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

doi:10.21203/rs.3.rs-2451141/v1

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Research Article

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

https://doi.org/10.21203/rs.3.rs-2451141/v1

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Journal Publication

published 09 Aug, 2023

Read the published version in BMC Oral Health →

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Objectives

Our aim was to provide an overview of the practices of French general dentists (GDs) and specialists (SDs) concerning the management of patients with inflammatory bowel diseases (IBDs), rheumatic inflammatory diseases (IRDs), and vasculitis on biologic disease-modifying antirheumatic drugs (bDMARDs), conventional DMARDs, or immunosuppressants (ISs).

Materials and Methods

We asked the members of French scientific societies and colleges of dentistry teachers to distribute an online survey over three months.

Result

In total, 105 practitioners fully completed the survey. SDs more frequently performed invasive surgical procedures and were more aware of the recommendations of learned societies than GDs. They encountered more post-operative complications for patients on bDMARDs. For both SDs and GDs, most patients were managed without stopping treatment and pre- and postoperative antibiotics were prescribed to more than 75% of patients. When medical treatment was stopped, the decision was made by the prescribing physician.

Conclusion

Complications were reported more frequently by SDs when highly invasive procedures were performed on patients under active drug therapy. Certain common procedures, such as scaling and root planing, appear to be safe, regardless of treatment management. However, adapted guidelines for the practice of dentistry are needed to standardize the management of patients on bDMARDS, conventional DMARDs, or ISs.

Clinical Relevance:

French dentists perform a wide range of oral procedures on patients on bDMARDS, conventional DMARDs, or ISs under antibiotic coverage and antiseptic mouthwashes. SDs reported more postoperative complications after extensive invasive procedures for patients under active drug therapy, despite their greater knowledge of recommendations on how to manage such patients.

biologic disease-modifying antirheumatic drugs

DMARDs

immunosuppressants

oral care

invasive procedure

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]. Transdisciplinary 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 a collaborative 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 5–7% [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.

When initiating therapy with bDMARDs, DMARDs, or ISs, current French guidelines recommend performing oral care (elimination of infectious foci and treatment of caries and periodontal disease) before starting treatment and to ensure dental follow-up every six months [6, 7]. Nevertheless, it is obvious that additional invasive dental procedures (e.g., pulp treatments, dental extractions) will be performed during the patient's lifetime and the dentist will then have to refer to national guidelines for the treatment of these patients. To date, in France, three scientific societies have proposed national recommendations: the French Society of Oral Surgery (SFCO) [7], the Club of Chronic Inflammatory Rheumatism (CRI), part of the French Society of Rheumatology [8], and the National Agency for Drug Safety (ANSM) [9]. However, these guidelines rely on a low level of evidence, as they are not based on literature in the field of dentistry, which is mostly composed of case reports. For example, for the CRI, the recommendations for drug discontinuation and antibiotic prophylaxis for dental extractions are based on publications related to joint surgery (e.g., abatacept guidelines, secukinumab guidelines). In addition, some recommendations provide no details by type of dental procedure and have not been updated for more than 10 years, the last update being in 2011 for the ANSM and the SFCO [10].

In France, oral health care for patients with IRDs and IBDs can be performed either by general dentists (GDs) or specialized dentists (SDs) working in a community-based dental office or hospital. Additionally, it should be noted that, in France, different paths can lead to training in dentistry and/or oral care (Fig. 1). As these training courses are different, they should be taken into account in assessing the knowledge and skills of SDs and GDs for the treatment of patients with IRDs and IBDs under drug therapy.

Given the diversity of molecules (bDMARDs, DMARDs, ISs) and the scarcity of available recommendations, as well as the differences in training and practice among dentists, it may be difficult for them to keep abreast of developments concerning these drugs and to take them into account in their practice. Our objective 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 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.

Study population

In France, all dentists with an academic position are members of the National College of Academic Teachers (College National d’Enseignants - CNE) in periodontology (CNEP), oral surgery (CNECO), pediatric dentistry (CNEOP), or restorative dentistry and endodontics (CNEOC). Moreover, many French specialized and general dentists with a special interest in a certain field of dentistry are members of the French Society of Oral Surgery (SFCO), the French Society of Periodontology and Oral Implantology (SFPIO), the French Society of Pediatric Dentistry (SFOP), and/or the French Society of Endodontics (SFE). In this study, all dentists reporting an activity limited to a field of specialization (oral surgery, periodontology, oral implantology, others) were considered to be "specialized dentists". Thus, the distinction was not made based on the level of the degree declared.

As patients with IRDs and IBDs may be followed by non-specialized or specialized dentists in office-based or hospital-based dental services, we invited the participation of the members of these scientific societies and National Colleges of Academic Teachers in dentistry by email, which allowed us to reach a large panel of dentists. Therefore, members of the SFCO, SFPIO, SFE, SFOP, CNEP, CNECO, CNEOP, and CNEOC were invited to participate in the online survey via mailing lists.

Insofar as the scientific societies have members based in Europe or Africa, and as we wished to evaluate professional practices with reference to French recommendations (SFCO, CRI, and ANSM), the study was limited to members practicing in France. As many dentists are members of both colleges of academic teachers and scientific societies, we could not estimate the number of dentists approached for the survey.

Data collection

A semi-structured questionnaire containing 53 questions was developed by the authors (KA, RS, MF, LR, and MG) for this survey. The questionnaire was divided into five sections, of which the main points were: 1 - the practitioner’s profile (gender, time since graduation, type of practice facility, and type of practice [generalist or specialist, with a choice of field of specialization]), type of degree, and experience with patients with IRD or IBD (number of patients treated per month by type of disease [i.e., IBDs, joint diseases, or vasculitis], reason for the first visit, and patient’s background treatment); 2 - participant's knowledge/training concerning the dental care of patients on biologics (yes/no, source of information; expected risks after dental invasive procedures); 3 - management of oral care of patients on biologics (nature of invasive procedures performed, management of the medical treatment, biological tests prescribed preoperatively, protocol for the use of antiseptics and antibiotics, declaration of postoperative complications occurring after invasive dental care procedures, and the nature of complications); 4 - same as 2 but on conventional DMARDs and ISs; 5 - same as 3 but on conventional DMARDs and ISs.

The biologics listed were the following (the main trade names were provided): anti-TNFα, anti-IL-1β, anti-IL-6, anti-IL-12/23, anti-lymphocyte B, anti-lymphocyte T, anti-IL-17, anti-integrin, and the targeted synthetic DMARD anti-JAK. The ISs listed, with examples of trade names, were the following: azathioprine, methotrexate, and cyclophosphamide. Corticoids were also listed. Participants were given the possibility to fill in "other molecules" in a free field.

The questionnaire was tested by nine generalized or specialized dentists with a community-based private or hospital practice. Their feedback on the comprehension of the questions and the ease of answering them helped us to improve and finalize the questionnaire. The questionnaire was distributed on a secure platform provided by the University of Paris (Lime Survey®), allowing online completion, storage of the answers, and data extraction. Participants were invited to complete the questionnaire by email in September 2020, with four reminders up to December 31, 2020. The email included a synopsis of the survey and the link to the online questionnaire.

Ethical approval for the study was granted by the APHP Centre Research Ethics Committee on June 15, 2020, and is registered under IRB registration number: #00011928.

Statistical analysis

Qualitative variables are presented as numbers and percentages and quantitative variables as numbers, means, and standard deviations.

We compared general dentists versus specialists with respect to their experience in managing patients with IRD or IBD (type of disease, number of patients, type of biologic/IS treatment), knowledge/training concerning dental care of patients with IRD or IBD, type of invasive procedure performed, management of medical treatment, perioperative oral-care protocols, and frequency of postoperative complications after invasive dental care procedures. Categorical variables were compared using Chi-squared or Fisher tests, as appropriate. Continuous endpoints were compared using Student’s t test.

Statistical analyses were performed using STATA software (Stata Statistical Software: Release 15. College Station, TX: StataCorp LLC). All tests were two-sided and a p value < 0.05 was the threshold for statistical significance.

Study population

In total, 246 practitioners participated in the survey but only 115 (46.75%) fully completed the questionnaire. Among them, 56.5% were women and 43.5% men (Table 1); 42% had graduated < 10 years, 32% between 10 and 20 years, and 26% > 20 years before the time of the survey. Forty-one percent practiced exclusively in hospitals, 39% practiced exclusively in community-based dental offices, and 35% had a mixed practice. In addition, 53% were GDs and 47% SDs, 21% were exclusively involved in oral surgery and implantology, 16% in periodontology and oral implantology, and 10% had another specialty (endodontics or pediatric dentistry). Approximately one third (30.43%) had a specialty degree in oral surgery or oral medicine. Finally, the dentists who answered the survey were settled in all regions of France, with most (75.66%) working in French regions other than Paris and the “Ile de France” region (Fig. 2).

Experience of French dentist in the management of oral care of patients on bDMARDs, conventional DMARDs, or ISs

Of note, the number of practitioners included in the analyses varied according to the field analyzed (i.e., training and knowledge of recommendations, experience in treating patients taking ISs or biologics or reporting of postoperative complications). We created a flow chart (Fig. 3) to highlight the number of GPs and SPs included by analysis.

In terms of the participants’ experience, 91.3% of the practitioners declared treating patients with IRD, 87.83% with IBD, and 62.61% with vasculitis (Table 2). The average number of patients received per month was 1.6 for IRD, 1.1 for IBD, and < 1 for vasculitis. The practitioners reported that patients were mostly treated with anti-TNFα (70.09%), followed by anti-lymphocyte B (33.64%). Thirty-one dentists (28.97%) did not know or did not remember the name of the biologics. Moreover, the patients were mostly treated with corticosteroids (85.04%), followed by the conventional DMARD methotrexate (79.43%). Only 9.34% of practitioners did not know or did not remember the name of the IS.

Regardless of treatment, the most frequent oral procedures performed were tooth extraction(s) (> 84%) and scaling and root planing (> 72%), whereas the least frequent procedure was preimplant surgery (approximatively 8.7%) (Table 3). SDs performed more invasive and complex procedures (i.e., preimplant surgery, mucosal or plastic surgery, and osseous surgery), whereas GDs performed mainly conservative care (i.e., rubber dam application, dental pulp treatment, scaling, and root planing) (p < 0.05). SDs also performed implant placement more frequently than the GDs, but the difference was statistically significant only for patients on bDMARDs (p = 0.01).

Dentist training and knowledge of the management of patients on bDMARDs, conventional DMARDs, or ISs

Most practitioners reported to have been trained and to have knowledge on the management of patients on bDMARDs (58.26%), conventional DMARDs, or ISs (59.13%), especially SDs (SDs vs GDs: 68.52% vs 49.18% for biologics and 68.52% vs 50.82% for DMARDs/IS, p < 0.05) (Table 4). The main sources of information were journal articles (> 71.64%), scientific societies (> 59.7%), and professional meetings, especially for SDs (SDs vs GDs: 54.05% vs 20% for biologics and 48.65% vs 22.58% for ISs, p < 0.05). The vast majority of practitioners who had no training or information expressed their willingness to gain some (> 97.87%). Almost half of the practitioners reported being aware of the professional recommendations, with a clear difference between SDs and GDs (61.11% vs 37.70% for recommendations on bDMARDs, p = 0.01). The main source of information was the French Society of Oral Surgery (SFCO) (> 79.31%).

Management of oral care of patients on bDMARDs, conventional DMARDs, or ISs by GDs and SDs

The main risks reported by practitioners in terms of oral care were infections (≥ 98.13%) and delayed healing (≥ 84.11%) (Supplemental Table 1). Globally, most practitioners did not prescribe biological tests before performing oral procedures (> 71.84%). The number of practitioners discontinuing the treatment differed by drug (bDMARDs: 62.50%; conventional DMARDs/ISs: 49.51%), a decision mainly made after consultation with the prescribing physician (> 76.7%). Among the practitioners, < 3% responded that the duration of discontinuation depended on the drug taken (2.88% for patients on biologics and 0.97% for patients on ISs) (Supplemental Table 1).

Antiseptic mouthwashes were frequently prescribed before invasive oral procedures, regardless of the molecule (> 66.99%), whereas single flash dose antibiotic prescription was less frequent (47.12% for bDMARDs and 43.69% for conventional DMARDs/IS). The management of infectious risk was carried out by the prescription of long-term antiseptic mouthwashes (> 71.84%) and antibiotics until mucosal healing (> 77.88%) (Supplemental Table 1).

Post-operative complications after invasive oral procedures declared by GDs and SDs for patients with IRD, IBD, or vasculitis on biologics or ISs

Most practitioners reported no postoperative complications after oral procedures (87.50% for patients on bDMARDs and 81.55% for those on conventional DMARDs/ISs) (Table 5). Complications were mainly associated with tooth extraction (< 18.45%), significantly more frequently in the SD than GD group (21.28% vs 5.26% for bDMARDs and 29.79% vs 8.93% for conventional DMARDS/ISs, p < 0.05). Among complications, delayed mucosal healing (21.28% vs 3.51% for bDMARDs and 25.53% vs 5.36% for conventional DMARDs/ISs, p < 0.05) and dry socket (14.89% vs 5.26 for bDMARDs, p = 0.09, and 1.28% vs 3.57% for conventional DMARDs/ISs, p = 0.005) were significantly more frequently reported by the SDs (Table 5).

Evaluation of the relationship between the management of medical treatment and oral care protocols, and the complications of invasive oral procedures for patients under treatment with biologics or ISs

We tested many relationships (Table 6, Supplemental Tables 2 and 3). The continuation of bDMARD treatment correlated with the occurrence of complications after mucoperiosteal flap rising with bone resection/curetting (p = 0.04) (Table 6), whereas dry socket correlated with the continuation of bDMARD treatment (p = 0.05) in the SD group (Table 6). The continuation of conventional DMARDs/IS treatment correlated with more complications after dental extraction(s) or mucoperiosteal flap rising with bone resection/curetting in the SD group (p = 0.02) (Table 7). Delayed mucosal healing also significantly correlated with the continuation of DMARDs/IS treatment in the SD group (p = 0.01) (Table 8). In addition, the relatioship between the continuation of conventional DMARDs/IS treatment and the occurrence of dry socket was borderline significant in the SD group (p = 0.05) (Table 8).

This study is among the largest to evaluate the practice of French dentists and to compare it 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, IBD, or vasculitis (more for IRD and IBD than for vasculitis, consistent with the prevalence of these diseases) and of being aware of the professional recommendations for the oral care of patients on bDMARDs, conventional DMARDs, or ISs. Overall, complications were more frequently reported by SDs, who treat patients with more severe and unstable forms of the disease (for whom immunosuppressive therapy is maintained) and who perform extensive surgical procedures with bone cutting. Of note, no complications were reported after procedures such as scaling, which is regularly performed (often during the patient's annual or semi-annual follow-up). This result is highly reassuring.

In terms of the management of the risk of infection, most dentists were accustomed to dealing with invasive oral treatment. Indeed, they applied the recommended procedures of prevention of infection, with antiseptics and antibiotics prescribed until mucous healing [7]. Despite these precautions, a notable percentage of infections or delayed healing was reported. These complications were more frequent when the procedure was invasive (dental extraction, procedures requiring a mucoperiosteal flap with bone cutting) and extensive (multiple versus simple dental extraction) and they correlated with the continuation of treatment. Moreover, these procedures were mainly reported by specialists.

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 (no randomized controlled trials or level I studies) on the risk of postoperative infection or the risk of a disease flare is emphasized, especially for bDMARDs, which is even more true for oral surgery.

To date, literature on that topic in oral surgery is scarce, as illustrated by a recent Cochrane systematic review on the prevention of complications after tooth extraction, in which none of the included studies evaluated tooth extraction in immunocompromised patients [13]. However, it is 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 (compared to gingivectomy or mucogingival surgery, for example). These complications were mainly alveolar osteitis, infection, or prolonged swelling and occurred more frequently in the presence of other risk factors of infection (active smoking, unbalanced diabetes) [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.

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]), as only 115 participants fully responded to the survey. We cannot calculate the participation rate because many dentists are simultaneously members of scientific or educational societies that were approached (e.g., the French Society of Periodontology and Oral Implantology - SFPIO - and the National College of Periodontology - CNEP). However, this level of participation is consistent with professional practice studies, for example, in the perioperative management of patients on oral anticoagulants undergoing oral, implant, or periodontal procedures in France (conditions which concern more patients and practitioners than the subject of our study) [19]. We observed a disparity in the response rate of dentists according to region, consistent with the current demography of dentists in the French territory. Indeed, France is a country characterized by strong regional inequalities in the density of dentists [20]. Although the proportion of GDs is higher than SDs in France (less than 1% of French dentists are qualified in oral surgery or oral medicine), we observed an over-representation of SDs, which can be explained by a recruitment bias due to (1) the way the survey was distributed (SDs are more often members of the scientific societies of their discipline), (2) the particular interest in the subject of the survey (SDs are more likely to treat patients with IMIDs), and (3) better adherence to medical scientific studies (participation in clinical studies is more frequent among interns during their medical training). Of note, (1) practitioners appear to have a good expertise in the management of IMID patients (the average number of IMID patients received per month was high, considering the prevalence of these diseases) and (2) practitioners globally remember the nature of the drugs taken by their patients. This emphasizes that it was the practitioners who responded to the questionnaire were concerned with the problem.

This survey shows that most SDs and GDs perform a wide range of oral procedures on patients on bDMARDS, conventional DMARDs, or ISs and 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 their greater knowledge of 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 because the present study was a declarative survey.

Ethical Approval and consent to participate

Ethical approval for the study was granted by the APHP Centre Research Ethics Committee on June 15, 2020, and is registered under IRB registration number: #00011928. Before answering the survey, all subjects gave their informed consent. I confirm that all the methods were carried out in accordance to relevant guideline and regulation.

Consent for publication

N/A

Availability of data and materials

The datasets used during the current study available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no conflicts of interest.

Funding
No funding to declare.

Authors' contributions

A.B., L.R., M.G., R.S. wrote the main manuscript, and M.F. and K.A. reviewed it. A.B and L.R. conducted the statistical analysis and prepared the tables; A.B and M.G prepared the figures; M.G, L.R., K.A, R.S, M.F. wrote the questionnaire. L.R and M.G performed the supervision, conceptualization and validation.

Acknowledgements

The authors thank all the dentists who responded to the survey and the SFCO, SFPIO, SFE, SFOP, CNEP, CNECO, CNEOP, and CNEOC for distributing the survey.

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Tables are available in the Supplementary Files section.

No competing interests reported.

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Editorial decision: Major revision
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You are reading this latest preprint version

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

Status:

Journal Publication

Version 1

Abstract

Objectives

Materials and Methods

Result

Conclusion

Clinical Relevance:

Figures

Introduction

Methods

Study population

Data collection

Statistical analysis

Results

Study population

Dentist training and knowledge of the management of patients on bDMARDs, conventional DMARDs, or ISs

Discussion

Conclusion

Declarations

References

Tables

Additional Declarations

Supplementary Files

Status:

Journal Publication

Version 1