EURO PEAN

SO CIETY O F
Review CARDIOLOGY ®

European Journal of Preventive

Cardiology

The perioperative dental screening 2017, Vol. 24(4) 409–425

! The European Society of
Cardiology 2017
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undergoing cardiothoracic, vascular DOI: 10.1177/2047487316682348
journals.sagepub.com/home/ejpc
surgery and other cardiovascular invasive
procedures: A systematic review

Elisabetta Cotti1, Mariantonietta Arrica2, Andrea Di Lenarda3,

Sara B Serri1, Pierpaolo Bassareo4, Luigi Padeletti5 and
Giuseppe Mercuro4

Abstract
Background: One controversial issue in the relationship between oral care and cardiovascular diseases is how and
whether to manage oral infections prior to cardiovascular surgery or other cardiovascular invasive procedures.
Design: We designed a systematic review to assess the information available on three main questions. Is there an
agreement on the need for dental evaluation and treatment before cardiovascular interventions? Are consistent clinical
recommendations or protocols available? Is dental treatment prior to cardiovascular interventions effective?
Methods: A systematic electronic search of MEDLINE, Scopus and Web of Science was performed from the database
inceptions up to 31 April 2016. Searches were performed using Boolean operators to combine medical subject headings
and free text words. Because this review included a large, heterogeneous group of study designs and sources, the results
were synthesised in a narrative approach.
Results: In total, 2447 studies were identified: 2099 (þ241 duplicates) were excluded after screening; 107 were included
for full-text assessment; 55 were excluded for not meeting the inclusion criteria; and 11 were not available. Thus, 44
studies meeting the inclusion criteria were analysed. We found that, for patients undergoing cardiovascular surgery, there
is a general agreement on the need for screening and treatment of dental infections, but not on the protocols. We also
found that there are conflicting indications on when and to what extent to perform the treatment and that the risk-to-
benefit ratios for these treatments are controversial.
Conclusion: No satisfactory answers regarding dental care before cardiovascular invasive procedures are available.

Keywords
Dental care, periodontitis, periapical abscesses, tooth extractions, periodontal debridement, heart surgery, cardiac
surgical procedures, aortic surgery, coronarography, angioplasty
Received 2 August 2016; accepted 13 November 2016

Introduction
1
Department of Conservative Dentistry and Endodontics, University of
Dental diseases are the most common illnesses in the Cagliari, Cagliari, Italy
world; furthermore, chronic oral infections such as 2
Department of Surgery, Microsurgery and Medical Sciences, University
periodontitis are now considered an independent risk of Sassari, Sassari, Italy
3
factor for the onset of cardiovascular disease (CVD), Cardiovascular Centre of Trieste, University of Trieste, Trieste, Italy
4
Department of Cardiology, University of Cagliari, Cagliari, Italy
and an increasing number of studies are associating the 5
Department of Cardiology, University of Florence, Florence, Italy
presence of apical periodontitis (endodontic infection)
Corresponding author:
with the risk of CVD.1–4 These are the reasons why, in Elisabetta Cotti, Universita degli Studi Di Cagliari, Via Roma 149, I-09124
recent years, there has been increased attention towards Cagliari (CA), Italy.
oral health. Email: cottiend@tin.it
410
The US Surgeon General has addressed the import-
ance of oral health, highlighting the association
between it and systemic health; the World Health
Organisation (WHO), in its latest World Assembly,
supported the integration between oral and general
health in the field of prevention and health promotion;
and, finally, the European Union (EU) has developed a
programme of health promotion policies for chronic
diseases, including the most common oral diseases.5–7
One of the important controversial issues in the rela-
tionship between oral health and CVD is how and
whether to relate screen for and manage oral infections
prior to cardiothoracic or vascular surgery and other
cardiovascular (CV) invasive procedures.
To date, the guidelines of the US and EU cardiology
and cardiac surgery associations have expressed incom-
plete and inconsistent information on salient issues
such as: (a) type and modality of dental assessment
required for those conditions; (b) treatment that
should be performed before the patient undergoes
heart surgery; (c) selection of treatments to be pro-
vided; (d) correct or preferred timing of the required
dental treatments; and (e) risks vs benefits associated
with dental treatment before CV procedures.8–10
Since patients are increasingly being referred to oral-
maxillofacial departments, to dental units in hospitals,
and to dental practitioners for dental examination and
treatment before heart surgery and CV invasive proced-
ures, we hope that in the near future there will be closer
cooperation between cardiologists and dentists to pro-
duce shared clinical recommendations to reduce the
peri-procedural risk in CV patients.
Purpose of the study
The purpose of this study was to determine whether there
is a need to call for a consensus on future clinical recom-
mendations, and this systematic review aimed to assess
the information in the literature on three main questions:
1. Is there an agreement on the need for dental evalu-
ation and treatment before major and minor CV
interventions?
2. Are consistent clinical recommendations or proto-
cols available?
3. What is the effectiveness of dental treatment prior to
CV interventions?
Methods
Search strategy. A systematic electronic search of
MEDLINE, Scopus and Web of Science was performed
from the database inceptions up to 31 April 2016. All
searches were performed using Boolean operators to com-
bine medical subject heading (MeSH) and free text words.
European Journal of Preventive Cardiology 24(4)
The search terms were matched for outcomes as follows:
a. periodontitis OR periodont* OR dental caries OR
periapical diseases OR periapical abscesses OR pul-
pitis OR periodontal abscesses OR tooth fractures
OR radicular fractures* OR root fractures* OR
dental fistula OR gingivitis OR gingival diseases
OR periimplantitis OR tooth mobility OR periim-
plant OR mucositis OR dental care OR oral health*
OR endodontics OR dental restorations* OR
dental prosthesis OR tooth extractions OR peri-
odontal debridement OR apical periodontitis
b. cardiosurgery OR cardiac surgery OR thoracic sur-
gery OR heart surgery OR CV surgery OR cardiac
surgical procedures OR thoracic surgery OR aortic
surgery OR coronarography* OR angioplasty*
Other sources. The reference lists of identified articles and
relevant papers known to reviewers were also examined.
Emails were sent to the authors of identified studies for
additional information when necessary.
Three reviewers were calibrated for the identification
of the eligible studies (M Arrica, E Cotti and SB Serri)
by a fourth reviewer (PP Bassareo) through successive
stages of triplicate independent screening among ran-
domly selected titles and abstracts in groups of five,
until a complete intra-examiner agreement was
obtained (k scores from the first to the last calibration
exercise: 0.86, 0.89, 0.91 and 1).
A parallel, triple-blind screening procedure of all
titles and abstracts retrieved by the electronic search
was performed by three reviewers (M Arrica, E Cotti
and SB Serri). The titles and abstracts were screened for
subject relevance. Studies that were not definitely
excluded based on the abstract information were also
selected for full-text screening. The reviewers examined
the full text of all relevant studies to screen for inclusion
possibility. When there was a disagreement for study
inclusion, a discussion was held with the fourth
reviewer (PP Bassareo) to reach a consensus.
Studies were eligible for inclusion if they met the
following criterion: all studies concerning the dental
management of patients undergoing cardiac or thoracic
surgery and other CV invasive procedures with no
limits for language or period of publication.
The exclusion criteria were agreed upon as follows:
(a) studies not concerning the topic selected; (b) dupli-
cates, and (c) studies not available from libraries for
full-text assessment.
Data extraction
Three reviewers (M Arrica, E Cotti, and SB Serri) inde-
pendently extracted data using a structured form
Cotti et al.
specifically developed for this review (provided in Table
1). The following information was extracted from each
included study: authors, year of publication, type of
paper, CV procedure considered, dental disease/treat-
ment discussed, performed/recommended pre-surgical
dental assessment, performed/recommended pre-surgi-
cal dental clearance, performed post-surgical dental
management, proposal of a standardised proto-
col for dental management, other recommendations
provided, and effectiveness of scheduled dental
treatment.
Thus, three possible outcomes were recognised: (a)
agreement on the need for dental screening and treat-
ment prior to CV interventions; (b) availability of clin-
ical recommendations and protocols; and (c)
suggestions on the timing and effectiveness of dental
treatments prior to minor and major CV interventions.
Any discrepancy that occurred during data extrac-
tion was resolved by consensus or discussion with the
fourth reviewer (P Bassareo).
Data synthesis
Since this systematic review included a large and het-
erogeneous group of study designs and sources, the
results and key information obtained from each of the
related articles was synthesised in a narrative approach.
Results
Literature search
The literature search yielded a total of 2447 primary
studies, of which 2099 (þ241 duplicates) were excluded
after title and abstract screening. Finally, 107 studies
were included for full-text assessment due to a relevant
title and abstract. A total of 55 were excluded because
they did not meet the general inclusion criteria, and 11
were not available from the online libraries. As a result,
41 studies met the inclusion criteria, and an additional
three papers were included after checking the references
of the relevant selected reviews and studies (see
Table 1).12–54
A flow diagram of the study selection process is pre-
sented in Figure 1.
Our search resulted in a list of 33 articles responding
to outcome (a), 19 articles targeting outcome (b), and
16 articles for outcome (c).
Outcome (a). Agreement on the need for dental
screening and treatment prior to cardiothoracic or
vascular surgery and other invasive CV procedures
A rationale for screening and optimising denti-
tion prior to elective cardiothoracic or vascular
411
surgeries was discussed in 35 of the selected
papers.11–13,15–17,20,22–26,29,30,35–46,48,50,52,53
The authors testified that many patients who require
cardiac surgery present with deep carious lesions, apical
periodontitis, complications of acute apical abscesses
and periodontitis, which represent potential odonto-
genic infections. The eradication of dental disease can
reduce the incidence of infective endocarditis after car-
diac valve replacement.47 Surgeons should consider
referral for dental assessment before elective bypass
grafting,45 in particular because a proportion of pros-
thetic vascular graft infections might be due to dental
sepsis.45,48
It was also stated that oral infections might increase
the likelihood of an unfavourable outcome of surgery.53
The results of a study based on a nationally represen-
tative cohort (596,190) of patients undergoing surgical
heart valve procedures in the USA during the years
2004–2010 strongly associated the presence of gingivitis
and periodontitis with a higher likelihood of postopera-
tive bacterial infections, higher hospitalisation charges
and longer hospital stays.11
In a survey on paediatric patients, it emerged that
only a minority of cardiologists (45%) recommended a
dental examination for the young patients prior to sur-
gery or catheterisation.15 On the other hand, a previous
report on children emphasised that cardiac surgery had
to be postponed in 12% of cases due to the detection of
dental infection.23
The incidence of patients requiring dental treatment
before heart transplantation was found to be up to 72%
of cases.37 Patients referred to the dental clinic prior to,
or after, valve surgery have been documented to exhibit
a very low level of dental health38 and, specifically, the
patients waiting for heart valve replacements had a
documented 58.3% incidence of apical periodontitis,
which was more often present in patients intended for
aortic valve replacement.26,27,38 Oral infections were
also observed among patients waiting for mitral and
aortic valve replacement, at a rate of 61% and 47%,
respectively, according to another report.29
In a cohort of patients scheduled for abdominal
aortic surgery, the presence of dental diseases was regis-
tered in 82% of the individuals, and 26% of them were
also found positive for infection with candida. It was
concluded that, even if the likelihood of oral infection
foci leading to prosthesis infection is relatively low,
prophylactic treatment of dental sepsis might eliminate
at least one source of aortic prosthetic infection and
should therefore be strongly considered.24
A thorough dental examination has been considered
a fundamental part of the overall pre-operative visit
before heart transplant,22, 30,36–40,46 heart valve replace-
ment,16,20,26,27,29,38,39,47,48 and aortic surgery,24,41 as
well as for patients with ventricular assist devices
Table 1. Data extraction form.
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Allareddy et al.11 2015 Retrospective study Surgical heart Gingivitis and Yes/yes No/yes – – – –
valve periodontitis
procedures
Baddour et al.12 2011 Scientific statement Cardiovascular Routine invasive – – – – No antibiotic –
implantable dental procedures prophylaxis
electronic
devices
Baker13 2000 Review Cardiovascular – – – No – Uncertain
implants and
devices
Bratel et al.14 2011 Controlled clinical Heart valve All dental diseases Yes/yes Yes, in the study – Yes – Ineffective
trial - prospective surgery group/no
Coutinho 2007 Cross sectional All cardiac All dental diseases Yes/yes – No No – –
et al.15 (survey to c. surgeries
surgeons)
Couturier 2000 Commentary Heart valve Periodontal /Recommended – – – – –
et al.16 replacement abscesses/All
dental treatments,
especially dental
surgery
Flynn and 2012 Overview Major vascular Periodontitis/Tooth /Recommended /Recommended – – – –
Silvay17 procedures extractions
Gandhi and 2015 Letter to editor Cardiovascular All dental diseases If they have not still Depending on the – No No indications for Uncertain
Silvay18 surgery provided their patients/- which patients
assessment and undergoing cardiac
clearance in other operations need
clinics/yes dental clearance
Golder and 1993 Overview Heart All dental diseases Yes/yes Recommended for Recommended for Yes – Effective
Drinnan19 transplantation active infections any condition
which might judged not to pos-
persist or situ- sibly evolve to
ations which acute stage for at
could evolve to least 12 months
acute infection
up to 6 months
from the car-
diac transplant
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Gutschik 1990 Cross sectional Heart valve Periodontal disease – – – No Antibiotic prophy- –
and Lippert20 (survey to replacement laxis. Topical use of
dentists) antiseptics in con-
nection to dental
treatments
Hackeberg 1999 Controlled Heart valve All dental diseases and Yes Yes, in the study A dental examination Yes Ineffective
et al.21 clinical trial- surgery treatments group/no was performed
prospective three weeks after
surgery in the
control group/no
Harms and 1986 Narrative review Heart All dental infections – Recommended Routine dental pro- No Soft and hard dental Effective
Bronny22 transplantation cedures can be tissue assessment
postponed until prior to the car-
maintenance levels diac transplant-
of immunosup- ation surgery is
pressants are mandatory.
reached Questionable
teeth should be
extracted
Hayes and 2001 Retrospective study Cardiac surgery Gum disease, dental Yes/yes Yes/yes 24/209 – No Primary care phys- –
Fasules23 caries, dental patients post- icians and cardi-
abscess, periodon- poned their ologists should
tal abscess, peri- surgery due a increase their
coronitis, mouth dental disease emphasis on oral
ulcer health in addition
to antibiotic
prophylaxis
Hayrinen- 2000 Prospective study Abdominal aortic Deep caries, severe Yes/yes -/Recommended – No –
Immonen surgery periodontitis,
et al.24 intraosseous foci,
poor denture, can-
dida infection
Jenkins et al.25 2015 Cross sectional Cardiac surgery Acute and chronic Yes/yes Yes/recommended – Proposed clinical Excellent oral hygiene –
oral infections pathway for and regular dental
treatment assessment is key
to reduce the risk
of infective
endocarditis
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Krennmair 1996 Cross sectional Cardiac valve Periapical Yes/yes No/- – No Interdisciplinary –
et al.26 replacement periodontitis cooperation is
necessary to min-
imise the social
and psychological
problems following
unexpected tooth
extractions
Krennmair 2007 Controlled Cardiac valve Dental foci and peri- Yes/yes Only potential foci No No Psychological and –
et al.27 clinical trial replacement odontal disease were removed/ social problem
yes related to the
dental treatments
may be reduce to a
minimum when the
patient is managed
in a appropriate
time
Landoni et al.28 2012 Web based inter- Major surgical – – – – – Chlorexidine oral
national consensus procedures rinse twice-daily
conference/Review administered might
reduce nosocomial
infections and
mortality in
patients undergo-
ing cardiac surgery
Lassnig et al.29 2004 Cross sectional Mitral/aortic valve Chronic apical peri- Yes/yes No/- No/- No – –
replacement odontitis, cysts and
remaining radices
Little and 1992 Review Heart Dental diseases -/Yes -/yes Discussed Medical Antibiotic prophylaxis –
Rhodus30 transplantation consultation for heart trans-
protocol plant patients
undergoing inva-
sive dental pro-
cedures.
Thrombin, splits
and pressure could
be supposed to be
managed after
dental surgery
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Lockhart et al.31 2009 Clinical controlled Valve replacement Invasive dental Yes/yes Concomitant/yes No No Concomitant
study procedures approach enables
patients to avoid a
second general
anaesthesia and
delay
Meyer et al.32 1999 Retrospective study Heart Dental foci Yes/yes Yes/yes Follow up after heart Treatment Dental treatment may Effective
transplantation transplantation for protocol only be completed after
oral assessment transplantation
without risk
Moosdorf33 2015 Letter to the editor/ Cardiac surgery Acute symptomatic -/Depending on the -/Depending on the – No Individualised
commentary dental infections/ patient’s situation patient’s planning should be
Extractions situation manage in close
proximity
to cardiac
surgeons,
oral surgeons and
anaesthesiologists
Nakamura 2011 Clinical controlled Heart valve Periodontal disease/ Yes/yes Yes/yes No No Effective
et al.34 study surgery tooth extractions and safe
and curettages
Natividad 2014 Review Intravascular Dental procedures – – – – Antibiotic prophy- –
et al.35 catheterises requiring manipu- laxes needed
lation of gums or
periapical region
Pàvek and 1985 Longitudinal study Cardiac surgery Untreated necrotic Yes/yes Yes/yes No No Antibiotic prophylaxis Effective
Kolonejova36 teeth or with
chronic apical
periodontitis
Pàvek and Bigl.37 1988 Longitudinal study Cardiac surgery Untreated necrotic Yes/yes Yes/yes Yes/no No Antibiotic prophylaxis Effective
teeth or with
Chronic apical
periodontitis
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Rogers38 1989 Prospective study Valvular surgery Oral infections Yes/yes Yes/yes No/- No Antibiotic prophy- Effective
laxis; high level of
oral care should be
maintained after
heart surgery
Rustemeyer and 2007 Cross sectional study Heart transplant Periodontitis, cysts, Yes/yes Yes/yes No/- Yes Patients should be Effective
Bremerich.39 and heart valve unrestorable teeth, integrated into and
replacement abscesses organised dental
or oral-maxillofa-
cial surgical follow
up program
Shetty and 2007 Review Heart transplant Major dental -/Yes -/Yes -/Only emergency No Epinephrine free solu- Effective
Gilbert40 treatments dental treatments tions should be
are allowed preferred for local
anaesthesia in
dental treatments/
antibiotic prophy-
laxes/more com-
plex dental
procedures
require steroid
supple-
mentation
Silvay41 2010 Retrospective study/ Aortic surgery All dental treatments Yes/yes Yes/yes No/No Medical Perioperative anes- Effective
Report consultation thesiologist’s func-
only tion is
irreplaceable
Smith 2014 Retrospective Cardiac surgery Dental extractions Yes/yes Yes/not definitive No/- – Future prospective Not
et al.42 review recommen- studies are needed definitive
dation to better deter- recommen-
mine optimal rec- dation
ommendations for
dental extractions
before cardiac
surgery
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Smith et al.43 2015 a Letter to the editor/ Cardiac surgery -/Depending on the -/Depending on the – No No Integrated care team –
Reply to Moosdorf patient’s situation patient’s situation model should be
exercised to opti-
mise care for
comorbid patients
undergoing dental
extractions
Smith et al.44 2015 b Letter to the editor/ Cardiac surgery – – – No No No long term out- Not definitive
reply to Gandhi comes such as late
onset endocarditis
could be assessed
in the previous
study
recommendation
Stansby and 1994 Cross sectional study Bypass grafting Periodontal disease Yes/yes -/Yes No No Patients should be
Byrne45 warned about the
importance of
dental care after
operation
Sung et al.46 2014 Cross sectional study Heart transplant Scaling and Yes/yes Yes/yes No Yes Antibiotic prophylaxis Effective
extractions and maintenance
of prior anticoagu-
lation. Antiplatelet
or antithrombin
regimen
Terezhalmy 1997 Cross sectional study Prosthetic vascu- Acute and chronic Yes/yes -/Yes -/- Oral examination A routine preopera- –
et al.47 lar graft oral/ordontogenic þ radiography tive dental exam-
conditions ination should be
deemed medically
necessary by third
party payers. A
randomized study
is required for
long-term
assessment.
(continued)
Table 1. Continued
Performed Performed Performed Standardised Effectiveness
Dental pre-surgical pre-surgical post-surgical protocol for of scheduled
Cardiovascular disease/dental dental assessment/ dental clearance/ dental dental Other dental
Authors Year Type of paper procedures treatment recommended recommended management management recommendations treatment

Thomas 2015 Case series Aortic prosthetic Periodontal disease No/yes No/yes -/- No Need for good oral –
48
et al. vascular graft hygiene post-
infection operatively can e
reinforced.
Chronic oral infec-
tion may be a risk
factor for the
development of
late-onset aortic
prosthetic vascular
graft infection
Venugopal 2011 Prospective study Cardiac valve Dental treatment Yes/no Yes/yes – Ongoing Referrals for dental –
et al.49 replacement treatment prior to
cardiac surgery are
often poorly timed
or even
unwarranted
50
Wu et al. 2008 Retrospective study Cardiac valve Chronic oral Yes/yes Yes/no Yes/yes No The necessity for Ineffective
surgery infections treatment of
chronic dental dis-
ease immediately
prior to cardiac
valve surgery
remains unclear
Yasny and 2007 Review Cardiac surgery Acute symptomatic -/Yes -/Yes -/Yes Yes Effective
Silvay51 dental infections
Yasny and 2009 Review Cardiac surgery Acute symptomatic -/Yes -/Yes -/Yes Yes Effective
White52 dental infections
Yasny53 2010 Review Cardiac surgery Acute symptomatic -/Yes -/Yes -/Yes Yes Effective
dental infections
Yasny and 2012 Review Cardiac surgery Acute symptomatic -/Yes -/Yes -/Yes Yes Healthcare providers Effective
Herlich54 dental infections should become
more familiar with
perioperative
dental consider-
ations in order to
implement effect-
ive and preventive
measures to
improve surgical
outcomes
Cotti et al.
2447 studies identified through database
searching
PubMed
Scopus
Web of science
107 full articles retrieved for
further assessment
41 studies included after full
text analysis
44 studies included for
synthesis.
Figure 1. Flow chart of the study selection process.
(VADs), 46 coronary artery stents, intravascular assist
devices,13 and before other invasive CV
procedures.35,42–44
In this regard, it has been suggested that a specia-
lised pre-anaesthesia clinic might play a role for the
perioperative evaluation of daily admission of patients
undergoing major CV surgery.17,51
In terms of CV implantable electronic devices, a con-
nection between infection of the device and dental
infection has not been established, thus rendering pre-
ventive measures unimportant.12
The clearance of dental infection is also reputed to
be valuable as a preventive measure to avoid treating
patients after CV surgical treatments. Following the
dental assessment, it is necessary to remove all focal
infection deposits before surgery because of the post-
operative anticoagulant susceptibility, and this is even
more important in patients undergoing transplant who
will undergo immune suppressive therapy following the
intervention.20,22,24,38,46
Prior to surgery it is not always the dentist who ini-
tiates or discovers the necessity of dental treatment for
a patient. In the preoperative period, a primary care
physician or other healthcare provider might be the
419
2099 excluded after title and
abstract screening
241 duplicates removed
55 exclude for unmeeting
general inclusion criteria
11 not available from libraries
3 full articles included from the
references of included study
first to look into the mouth of the patient.41,51,54 A
survey involving all oral-maxillofacial surgery
(OMFS) departments in the UK reported that most,
but not all, of the units offered dental assessment for
patients awaiting cardiac operations, that they preva-
lently performed dental extractions, and that they
referred patients who needed restorative work to out-
side general dentists. Some departments aimed to com-
plete treatment within seven days from the time of
referral, and most units did not perform antibiotic
prophylaxis. They concluded that there is a need for
‘a more integrated pathway for the management of
these patients’.25
Outcome (b). Clinical recommendations and
protocols
Detailed but inconsistent recommendations for the
dental/oral examination and for the treatment protocols
prior to elective cardiothoracic, vascular surgery, or other
invasive CV procedures were found in 22 of the selected
papers.11,17–22,25,30,31,33,36,40,43,44,49,51–54
Heart transplant patients are the most vulnerable
population among those undergoing cardiac surgery
420
and invasive procedures, and for this population, the
times and methods of intraoral therapy have been
described in more detail.19
A clinical pathway was proposed in which patients
with dental infections awaiting urgent cardiac surgery
are referred to the oral-maxillofacial surgery units for
dental extractions only. According to the same path-
way, CV patients with non-urgent conditions are
referred to dental department or dental practitioners
to undergo a full range of dental treatments before
the major surgery.25
Dental/oral examination. In general, and particularly in
critically ill patients, proper dental care is provided
during the patient’s hospitalisation, before the heart
surgery is performed.22,36,37 In some realities, the per-
centage of patients undergoing elective operations who
have dental clearance before seeing the surgeons
approximates 100%.18
The preoperative assessment of patients by a dentist
should include clinicalexamination19,20 and,
specifically:
1. comprehensive extra- and intraoral examination of
the hard and soft tissues, for any evidence of lesion
or infection;19,22,37,51,54
2. palpation of extra oral and intraoral tissues such as
the palate, floor of the mouth, tongue;54
3. overall assessment of oral hygiene;
4. exploration of the individual teeth,19,22,37,51,54
decayed, missing, filled teeth (DMFT) index assess-
ment,46and vitality tests to assess the status of the
dental pulp;37
5. exploration of all existing dental restorations and
prosthetic work for new or recurrent decay and for
the adequacy of the margins of the restorations;19,37,54
6. periodontal evaluation, probing of depths of the
pockets around the teeth; 19,38,51,54
7. radiographic examination, which should include
panoramic radiographs, a series of intraoral radio-
graphs, periapical and/or bitewings (radiographic
status), to supplement the clinical examination for
evidence of tooth decay, infections in the surround-
ing structures, moderate or severe periodontal
disease.19,21,37,46,51,54
The use of blood cultures before and after treatment has
also been mentioned.37 When necessary, patients can be
evaluated bedside using a head-light and wall suction.46
Moreover, anaesthesia care providers should focus
on the patient’s airway and check the condition of the
dentition and prosthetic appliances, to decrease the risk
of these being ingested by the patient, decrease the
chance of foreign-body aspiration of dislodged teeth,
and prevent postoperative infections.17,51,53,54
European Journal of Preventive Cardiology 24(4)
Treatment. The preoperative dental treatment should
depend on the individual situation of the patient.33,43,44
The dental and cardio-surgical team should establish
priorities, especially concerning important therapies
before transplants.40 Antibiotic prophylaxes should be
enforced when needed.30,37,46 Monitoring of
International Normalized Ratio (INR), haemostasis
and coagulation might be performed.47 Preventive tech-
niques should be enforced, and oral prophylaxis and
topical fluorides should be administered.22,30
Strict adherence to sterile techniques is mandatory.22
Medical consultation must occur before treating a
patient who has already received a heart transplant.30
An acute, symptomatic infection should be aggressively
treated if possible,33,51,54 teeth with extensive caries or
periodontitis should be extracted and dentures con-
structed.33 Endodontic treatment should be per-
formed.30 Treatment of chronic periodontal
conditions requiring multiple sessions should be care-
fully evaluated. Whether an extraction or periodontal
treatment is indicated, waiting for healing of the sur-
rounding bone and gingival tissues is recom-
mended.51,54 Extractions and scaling/root planning
can also be performed bedside in critical patients,
under sedation (short-acting benzodiazepines or other
sedative agents) following consultations. Bleeding con-
trol can also be achieved through the surgical activity,
use of a splint for compression and other post-operative
precautions.25,46 Any type of important intervention,
and especially multiple extractions, should be per-
formed by a team of oral surgeons and, if necessary,
anaesthesiologists, in close proximity to cardiac sur-
geons and intensive care.11,33
Timing for treatment. Treatments have been divided into
(a) treatments that must be performed before trans-
plants (extractions; large restorations; periodontitis);
(b) treatments that should be performed before trans-
plants (active gingivitis); and (c) treatments that can be
completed after transplants (elective: i.e. prosthetic
work).
Dental procedures should be performed at minimum
one week before surgery to ensure adequate healing
time. Ideally, a prolonged asymptomatic period of
one month is even more beneficial to minimise the
potential for recurrence of the infection and adverse
effects on the cardiac procedure.51,54 If possible, it
would be better to optimise dental health three
months before elective cardiac surgery to increase ade-
quate treatment options without placing too much
pressure on the operative units.49
Minor treatments are not to be performed preopera-
tively.46 In a retrospective case-control study of 21 in
patients scheduled for cardiac valve surgery between
January 1993–February 2004, who also needed dental
Cotti et al.
extractions, the dental work was performed in the CV
operating room just before the main surgery. The con-
trol group consisted of 17 patients with similar charac-
teristics treated either in the main operatory room or in
the hospital dental clinic 1–6 days before valve surgery.
All patients received preoperative antibiotics before the
dental surgery. No significant differences in the occur-
rence of early and late complications were observed
between the groups. The results suggest that concomi-
tant surgical procedures for dental and valvular heart
disease can be accomplished without clinically signifi-
cant complications. This approach should be con-
sidered for those patients who would benefit by
receiving the dental treatment, avoiding a second gen-
eral anaesthetic and/or a delay in cardiac surgery, and
by having their oral surgery performed in the safest
environment.31
Outcome (c). Effectiveness of dental treatments
We found that eight of the selected papers addressed the
effectiveness and risks of dental treatment in patients
waiting for a CV intervention.14,21,28,32,34,42,46,50
According to a web-based international consensus
conference (which involved more than 1000 physicians
from 77 countries), chlorhexidine oral rinses and select-
ive decontamination of the digestive tract resulted to be
two of the 14 perioperative interventions leading to a
reduction in mortality in adult surgery.28
Despite all the above mentioned considerations, the
risk-benefit ratio of performing dental treatment in
patients awaiting CV surgical procedures remains con-
troversial. Some of the available literature has
described dental treatment as safe and beneficial for
patients undergoing CV surgery.
In a cohort of 209 patients (age 65  10 years) sched-
uled for elective heart valve surgery, individuals with
severe periodontitis were treated (with tooth extractions
or with curettage) either within two weeks or longer
before the major surgery. During the mean follow-up
period of 60  16 months, no patient developed pros-
thetic valve endocarditis, and there were no postopera-
tive deaths. The investigators concluded that receipt
and timing of dental treatment do not affect the surgical
postoperative course and its success rates.34
Favourable indications were also obtained based on
a descriptive cross-sectional study conducted in 2008–
2012.46 Nine patients with advanced heart failure, who
had a ventricular assist device implanted either as a
bridge to transplant or as destination therapy, were
evaluated for dental infections and treated bedside
with dental extractions and scaling/root planing.
Antibiotic prophylaxis was also administered. All
patients were followed-up daily for seven days. No
patient developed local or systemic infections, including
421
ventricular assist device (VAD) cannula and device
infection, and the treatments did not result in near-
term (1–30 days) morbidity or mortality.
On the other hand, it has also been questioned
whether dental interventions may might actually
decrease post-operative infectious complications in
patients undergoing heart valve surgery.
In a retrospective, longitudinal study of 74 patients
who underwent cardiac transplantation, the patients
were divided into two groups: 43 patients in whom
dental foci were completely eliminated, and 31 for
whom treatment was not completed. The definition of
dental foci included periapical infected teeth (apical
periodontitis), semi-impacted teeth, and marginal
infected teeth. Patients were treated either at the max-
illo-facial clinic in the ‘high risk’ operation room or in
private dental practices. Two complications that
occurred in the clinic were bleeding and cardiopulmon-
ary insufficiency. Fewer complications occurred in cases
treated by dental practitioners. By comparing the infec-
tion rate, rejection rate, and mortality in the groups, no
difference was found in outcome between patients with
dental foci versus those without existing dental foci
before heart transplantation. Furthermore, the type of
oral foci had no influence on postoperative complica-
tions. It was emphasised that the attention to oral
health and dental treatment performed before heart
transplant did not influence the patients’ survival rate.32
According to two subsequent studies on the same
cohort of patients undergoing heart valve surgery,
even when adequate dental screening and proper
dental interventions were started 3–6 months prior to
the operations, the risk of post-operative infectious
complications did not decrease, and patients survival
was not improved in the short-term follow-up21 or 16
years later.14 These observations are in agreement with
the results from a retrospective clinical study in which
98 patients admitted for cardiac valve surgery were
divided into three groups: dentally unhealthy and
untreated (Group A), dentally healthy and therefore
not treated (Group B), and dentally unhealthy and trea-
ted (Group C). According to the data from this inves-
tigation, patients who had untreated dental infections
were not at a significantly greater risk for developing
infective endocarditis within six months of cardiac sur-
gery and did not have a significantly higher rate of
mortality compared to the dental healthy patients or
to the patients who received dental treatment. The
authors thus hypothesised that there might be no
need to treat chronic oral infections prior to cardiac
valve surgery.50
Finally, one of the most alarming reports comes
from a retrospective review conducted at the Mayo
Clinic on patients treated from January 2003–
February 2013. The cohort consisted of 205 patients
422
who underwent 208 dental extractions at an average of
seven days before their planned cardiac operations.
Antibiotics were also administered to these patients
before the surgery. In 7% of these cases, there were
delays of the cardiac operation due to complications
from the dental extractions; more importantly, major
adverse outcomes occurred among these patients until
the time of cardiac surgery or within 30 days after the
dental extractions. The occurrence of an 8% risk of
major adverse effects (defined as acute coronary syn-
drome, stroke, renal failure requiring dialysis, and the
need for postoperative mechanical ventilation) and a
3% risk of death before cardiac operation due to the
individual risk of anaesthesia and surgical procedures
in this patient population was described.46 Again, the
authors questioned the appropriateness of performing
dental surgery in patients with decompensated/
untreated heart disease and suggested that it be post-
poned until after the cardiac procedure.
Limitations
As with all systematic reviews, this one is limited by the
quality of the included studies which differed in typ-
ology, outcomes and consistency in their results. It is
important to observe that due to this heterogeneity, it
was not possible to perform a systematic appraisal of
included studies; nevertheless, a general low level of
cumulative evidence among the included studies
should be considered.
Discussion
How and whether to perform peri-operative dental
screening and manage dental infections in patients
undergoing cardiothoracic or vascular surgery and
other CV invasive procedures remain controversial
issues.
The joint guidelines of the American Heart
Association and the American College of Cardiology
recommend, whenever possible, a thorough dental
evaluation before heart surgery, valve replacement or
repair of coronary heart disease (CHD). The aim is to
prevent or reduce the incidence of late prosthetic valve
endocarditis caused by the viridans streptococci group.
However, no details about treatments and their timing
are provided.8 The European Society of Cardiology
prescribes a peri-operative antibiotic prophylaxis, start-
ing immediately before heart or vascular surgery and
continued for up to 48 h afterwards. Furthermore, the
elimination of potential sources of dental sepsis at least
two weeks prior to surgery is strongly recommended,
unless the procedure is performed in an emergency.9
The International Society for Heart and Lung
Transplantation recommends an annual dental
European Journal of Preventive Cardiology 24(4)
examination and treatment of problematic lesions and
abscesses for all potential transplant candidates.10
Interestingly, the American Society of
Anaesthesiologists and the Society of Thoracic
Surgeons do not provide clear recommendations in
this area.
The above mentioned documents have the serious
limit of having excluded the CV medium- or low-risk
patients and their need for dental examinations.
The purpose of our systematic review was to evalu-
ate (a) the information present in the literature concern-
ing agreement on the need for dental evaluation and
treatment before heart surgery and invasive CV inter-
ventions; (b) the availability and consistency of specific
clinical protocols; and (c) the possible advantages and
drawbacks of these procedures, to determine whether
there is a need to call for a consensus on clinical rec-
ommendations on this topic.
We found in the literature a general agreement on
the need for patients undergoing elective CV surgery to
receive screening and treatment of dental infections.
Despite this consensus, the oral assessment was not
always performed by a dentist.
A number of recommendations regarding the oral
examination procedures and the extent of intraoral
dental treatment in heart surgical patients is scattered
in different documents, mostly uncontrolled studies. All
of these opinions are the result of individual experiences
and are difficult to compare or integrate.11,13,
15,16,20,22–27,29,30,36–41,43–45,47,48,51–53
They range from extra- and intra-oral examination
and evaluation of oral hygiene to a detailed evaluation
of each tooth. Radiographic examinations vary from
panoramic to specific intra-oral radiographic sets.
Blood cultures have also been mentioned as a possible
adjunct to treatment.17,19,21,22,36,46,51,53,54
There is no a clear-cut opinion detailing when dental
treatment should be administered before CV surgery,
and who should be responsible for establishing priorities,
the dental team, or the cardio-surgical team.34,40,43,44
According to some authors, dental therapy should
be performed as extensively and comprehensively as
possible, whereas according to others, it must be limited
to severe conditions.34,40,46,51,54 Antibiotic prophylaxes
is not considered mandatory in all patients, but should
be administered when ‘needed’.30,37,46
As seen in the results, the most vulnerable popula-
tion is represented by the heart transplant patients, also
placed in post surgical immune-suppressive therapy,19
and by individuals undergoing cardiac valve replace-
ment.16,20,22,26,27,30,35–39,45,46 These patients seem to
consistently present with poor dental conditions, and
in particular with periodontitis and apical periodontitis,
which have been associated with postoperative infec-
tions and unfavourable surgical outcome.26,27,29,36,37
Cotti et al.
Results that compare the risk to the benefit of oral
examination and the elimination of infections in
patients scheduled for other CV invasive procedures,
who are in better overall physical condition, are virtu-
ally absent in the literature. Accordingly, no evidence
on the need/usefulness of oral antimicrobial prophy-
laxis in the case of CV implantable electronic devices
is available.12 The information referred to above is suit-
able for heart surgery and cannot be extended to other
invasive CV procedures.
The information concerning the timing of dental
treatments and their benefits on CV morbidity and
mortality is still insufficient and is also almost entirely
limited to the field of transplantation and heart surgery.
In some dental and cardio-surgical teams, almost all
patients undergo appropriate dental care, whereas in
other settings, patients mostly rely on outside
care.18,25,42 A dominant idea is to perform oral proced-
ures sufficiently in advance to ensure adequate healing
before surgery.49,51–54 Ideally, critical patients with
dental infections should be treated during their hospi-
talisation, either bedside in an oral-maxillofacial unit,
or in a major operatory room when dental clearance
(extractions) is needed.22,25,31,36,37 Patients in non-
urgent conditions can be treated in dental departments
within hospitals or in outside dental practices.25 Some
authors claim that the most urgent procedures should
be performed during the same heart surgery session.31
The advantage of performing a dental screening and
treatment in terms of patient’s outcome and the risk-to-
benefit ratio are controversial. Whereas some authors
describe preoperative dental treatments as effective and
safe, others speculate that managing dental foci does
not reduce the risk of postoperative infectious compli-
cations and can even be dangerous because of the risk
of major adverse effects.14,21,28,32,34,42,46,50 This contro-
versy has led to the consideration that dental infection
should not be neglected prior to heart surgery, but that
the extent of dental treatment should be tailored to the
patient’s clinical status and performed by a dental/med-
ical team.18,33,46 Furthermore, no studies have com-
pared different dental treatment options or re-
evaluated them over time in relation to the effect they
produced on the surgical outcome.
One more consideration concerns intubation and
mechanical ventilation in surgically treated cardiac
patients. This condition may lead to pulmonary infec-
tions, risk which is sharply increased when the scarce
oral hygiene is associated with smoking habits. A rou-
tinely performed oral care should prevent ventilation-
associated pulmonary infections in this setting.55–56
In conclusion, it is quite evident that satisfactory
answers regarding which patients intended for invasive
CV procedures require dental clearance remain unavail-
able. Importantly, a great part of the clinical reports on
423
this topic was conducted in severely compromised
patients. This might be why some of the findings sug-
gest that the advantage of eliminating dental foci might
be irrelevant or, indeed, that there might be more risks
than benefits in carrying out dental treatments.
Although detailed recommendations of scientific
societies are still lacking,8–10 this review seems to sug-
gest that the extent of dental treatment before CV inter-
ventions must be proportionate to the patient’s clinical
status (i.e. patients suffering from severe heart failure
should not undergo a rigorous pre-operative dental
clearance).
A dedicated protocol has yet to become a standard
practice used by heart and dental teams, and, therefore,
its development and routine implementation should
strongly be considered in the future. With the accept-
ance by surgeons and interventional cardiologists of the
link between oral health and CVD, dentists might
finally become regular members involved in the pre-
surgical preparation phase.
Author contribution
ADL, EC, GM, MA and LP contributed to the conception
and design of the work; EC, MA, PB and SBS contributed to
the acquisition, analysis of data for the work. EC, GM, MA
and PB contributed to the interpretation of data for the work.
EC and MA drafted the manuscript; ADL, GM and LP crit-
ically revised the manuscript. All gave final approval and
agreed to be accountable for all aspects of work ensuring
integrity and accuracy.
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with
respect to the research, authorship, and/or publication of this
article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
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