ADHA Access — February 2012
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Putting the Pieces Together:
The Role of the Oral Health Professional in Renal Organ Transplant Eligibility
Currently, there are over 88,000 Americans awaiting organ transplantation; 88 percent of them are in need of a renal transplant.1 As an oral health professional, do you know what is expected of you to help these patients proceed with their renal treatment?
Understanding End-Stage Renal Disease and the Need for Renal Transplantation
End-stage renal disease (ESRD) is the complete or almost complete failure of kidney function and is also known as renal or kidney failure. Common causes are chronic hypertension, progressing diabetes2 or the combination of both.3 Most patients with ESRD are first diagnosed with chronic kidney failure and then progress to ESRD as kidney function decreases.
These patients have three treatment options:
. Live with ESRD by receiving dialysis treatment three times per week
. Undergo kidney transplantation
. Forego any form of treatment at all
There are almost half a million Americans being treated for ESRD, and the numbers continue to increase,4 meaning there is also an increasing likelihood of having one of these people in your dental chair.
Pre-Renal Transplantation: A Patient’s Journey to Obtain Access to the Transplant Waiting List
Patients seeking organ transplantation will be directed to a local transplant program that will guide them through the process. Each program comprises a team of health care professionals such as nephrologists, surgeons, transplant coordinators, social workers and other hospital personnel who determine the requirements for each type of organ transplant. These teams are often partnered with the United Network for Organ Sharing (UNOS) and are able to organize the entire process for the patient.
Once a patient is involved with a transplant team, he or she is given a comprehensive assessment to determine his or her medical risk and eligibility for the organ waiting list.5 The majority of all organ transplant programs will require the patient to follow multiple procedures and undergo multiple examinations including, but not limited to:
. A complete physical exam
.. Lab testing to identify active infections, cancer, HIV and hepatitis status
. A radiological evaluation, such as a chest X-ray
. A cardiologic evaluation and an EKG
. Gastrointestinal testing
. Psychological and psychosocial evaluations
. A gynecological exam for females
. A dental examination and treatment of caries5
Pre-Renal Transplantation: Dental Treatment Guidelines
As of yet, there are no scienti..c studies to support a direct correlation between an ESRD patient’s oral status and the success of a renal transplant, so no universal treatment guidelines exist to minimize risk.4 Therefore, the experts on each hospital team must use their clinical experiences and professional opinions to determine any oral health-related considerations that will increase the likelihood of transplant success.
Like many other systemic conditions, renal failure affects the oral status of patients with ESRD. Health care professionals have noted that patients with renal failure exhibit bone loss in the mouth and those on dialysis are more likely to experience oral ulcers, infections, gingival hyperplasia, xerostomia, halitosis, swelling, gingivitis, stomatitis, caries, tooth loss and jaw discomfort.6-8 So when a transplant team requires a dental evaluation prior to the patient’s placement on the waiting list, oral health personnel may need to provide treatment that is speci..c to the pre-transplant patient’s oral conditions. A consultation with the patient’s nephrologist is recommended to determine the health status of each patient.
Dental treatment recommendations for the pre-renal transplant patient are also made with considerations for the patient’s possible health status post-transplantation. An article from the National Institute of Dental and Craniofacial Research (NIDCR) states, “A dental check-up is an important part of your pre-transplant evaluation. Because some medications you take after transplant can cause problems in your mouth, you want your mouth to be as healthy as possible before your transplant procedure.”9 For example, a carious lesion charted in the pre-transplant patient may manifest as a periapical abscess post-transplantation due to the immunosuppressive drugs, which could then lead to sepsis.7
Transplant personnel want to provide the best possible environment for the new kidney. As stated before, there is no evidencebased research indicating that removal of possible sources of infection in the mouth is connected to transplant success. However, some transplant teams consider it necessary prior to the ESRD patient gaining access to the waiting list and receiving a renal transplant.
Those procedures believed to be most necessary are:
. Extraction of non-restorable teeth and partially erupted third molars
. Treatment of all dental decay
. Elimination of oral infections
Additional suggested procedures include removal of orthodontic bands to improve home care, use of antimicrobial rinse, and reinforcement of good oral health instructions.5,10-12
Other considerations when scheduling ESRD patients prior to transplantation may include the possibility of antibiotic prophylaxis. This should be considered if the patient’s health requires placement of a flstula for dialysis or if extensive dental procedures are necessary. 7,13 It is also important to treat renal transplant patients on “non-dialysis” days to ensure there will no longer be any heparin (used to increase blood flow during dialysis) still in their system.7,14
Once a patient is approved to be placed on the waiting list, his or her dental care is not over. The average time from when a patient is ..rst placed on the waiting list to when they actually receive the kidney transplant is two years.11 Until the surgery, the pre-transplant patient is recommended to seek dental care regularly and use effective self-care measures to maintain oral health.1,4,14
Post-Renal Transplantation: Treatment Guidelines
Dental treatment of the post-transplant patient is just as critical to maintain oral health as treatment prior to the transplantation. Management at NIDCR has actually noted, “In some cases, it will be safer for patients to undergo extensive treatment after transplant as the new organ improves their health.”11 The post-transplant patient should wait anywhere from three to six months after transplantation to receive dental care, depending on his/her progress and the physician’s discretion.11 It is important to order a medical consultation prior to treatment of the post-transplant patient. Communicate with your patient’s physician about the patient’s general health and ability to tolerate treatment.11
In some situations, a physician may adjust the patient’s immunosuppressive medications prior to a dental visit.15 These medications may (a) alter dental treatment due to drug-drug interactions with the premedication and (b) cause side effects to the patient’s oral cavity.11 Immunosuppressive agents commonly have the following oral side effects: xerostomia, excessive bleeding, poor wound healing, gingival hyperplasia, oral ulcerations, cancers and/or tumors, numbness or tingling, stomatitis, joint pain, and opportunistic infections such as oral candidiasis, herpes simplex/zoster, hairy leukoplakia, aphthous ulcers, cytomegalovirus, EBV and toxoplamosis.8,11,15 Basic ally, treatment recommended for posttransplant patients is to treat any new infections since the transplantation and manage any side effects from medications.11,16
Conclusion
Due to the lack of de..ned pre- or post-renal transplant treatment guidelines, it is critical that oral health professionals use their own clinical experiences and professional judgment to determine what may be a source of infection in the patient’s mouth. This will enable treatment planning that will contribute positively to transplantation success.
References
1. Organ Procurement and Transplantation Network. Transplantation in the U.S. Available at: optn.transplant.hrsa.gov/latestData/rptData.asp. Accessed May 10, 2011.
2. MedlinePlus. End-stage kidney disease. Available at: www.nlm.nih.gov/ medlineplus/ency/actircle/000500.htm. Accessed Oct. 26, 2010.
3. Pirtle CJ. CDC state-speci..c trends in chronic kidney failure. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a3.htm. Accessed Oct. 25, 2010.
4. National Kidney Foundation Inc. End stage renal disease in the United States. Available at: www.kidney.org/news/newsroom/fs_new/esrdinUS. cfm. Accessed Oct. 25, 2010.
5. Steinman T, Becker B, Frost A, et l. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001; 71(9): 1189-1204.
6. Gallon LG. Pretransplant evaluation of renal transplant candidates. Seminars in Nephrology. 2002; 22(6): 515-25.
7. Gonyea J. Oral health care for patients on dialysis. Nephrol Nurs J. 2009; 36(3): 327-32.
8. Greenwood M, Meechan JG, Bryant DG. General medicine and surgery for dental practitioners part 7: renal disorders. Br Dent J. 2003; 195(4): 181-4.
9. Provanzana R. Importance of dental care for transplant recipients. American Association of Kidney Patients. 2005; 21 (1).
10. Gudapati A, Ahmed P, Rada R. Dental management of patients with renal failure. Gen Dent. 2002; 50(6): 508-10.
11. National Institute of Dental and Craniofacial Research. Dental management of organ transplant patient. Available at: https://www.nidcr.nih.gov/Oral- Health/Topics/OrganTransplantationOralHealth/OrganTransplantProf.htm. Accessed Accessed Oct. 25, 2010.
12. Rustemeyer J, Bremerich A. Necessity of surgical dental foci treatment prior to organ transplantation and heart valve replacement. Clin Oral Investigations. 2007; 11(2): 171-4.
13. Precious DS, Hinrichsen GJ. Dental considerations for patients on chronic dialysis and renal transplant recipients. J Can Dent Assoc. 1981; 47(9): 595-9.
14. Guggenheimer J, Mayher D, Eghtesad B. A survey of dental care protocols among US organ transplant centers. Clin Transplant. 2005; 19(1): 15-8.
15. National Institute of Dental and Craniofacial Research. Organ transplantation and your mouth. Available at: http://www.nidcr.nih.gov/OralHealth/ Topics/OrganTransplantationOralHealth/OrganTransplantPatient.htm. Accessed on: 10-26-10.
16. Goldman K. Dental management of patients with bone marrow and solid organ transplantation. Dent Clin North Am. 2006; 50(4): 659-76.
Additional Resources
Bloom R, Cardella C, Conti D. ASA: Getting a new kidney: facts about kidney transplants. Available at www.a-s-t.org/content/patient-education-brochures. Guggenheimer J, Eghtesad B, Stock D. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol. 2003; 95(4): 383-9.
Hofstra University. Bioengineering. Available at: people.hofstra.edu/sina_y_ rabbany/engg81/engg81courseoutline.html. Accessed Dec. 8, 2010.
Klassen J, Krasko B. The dental health status of dialysis patients. J Can Dent Assoc. 2002; 68(1): 34-8.
Sanford Health. Dialysis medications. Available at: north.sanfordhealth.org/ medicalservices/specialties/kidney/dialysis/medications.aspx. Accessed Oct. 29, 2010.
Pamela Mandola-Duncan, RDH, graduated in May 2011 from the University of Missouri–Kansas City, School of Dentistry, Division of Dental Hygiene and is working full-time in a private practice setting. She plans to continue her education in the future.
Lauren Zelle, RDH, graduated in May 2011 from the University of Missouri– Kansas City, School of Dentistry, Division of Dental Hygiene and is working part-time in a private practice setting. She plans to participate in dental cross-cultural outreach programs in the future.
Faculty mentors for this edition of Strive were Lorie Holt, RDH, MS and Tanya Villalpando-Mitchell, RDH, MS.
The Role of the Oral Health Professional in Renal Organ Transplant Eligibility
Currently, there are over 88,000 Americans awaiting organ transplantation; 88 percent of them are in need of a renal transplant.1 As an oral health professional, do you know what is expected of you to help these patients proceed with their renal treatment?
Understanding End-Stage Renal Disease and the Need for Renal Transplantation
End-stage renal disease (ESRD) is the complete or almost complete failure of kidney function and is also known as renal or kidney failure. Common causes are chronic hypertension, progressing diabetes2 or the combination of both.3 Most patients with ESRD are first diagnosed with chronic kidney failure and then progress to ESRD as kidney function decreases.
These patients have three treatment options:
. Live with ESRD by receiving dialysis treatment three times per week
. Undergo kidney transplantation
. Forego any form of treatment at all
There are almost half a million Americans being treated for ESRD, and the numbers continue to increase,4 meaning there is also an increasing likelihood of having one of these people in your dental chair.
Pre-Renal Transplantation: A Patient’s Journey to Obtain Access to the Transplant Waiting List
Patients seeking organ transplantation will be directed to a local transplant program that will guide them through the process. Each program comprises a team of health care professionals such as nephrologists, surgeons, transplant coordinators, social workers and other hospital personnel who determine the requirements for each type of organ transplant. These teams are often partnered with the United Network for Organ Sharing (UNOS) and are able to organize the entire process for the patient.
Once a patient is involved with a transplant team, he or she is given a comprehensive assessment to determine his or her medical risk and eligibility for the organ waiting list.5 The majority of all organ transplant programs will require the patient to follow multiple procedures and undergo multiple examinations including, but not limited to:
. A complete physical exam
.. Lab testing to identify active infections, cancer, HIV and hepatitis status
. A radiological evaluation, such as a chest X-ray
. A cardiologic evaluation and an EKG
. Gastrointestinal testing
. Psychological and psychosocial evaluations
. A gynecological exam for females
. A dental examination and treatment of caries5
Pre-Renal Transplantation: Dental Treatment Guidelines
As of yet, there are no scienti..c studies to support a direct correlation between an ESRD patient’s oral status and the success of a renal transplant, so no universal treatment guidelines exist to minimize risk.4 Therefore, the experts on each hospital team must use their clinical experiences and professional opinions to determine any oral health-related considerations that will increase the likelihood of transplant success.
Like many other systemic conditions, renal failure affects the oral status of patients with ESRD. Health care professionals have noted that patients with renal failure exhibit bone loss in the mouth and those on dialysis are more likely to experience oral ulcers, infections, gingival hyperplasia, xerostomia, halitosis, swelling, gingivitis, stomatitis, caries, tooth loss and jaw discomfort.6-8 So when a transplant team requires a dental evaluation prior to the patient’s placement on the waiting list, oral health personnel may need to provide treatment that is speci..c to the pre-transplant patient’s oral conditions. A consultation with the patient’s nephrologist is recommended to determine the health status of each patient.
Dental treatment recommendations for the pre-renal transplant patient are also made with considerations for the patient’s possible health status post-transplantation. An article from the National Institute of Dental and Craniofacial Research (NIDCR) states, “A dental check-up is an important part of your pre-transplant evaluation. Because some medications you take after transplant can cause problems in your mouth, you want your mouth to be as healthy as possible before your transplant procedure.”9 For example, a carious lesion charted in the pre-transplant patient may manifest as a periapical abscess post-transplantation due to the immunosuppressive drugs, which could then lead to sepsis.7
Transplant personnel want to provide the best possible environment for the new kidney. As stated before, there is no evidencebased research indicating that removal of possible sources of infection in the mouth is connected to transplant success. However, some transplant teams consider it necessary prior to the ESRD patient gaining access to the waiting list and receiving a renal transplant.
Those procedures believed to be most necessary are:
. Extraction of non-restorable teeth and partially erupted third molars
. Treatment of all dental decay
. Elimination of oral infections
Additional suggested procedures include removal of orthodontic bands to improve home care, use of antimicrobial rinse, and reinforcement of good oral health instructions.5,10-12
Other considerations when scheduling ESRD patients prior to transplantation may include the possibility of antibiotic prophylaxis. This should be considered if the patient’s health requires placement of a flstula for dialysis or if extensive dental procedures are necessary. 7,13 It is also important to treat renal transplant patients on “non-dialysis” days to ensure there will no longer be any heparin (used to increase blood flow during dialysis) still in their system.7,14
Once a patient is approved to be placed on the waiting list, his or her dental care is not over. The average time from when a patient is ..rst placed on the waiting list to when they actually receive the kidney transplant is two years.11 Until the surgery, the pre-transplant patient is recommended to seek dental care regularly and use effective self-care measures to maintain oral health.1,4,14
Post-Renal Transplantation: Treatment Guidelines
Dental treatment of the post-transplant patient is just as critical to maintain oral health as treatment prior to the transplantation. Management at NIDCR has actually noted, “In some cases, it will be safer for patients to undergo extensive treatment after transplant as the new organ improves their health.”11 The post-transplant patient should wait anywhere from three to six months after transplantation to receive dental care, depending on his/her progress and the physician’s discretion.11 It is important to order a medical consultation prior to treatment of the post-transplant patient. Communicate with your patient’s physician about the patient’s general health and ability to tolerate treatment.11
In some situations, a physician may adjust the patient’s immunosuppressive medications prior to a dental visit.15 These medications may (a) alter dental treatment due to drug-drug interactions with the premedication and (b) cause side effects to the patient’s oral cavity.11 Immunosuppressive agents commonly have the following oral side effects: xerostomia, excessive bleeding, poor wound healing, gingival hyperplasia, oral ulcerations, cancers and/or tumors, numbness or tingling, stomatitis, joint pain, and opportunistic infections such as oral candidiasis, herpes simplex/zoster, hairy leukoplakia, aphthous ulcers, cytomegalovirus, EBV and toxoplamosis.8,11,15 Basic ally, treatment recommended for posttransplant patients is to treat any new infections since the transplantation and manage any side effects from medications.11,16
Conclusion
Due to the lack of de..ned pre- or post-renal transplant treatment guidelines, it is critical that oral health professionals use their own clinical experiences and professional judgment to determine what may be a source of infection in the patient’s mouth. This will enable treatment planning that will contribute positively to transplantation success.
References
1. Organ Procurement and Transplantation Network. Transplantation in the U.S. Available at: optn.transplant.hrsa.gov/latestData/rptData.asp. Accessed May 10, 2011.
2. MedlinePlus. End-stage kidney disease. Available at: www.nlm.nih.gov/ medlineplus/ency/actircle/000500.htm. Accessed Oct. 26, 2010.
3. Pirtle CJ. CDC state-speci..c trends in chronic kidney failure. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5339a3.htm. Accessed Oct. 25, 2010.
4. National Kidney Foundation Inc. End stage renal disease in the United States. Available at: www.kidney.org/news/newsroom/fs_new/esrdinUS. cfm. Accessed Oct. 25, 2010.
5. Steinman T, Becker B, Frost A, et l. Guidelines for the referral and management of patients eligible for solid organ transplantation. Transplantation. 2001; 71(9): 1189-1204.
6. Gallon LG. Pretransplant evaluation of renal transplant candidates. Seminars in Nephrology. 2002; 22(6): 515-25.
7. Gonyea J. Oral health care for patients on dialysis. Nephrol Nurs J. 2009; 36(3): 327-32.
8. Greenwood M, Meechan JG, Bryant DG. General medicine and surgery for dental practitioners part 7: renal disorders. Br Dent J. 2003; 195(4): 181-4.
9. Provanzana R. Importance of dental care for transplant recipients. American Association of Kidney Patients. 2005; 21 (1).
10. Gudapati A, Ahmed P, Rada R. Dental management of patients with renal failure. Gen Dent. 2002; 50(6): 508-10.
11. National Institute of Dental and Craniofacial Research. Dental management of organ transplant patient. Available at: https://www.nidcr.nih.gov/Oral- Health/Topics/OrganTransplantationOralHealth/OrganTransplantProf.htm. Accessed Accessed Oct. 25, 2010.
12. Rustemeyer J, Bremerich A. Necessity of surgical dental foci treatment prior to organ transplantation and heart valve replacement. Clin Oral Investigations. 2007; 11(2): 171-4.
13. Precious DS, Hinrichsen GJ. Dental considerations for patients on chronic dialysis and renal transplant recipients. J Can Dent Assoc. 1981; 47(9): 595-9.
14. Guggenheimer J, Mayher D, Eghtesad B. A survey of dental care protocols among US organ transplant centers. Clin Transplant. 2005; 19(1): 15-8.
15. National Institute of Dental and Craniofacial Research. Organ transplantation and your mouth. Available at: http://www.nidcr.nih.gov/OralHealth/ Topics/OrganTransplantationOralHealth/OrganTransplantPatient.htm. Accessed on: 10-26-10.
16. Goldman K. Dental management of patients with bone marrow and solid organ transplantation. Dent Clin North Am. 2006; 50(4): 659-76.
Additional Resources
Bloom R, Cardella C, Conti D. ASA: Getting a new kidney: facts about kidney transplants. Available at www.a-s-t.org/content/patient-education-brochures. Guggenheimer J, Eghtesad B, Stock D. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol. 2003; 95(4): 383-9.
Hofstra University. Bioengineering. Available at: people.hofstra.edu/sina_y_ rabbany/engg81/engg81courseoutline.html. Accessed Dec. 8, 2010.
Klassen J, Krasko B. The dental health status of dialysis patients. J Can Dent Assoc. 2002; 68(1): 34-8.
Sanford Health. Dialysis medications. Available at: north.sanfordhealth.org/ medicalservices/specialties/kidney/dialysis/medications.aspx. Accessed Oct. 29, 2010.
Pamela Mandola-Duncan, RDH, graduated in May 2011 from the University of Missouri–Kansas City, School of Dentistry, Division of Dental Hygiene and is working full-time in a private practice setting. She plans to continue her education in the future.
Lauren Zelle, RDH, graduated in May 2011 from the University of Missouri– Kansas City, School of Dentistry, Division of Dental Hygiene and is working part-time in a private practice setting. She plans to participate in dental cross-cultural outreach programs in the future.
Faculty mentors for this edition of Strive were Lorie Holt, RDH, MS and Tanya Villalpando-Mitchell, RDH, MS.
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