Nov 01, 2021 Issue
 
 

Medical Clearance for Common Dental Procedures

 

KEVIN R. HERRICK, MD, PhD, Bay Area Community Health, San Jose, California; Loma Linda University School of Medicine, Loma Linda, California; Stanford University School of Medicine, Palo Alto, California; University of San Francisco School of Nursing and Health Professions, San Francisco, California

JENNIFER M. TERRIO, DDS, University of Colorado School of Dental Medicine, Aurora, Colorado

CRISPIN HERRICK, DDS, Denver Health, Denver, Colorado

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

Author disclosure: No relevant financial affiliations.

Article Sections

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.1–7 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

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

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

C

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

C

Consensus guidelines

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

C

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

C

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

C

Consensus of expert opinion, in the absence of clinical trials

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

B

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 https://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

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

C

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

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.

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