Removing infected teeth before Heart surgery is not always wise

Currently, removing abscessed or infected teeth before heart surgery is standard practice, as it decreases infection and inflammation risks during and after the procedure. The American College of Cardiology and American Heart Association classify dental extraction as a minor procedure with a less than 1 percent risk of death or non-fatal heart attack.

But although it is standard practice to remove bad teeth prior to heart surgery, there is only limited evidence that supports this practice. The new study set out to evaluate what harms may be associated with dental extraction before cardiovascular surgery.

“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,” says study author and anesthesiologist Dr. Mark M. Smith, from the Mayo Clinic in Rochester, MN.

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).

Dr. Smith and his colleagues found that 8% of patients who had teeth removed prior to heart surgery experienced adverse outcomes. These included heart attack, stroke, kidney failure and death. Overall, 3% of patients died after dental extraction and before the heart surgery could take place. But this study did have some limitations. Co-author and cardiac surgeon Dr. Joseph A. Dearani says: “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.” 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.”

Writing in a linked comment, Dr. Unsworth-White draws parallels with another recent change of consensus. In patients undergoing dental work who have existing heart problems, it has previously been standard practice to prescribe prophylactic antibiotics.

Again, this was because there is a known link between dental bacteremia and endocarditis. But more recent studies have suggested that the potential side effects of these antibiotics may outweigh the benefits. Dr. Unsworth-White explains:

“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.”