Precautions and special considerations are necessary in patients with certain medical conditions. You may consult with your physician or speak to the oral surgeon for specific recommendations.
Patients with heart valve disease may require antibiotic prophylaxis prior to surgery to prevent bacterial endocarditis. High-risk patients requiring antibiotics include those with artificial heart valves, a history of prior infective endocarditis, certain congenital heart conditions, constructed shunts, any repaired congenital defects with prosthetic valves or devices, and cardiac transplant with valve problems. Antibiotics are no longer necessary for patients with mitral valve prolapse, rheumatic heart disease, bicuspid valve disease, calcified aortic stenosis, congenital heart conditions such as ventricular septal defect, atrial septal defect, and hypertrophic cardiomyopathy. The new guidelines were updated in 2007 by the American Heart Association.*
Patients with a history of heart attacks, chest pains, enlarged hearts, arrhythmia, and valve disease may require special precautions. First, it is important to have a proper physical exam by your doctor to make sure your condition is stable. You may continue all of your medications without change throughout your treatment. Patients who have had a heart attack (myocardial infarction) may have elective oral surgery after six months to minimize risks. However, with a good functional status, necessary oral surgical procedures may be done between six weeks and three months without undue added risk.
Local anesthesia with epinephrine is used with caution and limited dosage in patients with cardiovascular disease. Sedation is highly recommended to minimize stress on a patient’s heart while providing continued monitoring and supplemental oxygen. Your oral surgeon may consult with your doctor for other necessary precautions.
*Reference: 2007, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Fever, Endocarditis, and Kawasaki Disease Committee, Council on Association: A Guideline From the American Heart Association Rheumatic Prevention of Infective Endocarditis: Guidelines From the American Heart Association.
High Blood Pressure:
Hypertension must be controlled with proper blood pressure medications prior to your surgery. Do not alter your regimen; all medications should be taken normally throughout your treatment.
Patients on Blood Thinners:
If you are on Coumadin, it is best to stop it 72 hours before surgery, if approved by your physician. If it is not advisable to stop the Coumadin, your physician may change the dosage and perform a blood test to check your levels. Patients on aspirin or Plavix may continue the medication as routine, although bleeding might be slightly more prolonged. Patients with bleeding disorders should see their hematologist prior to any oral surgery.
If having IV sedation, bring your inhaler with you on the day of surgery. Two puffs are usually recommended right before surgery. Patients with severe asthma that has required hospitalization may require other therapy by their physicians before surgery.
Patients with uncontrolled diabetes have significant chances of infection and poor healing. Proper control is essential for overall health. Well controlled diabetic patients can have oral surgery safely with no more risk for infections than non-diabetic patients. If you are insulin-dependent and having IV sedation, take half of your normal dose on the morning of surgery as you cannot eat or drink anything before sedation. You will be given IV fluids with dextrose to help keep you sugar level up during surgery. Non-insulin dependent patients may continue other medications as normally as possible. Antibiotics are often prescribed after the surgery as prophylaxis.
Patients on Steroids:
Patients with adrenal insufficiency or long term steroid therapy for various medical conditions have decreased production of natural steroids, critical in many regulatory functions of the body. These patients are instructed to take steroid supplements by doubling their normal dose on the morning of surgery. It may also be administered intravenously during surgery.
Patients on Bisphosphonates:
Patients taking bisphosphonate drugs may have an increased risk of osteonecrosis of the jaw bone. Patients using the oral form (Fosamax, Actonel, and Boniva) for more than three years should discontinue medication for three months before surgery. Those on the IV form (Zometa, Aredia, Boniva-IV form) are advised to avoid surgery and seek non-surgical options if at all possible. If surgery must be performed, the risks and benefits should be discussed thoroughly with Dr. kazemi.
It is always best to defer any elective oral surgery until after delivery. Treatment in the first or last trimester is avoided, unless absolutely necessary. However, if oral surgery must be performed due to pain or infection, local anesthesia is the only method of choice. Medications considered safest are acetaminophen, penicillin, codeine, erythromycin, and cephalosporin. Aspirin and ibuprofen are not to be used because of possible bleeding.
Medications known to enter milk and potentially affect infants should be avoided. Acceptable drugs can be delivered according to age and size of the baby. The older the child, the less chance of a problem with the drug. Drugs that can be used sparingly include acetaminophen, antihistamines, codeine, erythromycin, fluoride, lidocaine, and clindamycin. Drugs that are potentially harmful to the infant include ampicillin, aspirin, barbiturates, diazepam, penicillin, and tetracyclines.
Patients with gag reflex may have difficulty tolerating upper wisdom teeth surgery. IV sedation is highly recommended to prevent any gag reflex and make the patient comfortable during surgery.