What is the purpose of a preoperative dental evaluation for patients undergoing surgery?

Preoperative Dental Evaluation

A preoperative dental evaluation serves to identify and eliminate active odontogenic infections, assess for loose teeth or prostheses that could be dislodged during intubation, and reduce the risk of postoperative infectious complications—particularly in patients undergoing head/neck radiation therapy, cardiac valve surgery, or orthopedic procedures with prosthetic implantation. 1, 2

Primary Purposes of Preoperative Dental Assessment

Prevention of Anesthesia-Related Dental Trauma

• Dental damage is the most common complication of intubation and represents the largest source of lawsuits against anesthesiologists (17% of all anesthesia-related claims). 3
• The anesthesiologist must examine for loose crowns, dentures, or teeth that could be dislodged during laryngoscopy and intubation, potentially causing airway obstruction or aspiration. 3
• Patients with identified loose dental appliances should have them stabilized or removed by their dentist before elective surgery. 3

Identification and Treatment of Active Odontogenic Infections

• Patients may harbor quiescent but potent odontogenic infections from untreated dental caries or periodontal disease that can compromise surgical outcomes and increase treatment costs. 2
• Active dental abscesses represent a source of bacteremia that can seed surgical sites, particularly in procedures involving prosthetic material implantation. 2, 4
• In case-control studies of prosthetic joint infections, dental abscess was identified as the presumed source in 2.9% of cases (6/224 patients). 4

Special Considerations for High-Risk Surgical Populations

Head and Neck Cancer Patients Receiving Radiation Therapy

• Dental evaluation is mandatory for patients with oral cavity cancers or those receiving significant intraoral radiation, as radiation causes xerostomia and dramatically increases risk of dental caries, dentoalveolar infection, and osteoradionecrosis. 1
• The preoperative dental assessment must include complete oral and head/neck examination with radiographs of all teeth, risk assessment for caries and periodontal disease, and evaluation for periapical pathology. 1
• Any necessary dental extractions must be completed at least 2 weeks before starting radiation therapy. 1
• Long-term tooth prognosis and patient motivation for oral hygiene compliance should guide extraction decisions. 1

Cardiac Valve Surgery Patients

• While one study found no significant reduction in early postoperative infections (sepsis/endocarditis rates of 5.4% with preoperative dental treatment vs 1.9% without), this does not negate the importance of identifying active infections that require treatment before elective surgery. 5
• The evaluation focuses on eliminating active dental infections rather than routine prophylactic dental work. 5

Orthopedic Surgery with Prosthetic Implantation

• Although evidence is heterogeneous, cohort studies suggest infectious complications may be less frequent when preoperative dental examination is performed. 4
• When dental treatment is indicated preoperatively, it most commonly involves scaling-polishing (38%), extractions (24%), and restorative work (18%). 4
• The goal is maintaining favorable oral hygiene to reduce infection risk factors, even without definitive evidence mandating universal dental screening. 4

Essential Components of the Dental Evaluation

Clinical Examination Elements

• Assessment of loose teeth, crowns, bridges, or removable prostheses that pose intubation risks. 3
• Identification of active dental caries, periodontal disease, and periapical pathology. 1, 2
• Evaluation of oral hygiene status and patient compliance capacity. 1

Radiographic Assessment

• Complete radiographic evaluation of all teeth to identify occult periapical pathology not visible on clinical examination. 1

Patient-Specific Risk Stratification

• Past dental history and treatment compliance. 1
• Presence of conditions increasing infection risk (immunosuppression, diabetes, planned prosthetic implantation). 2, 4
• Planned surgical procedure type and associated infection risk. 1, 4

Timing and Coordination

• For elective surgery, dental evaluation should occur during preadmission testing when the anesthesiologist reviews medical history and performs physical examination. 3
• For head/neck radiation therapy, dental extractions must be completed at least 2 weeks before radiation initiation. 1
• The patient's general dentist should be involved in preoperative management, as routine dental examinations occur more frequently than surgical procedures. 3

Common Pitfalls to Avoid

• Do not assume all patients require extensive prophylactic dental work before surgery—focus on identifying and treating active infections and securing loose dental appliances. 4, 5
• Do not delay urgent or emergent surgery for routine dental clearance when no active infection is present. 6
• Do not overlook the anesthesia-related trauma risk from loose teeth or prostheses, which represents the most common and litigious complication. 3
• For patients undergoing head/neck radiation, do not underestimate the long-term consequences of radiation-induced xerostomia and the need for aggressive preventive dental care. 1