Oral infection in immunosuppressed renal transplant patients

Poor oral health status and short-term outcome of kidney transplantation

AIMS

This study aims to know whether poor oral health increases the risk of acute rejection and hospitalization in kidney allograft recipients.

METHODS AND RESULTS

This is a prospective cohort study. The same dentist followed participants for 2 months after renal transplant for monitoring oral health (clinical evaluation, DTMF index, and CPITN index), signs of graft rejection, infection, and hospitalization. We compiled rates and reasons for hospital readmission or extended hospital stay. The CPITN had a mean score of 0.38 ± 0.71, increasing to 0.90 ± 0.84, 60 days after transplant (P < .001). No one rejected the graft in the period of study. Patients with older age (P = .009; OR: 1.07; CI 95% 1.01-1.12) were at higher risk of hospitalization at each year of age and patients presenting pretransplant dental focus (P = .001; OR: 7.23; CI 95% 2.13-24.56) had 7.23 times more chance to be hospitalized in the first 2 months after the transplant. One participant was hospitalized due to acute foci of dental infection.

CONCLUSION

There was an association between dental focus and hospital readmission/stay. However, our methods do not provide conclusive proof of causality. Hospitalization due to acute dental infection was rare.

Oral and salivary changes in patients with chronic kidney disease: A clinical and biochemical study

Background:

Both chronic kidney disease (CKD) and its treatment can affect a wide range of tissues and systems. It directly or indirectly affects flow, concentrations and composition of saliva. Hemodialysis can effectively minimize most of these complications to some extent.

Aims:

The main aim of this study was to know the salivary content of sodium, potassium, calcium, urea, bicarbonate and oral manifestations in patients with CKD.

Materials and Methods:

For this study, 50 patients diagnosed with CKD and 50 systemically and periodontally healthy individuals were subjected to a detailed general and intraoral examination. Whole un-stimulated saliva samples of all the selected subjects were collected and subjected to calcium (Ca), phosphorous (P), sodium (Na), potassium (K), bicarbonate and urea analysis.

Statistical Analysis Used:

Paired t-test, Mann–Whitney test.

Results:

Among 50 study subjects, 26 subjects had reduced salivary flow in the range of 0.1–0.4 ml/min. Intraoral examination of the study subjects revealed pallor, increased deposition of calculus, bleeding gums, metallic taste, hypoplasia of teeth and fissured tongue. There was a significant difference between healthy and prehemodialysis patients in the salivary sodium, potassium, calcium, phosphorus, urea levels and the difference was insignificant in relation to bicarbonate levels.

Conclusions:

Alterations in salivary calcium, phosphorous, urea, sodium, potassium levels were significantly higher in the study groups when compared to control groups and the difference was insignificant in relation to bicarbonate level. The increased levels in dialysis patients correlated with renal disease severity.

Does oral health contribute to post-transplant complications in kidney allograft recipients?

OBJECTIVE

The significant number of complications in kidney graft recipients can not be easily explained. The paper assesses whether poor oral health increases the risk of acute rejections and hospitalizations in kidney allograft recipients.

MATERIALS AND METHODS

Ninety-one kidney transplant recipients were divided into three sub-groups according to post-transplant time (< 1, 1-5 and > 5 years). Dental examination evaluated oral hygiene index (OHI-S) and Community Periodontal Index of Treatment Needs (CPITN), which were correlated with the occurrence of post-transplant complications.

RESULTS

Within the first year after transplantation the indicators of the increased risk of hospitalizations and acute rejection episodes was the OHI-S (hazard ratio 1.02 and 1.11, respectively), also CPITN score correlated with acute rejections (R = 0.82, p < 0.01).

CONCLUSION

The neglect in oral health is associated with the increased risk of clinical complications within first year after kidney transplantation.

Oral lesions in renal transplant

To prevent rejection of kidney transplants, patients must be kept in immunosuppressive therapy for a long time, which includes the use of drugs such as cyclosporine, azathioprine, cyclophosphamide, and prednisone. The action of these drugs reduces the general immune response of transplant patients and thus increases their susceptibility to infections. Moreover, these drugs increase the potential of developing lesions. Therefore, oral hygiene in kidney transplant recipients contributes to maintenance of the transplanted organ and its function. Thus, an investigation of oral lesions could be counted as a notable work. The aim of this study was to investigate oral lesions in a group of 21 kidney transplant patients under immunosuppressive therapy attended during a 1-year period in the Nephrology Department of the Federal University of Sergipe, Brazil. Data related to sex, age, etiology of renal disease, types of renal transplant, time elapsed after transplantation, immunosuppressive treatment, use of concomitant agents, and presence of oral lesions were obtained. All patients received a kidney transplant from a living donor, and the mean posttransplantation follow-up time was 31.6 months; 71.5% used triple immunosuppressive therapy with cyclosporine A, azathioprine, and prednisone. Ten patients were also treated with calcium-channel blockers. Of the 21 transplant patients, 17 (81%) presented oral lesions. Gingival overgrowth was the most common alteration, followed by candidiasis and superficial ulcers. One case of spindle cell carcinoma of the lower lip was observed. Oral cavity can harbor a variety of manifestations related to renal transplantation under immunosuppressive therapy.

Orofacial diseases in solid organ and hematopoietic stem cell transplant recipients

OBJECTIVE

Solid organ transplant (SOT) and hematopoietic stem cell transplant (HSCT) recipients are at risk of several diseases, principally attributable to immunosuppression. This global overview of SOT/HSCT-associated orofacial diseases is aimed at providing a practical instrument for the oral healthcare management of SOT/HSCT recipients.

METHODS

Literature search was made through MEDLINE. The associations between orofacial diseases and SOT/HSCT were assessed using observational studies and case series and were classified into 'association', 'no association', and 'unclear association'.

RESULTS

Lip/oral cancers, drug-induced gingival overgrowth (DIGO), infections, including hairy leukoplakia and, less frequently, post-transplantation lymphoproliferative disorders (PTLDs) and oral lichenoid lesions of graft-versus-host disease (GVHD), were associated with SOT. Lip/oral cancers, GVHD, mucositis, DIGO, infections and, less frequently, PTLDs were associated with HSCT. Associations of orofacial granulomatosis-like lesions and oral mucosa-associated lymphoid tissue-type lymphoma with SOT, and of pyogenic granuloma and hairy leukoplakia with HSCT were unclear. Periodontal disease and dental caries were not associated with SOT/HSCT. For none of the local treatments was there a strong evidence of effectiveness.

CONCLUSIONS

Solid organ transplant/HSCT recipients are at risk of orofacial diseases. Adequate management of these patients alleviates local symptoms responsible for impaired eating, helps prevent systemic and lethal complications, and helps where dental healthcare has been neglected.

Gingival health status in renal transplant recipients: relationship between systemic inflammation and atherosclerosis

Cardiovascular disease (CVD) is the leading cause of mortality in renal transplant recipients (RTR). Systemic and periodontal inflammation has been suggested to have a possible role in the development of atherosclerosis. In the present study, we aimed to investigate the relationship between gingival health status, inflammation and atherosclerosis in RTRs. Eighty-three RTR (50 male, 33 female) were enrolled in the study. Routine biochemical analyses, serum lipoproteins, C-reactive protein, fibrinogen, homocystein, parathyroid hormone (PTH) and cyclosporin A (CsA) trough levels were studied. All patients had 24-h ambulatory blood pressure monitoring and B-mode ultrasound of the common carotid arteries. Gingival status was evaluated by the Löe and Silness gingival index (GI). Mean GI value was 2.3 +/- 0.5. Fifty patients (60.3%) had GI value >or= 2.1 (severe gingivitis; group A). Thirty-three patients (39.7%) had GI value < 2.1 (no or moderate gingivitis; group B). Age, carotid intima-media thickness (CIMT) and mean time on dialysis before transplantation were significantly higher in group A than in B. Systemic inflammation markers were not different between group A and group B. Mean CIMT was positively correlated with GI (r = 0.425; p = 0.001) and negatively correlated with high-density lipoprotein cholesterol (r = -0.256; p = 0.023). After the correction for confounding variables, mean CIMT was still significantly correlated with GI (r = 0.376, p = 0.02). In RTR, gingival inflammation seems to be associated with CIMT in the absence of systemic inflammation. Thus, gingivitis may, in part, play a role in the development of systemic atherosclerosis without causing any aggravation in systemic inflammatory response.

Evaluation of subgingival bacterial plaque changes and effects on periodontal tissues in patients with renal transplants under immunosuppressive therapy

OBJECTIVE

The purpose of this study was to identify the presence of periodontal microrganisms in 35 renal transplant patients before the transplant procedure.

STUDY DESIGN

At each time point, clinical parameters were recorded and subgingival plaque samples were collected from 4 different sites at days 30 and 90 after surgery. Samples were plated onto selective and nonselective media to determine total colony counts and the presence of putative periodontal pathogens. After transplant surgery, patients received immunosuppressive therapy.

RESULTS

Statistical analysis of the microbiologic data showed significant changes between time points. An increase in total counts of microrganisms was observed on day 90 after surgery. As a side effect of cyclosporine, 14 patients developed gingival overgrowth. Beta-hemolytic Streptococcus was more frequently detected in patients who did not present gingival overgrowth 90 days after surgery.

CONCLUSION

Quantitative and qualitative changes of the subgingival microflora can occur 90 days after transplant surgery, while patients are still under immunosupressive drugs.

Oral and dental aspects of chronic renal failure

The present article reviews, in detail, the current knowledge of the oral and dental aspects of chronic renal failure (CRF). Worldwide, increasing numbers of persons have CRF; thus, oral health care staffs are increasingly likely to provide care for patients with such disease. Chronic renal failure can give rise to a wide spectrum of oral manifestations, affecting the hard or soft tissues of the mouth. The majority of affected individuals have disease that does not complicate oral health care; nevertheless, the dental management of such individuals does require that the clinician understand the multiple systems that can be affected. The clinician should also consider the adverse side-effects of drug therapy and appropriate prescribing, in view of compromised renal clearance.

Oral manifestations and salivary flow rate, pH, and buffer capacity in patients with end-stage renal disease undergoing hemodialysis

OBJECTIVE

The aim of this study was to investigate oral manifestations and salivary changes in patients with end-stage renal disease undergoing hemodialysis.

STUDY DESIGN

Eighty-two patients undergoing hemodialysis for renal insufficiency were examined; 22 of these patients were randomly selected for salivary tests. Unstimulated whole saliva and stimulated parotid saliva were collected, and flow rate, pH, and buffer capacity were examined. Twenty-two healthy volunteers were included as controls.

RESULTS

Uremic odor, dry mouth, and taste change were common symptoms. Petechia and/or ecchymosis and increase of tongue coating were major signs. The flow rates of unstimulated whole and stimulated parotid saliva were decreased in the patient group. The pH and buffer capacity of unstimulated whole saliva were increased in the patient group, but stimulated parotid saliva did not show any significant differences.

CONCLUSIONS

Patients with end-stage renal disease undergoing hemodialysis showed apparent oral and salivary changes. The results help us understand the relationship between oral changes and renal insufficiency.

The importance of oral foci of infection in renal transplantation

During the treatment of patients with renal failure or renal transplants the most important consideration is to eliminate sources of infection before and after the treatment. Acute or chronic oral infections or bacteraemias resulting from dental procedures may cause serious complications in these patients who already have lowered host resistance caused by immunosuppressant therapy. In order to determine the latest concepts from some international transplantation centres relating to the importance of and the effect of infective sources in the oral cavity, a survey form was prepared which included several questions related to oral foci of infection and renal transplantations. Results obtained from 22 centres from 12 countries indicated that the majority of the centres included a dental examination in their routine protocol and required completion of any necessary dental treatment before transplantation. However, full agreement among all these centres on the necessity for dental examination as part of the protocol has not yet been reached.

Periradicular healing in a renal transplant patient

A patient with a renal transplant was referred for endodontic treatment due to a large radiolucent area surrounding three mandibular anterior teeth. Nonsurgical endodontic treatment was unsuccessful but subsequent periradicular curettage resulted in complete radiographic healing.

Oral herpes simplex infections in patients with leukemia

Thirty patients hospitalized for induction chemotherapy of acute leukemia were studied for incidence, severity, and clinical features of oral herpes simplex virus infections. In 50% of the patients with evidence of past herpes infection, recurrent oral herpes developed during the study. Herpes simplex virus was the major cause of oral mucosal lesions seen in patients with leukemia. A majority of the episodes involved multiple oral sites and caused large atypical lesions. All lesions healed after topical or intravenous acyclovir therapy. Herpes simplex infection should be ruled out in all cases of oral ulcers detected in patients being treated for leukemia.

Significance of the head and neck in late infection in renal transplant recipients

The present study was undertaken to evaluate the overall significance of the mouth and contiguous structures as sites of late opportunistic infection in renal transplant recipients, to define the flora of such infections, and to determine factors that place patients at risk of infection. Of 323 patients who underwent renal transplants, 57% developed infection at least 1 month postoperatively. Sex, donor source, or age did not influence the risk of infection. Of the posttransplant infections, 30.6% occurred in the head and neck, 21.9% in the respiratory tract, 23.7% in the urinary tract, and 10% at sites of trauma. Of head and neck infections, 16.4% were bacterial, 20.5% were viral, and 21.9% were fungal. In the remainder a definitive causative organism could not be identified. These results emphasize that the head and neck area is a major site of late opportunistic infection in renal transplant recipients.

Achieving oral health in patients with renal failure and renal transplants

The protocols for oral evaluation and treatment of patients with renal failure and renal transplants are presented. Guidelines for dental treatment planning are outlined, and extraction versus conservation of teeth is discussed. Information on special considerations involving dialysis, antibiotic prophylaxis, drug therapy, and immunosuppression is provided. The goal of treatment is to restore maximum function while minimizing the risk of oral infection after transplantation.

Cardiac transplantation: dental considerations

The same basic principles of dental management of the immunocompromised patient apply to patients receiving cardiac transplants: preimmunosuppressive therapy examination and elimination of all existing and potential sources of infection; counseling regarding the importance of meticulous oral hygiene obviating further medical complications; and frequent oral health assessments for interception of emerging oral problems, maintenance, and reinforcement of good oral care. Dental practitioners familiar with the more numerous patients with renal transplants will find differing therapy complications secondary to immunosuppression and maintenance drug regimens. The dental approach to the candidate for a cardiac transplant will differ in degree of morbidity and complexity of delivering necessary oral care before transplantation.

Occult dental infection causing fever in renal transplant patients

Fever secondary to odontogenic infection following successful renal transplantation is reported in three patients. All three patients initially lacked signs or symptoms localizing to the oral cavity, and two of the three patients did not have x-ray evidence of abscess formation. Two patients received antibiotic therapy without any apparent clinical response, and all three patients responded promptly to surgical extractions. Our patients illustrate that fever can be the only sign of dental sepsis in renal transplant recipients, and tooth extraction as empiric therapy may be necessary. Most important, however, is that the dental pathology responsible for their fever could have been detected and treated prior to transplantation. We recommend pretransplant dental evaluation of all patients with extraction of partially impacted molars and treatment of all periodontal disease and dental caries.

A retrospective study of microbiologic samples from oral mucosal lesions

This report describes findings in microbial samples from 271 patients with lesions of the oral mucous membranes. Analyses were made on the basis of direct microscopy and cultivation on nonselective and selective media incubated under aerobic and anaerobic conditions. Growth of bacteria was semiquantitatively determined according to a five-grade scale. Among the 134 samples for direct microscopy, fungi in yeast as well as hyphae phase, were identified in 39 cases. Among the cultivated samples, Candida albicans was detected in 107 cases, of which 71 were full-denture wearers. Staphylococcus aureus, coliform bacteria and Klebsiella were the most frequently isolated "nonoral" bacteria. In some cases also Streptococcus pyogenes, Haemophilus influenzae, Pseudomonas or other gram-negative aerobic bacteria were found. In 84 cases the bacteria mentioned were registered as single "nonoral" infection, and in 63 cases combinations of "nonoral" species occurred. In 51 of these 63 cases C. albicans was also involved. In 31 cases a significant quantitative increase of one or more oral bacterial species was registered. In 93 cases there was no indication of a microbial cause of the lesion. On the basis of these microbial findings, it might be presupposed that in the majority of cases microorganisms were of primary or secondary pathogenic importance to the lesions.

Inflammatory pathology in the dental system in renal transplantation

The importance of a thorough dental and oral examination before kidney transplantation is stressed and the number and type of dental and oral pathology in 13 cases of kidney transplantation without prior oral evaluation are presented.

Rhinomaxillary mucormycosis in a kidney transplant patient

Rhinomaxillary mucormycosis is an uncommon but important pathologic entity with a rapidly fatal course if treatment is delayed. This is of particular interest to dentists, since many of the earliest clinical signs appear in the oral and perioral regions. Successful therapy demands early diagnosis by biopsy, institution of amphotericin B therapy, and surgical débridement. A case of nonfatal rhinomaxillary mucormycosis is presented, and all other reported cases in transplant patients are reviewed.

Immunology in dentistry

Implications of immunology in dental treatment are explained through discussion of the basic scientific principles of allergy, autoimmunity, immunization, immune dysfunction, tumor immunology, immunosuppression, and transplantation immunobiology.

Comparison of the plaque microflora in immunodeficient and immunocompetent dental patients

The nature and extent of the immune dysfunctions in 20 immunodeficient patients, as well as the immunocompetence of 22 control subjects, were verified by cell-mediated responsiveness and immunoglobulin quantitations. Comparisons of the microbial composition of supragingival plaque between the two populations showed that a greater number of immunodeficient than control subjects harbored Candida sp. and Staphylococcus sp. Conversely, a lower number of immunodeficient than control subjects harbored Streptococcus mutans. Also, patients with immune dysfunctions had a lower dental caries experience than their immunocompetent counterparts.