Medically Complex

Protocols for the
DENTAL MANAGEMENT OF MEDICALLY COMPLEX PATIENTS
TOPIC PAGE
1. Bleeding Issues (including anticoagulants) 2
2. Cardiac Problems (heart murmurs, cardiac defects) 5
3. Cardiovascular Problems (high blood pressure, arrhythmias) 9
4. Central Nervous System Problems (seizures, stroke) 13
5. Diabetes 16
6. Immunosuppression 18
7. Infectious Diseases (tuberculosis, hepatitis, HIV, herpes, flu) 20
8. Kidney Problems 25
9. Liver Problems 26
10. Pregnancy 28
11. Prosthetic Joints 30
Protocols compiled by: Peter L. Jacobsen, Ph.D., D.D.S

Adjunct Professor, Department of Diagnostic Sciences
Director, Oral Medicine Clinic
[email protected]
Protocols maintained by: Alan Budenz, MS, DDS, MBA

Professor, Department of Biomedical Sciences and
Vice Chair, Department of Diagnostic Sciences
[email protected]
and
Anders Nattestad, DDS, Ph.D.
Professor, Department of Oral and Maxillofacial Surgery
[email protected]
University of the Pacific, Arthur A. Dugoni School of Dentistry
Please direct all comments, edits and suggestions to Alan Budenz [email protected] or write to:
Alan W. Budenz, DDS
Department of Diagnostic Sciences
University of the Pacific, Arthur A. Dugoni School of Dentistry
155 Fifth Street
San Francisco, CA 94103-2919
Updated August 2020
1
Bleeding Issues or Patients on Anticoagulants (1 of 11)

Questions to Ask / Necessary Information:
1. How long have you had a bleeding issue or, depending on the situation, how long
have you been on anticoagulant medication?
2. Describe your bleeding issue
3. Have you had problems with previous dental appointments?
4. What is the cause of your bleeding issue or why are you on anticoagulants?
5. Are your anticoagulants or bleeding issues due to low platelets?
6. What are your most recent laboratory results relative to your anticoagulation or
bleeding issue status?
Diagnostic Tests:
1. Bleeding issues secondary to liver disease:

a) INR - international normalized ratios
2. Aspirin and other non-steroidal anti-inflammatory agents.

a) Bleeding time.
3. Thrombocytopenia
a) CBC with a differential (which will give platelet count)
b) Bleeding time
4. Anticoagulant warfarin
a) INR
5. Anticoagulant Plavix and newer agents

a) There are NO reliable tests
Management During Dental Treatment:
1. No type of dental treatment should be rendered that has the potential for severe
bleeding (i.e. extractions, scale/root plane).
a) If INR greater than 3.5

b) If bleeding time greater than 10 minutes
c) If platelet count less than 60,000
2
Bleeding Issues or Patients on Anticoagulants – continued

2. If the bleeding parameters are greater than above, medical coordination is required.
For example, the physician may decrease the anticoagulant dose or provide packed
platelets or prescribe supplemental vitamin K until bleeding parameters are brought
into line consistent with dental treatment. It is preferred to maintain the patient’s
anticoagulation therapy without interruption, if at all possible.
3. With Plavix and newer anticoagulants, because there are NO reliable tests for
bleeding risk, we are working blind, so it is recommended to proceed very carefully,
taking the time to observe the patient’s ability to coagulate at each step of the
planned procedure and reducing the extent of the procedure if necessary. It is
preferred to maintain the patient’s anticoagulation therapy without interruption, if at
all possible.
4. Pradaxa (dabigatran), Xarelto (rivoraxaban), Eliquis (apixaban), and Savaysa

(edoxaban) are all members of a group of new oral anticoagulants that directly inhibit
thrombin (factor IIa), thereby blocking the generation of fibrin. After ingestion,
plasma concentrations of the drug peak within 2 hours. Nearly 85% of the drug is
eliminated in the urine and they have a half-life of 12 – 17 hours in patients with
normal renal function. Patients usually take these drugs twice a day to maintain
appropriate anticoagulant blood levels.
As with warfarin, these drugs do not need to be and should not be suspended for
dental procedures that have a potential for minimum or limited bleeding. Such
procedures should include conservative hemostatic measures such as removal of
granulation tissue and the use of hemostatic agents such as surgicel or gelfoam,
and suturing. Because the half-life of these drugs is so short, it is suggested that
consideration be given to performing the surgical procedure as late as possible after
the last dose of the drug.
Unless extensive bleeding is expected, there is no need to modify or suspend this

anticoagulant therapy. However, if there is a risk of extensive or extended bleeding,
then a consultation with the patient’s physician is appropriate and consideration
should be given to discontinuing the drug for 2 – 3 half-lives before the surgery (24 –
36 hours in patients with normal renal function). Depending on the reason for the
need for the anticoagulant, it may be recommended to provide substitution therapy
such as with low molecular weight mini-heparins, which should always be done in
close collaboration with the physician prescribing the drug.
5. If hemophilic, have physician administer proper replacement factors and run

necessary test to insure patient is within safe parameters.
6. During dental procedures minimize physical trauma and pack extraction sites that
have the potential to bleed with local pressures and other coagulation procedures,
i.e. Gelfoam. Obtain primary closure on any surgical sites, if possible.
3
Bleeding Issues or Patients on Anticoagulants – continued

7. Establish primary closure and/or put pressure on potential/actual bleeding site.
Be Alert For:
1) Easy or prolonged bleeding with minimal trauma (i.e. probing, wedge placed
between teeth for amalgam matrix)
2) Easy bruising / multiple bruises
Preventative / Precautions:
1. Assure the patient is aware of necessary lab tests that should be done close to
the time of dental treatment (within a week, or closer if they have had previous
problems). Some bleeding parameters can change quickly.
2. Avoid drugs that may cause drug interaction, such as erythromycin and
ketoconazol, which inhibit warfarin metabolism. Also avoid drugs that can
prolong bleeding, such as aspirin or other non-steroidal anti-inflammatories.
3. Encourage the patient to keep you informed of any drug changes and their use of
any over-the-counter medications and herbal supplements.
4. If the patient calls from home following treatment, instruct them to apply pressure
with gauze or cloth to the bleeding site for 10-30 minutes. If bleeding persists,
have the patient come into the office immediately or to a medical emergency
room.
https://medlineplus/bleedingdisorders (U.S. National Library of Medicine)

https://labtestsonline.org/conditions/bleeding-disorders (American Academy of Clinical Chemists)
https://www.wfh.org/en/resources-education/educational-materials (World Federation of
Hemophilia)
Centers for Disease Control and Prevention

Hereditary Blood Disorders Team Internet Address:
http://www.cdc.gov/ncbddd/blooddisorders/index.html
HANDI/National Hemophilia Foundation

Phone number: (800) 424-2634 Internet Address: http://www.hemophilia.org
Excellent site on anticoagulants: different types, brands, uses, side effects, and dental
precautions – http://medlineplus.gov/druginformation.html type “anticoagulants” into the
Search Box
Comprehensive site on bleeding problems to recommend to your patients:

http://www.chemocare.com/chemotherapy/side-effects/bleeding-problems.aspx
4
Cardiac Problems - heart murmurs, cardiac defects (2 of 11)

Questions to ask / Necessary Information:
1. When was your heart problem first diagnosed?
2. Have you ever been hospitalized because of your heart problem?
3. Did the doctor ever say you needed prophylactic antibiotics prior to dental
treatment?
4. Did the doctor ever say you didn’t need prophylactic antibiotics prior to dental
treatment?
Diagnostic Tests:
Medical consult to identify type of heart problem and whether prophylactic antibiotics
are needed, if patient unsure. Please note: the American Heart Association Guidelines
for the Prevention of Bacterial Endocarditis was revised in May of 2007. Most of the
patients who previously needed prophylactic antibiotics for dental procedures, including
those patients with diagnosed murmurs, now no longer need them.
PROPHYLACTIC ANTIBIOTIC COVERAGE FOR PREVENTION OF

BACTERIAL ENDOCARDITIS
Current American Heart Association Guidelines

Published May 8, 2007, Circulation, Vol 115.
Cardiac Conditions for Which Prophylaxis for Dental

Procedures is Recommended*
Prosthetic Cardiac Valve
Previous Infective Endocarditis
Congenital Heart Disease (CHD)
1. Unrepaired cyanotic CHD, including palliative shunts and conduits.

Completely repaired congenital heart defect with prosthetic material or device,
whether placed by surgery or by catheter intervention, during the first 6
months after the procedure (endothelialization occurs within 6 months of
procedure)
2. Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibits endothelialization)
5
Cardiac Problems - heart murmurs, cardiac defects – continued

3. Cardiac transplant recipients who develop cardiac valvulopathy
If the patient’s physician requests prophylaxis for the dental procedure, but the patient
does not meet the ADA/AHA criteria for needing it, then the physician should prescribe
the prophylaxis, the patient takes it under their direction, and they come to you for
dental procedures.
Except for the cardiac conditions listed above, antibiotic prophylaxis is no longer
recommended for any cardiac condition or problem.
1. If the patient needs prophylactic antibiotics, follow the American Heart

Association guidelines below:
Premedication requirements for patients with valvular heart disease or congenital

cardiac defects. If in doubt, have the patient consult their physician as to need.
Standard Regime
Rx Amoxicillin 500 mg.
Disp 4 tablets
Sig take 4 tablets (2.0 g) 30 – 60 minutes before procedure
Note 1) Children 50 mg/Kg. Do not exceed adult dose

2) No second dose is required for adults or children
Standard Regime for Patients Allergic To Amoxicillin/Penicillin
*Rx Clindamycin 150 mg.

Disp 4 tablets
Sig Take 4 tablets (600 mg) 30 – 60 minutes before procedure
Or
Rx Azithromycin 250 mg
Disp 2 tablets
Or
6
Rx Clarithromycin 250 mg
Disp 2 tablets
Or
*Rx Cephalexin 500 mg.
Disp 4 tablets
Sig Take 4 tablets (2 g) 30 – 60 minutes before procedure
Or
*Rx Cefadroxil 500 mg
Disp 4 tablets
Sig Take 4 tablets (2 g) 30 – 60 minutes before procedure
* Note: Cephalosporins should not be used in individuals with

immediate-type hypersensitivity reaction (urticaria,
angioedema, or anaphylaxis) to penicillins.
Note: Children’s dosage. (Do not exceed adult dose)
Clindamycin 20 mg/kg
Ceplalexin 50 mg/kg
Cepadroxil 50 mg/kg
Azithromycin 15 mg/kg
Clarithromycin 15 mg/kg
Patients Unable To Take Oral Medication
Ampicillin 2 g IV or IM within 30 minutes before procedure.

Children: 50 mg/kg IV or IM within 30 minutes before procedure.
7
For Patients Unable to Take Oral Medication and Allergic to Ampicillin,

Amoxicillin, Penicillin
Clindamycin 600 mg IV within 30 minutes before procedure.

Children: 20 mg/kg IV within 30 minutes before
procedure.
*Cefazolin 1 g IV or IM within 30 minutes before procedure

Children: 25 mg/kg IV or IM within 30 minutes
before operation.
*Note: Cephalosporins should not be used in individuals with

immediate-type hypersensitivity reaction (urticaria,
angioedema, or anaphylaxis) to penicillins.
2. If patient states they’re unsure whether prophylactic antibiotics are needed and
contact with their physician is not possible, then treat with standard guidelines if
an emergency, or refer patient for medical consult to establish need or lack of
need for antibiotic prophylaxis.
2. Document in the chart the time and dosage of antibiotics taken for prophylaxis.
Be Alert For:
Flu-like symptoms within two days, most commonly within two weeks, rarely within four
weeks following dental procedures. Such symptoms can be signs of bacterial
endocarditis, even if the patient has been properly prophylaxed. If they have such
symptoms they should see their physician.
1. Good oral hygiene.
2. Proper teeth cleaning and clorhexidine rinse prior to extractions to decrease

magnitude of possible bacteremias.
3. Gingivitis, and, especially, periodontitis, increases the frequency, intensity, and

duration of bacteremias.
Stress to the patient that they should take their prophylactic antibiotic medication within
the proper timeframe.
8
Cardiovascular Problems – high blood pressure, arrhythmias (3 of 11)

(High blood pressure, arrhythmia, congestive heart disease (angina pectoris)
A. High blood pressure
1. How high does your blood pressure get?
2. Do you know what your blood pressure usually is?
3. What is your blood pressure when you are taking medications?
4. Have you had any problems / side effects with your blood pressure medication?
5. Have there been any recent changes in your medications?
6. Have you ever had hypertensive episodes when the high blood pressure could not
be controlled?
7. Have you ever had to postpone dental treatment or had any problems with dental
care, relative to your blood pressure?
8. Did you take your medication today?
B. Arrhythmia
1. What kind of arrhythmia do you have?
2. What triggers the arrhythmia episodes?
3. Do you take your medication for your arrhythmia? If so, what medication, and did
you take it today?
4. Is the arrhythmia effectively controlled with medication?
C. Congestive heart disease
1. Do you get chest pains on exertion?
2. Can you walk up a flight of stairs without needing to rest to catch your breath or
getting chest pains?
3. Do you take medications for your congestive hear failure? If so, did you take them
today?
9
Cardiovascular Problems – high blood pressure, arrhythmias -

continued
Diagnostic Tests:
A. High blood pressure:
1. Take blood pressure.
2. Depending on situation, take blood pressure at beginning and end of appointment.
B. Arrhythmia:
1. Take patient’s peripheral (radial, carotid) pulse and feel for arrhythmia
C. Congestive heart disease:
1. Stress test by physician
A. High blood pressure.
1. Blood pressure is recommended to be measured for all new patients to obtain a

baseline reading.
2. Patients with Normal (<120 mm Hg systolic and <80 mm Hg diastolic) and Elevated
(120 – 129 mm Hg systolic and ≤80 mm Hg diastolic) blood pressures are good
candidates for all dental procedures and can normally receive local anesthesia with
epinephrine 1:100,000. Blood pressure should be reassessed at all recall
appointments, and for patients with Elevated BP it is recommended to be rechecked
prior to administering any local anesthesia injections/invasive treatments.
3. Patients with Stage 1 Hypertension (130 – 139 mm Hg systolic or 80 – 89 mm Hg

diastolic), require an overall assessment depending on the complexity of the planned
dental procedure and patient’s level of anxiety. Blood pressure should be measured
at every appointment.
4. Patients with Stage 2 Hypertension (≥140 mm Hg systolic or ≥90 mm Hg diastolic)

require an overall assessment depending on the complexity of the planned dental
procedure and patient’s level of anxiety. A medical consultation is highly
recommended. NO elective treatment should be rendered until blood pressure is
medically confirmed as under control. Some type of sedation such as
benzodiazepine (valium) or nitrous oxide may be appropriate before rendering any
emergency dental care. Blood pressure must be measured at every appointment.
10
Cardiovascular Problems – high blood pressure, arrhythmias -

continued
5. Patients with blood pressure greater than 180 mm Hg systolic or 110 mm Hg

diastolic are NOT to receive any routine dental treatment at our dental school and
should be referred for consultation with their physician.
6. Blood pressure greater than 180 mm Hg systolic and/or 120 mm Hg diastolic is

classified as Hypertensive Urgency, or Crisis. These patients should be referred
to a physician for IMMEDIATE evaluation and medical treatment. No dental
treatment should be rendered until blood pressure is medically confirmed as under
control.
7. Blood pressure greater than 180 mm Hg systolic with target organ damage and/or
greater than 120 mm Hg diastolic with target organ damage is a Hypertensive
Emergency. 911 Emergency Protocols should be implemented immediately.
8. In patients with controlled high blood pressure, using local anesthetic with a
vasoconstrictor such as 1:100,000 epinephrine or its equivalent is appropriate. The
ADA suggests a maximum of 40 μg (≈2 cartridges of 1:100,000 epi) then wait for at
least 10 minutes. If no problems arise, additional cartridges can be administered.
For patients with blood pressure above 140/90, epinephrine impregnated retraction
cord should be avoided.
B. Arrhythmia or congestive heart failure:
1. If patient’s arrhythmia or congestive heart failure is controlled, no special precautions

necessary.
2. If patient has an arrhythmic or congestive heart failure (angina pectoris) episode,

dental treatment should be delayed. If arrhythmia occurs in the midst of treatment
and treatment must be completed, discontinue until heart rhythm stabilized (may
require hospitalization for cardioversion), then complete treatment quickly and
calmly.
3. If angina pectoris occurs, stop treatment, administer oxygen, minimize stress and
wait until the pain resolves. Continue as needed, if necessary, and patient feels
capable of completing to a safe stopping point
4. Local anesthetic with vasoconstrictor (1:100,000 epinephrine or equivalent) is

appropriate. 1:50,000 concentration of epinephrine or equivalent should be avoided.
Epinephrine impregnated retraction cord should not be used.
11
Cardiovascular Problems – high blood pressure, arrhythmias –

continued
Be Alert For:
A. High blood pressure:
1. Request patient inform you if they feel as though their blood pressure is increasing
or if they are getting a headache. Some patients feel jittery, others feel as though
there is increased pressure behind the eyes.
2. Profuse bleeding, beyond what would be expected.
B. Arrhythmia:
1. Patient to inform you if they feel an arrhythmia. Sometimes this manifest as a

coughing or catching feeling in the chest. Other times it is a feeling of light
headedness.
Be reassuring with the patient. Under no circumstances should you panic as that will
only increase the patient’s anxiety which will cause the blood pressure to increase or
the arrhythmia to intensify or be prolonged. An alert, concerned, everything is in control,
we know what is happening and everything will be fine, professional demure is
appropriate.
12
Central Nervous System – seizures, stroke (4 of 11)

A. Stroke:
1. When did you have your stroke?
2. What loss of function occurred?
3. Have you recovered some function over time?
4. Have you ever had trouble with dental appointments or medical appointments?
5. Is there anything I need to know that will make you more comfortable or make it
easier for you to deal with the dental appointment?
6. Are you taking any medication related to the stroke or to prevent another stroke? If
so, what medication?
B. Seizures:
1. What type of seizure do you have?
2. What stimulates a seizure and do you have an aura prior to the seizure?
3. What is the cause of your seizures? (i.e. head injury, born with problem)
4. How frequently and when (time of day) do they usually occur?
5. What type of medications are you taking to control the seizures?
6. Does the medication work?
7. Do you take the medication regularly or do you discontinued it at times? If you did
discontinue, was it your decision or your doctor’s and what happened?
Diagnostic Tests:
A. Stroke:
1. If patient taking anticoagulant, then assess bleeding status (see Bleeding

Problems management protocol)
13
Central Nervous System – seizures, stroke - continued

B. Seizure:
1. If patient unclear about types of seizure or medications, and seizures are poorly
controlled, then medical consultation for the above information will be needed.
A. Stroke:
1. No special treatment considerations are necessary except those that the patient
notes could be of value (modifying dental treatment procedures based on the
patient’s perceived needs has an enormous positive psychological benefit for the
patient).
2. Depending on what areas have lost function, especially if the head and neck or oral
cavity area are affected, certain types of dental prostheses may or may not be
effective, i.e. removable prostheses may not be effectively retained without adequate
muscle tone, so fixed prostheses or implant may be needed.
B. Seizures:
1. Schedule patient early morning when they are well rested.
2. Patient should be instructed to take their medication properly for at least the several
days prior to the dental appointment.
3. Patient should be questioned at dental appointment whether in fact they have taken
the medication correctly.
4. If seizure occurs, it should be allowed to run its course. The primary concern will be
protection of the patient so they don’t hurt themselves and the protection of the
dentist and staff so the patient doesn’t hurt them.
5. Following a seizure, the decision to continue or discontinue treatment is based on

the patient’s condition (does the patient feel like he/she can complete the
procedure?) and the treatment needed.
Be Alert For:
A. Stroke:
1. Signs of recurrence of stroke, such as slurred speech, confusion, loss of balance

and inability to hold saliva in mouth, and transient ischemic attachs (TIA) manifest as
fainting and dizziness, with spontaneous recovery.
14
Central Nervous System – seizures, stroke - continued

2. Alert patient’s guardian to any new stroke signs or symptoms so physician can follow
up.
3. If patient taking anticoagulants, review Bleeding Problems protocol for additional

alerts.
4. If stroke has effected swallowing, suction frequently.
5. If stroke has effected eyelids, protect/cover eyes as needed.
B. Seizures:
1. Be alert to dental / oral damage secondary to seizure.
2. Be aware of possible gingival hyperplasia secondary to Dilantin.
Strokes and seizures:
1. Minimize stress, avoid procedures that may cause spiking of blood pressure,
consider pre-procedural anti-anxiety medication such as Valium, if patient is fearful.
Seizures:
2. Good oral hygiene. The better the oral hygiene, the less likely or less severe gingival
hyperplasia secondary to Dilantin.
15
Diabetes (5 of 11)
Questions to Ask / Necessary Information
1. Age first diagnosed?
2. Type of diabetes?
3. Medication being taken?
4. If Insulin is being taken, what is time interval and amount?
5. How often do you check your blood sugar?
6. Have you been hospitalized during the past year for problems related to your
diabetes?
7. Is your diabetes well controlled or does it get out of control at times?
Diagnostic Tests:
*1. Fasting blood sugar (reflects current control, that day). (> 126 mg/dL)
*2. Random plasma glucose > 200 mg/dL with symptoms (polyurina, polydipsia,
unexplained weight loss)
*3. 2 hour plasma glucose > 200 mg/dL following a 75g glucose load
4. Fructosamine test (reflects average control over last 2-3 weeks).
5. Glycated hemoglobin (HbA1c) (reflects average control over last 6-8 weeks).
(>7% = problem)
* Official diagnostic tests for diabetes
1. Patient should have eaten a balanced meal (includes fat and protein as well as
carbohydrates) within the last two hours before coming to the dental appointment.
2. Patient should have taken their medications (if they take medications).
3. Food (Power Bar or some other balanced nutritional supplement) should be

available if appointment lasts longer than two hours.
4. Early morning appointments.
16
Diabetes – continued
Be alert for:
1. Periodontal problems.
2. Candidiasis / xerostomia.
3. Poor response to treatment, especially periodontal therapy.
4. Poor healing.
5. Slow healing.
6. Any dental infection should be treated promptly i.e. with antibiotics and appropriate
incision and drainage.
1. Good home care.
2. Good glucose control.
3. Take medications predictably.
17
Immunosuppression (6 of 11)
Diseases: HIV, leukemia, primary immunosuppressive diseases
Medications: Cancer chemotherapeutic agents, immunosuppression drugs used in

organ transplant patients, corticosteroids to suppress severe auto-immune
diseases.
Questions To Ask / Necessary Information (Questions should be designed to evaluate

the severity of the immunosuppression and the reason for it. Questions will vary
depending on the reason the patient says they are immunosuppressed):
1. Why are you immunosuppressed?
2. How long have you been immunosuppressed?
3. Have you been hospitalized because of problems resulting from your

immunosuppression, i.e. infections?
4. Are you taking any prophylactic medication to prevent infections because of your
immunosuppression?
5. Has your doctor said that any special precautions should be taken during medical or
dental treatment to prevent (prophylax against) possible infections?
Diagnostic Tests:
1. CBC with a differential (especially platelet count, if planning surgery).
2. T-suppressor cell count (HIV patients).
3. Viral load (HIV patients).
1. Depending on severity of immunosuppressants, laboratory tests, primarily CBC with

differential, should be done immediately (within 5 days) of major invasive procedure,
i.e. extractions, scaling and root planing, periodontal surgery.
2. If white count below 2,000, no elective treatment until white count restored.
3. If platelet count is less than 60,000, no elective treatment. If emergency treatment is

needed with the risk of bleeding, then have physician give the patient a packed
platelet infusion prior to procedure.
18
Immunosuppression – continued
4. If patient is severely immunosuppressed and infection is present, consider
prophylactic antibiotics prior to oral surgical or periodontal surgical procedures.
5. Institute aggressive treatment of any dental infection, including antibiotics, incision

and drainage, and proceed with any necessary endodontic procedure or extraction.
6. Aggressively control any periodontal disease with proper cleaning and supplemental
medication such as clorhexidine rinse.
Be Alert For:
1. Periodontal infections
2. Yeast infections
3. Viral infections
4. Periapical problems, impacted teeth, poorly done endodontic procedures, oral

ulcerations.
1. Prior to organ transplant or when patient is most immunocompetant, consider

aggressive dental therapy to remove / resolve any possible dental problems, i.e.
scale / root plane for periodontal disease, extract impacted teeth, complete any
needed or expected endodontic procedures. Consider extracting teeth with
compromised endodontic prognosis.
2. Good oral hygiene.
3. Prophylaxis for viral and fungal infections.
Patient told to alert dentist or physician at first sign of any infection.
19
Infectious Diseases (7 of 11)

(Tuberculosis, hepatitis, HIV, herpes, the flu)
Questions To Ask / Necessary Information:
A. Tuberculosis:
1. When were you diagnosed?
2. Are you still having symptoms of active infection, such as coughing? Night sweats?
3. What medications have you taken and for how long?
4. Have you taken them as directed?
B. Hepatitis:
1. What type of hepatitis do you have?
2. Are you actively infected at this time?
3. Have you had any signs or symptoms of your hepatitis?
4. Have you had any change in your liver function tests?
5. Have you taken any medication specifically to treat your hepatitis?
6. If you had hepatitis B, do you know your hepatitis antigen status?
C. HIV:
1. When were you first infected?
2. What is your current CD4 t-cell count?
3. What is your current viral load?
4. Have you had any bleeding problems?
5. Have you had any specific diseases related to HIV infection?
6. Are you taking any specific medications for HIV infection?
D. Herpes / flu: (risk associated with these diseases is transmission to the healthcare
provider)
1. Are you actively infected at this time?
20
Infectious Diseases – continued

Diagnostic Tests:
A. Tuberculosis:
1. If tuberculin test is positive, then a chest x-ray should be taken.
2. If the chest x-ray is positive, or if there is obvious active infection, then sputum test
for tuberculosis baccilum should be done.
B. Hepatitis:
1. Hepatitis antigens and antibodies should be run.
2. If patient has active hepatitis, then liver function should be run or request physician
provide information as to liver function and coagulation status.
C. HIV:
1. Current laboratory tests including t-cell count, viral load, CBC with a differential to
give platelet count and white count should be done (refer to Pacific Protocols for the
Dental Management of Patients with HIV Disease).
D. Herpes / flu:
1. No specific laboratory tests need be run.
2. If patient is interested in which type of herpes they have, type 1 versus type 2, then
antibody tests can be run.
A. Tuberculosis:
1. No elective treatment rendered until physician says patient is not infectious (sputum
negative).
2. If emergency treatment is necessary, patient should be treated in a level 3 infection

control facility with hepafilter mask and laminar airflow.
3. In an actively infected patient, the air expelled when coughing is infectious and
should be avoided.
21
B. Hepatitis:
1. Since all patients are treated as though they are infectious and universal precautions
are applied, no special precautions are necessary when treating a patient actively
infected with the hepatitis virus (If patient is having liver problems secondary to
hepatitis, then review liver protocol).
C. HIV:
1. If patient is HIV infected but has had no medical problems, then no special
precautions are needed.
2. Since all patients are treated as though they are infectious, the usual universal
precautions are adequate for management.
3. If patient has signs and symptoms of immunosuppression, refer to protocols for

patients with immunosuppression.
4. Review the patient’s medications and any dental medications that may be used, to
insure no drug interaction.
D. Herpes / flu:
1. Since all patients are treated as though they are infectious, the normal universal
precautions apply and patient is safe for treatment.
2. If patient is feeling so poorly that they don’t feel strong enough for dental treatment,
they should be re-appointed.
3. If patient having herpes attack, no special precaution is necessary though patient

may want to have herpetic ulcer lubricated or even topical anesthetic applied to
minimize discomfort associated with manipulation of oral cavity.
Be Alert For:
A. Tuberculosis:
1. Oral ulceration or head and neck ulceration, advanced forms of tuberculosis can
manifest as what is termed caseating necrosis. Clinically it appears as an ulceration.
These ulcers have a high content of tubercular bacilli. Patients with such ulcerations
should not receive elective dental treatment until their T.B. infection is resolved.
22
B. Hepatitis:
1. Be alert for signs of jaundice. Follow the protocol for liver dysfunction.
C. HIV:
1. Be alert for oral manifestations of immunosuppression such as oral yeast infections,

viral infections and periodontal problems. Follow the protocol for
Immunosuppression.
2. Be alert for poor healing response and bone sequestration following extractions.
D. Herpes / flu:
1. With herpes, avoid traumatizing tissue as it may trigger a herpes attack.
2. If patient knows that herpes attack is precipitated by trauma, consider prophylactic

antiviral medication.
A. Tuberculosis:
1. Faithful taking of medication.
2. Good personal hygiene, hand washing, and not coughing on anybody.
3. Good nutrition and rest.
B. Hepatitis:
1. See liver dysfunction protocol.
C. HIV:
1. See immunosuppression protocol.
D. Herpes / flu:
1. For herpes, keep lesion lubricated.
2. Consider antiviral therapy.
23

3. Remind patient that herpetic lesion is contagious, especially when blister present
and up to two days after it bursts. Encourage them to observe appropriate personal
hygiene and avoid mucous membrane contact with other people when active lesion
present.
4. For flu, wash hands frequently.
5. Avoid coughing on people or possible contact with nasal secretions.
24
Kidney Problems (8 of 11)
1. What kind of kidney problem do you have?
2. Does it interfere with your everyday living?
3. Does it alter the way you eliminate medication?
Diagnostic Tests:
1. BUN (blood, urea, nitrogen)
2. Creatine clearance rate
1. Do not use drugs toxic to the kidney i.e. acetaminophen
2. Use caution and alter dosage form when using drugs eliminated by the kidney i.e.
penicillin (often reduced to 500 mg two times per day versus four times per day)
3. If patient on renal dialysis, dental treatment should be done on the day following
dialysis.
4. If patient has kidney transplant, see considerations under immunosuppression

protocol.
Be Alert For:
1. Drug toxicity because of accumulation.
2. Poor healing and oral ulcerations.
1. No special dental precautions needed
Patient should be counseled as to potential toxicity problems from certain prescriptions

and over-the-counter drugs, plus alcohol.
25
Liver Problems – (9 of 11)

1. How long have you had a liver problem?
2. What type of liver problem is it and how was it caused?
3. Do you feel unwell relative to the liver problem?
4. Have you noticed any problems such as bleeding, difficulty in metabolizing /

digesting food, or increased or decreased sensitivity to medication, from the liver
problem?
5. Do you ever get jaundice (do the whites of your eyes or your skin turn or look
yellow)?
6. Have you ever needed to be hospitalized because of your liver problem?
Diagnostic Tests:
1. SMA20 (specifically SGOT, AST, ALT)
2. PT & PTT
3. INR
1. If bleeding problems, follow bleeding problem protocol.
2. If unable to metabolize drugs, avoid using drugs metabolized in the liver such as
erythromycin and ketoconazol. Minimize local anesthetics.
3. If patient having problem with drug interactions, avoid drugs with high potential for
drug interaction used in dentistry i.e. erythromycin and ketoconazol.
4. Avoid drugs with potential for liver toxicity, i.e. acetaminophen, Tylenol, and any
other over-the-counter / non prescription drugs.
Be Alert For:
1. Easy bleeding
2. Yellow tint to skin, oral mucosa, and the whites of the eye.
3. Poor healing
26
Liver Problems – continued

4. Oral ulcers
1. Good oral hygiene to minimize oral hygiene problems.
2. Avoidance of drugs that are toxic to the liver, i.e. acetaminophen, alcohol.
27
Pregnancy (10 of 11)

1. What month of pregnancy are you in?
2. Are you currently seeing a physician for your pre-natal care?
3. Has your physician referred you to a high-risk OB?
4. Do you have any physical limitations, bed rest orders, or changes to daily activities?
5. Have you had complications with prior pregnancies?
Diagnostic Tests:
None. Patient will make the diagnosis.
Comprehensive dental care during pregnancy is now the standard of care.
Prevention, diagnosis, and treatment of oral diseases, including needed dental

radiographs and use of local anesthesia, are highly beneficial and can be
undertaken during pregnancy with no additional fetal or maternal risk when
compared to the risk of not providing care.
However, it is recommended that non-urgent and elective care be postponed,

if possible, until postpartum. This would include elective surgical procedures,
including asymptomatic wisdom tooth extractions, placement of dental
implants, and bone grafting for implant site development.
1. First three months of pregnancy –

a) There are no restrictions for delivering any needed dental treatment.
b) As with all dental treatment, minimize the amounts of medications. Lidocaine
is the safest local anesthetic agent to use. There are NO contraindications for
the use of local anesthetics with vasoconstrictors.
c) Educate the patient about the value of good oral hygiene and good nutrition.
2. Second trimester and first half of third –

a) This is the most ideal time for all dental treatment needed or desired during
the pregnancy.
b) As always, minimize drug and medication exposure.
c) Emphasize proper periodontal care and good nutrition.
28
Pregnancy – continued
3. Last half of third trimester –
a) Minimize dental treatment to necessary and/or emergency treatment.
b) As always, minimize drug and medication exposure.
c) To aid in preventing postural hypotensive syndrome in a pregnant patient
during dental treatment, the Oral Health During Pregnancy and Early
Childhood: Evidence-based Guidelines for Health Professionals recommends
the use of a small pillow under the patient’s right hip while positioning her in
the dental chair. It is also recommended to allow the patient to turn on her
side.
Be Alert For:
1. Periodontal problems: Besides the patient’s own risk of bone loss, severe
periodontal disease has been associated with low birth weight pre-term babies.
Good periodontal health is paramount to minimizing this risk.
2. Pyogenic granulomas (pregnancy gingivitis).
3. Minimize all drug use.
1. Good home care.
2. Emphasize good nutrition (adequate protein, folic acid supplements), and to

eliminate alcohol, tobacco, and recreational drug use.
29
Prosthetic Joints (11 of 11)

These guidelines have been revised to reflect the revised January 2015 guidelines on
The Use of Prophylactic Antibiotics prior to Dental Procedures in Patients with
Prosthetic Joints: Evidence-based clinical practice guideline for dental practitioners – a
report of the American Dental Association Council on Scientific Affairs [J Am Dent
Assoc 2015:146(1):11-16]
Please Note: Non-movable joints / bones (i.e. finger or toe bones), pins, wires, rods,
bolts, screws once stabilized (greater than 6 months in place with no problems) are not
covered by this protocol and there is no indication prophylactic antibiotic coverage for
dental procedures would be valuable.
Questions to Ask / Necessary Information
1. Which joint has been replaced?
2. Why was the replacement done?
3. Do you have diabetes or any medical problems including any inflammatory problems
or any immunosuppression problems?
Diagnostic Tests:
No diagnostic tests required.
The American Dental Association and the Council on Scientific Affairs, in January
of 2015, provided Clinical Recommendations relative to the Management of
Patients with Prosthetic Joints Undergoing Dental Procedures.
The primary recommendation is:
In general, for patients with prosthetic joint implants, prophylactic

antibiotics are not recommended prior to dental procedures to prevent
prosthetic joint infections.
They go on to note:
For patients with a history of complications with their joint replacement surgery
and who are undergoing dental procedures that include gingival manipulation or
mucosal incision, prophylactic antibiotics should only be considered after
consultation with the patient and their orthopedic surgeon.*
30
Prosthetic Joints – continued
They advise:
To assess a patient’s medical status, review of a complete health history is

always recommended when making final decisions regarding the need for
antibiotic prophylaxis.
There are no specific recommendations as to an antibiotic regime to be used, if

the clinician feels it is needed. Instead they suggest to the clinician:
*In cases where antibiotics are deemed necessary, it is most appropriate

that the orthopedic surgeon recommend the appropriate antibiotic regime,
and, when reasonable, write the prescription.
They provide the clinical reasoning behind the recommendations:
1. There is evidence that dental infections are not associated with prosthetic
joint infections.
2. There is evidence that antibiotics provided before oral care do not prevent
prosthetic joint implant infections.
3. There are potential harms of antibiotics including risks of anaphylaxis,
development of antibiotic resistance, and opportunistic infections like
Clostridium difficile.
4. The benefits of antibiotic prophylaxis may not exceed the harm for most
patients.
5. The individual patients circumstances and preferences should be considered
when deciding whether to prescribe prophylactic antibiotics prior to dental
procedures.
You should realize, as stated in the recommendation:
This report is intended to assist practitioners in making decisions about the

prophylactic use of antibiotics to prevent prosthetic joint infections. The
recommendations in this document are not intended to define a standard of care,
and rather should be integrated with the practitioners professional judgment and
the patient‘s needs and preferences.
In situations where the patient is medically compromised and may be prone to

infections, such as uncontrolled diabetes, chronic steroid use,
immunosuppressed for any reason, undergoing cancer chemotherapy, the joint
has been infected or shown signs consistent with an infection before or it has
been recently placed (less than 2 years), then the decision by the clinician or the
patient to use prophylactic antibiotics may be prudent and the patient’s
orthopedic surgeon may not be available. In that case, if the clinician elects to
31

prophylax the patient, it is reasonable to suggest using the medications in the
2003 AAOS/ADA guideline and in the current AHA guideline. These antibiotics
would be the ones most effective against organisms most commonly found in a
bacteremia associated with a dental procedure:
Amoxicillin, 2 g, 60 minutes before the appointment.
If allergic to penicillins, clindamycin 600 mg or azythromyzin 500 mg, 60 minutes before

the appointment.
There are those that feel that the prophylactic antibiotic of choice should be one
directed at the most common infecting organisms found in prosthetic joint infections,
which are staphylococcal organisms (which are uncommon in the oral cavity). Based on
this rationale, the appropriate antibiotic would be a cephalosporin:
Cephalexin, 2 g, 60 minutes before the appointment.
If allergic to penicillins, clindamycin 600 mg, 60 minutes before the appointment.
60 minutes before the appointment is suggested because prosthetic joint infections and
endocarditis are not the same diseases and penetration into a prosthetic joint location
may take longer than saturating a cardiac location. In reality, no one knows. Hence the
note below:
Please note: the above considerations as to an antibiotic regime are our respectful
opinion. As noted in the guidelines, a consultation with an orthopedic surgeon would be
the ideal way to identify an appropriate antibiotic regime and, as stated in the
recommendations, ideally the orthopedic surgeon would write the prescription.
It bears repeating, the ADA 2015 recommendations make it very clear that there is
no scientific evidence documenting the value of prophylaxing any dental patient
for the intention of preventing a prosthetic joint infection. On the other hand,
there is scientific evidence documenting side effects and complications from
unnecessary antibiotic use. Essentially, not using antibiotics may be safer than
using them. If you decide to use an antibiotic you should have a good reason and
it would be prudent to write that reason in the patient’s chart.
Again, if a patient has a moveable prosthetic joint replacement, the 2015 guidelines
state:
“In general, for patients with prosthetic joint implants, prophylactic antibiotics are
not recommended prior to dental procedures to prevent prosthetic joint infection.
The practitioner and patient should consider possible clinical circumstances that may
32

suggest the presence of a significant medical risk in providing dental care without
antibiotic prophylaxis, as well as the known risks of frequent or widespread antibiotic
use. As part of the evidence-based approach to care, this clinical recommendation
should be integrated with the practitioner’s professional judgment and the patient’s
needs and preferences.”
If a patient has a prosthetic joint plus any of the other medical problems below, their risk
of any infection increases and prophylactic antibiotics should be considered.
Patients at Potential Increased Risk of Hematogenous Total Joint Infection

• Immunocompromised/immunosuppressed patients
• Inflammatory arthropathies (e.g. rheumatoid arthritis, systemic lupus

erythematosus)
• Drug- induced immunosuppression
• Radiation-induced immunosuppression
• Patients with significant co-morbidities (e.g.: type 1 diabetes, obesity, smoking)
• Previous prosthetic joint infections
• Malnourishment
• Hemophilia
• HIV infection
• Insulin-dependent (Type 1) diabetes
• Malignancy
Suggested Antibiotic Regimes for "At Risk" patients (select one of these
antibiotics)
Rx Amoxicillin 500 mg
Cephalexin 500 mg
Cephradine 500 mg
Disp 4 tablets
Sig Take 4 tablets (2 grams), 1 hour before procedure.
33

Though no official recommendation is made relative to the appropriate antibiotic
to use if a patient has an immediate type allergic reaction (urticaria, angioedema,
anaphylaxis) to penicillin/amoxicillin (and, therefore, have a potential for a cross
reacting allergy to the cephalosporins), a reasonable alternative, given the
organisms found in the oral cavity, is clindamycin.
If patient Allergic to Penicillin/Amoxicillin
Rx Clindamycin 150 mg
Disp 4 tablets
Sig Take 4 tablets (600 mg), 1 hour before procedure.
Be alert for:
Pain in the joint following dental procedures. There is no specific time frame; an
infection could arise at any time from any source, including a bacteremia secondary to
dental procedures. The likelihood of a prosthetic joint infection secondary to dental
procedures is rare. The patient should follow up any unusual discomfort within the joint
with their physician.
The risk of prosthetic joint infection secondary to dental procedures is very rare. It
primarily occurs in unusual situations when comorbidities such as immunosuppression
or other types of medical problems are present. These medical problems increase the
susceptibility of any patient to any type of infection.
In the long run, the best way to minimize any possible seeding of a prosthetic joint, by
bacteria in the oral cavity, is to minimize oral cavity problems through good oral
hygiene.
There is no evidence to recommend for or against the use of oral antimicrobials such as
0.12% chlorhexidine.
34

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Protocols for the

DENTAL MANAGEMENT OF MEDICALLY COMPLEX PATIENTS

1. Bleeding Issues (including anticoagulants) 2

2. Cardiac Problems (heart murmurs, cardiac defects) 5

3. Cardiovascular Problems (high blood pressure, arrhythmias) 9

4. Central Nervous System Problems (seizures, stroke) 13

7. Infectious Diseases (tuberculosis, hepatitis, HIV, herpes, flu) 20

11. Prosthetic Joints 30

Protocols compiled by: Peter L. Jacobsen, Ph.D., D.D.S

Protocols maintained by: Alan Budenz, MS, DDS, MBA

Updated August 2020

Bleeding Issues or Patients on Anticoagulants (1 of 11)

2. Describe your bleeding issue

3. Have you had problems with previous dental appointments?

5. Are your anticoagulants or bleeding issues due to low platelets?

1. Bleeding issues secondary to liver disease:

2. Aspirin and other non-steroidal anti-inflammatory agents.

5. Anticoagulant Plavix and newer agents

Management During Dental Treatment:

a) If INR greater than 3.5

Bleeding Issues or Patients on Anticoagulants – continued

4. Pradaxa (dabigatran), Xarelto (rivoraxaban), Eliquis (apixaban), and Savaysa

Unless extensive bleeding is expected, there is no need to modify or suspend this

5. If hemophilic, have physician administer proper replacement factors and run

Bleeding Issues or Patients on Anticoagulants – continued

2) Easy bruising / multiple bruises

https://medlineplus/bleedingdisorders (U.S. National Library of Medicine)

Centers for Disease Control and Prevention

HANDI/National Hemophilia Foundation

Comprehensive site on bleeding problems to recommend to your patients:

Cardiac Problems - heart murmurs, cardiac defects (2 of 11)

1. When was your heart problem first diagnosed?

2. Have you ever been hospitalized because of your heart problem?

Management During Dental Treatment:

PROPHYLACTIC ANTIBIOTIC COVERAGE FOR PREVENTION OF

Current American Heart Association Guidelines

Cardiac Conditions for Which Prophylaxis for Dental

Prosthetic Cardiac Valve

Previous Infective Endocarditis

Congenital Heart Disease (CHD)

1. Unrepaired cyanotic CHD, including palliative shunts and conduits.

Cardiac Problems - heart murmurs, cardiac defects – continued

1. If the patient needs prophylactic antibiotics, follow the American Heart

Premedication requirements for patients with valvular heart disease or congenital

Rx Amoxicillin 500 mg.

Note 1) Children 50 mg/Kg. Do not exceed adult dose

Standard Regime for Patients Allergic To Amoxicillin/Penicillin

*Rx Clindamycin 150 mg.

Cardiac Problems - heart murmurs, cardiac defects – continued

*Rx Cephalexin 500 mg.

*Rx Cefadroxil 500 mg

* Note: Cephalosporins should not be used in individuals with

Note: Children’s dosage. (Do not exceed adult dose)

Patients Unable To Take Oral Medication

Ampicillin 2 g IV or IM within 30 minutes before procedure.

Cardiac Problems - heart murmurs, cardiac defects – continued

For Patients Unable to Take Oral Medication and Allergic to Ampicillin,

Clindamycin 600 mg IV within 30 minutes before procedure.

*Cefazolin 1 g IV or IM within 30 minutes before procedure

*Note: Cephalosporins should not be used in individuals with