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

This clinical content conforms to AAFP criteria for CME.

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

A medical consultation in preparation for a dental procedure should detail the patient's medical conditions, treatment plans, and current levels of management.7 A medical history, including allergies and use of herbal remedies and prescribed and over-the-counter medications, should be provided. It is essential to include any history of bisphosphonate use or cancer treatments.9 A relevant psychiatric history, including special needs, and the patient's resuscitation wishes or advance directive may be helpful.10

eFigure A is a sample consultation report form to assist physicians when evaluating patients before dental procedures (see template). Table 1 summarizes key concepts discussed in this article.1,5,9,1139

ConditionConcepts
Antibiotic prophylaxis
Infectious endocarditisThe American Heart Association recommends considering antibiotic prophylaxis only when dentogingival manipulations are planned for selected patients at highest risk of complications (Table 2).11
Prosthetic jointsPeriprocedural antibiotic prophylaxis does not affect the incidence of prosthetic knee or hip infections.12
Because dentists usually do not provide an antibiotic prescription, patients electing to use prophylaxis may need to obtain a prescription from their physician.13
Cardiovascular
Anticoagulation and antiplatelet therapiesFor patients undergoing dental procedures, evidence supports continuing antiplatelet and anticoagulation medications in therapeutic doses.1439
Dentists routinely manage bleeding in these patients using simple topical treatments, pressure packs, or sutures.19,20
Coronary artery diseasePatients can consider delaying elective dental procedures for six weeks after myocardial infarction or bare-metal stent placement or six months after drug-eluting stent placement.21,22
Patients are considered at low cardiac risk when undergoing dental procedures if they have no active cardiac conditions and can perform at least 4 metabolic equivalants.23
HypertensionMany dentists routinely measure blood pressure before dental procedures, but it is unclear whether a high preprocedural office-based measurement should postpone treatment.23
With a lack of evidence-based guidance, many dentists postpone elective dental procedures when the patient's blood pressure exceeds 160/100 mm Hg.23
Metabolic
Diabetes mellitusPatients with diabetes do not have an increased risk of infection from tooth extraction.24
Patients with diabetes have an increased risk of periodontal disease.1
Hepatic disease and cirrhosisThe need for perioperative platelet transfusion when platelet counts are below 50 × 103 per μL (50 × 109 per L) is being challenged.25,26
The preferred analgesic for patients with dental pain and compensated hepatic dysfunction is acetaminophen, and nonsteroidal anti-inflammatory drugs are usually avoided.27,28
Ascites is not an indication for initiating prophylactic antibiotics before dental treatment.28
It is reasonable to provide the dentist with a recent complete blood count, prothrombin time, and international normalized ratio.25,29
OsteoporosisA history of bisphosphonate use increases a patient's lifetime risk of osteonecrosis of the jaw and should be reported to the dentist.9,30
Patients should optimize their oral health before initiating bisphosphonates if possible.30
Perioperative bisphosphonate holidays have not been shown to be beneficial.31
Renal insufficiency and dialysisDaily oral care and semiannual dental checkups reduce mortality in patients receiving dialysis.5
Patients who have stage I to IV chronic renal failure or are undergoing peritoneal dialysis should avoid nephrotoxic medications, and renal dosage adjustments should be considered.32
For patients receiving extracorporeal dialysis, scheduling dental procedures between dialysis days can prevent patient fatigue and complications of heparin.33
Dentists should be provided with a recent glomerular filtration rate to determine the severity of renal disease and medication dosing adjustments.5,33
Other situations
CancerPatients should obtain dental treatments before chemotherapy or radiation when possible.34
Patients undergoing chemotherapy without radiation may receive routine dental care, but a complete blood count should be performed on the day of the planned treatment.34
Routine dental care should be postponed in patients receiving head and neck radiation therapy.34
A detailed history of head and neck radiation therapy, antiresorptive agents, or antiangiogenic agents should be communicated to the dentist.9,30,34
Pain and narcoticsMultimodal analgesia is superior to monomodal analgesia in the management of acute dental pain; combining acetaminophen with nonsteroidal anti-inflammatory drugs is highly effective.35,36
Initiating opioids may lead to addiction and should be considered only when other modalities fail.37,38
If used, opioid therapy should be limited to less than three to seven days, and precautions should be taken to help prevent long-term use or overdose.37,39

Antibiotic Prophylaxis

INFECTIOUS ENDOCARDITIS

For decades, the American Heart Association recommended prophylactic antibiotics for patients with cardiac conditions that might increase the risk of contracting infectious endocarditis during dental procedures. However, because studies have found that bacteremia occurs routinely with common activities such as chewing, brushing, and flossing and there is a lack of evidence that procedural prophylaxis is effective,40 the American Heart Association now recommends considering it only when dentogingival manipulations are planned for selected patients at highest risk of complications (Table 2).11

Prosthetic heart valves or heart valve repairs using prosthetic material
History of infectious endocarditis
Unrepaired cyanotic congenital heart disease or repaired congenital heart disease, with residual shunts or valvular regurgitation at the site of or adjacent to the prosthetic patch or device
Cardiac transplant with valve regurgitation due to a structurally abnormal valve

PROSTHETIC JOINTS

A high-quality prospective, case-control study found that antibiotic prophylaxis does not affect the incidence of prosthetic knee or hip infections.12 A 2013 joint guideline from the American Dental Association (ADA) and the American Academy of Orthopaedic Surgeons suggests that physicians consider discontinuing routine procedural antibiotic prophylaxis after discussing risks and benefits of antibiotic prophylaxis with patients.41 Since 2015, the ADA has recommended against routine prophylaxis for patients with prosthetic joints.13 Because dentists usually follow ADA guidelines, they often do not provide an antibiotic prescription; patients electing to use prophylaxis may need to obtain the prescription from their physician.13

Cardiovascular Conditions

ANTICOAGULATION AND ANTIPLATELET THERAPIES

For simple cleanings or single tooth extractions, evidence supports continuing antiplatelet and anticoagulation medications at a therapeutic international normalized ratio (INR) because the indications for these medications usually outweigh the risks of dental complications.14 Studies have demonstrated that patients taking a vitamin K antagonist at a therapeutic INR, direct oral anticoagulants, or daily aspirin are not at increased risk of uncontrollable bleeding after outpatient oral surgeries.1519 Another study of patients on nonaspirin antiplatelet therapy, alone or in combination with aspirin, demonstrated a negligible increased risk of bleeding after invasive dental treatments.20 Dentists routinely manage such perioperative bleeding using simple topical treatments, pressure packs, or sutures.19,20

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