Immune & Transplant

Dental Management of Patients with Immunosuppression (general)

Proceed with physician coordination, labs & precautions

Immunosuppressed / transplant patient: a stable immunosuppressed patient can usually undergo invasive care with the precautions below and appropriate blood tests.

Emergency vs routine management

If EMERGENCY — what to do

• Treat infection promptly — immunosuppression masks signs and allows rapid spread.Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
• Before invasive treatment obtain a recent FBC: ANC ≥ 1.0 × 10⁹/L and platelets ≥ 50 × 10⁹/L are generally needed for outpatient surgery.Ref: Elad S et al. MASCC/ISOO Clinical Practice Guidelines for oral care / mucositis in cancer therapy. Support Care Cancer 2015–2020

If ROUTINE — what to do

• Routine non-invasive care can proceed; liaise with the prescriber for surgical procedures.Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023

Clinical precautions

• Coordinate with the transplant / treating physician before invasive care
• Antibiotic prophylaxis is NOT routinely required for immunosuppression alone — decide case-by-case with the treating physician for invasive/surgical procedures. If indicated: Amoxicillin 2 g orally 1 hour before (adult); if penicillin-allergic, Clindamycin 600 mg or Azithromycin/Clarithromycin 500 mg orally 1 hour before.
• Meticulous infection control; treat any active oral infection promptly
• Avoid nephrotoxic NSAIDs; adjust drug doses to renal function
• Calcineurin inhibitors (tacrolimus, ciclosporin): avoid drugs that raise their levels — azole antifungals (fluconazole) and macrolides (erythromycin, clarithromycin); avoid NSAIDs (additive nephrotoxicity). Ciclosporin can cause gingival overgrowth.
• Local haemostatic measures

Information & tests to request

• Months since transplant — Immunosuppression is most intense in the first 3–6 months (and while treating rejection). We defer elective invasive dental care during this window.
• Absolute neutrophil count — ANC (x10⁹/L) — A full blood count checks for neutropenia (infection risk). We wait for ANC ≥1.0 (ideally ≥2.0) before invasive care; if <1.0 we defer or treat in a hospital setting.
• eGFR (mL/min/1.73m²) — Renal function guides safe drug choice and dosing (avoid nephrotoxic NSAIDs; adjust doses).
• Daily prednisolone-equivalent dose (mg) — This patient's condition/therapy is commonly associated with long-term corticosteroids, which can suppress the adrenal response to surgical stress. Enter the daily dose (0 if none) to determine whether supplementary stress-dose cover is needed.

At a glance by procedure

Initial assessment before lab results or timing details are entered.

Procedure	Initial assessment
Examination / radiographs	ROUTINE Routine non-invasive care with precautions
Supragingival scaling / polish	MODIFY / CAUTION Proceed with physician coordination, labs & precautions
Deep scaling / subgingival RSD (subgingival calculus)	MODIFY / CAUTION Proceed with physician coordination, labs & precautions
Root canal treatment	MODIFY / CAUTION Proceed with physician coordination, labs & precautions
Simple extraction (1–3 teeth)	MODIFY / CAUTION Proceed with physician coordination, labs & precautions
Surgical / bony extraction	MODIFY / CAUTION Proceed with physician coordination, labs & precautions
Implant placement	MODIFY / CAUTION Proceed with physician coordination, labs & precautions

Get a patient-specific decision in seconds

Combine all conditions, medications, lab results and the planned procedure — with anaesthetic dose calculation, lab requests and a referral letter PDF.

References

Transplant patients — dental management (BSDH / BSOM)
AHA 2021 (endocarditis prophylaxis only if a specific cardiac indication exists)
Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
Elad S et al. MASCC/ISOO Clinical Practice Guidelines for oral care / mucositis in cancer therapy. Support Care Cancer 2015–2020

This guide supports — and does not replace — professional clinical judgment. Always consider the individual patient and consult the treating physician when indicated.