need the premed with a pacemaker, which I hadn't originally learned to do. I wish things would stay the same for awhile; these changes make my head spin. Another thing is I'm seeing about the biphosphonates, which includes fosamax, is that it carries a risk of osteonecrosis if an extraction is done; that's pretty scary stuff if you ask me; seems every little old lady is on the stuff. And you can't treat it with hyperbaric oxygen. I know it's worse with the IV biphosphoates, but also, I don't know if this is yet widely known by dentists at this point. ares > I came across someone who had hip replacements and the hygienist asked me > about premed, stating that she thought that it should be done within 5 years [quoted text clipped - 11 lines] > widely known by dentists at this point. > ares This does change. As far as premed for prosthetic joints, I leave it up to the orthopedist. Most recently I was told 1 year postop, but I wouldn't take it for granted. The bisphosphonate story is getting some attention, esp. by the surgeons. From my reading, the problem seems to be mostly with the IV-administered drugs. However, no one has said that orally administered drugs are without risk. I received an alert from Novartis about ONJ. They are the makers of Zometa, which is administered by IV infusion. Generally this is indicated in patients with metastatic cancer, rather than osteoporosis. Steve  Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } Ah, so you're not the only one that heard one year; the hygienist looked at me like I had 2 heads when I said that, but they're always looking at me like that anyway I guess. Yeah, I got the Zometa stuff too, and there's another one, maybe Aredia was the name? And Actonel is another one. And Paget's disease is another one they use it for; I hadn't heard about that disease since school! Oh, I think I've seen your name on the listserve where they were talking about it again. ares > This does change. > As far as premed for prosthetic joints, I leave it up to the [quoted text clipped - 15 lines] > "nospam" to reply\par > } >Ah, so you're not the only one that heard one year; the hygienist looked at >me like I had 2 heads when I said that, but they're always looking at me >like that anyway I guess. We charge double for that .... sorry. 64 teeth ........ >Yeah, I got the Zometa stuff too, and there's another one, maybe Aredia was >the name? And Actonel is another one. And Paget's disease is another one [quoted text clipped - 22 lines] >> "nospam" to reply\par >> } > Ah, so you're not the only one that heard one year; the hygienist looked at > me like I had 2 heads when I said that, but they're always looking at me [quoted text clipped - 6 lines] > about it again. > ares I first heard about bisphosphonates and ONJ from the bulletin board of oral pathology: http://www.sdm.buffalo.edu/bbop/ Steve Here is a link: http://www.cdho.org/Recommend.pdf I believe these recommendations come from the ADA and American Heart Association. or http://www.ada.org/prof/resources/topics/antibiotic.asp SignatureRoy rem NADA to reply | Ah, so you're not the only one that heard one year; the hygienist looked at | me like I had 2 heads when I said that, but they're always looking at me [quoted text clipped - 26 lines] | > "nospam" to reply\par | > } > Here is a link: > http://www.cdho.org/Recommend.pdf > > I believe these recommendations come from the ADA and American Heart > Association. I find it hard to believe that the orthopedic association would allow those wretched cardios to set their antibiotic prophylaxis regimen up for them. Steve > or > > http://www.ada.org/prof/resources/topics/antibiotic.asp SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 >I came across someone who had hip replacements and the hygienist asked me >about premed, stating that she thought that it should be done within 5 years [quoted text clipped - 4 lines] >originally learned to do. I wish things would stay the same for awhile; >these changes make my head spin. Look it up on The American Heart Association web site. They will even send you the cards free of charge. >Another thing is I'm seeing about the biphosphonates, which includes >fosamax, is that it carries a risk of osteonecrosis if an extraction is [quoted text clipped - 3 lines] >widely known by dentists at this point. >ares Refer to OMFS -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > >I came across someone who had hip replacements and the hygienist asked me > >about premed, stating that she thought that it should be done within 5 years [quoted text clipped - 22 lines] > Take out the G'RBAGE > wubbabubbazG@RBAGEyahoo.com We had a discussion on Dentalcom.net about Fosamax use and the risk for osteonecrosis in Nov. 2004. Here is the link if anyone is interested: http://www.dentalcom.net/forum/showthread.php?t=168&highlight=fosamax -Sue >We had a discussion on Dentalcom.net about Fosamax use and the risk for >osteonecrosis in Nov. 2004. Here is the link if anyone is interested: > >http://www.dentalcom.net/forum/showthread.php?t=168&highlight=fosamax > >-Sue Another catchy term is "Fossy jaw." Joel We had a discussion about the use of Fosamax and the risk for osteonecrosis in Nov, 2004. Here is the link ifn case anyone is interested: http://www.dentalcom.net/forum/showthread.php?t=168&highlight=fosamax Best regards, Sue I do not know how my post got posted so many times. Sorry! That was NOT intentional -Sue >I do not know how my post got posted so many times. Sorry! That was >NOT intentional -Sue NEVERMIND, we always like reading your posts, even the duplicates! Joel >I came across someone who had hip replacements and the hygienist asked me > about premed, There is no unified consensus on this matter. I will pre-medicate any joint replacement patient if the replacement is less than a year old. I get a hold of the orthopedic surgeon after that and ask if they want me to continue. I do whatever they ask at that time (so long as it is not too goofy). I try to suggest what drugs and what regimen to use, since the average physician does not really understand the oral flora nor the severity of bacteremia after various dental treatments. If at all possible, I will ask the physician what antibiotic they prefer the first time I treat their patient. Some seem very happy with AHA guidelines, others want Keflex for three days, some want a week of some antibiotic cocktail. Others don't want any at all. As I stated, if the implant is less than a year old, I will insist on AHA guidelines at the minimum. I do not believe there is any solid research supporting any antibiotic premedication protocol for dental treatment in prosthetic joint patients. Just cover your gluteus with adequate protection by asking the surgeon how he would prefer to have his patient treated. Signature/ Amatus / >I came across someone who had hip replacements and the hygienist asked me > about premed, stating that she thought that it should be done within 5 [quoted text clipped - 15 lines] > widely known by dentists at this point. > ares Ah,..... well, you're saying a year, which I thought it was, and now I'm seeing 2 years recommended on sites; that's pretty much what I was confused about. ares > >I came across someone who had hip replacements and the hygienist asked me > > about premed, [quoted text clipped - 41 lines] > > widely known by dentists at this point. > > ares In the UK, the general view is that antibiotics should not be prescribed for covering patients with joint replacements undergoing invasive dental treatment. Some orthopedics will insist on the dentist providing cover, but if anything goes wrong with the cover dentists are left defenceless. My 2 cents is that the whole issue of AB cover is a waste of valuable medication and has to be reconsidered - urgently. George > In the UK, the general view is that antibiotics should not be > prescribed for covering patients with joint replacements undergoing [quoted text clipped - 6 lines] > > George George-- I'm sympathetic to your attitude. When I first joined the dental society about '77 or '78, I wrote a letter to the editor--I believe it was JADA. In it, I speculated that we'd probably killed more people with antibiotic prophylaxis than we saved from SBE. The reaction was something like, "OK, cowboy, I'd like to see you ride that horse into court!" Things may be different in the UK, but I'm towing the line. In fact, (though I don't have the studies at hand) over the years I've read enough to convince me that there is a significant risk of infection for patients with valvular heart disease, and that antibiotics do in fact cut the risk of SBE in these patients. My sense is that this isn't as settled an issue for anachoresis in prosthetic joints. However, in a world where even nominal dentists like Dr. Kulacz think that dentists are a bunch of idiots, how can I make a clinical decision to go up against the cardiologists and orthopods on something like this? Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } > However, in a world where even nominal dentists like > Dr. Kulacz think that dentists are a bunch of idiots, how can I make a > clinical decision to go up against the cardiologists and orthopods on > something like this? > > Steve I love the way you write...thanks for making me laugh this morning. T Hi Steve, As dentists we are powerless to make these decisions. Someday, the cardiologists and other consultants should get a spine and reconsider their stance on AB cover. The truth is that bacterial endocarditis is an extremely rare disease, more rare than adverse reactions to antibiotic courses. Moreover, I think I've recently read that AB cover will prevent endocarditis in a limited number of cases (I think it was between 15% and 25%). Lastly, bacteremia is caused by many things apart from dental treatment, including flossing. I never heard anyone taking 3 gs of penicillin before flossing. These things have convinced me that any benefits of AB cover are very small and far outweighted by the risks. But as you said, it's not our call. George > Hi Steve, > [quoted text clipped - 13 lines] > > George I've looked (but not to any great degree) without success for papers available online written addressing the concerns of people with prosthetic TMJs and antibiotic coverage for dental care. It seems that in these cases, the maxillofacial surgeons who implant these devices would have an opinion to share with orthopedists and cardiologists. (I looked to the URL Roy provided and there was no reference to TMJ replaced joints and the dental patient. Webby > Hi Steve, > [quoted text clipped - 13 lines] > > George I feel your pain. Bill Clinton Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } My opinion may not be popular, but I will voice it anyway. If you were the cardiac surgeon who had to remove an infected valve or who lost one or more of your patients to bacterial endocardtits after performing a life saving surgery.... woudln't you want to make damn sure that precautions were followed? If you were the patient, the patients son/ daughter, brother/sister, would you not want to make sure that precautions were followed? Certainly anytime someone flosses, cuts themselves, gets a bacterial (or viral) infection through illness... they are at risk. The risk is much higher for some than others. Since we have identified this risk... .... WHY PLAY WITH IT in your offices!!?? You guys have made me a little mad. If you had to deal with bacterial endocaridtis, heart failure, diabetes (and often these as co-morbidities) in very ill patients that you treat chronically, you may not think so lightly about this. Treating debilitating illness and dealing with dealth on a regular basis makes one take these precautions very seriously. Yes it happens. Do you want that <1% on your conscience, should it happen in your office? Respectfully, Sue link: http://www.emedicine.com/emerg/topic797.htm above decribes the incidence rate of prosthetic valve endocarditis. Stated: 2-4% of patients overall (include peri and post operative endocarditis, for both mechanical and tissue valves) 3% in the first post-operative year 0.5% in subsequent years Much more common complication is thromboembolic events: 34-44% within 15 years of implantation .. so for those pts on coumadin, as dentists you must make some decisions I would guess. Do you have pts stop taking their coumadin prior to having more involved dental work done, that may cause extensive bleeding? Thanks, -Sue > link: http://www.emedicine.com/emerg/topic797.htm > [quoted text clipped - 17 lines] > > -Sue This is a common event in an older population. In the past year I've treated one patient extensively on coumadin. His physician permits him to discontinue his coumadin 3 days prior to the procedure, and going back on it immediately afterwards. I did several extractions, and had a couple of times significant problems with bleeding, but we managed. Another patient had a much more serious cardiac condition, including valvular heart disease and cardiomyopathy, and was on a waiting list for a heart transplant. His physician basically refused to allow him to discontinue his meds. Furthermore, his physician refused to permit the multiple extractions he certainly needs. At the point the pain becomes acute, I'll let an oral surgeon consult and decide how and when to proceed on an inpatient basis. I don't touch this one. Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } > Another patient had a much more serious cardiac condition, including > valvular heart disease and cardiomyopathy, and was on a waiting list for a [quoted text clipped - 3 lines] > acute, I'll let an oral surgeon consult and decide how and when to proceed > on an inpatient basis. I don't touch this one. Find out what the usual bleeding time is for this patient from the physician. Get a fresh test just before the procedure. If the test is consistent, _consider_ doing the multiple extractions in small segments. Do 2-4 teeth at a time. You need to know what the patient's clotting ability is at the time of treatment. Consider having your OMFS get involved with the treatment, as he should be better able to handle emergencies. Signature/ Amatus / > >> link: http://www.emedicine.com/emerg/topic797.htm [quoted text clipped - 33 lines] > > Steve >>Another patient had a much more serious cardiac condition, including >>valvular heart disease and cardiomyopathy, and was on a waiting list for a [quoted text clipped - 10 lines] > is at the time of treatment. Consider having your OMFS get involved with > the treatment, as he should be better able to handle emergencies. This patient needs to be managed on an in-patient basis, on IV antibiotics, and only when the physician feels the cardiac status permits. Bleeding is the least of the issues here. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 > This patient needs to be managed on an in-patient basis, on IV > antibiotics, and only when the physician feels the cardiac status permits. > Bleeding is the least of the issues here. I see. Unfortunate for the patient. Signature/ Amatus / > >>>Another patient had a much more serious cardiac condition, including [quoted text clipped - 18 lines] > > Steve I don't remember porecisely (it's been a long time since I had a patient on warfarin for extractions), but I think the guideline here is if the INR is below 4, you can do the extraction without stopping the warfarin, but then you will have to pack with surgicel & suture. Let's you avoid stopping the warfarin, which may have detrimental effects to the patient's health. As always, follow the existing guidelines for the place you're practicing to the letter. George WARNING, better review this before your next patient! Joel >I don't remember porecisely (it's been a long time since I had a >patient on warfarin for extractions), but I think the guideline here is [quoted text clipped - 6 lines] > >George Joel, you are absolutely right! The target INR you should be seeking is 3.0 or below for simple extractions, assuming your surgery is adequately equipped with hemostatis measures. I found this that is pretty comprehensive: http://www.warfarinfo.com/dentalprocedures.htm I tend to follow the guidelines of the patient's GP or consultant. Most of the times they advise him to stop the warfarin without checking the INR. I think this is a great disservice to the patient, putting him in the a thromboembolic episode risk. George > .. so for those pts on coumadin, as dentists you must make some > decisions I would guess. Do you have pts stop taking their coumadin > prior to having more involved dental work done, that may cause > extensive bleeding? For 95% of what we do in a GP office, NO do not stop the anti-coagulant. Place some gel-foam and a couple of sutures, spend more time observing after the procedure, and give extra post-op instructions. A stroke is far worse than bleeding for 1-2 hours after an extraction ! Signature/ Amatus / > link: http://www.emedicine.com/emerg/topic797.htm > [quoted text clipped - 17 lines] > > -Sue > My opinion may not be popular, but I will voice it anyway. If you were > the cardiac surgeon who had to remove an infected valve or who lost one [quoted text clipped - 27 lines] > > Sue I agree with your conclusions, but not your inference that anyone takes this lightly. I've already stated that I haven't the standing to make this kind of medical judgement. In fact, as I posted, I always follow the recommendations of the orthopedist. For cardiac patients I follow the AHA recommendations, unless the cardiologist of record has a more stringent standard. I believe I have seen literature to suggest that SBE prophylaxis is effective; this is not at issue. What is at issue is the relative risk of anaphylaxis and other bad outcomes of the prophylaxis itself. This is more in the department of idle musing on my part--but it shouldn't be. This is an issue that should be thoroughly investigated. I'm quite sure that George is not suggesting that the legally and medically accepted standard should be discarded without corroborating evidence. If anyone knows if a comparative risk analysis has been done, I'd love to read it. Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } I pre-medicate all my heart murmur patients and most of my joint replacement patients. Not because I think it will save their life or their joint, but because I want to CMA. The patient is exposed to far greater bacteremia every time the brush or floss their teeth (if they have any gingivitis) than they will get from my treatments (outside of extractions and flap surgery). Some of these patients lose 2-3 cc of blood just from brushing their teeth. They don't pre-medicate every time the brush. Now,,,,, the risk is infinitesimally small. The legal risk for the dentist is great. If the patient gets SBE from brushing their own teeth that one time every 4-5 days (no sense brushing twice a day),,,,,,,,, and they had an occlusal restoration done in the dental office 3 weeks prior, ,,,,,,,, you know darned well you will hear from the blood sucking lawyer. SM >> My opinion may not be popular, but I will voice it anyway. If you were >> the cardiac surgeon who had to remove an infected valve or who lost one [quoted text clipped - 44 lines] > > Steve Too many people just don't "get it" and so you have to "get it"... TW :-) (P.S. Hi there!!!!) > I pre-medicate all my heart murmur patients and most of my joint replacement > patients. Not because I think it will save their life or their joint, but [quoted text clipped - 59 lines] > > > > Steve >I pre-medicate all my heart murmur patients and most of my joint replacement >patients. Not because I think it will save their life or their joint, but >because I want to CMA. REPLY The distinction is between regurgitating heart murmur and non-regurgitating heart murmur. The reasons for and against pre-medication have to do with beta-lactam for which there are over 500,000 references on Google. Actually we are doctors and this information is not above our heads. Its too bad that so many patients run circles around us when discussing pre-medication and stuff about which we should be experts. Joel Pfam 18.0 : Beta-lactamase Home | Analyze a sequence | Browse Pfam | Keyword search | Taxonomy search | Swisspfam | Help · Beta-APP <-- · --> Beta_elim_lyase. Beta-lactamase ... pfam.wustl.edu/cgi-bin/getdesc?name=Beta-lactamase - 23k - Cached - Similar pages Beta-lactamase - Wikipedia, the free encyclopedia Jacoby GA, Munoz-Price LS. The new ß-lactamases. N Engl J Med 2005;352:380-91. PMID 15673804. 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Pharmacotherapy 2001, 21:920-928. ... www.biomedcentral.com/1471-2334/5/86 - 93k - Oct 29, 2005 - Cached - Similar pages Beta-lactamase Beta-lactamase is a type of enzyme responsible for bacterial resistance to ... Therapeutic Decision-Making: Treatment With Beta-Lactamase Inhibitor ... www.websters-online-dictionary.org/ definition/english/be/beta-lactamase.html - 20k - Cached - Similar pages Betalactamases / ß-lactam resistance TEM1 beta-lactamase structure solved by molecular replacement and refined structure of the ... Beta-lactamases and bacterial resistance to antibiotics. Mol. ... www.antibioresistance.be/betalactamases.html - 11k - Oct 28, 2005 - Cached - Similar pages Result Page: 1 2 3 4 5 6 7 8 9 10 Next > The patient is exposed to far greater bacteremia >every time the brush or floss their teeth (if they have any gingivitis) than [quoted text clipped - 57 lines] >> >> Steve Very well stated Steve! I agree 100%...I too question the appropriateness of much pre-medication, but I will do what I am told until told differently...after all, I am an idi...well, you know. On numerous occasions where I have spoken with cardiologists and orthopods, many of them also question the merits of these regimens, but feel compelled to stick to the party line for now. T > > My opinion may not be popular, but I will voice it anyway. If you were > > the cardiac surgeon who had to remove an infected valve or who lost one [quoted text clipped - 46 lines] > > Steve > Very well stated Steve! I agree 100%...I too question the appropriateness of > much pre-medication, but I will do what I am told until told [quoted text clipped - 4 lines] > > T I love this country. Steve >>>My opinion may not be popular, but I will voice it anyway. If you were >>>the cardiac surgeon who had to remove an infected valve or who lost one [quoted text clipped - 46 lines] >> >>Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } Sue, I'm sorry we make you mad, but we mean well to our patients. The fact that bactaremia occurs many times during the day and not not only from dental treatment; everyday activities like flossing will cause it. Also only a limited number of endocarditis cases will be stopped by the AB cover. The case you are describing, a surgeon treating an infevted valve or a parent losing his child to endocarditis, is a knee-jerk reaction Sue. Because of a bad experience (and let's face it, life is full of those) you want to cover all the bases. But is it really worth it exposing the patient to unnecessary risks? That's not science. The chance of an adverse reaction to ABs is greater than endocarditis occuring and people die from ABs everyday. Would it feel better for the parent if his child died from the AB supposed to protect it? "If anyone knows if a comparative risk analysis has been done, I'd love to read it." Reply. Ditto. Thank you for sharing your positions. It makes more sense to me now. Yet I truly believe that AHA treatment guidelines are evidenced-based and not just a "party line." If the evidence shows that AB premed in these particular patients is a larger risk factor compared to no AB premed, then the guidelines should be changed. BTW, I vaguely recall something on DT. There is one fairly common antibiotic that is no longer prescribed in the dental office. I think it was related to cardiac arrhythmias. If it is erythromycin that is no longer prescribed, this antibiotic can cause Torsades des points in Long QT syndrome. Anybody know what I am talking about? My memory is foggy. Thanks, Sue > "If anyone knows if a comparative risk analysis has been done, I'd > love to read it." [quoted text clipped - 19 lines] > Thanks, > Sue You are correct. Erythromycin was discovered to carry an unacceptable risk of cardiac complications. I believe you're right that it was a risk of arrhythmia. This was an extremely widely-prescribed medication for maybe 50 years. One wonders how it took so long for such a serious side effect to show up. Penicillin allergic patients now are mostly getting clindamycin, cephalexin, cefadroxil, azithromycin or clarithromycin. I found a handout from a local oral surgeon Steven Schwartz, which sites an Advisory Statement of the American Dental Association and Academy of Orthopaedic Surgeons entitled "Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements", published in JADA July 1997, 128:1004-1008, and is available online at www.ADA.org. This includes a table of patients at "potential increased risk of hematogenous total joint infection", and includes --Immunocompromised/immunosuppressed patients, including inflammatory arthropathies: rheumatoid arthritis, systemic LE, or disease, drug or radiation-induced immunosuppression. --Other patients including (emphasis added) Insulin-dependent (type I) diabetes FIRST 2 YEARS FOLLOWING JOINT PLACEMENT Previous prosthetic joint infections Malnourishment Hemophilia The statement also has a list of dental procedures stratified for risk of bacteremia. Not unexpectedly, extraction and periodontal procedures are at the top of the list, and orthodontic adjustments and taking radiographs are at the bottom. Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 I think it should be a rule that people needing antibiotic coverage should be issued some sort of card.........ok, it seems that doctors are very lax about informing patients of this sort of need for pre med; most of my patients seem to be clueless about it. Then again, maybe it was thought they didn't need it. ares > > "If anyone knows if a comparative risk analysis has been done, I'd > > love to read it." [quoted text clipped - 56 lines] > Brooklyn, NY > 718-258-5001 >I think it should be a rule that people needing antibiotic coverage should >be issued some sort of card.........ok, it seems that doctors are very lax >about informing patients of this sort of need for pre med; most of my >patients seem to be clueless about it. Then again, maybe it was thought >they didn't need it. Is it only major things like heart valves and replaced joints that require preventative antibiotics? Or does it cover such things as ocular implants post enucleation? Do you know? Ann >ares > [quoted text clipped - 59 lines] >> Brooklyn, NY >> 718-258-5001 > Is it only major things like heart valves and replaced joints that > require preventative antibiotics? Or does it cover such things as > ocular implants post enucleation? Do you know? > > Ann I've never heard of antibiotic prophylaxis for any other procedures--except for organ transplants, esp. those who are immunosuppressed. Steve Is it only major things like heart valves and replaced joints that require preventative antibiotics? Or does it cover such things as ocular implants post enucleation? Do you know? Ann Ann, My husband (legally blind) had lens implants 3 years ago (experimental procedure). About 1.5 yrs ago he was diagnosed with root resorption and had to have a tooth removed. He then got a tooth implant. He was given prophylactic antibiotics, but I do not remember when in the course of this treatment he got them. There was quite a long delay after extraction (healing time prior to implant). In any case, the AB had nothing to do with his lens implant. The eye surgeon never told him he required AB prophylaxis. He did not indicate that Kirk was in any more danger of infection than anyone else. -Sue >Is it only major things like heart valves and replaced joints that >require preventative antibiotics? Or does it cover such things as [quoted text clipped - 14 lines] >surgeon never told him he required AB prophylaxis. He did not indicate >that Kirk was in any more danger of infection than anyone else. I don't know that lens implants are the same as implant after enucleation. The latter is more invasive but it does highlight that there are many sorts of implant procedures and I would like to know the criteria used to decide whether prophylactic ABs are necessary or not. Judging by what's been said there though, I doubt there's anything definite written down. Ann Ares, This is a good idea. I believe that some nurse/Drs are doing this on their own now. We deal (in my clinical research) with a lot of elderly pts that have heart failrue. These people often have comorbidities and are on at the very LEAST, 5 different medications. It is difficult to maintain pt compliance (taking each as prescribed), much less having them remember all of the precautions, contraindications etc. Also the pt is often older (memory not as good as a 30 yr-old), feels SICK a lot, .. well just imagine. It is not easy for them to be "perfect" pts (i.e. perfectly complaint, knowlegable about every aspect of their disease and drug regimen). Cheers, Sue Dr. Steve - Thanks for the info! I will look at it. I enjoy learning about these things. Speaking of which (as you mention the dangers of AB), in spite of the anger and attacks on people here, I think mercury amalgam should be replaced by something else. Why take chances? Hey Joel. Thanks for the B-lactam info. Are B-Lactamase producing bacteria more virulent than other bacteria? Thanks, Sue >Dr. Steve - Thanks for the info! I will look at it. I enjoy learning >about these things. Speaking of which (as you mention the dangers of >AB), in spite of the anger and attacks on people here, I think mercury >amalgam should be replaced by something else. Why take chances? Is there anything which works quite as well? I don't want my molars filled with something that is going to break down after a couple of years. The tooth can only take so much replacing of fillings before it breaks down and needs extracting. I'm quite attached to my teeth. I've had a couple of mercury amalgam fillings replaced recently but they had given me 40 years service. I don't expect them to have to be replaced again. Ann > Dr. Steve - Thanks for the info! I will look at it. I enjoy learning > about these things. Speaking of which (as you mention the dangers of [quoted text clipped - 6 lines] > Thanks, > Sue Sue: Just for future reference, Steve Mancuso is "Dr. Steve". I am just plain Steve. The third Steve is just "Dartos". Hope that makes sense. Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } Sue: Just for future reference, Steve Mancuso is "Dr. Steve". I am just plain Steve. The third Steve is just "Dartos". Hope that makes sense. Steve ******************************************* Steve Bornfeld ---> Steve Steve N Mancuso----> DrSteve "other" Steve ----> Dartos OK. Got it. Is it ok if I call Dartos "SW" -Sue >Sue: > [quoted text clipped - 3 lines] > >Hope that makes sense. Then who is Two-Cents Plain Steve? >Steve > [quoted text clipped - 6 lines] > > -Sue >>Sue: >> [quoted text clipped - 7 lines] > >>Steve Two-Cents Plain Mark's brother. >>******************************************* >>Steve Bornfeld ---> Steve [quoted text clipped - 4 lines] >> >> -Sue -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com > Sue: > [quoted text clipped - 6 lines] > > -Sue Got me there on that W. He's Fawks. Steve Signature{\rtf1\ansi\ansicpg1252\deff0\deflang1033{\fonttbl{\f0\fswiss\fcharset0 Arial;}} {\*\generator Msftedit 5.41.15.1507;}\viewkind4\uc1\pard\f0\fs20 Remove "nospam" to reply\par } >Sue: > [quoted text clipped - 14 lines] > > -Sue *N* ??????? What is wrong with Stephen ????? ``````````````````````` Stephen (What's a temporary?) ~~~~~~~~~~~~~~~~~~~~~ *N* ??????? What is wrong with Stephen ????? ``````````````````````` Stephen (What's a temporary?) ~~~~~~~~~~~~~~~~~~~~~ So Steve Mancuso would rather be called Stephen? I think a temporary is someone who fills in for awhile. -Sue >*N* ??????? > [quoted text clipped - 4 lines] > >So Steve Mancuso would rather be called Stephen? Or, Steverino, or Stevie, or Stefano, or Nucio, Just not Steven. ``````````````````````` Stephen (What's a temporary?) ~~~~~~~~~~~~~~~~~~~~~ >>*N* ??????? >> [quoted text clipped - 10 lines] > Stephen (What's a temporary?) > ~~~~~~~~~~~~~~~~~~~~~ Nucio--I like that!! Steve SignatureMark & Steven Bornfeld DDS http://www.dentaltwins.com Brooklyn, NY 718-258-5001 >>>*N* ??????? >>> [quoted text clipped - 6 lines] >> >> Or, Steverino, or Stevie, or Stefano, or Nucio, Just not Steven. >> ``````````````````````` >> Stephen (What's a temporary?) >> ~~~~~~~~~~~~~~~~~~~~~ >Nucio--I like that!! That is like saying Stevie. [ From Stefanucio. (Which is what my Mother always called me)] ``````````````````````` Stephen (What's a temporary?) ~~~~~~~~~~~~~~~~~~~~~ Or, Steverino, or Stevie, or Stefano, or Nucio, Just not Steven. ``````````````````````` Stephen (What's a temporary?) ~~~~~~~~~~~~~~~~~~~~~ OK. I appreciate the advice. It takes awhile to get to know people. Your initials are the same as mine, so it wil be easier to remember your request. Sue PS Amatus wrote: > Another patient had a much more serious cardiac condition, including > valvular heart disease and cardiomyopathy, and was on a waiting list for a [quoted text clipped - 3 lines] > acute, I'll let an oral surgeon consult and decide how and when to proceed > on an inpatient basis. I don't touch this one. Reply. Any patient that is on a waiting list for a heart transplant is very sick. "Valvular disease plus cardiomyopathy, on Xplnt list." Even as a non-doctor I can tell you this patient is in heart failure. I agree with both Dr. Steven B and Amatus. As someone who has been involved in heart failure management research for several years, I would agree that it is best to let the cardiologist make the calls on this one. On the hopeful side, just FYI. We have actually helped some patients get OFF the heart transplant list. Although we have not yet found a cure for heart failure, we have helped many achieve full quality of life when we developed a new device therapy. I (and hundreds of others) helped to achieve this. (not just Medtronic, but our comnpetitors too). As you can tell, I am very proud of this break-through accomplishment. :-) Explain. Some HF patients are candidates for a device therapy called cardiac resynchronization therapy (CRT). Many patients that have developed congestive heart failure have also developed an arrhythmia known as left bundle branch block (LBBB). This is a delay between the activation of the right and left ventricles, which normally beat together. Thus the heart pumps in an ansynchronous, uncoordinated fashion. (akinesis, I believe may be the correct term). This asynchronous pattern reduces even further the poor cardiac output that is a function of advanced heart failure (with or without added LBBB). The CRT device that is implanted provides biventricular pacing to resynchronizes the left and right ventricles. The pulse generator (i.e.the power source and programming device) is implanted subcutaneously near one of the pectoral muscles. Through the sublcavian vein 3 leads implanted. These are tunneled to the superior vena cava, right heart and one to through the coronary sinus. Those in the right heart include a pacing lead that rests in the right apex, and a sensing lead (to sense the instrinsic heart beat) that rests n the right atrial appendage. The third lead is placed in one of the left coronary veins (to pace the left side). The pulse generator device can then be programmed to provide an optimum AV (atrioventricular) delay for the individual patient. This results in a cooridanted beating pattern, which relieves a lot of stress on the heart. This also provides an increase in cardiac output. I can tell you we have had patients that have been confined to bed 20-22 hours a day. When the device is turned on, it is almost like a miracle. The face turns from gray/blue to pink. Suddenly they have enough blood going out to their body to meet is metabolic needs. It is so cool. Unfortuately not all pts are responders and we are working to detmermine why this is. It also is not a cure. Yet we have seen evidence of reverse remodelling, as has been shown with beta-blocker therpy. CRT does not eliminate the need for drugs, but often reduces the dosages required. Of course cost and reimbursement dollars are always something that needs consideration as well. There is much more work to do. Although it is not a miracle cure-all, many of our patients and their doctors have told us that this has been a Godsend for them. & to W_B. This is not intended as spam. I am not trying to sell anything. I am just letting you dentists know what is out there for some of these patients. There is some hope. Once on a transplant list does not mean one automatically stays there. Take Care, Sue >Or, Steverino, or Stevie, or Stefano, or Nucio, Just not Steven. > [quoted text clipped - 7 lines] > >Sue Weird, both of you have the initials "S & M". Kinky that. -- W_B Take out the G'RBAGE wubbabubbazG@RBAGEyahoo.com >> Dr. Steve - Thanks for the info! I will look at it. I enjoy learning >> about these things. Speaking of which (as you mention the dangers of [quoted text clipped - 11 lines] > Just for future reference, Steve Mancuso is "Dr. Steve". I am just plain > Steve. The third Steve is just "Dartos". Except for when I am posting as JME :=) > Hope that makes sense. > > Steve |
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