AME: No More Joint Premedication?

[00:00:00] Did you know Net32 was actually started by a dentist? Someone who is just fed up with how broken and expensive the supply process had become. This isn't some generic medical site. It was built specifically for dental practices. Thousands of dentists use it every day to save time and money. You'll find all the big brands you already know and trust just at better prices. Instead of calling reps or chasing down quotes, you can compare products and pricing in seconds. It's completely transparent and you're in control of what you spend. Same products, same vendors, less hassle and lower prices.

[00:00:30] The next time you need supplies, check Net32. Built by a dentist for dentists like you. Check them out at Net32.com. This is a production of the Very Dental Podcast Network.

[00:00:49] Alan Mead is a dentist with too much time on his hands and too much recording equipment in his basement. Armed with an obsession to bring entertaining and informative content to the dental world in a way that's never been done before. I give you the Alan Mead experience.

[00:01:09] Well, hello and welcome to another episode of the Alan Mead experience. I'm your host, Dr. Alan Mead. I'm a dentist, a podcaster, and I'm feeling very smug. I'll tell you a little bit about this smugness in a second. Okay, so I'm feeling smug because back in 2012 or so, I wrote a blog post. This was before I was podcasting. I was blogging a lot. I wrote a lot of my thoughts instead of spoke them into a microphone, which is interesting.

[00:01:38] The fact that I do these things differently. I really don't write much anymore. So in December of 2012, I wrote a piece that got a lot of attention for it. And it was about the new recommendations for joint replacement prophylaxis recommendations from the American Academy of Orthopedic Surgeons and the ADA.

[00:02:04] And it was a super frustrating. I thought it was one of the better things I'd ever written. Honestly, it was wildly sarcastic because I just felt like whatever guidance they were giving us was such a joke. But so anyhow, it turns out that they wrote these guidelines in 2012, which were kind of no guidelines at all. And then they updated them in 2017 with a website that helped you determine what the guidelines should be.

[00:02:29] And that was also not very helpful. So since 2012, we've been in a limbo about joint premedication. I'll go into it in a second. But then so I got all excited. I was on my bus ride home from Disney a couple of weeks ago, actually last week. Is that right? A couple of weeks ago. I saw that Melissa Seibert had posted on the new guidelines for joint premedication.

[00:02:52] And in actuality, joint premedication, the guidelines were actually these guidelines came out in like December of 2024. And I think they were slowly rolled out in publications and stuff over 25 and 26. I frankly had stopped paying attention to the guideline issue because I felt so defeated about it. And so I was very excited. She had posted this, that they were new guidelines. And I'm like, this is awesome. I'm going to totally write about it.

[00:03:17] And then I read them as if they were new like last week. And it turns out they weren't. They've been out for a while. Even the ADA Journal had an article on them, I guess, in February. And I'll post links to my original blog post. I'll post a link to the current guidelines as they're written so you guys can kind of take a look at it.

[00:03:41] Now, if you're treating patients mostly above a certain age in their 50s and above, generally speaking, you see a lot of patients that have had this revolutionary treatment where they've had one or more joints replaced, whether it's a knee or a hip or, you know. And for, okay, when I was in dental school in the 90s,

[00:04:03] everyone who had any kind of a heart murmur or a heart valve replacement or any kind of joint replacement, we used to throw a ton of antibiotics at these people. And there was never any question. We for sure were doing it. We would do like, I want to say it was like, we give them a giant dose of amoxicillin an hour before the appointment. And then like another giant dose of amoxicillin six hours after the appointment.

[00:04:27] Because the concern was after having dental work, it would cause this transient septicemia. Basically, anytime you make the gums bleed, you're going to get all the, you're going to get bacteria from the mouth go into the bloodstream and that it puts this new joint or old joint, whatever joint at risk. And so from here on out, we're going to cover our patients in antibiotic premedication to help prevent this risk.

[00:04:54] One of the problems is that we didn't have a ton of research that actually, you know, invasive dental procedures or frankly, not that invasive dental procedures caused enough septicemia to hurt a joint. We didn't really have the evidence. It was sort of assumed that we had that evidence, but we really didn't have the evidence. I don't know that there was much research done on it.

[00:05:17] And so I think for several reasons, first off, I don't think we were really great about antibiotic stewardship. I think we just threw antibiotics at everything. And I hope, I'm guilty at times of this too, but I hope that we do better with antibiotic stewardship now than we used to. Because we used to throw antibiotics at everything. And this was just one more thing like, hey, if we can give them antibiotics to make it so there's less risk, great, let's do it.

[00:05:44] So then in 2012, it's, I feel like there were a lot of us that felt like it was not a great thing to do, but there was no real science behind it. But as an individual dentist, what do you, what can you do? So in 2012, I was really excited because the American Dental Association and the American Association of Orthopedic Surgeons, the two groups that really, you know, are, have professionals that are affected by this, came out with some guidelines.

[00:06:09] And their guidelines were, were, once you dug into them a little bit, were very frustrating. I'm going to, I'm going to just read a couple of things that, that frustrated me the most, to be honest. First off, you, okay, so you got the guidelines. You're like, great, I'm going to finally find out what, what am I really supposed to do for these patients? And the guidelines in 2012 said, this summary of recommendations is not intended to stand alone. Treatment decisions should be made in light of all circumstances prevented by, presented by the patient.

[00:06:37] Treatments and procedures applicable to the individual patient rely on mutual communication between patient, physician, dentist, and other healthcare providers. So what they're kind of saying is that this, what I've said was, I read that and think these guidelines are perfectly fine, except you still have to evaluate patients on a case-by-case basis. And if you get sued, we don't have your back. So the reality is, is that these guidelines, they're saying it's a case-by-case basis.

[00:07:03] And I'm a dentist and I'm supposed to evaluate the, you know, the immunocompromised, like, status of any given patient and whether we should be throwing antibiotics. Bottom line is that if you have a functioning immune system, transient septicemia is happening all the time. When you think about it, if you floss your tooth a little too aggressively and causes bleeding, you have just caused a transient septicemia in that area.

[00:07:28] But my example was, if you bite on a Dorito just right and jag your gum or your, you know, you have just created a transient septicemia based on Doritos. You have a Dorito-based transient septicemia. So, you know, yeah, an extraction is maybe more invasive than that. But the reality is, is that it's a transient septicemia no matter what. And that's happening in human beings all the time.

[00:07:57] And if you have an immune system that's functioning correctly, it doesn't, it's not a risk. It's not, you know, it's taken care of. Your blood is chock full of immune system stuff that's going to kill those bacteria and make it so you don't have problems. If you're immune compromised, it's a different animal. And I mean, that no one is saying that someone with serious immune compromise might be better served by this.

[00:08:24] Although I got to say, even with that, the evidence isn't great that having an antibiotic on board, it's plausible, right? Like if you have antibiotics in the bloodstream and you have, you know, you're going to have a septicemia and you've got an immunocompromised person. Yeah, that it's plausible. I don't think they've done any actual research that would make me feel like, yes, this is for sure. But the reality is, is that the guidelines they gave you and they gave a whole bunch of them that were not based in good evidence. And they basically said it's a case by case basis.

[00:08:53] And it says you might, you might consider not, not giving them antibiotics. You might. And I might, I might, I might do a lot of things, right? But you might. That's what they said. It was very frustrating. They recommended some potential for, you know, do mouth rinses before procedures, blah, blah, blah. And so in 2012, what they purported to be guidelines were not guidelines.

[00:09:18] And, and I decided there and then that I was taking a stand and I told my patients that I'm not going to write, I'm not going to write for this stuff anymore. For hips and the, the, where the American Heart Association actually gives very specific guidelines for people with, with, you know, heart valve replacements and that sort of thing. I like that because of course I'm going to write for that. That's, that's given by the people who know what they're talking about. And I honestly, you would think that the orthopedic surgeons would be the people who know how this really affects joints.

[00:09:45] And I don't, I don't think that they're, they're acting like they're acting like it has more to do with the dentists. I don't know. In any, in any case, I, I had a policy in my office and my, my team hated it. My team hated it because it meant we had to spend a lot of time going back and forth with the office, the orthopedic surgeons. First off, most of the orthopedic surgeons around here felt condescendingly like you do what I want you to do and you write this for me. That's, I got a lot of that.

[00:10:14] And so we would then say, no, you, if you want it, you're going to write it. And those offices really pushed back against that. They felt like they have important things to do. You're just a dumb dentist and you write this because this is what we're saying. And I wouldn't do it. And, and it was always, my team hated it because it was always a big, it was always a big drama. Worse than that, all of a sudden you're putting the patient between two providers of theirs that are, that, that have different opinions on what should be done.

[00:10:41] And even though I had what I felt like the, the better, the better position based on what the ADA and the AOS had put out, there was, there was a ton of surgeons that still, they still didn't want to, they didn't want to comply with this. They wanted, they wanted to do what they've always done. And that's that. So I, it was a fight and, and it's been one of these things where over time, um, I just would, you know, if a patient comes in worried about this, I'd say, look, you don't have to have this.

[00:11:09] The funny thing that no one talks about is when you tell a patient that the evidence does not show that the antibiotic makes it any more risk. I have to say, I'm knocking on wood here, but I have not had a patient that's had a joint. I've not had a patient with a joint failure where they specifically said, this is because you extracted a tooth on me or something. I didn't, I've never had that. I've had the conversation a lot of times that I told them that I didn't think that they needed this because the evidence didn't show that it was the case. And if they wanted, if they felt strongly about it, I was going to have them talk to their surgeon.

[00:11:39] I will say that having the patient talk to the surgeon's office was always much more effective than having my office. Cause I think surgeons don't like being condescended to by a dentist saying, we're not going to do it. Um, this is all ego and feeling stuff, which is freaking stupid, but whatever, here we are. Um, so that's where I had left it after. And in 2017, they updated these guidelines a little bit by giving you a website where you could kind of plug in different things about your patient. Like when was the surgery done?

[00:12:08] What is this patient's health? You know, does this, are this a patient diabetic? And then they would sort of give you some kind of, well, you might, you might not. And so it was, it, it justified not giving the antibiotics slightly in certain cases. It was frankly not very helpful. Again, it was 2017. I got all flared up about it. I probably recorded something about it. I don't even know. But like up to this point, it's, it's always been, they tried to make it like it's, you might not have to do this, but the reality is every dentist out there.

[00:12:35] I know a lot of dentists who still just write the script because they're like, I don't want to be liable for the joint thing. But my thing is that any joint that fails, first off, everyone's always like, well, they, they found oral bacteria in it. So, you know, that it was from a septicemia from the mouth. I'm like, well, of course they did. The mouth has the most bacteria by far. What else? I mean, that's, that's what you would expect to be honest.

[00:12:59] Like where else, if it came from a transient septicemia, it probably did come from the mouth because the mouth is full of bacteria, but we cannot prevent all of those events from happening. It's so the, the, my understanding is if, if you get a joint failure, they ask, well, well, did you see the dentist recently? Well, and, and they may or may not. And of course they're always going to say it's dental care because they're, they're not going to own anything else. Joints fail. I mean, crowns fail. Restorations fail. Stuff fails. Human body. You know, we got stuff that fails.

[00:13:30] It is, is there blame? No. The one thing I will say is that if you have to replace or repair a joint that's failing, they get paid for that. That's something interesting. The doctors get paid. Insurance covers a joint failure. You know what they don't cover? They don't cover when a crown's been in the mouth for a couple of years and, and you get recurrent decay because you're a garbage mouth and you don't take care of your teeth. That's, it's a five-year warranty period where the dentist is on the hook for that. That's frigging awesome, by the way. That's a total aside. I'm not cranky or anything on Father's Day.

[00:14:01] Anyhow. So I feel like a lot of this has been, has been trying to place blame on failing stuff and stuff fails sometimes. But the reality is most joints do really well and most joints literally once they've had the recovery, they don't even think about it. Like, like when you think about the procedure that they're doing, it's kind of amazing. This issue in my mind, I've made it awfully big because it's something that always bothered me and maybe because I didn't like being condescended to by surgeons or whatever.

[00:14:30] But I always, and it was something to blog about. It was always sort of a, an ax to grind that I had. So you can imagine my, and I hadn't really thought much about it. We had always told people, you really don't need this. And if you're going to do it, I'm going to watch your surgeon to cover it. Crazy Dental already has some of the lowest prices on dental supplies anywhere. But you know what's even crazier? Free shipping. Head over to crazydentalprices.com, load up your cart, and use coupon code VERYSHIP. That's VERYSHIP for free shipping on every single order.

[00:14:59] Plus, every time you use that code, CRAZY Dental kicks back support to the Very Dental podcast network. Save money, get free shipping, and support the show. Use code VERYSHIP today. And for the most part, I've not made any exceptions to that that I can remember. It doesn't come up as often, which is to say maybe when we know someone has gotten a joint replacement, maybe they just, I don't know. I don't know. The other thing is, you have to remember, when you tell a patient that they don't need to do this anymore, they're psyched.

[00:15:29] There's a lot of patients that have had joint replacements 25, 30 years ago that remember taking giant handfuls of antibiotics before and after their dental appointments that are thrilled at the idea that they don't have to. They're thrilled because, A, antibiotics can cause stomach upset, obviously, especially when you're giving a giant dose of them. And, B, it's just one more thing to remember before your appointment. The classic, like literally we had lectures in dental school on how you should handle it if they forgot their premedication and stuff like that. And patients, as well as offices, don't really want to deal with this stuff. They've got a life to live.

[00:15:58] And they do forget these things because it's a weird thing to remember, anyhow. Now, the other thing worth remembering is that people can have reactions to antibiotics. And, you know, some people will find out that they are sensitive to an antibiotic because of the premedication prescription that you gave them. And, you know, and God only knows if you're allergic to amoxicillin, I want to say they fell back to clindamycin. Clindamycin is a – I don't prescribe clindamycin in my office anymore.

[00:16:26] I remember, God, when I first got out of dental school, I was prescribing clindamycin all the time, not thinking much of it. Well, clindamycin causes C. diff. I mean, if you have a patient that goes to the hospital with C. diff, it's probably because they were taking clindamycin, more than likely. And that is really serious. That's hospitalization. That's time away. That's medical issues. And I have patients that – I have patients that have kind of had to deal with this.

[00:16:53] I don't think it's been secondary to me prescribing clindamycin because I just don't prescribe it very much anymore. But it's a whole thing, you know. It's like – so I don't prescribe them if I don't feel like there's going to be a benefit. And I really don't feel like there's much of a benefit. There's certainly not a benefit that we're going to be able to trace directly back to our treatment. So I've – since 2012, I've been really hesitant to write for this stuff, and I generally don't.

[00:17:20] So now we come to the part of the show where I feel very smug. So I'm on the bus. I think it's driving back from Florida. I'm freaking Googling around. I'm sure I was doom scrolling on Instagram. Melissa had a story talking about the new guidelines from joint premedication. And I'm thinking to myself, oh, my God, there's new guidelines. I just assumed because she said they were new that they were like – they came out like this month. Well, they've been around for a little while. I just haven't talked about them.

[00:17:48] I haven't really paid attention to them, to be honest. So anyhow, my – what's interesting about these guidelines, I guess that's – what I'm going to tell you is that the guidelines published in late 2024 and rolled out last year basically say – they say the quiet part out loud. The quiet part that I – my quiet part out loud. It says that there's limited strength recommendation.

[00:18:12] There's a limited strength recommendation declaring that the routine systemic antibiotic prophylaxis before a dental procedure does not reduce the risk of periprosthetic joint infection. So in English, it doesn't work. Stop doing that. I've always felt that way. And I feel like that's a pretty strong thing. They actually word it in such a way where they say it may not. It may not work. It may not help, which may not is any kind of – none of this ever says it doesn't, but it may not work.

[00:18:42] And so at this point, they're not routinely recommending premedication for dentistry. That's coming from the AAOS. That's a big deal. So what they are saying is that there are specific guidelines as to when dental work should be done in, you know, temporally around a joint surgery. So before joint surgery, if you're doing invasive dental work, extractions, deep cleanings, anything bloody, it must be completed at least three weeks before the orthopedic surgeon cuts into that joint. Why?

[00:19:12] To let the oral mucosa actually heal so there isn't an open wound pouring bugs into the bloodstream during the orthopedic recovery. Okay. I can live with that. That's three weeks is what they're saying. And then after joint surgery, all elective care is to be benched for three months post-op. For 90 days, that joint is heavily vascularized. It's healing and it's sensitive. So no cleanings, no elective crowns. If you've got an emergency, you treat it. But otherwise, tell them to come back in three months. So those are guidelines I can live with.

[00:19:40] And frankly, those are guidelines that patients can probably tell you about. Like, so I'm going to tell you that three weeks before, you know, get your dentistry done three weeks before the surgery and then don't see them for three months after the surgery. And those are scientifically plausible. That's awesome. I love the fact that they're just flat saying that. And like I said, I'm going to give you a link to the guidelines so you can read them for yourself. But so this is great. Like, this is an actual guideline. Are we liable?

[00:20:10] It's a good question. So the reason that we wrote these prescriptions all this time was fear. It was fear. Frankly, it was fear of being sued. It was fear of not doing the right thing. And if the patient had a joint infection, they could sue us or get angry at us or, you know, it was kind of fear of the lawyers. Which is, I hate everything about fear of lawyers because it's, you're never making any decisions that you, that you're afraid of lawyers for, for the good reasons. You're not doing it for the good reasons of patients.

[00:20:40] Unless you honestly believe that a giant bolus of antibiotic is really helpful for patients and it was really preventing this. We're doing it so that we cross the T's, dot the I's so that the lawyers can't come after us. That sucks. I hate that. I've always hated that. And that, I'm a little bit of a contrarian that way because like, I think, I think all of us do the best we can with what we know in our skill set. And, and, you know, outcomes can't be guaranteed. So that, this sort of falls along those lines.

[00:21:09] And, you know, like an insurance policy of a giant bolus of antibiotic that probably doesn't do anything that, that essentially doesn't do anything. We know doesn't do anything to make us feel better is the wrong reason to do it. So what's cool is that the update flips this script from you might be liable if something happens, if you don't prescribe this stuff.

[00:21:29] Because the AAOS and the ADA are now in lockstep about not writing these scripts, the standard of care is officially to not premedicate a routine joint replacement patient. So that's awesome. Like the standard of care is such you don't write this. That's huge. So our liability is, is not, I'm not a lawyer.

[00:21:52] If this concerns you, you might talk to a lawyer, but this, from what I'm, how I'm going to live my life is that we are no longer liable. Actually, we are probably more liable if we write it and they have a reaction at this point. Because we were liable. We're always liable for that. If, if we write the prescription, they have a reaction. That's all, that's on us. So then, then the, the real, the real battle goes to the, the surgeons, the old school surgeons who are writing, who want us to do this even.

[00:22:21] And, and my suspicion is the AAOS statement did not change the feelings of one surgeon around me at all back in 2012 or 2017. My suspicion is the new one also does not. They are, they are either going to want it or not want it. They're not interested in here. They're going to do whatever they learned in school, whenever that was. Honestly, that sucks. This is such a basic thing because people go to the dentist. Amazingly enough, it's not like, it's not like it's a rare thing that your patient goes to the dentist.

[00:22:50] So I, I'm going to come up with a, and I'll, I'll even put my, my letter in, in the show notes. I have a letter and I'm basically going to send it to the surgeon. If there's any question about this, that, that makes it very clear that they can, if they want to go against the standard of care, which is not writing this antibiotic, that they, it's on them. They write the script and I want to see, I want to see a letter explaining why they're going against it. And I also want to see a copy of the prescription.

[00:23:20] So I'm, I'm going to be a dick about this is what I'm telling you. I'm going to take it to them because now I feel like I've, because the, the guideline from 2012 and 2017 was like, well, you might choose to do this. Now they're saying you shouldn't do. And, and I'm, I like that. I like, this is a better guideline for sure. So I, I, and if you hadn't heard about this, I, it doesn't necessarily change your life, but I mean, if there's, we, we need to be careful about the antibiotics we prescribe.

[00:23:46] And frankly, I, you know, there's no reason to have someone else twist your arm into writing, writing for an antibiotic that, that you don't need. So I'll, I'm going to actually just read it. I'm going to read the letter that I kind of came up with to you just a little bit. Okay. Here's, here's my letter or something like it. Dear Dr. Sawbones, our mutual patient is scheduled for a dental procedure at our office on the date. The patient indicated that your office routinely recommends systemic antibiotic pre-medication prior to dental appointments due to their history of total joint arthroplasty.

[00:24:16] Please be advised that our practice strictly adheres to evidence-based prescribing patterns and follows the AAOS clinical practice guidelines, CPG, on the prevention of total hip and knee arthroplasty, periprosthetic joint infection, PJI, in patients undergoing dental procedures. That, my friends, is a mouthful.

[00:24:35] So, as you're aware, the current AAOS guidelines state routine use of a systemic prophylactic antibiotic prior to a dental procedure in patients with a knee, hip or knee replacement may not reduce the risk of a subsequent periprosthetic joint infection. And that's cited from the AAOS statement. Now, mind you, you notice it says may not. It doesn't say does not, which I'd love it if it'd say it does not, but it may not.

[00:25:00] But the AAOS literature review establishes that the risk of transient bacteremia from routine dental procedures is no greater than that of daily activities, for instance, mastication and oral hygiene, and that the risks of overprescribing, such as severe adverse drug events, C. difficile infection, and antimicrobial resistance outweigh the unproven theoretical benefit to the prosthetic joint.

[00:25:25] Because my patient presents as a standard immunocompetent host with no documented history of PJI, revision implants, or megaprosthesis, routine antibiotic prophylaxis is not indicated under the current AAOS and ADA standards. And then I go on to give our practice protocol, which includes if the surgeon is going to override, I want evidence. I want a letter and I want to see the prescription. So that's what I'm going to do. It's strong stance. I think it's the right stance.

[00:25:53] And the reality is that they're essentially saying the exceptions are people who've had a failed joint before, immunocompromised people or any specific kind of what the mega joint or whatever they called it. The bottom line is megaprosthesis. It's not indicated by the AAOS and I'm going to stand by that. So this is sort of a, it's like a policy statement. The science is, is not as even as clear as that. You can say there's a lot of wishy-washy stuff around it, but I, I'm going to do that.

[00:26:21] And I'm just going to have that letter ready to go to send off to them because I'm just tired of this. And the patients then I, I, the thing that bothers me the most is that this puts the patient in between us and it still kind of does. Um, I feel even more bold to tell them that they should not be on an antibiotic at all. And they should say no to their surgeon. Um, I feel, I feel pretty bold about that. Uh, cause this, this essentially says it.

[00:26:48] Um, but I don't like putting the patient in a spot that they have to make this decision or have this conversation. So I'm going to try and have the conversation for them. I'm whether that's by me telling them in face to face that the evidence is very strong and these organizations are now recommending against it, which I think is great. And also that I'm going to send this to their, their surgeon and their surgeon can make the next move. This is not their thing to beg, plead, or borrow.

[00:27:12] It makes me feel terrible that there's patients that because over the years they've been premedicated for so long that they just feel like they need it. They need the antibiotic and it's, they, I think a lot of human beings of all types, surgeons, dentists, and patients think of antibiotics as just not that big of a deal. And because they're generally well tolerated by people, we can think that, but all you need, it's not a big deal until it is a big deal.

[00:27:39] And considering that it's not adding anything to our treatment to put them on the antibiotic, I think this is a really wise choice. So I, I am curious to hear what my friends out in, in the podcast listening world think about this. I know a lot of people think that I'm crazy to get so hung up on this stuff and maybe they're right to be all upset about it and stuff like that. I know some people were like me and were serious about, you know, putting this back in the face of the surgeon, blah, blah, blah. Curious. Is this something that, that you run into a lot or not really?

[00:28:09] And does this, does this new guideline and new, not two weeks new, but last couple of years new, apparently, uh, does this make you feel better about your stance? I'd love to hear about it. So go to the very dental Facebook group. If you are not a member yet, I'd like you to become a member. And all you have to do is request an invite and give me one of several passwords. Let me see if I can come up with them. I've got Papa Randy, Lipscomb, McWethy, BioClear, Hornbrook, Timmerman, Frank, or Gary.

[00:28:39] That's eight of them. I might be missing one, but that's the one of those will get you in. I love the fact that when people are asking, they come up with just the random, tell, why do I do these stupid passwords for years and years is because I want to let only let people into this group that listen to the podcast, which means it's a smaller group. It's a less, less dramatic group. It's not a shit show. Like a lot of other dental groups. I have made the mistake of looking at other dental Facebook groups and going, why do I do this?

[00:29:08] It's such a shit show. I just like I my piece is worth so much more than than being in those groups. But occasionally I get sucked into them. And it's fun to watch other people argue. I mean, I started out in Dentaltown. That's how it was all the time. But I just am so over that. I'm old and tired and my piece means more to me than that. So I generally don't spend. And so knowing that's the case, the very dental Facebook group is a nice, safe group. It's not super active because you know what? When you're yelling and screaming and fighting about stuff, there's a lot of activity. We don't have a lot of activity because there's none of that.

[00:29:38] But we do talk about stuff like this. For instance, does this premedication guideline make you feel better, worse, different? I'm just curious. So, hey, go to the Very Dental Facebook group and join up. Let's talk about this. I hope that all of your joints stay uninfected out there. And I hope you enjoy the podcast. If you do, tell a friend. Tell a dentist friend or a dental person, assistant, hygienist, whatever. We have a lot of good stuff coming up. I've got some great interviews in the can. I've got some great interviews planned.

[00:30:06] And I'm enjoying doing this good stuff. I had a lot of time to think about the podcast on my bus ride home from Florida. So, I've been trying to come up with cool guests and topics. So, I'm hoping that you enjoy that. Let me know. You can text me on Facebook. Obviously, I get all those. Or you can email me at simplebutnoteasyatgmail.com, which is a poorly branded email. But it is easy to remember. I'll be using it for you. Simplebutnoteasyatgmail.com.

[00:30:35] Thanks a ton for listening to the show. I appreciate you listening, and we will catch you next episode.