Association of a preoperative dental screening approach with 90-day mortality after cardiac valve surgery

Abstract

Objectives Preoperative dental screening (PDS) before valvular surgery has been adopted widely by cardiac surgeons to prevent poor outcomes associated with infections of oral origin. However, there is limited evidence to guide PDS protocols. This study was designed to compare a focused approach versus a comprehensive approach to PDS to determine its association with 90-day mortality. Study Design A retrospective cohort analysis was performed on 1835 adult patients who underwent elective valvular surgery and PDS at the Massachusetts General Hospital (MGH) and the Brigham and Women's Hospital (BWH) from January 2009 to December 2016. Patients with a history of intravenous drug abuse were excluded. At the MGH (n = 692), PDS involved a detailed dental examination, including diagnostic radiography and definitive therapy for teeth with active and/or chronic disease (comprehensive protocol). At the BWH (n = 1143), PDS consisted of minimal number of diagnostic radiographs limited to symptomatic teeth and intervention only when active signs of disease were observed (focused protocol). Univariate and multivariate analyses were performed to compare 90-day mortality rates after surgery with the 2 different approaches. Results There were no differences in demographic characteristics and baseline comorbidities between the 2 study sites. At the MGH, 340 (49.2%) of 692 patients received dental clearance at the initial visit, with 94.2% (n = 652) undergoing radiography. Dental findings included carious teeth (n = 250; 36.2%), root tips (n = 118; 17%), periodontically hopeless teeth (n = 48; 6.9%), and periapical infections (n = 149; 21.6%); 40 patients (5.8%) were symptomatic. Extractions were performed in 151 patients (21.8%), and 15 (2.2%) had postoperative complications. At the BWH, 1097 of 1143 patients (96%) received dental clearance at the initial visit, with 3.3% (n = 38) undergoing radiography. 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 (0.4%) had postoperative complications. There was no significant differences in 90-day mortality rates between the 2 study sites (10% vs 8.4%; P = .317). This remained unchanged in a multivariate model after adjusting for demographic characteristics and baseline comorbidities (odds ratio [OR] focused vs comprehensive: 1.32; 95% confidence interval [CI] 0.91–1.93); P = .14). Conclusions Despite the differences in PDS protocols at both study sites, there was no significant difference in 90-day mortality rates after valvular surgery. Further randomized comparative prospective studies are needed to validate and expand on these findings.