Oral care for solid organ transplant recipients

Today’s schedule began with a bang: A new adult female patient with a recent history of small bowel transplant checked in at the front kiosk. I was not yet feeling optimally wired at 7:30 a.m. when I brought her back to my operatory. Groggily stumbling through pleasantries, I attempted a discussion by stating one of the few facts I knew about organ transplantation: One-year graft survivals for some organs have been improving steadily since the introduction of cyclosporine in the 1980s.

How did I come to know this fact? Several years ago, I attended a speaking and consulting conference and shared a room with a total stranger named Cher Thomas, RDH. She was upbeat and friendly and after waking up in our hotel room on the first day of the conference, she asked me to help her unwrap some of her pills from foil packs. At first, I was a bit curious and wondered why she couldn’t do it herself until she showed me her pill box and the 40 slots, some of which were filled with pill packets. I then found out that Cher was a kidney transplant recipient whose native kidneys had failed due to a rare autoimmune disorder. Cher did not have any comorbidities prior to her diagnosis; but she did encounter several common side effects of chronic kidney disease, including hypertension, anemia, restless leg syndrome, insomnia, and lipid disorders. She was fortunate to avoid other common comorbidities such as diabetes, glucose intolerance, atherosclerosis, and other cardiovascular complications.

Solid organ transplantation and how it evolved over the years

Solid organ transplantation is a treatment for end-stage organ failure of the kidney, liver, pancreas, heart, lung and small intestine. Organs may be transplanted from living or deceased human donors. The list for people waiting for an organ far outnumber the source of donors.  

Solid organ transplantation (SOT) has evolved from an experimental animal model approach in the 20^th century to an established and definitive treatment option for end-organ dysfunction.¹

Kidney transplants and importance of immunosuppression

The first successful kidney transplant occurred in 1954. In that era, the successful transplant was between identical twins. With the introduction of immunosuppressant drug regimens in the 1980s, drugs like cyclosporine began to extend the life expectancy of patients in solid organ failure. In today’s world, the landscape of solid organ transplantation has completely changed based on continuing innovation that is no longer experimental and has improved patient survival and quality of life over time.  

In 1980, cyclosporine was considered the cornerstone of immunosuppression. Because of cyclosporine’s inherent nephrotoxicity, discovery and production of a wide variety of immunosuppressants have been introduced.

The National Institutes of Health states that cyclosporine revolutionized transplant rates, by lowering acute rejection rates and improving graft (the transplanted organ) survival rates. Afterwards, post transplant rates further improved with tacrolimus and mycophelic acid in the 1990s.²

Induction immunosuppressive agents (short term immunotherapy that is used during the first two years after receiving a transplant) has drastically lowered acute rejection; however, long term immunosuppressive agents continue to compromise survival of the graft due to nephrotoxicity.

A dental provider of any solid organ transplant may notice patients who remain on older immunosuppressive medications. If the older formulations are currently working for them, why change?  Today’s transplant recipients may be taking newer induction agents like alemtuzumab, efalizumab, and alefacept. Current maintenance regimens include cyclosporine, tacrolimus, sirolimus, everolimus, azathioprine, mycophenolic acid, and corticosteroids. Three of the very newest maintenance therapies include sotrastaurin, belatacept, and tofacitinib. Side effects of all immunosuppressants are usually quite similar and it’s something to keep in mind when reviewing side effects of newer immunosuppressive agents, too.²

With the success of immunosuppression that started with kidney transplants, heart, liver, lung, and even bowel transplants have become more common and solid organ transplants have become the standard of care for thousands of patients. They offer definitive long-term treatment to patients with otherwise limited options. Due to improvements in surgical and clinical outcomes, the SOL field has expanded but not without obstacles.¹ Small intestinal transplants experience the highest incidence of rejection when compared to other SOTs. 

Oral care considerations

As solid organ transplant recipients live longer, healthier, and active lives, their oral health care remains a priority. The National Institute of Dental and Cranial Research (NIDCR) created a document on the dental management of organ transplant recipients that can be easily accessed online: in.gov/isdh/files/OrganTransplantProf.pdf. Although this publication is due for an update, it is still a useful guide to help in decision making by addressing:

• Antibiotic prophylaxis-unlike AHA and AAOS recommendations immunosuppression, serious comorbidities, and the presence of oral bacteria (especially anaerobic) should be carefully considered. In all SOTs, infection may lead to sepsis and may also activate the immune response resulting in acute rejection.

• Infection-Infection can result in acute rejection and/or sepsis

• Excessive bleeding-consultation with the managing physician

• Medication considerations-in addition to immunosuppression, some patients taking corticosteroids may require special precautions to avoid adrenal crisis.

• Comorbidities-may be several

• Pre-translant dental considerations

• Post-transplant dental considerations

• Oral manifestations of Immunosuppressive therapy-xerostomia, fungal infections, gingival overgrowth, and/or masking of infection

Perhaps the most important advice is listed at the end of the document which states:

“Stay in close contact with your patient’s physician and tailor your treatment to meet his or her special needs.”

According to the National Kidney Foundation, anti-rejection medications can make the body more susceptible to the risk of infection so good oral hygiene is important.⁴ According to guidelines from the American Heart Association and the American Medical Association, it is recommended that no elective dental work, including prophylaxis be done during the first six months following a heart, lung, liver, kidney or pancreas transplant. Following the first six months, it is recommended that heart, lung, liver and kidney recipients seek routine exams and preventive hygiene care. A medical release form from the medical team endorsing dental care should be obtained.

Premedication prior to dental procedures for SOT patients is an important discussion with the patient and the patient’s SOT and primary care physician. The American Heart Association recommends premedication for a heart transplant patient with abnormal heart valve function.⁵ For lung transplant patients, the American Dental Association (ADA) recommends consulting with the treating physician to prescribe an antibiotic for premedication.⁶ The ADA also states that antibiotic prophylaxis may be unwarranted unless the person is predisposed for some reason to infection.⁶  Antibiotic prophylaxis for SOT recipients cannot be approached with a “cookie cutter” approach. The patients risk for sepsis and/or infection that may lead to rejection as well as the patient’s oral health (especially aerobic and anaerobic bacterial levels) should be considered before dental treatment.

References

1.      Black CK. Et al. Solid organ transplantation in the 21st century. Ann Transl Med. 2018 Oct; 6(20): 409.

2.     Kalluri HV and Kardinger KL. Current state of renal transplant immunosuppression: present and future. World J Transplant. 2012 Aug 24; 2(4): 51–68. 

3.     https://www.in.gov/isdh/files/OrganTransplantProf.pdf

4.     https://www.kidney.org/atoz/content/immuno

5.     https://www.heart.org/en/health-topics/infective-endocarditis

6.    https://www.ada.org/en/member-center/oral-health-topics/antibiotic-prophylaxis