Dental care before cardiac valve surgery: Is it important to prevent infective endocarditis?

An audit of pre-operative dental radiographs in patients who received no pre-operative dental input before cardiovalvular surgery

Purpose To radiographically characterise dental disease burden and related characteristics of referred patients awaiting cardiovalvular surgery (CVS) in the context of infective endocarditis (IE) risk.Methods Radiographic evidence of dental disease levels was assessed for patients referred for dental assessment pre-CVS using available orthopantomographs (OPTs) prescribed by the cardiology team. This group did not receive any pre-CVS dental intervention or treatment.Results The majority of OPTs were Quality Standard 2 (87.5%). There was radiographic evidence of dentoalveolar disease in those patients proceeding to CVS. Periodontal disease was most prominent, with 79% of patients having advanced bone loss. The mean number of apical lesions was 0.71. Overall decayed, missing, and filled teeth score was 16.4, along with mean missing teeth scores of 7.9. None of the patients have so far developed IE at a minimum of six-month follow-up.Conclusions In our context, the quality of the radiographs requested by non-dental clinicians and delivered by non-dental-school-based radiographic departments is suboptimal and needs to be addressed. This audit should help to inform the debate around the timing and delivery of evidence-based, specialist dental care for CVS patients.

The heart of it: dental care and cardiothoracic surgery

Both dental and cardiovascular disease are prevalent in the general population, have common risk factors and may be closely associated.Following cardiothoracic surgery, patients may be higher risk for developing infective endocarditis (IE) than the general population. Before cardiothoracic interventions, it is common practice for a dental assessment to be carried out and any necessary dental treatment provided. This aims to reduce the risk of IE arising from dental sources and avoid dental pain or infection during the peri- and post-operative period. There is little guidance on which treatments should be performed and when.Many patients with cardiac disease may have dental treatment provided safely in primary care. However, there is often a need to consider additional factors, including bleeding risk, condition stability or medication interactions. Dental teams must have an awareness of the implications of cardiac disease and provide reasonable adjustments to care provision where necessary, ensuring patient safety.This article proposes a protocol for dental management of patients awaiting cardiothoracic surgery and explores important considerations for dental care in this patient group.

Infective endocarditis and oral surgery input before cardiac surgery: time to prick the paradigm of pre-cardiac surgery assessments?

Purpose To review current practice regarding oral surgery input for patients awaiting cardiac valvular surgery and who are at risk of infective endocarditis (IE) in the context of the COVID-19 pandemic, and to stimulate debate around the indications for pre-operative oral surgery assessment. It also opens the way to developing a new research-based approach which is patient-centred, safe, effective and efficient.Methods A desk-top based patient review was undertaken between 27 March 2020 and 1 July 2022 to record the outcome of patients undergoing cardiac valvular surgery in Northern Ireland, following the revision of the referral guidelines for oral surgery intervention. Data were collected for all cardiac referrals to the oral surgery on-call service in the Royal Victoria Hospital, Belfast. Complications were recorded at two weeks, two months, and six months post-surgery, using Northern Ireland Electronic Care Records.Results In total, 67 cardiac patients were identified between 27 March 2020 and 1 July 2022: 65.7% of patients were male and had an average age of 68, while the female patients had an average age of 61. The mean interval of date of cardiology referral to surgery date was 9.7 working days, with 36% of patients referred within five days of the planned surgery date. Moreover, 39% had valvular surgery in combination with another type of cardiac surgery. No complications linked to dental aetiology were noted.Conclusions This paper raises questions about the advisability of oral surgery input before cardiac surgery for anything other than pain relief, management of acute dental sepsis, or IE whose source has been identified as an oral commensal. The COVID-19 pandemic has presented an opportunity to review current practice and open the way to developing a new approach which is patient-centred, safe, effective and efficient.

Effect of perioperative oral management on postoperative bloodstream infection in heart valve surgery patients

OBJECTIVE

There is a well-known relationship between oral hygiene and infective endocarditis. Epidemiological evidence regarding perioperative oral management (POM) for cancer surgery has been accumulated, but this evidence is not sufficient for cardiac surgery. Therefore, our purpose was to investigate whether POM can prevent postoperative complications in patients undergoing heart valve surgery.

SUBJECTS AND METHODS

Using single-arm medical information, we retrospectively enrolled 301 patients who underwent heart valve surgery between April 2010 and March 2019. The patient background was adjusted by the propensity score (PS). We then analyzed the impact of POM on postoperative bloodstream infection (PBSI), postoperative pneumonia, and mortality using PS inverse probability of treatment weighting (IPTW).

RESULTS

IPTW revealed that the POM group had a lower incidence of PBSI than the control group, with an odds ratio of 0.316 (p = 0.003). The mortality in the POM group was significantly lower than that in the control group (p = 0.023). Fourteen patients died in the present study and 6 of them were infection-related.

CONCLUSIONS

POM was significantly associated with decreased incidence of PBSI and mortality. The results suggest that POM is beneficial for the prevention of PBSI and mortality in patients undergoing heart valve surgery.

Pre-medical dental evaluation and treatment of oral infection - a survey study among hospital-affiliated dentists in Sweden

OBJECTIVE

To examine how hospital-affiliated dentists assess risk and evaluate oral foci of infection in patients facing certain medical treatments, and whether the nature of upcoming medical treatment affects the choice of dental intervention.

MATERIALS AND METHODS

A survey comprising six clinical cases (50 teeth) was sent to hospital-affiliated dentists in Sweden. A treatment option for the affected tooth/teeth in each case was selected whether the patient was facing heart valve surgery, chemotherapy, radiation therapy, intravenous bisphosphonate treatment, solid organ transplantation or was diagnosed with endocarditis.

RESULTS

Consensus in choice of dental treatment was high in 62%, moderate in 32% and low in 6% of the assessments. High variability of choice of treatment was seen for eight teeth whereas the remaining 42 teeth often received the same therapy regardless of medical issue. Chemotherapy and radiotherapy were thought to entail the highest risk for oral infectious sequelae with a risk ranging from 1% to 100%.

CONCLUSION

Pre-medical dental evaluations and recommended treatments are often uniform with the exception of the management of asymptomatic root canal treated teeth with persisting apical radiolucency and heavily decayed molars. In many instances, dental diagnosis has a greater impact on choice of treatment than the underlying medical issue and associated implications thereof.

Effects of perioperative oral care on postoperative inflammation following heart valve surgery

OBJECTIVE

Whether oral health care during the perioperative period can lead to a better outcome after heart valve surgery has not been adequately elucidated. We examined the effects of perioperative oral care on postoperative inflammation response in patients who underwent heart valve surgery.

MATERIALS AND METHODS

In this retrospective cohort study, 223 patients scheduled for single valve heart surgery were divided into the oral care, who underwent professional teeth cleaning or scaling within 3 days prior to surgery, and also following surgery at least twice a week (n = 111), and non-oral care (n = 112) groups. After propensity score matching, records of both groups (80:80) were examined after surgery to evaluate inflammation markers (white blood cell count [WBC], neutrophil/white blood cell ratio [NWR], C-reactive protein [CRP] level, body temperature [BT]).

RESULTS

WBC, NWR, CRP level, and BT were increased in both groups the day following surgery. Thereafter, CRP level, WBC, NWR, and BT on various days after surgery in the oral care group showed greater decreases as compared to the non-oral care group.

CONCLUSIONS

Perioperative oral health care can decrease postoperative inflammation in patients undergoing heart valve surgery and may be important to ensure a better outcome in those patients.

Dental management of patients with congestive heart failure before and after implantation of ventricular assist devices: linking the missing protocol

Objectives: There are no studies that have reviewed the pre- and post-operative dental protocols for the management of congestive heart failure (CHF) patients before and after implantation of the left ventricular assist device (LVAD). The aim of the present study was to review the pre- and post-operative dental protocols reported in indexed literature related to the management of CHF patients before and after implantation of ventricular assist devices (VAD). Design: The addressed focused question was "Is there a protocol for the dental management of end-stage CHF patients before and after VAD implantation?" Indexed databases were searched using various keywords. Letters to the Editor, review articles, and commentaries/expert opinions were excluded. Results: Seven studies were included and processed for data extraction. The number of participants ranged between 1 and 32 individuals, with age ranging between 14 and 66 years. Dental extractions were performed in 5 studies, and in 2 studies scaling and root planing was done for the treatment of periodontal diseases. One study assessed odontogenic infective foci and other lesions of the oral soft and hard tissues as a preoperative protocol. Six of the 7 studies did not report a dental therapeutic protocol, which was followed for the pre and/or post-LVAD implantation. Conclusions: It is recommended that standardized protocols should be adopted that allow the delivery of safe and effective pre- and postoperative dental care to VAD patients. Such protocols may help influence the morbidity and mortality rates and simultaneously improve the overall quality of life in vulnerable patients.

Clinical impact of periodontal disease on postoperative complications in gastrointestinal cancer patients

BACKGROUND

The effectiveness of perioperative oral management in gastrointestinal surgery remains unclear. To elucidate the clinical significance of oral care, we investigated the relationship between the oral environment and postoperative infectious complications (POICs) in patients undergoing gastrointestinal surgery.

METHODS

This was a single-institute and historical cohort study of 341 patients. The participants were isolated from consecutive patients undergoing planned radical resection for gastrointestinal carcinoma from January 2016 to June 2017. Dentists assessed the oral environment for periodontal disease, hygiene status, dry mouth, fur on tongue, and tooth stumps. All patients received scaling and tooth brushing instructions. A stepwise logistic regression analysis was conducted to identify risk factors for POICs among the different oral statuses.

RESULTS

The surgical procedures performed were gastrectomy in 123 (36.1%), colorectal resection in 185 (54.2%), and pancreatoduodenectomy or others in 38 (11.1%). POICs occurred in 48 patients (14.1%), including deep organ space infection in 20, surgical site infection in 11, anastomotic leakage in 5, urinary tract infection in 4, pneumonia in 2, and others in 6. After adjusting for confounding factors, periodontal disease was isolated as an independent risk factor for POICs (odds ratio 2.091, p = 0.037, 95% confidence interval 1.045-4.183). Other variables of oral environment such as hygiene status, dry mouth, fur on tongue, and tooth stumps did not have a significant impact on POICs.

CONCLUSIONS

Periodontal disease is a risk factor for infectious complications after gastrointestinal surgery.

Dental clearance and postoperative heart infections: Observations from a preoperative evaluation clinic for day-admission surgery

Every year, two-million hospitalised patients develop healthcare-associated infections with a consequent mortality eclipsing 90,000. The literature suggests that dental infections are one of many potential sources of these infections and may be associated with an increased risk of endocarditis in surgical patients, especially those undergoing cardiac procedures, though some studies have conversely shown no heightened risk of cardiac infections in patients forgoing pre-surgical dental screenings. We sought to elucidate whether patients seen at our preoperative evaluation clinic who obtained pre-surgical dental clearance experienced improved outcomes compared to those who did not receive dental clearance prior to their surgical interventions. The medical records of 196 consecutive patients were reviewed who were seen at the pre-anaesthesia evaluation prior to elective cardiac surgery from July 2017 to February 2018. Of this cohort, 102 patients had pre-surgical dental clearance, while 94 did not have dental clearance. Preoperative demographic and comorbidity data were analysed using independent t-tests. We found no significant differences between these group in terms of post-operation infections (zero instances versus four instances, p > 0.05), length of intensive care unit stay (two days versus two days, p = 0.815), or mortality associated with elective cardiac procedures (zero instances). Further evaluation of preoperative dental clearance and its potential to prevent morbidity (e.g. postoperative infections) is warranted.

Dental treatment and recommended management in patients at risk of infective endocarditis

Infective endocarditis (IF) is found in high-risk groups with congenital or acquired cardiac defects. It is caused by episodes of short bacteraemia. The magnitude and duration of bacteraemia caused by dental procedures are decreased by using antibiotic prophylaxis (AP). The aim of this study is to describe and discuss all clinical implications related to IF and dental procedures, and AP before invasive dental procedures. Maintenance of optimal oral health and hygiene is more important than AP in decreasing the risk of IF. Routine daily activities are associated with a similar risk of bacteraemia. It is estimated that antibiotics use in dentistry may represent up to 10% of total antibiotics use, and the risk of developing bacterial resistance should be taken into account.