You may remember that my daughter’s dentist and I had a pretty rocky road to travel on the way to our current state of mutual respect. Now, we routinely exchange information and I honestly feel as if he has come to learn about Caitlin’s condition so that he is treating her with the big picture in mind. (As an example, The Good Doc has curtailed mention of braces over the last three years – after I told him it would have to take a lower priority than getting two titanium hips.)
Three weeks ago, we were heading in for our routine six month check up. The office called me a few days ahead of time to remind us that Caitlin would need to take her prophylactic antibiotic about an hour before we arrived, as she was due for a cleaning. I knew that there were recommendations, based on the potential for bacteremia – the possibility that bacteria from the mouth can enter the blood through broken gums. But this caught me by surprise – because I thought that recommendation was only for one year after an implant surgery, and we were past that. So, I did a little reasearch…. and it looks like I was doubly wrong.
First of all, the recommendation was actually for two years. That was the recommendation of the American Academy of Orthpoedic Surgeons (AAOS) in 2003. That is what the American Academy of Pediatric Dentistry (AAPD) chooses to follow. Apparently, all these Academies don’t exactly agree. In the Guideline on this issue, the AAPD recognizes that there are “varying recommendations” between the AAOS and the American Dental Association (ADA) with regard to this issue and that they are “collaborating…to develop evidence-based recommendations.” Ok. So… this is confusing when there are varying suggestions from all of the experts. But based on this, it looks like Caitlin is supposed to take antibiotics before a dental cleaning for two years after her last surgery. This is the recommendation of the AAPD, and therefore the recommendation of my dentist, along with the obvious suggestion that I call Caitlin’s doctors for consultation.
So… phone call to the surgeon, where I obviously get voicemail and leave a message. Phone call next to our Rheumatology Nurse, who is an absolute goddess, so of course she picks up the phone right away. She checks the records, offers to call the doc but says that generally they only do the antibiotics for a year post-op. She offers to call in something if I want it… and frankly, what I wanted was to be able to get the dentist appointment out of the way on it’s scheduled day (which happened to be a school holiday – no missed classes!). We discussed it and opted for a repeat of her last dose of prophylactic amoxicillin.
The decision was made and then the surgeon’s assistant called me back. Actually, she said, they recommended prophylactic antibiotics before any”invasive” dental work for life. Yes… For. Life. Uhhhh… OK. So, a little look-see into that with the American Academy of Orthopedic Surgeons confirmed:
Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibiotic prophylaxis for joint replacement patients with one or more of the following risk factors prior to any invasive procedure that may cause bacteremia: and then the top four in the list:
- All patients with prosthetic joint replacement
- Immunocompromised/immunosuppressed patients
- Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic lupus erythematosus)
- Drug-induced immunosuppression
So…. yeah. That pretty much includes her.
Believe me – I’m not a fan of frequent antibiotics. I fall more in the camp of people who fear that frequent prescribing of antibiotics is not only destroying our body’s potential ability to fight things off unaided… but that we also may be creating some serious drug-resistant superbugs. And for the generally healthy population, I personally believe we should be careful with the thinking that we need an antibiotic to get over every little bug.
However. People who have had a joint replacement do not fall into the above category. Most of the people dealing with an auto-immune disease also do not fall into that category. An infection, even one stemming from a nick in the gums during a cleaning, can be devastating. So, in the never-ending balancing of risks that this disease seems to offer, looks like we’ll be risking tolerance to antibiotics for the sake of protecting against “adverse outcomes” from potential infection stemming from a dental cleaning.
By the way, in all of these recommendations, there was mention of prophylactic antibiotics for people with auto-immune disease, including rheumatoid arthritis and juvenile arthritis, especially if they are on immuno-suppressing medications. I must admit – in all the years that Caitlin has been going to the dentist while taking prednisone, methotrexate, cytoxan, cyclosproine and a host of other immune-modifying medications – I never knew this. I never asked. I trust our rheumatologist and he says that he did not consider her to be a high risk for infection before. Even if I had known it, I’m not sure how the risk-weighing debate would have ended…. maybe we would not have done anything differently. But even without a joint replacement, it might be worth discussing with your doctor/dentist if you have ra/ja or are on immuno-suupressive medications.
P.S. The dentist trip went off with out a hitch. No cavities… no signs of mouth/gum disease. Took the prophylactic antiobiotics – no side effects. And the dentist felt Caitlin was now stable enough to suggest a trip to the Orthodontist to discuss braces. I hope he knows what’s coming his way!