What are the contraindications for tooth removal?

Contraindications for Tooth Extraction

Tooth extraction should be avoided in patients with certain medical conditions that significantly increase the risk of complications, including previous head and neck radiation therapy, severe uncontrolled cardiovascular disease, and active untreated osteoradionecrosis. 1

Absolute Contraindications

• Previous head and neck radiation therapy: Patients who have received radiation therapy to the head and neck area are at high risk for developing osteoradionecrosis (ORN) after tooth extraction 1
• Pregnancy (first trimester): Due to potential risks to fetal development
• Uncontrolled bleeding disorders: Patients with severe coagulopathies without appropriate medical management
• Uncompensated heart failure: Risk of acute cardiovascular events during the procedure 2
• Severe uncontrolled hypertension: Increased risk of bleeding and cardiovascular complications

Relative Contraindications (Requiring Special Precautions)

Cardiovascular Conditions

• Recent myocardial infarction: Postpone elective dental procedures for at least 6 weeks 3
• Recent coronary stent placement: Delay elective procedures for 6 weeks after bare-metal stent placement or 6 months after drug-eluting stent placement 3
• Anticoagulant therapy: Not an absolute contraindication, but requires special hemostatic measures
  • For patients on warfarin or acenocoumarol with INR ≤3.0, extraction can proceed with local hemostatic measures (collagen tablets, sutures) 4
  • Multiple extractions (>2 teeth) in anticoagulated patients significantly increase bleeding risk 4

Infective Endocarditis Risk

• Antibiotic prophylaxis is only recommended for highest-risk cardiac patients 1:
  • Prosthetic heart valves or prosthetic material used for valve repair
  • Previous history of infective endocarditis
  • Unrepaired cyanotic congenital heart disease
  • Repaired congenital heart disease with residual defects
  • First 6 months after complete repair with prosthetic material

Patients with History of Head and Neck Radiation

• High risk of osteoradionecrosis: Patients who have received radiation therapy to the head and neck area require special management 1
  • Consider pentoxifylline 400mg twice daily and tocopherol 1000 IU once daily for at least 1 week before and 1-3 months after extraction
  • Prophylactic antibiotics should be considered
  • Chlorhexidine rinses before and after procedure

Oral Conditions

• Acute severe infection: While not an absolute contraindication, extraction in the presence of severe infection requires antibiotic coverage and careful technique 5
• Malignant lesions: Extraction may spread malignant cells; biopsy should precede extraction

Other Medical Conditions

• Uncontrolled diabetes: Increased risk of infection and delayed healing
• Bisphosphonate therapy: Risk of medication-related osteonecrosis of the jaw (MRONJ), especially with IV bisphosphonates 3
• Active chemotherapy or immunosuppression: Increased risk of infection and delayed healing
• Severe liver disease: Altered drug metabolism and potential bleeding risk; acetaminophen is the analgesic of choice 3

Special Considerations for Mandibular Advancement Device Users

Patients using mandibular advancement devices for sleep apnea should be evaluated for:

• Severe periodontal disease
• Severe pre-existing temporomandibular disorders
• Lack of adequate dentition for device retention 1

Management Approach for High-Risk Patients

1. Obtain complete medical history: Focus on cardiovascular conditions, bleeding disorders, medication use, and history of radiation therapy 6

2. For patients on anticoagulants:

   • Do not routinely discontinue anticoagulant therapy 1, 3
   • Use local hemostatic measures (sutures, gelatin sponges, tranexamic acid rinses)
   • Consider limiting number of extractions per session for patients on anticoagulants 4

3. For patients with history of head and neck radiation:

   • Consider prophylactic pentoxifylline and tocopherol therapy 1
   • Use atraumatic extraction techniques
   • Ensure primary closure of extraction sites

4. For patients with cardiac conditions:

   • Follow current guidelines for antibiotic prophylaxis 1
   • Monitor vital signs before, during, and after procedure
   • Consider stress reduction protocols (premedication, nitrous oxide)

By carefully evaluating these contraindications and taking appropriate precautions, dental practitioners can minimize the risk of complications associated with tooth extraction in medically compromised patients.