Dental surgeries in post-COVID patients

Dental Surgeries in Post-COVID Patients – Do you perform minor dental surgeries as part of your routine practice? Are you up-to-date on the tests that patients recovering from COVID-19 should undergo before a simple extraction?

It is recommended to postpone certain surgical procedures for specific periods after recovery. The severity of the patient's health condition during treatment and recovery from COVID-19 is taken into account.

Do you know how long you should wait? The literature still lacks clear guidelines for minor surgeries after recovery from COVID-19. Remember that infectious states can make patients prone to excessive inflammation and clotting.

Dental surgeries in post-COVID patients

History of the last 4 years.

This entire text is a transcription of an article that became famous in academic circles. A cavernous sinus thrombosis led to vision loss after a simple tooth extraction in a patient who recovered from Covid-19 Syndrome. The original article is from the Journal of Oral Maxillofacial Surgery, April 2022 80;709-713, 2022.

The original article can be found at the address of National Library of Medicine.

On January 7, 2020, the Chinese Center for Disease Control and Prevention first identified the virus now known as Coronavirus 2019 (COVID-19). In the city of Wuhan, using a sample collected from the back of the nose, researchers were able to detect the disease in a patient who had previously been diagnosed with atypical pneumonia. This disease causes severe flu-like symptoms, such as shortness of breath and acute damage to the heart and kidneys.

Changes in Coagulation Factors

The disease also induces a state of excessive blood clotting tendency. This results in damage to the inner linings of blood vessels, inhibits the dissolution of blood clots, and causes clot formation. Furthermore, low blood oxygenation promotes clotting within blood vessels. Moreover, this complex state of coagulation disorder can lead to clots in the veins, blockage of blood vessels in the lungs, generalized clotting within blood vessels, and clot formation in the veins of the brain, resulting in various aggravated neurological symptoms, especially in patients with clotting risks or diabetes mellitus.

Clinical Report

In an article published in the Journal of Oral Maxillofacial Surgery, the authors report a case of a patient with well-controlled diabetes who recently recovered from COVID-19 with the use of anticoagulants. However, he developed a blood clot in the veins of his brain and experienced worsening vascular and neurological symptoms. This led to vision loss in one eye after the extraction of a molar tooth.

A 69-year-old man with diabetes mellitus and hypertension was admitted to the hospital due to fever and low blood oxygen levels. During the physical examination, he showed signs of dehydration, blood pressure of 150/90 mm Hg, elevated random glucose levels (214 mg/dL), and HbA1c of 9%. His temperature was 37.9°C, he was breathing 18 times per minute, and his oxygen saturation was 88%.

The patient was conscious and had a normal neurological examination. Laboratory tests showed an elevated D-dimer level (2.6 mg/mL) and a low white blood cell count. A chest CT scan revealed subpleural opacities on both sides of the lungs. A polymerase chain reaction (PCR) test performed on a sample from the back of the nose confirmed COVID-19 infection. More details about the test results are in Table 1.

Hospital Procedures and Discharge

Treatment consisted of hospitalization, oxygen therapy, intravenous fluids, intravenous antibiotics, antiviral medications, corticosteroids, and anticoagulants. After 7 days, the patient showed significant improvement. Five days later, the PCR test came back negative. Doctors discharged him from the hospital with instructions to take an oral anticoagulant (Xarelto 10 mg, Rivaroxaban, Janssen, Egypt) daily.

Dental Intervention

Twelve days after being discharged from the hospital, the patient felt pain in his upper right second molar, which was broken. He sought treatment at a private dentist's office, who decided to extract the tooth without prescribing preventative antibiotics or checking his D-dimer levels. After the extraction, the patient began experiencing intense headaches and altered states of consciousness.

Back to the hospital

He was admitted to the intensive care unit (ICU) and underwent radiological and laboratory tests. A brain MRI with a contrast agent revealed the presence of clots in the transverse and sigmoid veins (Figure 1A). The MRI images also showed clots in the veins of the cavernous sinus and infections in the maxillary and sphenoid sinuses on the right side (Figures 1B, C).

After 9 days of treatment in the ICU, another MRI showed that the clots in the transverse and sigmoid veins were decreasing, and the patient was able to leave the ICU. However, he complained of swelling in his right cheek and difficulty moving his right eye in all directions. Subsequent clinical examination revealed an infection in the canine region of the mouth, with swelling inside and outside the mouth (Figures 2A, B).

Complications – Dental Surgery in Post-COVID Patients

The doctors referred the patient to the ophthalmology and otolaryngology departments for evaluation. The ophthalmologist observed that the patient had a pupil that did not respond adequately to light, a drooping eyelid, and difficulty moving the eye in all directions. The MRI revealed an obstruction in the central retinal artery, and the ophthalmologist confirmed the diagnosis of blood clots in the veins of the cavernous sinus.

Although rare, blindness resulting from cavernous sinus thrombosis is documented by researchers such as Walsh and Hoyt11, as well as by Ahmadi et al12.

In these cases, vision loss occurs due to the formation of corneal ulcers caused by improper eyelid closure or obstruction of the central retinal artery due to various reasons, such as:

compression in the orbital region, thrombus formation,

inflammation of the internal carotid artery,

toxic neuritis and ischemic optic neuropathy.

These factors align with the belief of the case report authors, who postulate that infection in the canine space, which is classically known, has the potential to spread to the brain. This is accompanied by an intense inflammatory reaction, combined with the patient's immunocompromised state, triggering vision loss.

Although the anesthesiology department's protocol suggests that elective surgeries should be postponed for 3 months after COVID-19 infection, this case was considered urgent and outside the usual protocol.

Case Discussion – Dental Surgeries in Post-COVID Patients

While COVID-19 spreads across the globe, the scientific literature still lacks clear guidelines for dentists and oral and maxillofacial surgeons who need to deal with recently recovered and infected patients. Meanwhile, ongoing research on the disease creates uncertainty about the medical modifications necessary to safely perform minor oral surgeries. However, when considering procedures such as tooth extraction, which is a minor surgical intervention, the American Society of Anesthesiologists and the Anesthesia Patient Safety Foundations released a joint statement on performing elective surgeries after recovery from COVID-19. In this document, they proposed different time intervals from diagnosis of the disease to surgery, depending on the severity of symptoms:

Recommendation for delaying dental surgeries in post-COVID patients.

- Asymptomatic, without respiratory symptoms – mild form	4 weeks
-symptomatic (e.g., cough) not requiring hospitalization	7 weeks.
– symptomatic diabetics, immunocompromised or hospitalized	10 weeks
– Severe or critical cases – ICU admission	12 weeks

These timeframes were established under the assumption that patients would have made a full recovery and would not be experiencing active COVID-19 symptoms at the time of surgery. It is important to note that these guidelines may vary according to the specific health recommendations of each region.

Within the context of the presented case, the extraction of the second upper molar in a patient who had recently recovered from COVID-19 was performed without adequately considering post-infection guidelines and the need for anticoagulants. This resulted in serious complications, including blood clots in the brain veins and vision loss. This underscores the importance of following appropriate medical guidelines when dealing with patients in similar circumstances.

Clinical Analysis Tests – Dental Surgeries in post-COVID patients

Finally, regardless of the severity of the patient's health condition during COVID-19, to perform any type of surgery in the first 3 months of recovery, it is recommended to carry out the following tests:

Therefore, the clinician should investigate the presence of normal D-dimer values as well as Partial Thromboplastin Time. The ESR gives us an insight into the patient's inflammatory status. Furthermore, in case of any alteration in the patient's coagulation regimen, the dentist should discuss it with the responsible physician.

In this regard, an international consensus advises against any elective surgical procedure within 3 months of recovery from COVID-19.

Similarly, this approach aligns with the approach of Zehani et al. in 201716, who emphasized the importance of providing preventive antibiotics before tooth extraction in uncontrolled diabetic patients to avoid serious infections. Likewise, this case highlights the association between the occurrence of cavernous sinus vein thrombosis and blindness, resulting from the failure to postpone tooth extraction to a safer time. It also exposes the negligence of safety precautions regarding the patient's immunological and thrombotic status.

Recommendations for Surgeons – Dental Surgeries in Post-COVID Patients

Expect an interval that may extend to 12 weeks if the patient required ICU admission. Maintain strict infection control, administer preventive antibiotics, and monitor patients' coagulation status in coordination with the attending physician. Note that the authors' recommendations are based on expert opinion but are awaiting the results of clinical trials to substantiate the protocols.

Learn about the client's medical history, including systemic problems, the time elapsed since the infection, and the level of difficulty the patient faced in recovering from COVID-19. Ask the client to undergo tests to identify possible alterations in coagulation factors, especially D-dimer, thromboplastin time, and blood glucose.

In addition, prescribe antibiotics and start medication before the procedure to protect the client from infection. Furthermore, the dentist should maintain good communication with the client's attending physician.

If necessary or if you are unsure, change the date of the procedure – allow more time – according to the recommended timelines.

We suggest that you also read our article on Diabetes Mellitus.

Author: Nivaldo Pinho Gonçalves, Periodontist, CROSC 9696.

Reference: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8848634/