Dental Management of the Organ Transplant Patient by tyndale



                                                         Dental Management of the

    National Institute of Dental
                                        Organ Transplant Patient
    and Craniofacial Research
                                   Improving the Nation’s Oral Health •

                                        Every year, more than 25,000 transplantation procedures are performed
                                        in the United States to replace solid organs, including the heart, intestine,
                                        kidney, liver, lung, and pancreas. Patients with conditions including end-
                                        stage renal disease, severe diabetes, advanced heart disease, and liver
                                        disease may undergo transplant procedures. Because advances in medical
                                        techniques and drug therapy have extended lives of organ transplant
                                        recipients, you may treat some of these patients in your practice.

                                        Organ transplant patients need specialized dental care. The compromised
                                        health and immune system of patients place them at increased risk for
                                        systemic as well as oral infections. This fact must be considered when
                                        planning dental treatment before and after transplantation and requires
                                        consultation with your patient’s physician.

        MANAGING ORAL Before treating a prospective transplant recipient, obtain and review the
  HEALTH BEFORE ORGAN patient’s medical and dental histories and perform a non-invasive initial
      TRANSPLANTATION oral examination (without periodontal probing). After the examination,
                      discuss the current status of your patient’s health and immune system, and
                      the degree of organ dysfunction with his or her physician. Decisions about
                      the timing of treatment, the need for antibiotic prophylaxis, precautions
                      to prevent excessive bleeding, and appropriate medication and dosage
                      should be considered during your discussion. Whether a patient can
                      tolerate dental treatment is another crucial concern. In some cases, it will
                      be safer for patients to undergo extensive treatment after transplant as the
                      new organ improves their health.

                                        Preparing for Dental Treatment
                                        Several factors should be considered before starting treatment:

                                        — Antibiotic Prophylaxis: Decide with the patient’s physician whether
                                          antibiotic prophylaxis is required to prevent systemic infection from
                                          invasive dental procedures. Unless advised otherwise by the physician,
                                          the American Heart Association’s standard regimen to prevent
                                          endocarditis ( is an accepted option.

                                        — Infection: If the patient presents with an active infection, such as
                                          a purulent periodontal infection or an abscessed tooth, antibiotics
                                          should be given to the patient before and after dental treatment to
                                          prevent systemic infection. Confirm the choice of antibiotic with the
                                          patient’s physician.
— Excessive Bleeding: Several factors                anticoagulants, beta blockers, calcium
  can cause bleeding problems in organ               channel blockers, diuretics, and
  transplant candidates, such as organ               others. Be aware of the side effects of
  dysfunction or their medications. Many             these medications, which range from
  may be anticoagulated, and some                    xerostomia and gingival hyperplasia
  may have a decreased platelet count.               to orthostatic hypotension and
  Patients with end-stage liver disease              hyperglycemia, and their interactions
  may have excessive bleeding because                with drugs you might prescribe.
  the liver is no longer producing
  sufficient amounts of clotting factors.            Likewise, use caution when prescribing
  Before treatment, assess the patient’s             medication to patients with end-
  bleeding potential with the appropriate            stage kidney or liver disease. Many
  laboratory tests and take precautions to           medications commonly used in
  limit bleeding.                                    dental practice, including NSAIDS,
                                                     opiates, and some antimicrobials,
    ❍   Consult with your patient’s                  are metabolized by these organs and
        physician about whether                      are not removed from circulation as
        antifibrinolytic drugs, vitamin K,           quickly in patients with markedly
        fresh frozen plasma, or other                reduced kidney or liver function.
        interventions are appropriate.               Prior to dental treatment, consult the
        The physician also may decide to             patient’s physician on appropriate
        temporarily decrease the patient’s           drug selection, dosage, and
        level of anticoagulation before              administration intervals.
        extensive dental surgeries. Some
        patients are only suitable for surgery    — Other Medical Problems: Patients
        in a hospital setting or dental offices     with end-stage organ failure may have
        designed to handle emergency                other major medical conditions. A
        medical situations.                         person with end-stage kidney disease,
                                                    for example, may have diabetes and/or
    ❍   Use aggressive suctioning                   significant pulmonary or heart disease.
        techniques when performing                  Carefully review your patient’s medical
        extractions or other invasive               history to determine what additional
        procedures to prevent your patient          treatment considerations your patient
        from swallowing blood. In a small           may have.
        number of patients with advanced
        liver disease, swallowed blood may        Dental Treatment
        increase risk for hepatic coma.           Whenever possible, all active dental
                                                  disease should be aggressively treated
    ❍   Manage bleeding sites with careful        before transplantation, since post-operative
        packing and suturing techniques.          immunosuppression decreases a patient’s
                                                  ability to resist systemic infection.
— Medication Considerations:
  Patients preparing to undergo                   — Eliminate or stabilize sites of oral
  organ transplantation usually take                infection. Patients with active dental
  multiple medications. These include               disease who can tolerate treatment

2                Dental Management of the Organ Transplant Patient
   should receive indicated dental           3 months following organ transplantation.
   care. Depending on the patient’s          Dosage of immunosuppressive medications
   condition, temporary restoration          is highest in the early post-transplant
   may be appropriate until his or her       period, and patients are at greatest risk
   health improves.                          for rejection of the transplanted organ
                                             and other serious complications during
— Extract nonrestorable teeth.               that time. Once the graft has stabilized,
                                             typically 3 to 6 months post-surgery,
— Consider removing orthodontic bands
                                             patients can be treated in the dental office
  or adjusting prostheses for patients
                                             with proper precautions.
  expected to receive cyclosporine after
  transplant, as some patients taking this   Preparing for Dental Treatment
  drug will develop gingival hyperplasia.    Treatment after transplantation requires
  The overgrowth can be minimized with       consultation with your patient’s physician.
  good plaque control, and removing          The medical consult can help you
  orthodontic bands may make it easier       understand your patient’s general health
  to maintain good oral hygiene.             and ability to tolerate treatment. Post-
                                             transplant patients vary widely in their
— Conduct dental procedures on days
                                             ability to endure dental treatment and
  that your patient with end-stage renal
                                             heal following invasive procedures. Your
  disease does not undergo hemodialysis.
                                             discussion needs to address whether your
— Counsel your patients about their oral     patient requires antibiotic prophylaxis and
  health. Explain that effective oral        if the physician will need to adjust other
  hygiene is crucial before and after        medications before treatment.
  transplantation and that more frequent
                                             — Infection: Patients who have
  dental appointments may be necessary
                                               undergone organ transplant surgery are
  if new dental disease develops.
                                               at increased risk for serious infection.
— Pay special attention to anxiety and         Bacterial, viral, and fungal infections
  pain tolerance in organ transplant           are more common, especially
  patients.                                    immediately after surgery. The
                                               decision to premedicate for invasive
— Instruct patients to bring a current         dental procedures and selection
  list of their medications, including         of the appropriate regimen should
  over-the-counter drugs, to every             be done in consultation with the
  appointment and note those that may          patient’s physician.
  be problematic.
                                             — Medication Considerations: Organ
                                               transplant recipients may be taking
                                               one or more medications that affect
MANAGING ORAL HEALTH AFTER                     dental treatment. Immunosuppressive
ORGAN TRANSPLANTATION                          agents can cause gingival hyperplasia,
Except for emergency dental care, patients     poor healing, and infections and may
should avoid dental treatment for at least     interact with commonly prescribed

               Dental Management of the Organ Transplant Patient                        3
   medications. Anticoagulant                    — Exercise care in prescribing
   medications may contribute to                   medications to avoid potentiating
   excessive bleeding problems, whereas            the renal and hepatic toxicities of
   a patient taking steroids is at risk for        immunosuppressants. Consult the
   acute adrenal crisis. The patient’s             patient’s physician to ensure proper
   physician may want to adjust these              drug selection and dosing.
   medications several days before an
   invasive dental procedure.                    — Prescribe an antimicrobial rinse when
Dental Treatment
All new dental disease should be treated         — Recommend saliva substitutes and
after the patient’s transplant has stabilized.     fluoride rinses for your patients with
                                                   dry mouth.
— Check your patient’s blood pressure
  before you begin treatment. Know               — Advise your patients to follow a
  baseline levels for each patient and             conscientious oral hygiene routine
  call his or her physician immediately            and emphasize the importance of oral
  if blood pressure exceeds accepted               health before and after transplantation.
  thresholds. Do not treat a patient when
                                                 Oral Complications
  this problem is present.
                                                 Side effects from immunosuppressive drugs
— Examine the patient’s mouth                    to prevent organ rejection are among
  thoroughly for dental infection, since         the most frequent oral health problems
  immunosuppressive medication can               affecting transplant recipients. Common
  hide signs of a problem. As a result,          immunosuppressive agents and their side
  infections are often more advanced             effects include:
  than they appear when detected. Treat
                                                 — Cyclosporine: Changes in liver/kidney
  all infections aggressively.
                                                   function, hypertension, bleeding
— Know your patient’s bleeding potential           problems, and poor wound healing
  and take appropriate steps to manage             are among the adverse effects of this
  excessive bleeding.                              potent agent, which also interacts with
                                                   a number of other drugs. Gingival
— Watch for signs of adrenal insufficiency         hyperplasia occurs in some patients;
  with surgical stress in patients taking          incidence varies and is dependent
  steroids. These patients may require             on each patient and his or her drug
  increased doses of steroids at the time          regimen. Calcium channel blockers,
  of extensive dental procedures to avoid          for example, may exacerbate the
  adrenal insufficiency syndrome. A                problem. Children tend to be more
  person experiencing this condition               susceptible to gingival overgrowth than
  may become hypertensive, weak,                   adults. Emphasize conscientious daily
  feverish, and nauseated and should be            oral hygiene to all patients.
  transported immediately to a hospital
  for treatment.

                Dental Management of the Organ Transplant Patient                           4
— Tacrolimus: An immunosuppressive           — Sirolimus: Side effects of this
  agent used increasingly in place of          anti-rejection drug can include
  cyclosporine, tacrolimus causes less         hypertension, joint pain, low white
  gingival overgrowth but is associated        cell count, hypercholesterolemia,
  with oral ulcerations and numbness           and oral ulceration.
  or tingling, especially around
  the mouth.                                 Marked Immunosuppression
                                             Several complications associated with
— Azathioprine: Bone marrow                  marked immunosuppression manifest in
  suppression and related                    the mouth, including oral candidiasis,
  complications such as stomatitis           herpes simplex/herpes zoster, hairy
  and opportunistic infections are           leukoplakia, aphthous ulcers, and
  significant side effects of this drug. A   uncommon viral and fungal infections.
  decrease in white blood cell counts        Progressive periodontal disease,
  and excessive bleeding may occur.          delayed wound healing, and excessive
                                             bleeding may also become problems for
— Mycophenolate mofetil: This                these patients.
  immunosuppressant is commonly
  used as an alternative to                  Notify the patient’s physician
  azathioprine. Adverse effects              if you notice signs of marked
  include decreased white cell               immunosuppression. In some cases,
  counts, opportunistic infections, and      the dosage of anti-rejection agents
  gastrointestinal problems.                 prescribed for patients may need to be
                                             reduced. This may help control the
— Corticosteroids: Hypertension and          opportunistic infections and other oral
  high blood glucose (steroid-induced        complications. However, there will
  diabetes) are among the numerous           be patients who must be maintained
  side effects of these drugs, along         on high-dose immunosuppression to
  with increased risk for infection,         prevent organ rejection. Treatment of
  poor wound healing, and depression.        oral opportunistic infection is necessary
  Adrenal suppression may occur,             in any transplanted patient.
  making invasive dental and medical
  procedures more difficult for your         Oral Malignancies
  patient. Corticosteroids may also          Screen patients for oral malignancies
  mask the early signs of oral infection.    at every appointment. Kaposi’s
  The trend toward using lower doses         sarcoma, lymphoma, and squamous cell
  of corticosteroids in combination          carcinoma of the lip are among the oral
  with other immunosuppressants              malignancies that sometimes occur in
  for post-transplant maintenance            organ transplant patients. Malignancies
  therapy has helped mitigate these          can occur decades earlier in transplant
  side effects.                              recipients than in people who are
                                             not immunosuppressed.

         Dental Management of the Organ Transplant Patient                           5
Organ Rejection                               ADDITIONAL READINGS
If a patient’s body begins to reject a
transplanted organ, only emergency            Little JW, Falace DA, Miller CS, Rhodus
dental care may be provided. Talk with        NL. Dental Management of the Medically
the patient’s physician about antibiotic      Compromised Patient (7th ed.). St. Louis,
prophylaxis or other special needs            MO: Mosby Inc., 2008.
before treatment.
                                              Goldman KE. Dental Management of
                                              Patients with Bone Marrow and Solid
                                              Organ Transplantation. In The Dental
POINTS TO REMEMBER                            Clinics of North America 50 (2006)
                                              Elsevier Saunders pp. 659-676.
— Organ transplant recipients are
  growing in number and living longer,
  increasing demand for specialized           For additional copies of this
  dental treatment.                           fact sheet contact:

— Effective dental treatment can play an         National Institute of Dental and
  important part in these patients’ lives          Craniofacial Research
  by preventing serious infection.               National Oral Health Information
— Stay in close contact with your patient’s      1 NOHIC Way
  physician and tailor your treatment to         Bethesda, MD 20892–3500
  meet his or her special needs.                 1–866–232–4528

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                                              Make as many photocopies as you need.

National Institutes of Health
National Institute of Dental and
Craniofacial Research
NIH Publication No. 10-6270
Reprinted October 2009

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