Dental work post-surgery

[MarkZ]

I'm getting a little ahead of myself since my surgery date isn't here yet. But I'm curious about a few dental related questions and looking for suggestions.

• How soon after surgery is it wise to get (non-emergency) dental work done?
• Prior to needing OHS I had considered dental implants for a couple extractions I've had. My thought is that this is probably too invasive and requires too much commitment after Coumadin, and leaning towards bridge instead. Thoughts from those who have faced similar question?
• Which dental procedures require bridging? Do you have to come off Coumadin even for cleanings and fillings? Or only for dental surgical procedures?

 

[dick0236]

When the time comes, I'd check with my Cardio or PCP before serious dental work. Simple cleanings should be OK soon after OHS.

I've never seriously considered implants.

Over my 50+ years on warfarin, I've never had dental work (cleaning, fillings, extraction, root canal, or "deep cleaning" that required bridging......or stopping warfarin, even tho my INR range is 2.5-3.5. That said, some folks do prefer to bridge. My only concern is the need for antibiotics before any invasive dental work......even simple cleaning.

 

[Eva]

Mark,
Easier to do all necessary dental work before surgery.
After surgery, you have to wait at least six months before dental cleaning!
And you need to take antibiotics one hour before each dental visit.
I had an implant in 2016. Cardio recommended bridging while my oral surgeon was ok if I could have my INR at my lower range on the day of extracting the tooth and on the day of inserting the implant! I did the latter and I was fine with both.
Good luck

 

[MarkZ]

Thanks, that's helpful to know. I'm getting as much done before my surgery as possible, but I know I can't fit it all in. I got the pretty invasive stuff done already (a couple extractions, root canal). With a late May surgery, I'm hoping I can continue additional dental work after the new year. That's also when my dental insurance max resets.

 

[MdaPA]

Note that you may require a dental clearance before your heart surgery to confirm that you don't have any infection, tooth abscess, etc.

 

[Chuck C]

Note that you may require a dental clearance before your heart surgery to confirm that you don't have any infection, tooth abscess, etc.

Yes, I had to get such clearance. UCLA had a form to bring to my dentist for sign off. I just scheduled my last cleaning 10 days before my surgery and got the sign off done at the same time. UCLA recommends waiting 6 months after surgery to get any dental surgery done.

 

[tom in MO]

I have a mechanical AVR.

• No presurgery clearance for me.
• The last time I read the guidelines, dental work did not require a change in coagulation therapy. The major risk for dental work is not bleeding but bacteria that might travel to your heart and cause endocarditis.
• Any dental work that involves the possibility of blood (e.g. cleaning) requires prophylactic antibiotics. My cardio recommends it for all dental work.
• At one time antibiotics were required if you had a BAV, but then the recommendations changed.
• For your specific problem that requires the Bentall procedure, ask your cardiologist if implants vs. bridge is a concern and if you need antibiotics..

 

[pellicle]

Which dental procedures require bridging? Do you have to come off Coumadin even for cleanings and fillings? Or only for dental surgical procedures?

none for all.

Bridging is only required if you have to come of warfarin for an extended time. Indeed the concept of bridging is to enable a transition from a slow acting AntiCoagulation Therapy to a faster acting one for the purposes of a tighter switch off of ACT.

Unless you are a patient at high risk of a clot (and simply Aortic Valve Mechanical is not a high risk) then the evidence is emerging that its safer to lower INR and then resume than have a narrow window of coagulation.

...

Summary ​

The perioperative management of patients on long-term warfarin therapy poses particular problems. This situation is exacerbated by the absence of randomised trials. The strategy used is based on the assessment of each patient's thromboembolic and bleeding risks. These determine the need for withholding warfarin and switching to heparin. Most patients having minor procedures can continue to take warfarin, provided that they are closely monitored and local measures are used to ensure adequate haemostasis​

...​

Do the benefits of anticoagulation outweigh the risks?​

The approach to the management of anticoagulation in patients with prosthetic valves undergoing non-cardiac surgery remains controversial. The need for perioperative anticoagulation in patients with mechanical heart valves has been questioned in a recent review. The authors argue that for every 10 000 patients with mechanical heart valves who are given perioperative intravenous heparin, three thromboembolic events are prevented at the cost of 300 major postoperative bleeding episodes​

full text for that here.

For highly invasive events (such as extractoins, root canals and cleaning) antibiotic cover may be needed.

For what its worth my dentist says I bleed less than many patients who aren't on ACT. I can assure you from what I spit out that I doo indeed bleed during sub-gingival cleaning.

 

[slipkid]

I just had a cleaning today. Not much bleeding at all, if any. Part of that is maybe my gums are pretty healthy lately, flossing & waterpicking every day.

I will say that while I was stuck on both plavix AND warfarin last year I was bleeding like crazy @ dentist, or even minor cuts, especially shaving. Which makes sense (double whammy of two very different anti-cogulation drugs).

 

[MarkZ]

Thanks all for the feedback. Yes CC has a form that needs to be approved by my dentist. Already signed, having a crown done before surgery. Otherwise putting everything off until January. They’ve always recommended antibiotics for me due to BAV but I’ve seen that this has been a debated topic in the literature.

It’s reassuring that I may only have to go low INR to get routine work done. I’m still not sure about dental implant vs bridge but I guess I have plenty of time to decide!

If y’all don’t mind an unrelated question — my wife and I had booked a week long cruise for November before this whole thing. With a late May surgery, do you think I’ll be in a position to go on the cruise, assuming all goes well? Or is 5-6 months still a little iffy?

 

[dick0236]

........ With a late May surgery, do you think I’ll be in a position to go on the cruise, assuming all goes well? Or is 5-6 months still a little iffy?

The cruise should not be a problem after 5-6 months, but I would buy the "cruise cancellation" insurance " "just in case".

 

[Keithl]

Good thread. I am having a deep cleaning in 2 weeks and debating whether to lower INR, or bridge to avoid bleeding as it is not uncommon for me to bleed with aggressive flossing so I suspect they will draw blood during the deep cleaning. I already have to pre-med. Since I am On-X I was debating getting down from 2.8 closer to 1.5 for the procedure

 

[ATHENS1964]

Ask your dentist, I who did the cleaning and a large filling did not reduce the inr at all. My doctor told me that I had a little more blood than a patient without anticoagulant therapy.
Also ask what antibiotic you should take before the treatment to protect against endocarditis, it is important do not forget it please.

 

[mecretired]

From someone who has had endocarditis twice (unknown reason)—taking your antibiotics is more important than lowering your inr. You do not want to introduce bacteria from your mouth into your bloodstream without antibiotics to take care of it.

 

[Keithl]

My doc makes me take 4 x 500mg amoxicillin 1 hour before.

 

[phil.nott]

I also take 4 x 500mg amoxicillin an hour before dental cleaning work and to be on the safe side take an additional 2 x capsules after the procedure. I too have had endocarditis and it was horrible. To be avoided at all costs!

 

[Chuck C]

My doc makes me take 4 x 500mg amoxicillin 1 hour before.

This is the standard of care and is what the guidelines call for.

See Tables 3 and 5

https://www.ahajournals.org/doi/pdf/10.1161/CIR.0000000000000969

 

[MrsBray]

I got an implant for tooth # 20 or 21. It was pricey, but I was SO OVER root canals and crowns. (All of my molars are crowned). I didn't have to do anything but pre-med.

 

[carolinemc]

I got an implant for tooth # 20 or 21. It was pricey, but I was SO OVER root canals and crowns. (All of my molars are crowned). I didn't have to do anything but pre-med.

Pre med is standard for heart people to prevent infection going to the heart.

 

[carolinemc]

When the time comes, I'd check with my Cardio or PCP before serious dental work. Simple cleanings should be OK soon after OHS.

I've never seriously considered implants.

Over my 50+ years on warfarin, I've never had dental work (cleaning, fillings, extraction, root canal, or "deep cleaning" that required bridging......or stopping warfarin, even tho my INR range is 2.5-3.5. That said, some folks do prefer to bridge. My only concern is the need for antibiotics before any invasive dental work......even simple cleaning.

Never do cleaning without pre med, for infection can go down with a simple cleaning. Any heart patient who has had Encarditis. can tell you. Prevention is a must, from doctor and dentists, for dentists will not touch a cardio person without premed.