Oral care for people with cystic fibrosis requiring a solid organ transplant
This clinical feature outlines the oral concerns that may arise in patients requiring solid organ transplantation as a result of cystic fibrosis. The aim of the feature is to provide recommendations to dental practitioners for the pre-surgery dental health check and post-transplantation dental management of such patients. It also outlines therapeutic management of solid organ transplant patients who may have oral consequences.
Despite major advances in the medical, paramedical and pharmacological management of cystic fibrosis, solid organ transplantation remains a viable treatment option for end-stage pulmonary disease. Increasingly, lung transplantation is offering people with cystic fibrosis whose disease has progressed to a critical stage hope of living a longer and healthier life.1 In 2019, the Irish Donor Network reported a record number of lung transplants, with 38 lung transplants undertaken, compared with 28 in 2018.2 In Ireland, lung transplantation is carried out in The Mater Misericordiae University Hospital, Dublin.
The oral cavity is host to more than 700 species of bacteria and represents an important entry point for possible infections. Depending on the level of infection and inflammation present in the mouth, swallowing, aspiration, and small injuries to mucous membranes can all trigger bacteraemia. Normally of no concern in healthy individuals, bacteraemia accompanying dental treatment in patients subject to immune suppression could be considered a potential cause of systemic illness. Dental assessment and appropriate treatment is considered in most transplant centres to be a compulsory prerequisite for solid organ transplantation. However, standardised guidelines providing counsel for pre-transplant dental health are deficient for patient and dental practitioner alike.
Dental practitioners play an important role in the provision of dental care for patients with chronic pulmonary illness and imminent transplantation throughout their lifetime. An emphasis should be placed on regular attendance, preventive therapies and patient education to ensure continuous, stable oral health. A dental infection has the potential to cause a heightened inflammatory response or result in the cancellation or postponement of a lifesaving transplantation procedure.3 In the absence of standardised guidelines, pre-transplant dental assessment should focus on the identification and elimination of potential sources of infection. Dentists should also be mindful when conducting this assessment that routine dental treatment is not recommended for six months post transplantation because of a heightened state of immunosuppression.4
When conducting a pre-transplant dental assessment, consideration should be given to:
- the patient’s previous dental history;
- medical stability;
- attitude to dental care;
- time constraints; and,
- planned future pharmacological therapies post transplantation, i.e., bisphosphonate therapy.
Following transplantation, recipients commit to lifelong immunosuppression therapy to prevent organ rejection (Figure 1).
Immediately post transplant, induction therapy provides a high degree of immunosuppression. This is supplemented with antimicrobial agents to provide prophylaxis against bacterial and fungal infections. Subsequent lifelong immunosuppression is provided at lower doses during maintenance therapy (Table 1).5
Immunosuppressive medications can complicate oral health. Drug-induced gingival hyperplasia (Figures 2 and 3) caused by the immunosuppressive drug cyclosporin A is a common complication. This risk is further amplified if a patient is prescribed a calcium channel blocker (e.g., nifedipine), has poor oral hygiene and untreated periodontitis.6 Oral hygiene and the patient’s periodontal health play a decisive role in the level of manifestations of such gingival alterations. Oral hygiene education and non-surgical periodontal treatment play central roles in the management of drug-induced gingival overgrowth.7
Long-term immunosuppression increases patient susceptibility to pathological oral conditions (Table 2).8 Immunosuppressive drugs are thought to cause malignancy by a carcinogenic effect or by increasing the carcinogenic effect of other agents combined with an immunosuppressive effect.9 The importance of regular oral examinations is essential so that any dysplastic or malignant changes can be detected early.
FIGURE 1: Prograf and Neoral are both used for immunosuppression following solid organ transplant.
FIGURE 2: Drug-induced gingival hyperplasia. © Picture copyright Prof. Anthony Roberts, Cork University Dental School and Hospital.
FIGURE 3: Drug-induced gingival hyperplasia. © Picture copyright Prof. Anthony Roberts, Cork University Dental School and Hospital.
FIGURE 4 (left): Leukoplakia on the buccal mucosa. FIGURE 5 (right): Leukoplakia on the lateral border on the tongue. © Pictures copyright Dr Richeal Ní Riordain, Cork University Dental School and Hospital.
Finally, the prescription of antibiotic prophylaxis for dental treatment following solid organ transplant is ambiguous and can be a source of concern for many practitioners. Surveys conducted in transplant centres in the US10 and Germany11 both concluded that due to lifelong immunosuppression, antibiotic prophylaxis should be given before dental treatment is undertaken. However, with regard to the type of dental measures (invasive or non-invasive procedures) and the choice of antibiotic, no clear recommendations could be established. Irish Dental Council guidelines state that antibiotic prophylaxis should be given to “cardiac transplantation recipients, who develop cardiac valvulopathy”. Consideration should be given to the type of antibiotic prescribed due to the increased risk of antibiotic allergy and multidrug resistance in this population. It is the authors’ recommendation that dental practitioners seek clarification from the patient’s specialist team in the absence of definitive guidelines.
A lifetime commitment to pharmacological therapies can jeopardise oral health and make the provision of dental treatment challenging. Dental practitioners play an important role in the promotion of oral health and in patient education. Continuity of dental care with an emphasis on disease prevention is paramount for patients with chronic pulmonary diseases such as cystic fibrosis that may require solid organ transplantation. Currently, there are no formal guidelines regarding the provision of dental care for this medically vulnerable cohort of patients. The authors hope that with ongoing research in this field formal guidelines will be developed to assist practitioner and patient decisions about appropriate healthcare for these specific clinical circumstances.
- Vermeulen, K.M., van der Bij, W., Erasmus, M.E., Duiverman, E.J., Koëter, G.H., TenVergert, E.M. Improved quality of life after lung transplantation in individuals with cystic fibrosis. Pediatr Pulmonol 2004;37 (5): 419-426.
- Cystic fibrosis Ireland. IDN Welcomes Record Year for Lung Transplants and Liver transplants in Ireland. 2020. [Internet]. [cited 2020 Apr 18]. Available from: https://www.cfireland.ie/about-cf/latest-news/idn-welcomes-record-year-for-lung-transplants-and-liver-transplants-in-ireland.
- Guggenheimer, J., Eghtesad, B., Close, J.M., Shay, C., Fung, J.J. Dental health status of liver transplant candidates. Liver Transplant 2007; 13 (2): 280-286.
- UpToDate.com. Prophylaxis of infections in solid organ transplantation. 2020. [Internet]. [cited 2020 Apr 3]. Available from: https://www.uptodate.com/contents/prophylaxis-of-infections-in-solid-organ-transplantation.
- Bartosik, W., Egan, J.J., Soo, A., Remund, K.F., Nölke, L., McCarthy, J.F., et al. A review of the lung transplantation programme in Ireland 2005-2007. Eur J Cardiothorac Surg 2009; 35 (5): 807-811.
- Trackman, P.C., Kantarci, A. Molecular and clinical aspects of drug-induced gingival overgrowth. J Dent Res 2015; 94: 540-546.
- de Vasconcelos Gurgel, B.C., de Morais, C.R.B., da Rocha-Neto, P.C., Dantas, E.M., Pinto, L.P., de Lisboa Lopes Costa, A. Phenytoin-Induced gingival overgrowth management with periodontal treatment. Braz Dent J 2015; 26 (1): 39-43.
- Osiak, M., Szubińska-Lelonkiewicz, D., Wychowański, P., Karakulska-Prystupiuk, E., Jędrzejczak, W., Wojtowicz, A., et al. Frequency of pathologic changes in the oral cavity in patients subjected to long-term pharmacologic immunosuppressive therapy after kidney, liver, and hematopoietic cell transplantation. Transplant Proc 2018; 50 (7): 2176-2178.
- Guggenheimer, J., Eghtesad, B., Stock, D.J. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2003; 95 (4): 383-399.
- Guggenheimer, J., Mayher, D., Eghtesad, B. A survey of dental care protocols among US organ transplant centers. Clin Transplant 2005; 19 (1): 15-18.
- Marcinkowski, A., Ziebolz, D., Kleibrink, B.E., Weinreich, G., Kamler, M., Teschler, H., et al. Deficits in oral health behavior and oral health status in patients after lung transplantation. Clin Respir J 2018; 12 (2): 721-730.
F. O’Leary, N. Coffey, F.M. Burke, M. Hayes
Cork University Dental School and Hospital, University College Cork
Corresponding author: Fiona O’Leary, Restorative Dentistry, Cork University Dental School and Hospital,
University College Cork E: firstname.lastname@example.org T: 021-490 1100