Low risk dental procedure in high risk patient

Low risk procedure in high risk
patient
- dental procedure in complex patient -
Helga Komen, MD
Department of Anesthesiology
Washington University in St Louis

Safety…
Dental procedures in complex patient

Anesthesia + Surgery = GOOD OUTCOME!!
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Dental extraction
is considered to be a minor procedure with the risk of
death or nonfatal myocardial infarction estimated to be less than
1%.
Poldermans D et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-
cardiac surgery. The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-
cardiac Surgery of the European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA).
European Heart Journal (2009) 30, 2769–2812

Cardiac risk stratification for non-cardiac surgical procedures
30-day rates of cardiac death and myocardial infarction
Poldermans D et al. Guidelines for pre-operative cardiac risk assessment and perioperative cardiac management in non-cardiac surgery.
The Task Force for Preoperative Cardiac Risk Assessment and Perioperative Cardiac Management in Non-cardiac Surgery of the
European Society of Cardiology (ESC) and endorsed by the European Society of Anaesthesiology (ESA). European Heart Journal (2009)
30, 2769–2812

Dental extraction
-indications-
• Regarding teeth…
– Infected teeth
– Apical infection
– Periodontal disease
– Dental sepsis
• …and related to surgery/therapy
– heart valve replacement
– organ transplant
– radiation/chemo therapy
– coronary bypass surgery
– ….

Dental extraction in cardiac patients
….Risks are much higher in cardiac patients!
– Major adverse outcomes* occurred in 8% (16/205) of
patients scheduled for cardiac surgery and undergone
dental extraction.
Among them, 38% (6/16) died after dental extraction
Smith et. al. Morbidity and Mortality Associated With Dental Extraction
Before Cardiac Operation. Ann Thorac Surg 2014;97:838–44
* Major adverse outcomes: death, bleeding, ACS, cerebrovascular accident (CVA),
transient ischemic attack, renal failure requiring dialysis.

Smith et. al. Morbidity and Mortality Associated With Dental Extraction Before Cardiac Operation. Ann Thorac Surg 2014;97:838–44

Possible mechanisms of adverse outcomes …
• Tissue damage
– Prothrombotic/fibrinolityc factors inbalance: hypercoagulability
• risk of perioperative coronary thrombosis, lifethreatening ischemia, arrhythmia.
• Stress response mediated by neuroendocrine factors
– tachycardia and hypertension
– ACTH/cortisol – normalises by POD1
• Fluid shifts

….should we get on with cardiac operations and
deal with the dental work at some other time, or risk
our patients luck, with good intent, and do dental
extraction now!!

Reasoning…
• Dental extraction is often performed prior to cardiac surgical procedures
(heart valve replacement, coronary artery bypass grafting, ventricular assist
device, heart transplant), to reduce the potential for postoperative infective
endocarditis (IE).
– The presence of dental disease may increase the risk and degree of
bacteremia associated with routine daily activities
• chewing food, tooth brushing, flossing, use of toothpicks
– Oral hygiene essential !!
» Current evidence suggests that poor oral hygiene and periodontal
diseases are likely to be responsible for the vast majority of cases of
IE that originate in the mouth
Badour et al. Infective Endocarditis in Adults: Diagnosis, Antimicrobial Therapy, and Management of Complications A Scientific Statement for Healthcare
Professionals From the American Heart Association Endorsed by the Infectious Diseases Society of America.Circulation. 2015;132:1435-1486
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American
Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on
Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
Circulation 2007;116:1736–54.

Pathogenesis of IE
1. formation of nonbacterial thrombotic endocarditis (NBTE) on
the surface of a cardiac valve or elsewhere that endothelial
damage occurs (due to turbulent flow)
2. bacteremia
3. adherence of the bacteria in the bloodstream to NBTE
4. proliferation of bacteria within a vegetation.

• Data to support invasive dental procedures before:
– coronary bypass
– ventricular assist devices
– total artificial heart implantation
….have not been published in the literature!
Smith et. al. Morbidity and Mortality Associated With Dental Extraction Before Cardiac Operation. Ann Thorac Surg 2014;97:838–44

Assessment of
cardiac patient
undergoing
noncardiac
surgery!
Fleischer et al. 2014 ACC/AHA Guideline on
Perioperative Cardiovascular Evaluation and
Management of Patients Undergoing Noncardiac
Surgery: Executive Summary. JACC
2014;64(22):2373–405

Assessment of cardiac patient undergoing noncardiac surgery
2014 ACC/AHA Guideline on Perioperative Cardiovascular Evaluation and Management of Patients Undergoing
Noncardiac Surgery

• It is reasonable for patients with heart failure (HF) with worsening dyspnea or
other change in clinical status to undergo preoperative evaluation of LV
function. (Class IIa; Level of Evidence (LOE) C)
• Reassessment of LV function in clinically stable patients with previously documented LV
dysfunction may be considered if there has been no assessment within a year. (Class IIb;
LOE C)
• It is reasonable for patients who are at an elevated risk for noncardiac surgery and
have poor functional capacity (<4 METs) to undergo noninvasive pharmacological
stress testing (either dobutamine stress echocardiogram or pharmacological stress
myocardial perfusion imaging) if it will change management (Class IIa; LOE B).
• EF% - values of less than 30% equate to severe heart failure
Noncardiac Surgery
Preop Eval

• Timing of elective noncardiac surgery post-PCI
– Noncardiac surgery should optimally be delayed 365 d after DES implantation
(Class I; LOE B).
• Elective noncardiac surgery after DES implantation may be considered after 180 d
(Class IIb; LOE B).
• Perioperative beta-blocker therapy
– Continue beta blockers (Class I;LOE B)
– It may be reasonable to begin perioperative beta blockers long enough in
advance to assess safety and tolerability, preferably >1 d before surgery (Class
IIb; LOE B)
– Consistent and clear associations exist between beta-blocker administration and adverse outcomes,
such as bradycardia and stroke.
– DECREASE and POISE studies excluded
Noncardiac Surgery
Periop Th

Rabbitts et al. Cardiac Risk of Noncardiac Surgery after Percutaneous Coronary Intervention with Drug-eluting Stents,
Anesthesiology 2008; 109:596–604
Timing of noncardiac surgery post-PCI

Timing of noncardiac surgery post CABG/post MI
• Post CABG 6wks, preferable 12 wks
• Post MI - 4-6 weeks to be a prudent period (for
emergent cases of dental work)
– Incidence of myocardial reinfarction during the perioperative
period is influenced by the time elapsed since the previous MI.
– Acute MI (1 to 7 days previously), recent MI (8 to 30 days
previously), and unstable angina are associated with the highest
risk of perioperative myocardial ischemia, MI, and cardiac death.

Noncardiac Surgery
Periop Th

• Continue statins in patients currently taking statins (Class I; LOE B).
• Continuation of ACE inhibitors or ARBs is reasonable perioperatively (Class
IIa; LOE B).
• In patients with stents undergoing surgery that requires discontinuation of
P2Y12 inhibitors, continue aspirin and restart the P2Y12 platelet receptor–
inhibitor as soon as possible after surgery (Class I; LOE C).
– Most dental procedures can be safely performed without having to withdraw
anti-coagulant therapy, provided the INR is 2.5 or below.
• local tranexamic acid as an antifibrinolytic agent postoperatively for 2 days
P2Y12 inhibitors: Clopidogrel (Plavix®), Prasugrel (Effient®), Ticlopidine (Ticlid®)
ARBs:Candesartan (Atacand), Losartan (Cozaar), Valsartan (Diovan)
Noncardiac Surgery
Periop Th

Noncardiac Surgery
Periop Th
• Discontinue – digitalis, diuretics, hypoglicemics
• Continue – statins, aspirin, beta blockers,
antihypertensives, antianginals

Cardiac patient having noncardiac surgery
-anesthesia management-
• Balance supply and demand
Preload - keep the heart small, decrease wall tension,
increase perfusion pressure
Afterload - maintain, hypertension better than hypotension!!
Contractility - depression is beneficial when LV function is
adequate
H R - slow (60-70/min)
Keep the heart rate and blood pressure within 20% of the
normal awake value (as you always do !)

• Smooth…
• Fentanyl upfront.. - blunt reflexes, hemodynamic stability
• Ketamine vs. propofol vs. etomidate
• Lidocain – 1.5-2 mg/kg, 4-6 mins before intubation
• Relaxants
– Vecuronium-least hemodynamic alterations.
– Rocuronium or cis are good choices
– Succinylcoline – possibly causing arrithmyas
– Atracurium – histamine release
Nasal intubation – watch for INR!!!
INDUCTION

• Inhalational anesthetics
– Sevoflurane – best choice
– Desflurane – irritation of the airway, tachycardia
– Isoflurane – possible coronary steal
• Controlled myocardial depression induced by a volatile anesthetic may be
useful to minimize the increase in sympathetic activity likely to develop in
response to intense stimulation e.g. direct laryngoscopy ,surgical
stimulation
• The 2014. ACC/AHA guidelines state that “it can be beneficial to use
volatile anesthetic agents during noncardiac surgery for the maintenance
of general anesthesia in patients in hemodynamically stable condition at
risk for myocardial ischemia”.
MAINTENANCE

MAINTENANCE

• Continuous automated ST trending monitors
• IBP (a. line)
– avoid hypotension, tachycardia
– target systolic/MAP
– LVAD!
• Non-invasive cardiac monitoring
– Cheetah?!
• Have ready vasoactives- phenylephrine infusion, epinephrine, norepi,
defibrilator, (nicardipine)
MONITORING

What if anyway happens intraop…
INTRAOPERATIVE MANAGEMENT OF MYOCARDIAL ISCHEMIA
• ST-segment changes on the ECG monitor (12 channel ECG)
– Prompt treatment of changes in heart rate and/or blood pressure .
– A persistent increase in heart rate can be treated by a β-blocker such as
esmolol.
– Nitroglycerin is an appropriate choice when myocardial ischemia is associated
with a normal or modestly elevated blood pressure.
• Hypotension - sympathomimetic drugs (phenylephrine, norepi, epi)
Fluid infusion can be useful.
• In an unstable hemodynamic situation - inotropes (dobutamine) or an
intra aortic balloon pump may be necessary.
Plan for early postoperative cardiac catheterization.

• Again!!!
– Goal is to monitor, prevent and treat ischemia or infarction.
• Continuous ECG monitoring is useful for detecting myocardial ischemia as
most adverse cardiac events occur within the first 48 hours
postoperatively.
• Avoid events that increase myocardial oxygen demand e.g. hypothermia,
pain, hypoxemia, hypercarbia, hemorrhage
• Avoid events that decrease myocardial oxygen supply e.g. hypovolemia ,
hypotension and inadequate hemoglobin concentration
– Patients taking β-blockers should continue to receive these drugs throughout
the perioperative period.
POSTOP

Enough with cardiac patients!!!

Dental procedures in pre-transplant patients
• Dental evaluation and dental work prior to transplantation
became standard of care
– It results in elimination of active infection and prevents posttransplant
infection/transplant rejection (Immunosuppression!)
• 50% of candidates for transplantation are >50 years of age, so it is more likely
they will have a greater prevalence of dental/ periodontal disease.
• Beware!!! - HIV / HBV / HCV
Melkos et al. Organ Transplantation-Assessment of dental procedures. Oral Biosciences and Medicine 2005;2(4):259-64.

Fabuel et al. Dental management in transplant pateints. J Cllin Exp Dent. 2011;3(1):43-52.

• Preop-medications consideration
– anticoagulants (INR, PT, PTT, CBC)
• Control of postop bleed - Oxidised Cellulose, Collagen Fibers, Suturing, Tamponate,
Mouth washing with Tranexamic acid 10-15mg/kg per day in 2-3 doses, Vitamin K
administration
– beta blockers
– calcium channel blockers
– Diuretics
– Steroids – avoidance of Addisonian crisis (substitution if >10mg
prednison/day)
• Intraop/postop medications consideration
– liver metabolism
– kidney metabolism

• Heart transplant
– Indication: end-stage heart failure (due to idiopathic cardiomyopathy
and end-stage coronary artery disease)
• As for before mentioned cardiac patients….
• Literature about the heart transplant population and dental
procedures is limited and inconclusive.

• Liver transplant
– Indication: chronic liver disorders (biliary and nonbiliary cirrhosis – Hep B,
Hep C, alchohol), hepatocellular carcinoma and severe acute hepatic
failure
– The goals of intraoperative management should be maintenance of
adequate hepatic blood flow and oxygen delivery
– impaired drug detoxication - avoid aspirin, ampicillin, benzodiazepins, LA
– Intraop: Reduce propofol/fentanyl; Yes atracurium and cisatracurium (do
not rely on hepatic excretion), Yes remifentanil (metabolized by tissue and
red cell esterases).
– Desflurane - ideal volatile agent, being the least metabolized in liver. It also
relatively preserves hepatic blood flow and cardiac output.
– high prevalence of tongue pathology (fissured tongue, saburral tongue,
depapillated tongue, hairy tongue and geographical tongue)
– gingival bleeding - coagulation factors abnormalities (INR)
– !! OG tube vs. oesophageal varices

• Kidney transplant
– Indication: end-stage renal disease (due to diabetes, hypertension,
glomerulonephritis, polycystic kidney disease, other urinary diseases)
– ongoing hemodialysis, diabetes, hypertension…
– the most common cause of death in these patients is cardiovascular
disease
– local anesthetics are metabolized in the liver - safe to use for dental
procedures

and post-transplant rejection
Melkos et al. Organ Transplantation-Assessment of dental procedures. Oral Biosciences and Medicine 2005;2(4):259-64
• 70/102 received dental treatment prior transplantation
• Post-transplant complications (rejection of the transplant, GvHD, oral mucositis)
occurred in 80% patients who didn`t have dental work prior transplant, and in 45%
who had dental work
• There was significant correlation between semi-impacted and impacted teeth and
complications (and not with dental foci)
• Dental treatment doesn`t have to be radical

VAD patient
…mostly LVAD
• Patients who have reached end-stage heart failure
• battery-powered pump that helps the left ventricle pump
adequate amounts of blood to the body
• "bridge to transplant“, "bridge to recovery“, “destiantion
therapy“
• Pulsatile - patients will have a palpable pulse and a measurable
blood pressure
• Rate – fixed or automatical adjust
• Output – L/min, dependent on preload/afterload
• Non pulsatile – continous flow devices
• Weak or non palpable pulse
• MAP is the key number – 65-85mmHg
• Pulsatility Index (PI) - Indicates volume status, right ventricle
function, and native heart contractility
• The VAD-nurse will be in the room!

VAD patient
Problems
• Bleeding (anticoagulants and platelet inhibitors)
• Thrombosis
• Infection
• Suckdown (low preload causes a nonpulsatle VAD to collapse the ventricle)
• Hemolysis (the VAD destroys blood cells)
• Arrhythmias -
– A patient can be in a lethal arrhythmia and be asymptomatic. Treat the patient not the
monitor.
– Do not initiate chest compressions unless instructed by VAD coordinator. Chest compressions
can disrupt the implanted equipment causing bleeding and death
– Electrical shock from cardiovert/ defib. will not damage any of the VAD equipment

Dental procedures prior to chemo/radiation
• Chemotherapy drugs cause all dividing cells to die
– mucous membranes are composed of rapidly dividing cells
– mucous membranes form a barrier against infections
– without them the mouth can become inflamed, and opportunistic
bacterial, yeast and fungal infections can occur
– chemo also affects the ability to salivate, causing plaque to build up
rapidly, thus increasing the incidence of gum infections and cavities
– chemo can cause drops in ANC (absolute neutrophil count) which
makes it harder to fight off infections.

• Patients undergoing radiation therapy are at risk for
developing oral complications
– Reduced resistance to bacterial, viral or fungal infections
which allows them to become opportunistic
– Demineralization and radiation caries
– Osteonecrosis
• redness and soreness in the mouth, a dry mouth, trouble
swallowing, changes in taste, or nausea
(head/neck)

• Patients should have a thorough exam - at least 1month prior
procedure
• Schedule oral surgery at least 7 to 10 days before therapy
begins
• Perform oral prophylaxis if indicated
• Smoking cessation!
• Preop CBC, BNP, Platelets,
• Postpone if platelets <50.000/mm3 , neutrophils <1.000/mm3
-preop-

Dental procedure in cardiac or pretransplant patient
Antibiotics
• Antibiotic prophylaxis is reasonable for all dental procedures that involve
manipulation of gingival tissues or periapical region of teeth or perforation of
oral mucosa only for patients with underlying cardiac conditions associated
with the highest risk of adverse outcome from IE
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from
the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the
Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group. Circulation 2007;116:1736–54

Dental procedures in
complex patient
American Heart Association (AHA) guidelines for the
prevention of infective endocarditis (IE), 2007.
Wilson W, Taubert KA, Gewitz M, et al. Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from
the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee, Council on Cardiovascular Disease in the
Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes
Research Interdisciplinary Working Group. Circulation 2007;116:1736–54.

Nishimura et al. ACC/AHA 2008. Guideline Update on Valvular
Heart Disease: Focused Update on Infective Endocarditis

American Heart Association (AHA) guidelines for the
prevention of infective endocarditis (IE), 2007.

- retrospective study was completed comparing outcomes for 17 patients undergoing
concomitant cardiac VRS and invasive dental procedures with outcomes for 16
patients undergoing similar procedures by a conventional approach

Conclusions
• Safety in anesthesia is a consequence of a good planning
• Dental extraction is considered to be a minor procedure
• Indications: heart valve replacement, organ transplant,
radiation/chemo therapy, coronary bypass surgery
• Risks of major adverse cardiac events (MACE) are much higher
in cardiac patients
• Be `gentle` with anesthesia in cardiac patients; think about
IBP monitoring
– Goal is to monitor, prevent and treat ischemia or infarction.
• Heart/liver/kidney transplant patients – think `for` the organ
in insufficiency
• Concomitant heart/dental procedure….I would love it to have
it in Barnes!

Safest technique is the one practitioner does
best !

Questions?

Low risk dental procedure in high risk patient

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