- Email: [email protected]
Council on Dental Therapeutics’ response:
I have no basis to either accept or reject the first two explanations. I reject the third because it totally ignores the holistic commit m ent of the dental profession to treat oral conditions as integral com ponents of the entire hum an system. While the technical excellence of American dentists is unparalleled, it does not occur in a vacuum. W hether the procedure be the placem ent of a Class II amalgam restoration, the surgical alteration of a Class III m alocclusion or the preparation of the maxilla for an eventual im plant, our dental “doctors” realize th at the success of these procedures depends on a positive response by the tissue and organ systems of the hum an body. I reject the final explanation because I see dentists as integral m em bers of the health care team possessing skills and knowledge m astered by only a m inute fraction of hum anity. They are active participants in the legal, ethical and political arenas of m odern life. They are civic leaders, philan thropists, scholars. Above all else they are healers. Truly, by any definition, they are deserving of the term “doctor.” Physicians and dentists-of course! Doctors and dentists—abso lutely not! Do you agree? 1. A m erican D ental A ssociation D epartm ent of State G overnm ent Affairs. M edicaid: h ow it relates to den tal care. JADA 1991; 122(6);83-4. 2. The A ssociated Press. T he Associated Press stylebook and libel m anual. New York: T he Associated Press; 1988:65.
10
JADA, Vol. 122, November 1991
LEM ADA devotes this section to com m ent by readers on topics of current interest in dentistry and reserves the right to edit all com munications. JADA requires that all letters be typed, double-spaced and signed. No more than 10 references should be included with each letter. The views expressed are those of the letter w riter and do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited. E R Y T H R O M Y C IN D O S IN G ER R O R IN B A C T E R IA L E N D O C A R D IT IS
The recom m endations by the American Heart Association on the prevention of bacterial endo carditis stated th at for amoxicillin/penicillin-allergic patients initial doses of erythrom ycin ethylsuccinate 800 milligram or erythromycin stearate 1.0 gram can be substituted.1'2The doses of these two erythrom ycin salts are not chemically equivalent. The ethylsuccinate salt has different absorption characteristics in adults than do the other salts requiring higher oral doses to achieve similar therapeutic effects.3Erythromycin 400 mg as the ethylsuccinate is equivalent to erythrom ycin 250 mg as the stearate, base or estolate.3“1Therefore, initial doses should be erythromycin ethylsuccinate 1.6 g or erythro mycin stearate 1.0 g. To exemplify the m isunder
standing between erythrom ycin salts and the potential for prescrip tion errors, we questioned 10 dentists and 10 physicians as to their acceptance of the erythro mycin dosing guidelines stated in this article. All practitioners considered the guidelines appro priate and were unaw are of the differences in the erythrom ycin salt equivalents. Pierre A. M aloney, Pharm.D. Paul W. Jungnickel, M.S. Jam es R. Campbell, M.E. U niversity o f Nebraska M edical Center Omaha, Neb. 1. D ajani AS, Bisno AL, C hung KJ, e ta l. Prevention of bacterial endocarditis: reco m m endations by the A m erican H eart Association. JAMA 1990;264:2919-22. 2. Council on D ental T herapeutics; A m erican H eart Association. Preventing b acterial endocarditis: a statem en t for th e den tal professional. JADA 1991;122(2):87-91. 3. Erythrom ycins. In: McEvoy GK, Litvak K, eds. AHFS Drug Inform ation. B ethesda, MD: A m erican Society of Hospital P h arm acists Inc; 1990:185-7. 4. E.E.S., Package Insert. A bbott Laboratories, N orth Chicago, IL. J u n e 1989.
Council on D ental T herapeutics’ response: The American Heart Association recom m endations on the Preven tion of Bacterial Endocarditis were published in the Dec. 12,1990 issue of the Journal of the American Medical Association and those portions pertinent to dentistry were published in the February 1991 issue of JADA. These new guidelines contain several changes from the November 1984 guidelines. Most notable among these are the change of oral regim en from penicillin to amoxicillin, the specification of two erythrom ycin and one clindamycin alternative regimes for amoxicillin-allergic patients, and the fact that these oral regimens are now recom m ended for high-risk (for example, prosthetic valve) patients who previously required parenteral
antibiotics. A com m on question about A the guidelines relates to the recom m ended dosing Ë regim en for JT m erythrom ycin Æ jg g g g jf ethylsuccinate. To obtain a 1 response to this question, the council contacted Dr. Adnan Dajani, Chairm an of the Committee on Rheum atic Fever, Endocarditis and Kawasaki Disease of the AHA, for clarification. He indicated that the com m ittee had also received m any inquiries on this m atter, and th at he would prepare a reply which would be published in JAMA. This appeared in the April 3,1991 issue, and is reproduced here for JADA readers. “In th e previous recom m endations from the American H eart Association concerning bacterial endocar ditis prophylaxis,1the regimen for erythrom ycin in patients who are allergic to penicillin was 1.0 g, followed by 500 mg, w ithout reference to a specific preparation of the drug. Because of the complex pharm acokinetics associated w ith various erythromycin preparations, as well as the among-study and inter individual variations, the com m ittee thought that specific preparations should be recom m ended. By simplifying the choices and tim ing of drug adm inistration, the committee believed th at m ore reliable erythrom ycin serum concen trations would be achieved when these recom m endations were widely applied. We appreciate that the two dosage forms recom m ended may not be fully equivalent; however, both should result in adequate serum levels against a 12
JADA, Vol. 122, November 1991
l hemolytic streptococci.2 K Furtherm ore, the committee h was concerned that larger doses of erythromycin ethylsuccinate might result in unacceptable gastrointestinal upset. The potential hepatotoxicity of erythrom ycin estolate makes it a less desirable agent for widespread use in prophylaxis of endocarditis. The pharmacokinetics of erythrom ycin preparations are complex. The com m ittee’s recom m endations do not prohibit the practitioner from substitution in preparation for those recom m ended. However, while doing so, the practitioner should be familiar with the form ulation’s specific pharm a cokinetic inform ation and instruct the patient accordingly. Adnan S. Dajani, M.D. Katliryn A. Taubert, Ph.D. For th e Com m ittee on Rheumatic Fever, Endocarditis and Kawasaki D isease o f the American H eart A ssociation Dallas 1. S hulm an ST, Am ren DP, Bisno AL, et al. P revention AWT o f bacterial endocarditis. Mr C irculation Mr 1984;70:1123A-27A. 2. Steigbigel NH. E rythrom ycin, lincom ycin, and clindam ycin. In: Mandell GL, Douglas RG Jr, B en n et JE, eds. P rinciples a n d practice of infectious diseases. 3rd ed. New York: Churchill Livingstone Inc; 1990:716-721. ”
The AHA committee based its recom m endation on data contained in Principles and Prac tice of Infectious Disease (Ref. 2 of Dr. Dajani’s letter) which showed adequate blood levels of the erythrom ycin base for the ethyl succinate and stearate prepara tions at the doses it recommends. It is noteworthy to m ention that the council also contacted Abbott Laboratories, one of the makers of erythrom ycin ethylsuccinate who
advocate using the 1600-mg dose to find out w hat data they had to support this recommendation. We were told that they had no data, but based this recom m endation on the AHA recommendations. Clearly, this is not the case. Dr. Dajani has indicated th at w hen the committee again meets to discuss the guidelines, this issue will be explored further. However, the comm ittee still believes that the erythrom ycin regimens given in the December 1990 report provide adequate coverage for patients susceptible for developing bacterial endocarditis. Cliff Whall, Ph.D. A ssistant Director Council on Dental Therapeutics D E N T IS T R Y ’S IM A G E
I wish to congratulate and thank Jim Pride for his comments in “Dealing With Dentistry’s Image Dilemma” (Sept). He made a nice case for upgrading our personal and professional images for the public. However, I would like to take his comments one step further. In my dealing | wi t h dentists on office designs and selection of equipm ent I often find an “attitude of apology” for being a dentist. Many dentists tell me th at they cannot accept a certain type of delivery system because “their patients will not accept it.” I find this disappointing because this often leads to the use of ergonomically incorrect and physically damaging delivery styles for the dental staff. I know of essentially no other health profession where the patient dictates the equipm ent to be used in their treatm ent. I believe that the dentist should use w hatever equipm ent arrangem ent
10
JADA, Vol. 122, November 1991
LEM ADA devotes this section to com m ent by readers on topics of current interest in dentistry and reserves the right to edit all com munications. JADA requires that all letters be typed, double-spaced and signed. No more than 10 references should be included with each letter. The views expressed are those of the letter w riter and do not necessarily reflect the opinion or official policy of the Association. Your participation in this section is invited. E R Y T H R O M Y C IN D O S IN G ER R O R IN B A C T E R IA L E N D O C A R D IT IS
The recom m endations by the American Heart Association on the prevention of bacterial endo carditis stated th at for amoxicillin/penicillin-allergic patients initial doses of erythrom ycin ethylsuccinate 800 milligram or erythromycin stearate 1.0 gram can be substituted.1'2The doses of these two erythrom ycin salts are not chemically equivalent. The ethylsuccinate salt has different absorption characteristics in adults than do the other salts requiring higher oral doses to achieve similar therapeutic effects.3Erythromycin 400 mg as the ethylsuccinate is equivalent to erythrom ycin 250 mg as the stearate, base or estolate.3“1Therefore, initial doses should be erythromycin ethylsuccinate 1.6 g or erythro mycin stearate 1.0 g. To exemplify the m isunder
standing between erythrom ycin salts and the potential for prescrip tion errors, we questioned 10 dentists and 10 physicians as to their acceptance of the erythro mycin dosing guidelines stated in this article. All practitioners considered the guidelines appro priate and were unaw are of the differences in the erythrom ycin salt equivalents. Pierre A. M aloney, Pharm.D. Paul W. Jungnickel, M.S. Jam es R. Campbell, M.E. U niversity o f Nebraska M edical Center Omaha, Neb. 1. D ajani AS, Bisno AL, C hung KJ, e ta l. Prevention of bacterial endocarditis: reco m m endations by the A m erican H eart Association. JAMA 1990;264:2919-22. 2. Council on D ental T herapeutics; A m erican H eart Association. Preventing b acterial endocarditis: a statem en t for th e den tal professional. JADA 1991;122(2):87-91. 3. Erythrom ycins. In: McEvoy GK, Litvak K, eds. AHFS Drug Inform ation. B ethesda, MD: A m erican Society of Hospital P h arm acists Inc; 1990:185-7. 4. E.E.S., Package Insert. A bbott Laboratories, N orth Chicago, IL. J u n e 1989.
Council on D ental T herapeutics’ response: The American Heart Association recom m endations on the Preven tion of Bacterial Endocarditis were published in the Dec. 12,1990 issue of the Journal of the American Medical Association and those portions pertinent to dentistry were published in the February 1991 issue of JADA. These new guidelines contain several changes from the November 1984 guidelines. Most notable among these are the change of oral regim en from penicillin to amoxicillin, the specification of two erythrom ycin and one clindamycin alternative regimes for amoxicillin-allergic patients, and the fact that these oral regimens are now recom m ended for high-risk (for example, prosthetic valve) patients who previously required parenteral
antibiotics. A com m on question about A the guidelines relates to the recom m ended dosing Ë regim en for JT m erythrom ycin Æ jg g g g jf ethylsuccinate. To obtain a 1 response to this question, the council contacted Dr. Adnan Dajani, Chairm an of the Committee on Rheum atic Fever, Endocarditis and Kawasaki Disease of the AHA, for clarification. He indicated that the com m ittee had also received m any inquiries on this m atter, and th at he would prepare a reply which would be published in JAMA. This appeared in the April 3,1991 issue, and is reproduced here for JADA readers. “In th e previous recom m endations from the American H eart Association concerning bacterial endocar ditis prophylaxis,1the regimen for erythrom ycin in patients who are allergic to penicillin was 1.0 g, followed by 500 mg, w ithout reference to a specific preparation of the drug. Because of the complex pharm acokinetics associated w ith various erythromycin preparations, as well as the among-study and inter individual variations, the com m ittee thought that specific preparations should be recom m ended. By simplifying the choices and tim ing of drug adm inistration, the committee believed th at m ore reliable erythrom ycin serum concen trations would be achieved when these recom m endations were widely applied. We appreciate that the two dosage forms recom m ended may not be fully equivalent; however, both should result in adequate serum levels against a 12
JADA, Vol. 122, November 1991
l hemolytic streptococci.2 K Furtherm ore, the committee h was concerned that larger doses of erythromycin ethylsuccinate might result in unacceptable gastrointestinal upset. The potential hepatotoxicity of erythrom ycin estolate makes it a less desirable agent for widespread use in prophylaxis of endocarditis. The pharmacokinetics of erythrom ycin preparations are complex. The com m ittee’s recom m endations do not prohibit the practitioner from substitution in preparation for those recom m ended. However, while doing so, the practitioner should be familiar with the form ulation’s specific pharm a cokinetic inform ation and instruct the patient accordingly. Adnan S. Dajani, M.D. Katliryn A. Taubert, Ph.D. For th e Com m ittee on Rheumatic Fever, Endocarditis and Kawasaki D isease o f the American H eart A ssociation Dallas 1. S hulm an ST, Am ren DP, Bisno AL, et al. P revention AWT o f bacterial endocarditis. Mr C irculation Mr 1984;70:1123A-27A. 2. Steigbigel NH. E rythrom ycin, lincom ycin, and clindam ycin. In: Mandell GL, Douglas RG Jr, B en n et JE, eds. P rinciples a n d practice of infectious diseases. 3rd ed. New York: Churchill Livingstone Inc; 1990:716-721. ”
The AHA committee based its recom m endation on data contained in Principles and Prac tice of Infectious Disease (Ref. 2 of Dr. Dajani’s letter) which showed adequate blood levels of the erythrom ycin base for the ethyl succinate and stearate prepara tions at the doses it recommends. It is noteworthy to m ention that the council also contacted Abbott Laboratories, one of the makers of erythrom ycin ethylsuccinate who
advocate using the 1600-mg dose to find out w hat data they had to support this recommendation. We were told that they had no data, but based this recom m endation on the AHA recommendations. Clearly, this is not the case. Dr. Dajani has indicated th at w hen the committee again meets to discuss the guidelines, this issue will be explored further. However, the comm ittee still believes that the erythrom ycin regimens given in the December 1990 report provide adequate coverage for patients susceptible for developing bacterial endocarditis. Cliff Whall, Ph.D. A ssistant Director Council on Dental Therapeutics D E N T IS T R Y ’S IM A G E
I wish to congratulate and thank Jim Pride for his comments in “Dealing With Dentistry’s Image Dilemma” (Sept). He made a nice case for upgrading our personal and professional images for the public. However, I would like to take his comments one step further. In my dealing | wi t h dentists on office designs and selection of equipm ent I often find an “attitude of apology” for being a dentist. Many dentists tell me th at they cannot accept a certain type of delivery system because “their patients will not accept it.” I find this disappointing because this often leads to the use of ergonomically incorrect and physically damaging delivery styles for the dental staff. I know of essentially no other health profession where the patient dictates the equipm ent to be used in their treatm ent. I believe that the dentist should use w hatever equipm ent arrangem ent