Dental Management of the Organ Transplant Patient 5

— Tacrolimus: An immunosuppressive 

agent 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 

immunosuppressant is commonly 

used as an alternative to 

azathioprine. Adverse effects 

include decreased white cell 

counts, opportunistic infections, and 

gastrointestinal problems.

— Corticosteroids: Hypertension and 

high blood glucose (steroid-induced 

diabetes) are among the numerous 

side effects of these drugs, along 

with increased risk for infection, 

poor wound healing, and depression. 

Adrenal suppression may occur, 

making invasive dental and medical 

procedures more difficult for your 

patient. Corticosteroids may also 

mask the early signs of oral infection. 

The trend toward using lower doses 

of corticosteroids in combination 

with other immunosuppressants 

for post-transplant maintenance 

therapy has helped mitigate these 

side effects. 

— Sirolimus: Side effects of this 

anti-rejection drug can include 

hypertension, joint pain, low white 

cell count, hypercholesterolemia, 

and oral ulceration. 

Marked Immunosuppression

Several complications associated with 

marked immunosuppression manifest in 

the mouth, including oral candidiasis, 

herpes simplex/herpes zoster, hairy 

leukoplakia, aphthous ulcers, and 

uncommon viral and fungal infections. 

Progressive periodontal disease, 

delayed wound healing, and excessive 

bleeding may also become problems for 

these patients. 

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 high-dose immunosuppression to 

prevent organ rejection. Treatment of 

oral opportunistic infection is necessary 

in any transplanted patient. 

Oral Malignancies

Screen patients for oral malignancies 

at every appointment. Kaposi’s 

sarcoma, lymphoma, and squamous cell 

carcinoma of the lip are among the oral 

malignancies that sometimes occur in 

organ transplant patients. Malignancies 

can occur decades earlier in transplant 

recipients than in people who are 

not immunosuppressed. 
Dental Management of the Organ Transplant Patient 

—	 Excessive Bleeding: Several factors 

can cause bleeding problems in organ 

transplant candidates, such as organ 

dysfunction or their medications. Many 

may be anticoagulated, and some 

may have a decreased platelet count. 

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. 

The physician also may decide to 

temporarily decrease the patient’s 

level of anticoagulation before 

extensive dental surgeries. Some 

patients are only suitable for surgery 

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 transplantation usually take 

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 you might prescribe. 

Likewise, use caution when prescribing 

medication to patients with endstage 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. 

Prior to 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 end-stage kidney disease, 

for example, may have diabetes and/or 

significant pulmonary or heart disease. 

Carefully review your patient’s medical 

history to determine what additional 

treatment considerations your patient 

may have. 

Dental Treatment 

Whenever possible, all active dental 

disease should be aggressively treated 

before transplantation, since post-operative 

immunosuppression decreases a patient’s 

ability to resist systemic infection. 

—	 Eliminate or stabilize sites of oral 

infection. Patients with active dental 

disease who can tolerate treatment 

2 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
—	 Tacrolimus: An immunosuppressive 

agent 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 

immunosuppressant is commonly 

used as an alternative to 

azathioprine. Adverse effects 

include decreased white cell 

counts, opportunistic infections, and 

gastrointestinal problems. 

—	 Corticosteroids: Hypertension and 

high blood glucose (steroid-induced 

diabetes) are among the numerous 

side effects of these drugs, along 

with increased risk for infection, 

poor wound healing, and depression. 

Adrenal suppression may occur, 

making invasive dental and medical 

procedures more difficult for your 

patient. Corticosteroids may also 

mask the early signs of oral infection. 

The trend toward using lower doses 

of corticosteroids in combination 

with other immunosuppressants 

for post-transplant maintenance 

therapy has helped mitigate these 

side effects. 

—	 Sirolimus: Side effects of this 

anti-rejection drug can include 

hypertension, joint pain, low white 

cell count, hypercholesterolemia, 

and oral ulceration. 

Marked Immunosuppression 

Several complications associated with 

marked immunosuppression manifest in 

the mouth, including oral candidiasis, 

herpes simplex/herpes zoster, hairy 

leukoplakia, aphthous ulcers, and 

uncommon viral and fungal infections. 

Progressive periodontal disease, 

delayed wound healing, and excessive 

bleeding may also become problems for 

these patients. 

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 high-dose immunosuppression to 

prevent organ rejection. Treatment of 

oral opportunistic infection is necessary 

in any transplanted patient. 

Oral Malignancies 

Screen patients for oral malignancies 

at every appointment. Kaposi’s 

sarcoma, lymphoma, and squamous cell 

carcinoma of the lip are among the oral 

malignancies that sometimes occur in 

organ transplant patients. Malignancies 

can occur decades earlier in transplant 

recipients than in people who are 

not immunosuppressed. 

Dental Management of the Organ Transplant Patient 5