Tooth extraction prior to cardiac surgery may increase risk of adverse outcomes

Dental extraction of abscessed or infected teeth is often performed to decrease the risk of infection during surgery and endocarditis (an inflammation of the inner layer of the heart) following surgery.

Cardiac surgeon Joseph A. Dearani, MD, along with anesthesiologists Mark M. Smith, MD and Kendra J. Grim, MD, and colleagues from the Mayo Clinic in Rochester, Minn., evaluated the occurrence of major adverse outcomes in 205 patients who underwent at least one dental extraction prior to planned cardiac surgery from 2003 to 2013. The median time from dental extraction to cardiac surgery was 7 days (average 35 days).

"Guidelines from the American College of Cardiology and American Heart Association label dental extraction as a minor procedure, with the risk of death or non-fatal heart attack estimated to be less than 1%," explained Dr. Smith. "Our results, however, documented a higher rate of major adverse outcomes, suggesting physicians should evaluate individualized risk of anesthesia and surgery in this patient population."

In this study, patients who underwent dental extraction prior to cardiac surgery experienced an 8% incidence of major adverse outcomes, including new heart attack, stroke, kidney failure and death. Overall, 3% of patients died after dental extraction and before the planned cardiac surgery could be performed.

Noting the limitations of their retrospective review, Dr. Dearani said: "With the information from our study we cannot make a definitive recommendation for or against dental extraction prior to cardiac surgery. We recommend an individualized analysis of the expected benefit of dental extraction prior to surgery weighed against the risk of morbidity and mortality as observed in our study."

Departure from Current Thinking

In an invited commentary in the same issue of The Annals, Michael Jonathan Unsworth-White, FRCS, from Derriford Hospital in Plymouth, United Kingdom, discussed the need for surgeons to take note of the study results. "'Accepted wisdom' leads surgeons to request dental reviews prior to cardiac surgery in many thousands of patients annually around the world," said Unsworth-White. "Dr. Smith's group asks us to question this philosophy. It is a significant departure from current thinking."

Unsworth-White noted another recent paradigm shift in the relationship between dental surgery and cardiac surgery. Prophylactic antibiotics have routinely been prescribed for patients undergoing dental work who also had existing heart problems because it had been accepted that there is a link between dental bacteremia and endocarditis. Individuals with pre-existing heart problems tend to have a higher incidence of endocarditis. "The American Heart Association and the National Institute for Health and Clinical Excellence in the UK have withdrawn support for this practice of prophylactic antibiotics because the danger from overuse of antibiotics outweighs any other potential risks. Regular tooth brushing, flossing, and even chewing gum are now recognized to dislodge as much, if not more, bacteremia than most dental procedures," he said.