- Before and after organ or stem cell transplantation, patients require
specialized dental management.
- Optimal dental management can play an important role in a transplant
patient’s quality of life.
- Work with the transplant patient’s medical team and tailor dental treatment
plans to meet the patient’s special needs.
According to the Health Resources and Services Administration, nearly 29,000 solid organ transplants and more than 6,300 stem cell transplants from unrelated donors were performed in the United States in 2013. Thousands more patients received stem cell transplants from their family members and far more than that received transplants from their own stem cells. Stem cell transplants are a treatment for life-threatening leukemia, lymphoma, or other diseases.
Of those who received a solid organ transplant in 2013, most (about 17,000) people received a kidney, usually because of end-stage kidney failure resulting from severe diabetes or high blood pressure. About 6,000 livers were transplanted, most often for people with hepatitis C virus or alcoholic liver disease. Other organs transplanted were the heart, lung, pancreas, and intestine.
Because the immune system of a transplant patient is compromised, the patient is at increased risk of oral and systemic infections and other complications and requires specialized dental care delivered by general dentists in collaboration with the medical team. Optimal management of the patient’s oral health requires communication between the dentist and the medical team.
Managing Oral Health Before Transplantation
Before treating a prospective transplant recipient, obtain and review the patient’s
medical and dental histories, perform a noninvasive initial oral examination
(without periodontal probing), and obtain radiographs. After the examination,
discuss with your patient’s physician the current status of your patient’s overall
health and immune system. Decisions about the timing of treatment, the need
for antibiotic prophylaxis, precautions to prevent excessive bleeding, and
the appropriate medication and dosage should be considered during your
Whether a patient can tolerate dental treatment is a crucial concern. For some
patients, it will be safer to undergo extensive dental treatment after their overall
health improves after transplantation.
Preparing for Dental Treatment
Before starting your patient’s dental treatment
before transplantation, consider several factors:
- Antibiotic prophylaxis: Consult with the
patient’s physician to determine 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 (http://www.heart.org/) is an
- Oral infection: If the patient presents with
an active oral 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.
Before transplantation, the active oral
infection must be eliminated.
- Excessive bleeding: Several factors can
cause bleeding problems in transplant
candidates, such as the disease itself or
medications. For example, patients may
have a decreased platelet count or be
on anticoagulant medications. Patients
with end-stage liver disease may have
excessive bleeding because the liver is no
longer producing sufficient amounts of
clotting factors. Before treatment, assess
the patient's bleeding potential with the
appropriate laboratory tests and take
precautions to limit bleeding.
- Consult with your patient's physician
about whether antifibrinolytic drugs,
vitamin K, fresh frozen plasma, or other
interventions are appropriate for critical
dental procedures. The physician also
may decide to temporarily decrease the
patient’s level of anticoagulation before
extensive dental surgeries.
Because of bleeding risk, some
patients are suitable for surgery only
in a hospital setting or dental offices
designed to handle emergency
- Use aggressive suctioning techniques
when performing extractions or other
invasive procedures to prevent your
patient from swallowing blood. In a
small number of patients with advanced
liver disease, swallowed blood may
increase risk for hepatic coma.
- Manage bleeding sites with careful
packing and suturing techniques.
- Medication considerations: Patients preparing to undergo organ or stem cell
transplantation may be taking multiple
medications. These include anticoagulants,
beta blockers, calcium channel blockers,
diuretics, and others. Be aware of the side
effects of these medications, which range
from xerostomia and gingival hyperplasia to
orthostatic hypotension and hyperglycemia,
and their interactions with drugs that you
Likewise, use caution when prescribing
medication to patients with end-stage
kidney or liver disease. Many medications
commonly used in dental practice,
including NSAIDS, opiates, and some
antimicrobials, are metabolized by
these organs and are not removed from
circulation as quickly in patients with
markedly reduced kidney or liver function.
Before dental treatment, consult the
patient’s physician on appropriate drug
selection, dosage, and administration
- Other medical problems: Patients with
end-stage organ failure may have other
major medical conditions. A person with
end-stage kidney disease, for example, may
have diabetes or significant pulmonary or
heart disease. Carefully review your patient’s
medical history to determine what additional
treatment considerations your patient
Whenever possible, all active dental disease
should be eliminated before transplantation,
since post-operative immunosuppression
decreases a patient’s ability to resist systemic
- Eliminate or stabilize sites of oral infection.
Patients with active dental disease who can
tolerate treatment should receive indicated
dental care. Depending on the patient’s
condition, temporary restoration may be
appropriate until his or her health improves.
- Extract nonrestorable teeth.
- Consider removing orthodontic bands or
adjusting prostheses if a patient is expected
to receive cyclosporine after transplant
because some people taking this drug
will develop gingival hyperplasia. The
overgrowth can be minimized with good
plaque control, and removing orthodontic
bands may make it easier to maintain good
- Conduct dental procedures on days that
your patient with end-stage renal disease
does not undergo hemodialysis.
- Pay special attention to your patient’s anxiety
and pain tolerance.
- Counsel the patient about oral health.
Explain that effective oral hygiene is crucial
before and after transplantation. The patient
may experience fewer oral and dental
problems after transplantation by reducing
the number of oral bacteria and inhibiting
- Instruct patients to bring a current list of their
medications, including over-the-counter
drugs, to every appointment and note those
medications that may be problematic.
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Managing Oral Health After
Except for emergency dental care, patients who
receive organ or stem cell transplants should
avoid dental treatment for at least 3 months.
Dosage of immunosuppressive drugs is highest
in the early post-transplant period, and patients
are at greatest risk for serious complications,
such as rejection of the transplanted organ,
during that time. Once the graft has stabilized
(which typically occurs within 3 to 6 months of
the transplant procedure) and the medical team
clears the patient for dental treatment, patients
can be treated in the dental office with
Preparing for Dental Treatment
Treatment after transplantation requires
consultation with your patient’s physician. The
medical consult can help you understand your
patient’s general health and ability to tolerate
treatment. Post-transplant patients vary widely
in their ability to endure dental treatment
and heal following invasive procedures. Your
discussion needs to address whether your
patient requires antibiotic prophylaxis and if the
physician will need to adjust other medications
- Infection: Patients who have had a
transplant procedure are at increased risk for
serious infection. Bacterial, viral, and fungal
infections are more common, especially
immediately after the procedure. The
decision to premedicate for invasive dental
procedures and selection of the appropriate
regimen should be done in consultation with
the patient’s physician.
- Medication considerations: Your
transplant patient may be taking one
or more medications that affect dental
treatment. Immunosuppressive drugs
can cause gingival hyperplasia, poor
healing, and infections and may
interact with commonly prescribed
medications. Anticoagulant medications
may contribute to excessive bleeding
problems, whereas a patient taking
steroids is at risk for acute adrenal crisis.
The patient’s physician may want to
adjust these medications several days
before an invasive dental procedure.
All new dental disease should be treated
after the patient’s transplant has stabilized.
Check your patient’s blood pressure
before you begin treatment. Know
baseline levels for each patient and call
his or her physician immediately if blood
pressure exceeds accepted thresholds.
Do not treat a patient when this problem
- Know your patient’s bleeding potential
and take appropriate steps to manage
- Prescribe an antimicrobial rinse
- Recommend saliva substitutes and
fluoride rinses if your patient has
- Advise your patients to follow a
conscientious oral hygiene routine and
emphasize the importance of oral health.
- Examine the patient’s mouth
thoroughly for dental infection, since
immunosuppressive drugs can hide signs
of a problem. As a result, infections are
often more advanced than they appear
when detected. Treat all infections
- Watch for signs of adrenal insufficiency
with surgical stress in patients taking
steroids. These patients may require
hydrocortisone replacement therapy at
the time of extensive dental procedures
to avoid adrenal insufficiency syndrome.
A person experiencing this condition
may become hypertensive, weak,
feverish, and nauseated and should be
transported immediately to a hospital for
- Exercise care in prescribing medications
to avoid potentiating the renal and
hepatic toxicities of immunosuppressant
drugs. Consult the patient’s physician to
ensure proper drug selection and dosing.
Side Effects of Immunosuppressive Drugs
Immunosuppressive drugs are associated
with side effects and oral complications.
These adverse reactions are among the most
frequent oral health problems affecting
transplant recipients, and the clinical
presentation of oral lesions may differ
from that observed in immunocompetent
Several complications associated with
immunosuppression manifest in the
mouth, including bacterial infections,
oral candidiasis, reactivation of herpes
simplex virus, uncommon viral and fungal
infections, hairy leukoplakia, and aphthous
ulcers. Oral ulcers may be caused by herpes
simplex virus reactivation or side effects of
systemic immunosuppression, and in stem
cell transplant patients, oral ulcers may be a
sign of graft-versus-host disease. In addition,
progressive periodontal disease, delayed
wound healing, and excessive bleeding may
become problems for these patients.
Notify the patient’s physician if you notice
signs of marked immunosuppression. In
some cases, the dosage of anti-rejection
agents prescribed for patients may need
to be reduced. This may help control the
opportunistic infections and other oral
complications. However, there will be
patients who must be maintained on high-dose
immunosuppression. Treatment of oral
opportunistic infection is necessary in any
Common immunosuppressive drugs and
their side effects include:
- Cyclosporine: Changes in liver/kidney
function, hypertension, bleeding
problems, and poor wound healing
are among the adverse effects of this
potent agent, which also interacts with
a number of other drugs. Gingival
hyperplasia occurs in some patients.
Calcium channel blockers, for example,
may exacerbate the problem. Children
tend to be more susceptible to gingival
overgrowth than adults. Emphasize
conscientious daily oral hygiene to all
- Tacrolimus: An immunosuppressive
drug used increasingly in place of
cyclosporine, tacrolimus causes less
gingival overgrowth but is associated
with oral ulcerations and numbness or
tingling, especially around the mouth.
- Azathioprine: Bone marrow suppression
and related complications such as
stomatitis and opportunistic infections
are significant side effects of this drug. A
decrease in white blood cell counts and
excessive bleeding may occur.
- Mycophenolate mofetil: This
immunosuppressive drug is commonly
used as an alternative to azathioprine.
Adverse effects include decreased white
cell counts, opportunistic infections,
and gastrointestinal problems.
- Corticosteroids: Steroid drugs increase
the risk of oral and systemic infection,
and at the same time, they may mask
the typical signs of infection occurring
in the mouth. Hypertension, high blood
glucose (steroid-induced diabetes),
poor wound healing, and changes in
mood are other side effects of these
drugs. If your patient has cushingoid
facies (moon face), you may find oral
lesions resulting from cheek and tongue
biting. In addition, adrenal suppression
may occur, making invasive dental and
medical procedures more difficult for
- Sirolimus: Side effects of this
immunosuppressive drug can
include hypertension, joint pain,
low white blood cell count, and
hypercholesterolemia. In addition,
because oral ulcers can result from
high levels of sirolimus, refer a patient
with oral ulcers to the transplant team
for drug titration.
Chronic Graft-versus Host Disease
In patients who receive a stem cell
transplant from a donor, an autoimmunelike
disease called chronic graft-versus
host disease (cGVHD) may develop,
usually within two years of transplantation.
cGVHD may affect multiple organ systems,
including the mouth, and you should
screen stem cell transplant patients at
every dental visit because treatment and
supportive care for pain, sensitivity, and dry
mouth are important.
Oral cGVHD has three components:
mucosal involvement, sclerotic involvement
of the mouth and surrounding tissues, and
salivary gland involvement:
- Mucosa: The oral mucosa presents with
the classic findings in cGVHD, including
lichenoid changes, erythema, ulcerations,
hyperkeratotic patches, and mucosal atrophy.
- Musculoskeletal tissue: Limited mouth
opening and limited tongue mobility
may be caused by involvement of the
temporomandibular joints or by sclerotic
changes in the perioral tissues.
- Salivary glands: Salivary gland dysfunction
may result from medication, inflammation,
and fibrosis of the major and minor salivary
Treatment and supportive care for the oral
effects of cGVHD should be coordinated
with the patient’s medical team. Patients may
need artificial saliva for dry mouth; topical
immunosuppressive agents, such as steroid
rinses, to manage their oral disease; and
palliative agents, such as lidobenalox rinse or
viscous lidocaine, to manage oral pain.
The long-term use of immunosuppressive drugs
and other treatments puts transplant patients at
risk of developing cancers, including cancers
of the oral cavity. Squamous cell carcinoma,
especially of the tongue, salivary gland, lip, or
throat; oral Kaposi’s sarcoma; and lymphoma are
among the malignancies that sometimes occur
in transplant patients. Because early detection
of oral cancer is essential for effective treatment,
screen patients at every appointment, and biopsy
new oral lesions that lack a clear etiology.
If a patient’s body begins to reject a transplanted
organ, only emergency dental care may be
provided. Before dental treatment, talk with the
patient’s physician about antibiotic prophylaxis
or other special needs.
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NIH Publication No. 14-6270