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 

accepted option. 

— 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 

medical situations. 

❍ 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 

might prescribe. 

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 

intervals. 

— Other medical problems: Patients with 

end-stage organ failure may have other 

major medical conditions. A person with 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
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 highdose immunosuppression. Treatment of oral 

opportunistic infection is necessary in any 

transplanted patient. 

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 

patients. 

— 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 

your patient. 

— 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: