Dental Perioperative Care

Aka: Dental Perioperative Care, Preoperative Evaluation Before Dental Procedure, Medical Clearance Prior to Dental Surgery

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II. Indications: Common Dental Procedures

  1. Dental Cleaning
  2. Tooth Extraction
  3. Dental Restoration (fillings, crowns, bridges and implants)
  4. Endodontic Procedures
  5. Dental Abscess Drainage
  6. Oral Mucosal biopsy

III. See Also

  1. Endocarditis Prophylaxis
  2. Surgical Antibiotic Prophylaxis
  3. Preoperative Guidelines for Medications Prior to Surgery
  4. Perioperative Diabetes Management
  5. Antiplatelet Therapy for Vascular Disease
  6. Perioperative Anticoagulation
  7. Preoperative Examination in Older Adults
  8. Preoperative Examination
  9. Preoperative Cardiovascular Evaluation
  10. Preoperative Evaluation in Kidney Disease
  11. Perioperative Beta Blocker
  12. Perioperative Cardiovascular Risk
  13. Deep Vein Thrombosis Prevention
  14. Postoperative Nausea and Vomiting Prevention
  15. Perioperative Corticosteroid
  16. Preoperative Respiratory Risk Modification

IV. Management: General

  1. Provide dentist with updated medication list, allergy list, problem list and relevant recent labs
  2. Analgesics
    1. Combining NSAIDs and Acetaminophen is very effective for dental related pain
    2. Limit use of short-term, breakthrough pain Opioids to <3-7 days
    3. Alert dentist to Opioid or Substance Abuse risk, and contraindications to other Analgesics

V. Management: Infectious Disease Prophylaxis

  1. Endocarditis Prophylaxis
    1. See Endocarditis Prophylaxis
    2. Perioperative prophylactic Antibiotics indications have been significantly reduced since 1997
      1. Bacteremia occurs with chewing, brushing and flossing
      2. SBE Prophylaxis has not been shown effective outside the highest risk patients
  2. Prosthetic Joint Infection Prophylaxis
    1. See Prosthetic Joint Infection Prophylaxis
    2. Dental perioperative prophylaxis of prosthetic hip and Knee Joint infections does not appear effective
    3. Prophylaxis is generally not recommended around the time of dental surgery in most patients

VI. Management: Cardiovascular Disease

  1. Anticoagulation and Antiplatelet Agents
    1. Provide dentist with most recent associated labs (e.g. CBC, INR)
    2. Antiplatelet and stable Anticoagulation (e.g. therapeutic INR) may be continued in most cases
      1. Routine dental cleanings and Tooth Extractions may be performed with continued medications
      2. Local bleeding is typically manageable with topical measures
      3. Ahmed (2019) J Maxillofac Oral Surg 23(8): 3183-92 [PubMed]
      4. Napenas (2009) J Am Dental Assoc 140(6): 690-5 [PubMed]
  2. Coronary Artery Disease
    1. Patients are at low Cardiac Risk if can perform 4 METS of Exercise and no active cardiac symptoms
    2. Dental procedures are typically delayed 6 weeks after MI, bare stent (or 6 months after DES stenting)
      1. However, needed invasive dental procedures may be performed despite recent events
      2. Provide adequate analgesia, Anesthesia, and anxiolysis
      3. Niwa (2000) Oral Surg Oral Med Oral Pathol Oral Radiol Endod 89(1): 35-41 +PMID: 10630939 [PubMed]
  3. Hypertension
    1. Asymptomatic Hypertension is unlikely to result in procedure complications
    2. However, dentists will typically delay procedures for Blood Pressure >160/100 mmHg
      1. Yarrows (2020) J Am Dent Assoc 151(4): 239-44 [PubMed]
    3. Optimize Blood Pressure prior to dental procedure to avoid procedure delays

VII. Management: Miscellaneous Conditions

  1. Diabetes Mellitus
    1. See Perioperative Diabetes Management
    2. Diabetes alone is not an indication for Antibiotic prophylaxis with routine dental procedures (e.g. extractions)
    3. Document Diabetes Mellitus control (e.g. Hemoglobin A1C) in preoperative assessment
    4. Optimizing Glucose control and reducing Xerostomia decreases dental disorder risks
  2. Cirrhosis
    1. Although CBC, INR may be considered before procedure, no value predicts complication or contraindication
    2. Severe Thrombocytopenia (10k to 50k) does not require Platelet Transfusionm prior to procedure
    3. Anaglesia with Acetaminophen (maximum 2 g/day); avoid NSAIDs
    4. May continue prophylactic Antibiotics if used for Ascites, but not specifically indicated for procedure prophylaxis
  3. Osteoporosis
    1. See Medication Causes of Jaw Osteonecrosis
    2. Alert dentist of medications and increased osteonecrosis risk
    3. Holding Bisphosphonates prior to procedure does not appear to reduce risk
      1. However, current dental practice is to stop Bisphosphonates 2 months before and for 3 months after
  4. Cancer
    1. Delay dental procedures if Absolute Neutrophil Count <1000, or Platelet Count <50k (some allow if >10k)
    2. Jaw Necrosis Risk with Head and Neck Radiation and Monoclonal Antibodies, Tyrosine Kinase Inhibitors
      1. See Medication Causes of Jaw Osteonecrosis
      2. Alert dentist of medications and increased osteonecrosis risk
  5. Chronic Kidney Disease
    1. See Preoperative Evaluation in Kidney Disease
    2. Maintain daily oral care and semiannual cleanings to reduce mortality in Hemodialysis patients
      1. Palmer (2015) Am J Kidney Dis 66(4): 666-76 [PubMed]
    3. Avoid nephrotoxic medications (e.g. NSAIDS) and follow Renal Dosing of medications
    4. Alert dentist to Kidney disease and most recent eGFR, Hemoglobin And Platelet Count
    5. Consider scheduling dental visits between Hemodialysis days to prevent Fatigue and bleeding complications

VIII. References

  1. Herrick (2021) Am Fam Physician 104(5): 476-83 [PubMed]

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