Complications After Dental Extractions in Patients Taking Biologic Agents

Andres Davila

Rogan Magee

Katherine France

Davila, Andres1, Magee, Rogan2, France, Katherine1
1University of Pennsylvania School of Dental Medicine, Department of Oral Medicine
2Sidney Kimmel Medical College at Thomas Jefferson University, Neurology


Biologics are an expanding class of therapeutics. As these agents have grown in number and application, more patients receive them, often chronically. While their impacts on healing have been elucidated in specific surgical contexts, effects on safe delivery of dental treatment remain unknown. This research estimated the rate of post-extraction complications in patients treated with biologic agents.


This retrospective case-control study analyzed Penn Dental Medicine patients who were treated with biologics during the peri-extraction period from July 1, 2017 – July 1, 2020. Complications within 30 days post-extraction were recorded. Demographic data were compiled descriptively, and complications were compared using chi-square tests. Relationships between agents were evaluated using multivariate logistic regression.


One-hundred twenty-one patients treated with biologics received 217 dental extractions during 146 encounters. Fifteen patients experienced 16 complications, consisting of: bleeding, post-surgical abscess, hematuria, pain, delayed wound healing, swelling, and alveolar osteitis. Notable or excessive pain was most commonly documented (14 of 16 cases; 88%). Patients who experienced complications were treated with seven biologic agents (dulaglutide, belimumab, adalimumab, aflibercept, tofacitinib, ranibizumab, ixekizumab) representing six mechanisms of action (GLP-1 agonists, B-cell activating factor antagonists, TNF antagonists, VEGF antagonists, JAK antagonists, and IL-17 antagonists). Complication after extraction was significantly elevated for patients receiving aflibercept (67 vs. 33%; p=0.027) and ranibizumab (100 vs. 0%; p=0.0034). When grouped by class, reported complication after extraction – specifically, excessive pain - was significantly elevated in patients treated with VEGF antagonists (80 vs. 20%; p=0.00014). On multivariate regression, treatment with aflibercept (p=0.0016) and ranibizumab (p=0.00010) remained significant predictors of complication.


The impact of biologics on the provision of and recovery after dental treatment remains unknown. In this study, pain was most commonly reported. Notably, patients treated with VEGF antagonists reported significantly more pain. While the connection between VEGF antagonism and pain is yet unclear, studies suggest that dysregulation of VEGF1R/VEGFR2 contributes to the progression and severity of pain in arthritis. Other reports link VEGF-A to nociception in chronic neuropathic pain.