Can dental procedures be performed before back surgery?

Dental Procedures Before Back Surgery

Yes, dental procedures can and often should be performed before back surgery, particularly to address active infections or unstable dental conditions that could pose risks during or after the surgical procedure. 1, 2

Rationale for Pre-Surgical Dental Assessment

A careful preoperative dental evaluation is recommended before elective surgery to identify and treat dental problems that could complicate anesthesia or increase infection risk. 3, 1 This is particularly important because:

• Damaged teeth and dental appliances represent the most common complication of intubation during general anesthesia 1
• Dental-related complications account for approximately 17% of anesthesia-related malpractice claims 1
• Active dental infections could theoretically seed surgical sites, though evidence for this is limited 4

Timing Considerations

Ideally, required dental treatment should be completed before elective back surgery whenever possible. 3 However, the specific timing depends on several factors:

For Routine Dental Procedures

• Minor dental procedures (cleanings, fillings, restorations, endodontics) can typically be performed without significant delay to planned surgery 3
• These procedures are classified as minimal bleeding risk with approximately 0% risk of major bleeding 3

For Invasive Dental Procedures

• Dental extractions and other invasive procedures should ideally be completed with adequate healing time before surgery 3
• Patients should be evaluated systematically (every 6-8 weeks) after dentoalveolar surgery until full mucosal coverage has occurred before proceeding with elective surgery 3

Special Considerations for Anticoagulation

If you are on anticoagulation therapy (warfarin, DOACs) or antiplatelet medications, these typically should NOT be stopped for minor dental procedures. 3, 5

• For patients on vitamin K antagonists (VKAs) undergoing minor dental procedures, continuing the VKA with co-administration of tranexamic acid mouthwash is preferred over complete interruption 3, 5
• Partial interruption (2-3 days) is an acceptable alternative if needed 3
• The risk of dental bleeding is generally low (approximately 5%) and self-limiting with local measures 3

Antibiotic Prophylaxis Considerations

Routine antibiotic prophylaxis before dental procedures is NOT recommended for most patients undergoing orthopedic surgery. 3, 2

• Multiple studies have failed to demonstrate an association between dental procedures and prosthetic joint infections 3
• The incidence of prosthetic joint infection following dental procedures is extremely low (<0.5%) 3
• Antibiotic prophylaxis is only indicated for patients with specific cardiac conditions at high risk for infective endocarditis (prosthetic cardiac valves, previous endocarditis, certain congenital heart diseases, cardiac transplant with valvulopathy) 3, 2

Specific Situations Requiring Caution

Patients on Antiresorptive Therapy

Any history of bisphosphonates, denosumab, or antiangiogenic therapies must be communicated to the dentist before invasive dental procedures. 3, 2

• For patients at elevated risk for medication-related osteonecrosis of the jaw (MRONJ), pentoxifylline (400 mg twice daily) and tocopherol (1,000 IU once daily) should be prescribed for at least 1 week before and 4 weeks after invasive dental procedures 3
• Elective dentoalveolar surgery should generally be avoided during active therapy with bone-modifying agents at oncologic doses 3

Patients with Recent Cardiac Events

Elective dental care should be avoided for 6 weeks after myocardial infarction or bare-metal stent placement, or for 6 months after drug-eluting stent placement. 2

Patients with Head and Neck Radiation History

For patients with prior head and neck radiation therapy (≥50 Gy to jaw), alternatives to dental extraction should be offered when possible, and oral antibiotics should be given before and after invasive procedures. 3

Practical Algorithm

1. Identify urgent dental needs: Active infections, loose teeth/prostheses, unstable dental conditions 1
2. Assess bleeding risk: Review anticoagulation/antiplatelet therapy and coordinate management 3, 5
3. Complete necessary dental work: Prioritize treatments that eliminate infection sources and stabilize dentition 3, 1
4. Allow adequate healing: Ensure mucosal coverage after invasive procedures before proceeding with back surgery 3
5. Coordinate with surgical team: Communicate dental status and any ongoing issues to anesthesiologist and surgeon 1, 2

Common Pitfalls to Avoid

• Do not unnecessarily stop anticoagulation for minor dental procedures - this increases thromboembolic risk without meaningful bleeding reduction 3, 5
• Do not prescribe routine antibiotic prophylaxis for prosthetic joint infection prevention - evidence does not support this practice and contributes to antibiotic resistance 3, 2
• Do not delay urgent dental treatment in patients with active infections - the infection risk outweighs surgical delay concerns 2
• Do not perform elective invasive dental procedures in patients on high-dose bone-modifying agents without careful risk-benefit assessment 3