By Robert Provenzano, MD, FACP

One of the major breakthroughs in medicine of the 20th century was the ability to replace failing kidney, liver, heart, lung or pancreas function through transplantation of a healthy organ. This was made possible through the development of immunosuppressive medications to prevent rejection of the transplanted organ. From 1990 to 2000, more than 200,000 organ transplants were preformed in the United States. During the same period, the number of transplantations performed annually increased from 15,677 to 22,773 (an increase of 45 percent).

These numbers reflect the improved success expected by transplant recipients. Patients receiving a kidney transplant can expect more than 90 percent five-year graft survival from a living donor. The improved survival rates and transplant outcomes is predicated upon proper screening and evaluation, as well as breakthroughs in surgical techniques and immunosuppressive therapies.

Despite these breakthroughs, infection continues to be a leading cause in graft loss or death of transplant recipients. Although evaluation for chronic infections in recipients is standard, the same cannot be said of pre-transplantation dental evaluation.

Several studies reveal that oral disease is prevalent in the renal dialysis community. Indeed, up to 50 percent of individuals in dialysis units have less-than-standard dental care. While there are many reasons for this – including limited funds, fear, or being assigned a low priority by the patient due to other more serious problems – this oversight can lead to problems if transplantation is performed.

Generally, most dental care is preformed on an emergency basis in the dialysis population. This supports the fact that there is often longstanding advanced disease prior to transplantation.

Pre-Transplant Dental Care

Surveys by the University of Pittsburgh show pre-transplant protocols widely vary in recommendation or requirement of a dental examination prior to being placed on the waiting list. There still seems to be no consensus of standard practice in the United States. Part of this variation is due to the lack of data or outcome assessments with respect to optimal dental management of transplant candidates. There have been no randomized control studies evaluating outcomes of patients screened and treated for dental disease to those who are not. Although there have been curable cases of severe dental infections – typically arising from gingival (gum) disease resulting in overwhelming systemic (general) infections and death – no trends have emerged.

When viewed from an overall health perspective, more data is accumulating showing untreated dental/gingival disease is associated with poor outcomes in the dialysis population. Chronic inflammation caused by dental disease triggers our immune system that has been shown to increase inflammatory products that can damage blood vessels resulting in accelerated athlorosclerosis (heart disease). It would therefore seem wise that patients give dental hygiene a higher priority when considering all other healthcare issues; particularly if they are considering transplantation. Below are pre-transplant dental guidelines to help you and your physician in its management.

Pre-Transplant Dental Guidelines

• Consult with patient’s physicians.

• Perform dental prophylaxis (cleaning).

• Treat all active dental disease.

• Remove all potential sources of acute or chronic infection.

• Remove all non-restorable teeth.

• Reinforce oral hygiene and home care  instructions.

• Daily use of antibacterial mouthwash.

Endocarditis

This is a rare bacterial infection of the heart valve that has been reported after organ transplantation. Despite its rarity, most patients are typically given antibiotic prophylaxis following transplantation if they are to have any dental work done. This has more or less been accepted as a standard of practice despite the lack of controlled randomized studies. If you are having dental work following transplantation, you should communicate with your transplant physician and nurse to have an understanding as to how they would best like to proceed. Do not be surprised if you are not given antibiotics, as more and more centers are concerned about the side effects of the medications versus the extremely low risk of the possibility of developing endocarditis.

Conclusion

There is ample evidence for the overall maintenance of good dental hygiene for all patients with a chronic disease. This need is magnified in individuals considering organ transplantation. Although there is not a consensus among transplant centers as to the level of importance for dental hygiene evaluation, this should not preclude patients from giving it a high priority and seeking good dental hygiene themselves. Patients should seek oral healthcare instruction and information from their transplant center or an oral healthcare professional.

On oral health maintenance program for dialysis patients should be reinforced by your dialysis team and yourself. A specific focus should be made if serious dental disease is identified to correct it prior to transplantation to decrease the possibility of worsening disease due to immunosuppressive therapies. Careful consideration by you (the patient) of those health issues specific to your needs will empower you and improve both short-term and long-term outcomes. Please discuss these issues with your dialysis or transplant care teams as it will benefit you both.

Robert Provenzano, MD, FACP, is chief of nephrology at St. John Hospital and Medical Center in Detroit. He is also president of the Renal Physicians Association.

This article originally appeared in the July 2005 issue of aakpRENALIFE, Vol. 21, No. 1.

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