Delay after heart surgery?

Dear Dianne, I have worked in the same practice for 15 years. During that time, many of our patients have undergone some type of heart surgery.

Dear Dianne,

I have worked in the same practice for 15 years. During that time, many of our patients have undergone some type of heart surgery, such as bypass surgery, placement of pacemakers, angioplasty, placement of stents, and placement of artificial valves. There seems to be no clear consensus on how long the patient should wait before undergoing dental treatment. I have searched the American Heart Association Web site but cannot find any answers.

Recently, a man came in for his prophylaxis. He indicated he was still recovering from heart bypass surgery performed just four weeks earlier. I was taught in school that we should wait six months after heart surgery to be safe. My doctor said there was no need to wait and instructed me to proceed. Since this went against what I had been taught, I was very uncomfortable treating this patient. To my knowledge, no untoward events happened after his dental appointment, but all the same, I felt like I was doing wrong.

Do you know how long we should wait after patients have heart procedures before treating them in the dental office?

Wondering in Wisconsin

Dear Wondering:

Your inquiry prompted me to research the American Heart Association Web site for information on this subject. Like you, I could not find anything related to safety and dental treatment performed after heart procedures. I even called and talked with a representative there. She stated that she did not know of any guidelines related to delaying dental treatment after heart procedures.

I also contacted several cardiology offices and asked what they recommended on delaying dental treatment. The answers I received were “no need for any delay” to “three to six months.” One office said only emergency dental care was recommended for a period of three months, which had been their standard protocol for many years. One cardiologist related to me that he had to have an emergency root canal one week after having heart bypass surgery. He felt that having the root canal was dangerous, but he had no choice.

Even though my question was about treatment delays, one doctor told me that he was still using the old premedication guidelines (which require a post-treatment dose of antibiotics) because after he changed to the new guidelines, he had four patients in one year develop endocarditis. (He seemed proud of the fact that he was “the only one in my group” that still uses the old guidelines!) I did not ask him how he came to the conclusion that his patients’ endocarditis came from some dental procedure, since patients can get bacteremias from a variety of actions, such as after each bowel movement, or simply flossing or brushing their teeth!

I contacted a physician who serves on the AHA committee that writes the premedication guidelines. He said there were no treatment delay guidelines, because no treatment delays were needed after heart procedures. He stated that if the patient feels well enough and sufficiently recovered, there is no need to delay treatment.

My former husband (now deceased) was a heart patient, so I checked with his cardiologist to find out what he recommends as a suitable time interval after heart surgery to have dental procedures. Dr. James McGukin of Carolina Cardiology Associates gave me this answer:

• Heart bypass surgery - three-month wait
• Pacemaker - three-month wait
• Stent - six-week to three-month wait
• Angioplasty or catheterization - no wait
• Artificial valves/pig valves or shunts - minimum three-month delay for dental treatment and lifelong antibiotic prophylaxis before dentistry

Also, Dr. McGukin recommended that if emergency dentistry must be performed on a patient who has received a heart bypass, pacemaker, or stent before the appropriate time interval has elapsed, that patient should be premedicated. After the time interval, no premedication is indicated for those procedures. Additionally, the amount of time needed for the patient to recover can vary significantly. For some patients, having open-heart surgery will require several months’ recuperation, during which time the patient will not feel like having dentistry done.

Obviously, there are varying opinions even among health-care professionals in the same profession.

Many years ago, I had a patient who was about 75 years of age. After I seated him, I updated his medical history. He stated there were no changes. This patient was on a four-month continuing care basis because of his periodontal condition. His tissue always bled and his home care was poor, even after repeated attempts to help him improve.

When I was almost finished with his visit, he said something about how his new “ticker” had really helped him. I said, “Excuse me, but did you say something about a new ‘ticker’?” He then proceeded to tell me that he had received a pacemaker four weeks earlier to help control the rhythm of his heart.

Suddenly, I was very uneasy! I had been taught somewhere along the way that there should be a period of time (I really could not remember how long) before any dental work could safely be performed after heart procedures. I asked him for the cardiologist’s name and excused myself to make a phone call. The nurse at the cardiology office checked with the doctor, and he said the patient should have been premedicated. We were then instructed to give the patient 2.0 grams of amoxicillin immediately. Although I had asked the patient about changes in his medical history, he simply forgot at that moment to tell me.

However, patients with pacemakers are not typically premedicated. The problem with this patient was that his physician felt the time interval from his pacemaker surgery to his dental visit was not long enough for him to be sufficiently healed and stable. That, and the fact that this patient bled easily on instrumentation, was justification for an antibiotic.

The ADA has a position paper posted on its Web site (ADA Statement on Antibiotic Prophylaxis) titled, “Prevention of Bacterial Endocarditis: Recommendations by the American Heart Association” (copyrighted 1998). Here is an excerpt from that position paper:

“In the case of prosthetic valve replacement, the risk of endocarditis increases postoperatively. In other conditions, such as closure of ventricular septal defect or patent ductus arteriosus without residual leak, the risk of endocarditis diminishes to the level of the general population after a six-month healing period. Data are insufficient to make recommendations for prophylactic therapy after closure of these lesions by transcatheter devices. There is no evidence that coronary artery bypass graft surgery introduces a risk for endocarditis. Therefore, antibiotic prophylaxis is not needed for individuals who have previously undergone this procedure. Noncoronary vascular grafts may merit antibiotic prophylaxis for the first six months after implantation.”

While this excerpt speaks of a six-month healing time and need for antibiotic prophylaxis, it does not recommend any particular waiting time for dental procedures to be performed. However, this may be why you remember something about waiting six months from your earlier educational experience.

Clear as mud, right? You can see that there are varying opinions on this topic. The safest protocol is to call the patient’s physician and find out if enough time has elapsed since the heart procedure was performed and if premedication is indicated. And don’t be surprised if you get different answers from different physicians!

Warm regards, Dianne

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