What are the guidelines for managing immunosuppressive (IS) medications prior to dental procedures?

Management of Immunosuppressive Medications Prior to Dental Procedures

For routine dental procedures, immunosuppressive medications should generally be continued without interruption, as there is no evidence that stopping these medications reduces infection risk, and antibiotic prophylaxis is not routinely indicated for immunocompromised patients undergoing dental care. 1

General Principles for Immunosuppressive Medication Management

Continue Medications Through Dental Procedures

• Conventional immunosuppressants (azathioprine, mycophenolate mofetil, methotrexate, cyclosporine, tacrolimus) should be continued through routine dental procedures without interruption 1
• The British Society of Gastroenterology confirms that immunosuppressive agents can be continued in the perioperative period for patients with inflammatory bowel disease needing procedures 1
• Evidence from surgical literature shows that purine analogues (azathioprine, mercaptopurine) do not adversely affect postoperative outcomes, and since these medications take 3 months to reach therapeutic levels and another 3 months to wash out, stopping them immediately before procedures has no measurable impact 1

Biologic DMARDs Management

• Biologic disease-modifying antirheumatic drugs (bDMARDs) including TNF inhibitors should be continued for routine dental procedures 1, 2
• For major oral surgery requiring general anesthesia or extensive tissue manipulation, consider timing the procedure at the end of the dosing cycle when drug levels are lowest 1
• Restart biologic therapy once the wound shows evidence of healing (typically ~14 days), all sutures/staples are removed, and there is no evidence of infection 1

Corticosteroid Management

• Patients on chronic corticosteroids should continue their current daily dose through dental procedures without stress-dose supplementation 1
• For patients on prednisone >20 mg daily for >6 weeks, consider tapering to lower doses before elective extensive oral surgery if feasible, as high-dose steroids increase infection risk 1
• Patients on physiological replacement doses (equivalent to hydrocortisone 20 mg daily) should receive their usual dose without additional supplementation 1

Antibiotic Prophylaxis Considerations

When Prophylaxis is NOT Indicated

• Antibiotic prophylaxis is not recommended for immunocompromised patients undergoing routine dental procedures including cleanings, fillings, or simple extractions 1, 3, 4
• The evidence shows no clinically significant association between dental treatment and systemic infections in immunosuppressed patients 1, 4
• Prophylaxis for prosthetic joint infection prevention is explicitly not recommended, even in immunocompromised patients with joint replacements 1, 4

Exceptional Cases Requiring Prophylaxis

Consider antibiotic prophylaxis only for the following high-risk scenarios: 3, 5

• Severe neutropenia (absolute neutrophil count <500 cells/μL)
• Primary immune deficiency disorders with documented severe T-cell or B-cell dysfunction
• Very high-dose immunosuppression (e.g., induction therapy for organ transplant, high-dose chemotherapy)
• Invasive procedures (extractions, implant placement, periodontal surgery) in patients with the above conditions

When prophylaxis is indicated, use amoxicillin 2g orally 1 hour before the procedure, or clindamycin 600mg for penicillin-allergic patients 6

Procedure-Specific Recommendations

Routine Procedures (No Special Precautions)

The following procedures can be performed without stopping immunosuppressants or prescribing prophylactic antibiotics: 1, 6

• Routine dental cleanings and scaling
• Restorative dentistry (fillings, crowns)
• Root canal therapy through non-infected tissue
• Routine anesthetic injections through non-infected tissue
• Dental radiographs
• Orthodontic adjustments

Invasive Procedures (Enhanced Monitoring)

For extractions, implant placement, and periodontal surgery: 1, 2

• Continue immunosuppressive medications unless patient has severe neutropenia or primary immunodeficiency
• Ensure optimal oral hygiene before the procedure
• Use meticulous surgical technique with primary closure when possible
• Monitor closely for signs of infection postoperatively
• Prescribe antibiotics therapeutically (not prophylactically) only if infection develops

Common Pitfalls to Avoid

• Do not routinely prescribe prophylactic antibiotics for immunocompromised patients, as this contributes to antibiotic resistance without proven benefit 1, 3, 4
• Do not stop conventional immunosuppressants (azathioprine, methotrexate, mycophenolate) immediately before dental procedures, as the short interruption provides no benefit and may risk disease flare 1
• Do not confuse cardiac prophylaxis guidelines with immunosuppression management—these are separate indications with different evidence bases 1
• Do not prescribe stress-dose corticosteroids for dental procedures in patients on chronic steroids; continue their usual dose 1

Coordination with Prescribing Physician

• For patients on complex immunosuppressive regimens or with severe underlying disease, communicate with the prescribing rheumatologist, gastroenterologist, or transplant physician regarding the planned procedure 1, 2
• Document the patient's current immunosuppressive regimen, disease activity, and recent laboratory values (particularly white blood cell count) 3, 5
• Emphasize the importance of maintaining excellent oral hygiene, as poor oral health poses greater infection risk than dental procedures themselves 1, 4