Immunosuppression and dentistry

Immunosuppression occurs when the body’s immune system is in a weakened state and unable to fight infections or diseases as easily as someone with a healthy immune system. Immunosuppression can be due to immunosuppressive medications or diseases.

Immunosuppressants are a classification of medications that prevent the body from attacking and destroying healthy cells or tissue inadvertently.¹ Either mode of suppression can increase the risk of opportunistic infections, delayed wound healing, and increased risk of cancers or other autoimmune disorders. This can lead to unforeseen dental complications and oral manifestations.

Who can be immunosuppressed?

Immunosuppression is often associated with patients undergoing cancer treatment. However, there are additional groups of people who can be immunosuppressed without a cancer diagnosis.

Examples of diseases treated with immunosuppressants:

• Autoimmune diseases: alopecia areata, Crohn’s disease, lupus, multiple sclerosis, psoriasis, rheumatoid arthritis, kidney diseases, type I diabetes
• Stem cell transplants: sickle cell disease, aplastic anemia
• Organ transplants: reduce the risk of the immune system attacking the newly transplanted organ and/or organ rejection

Examples of diseases that cause immunosuppression:

• Cancers: leukemia, lymphoma, multiple myeloma
• HIV/AIDS
• Genetic diseases

Common types of immunosuppressant medications encountered in the dental practice

To be able to identify patients who are immunocompromised, it is important to recognize common immunosuppressant medications. Medications commonly prescribed for well-known conditions and diseases can be easier to identify compared to the lesser-known ones. The use of generic versus name-brand medications can also make identification more complicated. Here are the classifications of immunosuppressants and specific examples of medications that dental professionals may encounter while reviewing health histories:

• Biologics: These lab-made medications target certain parts of the immune system by blocking specific antibodies responsible for causing inflammatory responses.² Examples of biologics include Humira and Remicade; these can be used to treat psoriasis, Crohn’s disease, rheumatoid arthritis, and ulcerative colitis.
• Corticosteroids: These are fast-acting anti-inflammatories that suppress an overactive immune system, help with hormone balance, and reduce inflammation.³ Prednisone and cortisone are corticosteroids commonly prescribed for a wide variety of conditions ranging from asthma to eczema to lupus. They are often used for shorter durations of time due to the increased risk of long-term side effects.
• Calcineurin inhibitors: This classification of medications block the activation of T-cells (white blood cells).⁴ Cyclosporin is commonly used as an anti-rejection medication postoperatively for transplant patients. It can also be used to treat patients with arthritis and psoriasis.
• Monoclonal antibodies: This singular antibody clone is used to seek out antigens and destroy them, thus stimulating the immune system. It can be used to treat patients with a broad range of conditions including kidney disease, cancer, COVID-19, and osteoporosis. This includes medications such as rituximab and Keytruda.⁵

Clinical manifestations of immunosuppression

The oral cavity is the gateway to our body; dental providers frequently are the first line of defense for screening a patient’s oral cavity for the evidence of systemic diseases or conditions. In a study published in May 2025, 97% of participating dentists and dental students reported that more education was needed regarding systemic conditions and associated oral manifestations.⁶ Dental providers should have a basic understanding of the oral manifestations that can accompany immunosuppression and the corresponding clinical presentation.

Neutrophil disorders can be the result of immunosuppression. Neutrophils are one of the main lines of defense against bacteria invading gingival tissues. Patients with a neutrophil deficiency can have a significant increase in biofilm production, which can lead to gingivitis or a rapid progression to periodontal disease.⁷

Herpetic lesions and increased risk of shingles is common among immunocompromised patients. Patients receiving monoclonal therapies have an increased risk of exposure to shingles and herpes. Patients are often on a prophylactic regimen of antiviral medications to reduce the risk of exposure. Those who present with early symptoms of a herpetic outbreak or shingles should be advised to contact their treating physician, and dental treatment should be rescheduled.⁸

Tuberculosis (TB) infections can be reactivated in patients taking biologic medications, and their TB status should be periodically monitored. However, patients experiencing a recurrent TB infection may present with redness and irritation in the back of the throat due to persistent coughing. Dental appointments should be rescheduled for patients with suspected recurrent TB.

Oral candidiasis is one of the most common oral complications due to immunosuppression. This fungal infection presents as a thick, white coating on the tongue and oral mucosa. In more severe cases, red, irritated mucosa can be present under the thick, white lesions. Patients can also experience burning and pain with oral candidiasis and may require an antifungal rinse to treat this condition.

Xerostomia and caries risk has been well documented as one of the most common side effects of medications. When saliva decreases, patients are at an increased risk of developing caries, especially along exposed root surfaces, interproximally, and around existing restorations. Patients who are experiencing nausea as a side effect of medications also have a higher acidity level in the oral cavity, thus increasing caries risk. These patients benefit from frequent in-office fluoride treatments or an at-home fluoride prescription.

Gingival hyperplasia is commonly seen in patients who are taking calcium channel blockers, but it can also be observed in those who are on corticosteroids. The areas of hyperplasia can be rectified once treatment has been completed, but good plaque control at home and more frequent dental cleanings are recommended.

Minimizing oral complications due to immunosuppression

Dental professionals cannot eliminate the risk of patients developing oral complications due to immunosuppression, but the goal should be to minimize the risks. A recent study reported that approximately 75% of dental treatment was completed without interruptions, and any halted dental treatment was at the discretion of the treating physician.⁹

A multidisciplinary approach to coordinate a patient's treatment and management of oral complications is essential; therefore, communication between the dental provider and physicians is vital. Most routine dental procedures can be performed on immunocompromised patients. If it has been determined that dental treatment should be temporarily suspended, dental professionals should assure patients that any oral conditions can be addressed at the completion of immunosuppressive therapy. Approaches to minimize oral complications can include:

• Prescription fluoride toothpaste
• Oral hygiene education
• Frequent recalls
• Increased frequency of radiographs
• Premedication when indicated by physician
• Patient education about the oral risks of immunosuppression

Conclusion

Immunosuppression is a complex health condition that should be assessed and treated with a multidisciplinary approach. It is important to remember that a patient can appear healthy even though they are medically compromised. A thorough evaluation of a patient’s medical history and establishing an oral baseline will allow dental professionals to provide patients with a comprehensive oral health-care routine, both during and after immunosuppression. 

Editor's note: This article appeared in the March 2026 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Immunosuppressants. Cleveland Clinic. Updated August 1, 2023. Accessed October 21, 2025. https://my.clevelandclinic.org/health/treatments/10418-immunosuppressants
2. Weiser P. Remicade vs. Humira. MedicalNewsToday. August 19, 2023. Accessed December 2, 2025. https://www.medicalnewstoday.com/articles/drugs-remicade-vs-humira
3. What to know about corticosteroids. MedicalNewsToday. March 18, 2020. Accessed December 1, 2025. https://www.medicalnewstoday.com/articles/corticosteroids
4. Calcineurin inhibitors. Drugs.com. 2019. Accessed November 23, 2025. https://www.drugs.com/drug-class/calcineurin-inhibitors.html
5. Monoclonal antibodies. Cleveland Clinic. November 16, 2021. Accessed November 21, 2025. https://my.clevelandclinic.org/health/treatments/22246-monoclonal-antibodies
6. Silva ACT, Braun LW, Romanini J, Martins MD, Martins MAT, Carrard VC. Knowledge about oral manifestations of systemic diseases among dentists and dental students. Oral Surg Oral Med Oral Path Oral Radiol. 2025;139(5):e113. doi:10.1016/j.oooo.2025.01.561
7. Wright AK. Aiding the immunocompromised: the critical role of oral hygiene in patient care. Waterpik. October 3, 2025. Accessed December 26, 2025. https://www.waterpik.fr/en-gb/blogs/professional-blog-posts/aiding-the-immunocompromised-the-critical-role-of-oral-hygiene-in-patient-care
8. Kissell D. Effects of immunosuppressive medications on oral health. Dimensions of Dental Hygiene. November 24, 2021. Accessed October 21, 2025. https://dimensionsofdentalhygiene.com/article/effects-immunosuppressive-meidcations-oral-health/
9. Bourgoin A, Agossa K, Seror R, Fumery M, Radoi L, Gosset M. Management of dental care of patients on immunosuppressive drugs for chronic immune-related inflammatory diseases: a survey of French dentists’ practices. BMC Oral Health. 2023;23(1):545. doi:10.1186/s12903-023-03258-7.