Dental Clearance?

Posted: 16 Jan 2023
Updated: 16 Jan 2023

First things first: iamnotadoctorthispostdoesnotconstitudemedicaladvicepleaseseeaprofessionalifyouhaveconcerns. Ta.

TIL: I Need a Dental Check-Up

During my cardiologist appointment in early January, they mentioned that I need a dental check-up. That was news to me!

So, the following day off I went to my dentist and booked an appointment. I got a panoramic dental x-ray (twice) because the machine was set too low and bumped into my shoulder ruining the exposure (whoops). We then encountered some confusion where they thought I had my valve replaced recently, and therefore needed antibiotics before my clean (it has yet to be done).

Panoramic dental x-ray: An x-ray covering the full mouth, both top and bottom.¹

Antibiotics before the clean? Not what I expected either. Let’s dive in!

There is an infection called “endocarditis” which affects the innermost layer of the heart, and it can be quite serious. It “is always fatal unless treated, and even with appropriate treatment it is associated with a one-year mortality rate of nearly 40%”.² Now, as it turns out the gums are the window to the blood (as the saying goes). “Approximately one-third of cases of endocarditis in New Zealand are caused by streptococci that are normal oral flora and are associated with plaque..”³

So, back to the antibiotics. Quite often during a dental clean, the gums may sustain minor lacerations. These can be due to flossing, the dremel (rotary dental tool), and other tools. As plaques etc. are removed a possibility exists that streptococci could enter the bloodstream. Once in the bloodstream, they could cause an infection in the heart (endocarditis).

NZ Dental Guidelines

The guidelines state that these people are at high risk of endocarditis:

• A prosthetic heart valve, either biological or mechanical
• Rheumatic valvular heart disease
• Previous endocarditis
• Unrepaired cyanotic congenital heart disease or a repair procedure within the last six months
• Cardiac shunts or conduits for palliation

Interestingly, I don’t have any of these. I will soon have a ?mechanical aortic valve, but that has not been done yet. So, technically, I did not need antibiotics before my clean.

Dental Clearance

Just for interest’s sake, I searched for some journal articles about dental hygiene/clearance prior to aortic valve surgery. Here is a selection of what I found.

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

Results: “No significant difference was detected (p = 0.496) in comparing the occurrence of IE in the group with dental preparation (6.4%) and without dental preparation (8.4%). The logistic regression model confirmed that dental treatment did not change the IE risk (p = 0.504) and indicated that age (p < 0.003) and gender (p = 0.013) were significant risk factors for IE.”⁴

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5454162/

Dental Procedures and the Risk of Infective Endocarditis

Results: “..the risk of IE remained insignificant after adjustment for antibiotic use..”⁵

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4985400/

Effect of dental treatment before cardiac valve surgery (Systematic review and meta-analysis)

Results: “Very low certainty in the evidence suggested uncertainty as to whether health outcomes for patients undergoing dental treatment before CVS differed from those who did not”⁶

Reference: https://jada.ada.org/article/S0002-8177(19)30333-2/fulltext

and finally,

Dental Workup Before Cardiac Surgery: Must or Risk

A letter to the editor of a journal writes “As a cardiac surgeon and dentist, allow me some remarks”. They then go on to say: “The indication for any dental work before cardiac surgery should be clearly defined and this is especially true for dental extractions. It is not poor dental hygiene with some caries lesions, but it is the periodontal infection and the apical abscess which need special attention.”⁷

Reference: https://www.annalsthoracicsurgery.org/article/S0003-4975(14)01521-5/pdf

Not So Cut and Dry

This is the interesting thing about lots of Science — medicine especially. In some cases, it is not as clear or as certain as you might expect. There is often a bit of an art to it, and general rules need to be flexible and applied patient-by-patient as the situation requires. That said, there are many areas where very solid evidence exists.

I was due for a dental check-up in January anyhow, so was glad to get my teeth cleaned. The removal of plaques will likely not be the make-or-break of my surgery, but every little bit counts. In the end, it is good for medicine to err on the side of conservatism and cautiousness.

“Over 60 years of published data still do not provide evidence on which to make strong recommendations for antibiotic prophylaxis against endocarditis at the time of dental procedures. The 2008 New Zealand guidelines represent a conservative consensus of local expert opinions and seven years after they were written there does not seem to be a good reason to change these recommendations.”³

Still, I didn’t need those antibiotics, even going by the conservative guidelines. Prescribe your antibiotics appropriately and finish your scripts, even if you’re feeling better!⁸

Mā te wā 👋

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