Impact and Association of Preoperative Oral Health and Dental Screening Approach on 90-Day Mortality After Cardiac Valve Surgery

• Main Author: Rao, Naman
• Format: Dissertation
• Language: English
• Published: 01.05.2019
• Subjects: 90-day mortality; dental characteristic; odontogenic infections; post-surgical valvular complication; Preoperative dental screening

Abstract paper 1- Background: Preoperative dental screening (PDS) prior to valvular surgery has been adopted widely by cardiac surgery to prevent poor outcomes associated with infections of oral origin. However, there is limited evidence to guide PDS protocols. This study was designed to understand the differences and association of focused and comprehensive approaches to PDS with post valvular surgery 90-day mortality. Methods: A retrospective cohort analysis was performed on all adult patients who underwent elective valvular surgery and PDS at two academic medical centers (MGH and BWH) from January 2009 to December 2016. Patients with a history of intravenous drug abuse were excluded. At MGH (n=692), PDS involved a dental examination including full series of diagnostic radiographs and definitive therapy for teeth with active and/or chronic disease (comprehensive protocol). At BWH (n=1143), PDS involved a dental examination that included selective diagnostic radiographs limited to symptomatic teeth and teeth with evidence of active infection (e.g. asymptomatic tooth with associated swelling and suppuration) and intervention only when active signs of disease were observed (focused protocol). Univariate and multivariable analysis were performed to compare 90-day mortality after surgery with the two different approaches. Results: A total of 1,835 patients met the inclusion criteria and their charts were reviewed. At BWH 1097/1143 (96%) patients received dental clearance at the initial visit with 3.3% (n=38) receiving radiographs. Dental findings included carious teeth (n=197, 17.2%), root tips (n=135, 11.8%), periodontically hopeless teeth (n=27, 2.4%), and periapical infections (n=20, 1.7%); 16 patients (1.4%) were symptomatic. Extractions were performed in 38 patients (3.3%), and 4 (10.5%) had post-extraction complications including pain, bleeding and infection. At MGH 245/692 (35.5%) patients received dental clearance at the initial visit with 94.2% (n=652) receiving radiographs. Dental findings included carious teeth (n=250, 36.1%), root tips (n=118, 17.1%), periodontically hopeless teeth (n=48, 6.9%), and periapical infections (n=149, 21.5%); 40 patients (5.8%) were symptomatic. Extractions were performed in 151 patients (21.8%), and 15 (9.93%) had post-extraction complications including pain, bleeding and infection. There was no significant difference in 90-day mortality between BWH and MGH (n=114, 10% vs n=58, 8.4%, p=0.257). This remained unchanged in a multivariable model after adjusting for demographics and baseline comorbidities (OR focused vs comprehensive:1.32 (95%CI:0.91-1.93), (p=0.14). Conclusions: There was no difference in 90-day mortality after cardiac valve surgery between patients who underwent a focused versus comprehensive PDS. Further prospective randomized comparative studies are needed to validate and expand on these findings. Abstract paper 2- Background- Odontogenic infections/ poor oral hygiene is one of the risk factors for developing post-surgical valvular complications. The magnitude and the impact to which these infections affect the post-surgical outcome especially early mortality remains unclear. This study was designed to evaluate the association of individual dental characteristic with the 90-day mortality. Methodology- A retrospective cohort analysis was performed on all adult patients who underwent valvular surgery and preoperative dental screening at Massachusetts General Hospital from January 2009 to December 2016. All valve surgery and dental data were procured using STS data set and electronic health record system of MGH respectively. Patients with a self-reported history of intravenous drug use and systemic infections were excluded from the study. We performed univariate and multivariable analysis for all the dental characteristics using logistic regression model. Odds Ratios (OR) and 95% CI’s were reported, and the significance level was 5%. Result- A total of 692 patients met the inclusion criteria of which, 58 (8.4%) patients died within 90-days and 634 (91.6%) patients survived after the valve surgery (within 90 days). Among the 90-day morality group and survived patients, the mean (±SD) age was 73.9±13.3 years vs 68.1±14.2 years with more females (n=32, 55.2% vs n=243, 38.3%). Although dental characteristics including dental complaint (n=1, 1.7% vs n=39, 6.2%), total number of teeth present (19.7 ± 8.1 vs 21.1 ±7.8), complete denture (n=9, 15.5% vs n=64, 10.1%), partial denture (n=1, 1.7% vs n=43, 6.8%), carious teeth (n=18, 31% vs n=232, 36.5%), root tips (n=5, 8.6% vs n=113, 17.8%), total number of asymptomatic root tips (0.3 ± 0.9 vs 0.6 ± 1.6), endodontically treated teeth (n=26, 44.8% vs n=289, 45.5%), periodontally hopeless teeth (n=3, 5.2% vs n=45, 7.1%) and tenderness on percussion (n=2, 3.4% vs n=17, 2.7%) varied amongst the group, the univariate and multivariable analysis showed no significant association of dental/ oral health characteristics with 90-day mortality. Conclusion- There was no significant association noted between dental characteristics and 90-day mortality. Further large prospective comparative studies are needed to validate and expand these findings. Master’s Program in Clinical Investigation