Pretransplant Treatment

Ideally, before transplantation, all active dental disease should be treated and acute and chronic infection eradicated. Impacted, periodontally involved and unrestorable teeth should be extracted. Nonvital teeth and those with periapical pathology should be endodontically treated or if a predictably successful outcome cannot be guaranteed, then extracted. Meticulous oral hygiene regimes should be established, taught and constantly reinforced for all patients.

While the pretransplant goals for the oral care of any organ transplant patient are essentially the same, namely to eradicate all oral infection and eliminate other significant oral pathology, the degree to which this can be accomplished in each different type of organ transplantation situation may vary considerably.

Hopefully, patients scheduled to undergo organ transplantation are stable enough medically to undergo any necessary dental treatment, including multiple extractions. This, however, is not always true, particularly in the case of patients who are suffering from end-stage renal, cardiac or hepatic disease. The frail and unstable status of many of these very sick patients often makes them poor candidates for even the most basic and straightforward dental procedure. Patients suffering from end-stage renal disease, for example, who are being maintained on dialysis, pose significant medical management difficulties that can seriously interfere with their dental treatment. The complexity of their fluid and electrolyte imbalance problems, their coagulopathies, their susceptibility to infection, their persistent anemia, their inability to metabolize and excrete certain medications and the possibility of septic emboli developing in their arteriovenous shunts, puts them at significantly increase risk during dental treatment. In patients scheduled for transplantation of other organs, their complicating medical problems may be quite different, but are no less important. When patients are seriously ill, it is still prudent to identify ahead of time any oral disease present even if definitive treatment has to be delayed until medical stabilization of the patient is achieved after transplantation.

In deciding which patients are fit enough to receive dental care prior to transplantation, the dentist and physician should consult together about the proposed treatment and its risks vs. benefits to the patient. Issues to be discussed include; the ability of the patient to tolerate the planned procedures, the need for additional pretreatment screening tests if surgical treatment is indicated; e.g., bleeding time, prothrombin time, partial thromboplastin time and platelet count. If significant abnormalities are found in the bleeding or coagulation profiles, the need to use antifibrinolytic agents, fresh frozen plasma or platelet replacement should be discussed.

The physician and dentist should also decide if antibiotic prophylaxis is needed prior to carrying out any invasive dental procedures. There are no hard and fast rules about the use of pretreatment antibiotics in this group of patients. The decision should be made taking into account the extent and virulence of any existing oral infection being treated and the degree to which the patient is vulnerable and susceptible to that infection spreading locally or systemically as a result of the planned dental manipulation. The final decision should be made on a case by case basis, depending upon the particular circumstances. With regard to patients with end-stage liver or kidney disease, drugs metabolized by the affected organ should be limited, so the consultation should include advice from the physician about any modification in the choice and dosage of medications which may be used by the dentist during treatment.

For those patients undergoing invasive dental treatment prior to organ transplantation they should be managed under the very strictest infection control con

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