Systemic Disorders and the Mouth

Hematologic disorders

People who have disorders that interfere with coagulation (eg, hemophilia, acute leukemia, thrombocytopenia) require medical consultation before undergoing dental procedures that might cause bleeding (eg, extraction, mandibular block, tooth cleaning). Patients with hemophilia should have clotting factors given before, during, and after an extraction and restorative dentistry requiring local anesthesia (eg, fillings). Most hematologists prefer that patients with hemophilia, especially those who have developed factor inhibitors, receive infiltrative local anesthetics instead of blocks for restorative dentistry.

Restorative dentistry can be completed in a dental office after consultation with a hematologist; however, if the patient has inhibitor to factor VIII, the dentistry should be performed in a hospital under general anesthesia. Oral surgery should be performed in the hospital in consultation with a hematologist. All patients with bleeding disorders should maintain a lifelong routine of regular dental visits, which includes cleanings, fillings, topical fluoride, and preventive sealants, to avoid the need for extractions.

Cardiovascular disorders

Elective dental care should be avoided for 4 to 6 weeks after myocardial infarction or bare-metal stent placement, or for six months after drug-eluting stent placement. For patients with symptoms requiring earlier dental evaluation and management, consultation with a cardiologist should be followed.

Endocarditis prophylaxis is required before dental procedures in patients with:

• Prosthetic cardiac valves or prosthetic material used for cardiac valve repair

• Previous history of bacterial endocarditis

• Unrepaired cyanotic congenital heart disease, including palliative shunts and conduits

• Completely repaired congenital heart defect with prosthetic material or device (for 6 months after the procedure)

• Repaired congenital heart disease with residual defects at the site or adjacent to the site of a prosthetic patch or prosthetic device

• Cardiac transplantation recipients with a valvulopathy

Dental treatment should not be avoided in patients with risk factors for endocarditis. The heart is better protected against low-grade bacteremias, which occur in chronic dental conditions, when dental treatment is received (with prophylaxis) than when it is not received. Patients who are to undergo cardiac valve surgery or repair of congenital heart defects should have any necessary dental treatment completed before surgery.

Adrenergic medications such as epinephrine and levonordefrin are added to local anesthetics to increase the duration of anesthesia. In some cardiovascular patients, excess amounts of these medications cause arrhythmias, myocardial ischemia, or hypertension. Plain anesthetic can be used for procedures requiring < 45 minutes, but in longer procedures or where hemostasis is needed, up to 0.04 mg epinephrine (2 dental cartridges with 1:100,000 epinephrine) is considered safe. Generally, no healthy patient should receive > 0.2 mg epinephrine at any one appointment. Absolute contraindications to epinephrine (any dose) are uncontrolled hyperthyroidism; pheochromocytoma; blood pressure > 200 mm Hg systolic or > 115 mm Hg diastolic; uncontrolled arrhythmias despite medication therapy; and unstable angina, myocardial infarction, or stroke within 6 months.

Some electrical dental equipment, such as an electrosurgical cautery, a pulp tester, or an ultrasonic scaler, can interfere with early-generation pacemakers.

Cancer

Extracting a tooth adjacent to a carcinoma of the gingiva, palate, or antrum facilitates invasion of the alveolus (tooth socket) by the tumor. Therefore, a tooth should be extracted only during the course of definitive treatment. In patients with leukemia or agranulocytosis, infection may follow an extraction despite the use of antibiotics.

Immunosuppression

People with impaired immunity are prone to severe mucosal and periodontal infections by fungi, herpes and other viruses, and, less commonly, bacteria. The infections may cause hemorrhage, delayed healing, or sepsis. Dysplastic or neoplastic oral lesions may develop after a few years of immunosuppression. People with late-stage HIV may develop Kaposi sarcoma; non-Hodgkin lymphoma; hairy leukoplakia; candidiasis; aphthous ulcers; or a rapidly progressive form of periodontal disease, HIV-associated periodontitis.

Endocrine disorders

Dental treatment may be complicated by some endocrine disorders. For example, people with hyperthyroidism may develop tachycardia and excessive anxiety as well as thyroid storm if given epinephrine. Insulin requirements may be reduced on elimination of oral infection in diabetics; insulin dose may require reduction when food intake is limited because of pain after oral surgery. In people with diabetes, hyperglycemia with resultant polyuria may lead to dehydration, resulting in decreased salivary flow (xerostomia), which, along with elevated salivary glucose levels, contributes to caries.

Patients receiving glucocorticoids and those with adrenocortical insufficiency may require supplemental glucocorticoids during major dental procedures. Patients with Cushing syndrome or who are taking glucocorticoids may have alveolar bone loss, delayed wound healing, and increased capillary fragility.

Joint replacement surgery

Antibiotic prophylaxis is sometimes recommended for patients within a window of time (often 1 to 2 years) following major joint replacement surgery joint (hip, knee, shoulder, elbow). However, there is no robust evidence that antibiotics taken before dental procedures in such patients prevent prosthetic joint infections because the organisms causing these infections are almost invariably of dermal rather than oral origin. Guidelines from several organizations do not recommend routine antibiotics for dental patients with orthopedic implants for the prevention of orthopedic implant infection (1, 2).

Joint replacement surgery references

1. 1. Hannon CP, Grosso MJ, Fillingham YA, et al. AAOS Clinical Practice Guideline Summary Prevention of Total Hip and Knee Arthroplasty Periprosthetic Joint Infection in Patients Undergoing Dental Procedures. J Am Acad Orthop Surg. 2025;33(21):e1260-e1267. doi:10.5435/JAAOS-D-25-00458

2. 2. Rethman MP, Watters W 3rd, Abt E, et al. The American Academy of Orthopaedic Surgeons and the American Dental Association clinical practice guideline on the prevention of orthopaedic implant infection in patients undergoing dental procedures. J Bone Joint Surg Am. 2013;95(8):745-747. doi:10.2106/00004623-201304170-00011

Neurologic disorders

Patients with a seizure disorder who require dental appliances should have nonremovable appliances that cannot be swallowed or aspirated.

Patients unable to brush or floss effectively may use 0.12% chlorhexidine rinses in the morning and at bedtime. In many countries outside the United States chlorhexidine is available at 0.2%. However, this higher strength has not been shown to be more effective for gingival health and may cause increased tooth staining.

Obstructive sleep apnea

Patients with obstructive sleep apnea who are unable to tolerate treatment with a continuous positive airway pressure (CPAP) or bilevel PAP (BiPAP) mask are sometimes treated with an intraoral device that expands the oropharynx. This treatment is not as effective as CPAP, but more patients tolerate using it.

Medications

Certain medications such as glucocorticoids, immunosuppressants, and antineoplastics compromise healing and host defenses. When possible, dental procedures should not be performed while these medications are being given.

Many medications cause dry mouth (xerostomia), which is a significant health issue, especially in older adults. Causative medications often have anticholinergic effects and include certain antidepressants, antipsychotics, diuretics, antihypertensives, anxiolytics and sedatives, nonsteroidal anti-inflammatory drugs (NSAIDs), antihistamines, and opioid analgesics.

Some antineoplastics (eg, doxorubicin, 5-fluorouracil, bleomycin, dactinomycin, cytosine, arabinoside, methotrexate) cause stomatitis, which is worse in patients with preexisting periodontal disease. Before such medications are prescribed, oral prophylaxis should be completed, and patients should be instructed in proper toothbrushing and flossing.

Medications that interfere with clotting may need to be reduced or stopped before oral surgery. Patients taking aspirin or clopidogrel generally should not stop taking them before undergoing dental surgery because the risk of thrombosis outweighs the increased bleeding risk. NSAIDs may be stopped for high risk bleeding procedures. Most patients taking an oral anticoagulant who have a stable international normalized ratio (INR) < 4 do not need to stop the medication before outpatient dental surgery (including extraction) because the risk of significant bleeding is very small and the risk of thrombosis may be increased when oral anticoagulants are temporarily stopped. For patients receiving hemodialysis, dental procedures should be performed the day after dialysis, when heparinization has subsided.

Phenytoin, cyclosporine, and calcium channel blockers, particularly nifedipine, contribute to gingival hyperplasia. Gingival hyperplasia develops in approximately 50% of patients taking phenytoin and 25% of patients taking cyclosporine or a calcium channel blocker. However, hyperplasia is minimized with excellent oral hygiene and frequent cleanings by a dentist.

Bisphosphonates can result in medication-related osteonecrosis of the jaw (ONJ) after an extraction. ONJ occurs primarily when bisphosphonates are given parenterally to treat bone cancer and to a much lesser extent when they are taken orally to prevent osteoporosis (risk of ONJ < 0.1%) (1). Diligent oral hygiene practices and regular dental care may help lower the risk of ONJ, but there are no validated techniques to determine who is at risk of developing medication-related ONJ. Stopping bisphosphonate therapy may not lower the risk and may increase the rate of bone loss in patients being treated for osteoporosis.

Medications reference

1. 1. Anastasilakis AD, Pepe J, Napoli N, et al. Osteonecrosis of the Jaw and Antiresorptive Agents in Benign and Malignant Diseases: A Critical Review Organized by the ECTS. J Clin Endocrinol Metab. 2022;107(5):1441-1460. doi:10.1210/clinem/dgab888

Radiation therapy

Extraction of teeth from irradiated tissues (particularly if the total dose was > 65 Gy, especially to the mandible) may be followed by osteoradionecrosis of the jaw, and thus should be avoided. This is a catastrophic complication in which extraction sites break down, frequently sloughing bone and soft tissue. In order to help avoid this potential complication, patients should have any necessary dental treatment completed before undergoing radiation therapy of the head and neck region, with time allowed for healing. Teeth that may not survive should be extracted. Necessary sealants and topical fluoride should be applied. After radiation, extraction should be avoided, if possible, by using dental restorations. Sometimes root canal therapy is performed, and the tooth is reduced down to the gum line in order to prevent bone atrophy. If extraction is required after radiation, 10 to 20 treatments in a hyperbaric oxygen chamber may forestall or prevent osteoradionecrosis (1).

Head and neck radiation often damages salivary glands, causing permanent xerostomia, which promotes caries. Patients must therefore practice lifelong good oral hygiene. A fluoride gel and fluoride mouth rinse should be used daily. Rinsing with 0.12% chlorhexidine for 30 to 60 seconds, if tolerated, can be done in the morning and at bedtime. Viscous lidocaine may enable a patient with sensitive oral tissues to brush and floss the teeth and eat.

A dentist must be seen at 3-, 4-, or 6-month intervals, depending on findings at the last examination. Irradiated tissue under dentures is likely to break down, so dentures should be checked and adjusted whenever discomfort is noted. Early caries may also be reversed by calcium phosphopeptides and amorphous calcium phosphate, which can be applied by a dentist or prescribed to a patient for at-home use.

Patients who undergo radiation therapy may develop oral mucosal inflammation and diminished taste as well as trismus due to fibrosis of the masticatory muscles. Trismus may be minimized by such exercises as opening and closing the mouth widely 20 times 3 or 4 times/day.

Radiation therapy reference

1. 1. Vanderpuye V, Goldson A. Osteoradionecrosis of the mandible. J Natl Med Assoc. 2000;92(12):579-584.