Methotrexate (MTX) is a widely prescribed disease-modifying anti-rheumatic drug used to manage chronic inflammatory conditions such as rheumatoid arthritis and psoriasis. The medication functions by suppressing the immune system to reduce inflammation and slow disease progression. For individuals on this treatment, an invasive dental procedure, such as a tooth extraction, raises questions about potential complications and the need to adjust medication. Managing dental surgery requires a coordinated approach between the patient, the dentist, and the prescribing physician to ensure both oral health and systemic disease control are maintained.
How Methotrexate Affects Oral Healing
MTX is classified as an anti-folate agent, interfering with the body’s use of folic acid, which is necessary for cell division and DNA synthesis. In the low doses used for autoimmune diseases, MTX primarily acts as an anti-inflammatory and immunosuppressive agent. This mechanism can potentially overlap with the body’s natural healing processes following surgery.
Wound repair, including the healing of bone and gum tissue after an extraction, relies heavily on the rapid proliferation of cell types like fibroblasts and epithelial cells. By inhibiting cell division, MTX can slow down tissue regeneration. Studies show MTX affects the proliferation of fibroblasts, which produce the connective tissue that closes the wound. This interference is dose-dependent, meaning higher doses carry a greater risk, though low-dose MTX has also been implicated in delayed healing.
The medication’s immunosuppressive nature also influences post-extraction recovery. By dampening the immune response, MTX can increase susceptibility to localized post-operative infection. This requires careful consideration of infection prevention strategies. The concern regarding MTX and dental extraction centers on balancing systemic inflammation control with robust, timely oral wound healing.
Guidelines for Adjusting Medication Before Surgery
The decision to stop or continue low-dose methotrexate before a dental extraction has evolved significantly. Early protocols recommended interrupting the medication to reduce the risk of impaired healing or infection. Current consensus, however, favors minimizing treatment disruption for patients with stable, well-controlled autoimmune conditions.
A temporary interruption of low-dose MTX carries a significant risk of causing a flare-up of the underlying condition, such as rheumatoid arthritis. A disease flare leads to increased pain, swelling, and joint damage, complicating recovery and delaying the return to normal function. For routine dental extractions, the most common modern guideline suggests patients should continue taking their low-dose MTX without interruption.
This protocol is based on the finding that the risk of a disease flare often outweighs the potential benefit to wound healing from a short drug holiday. The weekly dose of MTX used for autoimmune diseases (typically 7.5 mg to 25 mg) is considered low-dose and generally does not cause clinically relevant delays in wound healing.
Any decision to adjust the medication dose or schedule must be made through direct consultation between the dental surgeon and the patient’s prescribing physician. If a patient is taking high-dose MTX—common for certain cancer treatments—the protocol changes significantly due to the heightened risk of compromised healing. In the context of low-dose therapy, the dental team focuses on minimizing surgical trauma and managing local risks. Emphasis is placed on an atraumatic extraction technique with proper soft tissue closure to support the healing process.
Post-Extraction Care and Potential Complications
Following a dental extraction, patients taking methotrexate require enhanced vigilance and specific post-operative care. The primary complications to monitor are delayed wound healing and localized infection. Delayed healing may manifest as an unclosed surgical site or, in more severe cases, alveolar osteitis, commonly known as a dry socket.
A dry socket occurs when the blood clot in the extraction site is dislodged or dissolves prematurely, exposing the underlying bone and causing intense pain. While MTX’s influence on cell proliferation suggests a need for extra caution, patients must strictly adhere to post-operative instructions. This includes avoiding activities that could dislodge the clot, such as forceful rinsing, drinking through a straw, or smoking.
Patients should also be aware of signs of infection, including persistent swelling, fever, localized warmth, or pus draining from the site. Due to MTX’s immunosuppressive effect, an infection may progress quickly. The dental surgeon may recommend prophylactic antibiotics before or after the procedure to reduce infection risk.
Long-term MTX use, especially with drugs like corticosteroids or bisphosphonates, may raise the rare concern of medication-related osteonecrosis of the jaw (MRONJ) following an extraction. This necessitates meticulous surgical technique and comprehensive follow-up care. Regular communication with the dental team about any persistent symptoms is paramount for recovery.