7.3 The Medically Compromised Patient

A Systematic Framework

Whatever the systemic disease, the same structured approach keeps patients safe:

1. History - medical, drug (including over-the-counter and herbal), allergy, social and family history. Use a structured proforma and ask specifically about bleeding, anaemia, heart, respiratory, renal, liver, endocrine disease, hospital admissions and previous surgical problems.
2. Risk stratification - assess the impact on bleeding, healing, infection risk, drug interactions and the patient's ability to tolerate the appointment.
3. Modification - timing of appointment, sedation, LA/GA choice, drug selection, antibiotic or steroid cover, and whether to treat in primary or secondary care.
4. Seek advice - contact the patient's GP or specialist team when uncertain; document the conversation.
5. Treat conservatively when risk is high - retain restorable roots, use non-surgical endodontics, postpone elective work.

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MRONJ: Medication-Related Osteonecrosis of the Jaw

MRONJ is exposed bone in the maxillofacial region persisting for more than 8 weeks in a patient exposed to an anti-resorptive or anti-angiogenic drug without a history of radiation. UK guidance is from SDCEP (published 2017, reviewed and confirmed as extant in March 2024).

Drugs and Risk Stratification

Management Principles

• Aim for dental fitness before drug commencement - extractions and restorative work completed where possible.
• Routine dentistry (restorations, scale and polish, recall) - proceed normally.
• Low-risk extractions: perform straightforward extractions in primary care with local measures; no routine antibiotic or antiseptic prophylaxis specifically to prevent MRONJ; review healing at 8 weeks.
• Higher-risk extractions: explore all alternatives to extraction (retain roots if infection-free, endodontics, crowning); if extraction remains the most appropriate option, proceed as for low-risk patients and discuss risk for valid consent; consider specialist consultation for medically complex patients; review at 8 weeks.
• Do not stop bisphosphonates solely to enable extractions without specialist advice - the drug persists in bone for years.
• Refer any patient with spontaneous bone exposure or suspected MRONJ to oral surgery or special care dentistry.

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Renal Disease

Chronic kidney disease alters drug excretion, fluid balance and haemostasis.

Haemodialysis Patients

• Schedule dental treatment on a non-dialysis day (heparin used during dialysis leaves a residual anticoagulant effect).
• Do not measure blood pressure or take blood from the fistula arm.
• Risk of endocarditis from the fistula is low but infection control is paramount.
• Drug dosing - many dental drugs (including penicillin V, aciclovir, metronidazole) need dose adjustment; consult the BNF or the renal team.
• Platelet dysfunction from uraemia raises bleeding risk - consider local measures.
• Transplant patients on calcineurin inhibitors (ciclosporin) develop gingival overgrowth; tacrolimus less so.

Renal Transplant

• Dental infection risk is high because of immunosuppression - aggressive prevention.
• Prefer non-surgical management; defer routine work for 3-6 months post-transplant when immunosuppression is highest.

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Liver Disease

Liver disease impairs synthesis of clotting factors (II, V, VII, IX, X) and produces thrombocytopenia from hypersplenism. The prothrombin time / INR rises and platelets fall.

• Check INR and platelet count before invasive treatment in known liver disease.
• Proceed for straightforward extractions if INR 4.0 - similar threshold to warfarin - and platelets adequate.
• Severe coagulopathy - liaise with hepatology; consider fresh frozen plasma or vitamin K.
• Hepatitis B and C - additional cross-infection precautions as for all blood-borne viruses; routine care is appropriate.
• Patients with alcohol use disorder - bleeding risk, poor healing, drug interactions; assess capacity and consent carefully.

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Pregnancy

Dental treatment is safe in pregnancy. Key principles:

• Preferred timing - the second trimester is optimal for elective work; first trimester avoids teratogenic risk; third trimester risks supine hypotension.
• Local anaesthetic with epinephrine is safe in standard doses; avoid intravascular injection.
• Radiography - avoid where possible; a single low-dose periapical radiograph with a lead apron is not a contraindication when clinically justified.
• Medication - paracetamol is first-line analgesic; penicillins, cephalosporins and metronidazole (short course) are generally safe; avoid tetracyclines (tooth staining) and NSAIDs in the third trimester (premature closure of ductus arteriosus).
• Position the patient on the left side or with right hip elevated to avoid aortocaval compression.
• Elective treatment can be deferred until postpartum if risk is unclear.

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The Elderly and Frail Patient

Physiological reserve falls with age. Practical considerations:

• Polypharmacy - review interactions and postural hypotension; raise the chair slowly.
• Comorbidities - cardiac, respiratory, renal impairment combine.
• Cognitive impairment - consent and compliance; shorter appointments.
• Xerostomia from anticholinergics, antidepressants and antihypertensives - caries risk, salivary substitutes, fluoride.
• Osteoporosis treatment - bisphosphonates (see MRONJ).

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Corticosteroid Therapy and Adrenal Suppression

Long-term systemic corticosteroids (e.g. prednisolone >7.5 mg/day for >3 weeks) suppress the hypothalamic-pituitary-adrenal (HPA) axis. Under physiological stress (surgery, infection, trauma) the adrenals may not mount an adequate cortisol response, risking an adrenal crisis - hypotension, hyponatraemia, collapse.

Dental Management

• Routine dentistry under local anaesthetic - no additional steroid cover needed.
• More stressful procedures - multiple extractions, long surgery - consider supplementary hydrocortisone; a common UK approach is 100 mg intramuscular or intravenous hydrocortisone at the time of the procedure, but this varies and should follow specialist guidance or the prescribing clinician's advice.
• Consult the prescribing clinician if unsure.
• Never abruptly stop long-term steroids.

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Immunosuppression and Anticoagulants

• Immunosuppressed patients - neutropenia and impaired healing; check blood counts, treat infection promptly, aggressive prevention, single course of antibiotics for established infection only (not prophylactic unless local protocol).
• Warfarin - check INR within 24 hours of surgery; proceed for straightforward extractions if INR 4.0 using local haemostatic measures (sutures, oxidised cellulose, tranexamic acid 4.8% mouthwash 5 minutes four times daily for 5-7 days); do not stop warfarin without the anticoagulation team.
• Direct oral anticoagulants (DOACs) - for apixaban, rivaroxaban, dabigatran, avoid stopping where possible; consult the SDCEP anticoagulant guidance and consider missing one morning dose for higher-risk procedures.
• Antiplatelets (aspirin, clopidogrel) - continue for straightforward dental extractions.

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When to Treat in Secondary Care

Refer or treat in a hospital setting when:

• Significant uncontrolled systemic disease (recent MI, unstable angina, severe heart failure).
• Severe bleeding risk not manageable with local measures.
• Need for general anaesthesia or sedation beyond primary care scope.
• Complex MRONJ, established osteoradionecrosis, or extensive maxillofacial infection.
• Patients on complex chemotherapy regimens or within the intensive immunosuppression window after transplant.
• Pregnancy with obstetric complications or where specialist input is required.

When in doubt, seek medical advice first - document who gave it and when.