Questions about dental school...

[dental44]

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I've been accepted to several dental schools and have given my deposit to the school which I feel best suits me. However, I have been really second quessing many aspects of the profession. I wonder how much of my heart is into dentistry. I need to know-do you build a passion for partial dentures, bonding materials, and cavity preparation while in school? To be honest, I'm not really all that into these avenues of study (I mean I don't go to bed dreaming about these things every night). Do any other dental school bound individuals out there feel as I do? Have you dental students built a passion for all-things-dentistry while in school? Did you find yourself thinking as I currently do? Why did you choose dentistry (over medicine, for example)? I need answers to these questions or else I might actually withdraw. I worked in a clinic, but I've been out of dentistry for several months and my view of the profession has slowly changed. Do I just have jitters, or am I freaking out about such a huge life decision? Dental students help!

 

[UBTom]

No, you don't have to love all things dentistry to be a dentist. As a matter of fact, I daresay most dentists find themselves good at some particular procedures but hate doing other stuff... And that's perfectly OK-- One has to find a professional niche.

Heck, some dentists like doing only one kind of stuff and end up getting post-graduate training after dental school to do just that one kind of stuff... And become specialists. 😀 We are talking people such as orthodontists, oral surgeons, endodontists, etc.

The catch? You gotta survive everything that is dentistry for four years first... AND DO WELL (high GPA/class rank and good NBDE scores in order to specialize)

Dental school isn't for everybody. If you don't feel you want to deal with it, you will do yourself a favor if you withdraw and look for another career.

 

[River13]

These days dental school is a giant financial committment. For many people you move to another state and go somewhere around 50 thousand dollars in debt the first year...i.e. myeslf...there's not a lot of people out there who can bail after 1 year and handle that kind of debt load if its something they don't want to do...as my wife put it during our first year, "you're going to finish dental school whether you like it or not!" Luckily for me I enjoy it too-dentistry-not necessarrily dental school.

I guess the point I'm making is in my opinion, if you're not SURE you want to be a dentist, don't start (unless you've got tons of money or the school you're going to is really inexpensive). Dental school is hard, and it will be even harder if you're not into it. I would go back to the clinic you said you were in, or find some other private practitioner and spend a few days in the environment again to help you remember what its really like. If you still can't make up your mind, I would probably sit out a year before committing my life to something I wasn't at least 90% sure about. I'm glad I chose dentistry as a career, but its something I was 100% sure about before embarking.

Good Luck

 

[ser]

Do everybody love what they do? I mean I'm sure most accountants, some doctors and dentists hate what they do, but they still do it anyways. I keep hearing do what you love to do, if that's the case, I'd play my PS2 12 hours a day. If you don't have a passion for what you do, it's no big deal, just go for the money, get as much of those as you can, then retire at 40 with enough money, and do what you truely love doing. 😉

There are some people who love something, and is lucky enough to get paid or being good enough to get paid for it. e.g. most sucessful musicians, pro athletes etc. But not everyone loves doing something others will pay you to do, e.g. playing video games or is good enough to get paid to do what you love. e.g. most sports fans. I think in this case, just find something you can stand doing for a few years, then run with the money. That's my plan anyways.😎


...just my $.02...take it with a grain of salt.

 

[UBTom]

Originally posted by ser
Do everybody love what they do? I mean I'm sure most accountants, some doctors and dentists hate what they do, but they still do it anyways. I keep hearing do what you love to do, if that's the case, I'd play my PS2 12 hours a day. If you don't have a passion for what you do, it's no big deal, just go for the money, get as much of those as you can, then retire at 40 with enough money, and do what you truely love doing.

There is a difference between a hobby and a profession. If you don't know the difference (and it is painfully obvious you don't), you need to GROW UP.

Oh yeah... Here's an article on a dentist who was solely in it for the money just like you: http://www.buffalonews.com/editorial/20040116/1000968.asp

People with your kind of mentality is the last thing the dental profession needs.

 

[DaktarSaheb]

UBtom, good post and good article. I totally agree with you and people shouldn't be in this profession only for money. It offers great living with well paid job but you still have to atleast like what you do if you don't love it, IMHO.

Originally posted by UBTom
There is a difference between a hobby and a profession. If you don't know the difference (and it is painfully obvious you don't), you need to GROW UP.

Oh yeah... Here's an article on a dentist who was solely in it for the money just like you: http://www.buffalonews.com/editorial/20040116/1000968.asp

People with your kind of mentality is the last thing the dental profession needs.

 

[ser]

Who enjoys poking teeth 8 hours a day? I dunno, who would still be a dentist if they only get paid 30k a year?

I'm sure some people like what they do as a profession, but I'd say 90% of the general population would rather play than work. Work is just something they have to put up with to get money.

 

[UBTom]

Originally posted by ser
Who enjoys poking teeth 8 hours a day? I dunno, who would still be a dentist if they only get paid 30k a year?

I'm sure some people like what they do as a profession, but I'd say 90% of the general population would rather play than work. Work is just something they have to put up with to get money.

Looks like you STILL don't understand the difference between a hobby and a profession.

A hobby is something you do in your spare time to relax and enjoy yourself, with little consequence to others. Be it playing your PS2 or being a sports fan.

A PROFESSION like dentistry is when someone puts his/her health IN YOUR HANDS with VERY REAL consequences.

Sure, you make a bad move on your PS2 game and your character gets killed, you just start a new game. What happens when in a dental office you administer an antibiotic and your patient goes into anaphylactic shock? Can you bring him back to life by pressing a reset button?

Get it? A hobby is inconsequential. A profession is deadly serious.

Being a professional is more than just making money. It's about intellectual stimulation and challenge. It's about a lifetime of learning, keeping up with the latest developments and technology. It's about human relationships with patients, other professionals, and those in auxiliary positions who work for you. Dentistry is not simply "poking at teeth for 8 hours a day" and "retire by 40."

If you can't understand that, the dental profession is not for you.

 

[Temple2007]

Kinda had to grin when I read all these posts. But Im curious how many of you would be dentists if they only made, like Ser said, 30K. I know for damn sure I wouldnt. I agree with Ser and part of what Tom Hong said. I do the dentistry number 1 for the money, 2 for the flexablity the profession offers, 3 the challenging aspect of the field. You would have to be playing play station on the job to kill someone. I dont think general dentistry procedures are all that life threating. LOL

 

[UBTom]

Originally posted by Temple2007
Kinda had to grin when I read all these posts. But Im curious how many of you would be dentists if they only made, like Ser said, 30K. I know for damn sure I wouldnt. I agree with Ser and part of what Tom Hong said. I do the dentistry number 1 for the money, 2 for the flexablity the profession offers, 3 the challenging aspect of the field. You would have to be playing play station on the job to kill someone. I dont think general dentistry procedures are all that life threating. LOL

LOL, you just proved that the deadliest thing to a dental patient is a freshman dental student.

Why don't we take a look at general procedures which you thought "weren't all that life threatening"?

- How about a patient with certain heart conditions who has not premedicated and you went ahead and gave'em a cleaning?

- What are you going to do when in the process of cementing a 3-unit bridge your patient gags and aspirates the thing?

- How about a patient with angina pectoris in your chair for an emergency extraction because he is in pain?

- Or how about a patient in for a procedure who had been doing cocaine a few hours earlier and develops tolerance to the lido/epi. Tell me what happens when you try to inject more to try to numb'em up?

Heh, I WISH general dentistry is as inocuous as you make it sound!

Good thing you are only a freshman-- By the time you take the National Boards Part-II, you will realize that there are potential consequences to even general dentistry procedures. Let's hope you do before Temple inflicts you on the patients!

Sure, nobody would go into dentistry if it doesn't pay well, but that's not the point. I have never heard of any dentist going broke by being professional and doing good dentistry, but I sure as hell have heard of plenty of dentists who get in trouble because of greed, just like in that article I linked earlier.

The point is that there is a difference between leisure activities and a profession-- If you don't take a profession seriously, you shouldn't be in it!

 

[3rdMolarRoller]

If i happened to recieve a large sum of money...ah lets say powerball, I would do dentistry for free where it was needed most. I saw first hand how dentistry completly changed a person and I want to have that gratification of helping someone out...that is worth more then any sum of money.

 

[gryffindor]

Originally posted by ser
Who enjoys poking teeth 8 hours a day? I dunno, who would still be a dentist if they only get paid 30k a year?

A. I like poking teeth 8 hours a day.

B. I would still be a dentist. Think about it, some hygienists & dental assistants make 30k; we need them or our profession would fall apart. I often wonder why I didn't just go to a 2 year hygiene program straight out of high school. I like cleaning teeth, just give me a set of scalers and a radio and I'm good to go. I'd still be working on teeth 8 hours a day, but I would have been done a whole lot earlier with a lot less stress. But I'd probably be dissatisfied as a hygienist b/c I'd know I was capable of what my boss, the dentist, was doing hence here I am in dental school.

I don't know if everyone views dentistry as a hobby, but I do. I was asked at an interview "What are you passionate about?" I answered, even without thinking, "Dentistry." B/c for me it's true. They probably wanted to hear that I was passionate about something like "scrapbooking" or "horses" or "backpacking" but really, for me it's dentistry. There is so much to this profession than drill, fill, and bill and I love being a part of it. The money is a nice perk. But like Brocnizer said, even if I won the the lottery, I'd still be practicing where I was needed and probably teach, trying to help dental students see that there is more to being a dentist than rolling in the money and driving a beamer.

 

[dentalstudent]

I totally agree that some of us are in dentistry not just because of the money aspect but because we really do enjoy it. I am one of them. However, I have seen people who don't seem to enjoy it but do it because of other reasons.
I believe that the best dentists are the one who really do enjoy it and want to do their best to their patient's behalf rather than do certain procedures because they see only the $$ signs. As someone adviced me do your best to the patient and the money will follow. Therefore make sure you go into dentistry with the right reasons by researching it very carefully and shallowing several dentists and volunteering in a dental clinic.

 

[Temple2007]

Originally posted by UBTom
LOL, you just proved that the deadliest thing to a dental patient is a freshman dental student.

Why don't we take a look at general procedures which you thought "weren't all that life threatening"?

- How about a patient with certain heart conditions who has not premedicated and you went ahead and gave'em a cleaning?

- What are you going to do when in the process of cementing a 3-unit bridge your patient gags and aspirates the thing?

- How about a patient with angina pectoris in your chair for an emergency extraction because he is in pain?

- Or how about a patient in for a procedure who had been doing cocaine a few hours earlier and develops tolerance to the lido/epi. Tell me what happens when you try to inject more to try to numb'em up?

Heh, I WISH general dentistry is as inocuous as you make it sound!

Good thing you are only a freshman-- By the time you take the National Boards Part-II, you will realize that there are potential consequences to even general dentistry procedures. Let's hope you do before Temple inflicts you on the patients!

Sure, nobody would go into dentistry if it doesn't pay well, but that's not the point. I have never heard of any dentist going broke by being professional and doing good dentistry, but I sure as hell have heard of plenty of dentists who get in trouble because of greed, just like in that article I linked earlier.

The point is that there is a difference between leisure activities and a profession-- If you don't take a profession seriously, you shouldn't be in it!

I have may be a freshman but I have been around health care for quite a few years. The point I was making is that Dentistry is not usually life and death procedures (Deadly Serious is how you put it). Patients do not come to dentists with life and death problems. Its toothaches, chipped teeth, gingivitis, etc... You have to be professional in any health care position. I dont think that your passion for the field affects your ability to be competent in dentistry. If your patient choked to death on a three unit crown bridge you put in their mouth then you are very incompetent. (My mom could solve that problem, Hell any cub scout knows the hemlich manever ). LOL ..People are motivated to do things for many different reasons some are better motivators than others. But then again I am just a freshman
and I guess freshman are patients worse enemies or something like that.

 

[3rdMolarRoller]

Oral cancer is life and death. Only a 50% 5 year survival rate. So dentist do catch life and death. More examples...many more but I am studying for gross anatomy exam on fri

Hey temple2007, have you taken epi yet? They will list a crap load of diseases the dentist will catch that is life and death.

 

[ItsGavinC]

All that local we inject people with directly affects the myocardium and CNS--obviously that can have potentially drastic ramificatons (although LAs are extremely safe) based on patient history.

 

[aphistis]

Originally posted by Temple2007
Patients do not come to dentists with life and death problems.

They can, however, leave with them. Have you actually, y'know, learned anything this year?

 

[DcS]

Originally posted by UBTom


- How about a patient with certain heart conditions who has not premedicated and you went ahead and gave'em a cleaning?

Nothing happens, according to ADA and AHA guidelines, a prophy is not a procedure that puts a patient at risk for bacterial endocarditis. Hence, no need to pre-med for a cleaning.

 

[aphistis]

Originally posted by DcS
Nothing happens, according to ADA and AHA guidelines, a prophy is not a procedure that puts a patient at risk for bacterial endocarditis. Hence, no need to pre-med for a cleaning.

Don't let us get in your way, then. Let us know how the lawsuits turn out.

 

[no2thdk999]

Originally posted by aphistis
Don't let us get in your way, then. Let us know how the lawsuits turn out.

Here is the link for the latest AHA guidelines:
http://216.185.112.5/presenter.jhtml?identifier=1729

TECHNICALLY DcS could be correct in that the wording for the list of procedures where Ab prophylaxis is recommended includes "Prophylactic cleaning of teeth or implants WHERE BLEEDING IS ANTICIPATED" If you're not expecting bleeding Ab are not indicated. That would be a rare case and I would personally rather be safe than sorry, but these are GUIDELINES and it is ultimately up to the clinician to decide. As an aside the reason I would rather be safe than sorry is like aphistis said, legal rather than medical. For most the risk of SBE is a lot smaller than the risk of anaphylactic response to Amoxicillin.

The examples y'all are listing for dentistry being life and death are I don't want to say disingenuous, but don't really capture the essence of dental care. With the exception of oral cancer, which is our perogative and duty to diagnose and treat, there are very few things that even happen on a rare basis in dentistry that are life and death. There are lots of potentially life threatening diseases that reveal themselves in the oral cavity but very few that we would actually treat and not refer to their MD. Using the Ab pre-med as an example of life or death decision making could just as easily be extrapolated to the line chef at Jack in the Box knowing he has to cook the burgers at 160 degrees or he could kill somebody w/ E. coli. And I don't think the burger flipper considers his job life or death.

One of the great things about dentistry is that I don't deal with morbidly sick people everyday making decisions that affect the longevity of their life. My favorite comment from the internist that taught us a lecture on pre-op evaluation was "put your office on the second floor with no elevator, if they can get to your chair you can treat them." That is a little bit simplified but you get the point. You have really got to drop the ball (knock on wood) to kill somebody as a dentist.

I think part of this goes the the DDS vs MD thread. Physicians do deal with weightier stuff than we do as dentists. This doesn't make them more important, or more worthy of respect, or better people. Take the worlds' most talented neuro-surgeon with the most prestigious academic career and 100 articles to his name and ask him to fix my toilet that's flooding my house at 2AM on Christmas day and he'll stand their in 3 inches of S#!& right beside me. I'll take a high school drop out with 6 months of on the job plumbing training everytime.

What we do as dentists is not more or less important or worthy or esteemable than what physicians do. It's just different. We can improve quality of life in a way that no other professional can. Being an excellent dentist who treats his patients with respect, fairness, and dignity is it's own reward. If you want to make life and death decisions or think that's what makes dentistry great, you're going to be disappointed.

Besides MD's are just pill pushing HMO ****** anyway. 😀

JMHO
Rob

 

[Temple2007]

Originally posted by aphistis
They can, however, leave with them. Have you actually, y'know, learned anything this year?

In my post I didnt say anything about patients leaving with life and death problems. That is another story if a patient leaves your office worse, then that is your problem. As a Dentist you are incompetent, dont follow protocol, look at drug alergies, meds they are on, etc..

 

[Temple2007]

Originally posted by Brocnizer2007
Oral cancer is life and death. Only a 50% 5 year survival rate. So dentist do catch life and death. More examples...many more but I am studying for gross anatomy exam on fri

Hey temple2007, have you taken epi yet? They will list a crap load of diseases the dentist will catch that is life and death.

I havent taken this class yet. Sounds like a cool class though. Dentists will catch alot of problems that show up first in the mouth. The life and death problems they do find in patients mouths will usually be treated by someone else. You make catch it but, I dont think that you will be doing radiation therapy in your office for oral cancer. I need to study gross anatomy too but thanks for the input.

 

[UBTom]

Temple2007:

The past several posts by practicing dentists and dental students are EXACTLY what I'm talking about when it comes to taking one's profession seriously.

They make it their business to know and be able to discuss intelligently things that may turn your general dental procedure into a nightmare and cause VERY REAL harm to a patient... Which you naively dismiss as "You would have to be playing play station on the job to kill someone." (Your words.)

It might help if you and Ser stop looking at patients as simple cash cows for you to milk-- They are real people with real feelings to whom you can do REAL HARM if you grow complacent or adopt a blase attitude.

You want to be treated as a professional by your peers? Start acting like one!

 

[DcS]

Originally posted by aphistis
Don't let us get in your way, then. Let us know how the lawsuits turn out.

You are more likely to lose a lawsuit for medicating when it is not indicated, then for not medicating for a prophy. These are ADA and AHA guidelines, not folklore. These are guidelines that basically establish the laws. Set by our governing body and the american heart association. Do you even know how many documented cases of BE there have been from dental treatment as the true source of infection? Go do some research and come back and let me know. ZERO. ZILCH. NADA. There are exactly 0 cases of BE that can directly be attributed to dental procedures. It's all hypothetical. Which is why there is a big debate right now about whether it is necessary at all. Most practitioners maybe just premedicate for safety, but in a world of bacterial resistance and over-medicating doctors, there are many dental procedures where there is no risk for BE. If you are educated or experienced on the subject, then maybe you can come in here with sarcasm. But until then, please don't act like you know everything as a D1. For example, are you going to medicate someone with hip replacements their entire life? Since you probably don't know the answer, ADA and AHA guidelines say premedication is only indicated for 2 years post joint replacement. Are you telling me you are going to medicate this person the entire time in your office to prevent a lawsuit? LMAO. Come back when you know what you are talking about.


The only reason I go into depth is because over medication is a significant problem in our healthcare system. ADD and ADHD, for example, is very over-diagnosed and there are a ton of kids taking ritalin on a daily basis that shouldn't. I've taken an entire course on this.

Of course, like Rob said, there are procedures where bleeding is anticipated during prophies where you need to pre-med. Once in general practice, those cases will be fewer than you think. Furthermore, in cases where you prophy and someone is bleeding during the procedure, as long as you give them meds within the 1st 2 hours then they will be protected. It's better to wait for a prophy and give as necessary, than needless pump ABs through your patients. No one will stop you from pre-medicating anytime you are unsure to save your own butt. Most dentists do. But people underestimate bacterial resistance and its ramifications for the future.


If you want to talk the talk like you know what you are saying, then I'd suggest you go read that article Rob posted. You and gavin drive me nuts, you act as if you know everything about dentistry even though you haven't picked up 1 instrument and used it on a live patient. People like Tom post and know their stuff, while being humble about it at the same time.

 

[larryt]

Originally posted by DcS
Nothing happens, according to ADA and AHA guidelines, a prophy is not a procedure that puts a patient at risk for bacterial endocarditis. Hence, no need to pre-med for a cleaning.

How about patients with heart's murmur and valve replacement ? I was taught to premed them all before prophy. Is this true ?

 

[seanjohn]

I apologize for the irrelevant post I am about to make to this thread.

Aphistis, or Bill as you like to be called... you look exactly like my oral and maxillofacial surgeon that extracted my wisdom teeth, who also looks like Ari Fleisher, the former press secretary of the white house. I'm sure you know him since I do and I'm Canadian, anyways, I really think you should become an oral and maxillofacial surgeon Bill, it suits you well. For the sake of order in the universe become an oral and maxillofacial surgeon!
Thank you. 🙂

 

[aphistis]

Originally posted by seanjohn
I apologize for the irrelevant post I am about to make to this thread.

Aphistis, or Bill as you like to be called... you look exactly like my oral and maxillofacial surgeon that extracted my wisdom teeth, who also looks like Ari Fleisher, the former press secretary of the white house. I'm sure you know him since I do and I'm Canadian, anyways, I really think you should become an oral and maxillofacial surgeon Bill, it suits you well. For the sake of order in the universe become an oral and maxillofacial surgeon!
Thank you. 🙂

That's a new one, actually 😀 I've been told on several occasions that I resemble Dr. Green (Anthony Edwards) from the series ER, but never the White House press secretary. I'll have to look more closely at a few shots of Fleischer to see.

As for your recommendation about OMS, thanks for the vote of confidence 😀 It's a little early for me to be thinking about specializing, though. I've mentioned a few different times that for the time being, I'm in dental school to become a dentist; and as a recent post mentions accurately, if artlessly, I'm waiting till I hit the clinics before I even consider specializing.

Thanks all the same, though; and good luck to you!

 

[DcS]

Originally posted by larryt
How about patients with heart's murmur and valve replacement ? We was taught to premed them all before prophy. Is this true ?

Valve replacement = yes

Heart murmur...if it's with regurgitation=yes
...if there is not regurgitation, then no

Most likely you will need a letter from an MD confirming whether or not the murmer is with or w/o regurgitation.

 

[DcS]

Originally posted by aphistis
Now, now, now. Do you administer prophylaxis for certain heart conditions (as Tom originally indicated and I agreed with) or not (as you initially claimed, and extended into a pretty deliberate broad-spectrum assault on my cognitive capability)?

Come on, doctor, we're waiting for a conclusive diagnosis here.

Are you incapable of reading comprehension? I clarified your questions. Tom was incorrect. For a normal prophy, you do not need to pre-med a "heart patient". The only time you would pre-med a prophy is if you anticipated bleeding.

If someone has a heart murmur without regurgitation, you never have to pre-med, regardless of the procedure. If they do have regurgitation (or a prosthetic valve), you only have to premed for procedures which will involve bleeding. I will go ahead and list the procedures for you, so I don't get another post with you questioning what procedures, here is a little informational session of endocarditis.

Definition: infection of heart valve, endocardium, or endothelium

Must have: susc individual, bacterimia

High risk pts (need premed): prosthetic heart valves, previous hx of BE, CCCHD, polmonary shunts.

moderate risks (need premed): MVP with regurgitation, RhHD, hypertrophic cardiomyopathy

negligible risk: (prophy not necessary): CABG, MVP w/out regurg, innocent murmers, RhF w/out valvular dysfunction, pacemakers

Procedures requiring prohylaxis

extractions, perio procedures (prophy w/ anticipated bleeding), implant placement, endo or RCT BEYOND apex, sub-g placement of antiobiotic fibers, ortho band placement, intra-lig injection

Procedures where no prophylaxis is needed
Operative, LA injection, rubber damn, radiographs, suture removal, impressions, prophys w/out antic bleeding, impressions, pros placement, retraction cords, ortho bracket placement.


Like I said, in the case of a prophy, it's best not to premed. IF the pt does start to bleed, you can medicate on the spot or w/in 2 hours and will get the same amount of protection.

Oh yeah, and fyi:

premed: amoxicillin 2.0g 1 hr pre tx, clindamycin 600mg 1 hour pre if allergic to amox.

Should be crystal clear at this point i should think. If you still want to argue it, feel free to contact the ADA or the AHA, since this was taught to my class directly from those guidelines.

 

[trypmo]

I happen to know that it can be *really* important for ppl with a heart condition to be premedicated with antibiotics, especially if they have a whole lot of tartar, calculus, caries, or other bacteria-y hiding places in there. If I hadn't been informed of this, I could've lost a close family member to a simple dental procedure, so, um, yeah, I'd say that's important.

 

[DcS]

Originally posted by trypmo
I happen to know that it can be *really* important for ppl with a heart condition to be premedicated with antibiotics, especially if they have a whole lot of tartar, calculus, caries, or other bacteria-y hiding places in there. If I hadn't been informed of this, I could've lost a close family member to a simple dental procedure, so, um, yeah, I'd say that's important.

Since removal of that calculus etc would create bleeding, then yes they would need antibiotics.

As far as the chance of losing a family member to BE, there have been 0 cases directly linked to dental induced endocarditis. Your farmily member is much more likely to be lost driving to the dentist. I'm not trying to undermine the condition, but the risk isn't really what people think it is.

 

[no2thdk999]

Originally posted by DcS
Are you incapable of reading comprehension? I clarified your questions. Tom was incorrect. For a normal prophy, you do not need to pre-med a "heart patient". The only time you would pre-med a prophy is if you anticipated bleeding.

If someone has a heart murmur without regurgitation, you never have to pre-med, regardless of the procedure. If they do have regurgitation (or a prosthetic valve), you only have to premed for procedures which will involve bleeding. I will go ahead and list the procedures for you, so I don't get another post with you questioning what procedures, here is a little informational session of endocarditis.

Definition: infection of heart valve, endocardium, or endothelium

Must have: susc individual, bacterimia

High risk pts (need premed): prosthetic heart valves, previous hx of BE, CCCHD, polmonary shunts.

moderate risks (need premed): MVP with regurgitation, RhHD, hypertrophic cardiomyopathy

negligible risk: (prophy not necessary): CABG, MVP w/out regurg, innocent murmers, RhF w/out valvular dysfunction, pacemakers

Procedures requiring prohylaxis

extractions, perio procedures (prophy w/ anticipated bleeding), implant placement, endo or RCT BEYOND apex, sub-g placement of antiobiotic fibers, ortho band placement, intra-lig injection

Procedures where no prophylaxis is needed
Operative, LA injection, rubber damn, radiographs, suture removal, impressions, prophys w/out antic bleeding, impressions, pros placement, retraction cords, ortho bracket placement.


Like I said, in the case of a prophy, it's best not to premed. IF the pt does start to bleed, you can medicate on the spot or w/in 2 hours and will get the same amount of protection.

Oh yeah, and fyi:

premed: amoxicillin 2.0g 1 hr pre tx, clindamycin 600mg 1 hour pre if allergic to amox.

Should be crystal clear at this point i should think. If you still want to argue it, feel free to contact the ADA or the AHA, since this was taught to my class directly from those guidelines.

This post has 1 flat out error, 2 errors by omission (incomplete answer), and one item that would only be correct in very rare instances.

Wanna guess what they are? 🙂

Rob

 

[aphistis]

And now again. First...

Originally posted by DcS
Are you incapable of reading comprehension? I clarified your questions. Tom was incorrect. For a normal prophy, you do not need to pre-med a "heart patient".

But immediately prior, directly responding to a post explicitly asking about prophylaxis for an ordinary dental prophy...

Originally posted by DcS
Valve replacement = yes

Heart murmur...if it's with regurgitation=yes

To summarize: so far, you've managed to answer a pretty simple procedural question with "yes," "no," AND "sometimes," (have you considered a career in politics?) and still had time to loft a number of personal insults my way. I was perfectly aware of the clinical indications and methods for antibiotic prophylaxis prior to this thread, but thanks anyway. My main interest at this point has become seeing how many different answers we can get out of you before you finally settle on something.

 

[gryffindor]

Alright DcS. I am fully aware of all the guidelines you posted, and I'm sure Tom is too. I don't know what Tom said that was wrong (did the post get deleted?) but aren't you in second year? You can't possibly have seen the spectrum of cases Tom & I have encountered days from graduation.

Maybe your faculty at UNC are fully aware of the ADA/AHA guidelines and follow them strictly. And when I'm in practice calling the shots, I too will adhere to the guidelines with my best judgement. But we have MANY faculty here where you can bold & highlight the ADA/AHA guidlelines and wave it in their faces, and they will still refuse to supervise you if the patient did not premedicate for the appointment for a fixed impression (cord packing involved) or prophy (don't know if they'll bleed or not). Yeah, you could give them the meds on the spot or within 2 hours but at our clinics, we do not dispense any medications. Either the patient comes in reporting they took it or nothing.

We have an Oral Medicine faculty parading around clinic telling everyone that the guideline is "You don't have to pre-medicate a prosthetic joint replacement patient two years after the surgery." Agreed. However, the OMS professor doesn't believe that this guideline is really acceptable and either wants the patient to pre-med before they are seen in the OMS clinic or call the orthopedic physician to get their opinion (has happened to me TWICE this month already).

Or the patient where their medical history clearly indicates that pre-med is not required, yet the patient says their physician insists. So we contact the physician, explain our stance and get a fax back - "Continue pre-med. Pt is a diabetic." Huh? Makes no sense to me.

Or the patient who says "I just had an echo, my doctor said I don't have to pre-med anymore, the condition cleared up (of course, the doctor had given her a script of TETRACYCLINE to pre-med with). Again, contact the doctor to verify the results of the echo. Doc writes back "Continue SBE prophylaxis."

Or where the patient's guardian walks in with a pre-med script from the Nurse Practitioner. When questioned why the NP gave this, she says "They told me it will prevent infections for her (the pt) at the dental visit, b/c she has Alzheimers." I'm currently in the physician contact process for this one.

How about the patient who does not have a physician and has no intention of seeing one? She reports an open-heart valve repair surgery when she was four. Now what? We can't contact a physician for an opinion of the heart condition. Pre-med or not? Better safe than sorry, our clinic recommends we pre-med her.

WHY??? B/c it's not as cut and dry as you would like to believe. I had ZERO patients my junior year who needed pre-med and this year I've have many more than the experiences I recounted. It's probably more legal protection than anything else, but the point is the guidelines aren't adhered to in clinical situations b/c of conditions beyond the control of the dentist (like MD ignorance). And you are forced to continue pre-medicating a patient who may not need it (like the diabetic).

 

[aphistis]

Originally posted by griffin04
I don't know what Tom said that was wrong (did the post get deleted?) but aren't you in second year?

The post he quoted is one I made, then thought better of and deleted a few moments later. I guess I didn't get there in time.

 

[DcS]

Originally posted by griffin04
Alright DcS. I am fully aware of all the guidelines you posted, and I'm sure Tom is too. I don't know what Tom said that was wrong (did the post get deleted?) but aren't you in second year? You can't possibly have seen the spectrum of cases Tom & I have encountered days from graduation.

Maybe your faculty at UNC are fully aware of the ADA/AHA guidelines and follow them strictly. And when I'm in practice calling the shots, I too will adhere to the guidelines with my best judgement. But we have MANY faculty here where you can bold & highlight the ADA/AHA guidlelines and wave it in their faces, and they will still refuse to supervise you if the patient did not premedicate for the appointment for a fixed impression (cord packing involved) or prophy (don't know if they'll bleed or not). Yeah, you could give them the meds on the spot or within 2 hours but at our clinics, we do not dispense any medications. Either the patient comes in reporting they took it or nothing.

We have an Oral Medicine faculty parading around clinic telling everyone that the guideline is "You don't have to pre-medicate a prosthetic joint replacement patient two years after the surgery." Agreed. However, the OMS professor doesn't believe that this guideline is really acceptable and either wants the patient to pre-med before they are seen in the OMS clinic or call the orthopedic physician to get their opinion (has happened to me TWICE this month already).

Or the patient where their medical history clearly indicates that pre-med is not required, yet the patient says their physician insists. So we contact the physician, explain our stance and get a fax back - "Continue pre-med. Pt is a diabetic." Huh? Makes no sense to me.

Or the patient who says "I just had an echo, my doctor said I don't have to pre-med anymore, the condition cleared up (of course, the doctor had given her a script of TETRACYCLINE to pre-med with). Again, contact the doctor to verify the results of the echo. Doc writes back "Continue SBE prophylaxis."

Or where the patient's guardian walks in with a pre-med script from the Nurse Practitioner. When questioned why the NP gave this, she says "They told me it will prevent infections for her (the pt) at the dental visit, b/c she has Alzheimers." I'm currently in the physician contact process for this one.

How about the patient who does not have a physician and has no intention of seeing one? She reports an open-heart valve repair surgery when she was four. Now what? We can't contact a physician for an opinion of the heart condition. Pre-med or not? Better safe than sorry, our clinic recommends we pre-med her.

WHY??? B/c it's not as cut and dry as you would like to believe. I had ZERO patients my junior year who needed pre-med and this year I've have many more than the experiences I recounted. It's probably more legal protection than anything else, but the point is the guidelines aren't adhered to in clinical situations b/c of conditions beyond the control of the dentist (like MD ignorance). And you are forced to continue pre-medicating a patient who may not need it (like the diabetic).

I completely agree with all of this. My initial post referring to Tom's post was more in curiousity whether we were getting taught some things that were different from other students (like u guys up in buffalo). Then people come in w/ smart ass comments who really have no education on the topic. I guess it all boils down to practice philosophy. I'm not saying I will only prescribe meds on a limited basis, but I do feel there is some worth to a discussion of blind Rx to just about everyone under the sun who has very minimal risk. It is certainly debatable (as we have seen here), but it is a legitimate question.

 

[larryt]

Originally posted by no2thdk999
This post has 1 flat out error,

hypertrophic cardiomyopathy


2 errors by omission (incomplete answer),


Premed: SLE, rheumatic fever


and one item that would only be correct in very rare instances.


clindamycin 600mg 1 hour pre if allergic to amox. ---> for premed ?


Wanna guess what they are? 🙂

Rob [/B]

Just from top of my head. correct me if I'm wrong.

 

[larryt]

Originally posted by griffin04
It's probably more legal protection than anything else, but the point is the guidelines aren't adhered to in clinical situations b/c of conditions beyond the control of the dentist (like MD ignorance). And you are forced to continue pre-medicating a patient who may not need it (like the diabetic).

The doctors recommended pre-med for couple of my patients with uncontrolled diabetes. I asked my MD friend about this and he also confirmed about those recommendations. I guess it's a standard practice for them.

 

[no2thdk999]

Originally posted by no2thdk999
This post has 1 flat out error, 2 errors by omission (incomplete answer), and one item that would only be correct in very rare instances.

Larryt thanks for asking!

Flat out error: "IF the pt does start to bleed, you can medicate on the spot or w/in 2 hours and will get the same amount of protection."

If that were true then the guidelines would not say take 1 hour before dental treatment, they would say take if bleeding occurs up to 2 hours post-op. That is not how it is worded. A similar analogy would be the best way to prevent hear disease is routine physicals, diet, and exercise but if you're having an MI take an aspirin and get to the ER. Both are a good idea but they are not "the same amount of protection". This is GUARANTEED to come up in your practice. Pt. shows up and forgot to take required pre-med. Do you reschedule them and lose the production for that day, have them take it wait and hour and throw off the schedule for the next patient, or have them take it and get to work right away? Each choice has a potential detriment to you or the patient.

1st error of omission: "If someone has a heart murmur without regurgitation, you never have to pre-med, regardless of the procedure."

You would still premed them if they had another condition that warranted it such as a previous SBE or new hip.

2nd error of omission: "premed: amoxicillin 2.0g 1 hr pre tx, clindamycin 600mg 1 hour pre if allergic to amox."

This is true for adults and kids over 40kg. If they are less than 40 kg then it's 50mg/kg of Amoxicillin or 20mg/kg of Clindamycin.

Correct in rare instances: "Like I said, in the case of a prophy, it's best not to premed. IF the pt does start to bleed..."

Maybe you're only treating hygienists but most patients I see have at least a mild gingivitis and/or a few places that bleed to light probing. Most prophy patients are likely to have some minor bleeding and I would premed just about every time.

If have a patient who had SBE about 2 weeks after a dental cleaning. I don't think you could prove that it was from the prophy and not something else but hearing him tell about the 12 weeks in the hospital made me take this much more seriously than I had previously.


JMHO
Rob

 

[larryt]

Originally posted by no2thdk999


Correct in rare instances: "Like I said, in the case of a prophy, it's best not to premed. IF the pt does start to bleed..."

Maybe you're only treating hygienists but most patients I see have at least a mild gingivitis and/or a few places that bleed to light probing. Most prophy patients are likely to have some minor bleeding and I would premed just about every time.


JMHO
Rob

True! no matter how good we are, we will most likely cause some minor bleedings during probing (99.9%). Why take any chance ?

 

[DcS]

Originally posted by no2thdk999

Flat out error: "IF the pt does start to bleed, you can medicate on the spot or w/in 2 hours and will get the same amount of protection."

If that were true then the guidelines would not say take 1 hour before dental treatment, they would say take if bleeding occurs up to 2 hours post-op. That is not how it is worded. A similar analogy would be the best way to prevent hear disease is routine physicals, diet, and exercise but if you're having an MI take an aspirin and get to the ER. Both are a good idea but they are not "the same amount of protection". This is GUARANTEED to come up in your practice. Pt. shows up and forgot to take required pre-med. Do you reschedule them and lose the production for that day, have them take it wait and hour and throw off the schedule for the next patient, or have them take it and get to work right away? Each choice has a potential detriment to you or the patient.

This is incorrect. Go read the guidelines that were posted on the first page, by you I think. Here is a section that describes it in detail:

" It is recognized that unanticipated bleeding may occur on some occasions. In such an event, data from experimental animal models suggest that antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis. 32 Antibiotics administered more than 4 hours after the procedure probably have no prophylactic benefit. "

1st error of omission: "If someone has a heart murmur without regurgitation, you never have to pre-med, regardless of the procedure."

You would still premed them if they had another condition that warranted it such as a previous SBE or new hip.

No kidding, I was only referring to a murmur without any other condition. Obviously, if they have a murmur with a prosthetic valve or new hip, those would take precedence. As per the risk levels and guidelines.

2nd error of omission: "premed: amoxicillin 2.0g 1 hr pre tx, clindamycin 600mg 1 hour pre if allergic to amox."

This is true for adults and kids over 40kg. If they are less than 40 kg then it's 50mg/kg of Amoxicillin or 20mg/kg of Clindamycin.

What I posted were general guidelines. I didn't go into every detail and exception. Obviously, if you want to bust my balls over things I left out, you can. There are many grey areas in a topic like this.

 

[aphistis]

Originally posted by DcS
I didn't go into every detail and exception. Obviously, if you want to bust my balls over things I left out, you can.

What I find most entertaining about this comment is how offended and defensive you seem to be about being called out by people who know more than you. After all, you didn't seem to mind "busting my balls" about my cavernous inexperience; but now you're trying to argue, with people out there doing the job, by waving ADA pamphlets. This is getting pretty rich--keep it coming.

 

[no2thdk999]

Originally posted by DcS
This is incorrect. Go read the guidelines that were posted on the first page, by you I think. Here is a section that describes it in detail:

" It is recognized that unanticipated bleeding may occur on some occasions. In such an event, data from experimental animal models suggest that antimicrobial prophylaxis administered within 2 hours following the procedure will provide effective prophylaxis. 32 Antibiotics administered more than 4 hours after the procedure probably have no prophylactic benefit. "

I would disagree that the above says that pre med at the time of bleeding or up to 2 hours after is equipotent to the general guidelines. It's a 15+ page document and you've taken one paragraph of what to do in an unforseen event based on experimental animal models and applied it across the board.

No kidding, I was only referring to a murmur without any other condition. Obviously, if they have a murmur with a prosthetic valve or new hip, those would take precedence. As per the risk levels and guidelines.

Still not true! If you have a murmur w/o regurgitation with no other concurrent heart abnormalities there is still a time where it would be prudent to pre-med, i.e. if the patient has a history of previous SBE.

What I posted were general guidelines. I didn't go into every detail and exception. Obviously, if you want to bust my balls over things I left out, you can. There are many grey areas in a topic like this.

Sorry, when you said "Should be crystal clear at this point i should think." I figured you were being all inclusive. Consider your balls busted. 😉

 

[UNLV OMS GUNNABE]

I fail to see the satisfaction gained by trying to 1-up each other all the time; although, it does provide some cheap entertainment.

 

[RaiderNation]

I honestly have to say that I love threads like this. Also, I love contributing to them as well...adding fuel to the fire if you will.

I think this whole conversation was started because someone said people don't usually come into to dental offices with life-threatening problems. Sorry dental students...I have to agree. Sure, a dentist can overlook a medical problem the patient has, or give him/her the wrong antibiotic and it could possibly end up in death, but c'mon guys, lets quit making ourselves out to be daily life-savers and get real. Do more patients die on doctors hands or dentists hands? Usually your teeth do not pose a life-threatning problem, notice I said usually. I don't want all these D1 and D2 students to go psycho on me.

Bottom of the line is sure a dental patient can die in the chair due to the dentists stupidity...but we're not talking about heart surgery here. How many of us would go to the heart surgeon every six months? Now I'm just waiting for all the dental students to jump on me and say "well, if thats what it took to keep me healthy, then I WOULD go through heart surgery every six months!" Get real!

 

[ItsGavinC]

Originally posted by RaiderNation
Now I'm just waiting for all the dental students to jump on me and say "well, if thats what it took to keep me healthy, then I WOULD go through heart surgery every six months!" Get real!

You make some good points, but your analogy isn't correct. Cardiac surgeons don't typically apply preventative measures.

Cardiologists, on the other hand, do apply preventative measures more frequently. And, people DO visit their Cardiologist every 3, 4, 5, and even 6 months to ensure cardiac stability.

And I'll further add fuel to the fire by saying that people DO come into the dental office with life-threatening problems. Sure, those problems are nearly always NOT related to dentition (or even the oral cavity), but that doesn't negate the fact that MANY patients have life-threatening problems/systemic disorders. HTN is a serious problem. Do we fix HTN? Nope. Should we be aware of it? Absolutely. Not only for our immediate treatment but also, if needed, to refer the patient to their primary physician. It may be that the patient never visits their physician and thus are unaware of their HTN. When they stop by the office for a routine oral procedure, however, that's a great time to check their pressures.

Are we daily life-savers? Not in my eyes. Can we do more harm than good to patients if we aren't aware of their pre-existing conditions and history? Absolutely. Can we pickup symptoms of systemic disease and refer to our physican friends? You bet.

 

[RaiderNation]

Originally posted by ItsGavinC
You make some good points, but your analogy isn't correct. Cardiac surgeons don't typically apply preventative measures.

Cardiologists, on the other hand, do apply preventative measures more frequently. And, people DO visit their Cardiologist every 3, 4, 5, and even 6 months to ensure cardiac stability.

And I'll further add fuel to the fire by saying that people DO come into the dental office with life-threatening problems. Sure, those problems are nearly always NOT related to dentition (or even the oral cavity), but that doesn't negate the fact that MANY patients have life-threatening problems/systemic disorders. HTN is a serious problem. Do we fix HTN? Nope. Should we be aware of it? Absolutely. Not only for our immediate treatment but also, if needed, to refer the patient to their primary physician. It may be that the patient never visits their physician and thus are unaware of their HTN. When they stop by the office for a routine oral procedure, however, that's a great time to check their pressures.

Are we daily life-savers? Not in my eyes. Can we do more harm than good to patients if we aren't aware of their pre-existing conditions and history? Absolutely. Can we pickup symptoms of systemic disease and refer to our physican friends? You bet.

I see your point. I agree.

 

[aphistis]

Originally posted by ItsGavinC
You make some good points, but your analogy isn't correct. Cardiac surgeons don't typically apply preventative measures.

Cardiologists, on the other hand, do apply preventative measures more frequently. And, people DO visit their Cardiologist every 3, 4, 5, and even 6 months to ensure cardiac stability.

And I'll further add fuel to the fire by saying that people DO come into the dental office with life-threatening problems. Sure, those problems are nearly always NOT related to dentition (or even the oral cavity), but that doesn't negate the fact that MANY patients have life-threatening problems/systemic disorders. HTN is a serious problem. Do we fix HTN? Nope. Should we be aware of it? Absolutely. Not only for our immediate treatment but also, if needed, to refer the patient to their primary physician. It may be that the patient never visits their physician and thus are unaware of their HTN. When they stop by the office for a routine oral procedure, however, that's a great time to check their pressures.

Are we daily life-savers? Not in my eyes. Can we do more harm than good to patients if we aren't aware of their pre-existing conditions and history? Absolutely. Can we pickup symptoms of systemic disease and refer to our physican friends? You bet.

As usual, my thoughts exactly, but more effectively communicated.

 

[larryt]

Originally posted by ItsGavinC
Not only for our immediate treatment but also, if needed, to refer the patient to their primary physician. It may be that the patient never visits their physician and thus are unaware of their HTN.

add Ludwig's angina. 🙁 🙁 We had 1 case last week at our hospital's ER. We lost him.