For best tooth health an electric toothbrush can be very helpful (although messy) and the best flossing aid is the Listerine Floss Holder (according to a FAPG dentist).
Wisdom Teeth Extraction
Wisdom teeth are so variable in size, root growth and position, it's impossible to generalize the best approach to extraction for a FA'er. Patients are also varied in their management needs.
Usually, somewhere from 16 to 23 years of age there is a sweet spot for removal, when bone is soft and roots are not fully formed and the extraction is easier on the patient. Taking them out later is always an option, but with fully formed roots and dense bone there will be more trauma and slower recovery. It's also nice to get them out when patients are not missing work (older with a real job) and when they are on the parents' insurance. Leaving wisdom teeth in can cause decay, infection and crisis of sudden pain and swelling in the future. There are a lot of retained wisdom teeth in people's heads of all ages that don't ever cause a problem. It can be a tough call to know when it's best to go through surgery to remove them. The risk of waiting is the FA'er may have a minor crisis of decay or gum infection that has to be dealt with immediately and then have the tooth out. Dentists argue about this all the time.
The best protocol is to have it done in a hospital (not at an outpatient/surgery center) under general anesthesia with an anesthesiologist present who has been educated about FA and with all of the usual warnings about fluids.
Sedation with an oral surgeon is the most common, just a local anesthetic can work, or with nitrous oxide and a local anesthetic. There is no problem with FA and gas. It is best to consult with your dentist and appropriate medical doctors to see what is best for each person. With a clinically asymptomatic FA heart, I would recommend the same care as a non FA patient. With a compromised heart, I would involve the cardiologist, oral surgeon, and anesthesiologist to decide surgical care.
Types of Sedation
Many of our local anesthetics have vasoconstrictors in them which can raise the heart rate and may make people with heart conditions uncomfortable. They can still be used on FA'ers, but only a little and they should be injected very slowly so any increased heart rate is slow to occur. Carbocaine (without the vasoconstrictor) can also be used, it will not raise the heart rate, but the numbness may not last as long.
Dentists usually have these different local anesthetics on hand and ready to use.
With general anesthesia the patient would die unless a breathing tube is used. With sedation (deep or light) patient breathes unassisted and reflexes are intact, so people will cough and protect their airway naturally. Patients will talk etc. but not remember. The anesthesiologist needs to be there to adjust the drugs to reach and stay at the desired level of sedation, everybody is different, and also to place a tube and breathe the patient if ever necessary.
IV sedation, so the drugs can be adjusted rapidly, hospital with an anesthesiologist so intubation could be done rapidly if necessary.
Planning on intubation upfront does totally protect the airway and could be considered safer, although seems more aggressive to us parents. I am far from an expert on sedation, I will sometimes prescribe oral valium or halcion for in office dentistry, but I would never sedate someone with heart disease and dysphagia in my office. I don't know specifics about IV sedation drugs except as I've learned from other FAPG posts that propofol should be avoided to protect the heart.
Getting Teresa's care through the special needs dental clinic and in the hospital is great. They may be open to using IV sedation without a breathing tube if you ask them. Although, intubation may be safer for Teresa. Both ways will probably work very well. This surgery will not take long and it sounds like your getting personal evaluation and planning, which is what we all want. Tell them your worried about the intubation and let them explain to you why it's better for Teresa.
If extraction is the choice, I would have an oral surgeon do it with light sedation, excellent local anesthetic (dead numb), in a hospital with an anesthesiologist there.
Cautions about Propofol, which should not be used on anyone with a heart condition:
Antibiotics
The need for antibiotics to cover an infected tooth would be the call of the dentist performing the surgery. In general a small localized infection is ok, and a larger infection would be covered with antibiotics, but each case is different.
The new American Heart Association guidelines say: Patients who have taken prophylactic antibiotics routinely in the past but no longer need them include people 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 are aimed at patients who would have the greatest danger of a bad outcome if they developed a heart infection.
Preventive antibiotics prior to a dental procedure are advised for patients with:
- artificial heart valves
- a history of infective endocarditis
- certain specific, serious congenital (present from birth) heart conditions, including
- unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits
- a completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure
- any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
- a cardiac transplant that develops a problem in a heart valve.
The new recommendations apply to many dental procedures, including teeth cleaning and extractions. Patients with congenital heart disease can have complicated circumstances. They should check with their cardiologist if there is any question at all as to the category that best fits their needs.
Questions to Ask
- Ask them if they're planning to place a breathing tube for general anesthesia or is this a sedation with the FA'er breathing on her own.
- Also, ask if they will run IV fluids and how much? See Emergencies: Hospital and ER.
- Is Propofol being considered?
Here are inputs by FA parents and IS NOT VETTED for safety or effectiveness.
Talk to your doctor before launching off too far into these things that have worked
individually for others.
- My FA son was supposed to have his wisdom teeth removed. The oral surgeon wanted him to be checked out by his doctor first. His doctor ordered an EKG and ECHO, which we thought was going a little overboard. Well, lo and behold Jeff was in A-Fib. Needless to say the extraction was put on hold until this was under control.
- Weigh the risks/benefits. Marissa was supposed to have wisdom teeth out someday... I don't know if we'll do it. Is it necessary to remove them? Our dentist is amazing and we've decided we were only going to do what is absolutely necessary with Marissa, as she has enough challenges.
- She's having it (wisdom teeth) done in an outpatient hospital setting and "twilight sleep" anesthesia rather than a general. We had the oral surgeon consult with Paige's cardiologist due to her mild HCM.
- My FA daughter had her wisdom teeth taken out 3 weeks ago. The oral surgeon had her do it in the hospital with an anesthesiologist. She did not have general anesthesia. The anesthesiologist was extremely careful and did research on FA. He did not use propofol. He used Versed and Dilaudid to keep her deeply sedated. She did very well. They watched her heart closely.
- My first FA'er had hers out IN the hospital, but not intubated - the second FA'er had hers out a year later without even in the hospital - the first FA'er is progressed farther, has some minor hypertrophy, but they were being cautious. They felt they would be fine with in office for the second FA'er who has nothing but a little wobbliness - all went well for both!!
- My younger FA son got an icepack holder from the surgeon that velcroed around his head. It had pockets on each side of his face for icepacks. This was perfect for him as he didn't need to hold the packs on his face. Because he was able to be diligent about icing himself, the swelling was able to be kept to a minimum.
- My FA'er had no issues at all, did quite well but did end up getting dehydrated about 5 days after due to lack of keeping herself hydrated and following her parents instruction - can you imagine?
- Sometimes during the extraction of tooth dentists are turning to sedation of children, to avoid the anxiety and "panic attacks". A substance widely used in children is Hydrosxycine, this drug is also used for the treatment of itches and irritations. A mother of a 12 years old FA girl told me that the doctor prescribed it to her daughter for itching, and that her balance worsened very quickly, and she needed several days after discontinuation of therapy to recover. It might be good to avoid this product, and have the doctor or dentist look for a safer alternative.
