What comprehensive dental management options should be considered for a patient, including preventive, restorative, endodontic, periodontal, prosthetic, and surgical treatments while accounting for medical comorbidities, medications, and patient preferences?

Comprehensive Dental Management Options

Dental management should prioritize preventive care and conservative, reversible treatments first, with a systematic approach that addresses medical comorbidities—particularly antiresorptive therapy, anticoagulation, and cardiovascular disease—before proceeding to invasive procedures. 1, 2

Initial Assessment and Risk Stratification

Medical History Screening

• Screen for antiresorptive or antiangiogenic therapy (bisphosphonates, denosumab, bevacizumab) as this fundamentally alters surgical planning and requires coordination with the oncologist before any invasive dental procedures 1
• Document anticoagulation status (warfarin, DOACs, antiplatelet agents) but do not discontinue these medications for routine dental procedures including extractions, cleanings, restorations, endodontics, or abscess drainage 2
• Identify recent cardiovascular events: defer elective dental care for 6 weeks after myocardial infarction or bare-metal stent placement, or 6 months after drug-eluting stent placement 2
• Assess diabetes control as uncontrolled hyperglycemia markedly worsens periodontal treatment outcomes and increases MRONJ risk 1, 3, 4
• Review medications for gingival hyperplasia (calcium channel blockers, cyclosporine) and coordinate with prescribing physician for possible substitution 3, 4

Dental and Periodontal Examination

• Complete dental examination with panoramic radiograph and intraoral films to identify caries, periapical pathology, periodontal disease, and bone quality 1
• Periodontal assessment including probing depths, furcation involvement, mobility, and inflammation to stage disease severity 3, 4
• Evaluate prosthetic fit for denture-related trauma that increases MRONJ risk 1

Preventive Care Protocol

Daily Oral Hygiene (All Patients)

• Brush with ultra-soft bristle toothbrush within 30 minutes after eating and before bed, ensuring gingival sulcus is included 1
• Use prescription-strength fluoride toothpaste and remineralizing products containing calcium and phosphate 1
• Floss daily with waxed floss to minimize gingival trauma 1
• Rinse three times daily with bland solution (1 teaspoon salt + 1 teaspoon baking soda in 4 cups water) to raise oral pH and prevent acidogenic bacteria 1
• Avoid alcohol-based mouthwashes and petroleum-based lip products 1
• Remove dentures for at least 8 hours per 24 hours and soak in rinsing solution 1

Professional Maintenance Schedule

• Six-month recall visits for all patients once on maintenance, with more frequent visits (every 3 months) for active periodontal disease 1, 3, 4
• Professional mechanical plaque removal (scaling and supragingival debridement) as cornerstone of gingivitis prevention 3
• Annual panoramic radiographs for patients on antiresorptive therapy to monitor for early MRONJ signs 1

Treatment by Condition

Periodontal Disease

Gingivitis:

• Scaling and supragingival debridement combined with patient education on proper brushing technique 3
• Adjunctive chlorhexidine mouthwash or natural alternatives (triphala, aloe vera, turmeric) for chemical plaque control 3

Periodontitis:

• Subgingival scaling and root planing as primary nonsurgical treatment for all severity levels 3, 4
• Twice-yearly maintenance visits with periodontal risk reassessment and additional debridement as needed 3, 4
• Systemic antibiotics (amoxicillin 500 mg + metronidazole 500 mg) only when disease exhibits aggressive features or fails mechanical therapy alone, providing additional 0.6 mm probing depth reduction 4
• Alternative host modulation with sub-antimicrobial doxycycline 20 mg twice daily for 3-9 months achieves 0.9 mm probing depth reduction 4
• Never prescribe antibiotics without concurrent mechanical debridement as they cannot eradicate biofilm in isolation 4
• Aggressive risk factor modification: smoking cessation, diabetes control, medication review for gingival hyperplasia 3, 4

Dental Caries and Pulpal Disease

Restorable Teeth:

• Root canal therapy is preferred when tooth has adequate crown structure, is periodontally sound, and this is the first endodontic intervention 5
• Surgical management (root canal or extraction) is first-line treatment for dental infections; antibiotics alone are ineffective and contribute to resistance 5
• Add antibiotics only for: systemic involvement (fever, malaise, lymphadenopathy), medically compromised patients, infections extending into facial spaces, or diffuse swelling that cannot be drained 5

Non-restorable Teeth:

• Extraction is indicated for extensive caries, severe crown destruction, structural compromise preventing restoration, severe periodontal disease, or failed previous endodontic treatment 1, 5

Temporomandibular Disorders (TMD)

First-Line Conservative Management:

• Reassurance, jaw rest, and avoiding irritating behaviors (excessive movement) 1
• NSAIDs and heat application for pain control 1
• Oral appliance for bruxism, jaw exercises, manual mobilization 1
• Psychological/cognitive behavioral therapy, meditation, relaxation strategies, sleep hygiene education 1
• Avoid routine irreversible alteration of temporomandibular joints, jaws, occlusion, or dentition 1

Second-Line Options (if first-line unsuccessful):

• Intra-articular injections, arthrocentesis, arthroscopic procedures 1
• Arthrotomy/arthroplasty, disc surgery, joint replacement only in selected patients with joint destruction or ankylosis 1

Special Considerations for Patients on Antiresorptive Therapy

Before Starting Therapy (Non-Urgent Setting)

• Complete all medically necessary dental procedures before initiating bisphosphonates or denosumab 1
• Ensure full mucosal healing of extraction sites before starting therapy 1
• Coordinate care plan between dentist and oncologist to time procedures appropriately 1

During Active Therapy

• Avoid elective dentoalveolar surgery (non-medically necessary extractions, alveoloplasties, implants) during oncologic-dose antiresorptive therapy 1
• Exceptions may be considered when oral function is impaired or disease cannot be controlled without surgery, after dental specialist reviews risks/benefits with patient and oncology team 1
• If surgery is performed: evaluate patient every 6-8 weeks until complete mucosal coverage occurs 1
• Insufficient evidence supports or refutes temporary discontinuation of antiresorptives before surgery; defer to treating physician discretion 1

MRONJ Diagnosis Requires All Three Criteria:

1. Current or previous antiresorptive/angiogenic inhibitor treatment
2. Exposed bone or bone probeable through fistula persisting >8 weeks
3. No history of jaw radiation or metastatic disease to jaws 1

MRONJ Management by Stage:

• At risk: No treatment needed, maintain excellent oral hygiene 1
• Stage 1: Conservative therapy, improve oral hygiene, topical antibiotic rinses 1
• Stage 2: As Stage 1 plus systemic antibiotics if infection suspected, consider surgical debridement 1
• Stage 3: As Stage 2 plus surgical debridement/resection, jaw reconstruction if necessary 1

Radiation Therapy Considerations

Pre-Radiation Dental Clearance

• Complete clearance protocol (≥2 weeks healing time): restore all teeth, extract teeth with probing depth ≥5 mm, furcation II-III, mobility II-III, extract symptomatic partially erupted third molars 1
• Partial clearance protocol (<2 weeks healing time): restore deep caries only, extract severely diseased teeth, extract symptomatic third molars 1
• Limited clearance protocol (non-curative intent): intervene only if symptomatic 1

During and After Radiation

• Avoid elective surgery in radiated fields due to osteoradionecrosis risk 1
• Apply clearance protocols only to teeth receiving therapeutic radiation dose 1

Prosthetic Considerations

Denture Management

• Ensure proper fit to avoid mucosal trauma, especially in patients on antiresorptive therapy 1
• Remove dentures at least 8 hours daily and maintain with proper cleaning 1
• Moisturize oral cavity with non-petroleum-based lubricants (plant or animal-based fats) 1

Implant Placement

• Contraindicated during oncologic-dose antiresorptive therapy unless oral function is severely impaired and specialist reviews risks 1
• Long-term prognosis comparable to root canal-treated teeth when placed in appropriate candidates 6

Cost and Access Considerations

• Preventive care reduces treatment expenditures particularly for restorative, prosthodontic, and periodontic services 7
• Communicate medical necessity of dental care to medical insurance carriers when dental insurance is absent, as oncology guidelines may support medical coverage 1
• Discuss less expensive alternatives when multiple treatment options have comparable benefits and harms 1

Critical Pitfalls to Avoid

• Never prescribe antibiotics without surgical source control for dental infections 5
• Never discontinue anticoagulation for routine dental procedures 2
• Never perform elective surgery on patients receiving oncologic-dose antiresorptives without specialist consultation 1
• Never delay periodontal treatment while awaiting additional tests when clinical diagnosis is clear 4
• Never use antibiotics as monotherapy for periodontitis; mechanical debridement is essential 4
• Never extract restorable teeth solely due to patient anxiety; address anxiety with sedation instead 5