Concomitant surgical treatment of dental and valvular heart diseases.

BACKGROUND: Invasive dental procedures are often indicated before cardiac valve surgery. The purpose of this case-control study was to determine the risks and benefits of concomitant dental and thoracic surgery. METHODS: Critically ill cardiac inpatients requiring cardiac valve surgery were referred by the Department of Thoracic and Cardiovascular Surgery to our Oral Medicine consult service. Those requiring dental extractions were considered for dental treatment during the same general anesthetic as the cardiac surgery. These study patients were compared with control patients who had extractions before valve surgery in a different setting. There was no attempt to analyze the impact of this practice on the development of infective endocarditis. All patients received broad-spectrum antibiotics during dental surgery. RESULTS: Twenty-one patients had concomitant oral and cardiac valve surgery. Seventeen patients were in the control group. There were no statistically significant differences between cases and controls in demographics, length of stay, nature of the dental surgery, mean number of teeth removed, oral bleeding, or postoperative infections. One patient in the control group developed prosthetic valve endocarditis versus none in the concomitant surgery group. CONCLUSIONS: This case-control study suggests that concomitant surgical procedures for dental and valvular heart disease can be accomplished without clinically significant oral complications. Given the risk from poor oral health following cardiac valve surgery, this approach should be considered for patients who would benefit by avoiding a second general anesthetic and/or a delay in cardiac surgery, and by having their oral surgery performed in the safest environment.

Odontogenic signs and symptoms as predictors of odontogenic infection: a clinical trial.

BACKGROUND: The authors conducted a study to determine if odontogenic signs and symptoms in the emergency department predicted the development of overt odontogenic infection at a follow-up dental visit. METHODS: One hundred ninety-five patients with odontalgia, but without overt signs of infection, were enrolled in a prospective, double-blind, randomized clinical trial. Data included dental diagnosis, pain characteristics, presence of caries and restorations, presence and size of periapical radiolucencies and other diagnostic test results. RESULTS: Thirteen of 134 subjects for whom data were available had signs of infection at the follow-up visit. Subjects in the follow-up infected (FU-I) group had larger baseline radiolucencies than did subjects in the follow-up noninfected (FU-NI) group, and restorations were more prevalent for involved teeth in the FU-I group than in the FU-NI group. CONCLUSIONS: A relationship exists between radiolucency size and the presence of amalgam restorations in patients who develop clinical signs of infection. Penicillin did not appear to influence this progression. CLINICAL IMPLICATIONS: Antibiotics are not effective in preventing the development of odontogenic infection when definitive dental therapy cannot be provided for acute pain in the absence of clinical signs of infection. Although the overall risk of developing infection is low, early treatment is indicated for teeth with larger periapical radiolucencies, amalgam restorations or both.

Efficacy of penicillin for dental pain without overt infection.

OBJECTIVES: Dental pain is a common presenting symptom in the acute care setting. Even in the absence of overt infection, many physicians routinely prescribe antibiotics such as penicillin. The authors sought to test the hypothesis that penicillin is not necessary or beneficial in the treatment of undifferentiated dental pain without overt infection. METHODS: This prospective, randomized, double-blind, placebo-controlled trial was conducted at an urban teaching hospital with approximately 105,000 emergency department visits per year. A convenience sample of adult emergency department patients presenting with dental pain and no clinically overt infection was randomized to receive penicillin or placebo. A structured evaluation was performed at enrollment and again at a 5- to 7-day follow-up visit. The main outcome measure was evidence of overt dental infection at the 5- to 7-day follow-up visit. RESULTS: A total of 195 patients were enrolled. Ninety-eight (50%) were randomized to treatment with penicillin. A total of 125 patients (64%) were followed up. Outcome data were identified for nine additional study patients, who returned to the dental clinic or emergency department outside of the scheduled follow-up period and were included in the final analysis. Overall, 13 of 134 patients (9%) developed signs of infection: six of 64 (9%) from the penicillin group and seven of 70 (10%) from the placebo group (p = 0.90). There was no significant difference between the penicillin and placebo groups in baseline characteristics, medication compliance, or visual analog scale pain scores at enrollment. CONCLUSIONS: These data support the hypothesis that penicillin is neither necessary nor beneficial in the treatment of undifferentiated dental pain in the absence of overt infection.