Dental Management of the Renal Transplant Patient

Department of Pediatric Dentistry
Lutheran Medical Center

Name: Craig Elice Date: January 15, 2010
Article title: Dental Management of the Renal Transplant Patient
Author(s): Rhodus NL, Little JW
Journal: Compend Contin Educ Dent
Volume (number): 14(4)
Month, Year:
Major topic: Renal Transplant, dental management
Type of Article: Review of Literature
Main Purpose: The article reviewed the indications, process, systemic and oral complications and management of dental patients receiving a kidney transplant
Findings: Indications for renal transplant include chronic renal disease or end-stage renal disease (ERSD). Along with the deterioration of the nephrons comes hypertension, diabetes, congestive heart failure, infections, urinary tract obstructions, hypercalcemia and elevated potassium which all require medical management. Problems managing these issues leads to hemodialysis. Renal transplantation can free the patient from dialysis, but has a host of problems along with it such as graft rejection, chronic immunosuppression, susceptibility to infections, and poor wound healing. Oral complications may include gingivitis, desquamation, and ulceration of the oral mucosa. Oral candidiasis, and HSV I are common. Cyclosporine, azathioprine, prednisone and ALG are common immunosuppressive medications which have many adverse effects. Cyclosporine can cause severe kidney and liver changes, hypertension,, anemia, and bleeding problems as well as gingival hyperplasia, hirsutism, and various cancers of the skin. Azithioprine causes bone marrow suppression increasing the risk of infection and excessive bleeding from anemia, thrombocytopenia, and leucopenia. ALG also causes hemolysis, leukopenia, thrombocytopenia, and tumor development as well as infections. Prednisone acts as an anti-inflammatory agent which has side effects including hypertension, diabetes mellitus, osteoporosis, impaired healing and psychoses. Dental management focuses on elimination of infection by restoring or extracting teeth and disease prevention such as good oral hygiene, antimicrobial mouthwashes, and professional dental cleanings and fluoride applications. Consultation with the physician is important to determine degree of renal dysfunction and the need for antibiotics to prevent infective endocarditis. The need for antibiotics is controversial and is best determined by a physician consult. The dentist should avoid drugs metabolized or excreted by the kidney. Management of these patients can be divided into two phases. The first phase occurs immediately posttransplant when complications and rejection are most likely. Only emergency dental care is provided, while routine dental care is contraindicated. The second phase a.k.a. the stable phase often requires antibiotic prophylaxis. Due to the altered oral flora, the type of antibiotic is uncertain. Patients are at increased risk of infections from the environment therefore infection control procedures are necessary. Patients are susceptible to HBV, HIV, CMV, Epstein Barr, etc. In addition to post-operative infections, the dentist must be wary of risks of excessive bleeding and adverse reactions to physical and emotional stress. Anticoagulants and high doses of prednisone are common medications. If the level of anticoagulation is greater than 2 and a half times the normal PT, the medication dosage should be reduced. Depending of the procedure, it may take 3-4 days of reduced dosage to improve the PT. Avoidance of drugs metabolized or excreted by the kidneys is important. Local anesthetics and antibiotics like penicillin, erythromycin, amoxicillin, and clindamycin are generally safe. Aminoglycosides and tetracycline should not be prescribed as well as aspirin and phenacetin. Analgesics like acetaminophen, codeine, are safe. Patients taking steroids need a physician consult to determine the necessity for a change in dose. Patients on a chronic 5mg dose of prednisone may need to double or triple their normal dose the morning of, and 1 hour preop. Taking a patients blood pressure prior to dental treatment is probably good practice because one of the side effects of cyclosporine is hypertension. Signs of over-immunosuppression include recurrent HSV infections, herpes zoster, candidiasis, large slow to heal aphthous ulcers and infrequently lymphoma, Kaposi’ sarcoma, and hairy leukoplakia.
Key points/Summary: Medical consultation is necessary to establish the following: current status of patient, degree of immunosuppression and if graft rejection is present, need for prophylactic antibiotics, need for steroid supplementation, need to alter anticoagulation dosage, presence of hypertension, current status of renal function, and medications that should be avoided. Dental management should focus on removal of infection and good dental health through oral hygiene practices, cleanings, and fluoride.
Assessment of article: Good article but I think it is dated.