Medical Clearance for Common Dental Procedures


Am Fam Physician. 2021 Nov ;104(5):476-483.

Author disclosure: No relevant financial affiliations.

Medical consultations before dental procedures present opportunities to integrate cross-disciplinary preventive care and improve patient health. This article presents recommendations related to patients with certain medical conditions who are planning to undergo common dental procedures, such as cleanings, extractions, restorations, endodontic procedures, abscess drainage, and mucosal biopsies. Specifically, prophylactic antibiotics are not recommended for preventing prosthetic joint infections or infectious endocarditis except in certain circumstances. Anticoagulation and antiplatelet therapies typically should not be suspended for common dental treatments. Elective dental care should be avoided for six weeks after myocardial infarction or bare-metal stent placement or for six months after drug-eluting stent placement. It is important that any history of antiresorptive or antiangiogenic therapies be communicated to the dentist. Ascites is not an indication for initiating prophylactic antibiotics before dental treatment, and acetaminophen is the analgesic of choice for patients with liver dysfunction or cirrhosis who abstain from alcohol. Nephrotoxic medications should be avoided in patients with chronic kidney disease, and the consultation should include the patient's glomerular filtration rate. Although patients undergoing chemotherapy may receive routine dental care, it should be postponed when possible in those currently undergoing head and neck radiation therapy. A detailed history of head and neck radiation therapy should be provided to the dentist. Multimodal, nonnarcotic analgesia is recommended for managing acute dental pain.

Integrating patients' medical and dental health care is important because there are correlations between periodontal disease and some medical conditions, such as diabetes mellitus, coronary artery disease, hypertension, kidney disease, and rheumatoid arthritis.17 Medical consultations before dental procedures present opportunities to integrate cross-disciplinary preventive care and provide recommendations for treatment considerations before, during, and after a dental visit. Although dentists are ultimately responsible for the treatments they provide, they need the patient's complete medical information and often consult physicians when planning common dental procedures, such as cleanings, extractions, restorations (e.g., fillings, crowns, bridges, implants), endodontic procedures, abscess drainage, or mucosal biopsies.8

 Enlarge     Print


Clinical recommendationEvidence ratingComments

A medical consultation in preparation for a dental procedure should include the patient's medical conditions, treatment plans, and current levels of management; any resuscitation directives; and any history of therapy with bisphosphonates or other antiresorptive drugs, antiangiogenic drugs, or head and neck radiation.7,9,10,34


Consensus of expert opinion

A history of orthopedic joint replacement is not an automatic indication for prophylactic antibiotics, and physicians should consider discontinuing routine procedural antibiotic prophylaxis after discussing risks and benefits with patients.13,41


Consensus guidelines

For simple cleanings or single tooth extractions, it is reasonable to continue oral anticoagulation and antiplatelet therapies at therapeutic doses.14


Consensus of expert opinion

Consider postponing elective dental treatments for six weeks after myocardial infarction or bare-metal stent placement and for six months after drug-eluting stent placement.14,21


Consensus of expert opinion

Consider optimizing a patient's oral health before initiation of chemotherapy or head and neck radiation therapy to avoid adverse sequelae.34,44


Consensus of expert opinion, in the absence of clinical trials

Recommend multimodal analgesia for management of acute dental pain, if not contraindicated.35,36


Expert guidelines supported by clinical trials

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to

The Authors

show all author info

KEVIN R. HERRICK, MD, PhD, is director of education and research at Bay Area Community Health, San Jose, Calif.; an assistant clinical professor of family medicine at Loma Linda (Calif.) University School of Medicine; an adjunct clinical instructor at Stanford University School of Medicine, Palo Alto, Calif.; and an affiliate faculty member at the University of San Francisco (Calif.) School of Nursing and Health Professions....

JENNIFER M. TERRIO, DDS, is an orthodontic resident dentist at the University of Colorado School of Dental Medicine, Aurora.

CRISPIN HERRICK, DDS, is a general practice resident dentist at Denver (Colo.) Health.

Author disclosure: No relevant financial affiliations.

Address correspondence to Kevin R. Herrick, MD, PhD, 5504 Monterey Rd., San Jose, CA 95138. Reprints are not available from the authors.


show all references

1. Demmer RT, Holtfreter B, Desvarieux M, et al. The influence of type 1 and type 2 diabetes on periodontal disease progression: prospective results from the Study of Health in Pomerania (SHIP). Diabetes Care. 2012;35(10):2036–2042....

2. Gustafsson N, Ahlqvist J, Näslund U, et al. Associations among periodontitis, calcified carotid artery atheromas, and risk of myocardial infarction. J Dent Res. 2020;99(1):60–68.

3. Sanz M, Del Castillo AM, Jepsen S, et al. Periodontitis and cardiovascular diseases. Consensus report. Glob Heart. 2020;15(1):1.

4. Muñoz Aguilera E, Suvan J, Buti J, et al. Periodontitis is associated with hypertension: a systematic review and meta-analysis. Cardiovasc Res. 2020;116(1):28–39.

5. Palmer SC, Ruospo M, Wong G, et al.; ORAL-D Study Investigators. Dental health and mortality in people with end-stage kidney disease treated with hemodialysis: a multinational cohort study. Am J Kidney Dis. 2015;66(4):666–676.

6. Stephens MB, Wiedemer JP, Kushner GM. Dental problems in primary care. Am Fam Physician. 2018;98(11):654–660. Accessed March 17, 2021.

7. Glurich I, Schwei KM, Lindberg S, et al. Integrating medical-dental care for diabetic patients: qualitative assessment of provider perspectives. Health Promot Pract. 2018;19(4):531–541.

8. Gary CJ, Glick M. Medical clearance: an issue of professional autonomy, not a crutch. J Am Dent Assoc. 2012;143(11):1180–1181.

9. Ruggiero SL, Dodson TB, Fantasia J, et al. American Association of Oral and Maxillofacial Surgeons position paper on medication-related osteonecrosis of the jaw—2014 update [published corrections appear in J Oral Maxillofac Surg. 2015;73(7):1440, and J Oral Maxillofac Surg. 2015; 73(9):1879]. J Oral Maxillofac Surg. 2014;72(10):1938–1956.

10. Wang YC, Lin IH, Huang CH, et al. Dental anesthesia for patients with special needs. Acta Anaesthesiol Taiwan. 2012;50(3):122–125.

11. Nishimura RA, Otto CM, Bonow RO, et al. 2017 AHA/ACC focused update of the 2014 AHA/ACC guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation. 2017;135(25):e1159–e1195.

12. Berbari EF, Osmon DR, Carr A, et al. Dental procedures as risk factors for prosthetic hip or knee infection: a hospital-based prospective case-control study [published correction appears in Clin Infect Dis. 2010;50(6):944]. Clin Infect Dis. 2010;50(1):8–16.

13. Sollecito TP, Abt E, Lockhart PB, et al. The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints: evidence-based clinical practice guideline for dental practitioners—a report of the American Dental Association Council on Scientific Affairs. J Am Dent Assoc. 2015;146(1):11–16.e8.

14. Guyatt GH, Akl EA, Crowther M, et al. Executive summary: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians evidence-based clinical practice guidelines [published corrections appear in Chest. 2012;141(4):1129 and Chest. 2012;142(6):1698]. Chest. 2012;141(2 suppl):7S–47S.

15. Nematullah A, Alabousi A, Blanas N, et al. Dental surgery for patients on anticoagulant therapy with warfarin: a systematic review and meta-analysis. J Can Dent Assoc. 2009;75(1):41.

16. Al-Mubarak S, Al-Ali N, Abou-Rass M, et al. Evaluation of dental extractions, suturing and INR on postoperative bleeding of patients maintained on oral anticoagulant therapy. Br Dent J. 2007;203(7):E15.

17. Ahmed I, Younis M, Shah AA. Extraction in patients on oral anticoagulant therapy with and without stopping the drug: a comparative study. J Maxillofac Oral Surg. 2019;18(4):555–558.

18. Berton F, Costantinides F, Rizzo R, et al. Should we fear direct oral anticoagulants more than vitamin K antagonists in simple single tooth extraction? A prospective comparative study. Clin Oral Investig. 2019;23(8):3183–3192.

19. Madan GA, Madan SG, Madan G, et al. Minor oral surgery without stopping daily low-dose aspirin therapy: a study of 51 patients. J Oral Maxillofac Surg. 2005;63(9):1262–1265.

20. Napeñas JJ, Hong CHL, Brennan MT, et al. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. J Am Dent Assoc. 2009;140(6):690–695.

21. Roberts HW, Mitnitsky EF. Cardiac risk stratification for postmyocardial infarction dental patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(6):676–681.

22. Niwa H, Sato Y, Matsuura H. Safety of dental treatment in patients with previously diagnosed acute myocardial infarction or unstable angina pectoris. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2000;89(1):35–41.

23. Yarows SA, Vornovitsky O, Eber RM, et al. Canceling dental procedures due to elevated blood pressure: is it appropriate? J Am Dent Assoc. 2020;151(4):239–244.

24. Fernandes KS, Glick M, de Souza MS, et al. Association between immunologic parameters, glycemic control, and postextraction complications in patients with type 2 diabetes. J Am Dent Assoc. 2015;146(8):592–599.

25. Medina JB, Andrade NS, de Paula Eduardo F, et al. Bleeding during and after dental extractions in patients with liver cirrhosis. Int J Oral Maxillofac Surg. 2018;47(12):1543–1549.

26. Cocero N, Bezzi M, Martini S, et al. Oral surgical treatment of patients with chronic liver disease: assessments of bleeding and its relationship with thrombocytopenia and blood coagulation parameters. J Oral Maxillofac Surg. 2017;75(1):28–34.

27. Benson GD, Koff RS, Tolman KG. The therapeutic use of acetaminophen in patients with liver disease. Am J Ther. 2005;12(2):133–141.

28. Ge PS, Runyon BA. Treatment of patients with cirrhosis. N Engl J Med. 2016;375(8):767–777.

29. Radmand R, Schilsky M, Jakab S, et al. Pre-liver transplant protocols in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;115(4):426–430.

30. Vahtsevanos K, Kyrgidis A, Verrou E, et al. Longitudinal cohort study of risk factors in cancer patients of bisphosphonate-related osteonecrosis of the jaw. J Clin Oncol. 2009;27(32):5356–5362.

31. Glick A, Sista V, Johnson C. Oral manifestations of commonly prescribed drugs. Am Fam Physician. 2020;102(10):613–621. Accessed March 17, 2021.

32. Munar MY, Singh H. Drug dosing adjustments in patients with chronic kidney disease. Am Fam Physician. 2007;75(10):1487–1496. Accessed March 17, 2021.

33. Costantinides F, Castronovo G, Vettori E, et al. Dental care for patients with end-stage renal disease and undergoing hemodialysis. Int J Dent. 2018;2018:9610892.

34. Levi LE, Lalla RV. Dental treatment planning for the patient with oral cancer. Dent Clin North Am. 2018;62(1):121–130.

35. Ong CKS, Seymour RA, Lirk P, et al. Combining paracetamol (acetaminophen) with nonsteroidal antiinflammatory drugs: a qualitative systematic review of analgesic efficacy for acute postoperative pain. Anesth Analg. 2010;110(4):1170–1179.

36. Mehlisch DR. Double-blind, single-dose comparison of bromfenac sodium, tramadol, and placebo after oral surgery. J Clin Pharmacol. 1998;38(5):455–462.

37. Dowell D, Haegerich TM, Chou R. CDC guideline for prescribing opioids for chronic pain - United States, 2016 [published correction appears in MMWR Recomm Rep. 2016;65(11):295]. MMWR Recomm Rep. 2016;65(1):1–49.

38. Farooqi OA, Bruhn WE, Lecholop MK, et al. Opioid guidelines for common dental surgical procedures: a multidisciplinary panel consensus. Int J Oral Maxillofac Surg. 2020;49(3):397–402.

39. Alam A, Gomes T, Zheng H, et al. Long-term analgesic use after low-risk surgery: a retrospective cohort study. Arch Intern Med. 2012;172(5):425–430.

40. Tubiana S, Blotière PO, Hoen B, et al. Dental procedures, antibiotic prophylaxis, and endocarditis among people with prosthetic heart valves: nationwide population based cohort and a case crossover study. BMJ. 2017;358:j3776.

41. Watters W III, Rethman MP, Hanson NB, et al.; American Academy of Orthopaedic Surgeons; American Dental Association. Prevention of orthopaedic implant infection in patients undergoing dental procedures. J Am Acad Orthop Surg. 2013;21(3):180–189.

42. Shi Q, Xu J, Huo N, et al. Does a higher glycemic level lead to a higher rate of dental implant failure?: A meta-analysis. J Am Dent Assoc. 2016;147(11):875–881.

43. Vasanthan A, Dallal N. Periodontal treatment considerations for cell transplant and organ transplant patients. Periodontol 2000. 2007;44:82–102.

44. National Cancer Institute. Oral complications of chemotherapy and head/neck radiation. Updated December 16, 2016. Accessed May 30, 2020.

45. Nabil S, Samman N. Incidence and prevention of osteoradionecrosis after dental extraction in irradiated patients: a systematic review. Int J Oral Maxillofac Surg. 2011;40(3):229–243.

46. Cooper SA, Precheur H, Rauch D, et al. Evaluation of oxycodone and acetaminophen in treatment of postoperative dental pain. Oral Surg Oral Med Oral Pathol. 1980;50(6):496–501.



Copyright © 2021 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article