Management of dental care of patients on immunosuppressive drugs for chronic immune-related inflammatory diseases: a survey of French dentists’ practices

There is increasing evidence of a bidirectional relationship between oral and general health, underscoring the importance of treating oral diseases prior to the initiation of certain systemic therapies [1]. Collaboration between dentists and physicians is necessary for oral care, as described in transdisciplinary consensus articles for patients with diabetes mellitus or cardiovascular diseases [2, 3]. Such an approach is also necessary for patients with immune-related inflammatory disorders (IMIDs), such as chronic inflammatory bowel diseases (IBDs) and chronic inflammatory rheumatic diseases (IRDs), particularly when treated with immunosuppressants (ISs), conventional disease-modifying antirheumatic drugs (DMARDs), and/or biologics (bDMARDs). Different populations show considerable variation in the frequency of the disease, but the estimated prevalence of IMIDs in Western society is 5 to 7% [4]. The development of effective biologics over the past few decades has dramatically improved clinical outcomes and new molecules are emerging regularly [5]. Thus, it is important for dentists and prescribing physicians to be able to refer to common recommendations when performing oral care on these patients. However, to date, there are no international transdisciplinary recommendations on the management of invasive oral procedures in patients with IMIDs on ISs, DMARDs, or bDMARDs.

To date, in France, three scientific societies have proposed national recommendations: the French Society of Oral Surgery (SFCO) [6], the Club of Chronic Inflammatory Rheumatism (CRI), part of the French Society of Rheumatology [7], and the National Agency for Drug Safety (ANSM) [8]. They agree on the elimination of infectious foci and the treatment of caries and periodontal disease by general dentists (GDs) or specialized dentists (SDs) working in a community-based dental office or hospital, before starting medical treatment [5, 9]. The challenge is to manage the risk of infection in oral care once the treatment has started. Indeed, these three guidelines diverge, rely on a low level of evidence, are not based on literature in the field of dentistry, provide no details by type of dental procedure, and have not been updated for more than 10 years for the ANSM and the SFCO [10]. This situation is confusing. There is therefore an urgent need to evaluate the knowledge and practices of dentists regarding invasive oral treatments in real-life situations. For this purpose, the existence of different training courses in dentistry and/ or oral care in France (supplemental Fig. 1) must be considered when assessing the knowledge and skills of dentists in the management of these patients.

Our objective of this study was to evaluate, through a national survey, the practices and knowledge of dentists with general or specialized practice concerning the risks and their prevention during the dental care of IMIDs patients on biologics or ISs in France.

A multidisciplinary collaboration was established between research teams working in various fields, namely rheumatology (RS), gastroenterology (MF), oral surgery, oral implantology, and periodontology (AB, KA, LR, MG), to conduct a national cross-sectional survey among members of dental scientific societies concerning the dental management of patients with IMIDs, in particular, those with IRDs, IBDs, or vasculitis, receiving bDMARDS, DMARDs, and/or ISs. The dentists (KA, LR, MG) involved in this study all have an academic position and a hospital practice.

This study is among the largest to compare the practice of French dentists with existing national recommendations on the management of oral care in patients with IMIDs treated with chronic medications. Most of the participants reported having experience in the management of patients with IRD and IBD than for vasculitis, consistent with the prevalence of these diseases. They also declared being aware of the professional recommendations. Overall, complications were more frequently reported by SDs. It can be explained by the fact that they used (i) to treat patients with more severe and unstable forms of the disease with the continuation of immunosuppressive therapy and (ii) to perform extensive surgical procedures with bone cutting. Of note, no complications were reported after procedures such as scaling, which is regularly performed during the patient’s annual follow-up. This result is highly reassuring.

In terms of the management of the risk of infection, most dentists applied the recommended procedures for prevention of infection by prescribing antiseptics and antibiotics until mucosal healing [6]. Despite these precautions, a notable percentage of infections or delayed healing was reported. These complications were more frequent when the procedure was invasive and extensive, and they correlated with the continuation of treatment.

Of note, the current joint American College of Rheumatology/American Association of Hip and Knee Surgeons recommendations (Grade B recommendations) for the perioperative management of patients with RA or systemic lupus erythematosus in orthopedic surgery concludes that (1) conventional DMARDs should be continued for orthopedic surgery and (2) bDMARDs should be temporarily suspended perioperatively (depending on the molecule). bDMARDs should be resumed approximately two weeks after surgery [11, 12]. The paucity of literature on the risk of postoperative infection or the risk of a disease flare-up is emphasized, especially for bDMARDs, and particularly for oral surgery cases.

To date, literature on that topic in oral surgery is scarce. In a recent Cochrane systematic review on the prevention of complications after tooth extraction, none of the included studies evaluated tooth extraction in immunocompromised patients [13]. It is however known that there is a correlation between the invasiveness of oral surgery and the incidence and severity of postoperative complications in the general population. For example, in a retrospective study of 3,900 patients, complications occurred more frequently after the extraction of impacted mandibular or third maxillary molars and bone surgery. These complications were mainly alveolar osteitis, infection, or prolonged swelling and occurred more frequently in the presence of other risk factors of infection [14]. Here, we conducted a declarative questionnaire to carry out a practice survey, but our objective was not to investigate risk factors for infections following invasive care. If this had been the case, assessing the use of bisphosphonates, which are widely prescribed for patients with rheumatoid arthritis, would have been an essential point to note because they increase the risk of postoperative complications [15]. Indeed, cases of osteonecrosis of the jaw in the absence of antiresorptive or antiangiogenic drugs have been described in patients with rheumatoid arthritis or idiopathic arthritis treated with prednisolone, methotrexate, or bDMARDs (adalimumab) [16, 17]. In contrast without our study, only 18% of the respondents in a recent Japanese survey that included 206 dentists [13] asked the prescribing physician to request temporary discontinuation of conventional DMARDs, bDMARDS, ISs, or corticoids. These discrepancies with our results could be explained by different recommendations between countries.

One limitation of our study is the representativity of the French dentist population. The number of participants in the present study was small with respect to the population of dentists in France (44,000 according to the National Council of the Order of Dental Surgeons [18]). The participation rate was estimated at approximately 11%. It is consistent with previous professional practice studies, for example, in the perioperative oral care management of patients on anticoagulants, a condition which concerns more patients and practitioners than the subject of our study [19]. A disparity was observed in the response rate of dentists according to region, consistent with the current demography of dentists in the French territory [20]. Moreover, an over-representation of SDs was observed, which can be explained by a recruitment bias due to (i) the way the survey was distributed, (ii) a particular interest in the subject of the survey, and (iii) better adherence to medical scientific studies.

The second major limitation is due to the method of data collection. The use of a self-administered questionnaire is per se associated with various biases. Measurement bias was limited by having the questionnaire tested by a panel of dentists, which were distributed via numerous societies and colleges. Recall and subjective biases were not excluded. For example, a significant difference between the percentages of practitioners who did not know the names of bDMARDs versus ISs or cDMARDs was observed. However, it may be explained by the fact that dentists are more familiar with ISs or cDMARDs, which are more widely prescribed and have been prescribed for longer. Nevertheless, even though a self-administered questionnaire may not be as well completed as a questionnaire administered in face-to-face interviews, it does allow for the inclusion of a greater number of participants.

This survey shows that most SDs and GDs perform a wide range of oral procedures on patients using bDMARDS, conventional DMARDs, or ISs. They declared being compliant with the recommendations for oral invasive care of treating patients under antibiotic coverage and antiseptic mouthwashes. Due to their education and expertise, SDs more frequently performed invasive and complex treatments (multiple tooth extraction, surgery with open flap access and bone cutting). They thus reported having more patients with postoperative complications, despite having greater knowledge regarding recommendations for the management of such patients. Complications appear to mainly occur after highly invasive procedures, possibly when ISs are not suspended. Finally, certain common procedures, such as scaling and root planing appear to be safe. However, adapted dental practice guidelines are needed to standardize the management of patients on bDMARDS, conventional DMARDs, or ISs. Real-life data obtained by conducting sufficiently powerful prospective studies are needed as the present study was only a declarative survey.