Parameters of Care A

Parameters of Care
for the
Treatment
of
Dental Patients
Charles D. Fuszner, DMD

Bhavik A. Mohanlal, BBA, MBA
Drew M. Williamson, BA
A.T. Still University

Missouri School of Dentistry and Oral Health
St. Louis, Missouri – Kirksville, Missouri
PARAMETERS OF CARE
for the
Treatment
of
Dental Patients
Charles D. Fuszner - Bhavik A. Mohanlal - Drew M. Williamson
A.T. Still University - Missouri School of Dentistry and Oral Health

Fifth Revision – December, 2019
Copyright © 2018
by Charles D. Fuszner, DMD
TX 0008-660-126
ATN: 3514469.0002 SRVR: 1-7032810051
All rights reserved under United States, International and Pan-American Copyright Conventions.
No part of this publication may be reproduced, stored in a retrieval system or transmitted in any form
by any means without prior written permission from the author.
The authors may be contacted at cfuszner@atsu.edu

Table of Contents
Guidelines for Premedication of Patients ......................................................................... Page 1
Guidelines for Patients with Cardiac Stents or Coronary Bypass Surgery .......................... Page 8
Guidelines for Patients with Organ Transplants ............................................................................Page 11
Guidelines for Patients on Dialysis .................................................................................... Page 16
Guidelines for Patients with Orthopedic Pins, Plates, Screws, and Rods .......................... Page 18
Blood Pressure Treatment Guidelines ............................................................................... Page 20
Guidelines for Patients Receiving Anti-Coagulation Therapy ............................................. Page 22
Guidelines for the Treatment of Patients with Diabetes Mellitus.......................................Page 26
Guidelines for Patients Taking Antiresorptive or Antiangiogenic Medications ..................Page 29
Guidelines for the Use of Local Anesthetics ...................................................................... Page 34
Guidelines for Selection and Use of Needles for Delivery of Local Anesthetic Agents...... Page 37
Guidelines for the Treatment of Pregnant Patients ..................................................... Page 39
Guidelines for the Appropriate Use of Antibiotics .................................................. Page 42
Guidelines for the Appropriate Use of Opioids ......................................................... Page 45
Guidelines for the Treatment of Patients with Autoimmune Diseases ...............................Page 48
Guidelines for the Use of Medicated Retraction Cords / Agents ................................... Page 50
Guidelines for Use of Nitrous Oxide ..................................................................... Page 52
Guidelines for the Use of Vasoconstrictors ...................................................................... Page 57
Smoking Cessation Guidelines and Supportive Materials ................................................. Appendix A

Preface
Like so many other works of this type, the genesis for this manual came out of need.
In January of the year 2017, the fledgling A.T. Still – Missouri School of Dentistry and Oral Health
(ATSU-MOSDOH) was soon to graduate its inaugural class. By the guidelines of the American
Dental Association’s Commission on Dental Accreditation (ADA-CODA) MOSDOH was to be faced
with its first major accreditation site visit. Leadership believed, wisely so, that a reference manual
was needed to fulfill CODA standards pertaining to clinical patient care. I was asked to take on
the challenge and assigned the task. Soon after, an early version of this manual was penned.
The manual was titled Parameters of Care for the Treatment of Dental Patients. Upon review by
the members of the accreditation site-visit team, much to our surprise, glowing praises were
bestowed upon the school for not only meeting CODA requirements, but for creating a document
that addressed many of the parameters of care that had often been managed either colloquially,
anecdotally, or without much researched or documented evidence supporting the use of such
parameters or clinical guidance.
After discussion with other faculty at MOSDOH, a decision was made, as the old saying goes, to
dial this up to the next level. With the solid support of administration, collaborative work began
to expand the material content and place it in a formal manual-type format. Plans were devised
to research the existing topics annually, or sooner if collective wisdom thought required, and to
search for new topics to add as significance would dictate. The ultimate goal: to have a new
manual annually.
After several unofficial revisions, this manual was born.
We hope you find this manual useful and informative, and hope that it may lead to better patient
care throughout the profession. Enjoy!

St. Louis, Missouri
Forward
“Primum non nocere.” (First, do no harm.)
From the Hippocratic Oath
“We sometimes forget that a main goal is to have a patient who walks into
your dental office ultimately be able to walk out when the dental
treatment is finished.”
Michael J. Wahl, DDS; Noted author, researcher and private practice dentist, Wilmington, DE
We all know that there are many ways to practice dentistry.

Over time, every clinical dentist establishes personal preferences in the way they practice. These
preferences are distilled out of many influencing factors. Starting with what was originally taught
to us in dental school, we become influenced by what we read in journals or other publications,
what has been learned attending seminars or continuing education courses, and what has been
absorbed anecdotally. Much is from nothing more than good old-fashioned lessons learned through
the common sense experiences of daily patient contact. It is easy to see why, after several decades
of practicing, complacency often sets in.
There are times when I have asked a fellow dentist why they do something, whereupon it is often
common to get a response the likes of, “I don’t know how I learned to do it that way,” or “I think that
is just what I have always done.” However, as many experienced practitioners are fully aware, there
are many things done in treating patients that are often done for the wrong reasons. Unfortunately,
there are also many things done in the treatment of patients that should not be done. Or if done, it
is done at potentially a great risk.
This is a manual of treatment parameters for the patient’s well-being. A guidebook of guidelines
that if followed, will give a dental practitioner the best chance to successfully achieve both of the
objectives listed at the beginning of this forward.
That said, this is not intended to be a manual of tooth engineering or preparation design parameters.
Nor is it intended to describe how to accomplish certain restorative procedures. For example, it does
not address when a post should be placed in an endodontically treated tooth, or how long a crown’s
ferrule should be, or what type of clasp should be placed on a free-end abutment of a Kennedy Class-
I partial framework. There are many well established, easily found references that handle such
topics. Instead, this is a reference designed specifically to reduce the risk of medical complications
while performing day-to-day dental treatment, presented in a format that is easy to understand.
Some who have read this manual have asked me if it is my opinion that this content represents the
standard of care as applied to patient care. In my experience, standard of care is only established on
a specific day when a jury verdict in a dental or medical malpractice case is decided. But there are
certainly some areas of content, such as the well-established guidelines on premedication against
bacterial endocarditis that have been credibly established, both academically and by court precedent,
and indisputably stand as a standard of care.
Others are areas that fall under the category of what is best stated as most prudent guidelines. By
following the guidelines set forth in this manual, the clinical dentist will place themselves in the most
optimal position from which to assure safe patient care, thus achieving the goal of “first do no harm.”
Much of this manual should almost assuredly be considered good advice to heed, and following these
guidelines will go a long way in your avoiding a future visit from a plaintiff’s attorney as well.
In my brief time at ATSU-MOSDOH, I have found this new dental school to be a most unique place,
filled with extremely bright and highly motivated faculty and students. People passionately dedicated
to the profession of dentistry at a level unlike anything I have ever experienced. It is an absolute
privilege to have the opportunity to teach at this institution and work with such fine people. I truly
look forward to every day I spend at the school and for the good it represents.
Many thanks go out to these great colleagues of mine that have assisted me in this project. I have
listed their names on the inside of the back cover. Their inspiration, knowledge, wisdom and guidance
in the assimilation and review of this material, and the formatting of this manual, is commendable.
It could not have been done without them. I am energized by their pledge to continue what is to be
an ongoing mission of revising content, updating research and establishing relevancy of the
recommendations stated.
Our goal is to always have the most current, evidence-based guidelines as can possibly be delivered
in one manual, and make it available for the reference and use of dentists and dental students
everywhere.
To yours in the best care of our patients that is possible,

Assistant Professor, Comprehensive Care
AT Still University – Missouri School of Dentistry and Oral Health - St. Louis, Missouri
Guidelines
for
Premedication of Patients
Premedication Guidelines
The following guidelines shall be in effect regarding appropriate indications for use of antibiotic
premedication prior to dental treatment. The policy of MOSDOH/AFFINIA is to follow
recommendations accepted by the American Dental Association (ADA) in all circumstances unless
alternative premedication regimens have been prescribed in accordance with a patient’s treating
physician’s recommendations.
Following a thorough evaluation of a patient’s medical history, a MOSDOH faculty member or

appropriate AFFINIA provider will determine the need for premedication. MOSDOH faculty or an
appropriate AFFINIA provider will then provide premedication according to premedication guidelines.
A) Premedication for Prevention of Infective Endocarditis (IE):

As of December 2019, the most current guidelines are from the year 2008, which is the most
recent year recommendations were modified and adapted. The recommendations are
summarized in chart-format below.
Source: Prevention of infective endocarditis. J Am Dent Assoc. 2008:139 (1); Special Supplement.
Cardiac Conditions Requiring Premedication
Cardiac conditions associated with the highest risk of adverse

outcome from endocarditis for which prophylaxis with dental
procedures is reasonable.
⁻ Prosthetic cardiac valve or prosthetic material used for cardiac valve repair
⁻ Previous infective endocarditis
⁻ Congenital heart disease (CHD)*
⁻ 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 six
months after the procedure†
⁻ Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
⁻ Cardiac transplantation recipients who develop cardiac valvulopathy
*Except for the conditions listed above, antibiotic prophylaxis is no longer recommended
for any other form of CHD.
†Prophylaxis is reasonable because endothelialization of prosthetic material occurs within
six months after the procedure.
Source: J Am Dent Assoc. 2008:139 (1) – page s17.
Page | 1
Dental procedures for which endocarditis prophylaxis is reasonable
All dental procedures that involve manipulation of gingival tissue or the periapical region of
teeth, or perforation of the oral mucosa.
Dental procedures and events for which prophylaxis is not indicated
Routine anesthetic injections through non-infected tissue.

Taking of dental radiographs.
Placement of removable prosthetics.
Placement of removable orthodontic appliances.
Adjustment of orthodontic appliances.
Placement of orthodontic brackets.
Shedding of primary teeth.
Bleeding from trauma to the lips or oral mucosa.
Antibiotic Regimens for Prevention of Infective Endocarditis
Regimens for a dental procedure.

SITUATION AGENT REGIMEN: SINGLE DOSE 30-60
MINUTES BEFORE PROCEDURE
Adults Children
Oral Amoxicillin 2 grams 50 milligrams
per kilogram
* †
Unable to Take Oral Ampicillin 2g IM or IV 50 mg/kg IM
Medication OR or IV
Cefazolin or 50 mg/kg IM
Ceftriaxone 1g IM or IV or IV
Allergic to Penicillin Cephalexinǂ§ 2g 50 mg/kg
or Ampicillin Oral OR
Clindamycin 600mg 20 mg/kg
OR
Azithromycin or 500mg 15 mg/kg
Clarithromycin
Allergic to Penicillin Cefazolin or 1g IM or IV 50 mg/kg IM
or Ampicillin and Ceftriaxone§ or IV
Unable to Take Oral OR
Medication Clindamycin 600mg IM or IV 20 mg/kg IM
or IV
*IM: Intramuscular
†
IV: Intravenous.
ǂ
Or other first – or second-generation oral cephalosporin in equivalent adult or
pediatric dosage.
§
Cephalosporins should not be used in a person with a history of anaphylaxis,
angioedema or urticarial with penicillin or ampicillin.
Page | 2
Special note for patients currently receiving antibiotics
If a patient is currently receiving chronic antibiotic therapy with an antibiotic that is also recommended for
IE prophylaxis for a dental procedure, it is prudent to select an antibiotic from a different class rather than
to increase the dosage of the current antibiotic. For example, antibiotic regimens used to prevent the
recurrence of acute rheumatic fever are administered in dosages lower than those recommended for the
prevention of IE. Patients who take an oral penicillin for secondary prevention of rheumatic fever or for other
purposes are likely to have viridans group streptococci in their oral cavity that are relatively resistant to
penicillin or amoxicillin. In such cases, the provider should select either clindamycin, azithromycin or
clarithromycin for IE prophylaxis for an indicated dental procedure. Because of possible cross-resistance of
viridans group streptococci with cephalosporins, this class of antibiotics should be avoided. If possible, it
would be preferable to delay a dental procedure until at least 10 days after completion of the antibiotic
therapy. This may allow time for the usual oral flora to be re-established.
Source: J Am Dent Assoc. 2008:139 (1) – page s19 – s20
B) Premedication and Management of Patients with Prosthetic Joints (PJ):

As of December 2019, the most current guidelines are from the year 2015, which is the most recent
year recommendations were modified and adapted. The recommendations are summarized in chart-
format below.
Recommendation for Patients with PJ
In general, for patients with prosthetic joint implants, prophylactic antibiotics are not recommended prior
to dental procedures to prevent prosthetic joint infection.
Special note: The practitioner and the patient should consider possible clinical circumstances that may 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.
Clinical circumstances where it is deemed prudent to administer prophylactic antibiotics to patients with PJ:
Presence of two or more co-morbidities, including high blood pressure, cardiac arrhythmias or obesity.
Diabetes mellitus.
Patient who is immunocompromised.
Rheumatoid arthritis.
Current use of systemic steroids.
Current malignancy.
History of chronic kidney disease.
In cases where antibiotics are deemed necessary, it is most appropriate that the orthopedic surgeon
recommend the appropriate antibiotic regimen, and when appropriate, write the prescription.
Source: The use of prophylactic antibiotics prior to dental procedures in patients with prosthetic joints. J Am Dent Assoc 2015:146 (1)
Page | 3
Special note:
In 2016, The American Academy of Orthopedic Surgeons released a position statement
on Appropriate Use Criteria for the Management of Patients with Orthopedic Implants
Undergoing Dental Procedures.
Their recommendations, in chart format, are on the following two pages. These charts
may be relied upon as needed for additional detailed direction regarding the
premedication of patients having prosthetic joints prior to dental treatment.
Page | 4
Page | 5
Page | 6
Guidelines for Patients
with
Cardiac Stents
or having had
Coronary Bypass
Surgery
Guidelines for Patients with Cardiac Stents or Cardiac Bypass
A) Cardiac Stents and Angioplasty:

As of December 2019, the most current guidelines are from the year 2008, which is the most recent year
recommendations were modified and adapted by The American Academy of Family Physicians. Research
has concluded that coronary artery stent placement and cardiac angioplasty is not associated with long
term risk of infection. It is well established that a patient can be at increased risk for cardiac arrythmias
within the first 3 months after surgery. The recommendations are as follows:
1) Routine dental treatment should be postponed for a minimum period of 3 months, with
exact date determined after consultation with the patient’s physician.
2) If emergent invasive dental procedures are required in the first 30 days after surgery,
antibiotic prophylaxis is advised, and appropriate measures taken to monitor for
arrythmias.
3) After 3 months post-surgery, routine dental procedures can resume, and antibiotic
prophylaxis for dental procedures is not needed unless otherwise directed by the patient’s
physician.
Source:
American Academy of Family Physicians, Position Paper; 2008:
https://www.aafp.org/afp/2008/2015/p538.html
What precautions and measures do I have to consider when providing dental treatment to a patient with a coronary artery stent? J Can
Dent Assoc 2006:72 (7) 619-621
Page | 8
B) Coronary Artery Bypass Surgery:
As of December 2019, the most current guidelines are from the year 2008, which is the most recent year
recommendations were modified and adapted by The American Academy of Family Physicians. Research
has concluded that coronary artery bypass surgery is not associated with long term risk of infection. It is
well established that a patient can be at increased risk for cardiac arrythmias within the first 3 to 6 months
after surgery. The recommendations are as follows:
1) Routine dental treatment should be postponed for a minimum period of 3-6 months, with
exact date determined after consultation with the patient’s physician.
arrythmias.
3) After 6 months post-surgery, routine dental procedures can usually resume. Consultation
with patient’s physician is advised. Antibiotic prophylaxis for dental procedures is not
needed unless otherwise directed by the patient’s physician.
Source:
American Academy of Family Physicians, Position Paper; 2008:
https://www.aafp.org/afp/2008/2015/p538.html
What precautions and measures do I have to consider when providing dental treatment to a patient with a coronary artery stent? J Can
Dent Assoc 2006:72 (7) 619-621
Page | 9
Guidelines
for
Patients
with
Organ Transplants
Guidelines for Patients with Organ Transplants
According to guidelines from the American Medical Association, it is recommended

that no elective dental work, including cleanings, be performed during the first six
months following a heart, kidney, liver, lung or pancreas transplant.
Source: https://www.pennmedicine.org/updates/blogs/transplant-update/2016/december/dentist-visits:post-transplant
If emergent dental care is required in first 3-6 months post-transplant:

As of December 2019, data suggests the following precautions be taken if emergent dental care is
required within the first 3-6 months after transplantation:
1) Consultation with patient’s physician is mandatory.

2) Premedicate prior to invasive dental procedures is likely required due to immunosuppressive
therapy and high risk for serious infection. Selection of the appropriate drug should be made in
conjunction with the patient’s physician.
3) Check patient’s blood pressure before treatment to establish baseline levels. Contact physician
or other appropriate emergency personnel if blood pressure exceeds accepted thresholds. Do
not treat patient if BP exceeds accepted thresholds.
4) Examine patient’s mouth thoroughly for possible dental infection as immunosuppressive therapy
can mask signs of problems. As a result, know that infections can often be more advanced than
they appear when detected.
5) Treat all infections aggressively.
6) Know patient’s bleeding potential.
7) Observe for signs of adrenal insufficiency with surgical stress in patients taking steroids. This may
require increased doses of steroids at time of dental procedures to avoid adrenal insufficiency.
8) Exercise care in prescribing medications to avoid potentiating renal and hepatic toxicities of
immunosuppressants.
9) Transport immediately to hospital or other appropriate emergency facility if patient shows any of
the following signs of adrenal insufficiency:
a) Sudden-onset weakness.
b) Sudden spike if temperature (fever).
c) Sudden-onset extreme nausea.
Source: https://www.in.gov/isdh/files/OrganTransplantProf.pdf
Page | 11
A) Heart Transplants:
As of December 2019, minimal data suggests infective endocarditis appears to be any more prevalent in
heart transplant recipients than in the general population, however the risk of infective endocarditis is
considered highest in the first 6 months after transplant. This is presumed to be due to endothelial
disruption, high-intensity immunosuppressive therapy, the need for frequent central venous catheter
access, and frequent endomyocardial biopsies. As such, the current recommendations are as follows:
1) Routine dental treatment should be postponed for a minimum period of 6 months after
transplant, with exact date determined after consultation with the patient’s physician.
arrythmias, major vessel dissection and sudden-onset cardiac arrest.
3) After 6 months post-transplant, routine dental procedures should only resume after
consultation with and permission of patient’s physician. Antibiotic prophylaxis for dental
procedures is likely required and should be directed by the patient’s physician.
https://www.in.gov/isdh/files/OrganTransplantProf.pdf
Page | 12
B) Kidney, Liver, Pancreas and Lung Transplants:
As of December 2019, data suggests that once a 6-month time period after transplant surgery has
elapsed, there is no risk of infection to the transplanted kidney, transplanted liver, transplanted pancreas
or transplanted lung(s) from dental procedures. Assuming antibiotic premedication is not required due
to other medical conditions, the current recommendations are as follows:
1) Routine dental treatment should be postponed for a period of 6 months after transplant,
with exact date determined after consultation with the patient’s physician.
complications, including major vessel dissection and sudden-onset cardiac arrest.
3) After 6 months post-transplant, routine dental procedures may resume after consultation
with and permission of patient’s physician. Antibiotic prophylaxis for dental procedures is
not required unless directed by the patient’s physician.
NOTE: If chemoprophylaxis is deemed necessary, the American Heart Association (AHA)

standard regimen is suggested unless otherwise directed by the patient’s transplant surgeon,
nephrologist or supervising physician.
https://www.in.gov/isdh/files/OrganTransplantProf.pdf
Page | 13
Guidelines for Patients preparing for Organ Transplants
As of December 2019, data suggests the following precautions be taken prior to transplantation:
1) Consultation with patient’s physician is mandatory.

2) Premedicate prior to invasive dental procedures if requested by physician. Unless advised
differently by the physician, the American heart Association’s standard regimen to prevent
endocarditis is an accepted option.
3) Active infections of odontogenic origin should be treated with a minimum of 7-days regimen
of antibiotics to minimize risk of systemic infection.
4) Counsel patients on importance of maintaining good oral health, as effective oral hygiene is
crucial before and within the first 6-months of transplant.
5) Pay special attention to anxiety and pain tolerance in organ transplant patients.
6) Instruct patients to bring a complete list of their medications, including OTC drugs, to every
appointment and note those drugs that may be problematic.
7) Be aware of patients bleeding potential and take appropriate steps to manage excessive
bleeding.
8) All active dental disease should be aggressively treated before transplantation. This includes:
a) Eliminate or stabilize sites of oral infection. Patients with active dental disease who can
tolerate treatment should receive indicated dental care. Depending on the patient’s
condition, temporary restorations may be appropriate until their health improves.
b) Extract non-restorable teeth.
c) Consider removing orthodontic bands or modifying protheses for patients expected to
receive cyclosporine due to possible gingival hyperplasia. Gingival overgrowth may be
minimized with good plaque control, and removal of orthodontic bands may make it easier
to maintain good oral hygiene.
Source: https://www.in.gov/isdh/files/OrganTransplantProf.pdf
Page | 14
Guidelines
for
Patients on Dialysis
Guidelines for Patients on Dialysis
As of December 2019, data suggests the following precautions be taken prior to transplantation:
1) Consultation with patient’s physician prior to treatment is advised.

2) Perform all non-emergent dental treatment on a non-dialysis day. This will assure the
patient is non debilitated by the dialysis treatment, that the bloodstream is free of toxic
metabolites and that the anticoagulative effects of heparin has worn off.
3) Attempt to perform dental treatment in the morning, in a quiet environment and avoid
abrupt and unexpected movements that could startle the patient.
4) Avoid elective invasive treatment until a hematologic study is analyzed to give information
on coagulation times, platelet counts, hematocrit and hemoglobin levels and platelet
adhesiveness.
5) Avoid nephrotoxic drugs such as the tetracyclines or aminoglycosides.
6) Monitor blood pressure throughout treatment for signs of sudden hypertension.
7) Pay special attention to anxiety and pain tolerance in patients receiving high-dose
corticosteroid therapy for an extended period of time. These patients may require
supplemental steroid administration to avoid stress-related adrenal crisis.
8) Aspirin is contraindicated as it increases platelet dysfunction, increases the risk gastric
hemorrhage and contributes to deterioration of renal function.
9) Ketoprofen, ibuprofen and naproxen are contraindicated due to the potential to trigger
sudden-onset hypertension or bleeding.
NOTE REGARDING USE OF LOCAL ANESTHETICS:

All injectable local anesthetics may be safely used due to their hepatic elimination.
NOTE REGARDING PAIN MANAGEMENT:

Acetaminophen and Codeine is acceptable for use without modification of dosages.
Page | 16
Guidelines
for
Patients
with
Orthopedic Pins,
Plates, Screws and Rods
Guidelines for Patients with Orthopedic pins, plates, screws or Rods
Research as of December 2019, indicates data is unchanged since 1997. It suggests the following
regarding patients undergoing dental treatment who have orthopedic pins, bone-plates, fixation screws
or support rods:
Antibiotic prophylaxis is not indicated for dental patients with pins, plates, screws or rods in
most circumstances unless otherwise directed by the patient’s physician or orthopedic surgeon.
Consultation with the patient’s physician is not required unless coexisting systemic medical
conditions become a concern for the dentist.
Source:
1) American Dental Association, American Academy of Orthopedic Surgeons, Whall Jr, CW: Joint Advisory Statement, 1997
https://www.ncbi.nlm.nih.gov/pubmed/9231605
Page | 18
Blood Pressure
Treatment Guidelines
Blood Pressure Guidelines
In November 2017, the American Heart Association (AHA) announced changes to the definition and
classification of hypertension. These changes, combined with existing literature dating back 10 years,
establishes general guidelines that seem to be based on well-reasoned evidence, and are guidelines
that have withstood repeated analysis by a number of credible academic authorities with the end
goal to modify if evidence would dictate.
The following guidelines shall be in effect regarding appropriate parameters for dental treatment:
1) All patients must have their blood pressure taken prior to dental treatment.
2) High or elevated blood pressure readings must be re-taken in 5-10 minutes.
3) When systolic and diastolic blood pressure readings fall into differing categories, patients will be
classified according to the higher category. In all cases, the supervising faculty member shall be
informed of the patient’s blood pressure readings prior to initiating treatment.
MOSDOH/AFFINIA guidelines governing Dental Treatment for Patients with High Blood Pressure:
CATEGORY BP (mm Hg) Systolic / Diastolic Modification of Dental Care

Normal <120 / <80 No Modification Necessary
Elevated 120-129 / <80 No Modification Necessary
Stage-1 Hypertension * 130-139 / 80-89 Modify treatment at discretion; Use

caution injecting epinephrine
Stage-2 Hypertension * 140-179 / 90-119 Assess on individual basis with regard to type
and duration of dental procedure; Use
caution injecting epinephrine
Hypertensive Crisis >180 / >120 Avoid elective dental care; Use extreme
If sustained, emergency care is needed. caution injecting.
*Asymptomatic patients with organ damage or poorly controlled diabetes mellitus. Organ damage includes left ventricular
hypertrophy, angina, prior myocardial infarction, prior coronary revascularization, heart failure, stroke, transient ischemic attack,
nephropathy, peripheral arterial disease or retinopathy.
References:
1. Joint report of American College of Cardiology and American Heart Association: New high blood pressure guidelines. American
Heart Association. November, 2017; Available at: http://AHA.org/bpguidelines2017/suppl.
2. Miller, CS, Glick M, Rhodus, NL. 2017 Hypertension guidelines. JADA 149(4):229-231
3. Munter P, Whelton PK. Using predicted cardiovascular disease risk in conjunction with blood pressure to guide antihypertensive
medication treatment. J AM Col Card. 2017; (69)19:2446-56
Page | 20
Guidelines
for
Patients Receiving
Anti-coagulation
Therapy
Anti-coagulation Therapy Guidelines
The following guidelines shall be in effect regarding appropriate indications for treating patients
undergoing dental procedures which may induce bleeding who are also undergoing anticoagulation
therapy.
The policy of MOSDOH/AFFINIA is to follow recommendations based on the most current evidence
suggested by authoritative publications unless alternative regimens have been prescribed in
accordance with a patient’s treating physician’s recommendations.
1) Patients taking Warfarin:
As of December 2019, the most current consensus from literature reviewed supports the
following position:
“The risk of uncontrolled life-threatening bleeding is so low that it is not necessary to stop anticoagulation
therapy even for a short interval and risk thromboembolism in patients on oral anticoagulants.”
Source: Beirne OR. Evidence to continue oral anticoagulation therapy for ambulatory oral surgery. J Oral Maxillofac Surg. 2005; 63:540-545
Policy regarding use of Warfarin:
Dental procedures may be performed upon patients taking Warfarin

assuming a current (30 days or less) INR is within therapeutic range.
Elective dental care should be avoided if a patient’s INR is >4.0 or if the most
recent INR is older than 30 days.
Source: American College of Chest Physicians evidence-based clinical practice guidelines for peri-operative management of antithrombotic
therapy, 8th ed. Chest. 2012; 141:e326S-e350S
At the discretion of the supervising faculty, it is considered prudent to employ adjunctive local
hemostatic measures for all patients undergoing procedures which may induce bleeding.
These measures include biting on gauze, absorbable gelatin sponges, and sutures.
References:
1) Doonquah L, Mitchell AD. Oral surgery for patients on anticoagulation therapy: current thoughts on patient management. Dent
Clin North Am.2012;56:2541.
2) Wahl MJ. Myths of dental surgery in patients receiving anticoagulation therapy. J Am Dent Assoc. 2000; 131:77-81.
3) Bajkin BV, Bajkin IA, Petrovic BB. The effects of combined oral anticoagulant-aspirin therapy in patients undergoing tooth
extractions: a prospective study. J Am Dent Assoc. 2012; 143:771-776
Page | 22
2) Patients taking Antiplatelet Agents:
As of December 2019, the most current consensus from literature reviewed supports the
following position:
“Given the relative ease with which the incidence and severity of oral bleeding can be reduced with the
use of local measures and the unlikely occurrence of bleeding once an initial clot has formed, there is little
to no indication to interrupt antiplatelet drugs for dental surgery.”
Source: Prevention of premature discontinuance of antiplatelet therapy: a science advisory from the American Heart Association, American
College of Cardiology, Society for Cardiovascular Angiography and Intervention and the American dental Association with representation from the
American College of Physicians. Circulation. 2007; 115: 813-818
Policy regarding use of Antiplatelet Agents:
Dental procedures may be performed upon patients taking antiplatelet medications.
At the discretion of the supervising faculty, it is considered prudent to employ adjunctive local
hemostatic measures for all patients undergoing procedures which may induce bleeding.
These measures include biting on gauze, absorbable gelatin sponges, sutures and biting on
gauze.
Source: Wahl MJ. Dental surgery and antiplatelet agents: bleed or die. A Jour Medic. 2013; 127 (4): 261-267
Antiplatelet agents shall include the following:

Acetylsalicylic Acid (ASA) (Aspirin)
Clopidogrel (Plavix)
Ticlopidine (Ticlid)
Cilostazol (Pletal)
Dipyridamole (Persantine)
Ticagrelor (Brilinta)
References:
1. Douketis JD, Spyropoulos AC, Spencer FA, et al. Perioperative management of antithrombotic therapy: antithrombotic therapy and
prevention of thrombosis, 9th ed: American College of Chest Physicians evidence based clinical practice guidelines. Chest.
2012;141(Suppl):e326S-350S.
2. Brennan MT, Wynn RI, Miller CS. Aspirin and bleeding in dentistry: an update and recommendations. Oral Surg Oral Med Oral Pathol
Oral Radiol. 2007;104:316-323
3. Napenas JJ, Oost FC, Degroot A, et al. Review of postoperative bleeding risk in dental patients on antiplatelet therapy. Oral Surg
Oral Med Oral Pathol Oral Radiol. 2013;115:491-499.
4. van Diermen DE, van der Wall I, Hoogstraten J. Management recommendations for invasive dental treatment in patients using oral
antithrombotic medications, including novel anticoagulants. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:709-716.
Page | 23
3) Patients taking Direct Oral Anticoagulants (DOACs):
As of December 2019, after an extensive review of the literature, MOSDOH/AFFINIA has
concluded that no clear position statement exists governing treatment of patients receiving
Direct Oral Anticoagulant (factor-X inhibitors) medications.
DOACs currently include the following three drugs:

Dabigatran (Pradaxa)
Rivaroxaban (Xarelto)
Apixaban (Eliquis)
The available studies make the following recommendations as a prudent, best-practice
recommendation until further research can be completed and results released:
“Although not proven, the peri-procedural risk of bleeding for patients taking DOACs is estimated
to be equal to or less than that of warfarin, but as there is no reversal agent, additional caution is
required when assessing risk. The risk balance may change in the future if reversal agents become
available, but data to suggest that bleeding following invasive procedures will fail to alternative
local hemostatic measures in patients taking DOACs are limited.
Since the thromboembolic risk associated with interrupting a DOAC would appear to be lower
than that of warfarin agent, missing dabigatran or apixaban, or delaying rivaroxaban would be
advised prior to procedures with a higher risk of bleeding. No such interruption would appear to
be necessary prior to procedures with no or low bleeding risk.”
Source: Johnson S. An evidence summary of the management of patients taking direct oral anticoagulants (DOACs) undergoing dental surgery.
Int. J. Oral Maxillofac Surg. 2016; 45: 618-630.
PROCEDURES DEEMED HAVING A HIGHER RISK OF BLEEDING:
Extraction of 3 or more teeth.

Surgical extraction of teeth requiring laying of flap or removal of bone.
Periodontal flap surgery or bone grafting.
Gingival curettage procedures.
Biopsies involving incisions or extensive bone removal.
It is the policy of MOSDOH/AFFINIA that any discontinuance or delay of a DOAC will not be
implemented without first consulting with the patient’s treating or prescribing physician.
Page | 24
Guidelines
for the
Treatment
of
Patients With
Diabetes Mellitus
Treatment Guidelines for Patients with Diabetes Mellitus
The International Expert Committee on Diabetes Care Special Report of 2011 recommended, and the
American Diabetes Association affirmed, the use of the HbA1c test to diagnose diabetes, with a
threshold of ≥6.5% to diagnose diabetes. Pharmacological interventional therapy often will not be
necessary until HbA1c levels exceed 7%.
As of December, 2019, and extensive review of the literature has concluded that no clear position
statement exists governing treatment of patients with HbA1c levels ≥6.5% that are to undergo dental
surgical procedures, however available studies do suggest the following recommendations as a
prudent, best-practice recommendation until further research can be completed and results released:
HbA1c < 7.0% No modifications of treatment required.
HbA1c between 7.1% - 9.0% Consider deferring elective treatment of asymptomatic

patients requiring oral surgical, invasive periodontal* or
endodontic procedures.
Routine restorative procedures may proceed with special

awareness to any possible post-procedural infection.
Emergency procedures on symptomatic or infected patients

should be considered for post-operative antibiotic therapy.
HbA1c > 9.0% Defer elective treatment of asymptomatic patients requiring

oral surgical, invasive periodontal* or endodontic procedures.
Refer patient to physician for glycemic control.
Defer routine restorative procedures. Refer patient to

physician for glycemic control.
Emergency oral surgery procedures on symptomatic or

infected patients should be followed with post-procedural
antibiotic therapy and closely observed for signs of infection.
It is the policy of MOSDOH/AFFINIA that any patient diagnosed with Diabetes Mellitus have a
current (3-months old or less) HbA1c prior to undergoing any non-emergent dental procedure.
*Note: Non-surgical periodontal therapy is not considered an invasive periodontal procedure,

and maybe performed at the discretion of the supervising faculty as a treatment modality to aid
in the reduction of a patient’s elevated HbA1c through the elimination of soft tissue disease. At
the discretion of the supervising faculty, adjunctive administration of antibiotics may also be
deemed appropriate.
Page | 26
As of January 2017, the American Diabetes Association, supported by a consensus of available
research and literature, has accepted and recommended the use of the estimated average
glucose, or eAG as a reliable reporting indicator for diabetes management. The eAG reports in
the same units that patients see routinely in daily blood glucose measurements. Some physicians
will prefer to report average glucose levels to their patients using the eAG indicator. The following
chart will allow conversion between eAG and HbA1c for treatment guidance.
Conversion Chart between eAG and HbA1c
HbA1c % eAG mg/dl
6.0 126
6.5 140
7.0 154
7.5 169
8.0 183
8.5 197
9.0 212
9.5 226
10.0 240
It is the policy of MOSDOH / AFFINIA that any patient diagnosed with Diabetes Mellitus have a
current (3-months old or less) eAG prior to undergoing any non-emergent dental procedure
References:
1. Inzucchi SE. Position Statement of the American Diabetes Association and the European Association for the Study of Diabetes:
The management of hyperglycemia in Type-2 Diabetes. Diabetes Care. 2012; 35:1364-1374.
2. Position statement: Diagnosis and classification of Diabetes Mellitus. Diabetes Care. 2011; 34:s62-s69
3. Aronovich S, Skope LW, Kelly JPW, Kyriakides TC. The relationship of glycemic control to the outcomes of dental extractions. J
Oral Maxillofac Surg. 2010;68:2955-2961.
4. Position statement: Recommendations on use of eAG for measurement of glycemic control. American Diabetes Association.
2017; Available at: http://professional.diabetes.org/diapro/glucose_calc
5. Nathan DM, Kuenen J, Borg R, Zheng H, Schoenfeld D, Heine RJ. Translating the hemoglobin A1c assay into estimated average
glucose values. Diabetes Care. 2008; 29:45-51.
Page | 27
Guidelines
for the
Treatment
of
Patients Taking
Antiresorptive
or
Antiangiogenic Medications
Treatment Guidelines for Patients taking Antiresorptive (Bisphosphonate)
Medications or Antiangiogenic Medications
In order to assist MOSDOH/AFFINIA in the dental treatment of patients receiving Antiresorptive or
Antiangiogenic therapy, guidelines have been developed with the ultimate goal to:
1) Assess risk estimates of developing Medication-Related Osteonecrosis of the Jaws (MRONJ).
2) Compare the risks and benefits of medications related to osteonecrosis of the jaw (ONJ) to aid
decision making for the treating dentist, dental specialist and patient.
3) Offer guidance to clinicians regarding MRONJ prevention measures and management strategies
for patients undergoing antiresorptive or antiangiogenic therapy.
The following are medications included:
Antiresorptive Medications:
Intravenous Bisphosphonates:
Used to manage cancer-related conditions, including hypercalcemia of malignancy, skeletal related

events associated with bone metastases in the context of solid tumors such as breast cancer, prostate
cancer and lung cancers, and for management of lesions in multiple myeloma. Also used in management
of osteoporosis.
Pamidronate (Aredia) - Cancer
Zolendronate (Zometa) - Cancer
Zolendronate (Reclast) - Osteoporosis
RANK Ligand Inhibitors:
Used to manage cancer-related skeletal events associated with bone metastases in the context of solid
tumors such as breast cancer, prostate cancer and lung cancers. Note: it is NOT indicated for management
of lesions in multiple myeloma. Also used in management of osteoporosis.
Denosumab (Prolia) - Osteoporosis
Denosumab (Xgeva) - Cancer
Antiangiogenic Medications
Used in treatment of gastrointestinal tumors, renal cell carcinomas, neuro-endocrine tumors, and other
malignancies.
Bevacizumab (Avastin) - Cancer (No longer approved for Breast Cancer treatment as of November 11,
2011)
Sunitinib (Sutent) - Cancer
Sorafenib (Nexavar) - Cancer
Sirolimus (Rapamune) - Organ rejection of renal transplant

Source: King Rebecca et al. Medication-related osteonecrosis of the jaw related to bisphosphonates and denosumab-a review. Oral Surgery, Oral
Pathology and Oral Radiology Volume 127, Issue 4, 289-299
Page | 29
As of December 2017, and after an extensive review of the literature, MOSDOH/AFFINIA supports
the following management strategies:
For patients about to initiate Antiresorptive or Antiangiogenic treatment for cancer therapy:
1) Encourage a multidisciplinary approach, including collaboration with the patients treating
physician(s) prior to initiating antiresorptive or antiangiogenic therapy as an ONJ preventive
measure. This should include thorough examination of the oral cavity and radiographic
assessment where indicated, and appropriate dental treatment.
2) Identification of acute infection and sites of potential infection in an effort to prevent future
sequelae that could be exacerbated once drug therapies begin. Assessment should include
factors such as patient motivation, patient education regarding dental care, fluoride
applications, chlorhexidine rinses, tooth mobility, periodontal disease, presence of root
fragments, caries, periapical pathology, edentulism and denture stability.
3) Non-restorable teeth and those with a poor prognosis should be extracted. Any other
necessary elective dentoalveolar surgery should be completed.
4) If systemic conditions permit, antiresorptive and antiangiogenic therapy should be delayed
until the extraction / surgical site has mucosalized (14-21 days).
5) Patients with full or partial dentures should be examined for areas of mucosal trauma,
especially along the lingual flange area.
6) Educate the patient to the importance of dental hygiene and regular dental evaluations.
7) Instruct the patient to immediately report any pain, swelling or exposed bone.
For patients about to initiate Antiresorptive treatment for osteoporosis:

1) Patients should be educated to the potential risks of MRONJ as antiresorptive therapy is likely
to exceed 4 years of treatment.
2) Patients should be counseled as to the importance of optimizing dental health throughout
the treatment period and beyond.
For asymptomatic patients receiving IV antiresorptive or antiangiogenic treatment for cancer:

1) Encourage patients to maintain good oral hygiene.
2) Avoid procedures that involve direct osseous surgery.
3) Avoid placement of dental implants.
Page | 30
For asymptomatic patients receiving oral antiresorptive therapy for osteoporosis for ≤4 years:
1) At this time, all evidence suggests that elective dentoalveolar surgery does not appear
contraindicated, with estimated risk of compromised bone healing at <1%.
2) If certain comorbidities exist, or if history of chronic corticosteroid use, careful consideration
of risk vs. benefit should be employed prior to commencement of elective dentoalveolar
surgical procedures.
3) If systemic conditions permit, the dentist, after consulting with treating physician, may
consider discontinuation of oral BPs for a period of two months prior and for 3 months after
elective dental surgery to lower the risk for MRONJ.
For asymptomatic patients receiving oral antiresorptive therapy for osteoporosis for >4 years:
1) At this time, all evidence suggests that elective dentoalveolar surgery does not appear
contraindicated; however, evidence suggests the risk of compromised bone healing to be <1%.
Careful consideration of risk vs. benefit should be employed prior to commencement of
elective dentoalveolar surgical procedures.
2) The dentist, after consulting with treating physician, may consider discontinuation of oral BPs
for a period of two months prior and for 3 months after elective dental surgery to lower the
risk for MRONJ.
For patients with a history of having taken an oral BP for <4 years and have no clinical risk
factors:
1) No alteration or delay in treatment is necessary. This includes any and all procedures common
to oral and maxillofacial surgeons, periodontists, and other dental providers.
2) It is suggested that if dental implants are placed, informed consent should be provided related
to possible long-term implant failure and the low risk of developing ONJ if the patient
continues to take an antiresorptive agent. It should be emphasized to the patient the
importance of being placed on a regular recall schedule.
For patients with a history of having taken an oral BP for <4 years and have taken corticosteroids
or antiangiogenic medications concomitantly:
1) Prescribing provider should be contacted to consider discontinuation of the oral BP for at least
2 months prior to oral surgery if systemic conditions permit.
2) Antiresorptive drug should not be restarted until osseous healing has occurred.
Page | 31
For patients with a history of having taken an oral BP for >4 years and have taken corticosteroids
or antiangiogenic medications concomitantly:
1) Prescribing provider should be contacted to consider discontinuation of the oral BP for at least
2 months prior to oral surgery if systemic conditions permit.
2) Antiresorptive drug should not be restarted until osseous healing has occurred.
3) Educate the patient to the importance of dental hygiene and regular dental evaluations.
4) Instruct the patient to immediately report any pain, swelling or exposed bone.
References:
1. Ruggiero SL, Aghaloo T, et al. Position paper on Medication-Related Osteonecrosis of the Jaw: Surgical Update by The American
Association of Oral and Maxillofacial Surgeons. J Oral Maxillofac Surg. Surgical Update. 2014; 25-2 (Suppl): 2-23.
2. Lo JC, O’Ryan FS, Gordon NP, et al. Prevalence of osteonecrosis of the jaw in patients with oral bisphosphonate exposure.
J Oral Maxillofac Surg. 2010; 68(2):1167-1179.
3. United States Food and Drug Administration: Safety Information. Available at:
http://www.fda.gov.safety/medwatch/safetyinformation. Accessed January 20, 2017.
4. Papapoulos S, Chapurlat R, Libanati C et al. Five years of denosumab exposure in women with postmenopausal osteoporosis: results
from the first two years of the FREEDOM extension. J Bone Miner Res. 2012; 27(3):649-701.
5. Hellstein JW, Adler RA, Edwards B et al. Managing the care of patients receiving antiresorptive therapy for prevention and treatment
of osteoporosis. JADA 2011; 12:1243-51.
6. Smidt-Hansen T, Folkman TB, Fode K et al. Combination of zoledronic acid and targeted therapy is active but may induce ONJ in
patients with metastatic renal cell carcinoma. J Oral Maxillofac Surg. 2013; 71(9):1532-40.
7. Kim YH, Lee HK, Song SI et al. Drug holiday as a prognostic factor of medication-related osteonecrosis of the jaw. J Korean Assoc Oral
Maxillofac Surg. 2014; 40(5):206-210.
8. Yoshiga D, Yamashita Y, Nakamichi I et al. Weekly teriparatide injections successfully treated advanced bisphosphonate-related
osteonecrosis of the jaws. OsteoporosInt. 2013; 24:2365-69. Available at
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3706737/pdf/198_2013_Article_2277.pdf. Accessed November 9, 2017.
Page | 32
Guidelines
for the use of
Local Anesthetics
Treatment Guidelines for the Use of Local Anesthetics
The following guidelines shall be in effect regarding use of and indications for use of local anesthetic
agents:
There are many acceptable local anesthetics available for use. MOSDOH/AFFINIA understands there
are differences in philosophy as to which anesthetic has suitability in various circumstances. As such, it
is the policy of MOSDOH/AFFINIA to permit the administration of any of the following listed
acceptable anesthetics at the discretion of the supervising faculty or AFFINIA provider.
It is the policy of MOSDOH/AFFININA that ester-based injectable local anesthetics shall not be
used due to their potential toxicity and a general consensus that better injectable local
anesthetics exist.
It is acceptable to use ester-based topical formulations for obtaining pre-injection topical-

mucosal anesthesia.
Controversy exists as to the appropriateness of the use of Articaine 4% in nerve block injections,
mostly focused on the inferior alveolar nerve (IAN) block. It is the opinion of MOSDOH / AFFININA
that sufficient data supports the safe use of Articaine 4% as an appropriate injectable local anesthetic
for use in IAN block injections.
Use of Local Anesthetics in Special Populations: Pregnancy, Nursing, Pediatrics.

Pregnancy: Lidocaine and Prilocaine local anesthetics are classified as ‘B’ [Caution advised – no evidence
of 2nd or 3rd trimester risk; fetal harm possible but unlikely]. All other local anesthetics, and Epinephrine,
are classified as ‘C’ [Weigh risk/benefit – weigh possible fetal risk vs. maternal benefit; see package insert
for drug-specific recommendations]. The preponderance of evidence in the literature as of February
2017, suggests that to minimize exposure of the fetus to the effects of the local anesthetic, it is prudent
to select a drug with a shorter elimination half-life. Articaine, with a 27-minute half-life, is considered
preferable to the 90-minute or greater half-life of the other available local anesthetics.
Source: Malamed SF. Articaine 30 years later. J Oral Health. 2016;2:48-49.
Nursing: FDA categories for nursing infants are ‘S’ [Safe], ‘S?’ [Safety in nursing infants unknown] and
‘NS’ [Not safe for nursing infants] Lidocaine is the only ‘S’ local anesthetic. All others, and Epinephrine
(in dental concentrations), are ‘S?’ Following exposure to any drug, it is considered prudent to advise
the nursing mother to pump and discard the milk for a period covering six elimination half-lives of the
drug administered. For all local anesthetics, except Articaine, this is a period of nine hours. For
Articaine, this is a period of four hours.
Page | 34
Note: It is not uncommon for nursing mothers in the need of dental care to ask their dentist, “Will the
drug (e.g. lidocaine) be in the milk?” The answer will always be ‘Yes.’ The concept of “pump and discard”
successfully handles this situation.
Pediatrics: The majority of local anesthetic overdoses develop as a result of the over administration of the drug,
most commonly in patients weighing under 30 kg (66 lbs) who are well behaved and in need of multiple quadrants
of dental care. The preponderance of evidence in the literature as of February 2017, suggests that to reduce the
risk of overdose in pediatric patients, it is prudent to select a drug with a shorter elimination half-life. Articaine,
with a 27-minute half-life, is considered preferable to the 90-minute or greater half-life of the other available local
anesthetics. In addition, since Articaine undergoes metabolism in the plasma, as well as in the liver, it is preferred
in lighter weight patients.
Local Anesthetics Available at MOSDOH/AFFINIA with their Maximum Recommended Doses:
Drug Mg/kg Absolute maximum
Articaine HCl 4% 7 n/a

1:100,000 epi
1:200,000 epi
Bupivacaine HCl 0.5% 2 90

1:200,000 epi
Lidocaine HCl 2% 7 500

1:50,000 epi
1:100,000 epi
Mepivacaine HCl 3% 6.6 400

without epi
Prilocaine HCl 4% 8 600

without epi
References:
1. Malamed SF. Articaine 30 years later. J Oral Health. 2016;2:52-53.
2. United States FDA Pregnancy Categories. Available at: http://www.drugs.com/pregnancy-categories.html. Accessed January 20, 2017,
3. Garisto GA, Gaffen AS, Lawrence HP, Tenenbaum HC, Haas DA. Occurrence of paresthesia after dental local anesthetic administration
in the United States. J Am Dent Assoc. 2010;141(7):836-844.
4. U.S. Food and Drug Admistration Center for Drug Evaluation and Research, Office of Post-Marketing Risk Assessment. Revised 9
January 2009. Available at: http://www.fda.gov/Drugs/Guidance-
ComplianceRegulatoryInformation/Surveillance?AdverseDrugEffects/default.htm.
5. Brandt RG, Anderson PF, McDonald NJ, Sohn W, Peters MC. The pulpal anesthetic efficacy of articaine versus lidocaine in dentistry: a
meta-analysis. J Am Dent Assoc. 2011;142(5):493-504.
6. Malet A, Faure MO, Deletage N, Pereira B, Hass J,Lambert G. The comparative cytotoxic effects of different local anesthetics on a
human neuroblastoma cell line. Anesth Analg. 2015;120(3):589-596
Page | 35
Guidelines
for the
Selection and Use

of
Needles
for the
Delivery of
Local Anesthetic Agents
Guidelines for Selection and Use of Needles for Delivery of Local Anesthetic Agents
Controversy exists as to the appropriateness of using short (21-millimeter) or small diameter (30-
gauge) needles during IAN-block injections. Reported problems include inadvertent breakage of the
needle (especially in children under the age of 10) and failure to obtain reliable positive aspiration.
After review of the current literature, the following recommendations based on best-practice
guidelines shall be in effect regarding the selection of needles for the delivery of local anesthetic
agents:
For all IAN-block injections, it will be the policy of MOSDOH / AFFINIA to use a long (32-
millimeter) needle and nothing smaller than a 27-gague needle.
For all other injections, it is acceptable to use any gauge or length needle that the
supervising faculty or treating dentist would deem appropriate.
Proper technique and patient management are essential to prevent fracture of needles.
Avoid bending needles before injection. Avoid insertion of the needle to the hub to reduce
the likelihood of breakage and creating an irretrievable needle.
NOTE: The use of ultra-short needles (10-millimeters) shall not be permitted.
References:
1. Malamed SF, Reed K, and Poorsattar S. Needle breakage: incidence and prevention. Dent Clin North Am 2010; 54:745-756.
2. Pogrel MA. Broken local anesthetic needles: a case series of 16 patients, with recommendations. J Am Dent Assoc. 2009;
140:1517-1522.
3. Orr DL. The broken needle: report of case. JADA 1983; 107:603-604.
4. Brooks J, Murphy, MT. A novel case of a broken dental anesthetic needle transecting the right internal carotid artery. J Am
Dent Assoc. 2016; 147:739-742
Page | 37
Guidelines
for the
Treatment
of
Pregnant Patients
Guidelines for the Treatment of Pregnant Patients
For many years, controversy existed as to the appropriateness of performing routine dental
treatment during pregnancy. In the past, dentists were advised to either avoid elective treatment
during pregnancy due to perceived risk to the developing fetus, or to limit elective treatment to the
middle trimester. Limiting treatment to the middle trimester theoretically avoided potential
teratogenic effects during the first trimester and avoided potential spontaneous delivery during the
third trimester. After a December 2019 review of the current literature, the following
recommendations shall be in effect regarding the dental treatment of pregnant patients:
The use of dental local anesthetics, as well as dental treatment during pregnancy, do not
represent a major teratogenic risk. There seems to be no reason to prevent pregnant women
from receiving dental treatment and local anesthetic during pregnancy.
It is considered prudent to consider the wishes of the pregnant patient prior to performing elective
dental treatment, and, after explaining the risk of postponement of dental care versus the risk of
maternal / fetal harm, consider the preferences of the patient prior to commencement of any dental
procedure.
It is not required to consult with the patients treating physician prior to initiating any elective dental
care, however, if coexistent medical conditions are of concern to the treating dentist, consultation with
the patient’s physician is both prudent and advised.
It is considered prudent during the second and third trimesters of pregnancy to use caution while
positioning the patient in a reclined position, and to monitor stress-levels of the patient, so as not to
induce contractions.
References:
1. California Dental Association Foundation. Oral Health During Pregnancy & Early Childhood: Evidenced-Based Guidelines for Health
Professionals.Sacramento, CA.: California Dental Association Foundation; 2010. Available at:
http://www.cdafoundation.org/Portals/0/pdfs/poh_guidelines. pdf. Accessed April 13, 2015.
2. American College of Obstetricians and Gynecologists Women’s Health Care Physicians; Committee on Health Care for Underserved
Women. Committee Opinion No. 569: oral health care during pregnancy and through the lifespan. Obstet Gynecol. 2013;122(2 pt
1):417-422.
3. LaBorde JB, Holson RR, Bates HK. Developmental toxicity evaluation of lidocaine in CD rats. Teratology. 1988;37(5):472.
4. Fujinaga M, Mazze RI. Reproductive and teratogenic effect of lidocaine in Sprague-Dawley rats. Anesthesiology. 1986;65(6):626-632.
5. Malamed SF. Handbook of Local Anesthesia. 4th ed. St. Louis, MO: C.V. Mosby; 1997.
6. Gaffield ML, Gilbert BJ, Malvitz DM, Romaguera R. Oral health during pregnancy: an analysis of information collected by the pregnancy
risk assessment monitoring system. J Am Dent Assoc. 2001;132(7):1009-1016.
7. George A, Shamim S, Johnson M, et al. How do dental and prenatal care practitioners perceive dental care during pregnancy? Current
evidence and implications. Birth. 2012;39(3):238-247.
Page | 39
Guidelines for the Treatment of Pregnant Patients - References (cont):
8. Pina PM, Douglass J. Practices and opinions of Connecticut general dentists regarding dental treatment during pregnancy. Gen Dent.
2011;59(1): e25-e31.
9. Strafford KE, Shellhaas C, Hade EM. Provider and patient perceptions about dental care during pregnancy. J Matern Fetal Neonatal
Med. 2008;21(1):63-71.
10. Michalowicz BS, DiAngelis AJ, Novak MJ, et al. Examining the safety of dental treatment in pregnant women. J Am Dent Assoc.
2008;139(6): 685-695.
11. Hagai A, Diav-Citrin O, Shechtman S, Ornoy A. Pregnancy outcomes after in utero exposure to local anesthetics as part of dental
treatment – A prospective comparative cohort study. J Am Dent Assoc. 2015;146:572-580.
Page | 40
Guidelines
for the
Appropriate Use
of
Antibiotics
Guidelines for the Appropriate Use of Antibiotics
As of December 2019, neither the American Dental Association (ADA), nor the Center for Disease
Control (CDC), or any other credible scientific body, has established a national prescribing guideline
regarding prescribing and use of antibiotics. Until national guidelines are established and endorsed
by the ADA or other academically acceptable dental specialty organizations, dentists must continue
to use their judgment to optimize antibiotic prescribing.
Until such time, and to aid in addressing concerns being raised regarding the increased use of
antibiotics and its potential to contribute to antibiotic-related adverse effects, and, after an extensive
review of the literature, MOSDOH/AFFINIA has adopted the policy to follow published “Clinical tips
for antibiotic prescribing by dentists” as published in the Journal of the American Dental Association
in August, 2016 as a guide to faculty, students and AFFINIA providers regarding the use of Antibiotics
as it relates to the delivery of dental care:
Clinical tips for antibiotic prescribing by dentists.

PRETREATMENT CONSIDERATIONS
• Make the correct diagnosis of an oral bacterial infection.
• Recognize that antibiotics are rarely helpful for effective control of a localized oral infection.
• Therapeutic management interventions, such as incision and drainage, extraction, or
endodontic therapy, are appropriate first steps in treating most oral bacterial infections.
Weigh the potential benefits and risks of antibiotics before prescribing. Toxicity, allergy,
adverse effects, and Clostridium difficile infection can occur even with a single dose.21
• Prescribe antibiotics (and all other prescriptions) only for patients of record.
• Prescribe antibiotics only for bacterial infections you have been trained to treat.
• Do not prescribe antibiotics for oral viral infections, fungal infections, or oral ulcerations
related to trauma or aphthae.
• Understand and implement national recommendations for antibiotic prophylaxis for the
medical concerns for which guidelines exist (for example, cardiac defects).
• Review the patient’s medical history to
• assess medication allergies, drug-drug interactions, and the potential for other
adverse drug events;
• Review pregnancy status and medical conditions that would affect antibiotic
selection.
MAINTAINING OPTIMAL PRESCRIBING PRACTICES

• Provide training to staff members to improve the probability to patient adherence to the
antibiotic prescription.
• Ensure you are up to date on appropriate management of oral bacterial infections by
attending continuing education courses or conferences on the topic or accessing dental
journals or pharmacology texts on the topic.
Page | 42
CHAIRSIDE PRESCRIBING
• Ensure that antibiotic expertise or references are available and can be accessed during patient
visits.
• Avoid prescribing based on
 nonevidence-based historical practices;
 patient demand or expectations;
 convenience of clinician or patient;
 pressure from other health care professional.
• Make and document the diagnosis, treatment steps, and if prescribed, the rationale for antibiotic
use in the patient chart.
• Prescribe only when clinical signs and symptoms of a bacterial infection suggest systemic spread,
such as fever or malaise along with localized oral swelling.
• Use the most targeted (narrow-spectrum) antibiotic for the shortest duration possible (2-3 days
after the clinical signs and symptoms subside) for otherwise healthy patients.
• For empirical treatment, revise antibiotic regimens on the basis of patient progress and, if needed,
culture results.
• Consider a conversation about antibiotic use with referring specialists about their own antibiotic
prescribing protocols.
ENGAGING THE PATIENT
• Educate your patients about
 taking the antibiotic exactly as prescribed;
 taking only antibiotics prescribed for themselves
 not saving antibiotics for future illness.
References:
1. Fluent MT, Jacobsen PL, Hicks LA. Considerations for responsible antibiotic use in dentistry. J Am Dent Assoc. 2016;147(8):683-686.
2. Centers for Disease Control and Prevention. Antibiotic resistance threats in the United States, 2013. Available at: http://www.cdc.gov/
drugresistance/pdf/ar-threats-2013-508.pdf. Accessed January 26, 2017.
3. Talbot GH, Bradley J, Edwards JE Jr, et al. Bad bugs need drugs: an update on the development pipeline from the Antimicrobial
Availability Task Force of the Infectious Diseases Society of America. Clin Infect Dis. 2006; 42(5):657-668.
4. Cope AL, Chestnutt IG. Inappropriate prescribing of antibiotics in primary dental care: reasons and resolutions. Prim Dent J.
2014;3(4):33-37.
5. Fleming-Dutra, K. Why do we prescribe antibiotics when they aren’t needed? Safe Healthcare Blog, Centers for Disease Control and
Prevention website. May 4, 2016. http://blogs.cdc.gov/safe-healthcare/why-do-we-prescribe-antibiotics-when-they-a r en’ t -
needed/.
Accessed January 26, 2017.
6. Spellberg B, Blaser M, Guidos RJ, et al. Combating antimicrobial resistance: policy recommendation to save lives. Clin Infect Dis.
2011;52 (suppl 5):s397-s428.
7. Stein K, Singhal S, Marra F, Quiñonez. The use and misuse of antibiotics in dentistry – A scoping review. J Am Dent Assoc. 2018;
149(10):869-884.e5.
Page | 43
Guidelines
for the
Appropriate Use
of
Opioids
Guidelines for the Appropriate Use of Opioids
Over the past ten years there has been an increasing concern over the use of opioid-analgesics in
America as well as other countries. This concern has recently led to the reclassification of
Hydrocodone-containing products from Schedule-III controlled substances to Schedule-II. The
concerns with opioids include increases in the risk of patients’ experiencing adverse effects such
as nausea, vomiting and psychomotor impairment, an increase in the risk of central nervous
system depression, and what has been determined to be a significant risk of drug misuse and
abuse.
Much research has been conducted over the past 10 years to determine efficacy of non-opioid-
based alternative drug therapies. As of January 2017, a review of the literature clearly concludes
that pain control regimens utilizing combinations of NSAIDs (ibuprofen or naproxen) with
acetaminophen (N-acetyl-p-aminophenol, or APAP) are just as effective, if not more effective, at
relieving most dental pain.
After an extensive review of the literature, in an effort to aid in addressing the multitude of
concerns being raised regarding the increased use and abuse of opioid-analgesics, and to provide
our patients with the safest, most effective and most responsible pain control, MOSDOH/AFFINIA
has adopted the following guidelines regarding control of acute postoperative dental pain as a
guide to faculty, students and AFFINIA providers regarding the use of opioids:
Stepwise guidelines for acute postoperative pain management in dentistry.

PAIN SEVERITY ANALGESIC RECOMMENDATION*
Mild Ibuprofen (200-400 milligrams)
q† 4-6 hours: prnǂ for pain
Mild to Moderate Ibuprofen (400-600mg)
q 6 hours: fixed interval for 24 hours
Then Ibuprofen (400 mg) q 4-6 hours: prn for pain
Moderate to Ibuprofen (400-600 mg) with APAP (500mg)
Severe q 6 hours: fixed interval for 24 hours
Then Ibuprofen (400 mg) with APAP (500mg) q 6 hours: prn for pain
Severe Ibuprofen (400-600) with APAP (650mg) with hydrocodone (10mg) q 6 hours: fixed interval
for 24-489 hours
Then ibuprofen (400-600mg) with APAP (500mg) q 6 hours: prn for pain
*Additional considerations:
 Patients should be warned to avoid acetaminophen, N-acetyl-p-aminophenol (APAP), in other medications.
Maximum daily dose of APAP is 3,000 mg per day. To avoid potential APAP toxicity, a dentist should consider
prescribing an opioid rescue medication containing ibuprofen.
 Maximum dose of ibuprofen is 2,400 mg per day. Higher maximal daily doses have been reported for
osteoarthritis when under the direction of a physician.
 A decrease in post-operative pain severity has been demonstrated when A nonsteroidal anti-inflammatory
drug is administered pre-emptively.
 Long-acting local anesthetics can delay onset and severity of postoperative pain.
 A perioperative corticosteroid (dexamethasone) may limit swelling and decrease postoperative discomfort
after third-molar extractions.
† q: Every.
ǂ prn: As needed.
Page | 45
Guidelines for the Appropriate Use of Opioids (cont).
References:
1. 1. Moore PA, Hersch EV Combining ibuprofen and acetaminophen for acute pain management after third molar extractions. J Am
Dent Assoc. 2013;144(8):898-908.
2. Mehlisch DR, Sollecito WA, Helfrick JF, et al. Multicenter clinical trial of ibuprofen and acetaminophen in the treatment of postoperative
dental pain. JADA 1990;121(2):257-263.
3. Denisco RC, Kenna GA, O’Neill MG, et al. Prevention of prescription opioid abuse: the role of the dentist. JADA 2011(7);142; 800-810.
4. Derry S, Wiffen PJ, Moore RA. Relative efficacy of oral analgesics after third molar extractions: a 2011 update. Br Dent J
2011;211(9):419-420.
Page | 46
Guidelines
for the
Treatment
of
Patients
with
Autoimmune Disease
Guidelines for Treatment of patients with Autoimmune Diseases
A December 2019 review of the literature reveals that there is no clear consensus or established
policy as to the appropriateness of administering antibiotic premedication to dental patients with
autoimmune diseases. The exceptions are rheumatoid arthritis patients with prosthetic joints,
where the evidence suggests it is prudent to premedicate prior to a dental procedure, as discussed
in guideline 1(B) earlier in the guidelines.
A preponderance of the evidence suggests the following:
In patients with auto-immune disease/disorders, it is prudent to weigh the severity of the

disease along with any presence of co-morbidities against the risks of non-premedication,
and, when possible, consult with the treating physician for recommendations on a case-by-
References:
1. NHS Choices. Rheumatoid arthritis. 2014. Online information available at http://www.nhs.uk/conditions/Rheumatoid-
arthritis/Pages/Introduction.aspx (accessed January, 2017).
2. Gullick N J, Scott D L. Co-morbidities in established rheumatoid arthritis. Best Pract Res Clin Rheumatol. 2011;25:469–483.
3. Payne J B, Golub L M, Thiele G M, Mikuls T R. The link between periodontitis and rheumatoid arthritis: a periodontist's
perspective. Curr Oral Health Rep. 2015;2:20–29.
4. Ortiz P, Bissada N F, Palomo L et al. Periodontal therapy reduces the severity of active rheumatoid arthritis in patients treated
with or without tumor necrosis factor inhibitors. J Periodontol. 2009;80:535–540.
5. Hays J W, Sarmadi M, Moutsopoulos N M. Oral manifestations of systemic autoimmune and inflammatory diseases: diagnosis
and clinical management. J Evid Based Dent Pract. 2012;12:265–282.
6. Zero D T, Brennan M T, Daniels T E et al. Clinical practice guidelines for oral management of Sjögren disease: Dental caries
prevention. J Am Dent Assoc 2016;147:295–305.
7. Carr A J, Ng W F, Figueiredo F, Macleod R I, Greenwood M, Staines K. Sjögren's syndrome–an update for dental practitioners. Br
Dent J. 2012;213:353–357.
8. Patton L L, Glick M (eds). The ADA practical guide to patients with medical conditions. 2nd ed. New Jersey: Wiley-
Blackwell, 2015.
9. Donaldson M, Epstein J, Villines D. Managing the care of patients with Sjögren syndrome and dry mouth: comorbidities,
medication use and dental care considerations. J Am Dent Assoc. 2014;145:1240–1247.
10. Ruggiero S L, Dodson T B. American Association of Oral and Maxillofacial Surgeons position Paper on Medication-Related
Osteonecrosis of the Jaws2014 Update. J Oral Maxillofac Surg. 2014;72:2381–2382.
11. British Society of Rheumatology. BSR/BHPR non-biologic DMARD guidelines. 2016. Online information available
at http://www.rheumatology.org.uk/includes/documents/cm_docs/2016/f/full_dmards_guideline_and_the_executive_summar
y.pdf (accessed January, 2017)
Page | 48
Guidelines
for the use of
Medicated
Retraction Cords / Agents
.
Guidelines for Use of Medicated Retraction Cords and Retraction Agents
Gingival retraction using retraction cord continues to be the most popular method for controlling
gingival moisture and sulcular topography during restorative procedures that encroach upon or
into the sulcular and peri-sulcular area. Chemically active gingival retraction agents are
categorized as Class-I (vasoconstrictors, adrenergics) or Class-II (hemostatic agents, astringents).
Concerns exist over the use of Class-I racemic epinephrine-impregnated cords due to the
possibility for sudden elevation of blood pressure and increase in heart rate.
Many studies have been conducted on various chemically impregnated retraction cords and
retraction systems. As of December 2017, review of the literature reveals a consensus that there
is no benefit in the use of epinephrine-impregnated retraction cord over other impregnated cords
in either the ability to control gingival hemorrhage or in the mechanical displacement of tissue.
Given the available evidence, MOSDOH/AFFININA has adopted the following policy regarding the
use of epinephrine-impregnated retraction cord and epinephrine-containing retraction systems:
The use of epinephrine-impregnated retraction cord and epinephrine-containing

retraction systems will not be permitted.
References:
1. Tarighi P, Khoroushi M, A review on common chemical hemostatic agents in restorative dentistry. Dent Res J. 2014;11(4):423-
428
2. Donovan TE, Gandara BK, Nemetz H. Review and survey of medicaments used with gingival retraction cords. J Prosthet
Dent. 1985;53:525–31.
3. Kumbuloglu O, User A, Toksavul S, Boyacioglu H. Clinical evaluation of different gingival retraction cords. Quintessence
Int. 2007;38:e92–8.
4. Al Hamad KQ, Azar WZ, Alwaeli HA, Said KN. A clinical study on the effects of cordless and conventional retraction techniques on
the gingival and periodontal health. J Clin Periodontol. 2008;35:1053–8.
5. Phatale S, Marawar PP, Byakod G, Lagdive SB, Kalburge JV. Effect of retraction materials on gingival health: A histopathological
study. J Indian Soc Periodontol. 2010;14:35–9.
6. Akca EA, Yildirim E, Dalkiz M, Yavuzyilmaz H, Beydemir B. Effects of different retraction medicaments on gingival
tissue. Quintessence Int. 2006;37:53–9.
Page | 50
Guidelines
for the use of
Nitrous Oxide
Guidelines for Administration of Nitrous Oxide
Both the American Dental Association (ADA) and the American Academy of Pediatric Dentistry
(AAPD) recognizes nitrous oxide / oxygen inhalation (N2O/O2) as a safe and effective technique to
reduce anxiety, produce analgesia, and enhance opportunities for high-quality care. It is the policy
of MOSDOH / AFFINIA that N2O/O2 administration shall be taught as part of the standard
undergraduate dental curriculum, and utilized at the discretion of the faculty as needed.
Accordingly, the goal of MOSDOH / AFFINIA is to establish and employ work practices and
standard procedures that act to minimize worker exposure to N2O/O2 as well as ensure safety of
the patient at all times.
A. Exposure Control Guidelines:

Engineering, administrative and work-practice controls shall be implemented at MOSDOH /
AFFINIA according to established Occupational Safety and Health Administration (OSHA) and
American dental Association (ADA) recommendations in order to minimize exposure risk to
treatment providers, auxiliary and other support personnel within the building where the
N2O/O2 is used. This shall include:
i) The use of primary engineering controls such as:
• use of properly fitting nasal scavenging masks on both adult and pediatric patients.
• use of Local Exhaust Ventilation (LEV) near the patient’s mouth.
• regular inspection of nitrous oxide delivery and scavenging equipment for leaks.
• regular inspection of nitrous oxide delivery system for functioning fail-safe
mechanism.
• acceptable building ambient air recirculation and control mechanisms.
• utilization of supplemental LEV when N2O levels cannot be adequately controlled
using nasal masks.
• ambient air exposure monitoring.
ii) Prudent best-practice protocols such as:

• not starting nitrous oxide gas flow before the delivery mask has been applied to
patient.
• turning off the nitrous oxide flow before turning off the oxygen flow.
• training personnel involved in N2O/O2 administration / monitoring on current safe-
handling procedures.
• providing periodic updated training for personnel involved in N2O/O2 administration /
monitoring.
Page | 52
B. Indications for use of N2O/O2:
A review of the literature in December 2019, suggests the following accepted indications for
the use of nitrous oxide/oxygen analgesia/anxiolysis. Be aware that potential medical
complications may arise, or potential drug interactions may take place. Dentist should be
aware of and trained in appropriate emergency management protocols prior to administering
N₂O/O₂.
Fearful, anxious or obstreperous patient.

Certain patients with special health care needs.
A patient whose gag reflex interferes with dental care.
A patient for whom profound local anesthesia cannot be obtained.
A cooperative child undergoing a lengthy dental procedure.
C. Absolute Contraindications for use of N2O/O2:
A review of the literature in December 2019, suggests the following contraindications for the
use of nitrous oxide/oxygen analgesia/anxiolysis:
Chronic obstructive pulmonary disease (COPD).

Severe emotional disturbances or active substance abuse.
Patient having respiratory difficulty due to asthma.
Pregnancy.
Treatment with bleomycin sulfate.
Methylenetetrahydrofolate reductase deficiency.
Cobalamin deficiency.
Nasal Obstruction.
High intracranial pressure due to intracranial disorder.
As a substitute for general anesthesia.
Patient refusal.
Lack of or inadequate gas recovery affecting dental team.
Recent (3-months or less) surgery to the ear.
D. Relative contraindications for use of N₂O/O₂, or conditions where consultation with

treating physician is strongly recommended prior to administration of N2O/O2:
A review of the literature in December 2017, suggests that N₂O/O₂ may be used with caution.
Be aware that potential medical complications may arise, or potential drug interactions may
take place. Dentist should be aware of and trained in appropriate emergency management
protocols prior to administering N₂O/O₂. Consultation with a patient’s treating physician may
be warranted prior to administration of nitrous oxide/oxygen analgesia/anxiolysis if any of the
following significant underlying medical conditions exist:
Page | 53
Relative contraindications for use of N₂O/O₂, or conditions where consultation with treating
physician is strongly recommended prior to administration of N2O/O2 (cont).
Acute severe head injury.

Pulmonary disease.
Current respiratory infection.
Psychiatric patients.
Immune-compromised patients.
Multiple sclerosis.
Patients using marijuana or hallucinogenic drugs.
Blocked middle ear.
Congestive heart failure.
Sickle cell disease.
Acute otitis media.
Recent tympanic membrane graft.
Repeated exposures to N₂O/O₂ less than one week apart.
E. Special Considerations Regarding Safety While Administering Oxygen:
Reports of patient fires have been a concern within the medical and dental community over the past 75
years plus. Oxygen, when administered in 100% concentrations, is highly combustible and flammable.
A heightened awareness of fire risk is necessary while administering 100% oxygen to

patients at all times.
Special considerations should be given to performing procedures that have potential to generate a spark,
produce heat or otherwise have potential to produce an ignition source. The list below are examples of
procedures that should be avoided while in close proximity to a patient receiving 100% oxygen:
Adjustment of titanium posts, titanium abutments or zirconia crowns with burs or other spark-
producing instruments.
Use of electrosurgery, electrocautery or laser.
Use of fiberoptic cables and lights.
Other procedures that could produce heat and spark from dental burs.
Use of battery burners.
Use of Bunsen burners or alcohol torches.
Page | 54
Guidelines for Administration of Nitrous Oxide (cont.)
References:
1. American Dental Association. Guideline for the use of sedation and general anesthesia by dentists. 2007. Available at
“http://www.ada.org/sections/about/pdfs/ anesthesia_guidelines.pdf”. Accessed January 27, 2017.
2. American Society of Anesthesiologists. Practice guidelines for sedation and analgesia by nonanesthesiologists: An updated report by
the American Society of Anesthesiologists task force on sedation and analgesia by nonanesthesiologists. Anesthesiology
2002;96:1004-17.
3. Paterson SA, Tahmassebi JF. Pediatric dentistry in the new millennium: Use of inhalation sedation in pediatric dentistry. Dent Update
2003;30(7):350-6, 358.
4. Duncan GH, Moore P. Nitrous oxide and the dental patient: A review of adverse reactions. J Am Dent Assoc 1984;108(2):213-9.
5. Clark MS. Contemporary issues surrounding nitrous oxide. In: Malamed SF, ed. Sedation: A Guide to Patient Management. 5th ed. St.
Louis, MO: Mosby Elsevier; 2010:256.
6. Rowland AS, Baird DD, Shore DL, Weinberg CR, Savitz DA, Wilcox AJ. Nitrous oxide and spontaneous abortion in female dental
assistants. Am J Epidemiol 1995;141 (6):531-7.
7. Fleming P, Walker PO, Priest JR. Bleomycin therapy: A contraindication to the use of nitrous oxide-oxygen psychosedation in the
dental office. Pediatr Dent 1988;10 (4):345-6.
8. Selzer R, Rosenblatt D, Laxova R, Hogan K. Adverse effect of nitrous oxide in a child with 5,10- methylenetetrahydrofolate reductase
deficiency. N Engl J Med 2003; 349(1):45-50.
9. Ogundipe O, Pearson MW, Slater NG, Adepegba T, Westerdale N. Sickle cell disease and nitrous oxide-induced neuropathy. Clin Lab
Haematol 1999;21(6):409-12.
10. Fish BM, Banerjee AR, Jennings CR, et al. Effect of anaesthetic agents on tympanometry and middle-ear effusions. J Laryngol Otol
2000;114(5):336-8.
11. Moss E, McDowall DG. ICP increase with 50% nitrous oxide in oxygen in severe head injuries during controlled ventilation. Br J Anaest
1979;51(8):757-61.
12. Malamed SF. Sedation: A Guide to Patient Management. 5th ed. St. Louis, MO: Mosby Elsevier; 2010:248-259.
13. Kupietzky A, Tal E, Shapira J, Ram D. Fasting state and episodes of vomiting in children receiving nitrous oxide for dental treatment.
Pediatr Dent 2008;30(5):414-9.
14. American Academy of Pediatric Dentistry. Policy on minimizing occupational health hazards associated with nitrous oxide. Pediatr
Dent 2013;35(special issue): 80-1.
15. Bosack RC, Bruley ME, VanCleave AM, Weaver JM. Patient fire during dental care: A case report and call for safety. J Am Dent Assoc
2016;147(8):661-666.
16. Schuman I. Nitrous oxide: use and safety. J A Gen Dent 2016; April CE sup (1).
Page | 55
Guidelines
for the use of
Vasoconstrictors
Guidelines for the Use of Vasoconstrictors
Vasoconstrictors serve an important role in dentistry when added to injectable local anesthetics.
Their role is to provide a deeper, more prolonged anesthesia, hemostasis and prevent toxicity by
slowing the anesthetic’s absorption into the bloodstream. There are two vasoconstrictors used
in injectable dental local anesthetic agents: epinephrine and levonordefrin (Neo-Cobefrin). A
significant body of evidence suggests there be a prudent use of vasoconstrictors.
Given the available evidence, MOSDOH / AFFININA has adopted the following policy regarding the
use of vasoconstrictors in local anesthetics:
A) Absolute contraindications to the use of vasoconstrictors.

Local anesthetics containing vasoconstrictors shall not be used in the following circumstances:
ABSOLUTE CONTRAINDICATIONS TO THE USE OF VASOCONSTRICTORS
Unstable angina.
Myocardial infarction (MI) within the past 3-months.
Coronary artery bypass surgery within the past 6-months.
Cardiac stent placement within the past 3-months.
Refractory cardiac arrhythmias.
Untreated or uncontrolled hypertension.
Untreated or uncontrolled congestive heart failure.
Uncontrolled hyperthyroidism.
Uncontrolled diabetes.
Sulfite sensitivity.
Steroid dependent asthma.
Pheochromocytoma.
Narrow-angle glaucoma.
Page | 57
C) Relative contraindications to the use of vasoconstrictors.
Local anesthetics containing vasoconstrictors may be used with caution. Be aware that potential
medical complications may arise, or potential drug interactions may take place. Dentist should
be aware of and trained in appropriate emergency management protocols prior to the injecting
of any local anesthetic containing a vasoconstrictor.
RELATIVE CONTRAINDICATIONS TO THE USE OF VASOCONSTRICTORS
Patients whose blood pressure is ≥140 systolic or ≥90 diastolic.
Patients taking tricyclic antidepressants.
Patients taking phenothiazine compounds.
Patients taking mono-amine oxidase inhibitors (MAOI).
Patients taking β-blockers with special concern with patients taking non-selective β-blockers.
Patients taking calcium channel blockers.
Patients taking anti-arrhythmic medications, including amiodarone, encainide, flecainide,

lorcainide, mexiletine, pirmenol, propafenone or tocainide.
Known or suspected cocaine abusers.
References:
1. Goulet JP, Perusse R, Turcotte, JY. Contraindications to vasoconstrictors in dentistry. OOO. 1992;74:679-91.
2. Malamed SF. Handbook of local anesthesia. 6th ed. Elsevier Health Sciences; St. Louis, MO: C.V.Mosby; 2014.
3. Malamed SF. Medical emergencies in the dental office. 7th ed. Elsevier Health Sciences; St. Louis, MO: C.V.Mosby; 2015
4. Reyes-Fernadez S, Romero-Castro NS, Contreras-Palma GM, Nieves-Hosiko V, Cebreros-Lopez DI. Influence of Vasoconstrictors added
to dental anesthetics on blood pressure and heart rate. Revista Cubana de Estomatologia. 2017;54-2:1-10
5. Hersh EV, Giannakopoulos H. Beta-adrenergic blocking agents and dental vasoconstrictors. Dent Clin North Am. 2010;54(4):687-696.
6. Torres-Lagares D, Serrera-Figallo MA, Machuca-Portillo G, et.al. Cardiovascular effect of dental anesthesia with various epinephrine
concentrations in medically compromised cardiac patients: a cross-over, randomized, single blinded study. Med Oral Patol Oral Cir
Bucal. 2012;17(4):655-60.
Page | 58
A special thank you to the following people who have helped to make this manual possible:
For their review of content and scholarly recommendations -

David Scott Dunivan, DMD, MS; Associate Professor and Director, Section of Periodontics. AT Still University –
Missouri School of Dentistry and Oral Health.
Matthew M. Greaves, DDS, MS; Assistant Professor and Comprehensive Care Unit Director. AT Still University –
Missouri School of Dentistry and Oral Health.
Robert T. Reti, DDS; Adjunct Assistant Professor, Oral and Maxillofacial Surgery. AT Still University – Missouri
School of Dentistry and Oral Health.
Brandon M. Bushong, DMD, MS; Adjunct Assistant Professor, Periodontics. AT Still University – Missouri School
of Dentistry and Oral Health.
Karl M. Shanker, DDS; Associate Professor and Director, Section of Special Needs. AT Still University – Missouri
School of Dentistry and Oral Health.
Romana G. Mueller, BSRDH, MS; Assistant Professor, Dental Hygiene, Sections of Periodontics. AT Still University
– Missouri School of Dentistry and Oral Health.
Robert J. Theobald, Jr., PhD; Professor, Department of Pharmacology. AT Still University – Kirksville College of
Osteopathic Medicine.
Richard J. Vargo, DMD, DABOMP, FAAOM; Assistant Professor and Director, Section of Oral Maxillofacial
Pathology.
Timothy E. Pratt, MD; Private Practice of Internal Medicine and Vice President for Medical Affairs, St. Clare
Hospital, St. Louis, Missouri.
James R. Donnell, MD; Chairman, Department of Emergency Medicine and Director of Emergency Department,
St. Clare Hospital, St. Louis, Missouri
For their talents and efforts in the area of formatting, editing and IT support -
Nae’Wanda Moore; Administrative Assistant. AT Still University – Missouri School of Dentistry and Oral Health.
Maria Evans; Department of Information technology. AT Still University – Missouri School of Dentistry and Oral
Health.
To our administration at A.T. Still University – MOSDOH for their ongoing support of this
project:
Dwight E. McLeod, DDS, MS, MPH; Dean, ATSU-MOSDOH, St. Louis and Kirksville, Missouri.
Poonam M. Jain, DDS, MS, MPH; Vice-Dean, ATSU-MOSDOH, St. Louis, Missouri,
Page | 59
APPENDIX A
Both graphics are from: The Public Health Service-sponsored Clinical Practice Guideline Treating
Tobacco Use and Dependence: 2008 Update 2008.
Motivational Interviewing / OARS by Miller & Rollnick 2013, Gilford Press (for those not ready to
quit)
Open-ended questions are ones that keep the conversation going; ones that cannot be answered by one word (like
yes or no). You are trying to explore the ambivalence (both sides) and augment the discrepancy (difference)
between them. We want to avoid having them feel judged. What follows are examples:
• What brings you here today?
• How can this program help you/feel safer/support you?
• How do you think your friends/family help or hinder your progress?
• Tell me more about when this first began.
• Tell me more about this.
• Such as?
• Tell me about your goals in your
Affirmations are statements that we use to highlight their competence and accentuate the positive—their
strengths and effort. It must be genuine. The strengths usually are related to their values, goals, skills, effort or life-
style or recognizing challenges or experiences they are going through. They are not compliments (you acting as a
judge), and it is preferable not to begin them with “I am…” statements, such as “I am so proud of you!”
• Even if you feel like it is not fair, you are not willing to let that interfere with your dreams for the future.
• Despite the challenges you face, you remain positive.
• Despite feeling discouraged you, aren’t giving up.
• You are determined to do what’s best for yourself. . .
• It must’ve taken lots of effort to. . .
• It’s impressive that you showed up today in spite of being. .
Reflect: Simple or straight reflections: Tells the student/client that you understood what
they said. (C=client and P=Practitioner/you)
C: Its not important to me if I quit smoking. I just want to get my mom off my back.
P: The real reason you would quit smoking is because of your mom.
Summaries provide an additional way to help guide the conversation (toward change talk) while making sure
you’ve heard and understood (including their feelings) everything the client/student has said. It helps to show the
client that you have been truly listening as you prepare to deepen the conversation or change the direction as you
move ahead.
Summarizing is a way to pick the most important aspects of the conversation to help strengthen the discrepancy of
the ambivalence in which they find themselves. It is like picking a bouquet of flowers from a field of wild flowers.
• Build rapport
• Show that you are understanding their thoughts/feelings
• Communicate your interest in your client
• Reflect ambivalence (pros or cons)
Sample Questions:
It sounds like you are concerned that your grandchildren may see you smoke. We are here to help. Would it be OK to
talk about some ways to help you quit?
Sounds like you are tired of the cost and hassle of smoke but are not sure you can quit. We are here to help. Would
you like to talk about effective ways to help you quit?
I know you are not ready to quit. But as your dentist, I need to let you know that we found bone loss most likely due
to your smoking. You are not able to fight the bacterial infection causing your bone to break down. Would it be OK
to see how you are doing with your smoking at your next visit?
I
INDEX
A
Abutments 54
Acetaminophen 16, 45, 46
Acetylsalicylic 23
ADA 1, 42, 48, 52, 55
Adrenergics 50
Alcohol 54
Allergic 2, 42
Alveolar 34
American Dental Association 1, 42, 48, 52, 55
Aminoglycosides 16
Amiodarone 58
Amoxicillin 2, 3
Ampicillin 2
Analgesia 45, 46, 52, 53, 55
Anaphylaxis 2
Anesthesia 2, 16, 33-37, 39, 40, 45, 53, 55, 57, 58
Angina 20, 57
Angioedema 2
Angioplasty 8
Antiangiogenic 28-32
Anti-arrhythmic 58
Antibiotic 1-3, 8, 9, 12-14, 18, 26, 41-43, 48
Anticoagulants 16, 21-24
Antidepressants 58
Antihypertensive 20
Anti-Inflammatory 45
Antimicrobial 43
Antiplatelet 23
Antiresorptive 28-32
Antithrombotic 22, 23
Anxiety 14, 16, 52, 53
Apixaban 24
Aredia 29
Arrest 12, 13
Arrhythmias 3, 8, 9, 12, 57
Arthritis 3, 48
Articaine 34, 35
Aspirin 22
Asthma 53, 57
Astringents 50
Autoimmune 47, 48
Avastin 29
Azithromycin 2, 3
B
Bacterial 42, 43
Beta-adrenergic 58
Bevacizumab 29
Biopsies 12, 24
Bleed 2, 11, 14, 16, 22-24
Bleomycin 53, 55
Block 34
Blood 3, 11, 16, 19, 20, 27, 50, 57, 58
Bone 18, 24, 29-32
Bupivacaine 35
Bypass 7-9, 57
Calcium 58
Cancer 29, 30
Carcinoma 29, 32
Cardiac 1, 3, 7-9, 12, 13, 20, 23, 42, 57, 58
Caries 30, 48
Carotid 37
Catheter 1, 12
CDC 42, 43
Cefazolin 2
Ceftriaxone 2
Centers for Disease Control 42, 43
Cephalexin 2
Cephalosporin 2, 3
Chemoprophylaxis 13
Chlorhexidine 30
Chronic obstructive pulmonary disease 53
Cilostazol 23
Clarithromycin 2, 3
Clindamycin 2, 3
Clopidogrel 23
Clostridium 42
Coagulation 16
Cobalamin 53
Cocaine 58
Codeine 16
Combustible 54
Comorbidities 3, 31, 48
Complications 13, 53, 58
Congestive 54, 57
Consultation 8, 9, 11-14, 16, 18, 24, 31, 39, 48, 53
Contractions 39
Contraindicated 16, 31, 53, 55, 57, 58
COPD 53
Corticosteroid 16, 31, 32, 45
Cross-resistance 3
Crowns 54
Curettage 24
Cyanotic 1
Cyclosporine 14
Cytotoxic 35
Dabigatran 24
Debilitated 16
Denosumab 29, 32
Dentoalveolar 30, 31
Denture 30
Depression 45
Dexamethasone 45
Diabetes 3, 20, 25-27, 57
Dialysis 15, 16
Diastolic 20, 58
Dipyridamole 23
Direct oral anticoagulant 24
DOAC 24
Dosage 2, 3, 11, 16, 35, 42, 45
Drainage 42
Drug resistance 43
Dysfunction 16
Edentulism 30
Electrocautery 54
Eliquis 24
Emergency 8, 9, 11-13, 20, 26, 53, 58, 59
Encainide 58
Endocarditis 1, 2, 12, 14
Endodontic 26, 42
Endomyocardial 12
Endothelial 1, 12
Epinephrine 20, 34, 50, 57, 58
Ester-based 34
Extract 14, 22, 24, 27, 30, 42, 45, 46
F
Factor-X 24
FDA 32, 34, 35
Fetal 34, 39, 40
Flammable 54
Flecainide 58
Flora 3
Fluoride 30
Food and Drug Administration 32, 34, 35
Fungal 42
Gastric 16, 29
Gauge 37
Gelatin 22, 23
Gingival 2, 14, 24, 50
Glaucoma 57
Glucose 27
Glycemic 26, 27
Graft 24, 54
Half-life 34, 35
Hallucinogenic 54
Hazards 55
Heart 1, 11-14, 20, 23, 50, 54, 57, 58
Hematocrit 16
Hemoglobin 16, 27
Hemorrhage 16, 50
Hemostasis 22-24, 50, 57
Heparin 16
Hepatic 11, 16
Hydrocodone 45
Hypercalcemia 29
Hyperglycemia 27
Hyperplasia 14
Hypertension 16, 20, 57
Hyperthyroidism 57
Hypertrophy 20
Ibuprofen 16, 45, 46

Immune-compromised 3, 54
Immunosuppressants 11, 12
Implant 3, 4, 30, 31
Impregnated 50
Infarction 20, 57
Infected 3, 8, 9, 11, 13, 14, 26, 30, 42, 43, 54
Infective 1, 2, 12
Inferior alveolar nerve 34, 37
Inflammatory 48
Inhalation 52, 55
Injection 2, 16, 20, 32, 34, 37, 57, 58
Intracranial 53
Intramuscular 2
Intravenous 2, 29
Ischemic 20
I.V. 2, 30
Joint replacement 3, 4, 18, 20, 48
Ketoprofen 16
Kidney 3, 11, 13
Laser 54
Levonordefrin 57
Lidocaine 34, 35, 39
Ligand 29
Local anesthetic 16, 22-24, 33-37, 39, 40, 42, 43, 45, 52, 53, 57, 58
Lorcainide 58
Lung 11, 13, 29
Malignancies 3, 29
Maxillofacial 31, 32, 48, 59
Medical 1, 3, 11, 13, 18, 39, 42, 48, 53, 54, 58, 59
Medication 2, 11, 14, 20, 23, 24, 28, 29, 31, 32, 42, 45, 48-50, 58
Medication-related osteonecrosis of the jaw 29-31
Mepivacaine 35
Metabolism 16, 35
Metastases 29, 32
Methylenetetrahydrofolate 53, 55
Mexiletine 58
Monoamine 58
MRONJ 29-31
Mucosa 2, 30
Myeloma 29
Myocardial 20, 57
N
N-Acetyl-P-Aminophenol 45
Narrow-Spectrum 43
Necrosis 48
Needles 36, 37
Neo-Cobefrin 57
Nephropathy 13, 20
Nephrotoxic 16
Nerve 34
Neuroblastoma 35
Neuro-endocrine 29
Nitrous 51-53, 55
Non-dialysis 16
Non-opioid-based 45
Nonsteroidal anti-inflammatory drugs 45
NSAIDS 45
Obesity 3
Obstetricians 39
Obstreperous 53
Obstruction 53
Odontogenic 14
ONJ 29-32
Opioid 44-46
Organs, Transplant 1, 10-14, 16, 29
Orthodontic 2, 14
Orthopedic 3, 4, 17, 18
Osseous 30-32
Osteoarthritis 45
Osteonecrosis 29, 32, 48
Osteonecrosis of the jaw 29-32
Osteoporosis 29-32
OTC 14
Otitis 54
Overdose 35
Overgrowth 14
Over-the-counter 14
Oxidase 58
Oxide 51-53, 55
Oxygen 52-55
P
Pain 14, 16, 30, 32, 45, 46

Palliative 1
Pamidronate 29
Pancreas 11, 13
Pathology 30
Pediatric 2, 34, 35, 52, 55
Penicillin 2, 3
Periodontal 24, 26, 30, 48, 50
Periodontics 31, 48, 59
Periodontitis 48
Perioperative 22, 23, 45
Peri-procedural 24
Peri-sulcular 50
Persantine 23
Phenothiazine 58
Pheochromocytoma 57
Pins, Orthopedic 17, 18
Pirmenol 58
Plaque 14
Plasma 35
Platelet 16
Plates, Orthopedic 17, 18
Plavix 23
Postmenopausal 32
Postoperative 23, 26, 45, 46
Post-surgery 8, 9
Post-transplant 11-13
Pradaxa 24
Pregnancy 34, 35, 38-40, 42, 53
Premature 23
Premedicate 1, 3, 4, 11, 13, 14, 48
Prescribe 1, 3, 11, 22, 24, 31, 32, 42, 43, 45, 46
Prilocaine 34, 35
Prolia 29
Propafenone 58
Prophylactic 1-3, 8, 9, 12, 13, 18, 42
Prostate 29
Prosthetic, Joints 1-4, 14, 48
Psychiatric 54
Psychomotor 45
Pulmonary 53, 54
Pulpal 35
R
Racemic 50
Radiographic 2, 30
Reductase 53, 55
Refractory 57
Renal 11, 16, 29, 32
Repair 1
Reproductive 39
Rescue inhaler 45
Respiratory 53, 54
Retinopathy 20
Retraction 49, 50
Revascularization 20
Rheumatic 3
Rheumatoid 3, 48
Rivaroxaban 24
Rods, Orthopedic 17, 18
Safely 16, 32, 34, 40, 45, 52, 54, 55

Scavenging 52
Schedule-II 45
Schedule-III 45
Sclerosis 54
Screws, Orthopedic 17, 18
Sedation 55
Sequelae 30
Sickle 54, 55
Sjögren’s syndrome 48
Society 23, 43, 48, 55
Sorafenib 29
Stent, Cardiac 7-9, 57
Steroid 3, 11, 16, 57
Streptococci 3
Stress 11, 16, 39
Stroke 20
Sudden-onset 11-13, 16, 50
Sulcular 50
Sulfate 53
Sulfite 57
Sunitinib 29
Surgery 1, 7-9, 11-13, 22-24, 26, 30-32, 53, 57, 59
Sutures 22, 23
Swelling 30, 32, 43, 45
Symptomatic 26
Systemic 3, 14, 18, 30-32, 43, 48
Systolic 20, 58
T
Teratogenic 39
Teriparatide 32
Tetracyclines 16
Third-molar 45
Thromboembolic 22, 24
Thrombosis 23
Ticlopidine 23
Titanium, Rods, Pins, Screws, Plates 54
Tocainide 58
Tolerance 14, 16
Topical 34
Toxic 11, 16, 34, 39, 42, 45, 57
Transplant organs 1, 10-14, 16, 29
Trauma 2, 30, 42
Tricyclic 58
Trimester 34, 39
Tumor 29, 48
Tympanic 54
Ulcerations 42
Urticarial 2
Valve 1
Valvulopathy 1
Vasoconstrictor 50, 56-58
Venous 12
Ventilation 52, 55
Ventricular 20
Viral 42
Viridans 3
Vomiting 45, 55
Warfarin 22, 24
Women 32, 39, 40
Xarelto 24
Xgeva 29
Z
Zirconia 54
Zolendronate 29
Zometa 29

Parameters of Care A

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Parameters of Care A

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Parameters of Care

Charles D. Fuszner, DMD

A.T. Still University

Charles D. Fuszner - Bhavik A. Mohanlal - Drew M. Williamson

A.T. Still University - Missouri School of Dentistry and Oral Health

The authors may be contacted at cfuszner@atsu.edu

Guidelines for Patients with Organ Transplants ............................................................................Page 11

Guidelines for Patients on Dialysis .................................................................................... Page 16

Blood Pressure Treatment Guidelines ............................................................................... Page 20

Guidelines for Patients Receiving Anti-Coagulation Therapy ............................................. Page 22

Guidelines for the Treatment of Patients with Diabetes Mellitus.......................................Page 26

Guidelines for Patients Taking Antiresorptive or Antiangiogenic Medications ..................Page 29

Guidelines for the Use of Local Anesthetics ...................................................................... Page 34

Guidelines for the Treatment of Pregnant Patients ..................................................... Page 39

Guidelines for the Appropriate Use of Antibiotics .................................................. Page 42

Guidelines for the Appropriate Use of Opioids ......................................................... Page 45

Guidelines for the Treatment of Patients with Autoimmune Diseases ...............................Page 48

Guidelines for Use of Nitrous Oxide ..................................................................... Page 52

Guidelines for the Use of Vasoconstrictors ...................................................................... Page 57

Smoking Cessation Guidelines and Supportive Materials ................................................. Appendix A

Charles D. Fuszner, DMD

We all know that there are many ways to practice dentistry.

Charles D. Fuszner, DMD

Following a thorough evaluation of a patient’s medical history, a MOSDOH faculty member or

A) Premedication for Prevention of Infective Endocarditis (IE):

Cardiac Conditions Requiring Premedication

Cardiac conditions associated with the highest risk of adverse

six months after the procedure.

Source: J Am Dent Assoc. 2008:139 (1) – page s17.

Source: J Am Dent Assoc. 2008:139 (1) – page s18.

Dental procedures and events for which prophylaxis is not indicated

Routine anesthetic injections through non-infected tissue.

Source: J Am Dent Assoc. 2008:139 (1) – page s18.

Antibiotic Regimens for Prevention of Infective Endocarditis

Regimens for a dental procedure.

Source: J Am Dent Assoc. 2008:139 (1) – page s20.

Source: J Am Dent Assoc. 2008:139 (1) – page s19 – s20

B) Premedication and Management of Patients with Prosthetic Joints (PJ):

Recommendation for Patients with PJ

A) Cardiac Stents and Angioplasty:

According to guidelines from the American Medical Association, it is recommended

If emergent dental care is required in first 3-6 months post-transplant:

1) Consultation with patient’s physician is mandatory.

NOTE: If chemoprophylaxis is deemed necessary, the American Heart Association (AHA)

1) Consultation with patient’s physician is mandatory.

1) Consultation with patient’s physician prior to treatment is advised.

NOTE REGARDING USE OF LOCAL ANESTHETICS:

NOTE REGARDING PAIN MANAGEMENT:

CATEGORY BP (mm Hg) Systolic / Diastolic Modification of Dental Care

Elevated 120-129 / <80 No Modification Necessary

Stage-1 Hypertension * 130-139 / 80-89 Modify treatment at discretion; Use

1) Patients taking Warfarin:

Policy regarding use of Warfarin:

Dental procedures may be performed upon patients taking Warfarin

Policy regarding use of Antiplatelet Agents:

Dental procedures may be performed upon patients taking antiplatelet medications.

Antiplatelet agents shall include the following:

DOACs currently include the following three drugs:

PROCEDURES DEEMED HAVING A HIGHER RISK OF BLEEDING:

Extraction of 3 or more teeth.

HbA1c < 7.0% No modifications of treatment required.

HbA1c between 7.1% - 9.0% Consider deferring elective treatment of asymptomatic

Routine restorative procedures may proceed with special

Emergency procedures on symptomatic or infected patients