E10

antihypertensives and anticoagulants. Each patient should be evaluated and treated on a case-by-case basis following consultation between the physician and dentist. It is the unpredictability of the degree of stability that will be achieved after transplantation that makes it imperative to be firm and resolute in the presurgical treatment planning of these patients. The dental management of a fragile, unstable, heavily medicated transplant patient with multiple, complex and serious oral problem can be very difficult.

Predisposition to Infection

Because patients who are immunosuppressed with cyclosporine, azthioprine and prednisone are at increased risk of infection generally, they probably should receive prophylactic antibiotics prior to any significantly invasive dental treatment. For those patients, however, with immaculate oral hygiene and healthy mouths, the need for antibiotic coverage for basic, minimally invasive procedures is less clear. There is no documented evidence that such patients are at an increased risk of infection, following dental manipulation. The decision to use prophylactic antibiotics should be made depending upon each patient's individual circumstances.

Adrenal Suppression

During the stable posttransplantation phase, the possible effects of suppression of adrenal function should be considered in patient's undergoing dental treatment. For many patients even routine dental procedures are significantly stress provoking. When more major and complex surgical procedures are anticipated, the additional and unavoidable stress placed on the patient should be evaluated, when necessary a steroid boost may be indicated to see the patient through the stressful period. In cases of patients taking more than 5 mgs of prednisone daily, they should at least double their dose on the day of the scheduled procedure. In some cases, the steroid boost may need to increase even greater and continued longer, particularly if postoperative pain is expected. It is important in managing patients during this stage of their transplant treatment to use stress reduction techniques as part of their overall management plan.

Medication Use

Depending upon the level of function of the transplanted organ in liver and kidney transplants, it may be necessary for the dentist to select different drugs or modify dosages of drugs in order to avoid the production of toxic levels.

Oversuppression

In the mouth, evidence of overimmunosuppression may be manifest by the development of fungal or viral infections of the mucous membranes. Depending on the severity of the condition, topical or systemic treatment with ketoconazole or acyclovir is indicated. Delayed healing of oral wounds and slow healing of simple traumatic oral ulcers may also indicate that the patient is being over-immunosuppressed. Additionally, the increase incidence of carcinoma of the lip and lymphoma in patients receiving too much immunosuppression should be kept in mind by the dentist who is seeing posttransplant patients on a regular basis.

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