Dental surgery, primary care and malpractice risk: What to know about medical clearances for oral care

Oral health is part of a patient’s overall health, so routine dental examinations and cleanings are foundational.

When a dentist identifies a more serious medical concern in a patient’s mouth, procedures and technologies have advanced to improve the likelihood of a successful outcome. Like any surgical intervention, dental operations may create risks for patients, and dentists enlist the help of primary care physicians to ensure patients are healthy enough to handle the intervention.

Medical clearance becomes a key step toward starting a successful treatment path. But to ensure patient health and reduce liability, primary care physicians must do more than simply sign off for treatment.

What malpractice risks can arise when physicians provide medical clearance for dental surgery?

Physicians who clear patients for dental surgery without understanding key differences between medical and dental surgery can inadvertently create malpractice exposure for themselves and for the dentist, especially around hemostasis, sedation, systemic disease, and high-risk medications such as antithrombotic and bisphosphonates.

Once a physician issues written medical clearance, they have arguably accepted a duty to exercise reasonable care in assessing perioperative risk for the specific procedure contemplated, not just for surgery in general. If their assessment is based on a hospital or operating room paradigm, rather than office-based dental surgery with local hemostatic control, that opinion may fall below the applicable standard of care.

What is the best way to begin medical clearance for dental procedures?

Communication is key, so start there. Malpractice claims commonly arise from communication failures and handoff errors between providers, including inaccurate or incomplete transmission of key clinical information and recommendations. A clearance letter that simply says “patient must stop all blood thinners” or “not a candidate for surgery,” without procedure-specific rationale, risk-benefit analysis or documentation of shared decision-making, can be framed as a negligent, misleading consultation if harm follows — stroke, myocardial infarction, uncontrolled bleeding or denial of necessary care.

What does current evidence say about managing anticoagulants and antiplatelet therapy for dental procedures?

Evidence and professional guidance now state that for most patients on warfarin, traditional antiplatelets and even direct oral anticoagulants, routine and many moderately invasive dental procedures, such as implant placement, can proceed without interrupting therapy, using local measures and respecting international normalized ratio and bleeding-risk parameters.

Key points the nondental physician may miss are as follows:

• The American Dental Association and multiple consensus reviews conclude that for most patients, it is not necessary to alter aspirin, warfarin or dual antiplatelet therapy prior to dental intervention.
• For low to moderate bleeding-risk dental procedures, single or dual antiplatelet therapy and warfarin at therapeutic international normalized ratio (commonly less than or equal to 3.5 to 4.0, depending on the guideline) are usually continued, with local hemostatic techniques.
• For direct oral anticoagulants, many sources recommend a brief interruption of one to two days and scheduling at trough concentration for most dental implant surgery. Those with a higher risk of bleeding would hold for 48 hours.

What liability could arise if a physician advises stopping anticoagulants unnecessarily?

If a physician unfamiliar with dental hemostasis reflexively instructs the patient to stop dual antiplatelet therapy, warfarin or direct oral anticoagulants for more than two to three days before implant placement — contrary to contemporary dental and anticoagulation guidance — and the patient sustains a stroke or stent thrombosis, plaintiffs can argue the following:

• The physician’s recommendation deviated from evidence-based standards for dental procedures.
• The dentist reasonably relied on the physician’s written directive to alter anticoagulation.
• The injury, such as embolic stroke, was a foreseeable consequence of unnecessary interruption.

Why do physicians sometimes overestimate bleeding risk for dental procedures?

In hospital medicine and major surgical specialties, hemostasis assumptions often presume large operative fields, general anesthesia, hidden bleeds and the inability to apply site-specific measures for hours. In contrast, dental implant and extraction sites are small vascular beds where the dentist can use atraumatic technique, flap design and primary closure; apply local hemostatic agents, sutures, pressure and tranexamic acid rinses; and stage procedures or limit the initial surgical field.

Guidelines explicitly note that with such measures, postoperative bleeding risk for anticoagulated dental patients is typically manageable, and that the thromboembolic hazard of stopping therapy often outweighs bleeding risk. A physician who does not understand these dental-specific hemostatic strategies may systematically overestimate bleeding risk and underestimate thrombotic risk. That can lead to recommendations that fall outside evidence-based practice and open the door to malpractice claims if harm ensues.

What should physicians understand about sedation in office-based dental surgery?

Office-based dental intravenous or oral sedation is fundamentally different from monitored anesthesia care in a hospital, particularly regarding staffing, monitoring and immediate rescue resources. A physician may clear a patient for sedation based on an assumption of hospital-grade monitoring and rapid access to crash teams, when the dental setting relies heavily on the dentist’s training, advanced cardiac life support preparedness and preplanned emergency protocols.

What factors should physicians consider when evaluating sedation risk for dental procedures?

Physicians’ clearance may be criticized as nonspecific and below the standard of care for a consultation if the physician fails to clarify or consider the following:

• What level of sedation and which agents are anticipated
• Interactions with the patient’s current medications, such as beta blockers, central nervous system depressants or opioids
• Conditions such as severe sleep apnea, morbid obesity or unstable cardiopulmonary disease in the context of an office setting

This is especially true if an adverse sedation event occurs and the documentation shows the physician never engaged with the realities of dental sedation. Communication failures between providers are a known driver in nearly half of malpractice claims, including those involving perioperative risk.

Why do bisphosphonates and antiresorptive therapies create unique risks in dental surgery?

Systemic bisphosphonate and other antiresorptive therapy is strongly associated with medication-related osteonecrosis of the jaw, especially after invasive dentoalveolar procedures such as extractions and, to a lesser extent, implant placement. Studies show that tooth extraction markedly increases the risk of osteonecrosis compared with nonextraction dental care, with some analyses reporting a 33- to 333-fold higher risk. Implant surgery carries lower risk of medication-related osteonecrosis of the jaw than extraction but is not risk-free; risk rises with intravenous or oncologic dosing and duration of therapy. Oral bisphosphonate use for osteoporosis has substantially lower risk of medication-related osteonecrosis of the jaw than high-dose intravenous regimens for malignancy, but it still warrants patient education and careful surgical planning.

A nondental physician may regard a proposed implant or extraction as minor and issue blanket clearance without the following:

• Recognizing that medication-related osteonecrosis of the jaw is a dental-specific complication strongly linked to these procedures
• Discussing duration, route and indication of antiresorptive therapy in the context of jawbone risk
• Collaborating with the dentist on risk mitigation, such as timing, drug holidays when appropriate or alternative treatment plans

How can medication-related osteonecrosis of the jaw lead to shared malpractice exposure?

If medication-related osteonecrosis of the jaw develops and documentation reveals that the physician knew of long-term intravenous bisphosphonate use but never addressed jaw risk or coordinated care, plaintiffs may argue a breach of duty in the consultation. The dentist may be accused of negligence in technique or consent, and the physician of negligent clearance or failure to warn, creating multidefendant malpractice exposure.

What legal vulnerabilities can arise from poorly defined medical clearance?

When a physician’s clearance does not reflect the real risk profile of office-based dental surgery, several legal vulnerabilities emerge. The dentist may rely on a misleadingly reassuring or overly restrictive opinion and incorporate it into informed consent, inadvertently misinforming the patient about comparative bleeding versus thrombotic risk. If communication between providers is poor or undocumented, each may blame the other for omissions about anticoagulants, bisphosphonates or medical instability; communication breakdowns are documented contributors in a large fraction of malpractice cases and increase claim severity. Clearance letters that dictate medication changes without clear rationale can be interpreted as practicing outside one’s area of expertise, especially if they contradict specialty guidelines, such as insisting on a five-day direct oral anticoagulant hold for low-risk implant surgery, and precipitate preventable harm.

What model of collaboration between physicians and dentists is more defensible?

To develop a more defensible model, physicians should require that dentists go beyond requesting just a generic “clear or not clear” statement. The dentist should define the specific procedure, bleeding profile, and proposed local hemostatic and sedation plan, and then ask the physician focused questions about systemic risk and drug management. This preserves the dentist’s responsibility for procedural risk while limiting the physician’s opinion to medical optimization within their expertise — for example, cardiac, renal or endocrine status — and evidence-based guidance on whether antithrombotic or antiresorptive can be safely maintained. Structured, documented communication and explicit acknowledgment of current dental guidelines on antithrombotic management and risk of medication-related osteonecrosis of the jaw narrow the gap between medical and dental paradigms and reduce the misaligned expectations that fuel malpractice claims.

Will this model of collaboration also ensure patient safety?

A safer, more patient-centered approach is not to abandon medical consultation, but to redefine it around what actually happens in the dental office. Above all, seek clarity and offer it in your assessments of patients. Physicians should insist that dentists clearly describe the planned procedure, its bleeding and sedation profile, and any specific concerns about medications or underlying medical conditions. That clarity allows the physician to provide focused, evidence-based guidance on systemic risk and medication management.

Does this mean there is a one-size-fits-all approach to working with dentists and patients?

Like so many things in medicine, each patient and dental procedure presents unique considerations. Decisions about continuing or stopping medications before dental surgery should be made in collaboration between the dentist, the primary care physician and appropriate specialists. These decisions should be based on the specific dental procedure being performed rather than standard medical or general surgical guidelines.

This kind of structured collaboration protects patients from avoidable complications, lowers malpractice exposure for everyone involved and brings dental surgery decisions up to the same standard of rigor expected in hospital-based care.

Robert Resnik, M.D., MBA, is a board-certified internal medicine physician practicing in Cary, North Carolina. He earned his medical degree from Eastern Virginia Medical School and completed his residency at East Carolina University. He also holds an MBA from Duke University. He has co-authored three textbook chapters on medical evaluation and risk assessment for dental implant patients and is a frequent lecturer to dentists and physicians on medical risk stratification and appropriate medical clearance to enhance patient safety.