Dental Care May Not Increase Risk for Second Vascular Events

Laird Harrison

November 08, 2012

Patients may not need to delay dental procedures after vascular events such as heart attacks, researchers report in an article published in the November issue of the Journal of the American Dental Association.

Daniel Skaar, DDS, MBA, assistant professor, Developmental and Surgical Sciences, School of Dentistry, University of Minnesota, Minneapolis, and colleagues analyzed records of 50,329 Medicare patients and found that those who had a vascular event closely followed by a dental procedure were no more likely to have a second vascular procedure than those who delayed the dentistry.

Inflammation may contribute to strokes, heart attacks, and other vascular events. Dental procedures such as scaling and root planing, endodontics, and extractions may release bacteria from the mouth into the bloodstream, potentially increasing vascular inflammation and thereby increasing the risk of a vascular event, Dr. Skaar said.

The American College of Cardiology/American Heart Association guidelines on preoperative care give multivariate risk indexes for invasive surgical procedures. The guidelines do not specifically mention dental procedures, but most clinicians have assumed that dental procedures can be treated in the same way as other ambulatory procedures and considered them to carry a low risk for complications. ''In this area of vascular events, there really are no guidelines per se,'' Dr. Skaar said.

Still, many textbook authors have advised postponing nonemergent elective dental care in patients who have recently had vascular events. Some have recommended doing the procedures within a few weeks, and others have suggested waiting 6 months.

''I don't think [our study] will definitively answer the question, but hopefully it sheds light on it,'' Dr. Skaar told Medscape Medical News.

A previous study looking at Medicaid claims showed an increased risk for ischemic stroke or myocardial infarction in those patients who had had an invasive dental procedure in the previous 4 weeks, with the risk gradually subsiding to baseline over the course of 6 months. However, that study only looked at first-ever strokes or infarctions in patients who had dental procedures.

In contrast, the current study in Medicare patients looked at patients who had already had a first vascular event to see how many had second vascular events 30, 60, 90, or 180 days after a dental procedure.

The researchers used the Medicare Current Beneficiary Survey, an annual nationally representative survey of 12,000 Medicare participants conducted by a private survey company under contract with the US government. They analyzed records from 1998 to 2007, noting data on smoking, diabetes, hypertension, coronary artery disease, congestive heart failure, myocardial infarction, heart attack, hardening of the arteries, and angina pectoris.

They also tracked dental radiographs, cleanings, restorations, extractions, root canal therapy, bridges, and dentures, among other procedures. They classified cleanings, extractions, and endodontic procedures as invasive because they are associated with bacteremia or inflammation, but classified the other procedures as noninvasive.

Of the 50,329 participants, 2035 had vascular events and 445 of those (21.9%) had second vascular events. Of those patients who had a first vascular event, 283 had dental procedures, and of these participants, 24 (8.5%) had second vascular events.

Of 102 patients who had invasive dental procedures within 60 days of a first vascular event, 12 (11.8%) had second vascular events.

Overall, the researchers found no statistically significant association between undergoing a dental procedure and having a second vascular event in any of the intervals studied. (Hazard ratios were less than 1.0 for all the periods but did not reach statistical significance.)

The researchers also found that the hazard ratios did not change significantly with the intervals examined and did not change when the researchers adjusted for comorbidities such as smoking, diabetes, and hypertension.

Ann Bolger, MD, a spokesperson for the American Heart Association, told Medscape Medical News that the database used in the study does not give a clear enough picture of the medications used by the patients and of their outcomes to answer all the important questions about vascular events and dental procedures.

''What makes us feel better is that there is no overwhelming negative impact of having dental procedures after a vascular event,'' said Dr. Bolger, a professor of clinical medicine at the University of California, San Francisco.

With no definitive guidelines in place, Dr. Bolger said clinicians must use their judgment to weigh the risk for a given dental procedure against its benefits. Factors to consider include the seriousness of the patient's cardiovascular disease, the urgency of the dental procedure, and other health problems and medications.

Dentists should never ask or encourage a patient to suspend medications that he or she is taking for vascular conditions, nor should they prescribe nonsteroidal anti-inflammatory drugs without consulting with the patients' physicians, Dr. Bolger advised.

The study was supported in part by the Erwin Schaffer Chair in Periodontal Research and a grant from the National Center for Advancing Translational Sciences, National Institutes of Health, Bethesda, Maryland. The authors and Dr. Bolger have disclosed no relevant financial relationships.

JADA. 2012;143:1190-1198. Abstract