Oral lesions in organ transplant patients

Natural Bioactive Compounds in the Management of Oral Diseases in Nephropathic Patients

Among the chronic non-communicable degenerative diseases (CDNCDs), chronic kidney disease (CKD) represents a global public health problem. Recent studies demonstrate a mutual cause–effect relationship between CKD and oral diseases, in which the presence of one induces the onset and faster progression of the other. In particular, the oral cavity alterations more frequent in CKD patients are: chronic periodontitis diseases, bone lesions, oral infections, and oral cancer lesions. Currently, a standardized therapy for the treatment of oral diseases is lacking. For this reason, natural bioactive compounds (NBCs), characterized by several health effects, such as antioxidant, antimicrobial, anti-inflammatory and anti-cancer actions, represent a new possible adjuvant therapy in the management of these pathological conditions. Among NBCs, polyphenols play a leading role due to positive modulation of oral microbiota, preventing and correcting oral dysbiosis. Moreover, these compounds exert anti-inflammatory effects, such as inhibiting the production of pro-inflammatory cytokines and the expression of cycloxigenase-2. In this light, the formulation of a new mouthwash/gel/gingival paste, with a high content of polyphenols in association with NBCs characterized by antimicrobial action, could represent a future therapy of oral disease in CKD patients.

Oro-Dental Health and Primary Nephrotic Syndrome among Vietnamese Children

Primary nephrotic syndrome (PNS) is common in children, affecting the soft and hard tissues of the oral cavity. This study aimed to investigate the percentage of dental caries, gingivitis, hypertrophic gingivitis, and developmental defects of enamel (DDE) in children with PNS. The association of PNS with these diseases and oral care behavior was also assessed. A total of 407 children with PNS and 407 age- and gender-matched controls were recruited. PNS was diagnosed based on blood and urinary tests. The Simplified Oral Hygiene Index (OHI-S), the Gingival Index (GI), the Gingival Overgrowth Index (GOI), the Decayed, Missing, and Filled Teeth Index (dmft/DMFT), and DDE were collected. The PNS patients showed significantly higher scores of OHI-S, GI, and dmft, and higher proportions of dental caries and DDE than those of the controls (p < 0.001). It is necessary to establish a periodic dental protocol for PNS patients to improve their oral health status.

Does the Microbiome Affect the Outcome of Renal Transplantation?

The role of the human microbiome in health and disease is becoming increasingly apparent. Emerging evidence suggests that the microbiome is affected by solid organ transplantation. Kidney transplantation is the gold standard treatment for End-Stage Renal Disease (ESRD), the advanced stage of Chronic Kidney Disease (CKD). The question of how ESRD and transplantation affect the microbiome and vice versa includes how the microbiome is affected by increased concentrations of toxins such as urea and creatinine (which are elevated in ESRD), whether restoration of renal function following transplantation alters the composition of the microbiome, and the impact of lifelong administration of immunosuppressive drugs on the microbiome. Changes in microbiome composition and activity have been reported in ESRD and in therapeutic immunosuppression, but the effect on the outcome of transplantation is not well-understood. Here, we consider the current evidence that changes in kidney function and immunosuppression following transplantation influence the oral, gut, and urinary microbiomes in kidney transplant patients. The potential for changes in these microbiomes to lead to disease, systemic inflammation, or rejection of the organ itself is discussed, along with the possibility that restoration of kidney function might re-establish orthobiosis.

Protein Ingredient in Saliva on Oral Dryness Patients Caused by Calcium Blocker

Oral dryness as a side effect of certain drugs is increasing. The aim of this study was to examine the change of the protein ingredient in saliva of oral dryness patients caused by calcium blocker. Six patients taking calcium blocker and six healthy elderly were enrolled. Unstimulated salivary flow rate, protein concentration, and flow rate of protein were measured and compared between the patients taking calcium blocker and healthy elderly. iTRAQ (Isobaric Tag for Relative and Absolute Quantitation) proteomic analysis was performed to extract the salivary protein changed in patient taking calcium blocker, and the intensities of Western blotting products were quantified (unpaired t-test). Unstimulated salivary flow rate was significantly lower on patients taking calcium blocker (p < 0.01). Protein concentration tended to be higher and the flow rate of protein tended to be lower on patients. As the result of iTRAQ proteomic analysis, calmodulin-like protein 3, glutathione S-transferase P, and keratin type I cytoskeletal 13 increased characteristically in patient taking calcium blocker, and the expression in calmodulin-like protein 3 was significantly larger (p < 0.01). The results of this study indicated that calmodulin-like protein 3 increased in patients taking calcium blocker and could be a salivary biomarker for oral dryness caused by calcium blocker.

Differences in the Incidence of Pathologic Lesions on the Oral Mucosa in Patients Undergoing Hemodialysis vs Renal Organ Transplant Recipients Subjected to Long-term Pharmacologic Immunosuppressive Therapy

Disorders of homeostasis and an increased incidence of infection in patients undergoing hemodialysis causes frequent appearance of pathologic changes in the oral mucosa. The organ transplant and subsequent pharmacologic immunosuppression may result in systemic disorders manifesting by pathologic oral lesions.

METHODS

The study was conducted on 18 patients undergoing hemodialysis and 18 patients after renal transplant. The study comprised case taking and physical examination, including detailed intraoral and extraoral examination.

RESULTS

The intraoral examination revealed gingivitis in 61.1% of patients in both groups. In the renal transplant group compared with the hemodialysis group 55.6% vs 38.9% of patients had gingival recession, 55.6% vs 44.4% had periodontitis, 27.8% vs 22.2% had macroglossia, and 11.1% vs 5.6% had geographic tongue, respectively. In the patients on hemodialysis leukoplakia and pallor or pathologic pigmentation of oral mucosa were more frequently observed lesions. Other significant findings in the renal transplant group were lingual papillary atrophy, aphthae, and erythroplakia. Patients of both group reported xerostomia, halitosis, gum bleeding, dysgeusia in their history.

DISCUSSION

Both groups of patients after renal transplant and patients undergoing hemodialysis presented pathologic lesions in the oral cavity. The study revealed the differences between type and frequency of these pathologic changes, which shows different effect of the above methods of treatment of end-stage renal failure on the oral cavity.

Adverse Drug Reactions in the Orofacial Region

A wide spectrum of drugs can sometimes give rise to numerous adverse orofacial manifestations, particularly dry mouth, taste disturbances, oral mucosal ulceration, and/or gingival swelling. There are few relevant randomized double-blind controlled studies in this field, and therefore this paper reviews the data from case reports, small series, and non-peer-reviewed reports of adverse drug reactions affecting the orofacial region (available from a MEDLINE search to April, 2003). The more common and significant adverse orofacial consequences of drug therapy are discussed.

Oral pathology in inflammatory bowel disease

The incidence of inflammatory bowel diseases (IBD) - Crohn’s disease (CD) and ulcerative colitis (UC) - has been increasing on a global scale, and progressively, more gastroenterologists will be included in the diagnosis and treatment of IBD. Although IBD primarily affects the intestinal tract, extraintestinal manifestations of the disease are often apparent, including in the oral cavity, especially in CD. Specific oral manifestations in patients with CD are as follows: indurate mucosal tags, cobblestoning and mucogingivitis, deep linear ulcerations and lip swelling with vertical fissures. The most common non-specific manifestations, such as aphthous stomatitis and angular cheilitis, occur in both diseases, while pyostomatitis vegetans is more pronounced in patients with UC. Non-specific lesions in the oral cavity can also be the result of malnutrition and drugs. Malnutrition, followed by anemia and mineral and vitamin deficiency, affects the oral cavity and teeth. Furthermore, all of the drug classes that are applied to the treatment of inflammatory bowel diseases can lead to alterations in the oral cavity due to the direct toxic effects of the drugs on oral tissues, as well as indirect immunosuppressive effects with a risk of developing opportunistic infections or bone marrow suppression. There is a higher occurrence of malignant diseases in patients with IBD, which is related to the disease itself and to the IBD-related therapy with a possible oral pathology. Treatment of oral lesions includes treatment of the alterations in the oral cavity according to the etiology together with treatment of the primary intestinal disease, which requires adequate knowledge and a strong cooperation between gastroenterologists and specialists in oral medicine.

Oral candidiasis in patients with renal transplants

OBJECTIVES

Oral candidiasis (OC) is a frequent oral lesion in renal transplant patients (RTPs). Despite the increased prevalence of OC in RTPs, no study has examined related risk factors. The aims of this study were to analyze the prevalence of and risk factors for OC in RTPs compared with age- and gender-matched healthy control group (HC) as well as determine the incidence of OC after transplantation.

STUDY DESIGN

[corrected] We analyzed the prevalence and risk factors of OC in a group of 500 RTPs (307 men, 193 women, mean age 53.63 years) and 501 HC subjects (314 men, 187 women, mean age 52.25 years). Demographic and pharmacological data were recorded for all subjects. Incident cases of OC were ascertained retrospectively from outpatient clinical records only in the RTP group.

RESULTS

The prevalence of OC was 7.4% in RTPs compared with 4.19% in HC (P<0.03). The most frequent type of OC in the two groups was denture stomatitis. Statistical association was found between OC and age, mycophenolate mofetil dose and blood levels, dentures and tobacco. The multiple logistic regression model only chose for denture variable. According to the outpatient clinical records, 24 RTPs suffered OC during the first moth post-transplant. Severe lesions affecting the oral cavity and pharynx appeared in 79% of the OC cases.

CONCLUSIONS

This study shows a lower prevalence of OC in RTPs than previous reports. Denture stomatitis was the most frequent OC prevalence form described in RTPs. Severe candidiasis is more frequent in the immediate posttransplant period. The presence of denture is an important risk factor of OC. These results emphasise the importance of adequate pre- and post-transplant oral health and denture cleaning and adjustment is recommended for these subjects to prevent this infection.

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.

Integrity of the oral tissues in patients with solid-organ transplants

The relationship between the use of immunosuppressants in solid-organ transplant patients and oral tissue abnormalities has been recognized. The objective of this study was to determine the state of oral tissue integrity in renal, heart, and liver transplant patients who are on continuous medical and dental control. Forty patients of both sexes were clinically evaluated at the Clinical Hospital of the University of Chile to identify pathologies of oral mucosa, gingival enlargement (GE), decayed, missing, filled teeth (DMFT) index, and salivary flow. The average age of the transplant subjects was 49.4 years, and the age range was 19 to 69 years. Most subjects maintained a good level of oral hygiene, and the rate mean of DMFT was 14.7. The degree of involvement of the oral mucosa and GE was low (10%). Unlike other studies, the frequency of oral mucosal diseases and GE was low despite the fact that these patients were immunosuppressed. Care and continuous monitoring seem to be of vital importance in maintaining the oral health of transplant patients.

Molecular diagnostics for head and neck pathology

Molecular diagnostic techniques are quickly finding a role in the detection and diagnosis of tumors, and in predicting their behavior. They may also prove useful in developing new therapeutic approaches to head and neck cancer. The surgeon working in the craniomaxillofacial region should have an understanding of these technologies, their availability in various settings, and how they affect various aspects of treatment, particularly in the detection and treatment of malignancies. This article offers an overview of recent advances in molecular diagnostic techniques, with their implications for diagnosis and management of head and neck tumors.

Lip and oral mucosal lesions in 100 renal transplant recipients

BACKGROUND

Renal transplant recipients (RTRs) appear to be more susceptible to the development of oral mucosal disease and lip cancer as a result of graft-preserving immunosuppressive therapy. However, reports regarding these pathologies other than lip cancer are scarce and not studied in a detailed manner in this patient population.

OBJECTIVE

The aim of this study was to determine the prevalence rates and clinical features of lip lesions and oral mucosal lesions (OMLs) in RTRs.

METHODS

In all, 100 consecutive RTRs (21 female and 79 male) and 79 healthy age- and sex-matched control subjects (23 female and 56 male) were screened for all pathologic and pseudopathologic lip lesions and OMLs, with special interest on precancerous and cancerous lesions. Information about possible associated risk factors such as smoking and alcohol consumption was also obtained. Dermatologic investigation included clinical observation and direct microscopic examination, culture, and histopathological evaluation when indicated.

RESULTS

One or more lip lesions, OMLs, or both were noted in every participant of both groups. Fordyce spots on the lips was the most common lesion in the patient group (73%), followed by diffuse gingival enlargement (39%), fissured tongue (35%), and oral candidiasis (26%). The last 3 disorders were significantly more common in RTRs, whereas the frequency of Fordyce spots in patients and control subjects was similar. No actinic cheilitis, lip cancer, or oral malignancy was observed.

LIMITATIONS

This was a relatively small sample size for evaluating precancerous and cancerous lip lesions and OMLs, as they are less frequently observed than benign lesions.

CONCLUSIONS

Some of the benign OMLs (oral candidiasis and diffuse gingival enlargement) are increased in RTRs mainly as a result of the immunosuppressive therapy or drug side effects. Precancerous or cancerous lesions were not observed on the lips or the oral mucosa of our RTRs. This finding is in direct contrast with those of previous studies, yet this can be related to the limited sample size of this study regarding these lesions.

Head and neck cancer in renal transplant patients in Finland

CONCLUSIONS

This study found a 0.8% incidence of non-cutaneous head and neck cancer during a mean follow-up of 10 years. The benefits of successful renal transplantation clearly outweigh the observed risk of malignancy.

OBJECTIVE

Increased cancer incidence after organ transplantation is well documented but few studies have reported on the rate of head and neck malignancies among these patients. This study aimed to determine the incidence and specific sites of head and neck cancer in a nationwide series of renal transplant patients in Finland.

PATIENTS AND METHODS

Data from the National Kidney Transplant Registry and the Finnish Cancer Registry were used. A total of 2884 kidney transplant patients from the period 1964 to 1997 were followed for cancer incidence during the period from 1967 to 2003.

RESULTS

There were 113 non-lymphomatous head and neck malignancies. The standardized incidence ratio (SIR), as compared with the general population, was 13.6, with a 95% confidence interval (CI) of 11.2-16.2. The SIR was significantly elevated for cancers of the skin (47.3, 95% CI 36.3-60.7), lip (31.8, 95% CI 20.8-46.6), oral cavity (6.5, 95% CI 2.4-14.0) and thyroid (5.8, 95% CI 3.0-10.2).

Detection of the Epstein-Barr virus (EBV) by in situ hybridization as definitive diagnosis of hairy leukoplakia

Histopathological findings in cases of hairy leukoplakia (HL) are not exclusive to this lesion. A total of 36 tissue samples from patients previously diagnosed with HL based solely on morphological aspects were used in this study. Our purpose was to confirm the presence of Epstein-Barr virus (EBV) in these tissue samples by in situ hybridization (ISH), and to compare the detection of EBV with specific histopathological findings observed in each case. Among the 36 specimens, 80.55% were EBV positive, confirming the previous clinical and histhophatological diagnosis. None of the histopathological findings analyzed correlated with the presence or absence of EBV. This shows that a definitive diagnosis of HL cannot be established based on histopathological findings alone. Because there are many important implications on the establishment of definitive diagnosis of HL, the detection of EBV by ISH is obligatory.

Gastrointestinal complications following transplantation

Gastrointestinal complications are common after kidney, liver, pancreas, heart, and lung transplantation. Complications can include gastrointestinal conditions preceding the transplantation, viral, fungal, and bacterial gastrointestinal infections, and gastrointestinal side effects of medications including immunosuppressive agents. Establishing the etiology of gastrointestinal complaints is often difficult because any one or a combination of these factors might be contributory in the same patient.

Lip hypertrophy secondary to cyclosporine treatment: a rare adverse effect and treatment considerations

Gingival hypertrophy is a well-known and extensively documented undesirable side effect of cyclosporine in posttransplant patients. However, severe lip enlargement associated with cyclosporine is less recognized and has seldom been reported in the literature. Lip enlargement may lead to social, physical, and psychological stress, especially in the older childhood and adolescent age groups. We present a case of marked lip hypertrophy and concomitant gingival hypertrophy secondary to cyclosporine (Neoral) treatment in a pediatric bilateral lung transplant recipient. We also discuss the various side effects and treatment considerations available including more recent substitution therapy. Cyclosporine has most effectively and conclusively enabled transplantation of solid organs by reducing transplant-associated morbidity. We believe clinicians should be knowledgeable and aware of lip hypertrophy associated with cyclosporine use. This rare and less understood adverse effect should be recognized during the clinical evaluation of the posttransplant patient.

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.

Cyclosporin-induced gingival overgrowth in children

Cyclosporin is a potent immunosuppressant drug commonly used to prevent organ transplant rejection. In recent years, there has been a widening of its therapeutic use and an increase in the number of patients undergoing transplantation. Gingival overgrowth is one of several oral side-effects of cyclosporin, with a quoted prevalence of between 8% and 100%. There is continued debate over the factors which modify the degree of overgrowth, including individual sensitivity, age, dose of drug, duration of drug therapy and the presence of dental plaque. The exact mechanism of gingival overgrowth is still being debated, but appears to be caused by a combination of the proliferation of fibroblasts within the gingival tissue, an increase in the deposition of collagen and extracellular matrix, and a decrease in phagocytosis with a net gain in gingival tissue mass. A number of treatment options are utilized in the treatment of gingival overgrowth, including CO2 laser surgery, improved oral hygiene, the use of antibiotics such as metronidazole and azithromycin, and surgical intervention. In the clinical application of cyclosporin, there is little correlation between cyclosporin dose, serum trough levels and total exposure to the drug, making it difficult to achieve the desired therapeutic response. These problems were previously further complicated by the variability of absorption of the drug via the gastrointestinal tract. The original cyclosporin formulation, Sandimmune, was replaced by a new formulation, Neoral, which has a more reliable absorption, and gives a closer correlation between trough concentration levels and individual bioavailability. There is a conflict of opinion over whether or not the side-effect profile of Neoral varies from its precursor Sandimmune. It has yet to be seen whether the increased bioavailability of Neoral will result in an increased severity and prevalence of gingival overgrowth. An alternative immunosuppressant drug, tacrolimus, which is a macrolide antibiotic with a different side-effect profile, has emerged as a substitute for cyclosporin in organ transplantation. However, there have been conflicting reports of its side-effects and its capacity to cause gingival overgrowth.

Cyclosporin-Induced Gingival Overgrowth: A Clinical–Epidemiological Evaluation of 121 Italian Renal Transplant Recipients

BACKGROUND

Although other immunosuppressive agents have been recently introduced (e.g., tacrolimus), it has been calculated that in the next decade about 1 million people will still be taking cyclosporin (CsA). The association between gingival overgrowth (GO) and the use of CsA is still not clear. In the present study we evaluated the prevalence and the degree of GO in a group of Italian renal transplant patients and the possible relationship between gingival lesions and demographic, oral, systemic, and pharmacological variables.

METHODS

One hundred twenty-one renal transplant recipients receiving immunosuppressive therapy with CsA were evaluated in this study. Patients were classified in two groups. In the first (screening group), we included all those patients referred by the Parma University Renal Transplant Center for a general oral checkup, with no specific indications for GO. The second group (non-screening group) included all those patients who specifically had been referred to the Oral Pathology and Oral Medicine Unit because of GO. We considered the following variables: gender, daily CsA dose, duration of immunosuppressive treatment, CsA plasma concentration, concomitant use of another immunosuppressive agent (azathioprine), use of other GO inducers (calcium channel blockers, anti-epileptic drugs), oral hygiene scores, and other drugs taken at the time of oral examination.

RESULTS

Fisher's exact test and chi square test demonstrated that in the screening group, duration of immunosuppressive treatment and oral hygiene scores were associated both with the prevalence and the high GO scores (P (1) (DIT) <0.0001; P (2) (DIT)=0.0023; P (1) (hyg)=0.0084; P (2) (hyg)=0.0068). In the screening group, concomitant use of CsA and azathioprine is related to a low development degree of GO (P=0.0088). In the non-screening group, we found a significant association between poor oral hygiene and high degree of GO (P=0.0349).

CONCLUSION

In addition to a probable genetic predisposition, duration of immunosuppressive treatment and oral hygiene status are the most important variables related to development and degree of GO during the use of CsA in this study.

Cyclosporin A specifically affects nuclear PLCbeta1 in immunodepressed heart transplant patients with gingival overgrowth

One of the most commonly observed adverse effects of cyclosporin A (CsA) is the development of gingival overgrowth (GO). Fibroblasts are involved in GO, but the question why only a percentage of patients undergoing CsA treatment shows this side-effect remains unanswered. In a previous study, CsA has been demonstrated to induce over-expression of phospholipase C (PLC) beta(1) in fibroblasts of patients with clinical GO, in cells from both enlarged and clinically healthy gingival sites. In this work, we assessed the expression of PLCbeta isoforms to investigate whether the exaggerated fibroblast response to CsA related to increased PLCbeta(1) expression could also be detected in CsA-treated patients without clinical signs of GO. Our results support the hypothesis of a multi-factorial origin of gingival overgrowth, including specific changes within the gingival tissues orchestrating fibroblastic hyper-responsiveness as a consequence of a long-term in vivo exposure to cyclosporin A.

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.

Detection of Epstein-Barr virus (EBV) in the oral mucosa of renal transplant patients

The purpose of this study was to determine the prevalence of Epstein-Barr virus (EBV)-DNA in the oral mucosa of renal transplant patients and observe the efficacy of mouth rinses with phosphate-buffered saline (PBS) to eliminate EBV present in the saliva. Lingual, gingival, and buccal cytobrushings were obtained from normal oral mucosa of 10 renal transplant patients and 10 normal subjects, and were examined through polymerase chain reaction (PCR), before and after rinses with PBS. EBV-DNA was detected in 86.6% of renal transplant recipients and in 46.6% of healthy subjects. No significant difference was observed between oral scrapes obtained before and after rinses with PBS with regard to detection of EBV-DNA. Our results suggest that the use of PCR to detect the presence of EBV-DNA in oral mucosa in the absence of specific lesions gives rise to the problem of identifying the viral replication sites. In addition, PBS was not effective at minimizing contamination by saliva.

Keratosis follicularis of the oral mucosa with oral squamous cell carcinoma

Darier's disease or keratosis follicularis is a genodermatosis which may involve the oral mucosa. Malignant degeneration is rare. We report the first case of the combined manifestation of oral keratosis follicularis and oral squamous cell carcinoma and discuss the possible involvement of ATP2A2 (located in 12q23-24.1) which encodes the sarco/endoplasmic reticulum Ca(2+)-ATP isoform 2 (SERCA2), in the pathogenesis.

General medicine and surgery for dental practitioners. Part 7: renal disorders

Patients with kidney disorders are increasingly encountered in dental practice due to improvements in medical care leading to prolonged life expectancy. In order to provide appropriate and safe dental care for these patients it is important to have a working knowledge of renal disorders and related problems.

Lip hypertrophy secondary to cyclosporin treatment

Gingival hypertrophy is a well-documented side effect of cyclosporin therapy, but severe lip enlargement is less frequently recognised. This can lead to poor body image, low self-esteem and non-compliance, especially in the older childhood and adolescent age groups. We describe two paediatric renal transplant recipients who had marked lip hypertrophy as a consequence of cyclosporin (Neoral) treatment. On changing the immunosuppression to tacrolimus (Prograf), this resolved. We recommend that a change in immunosuppressant therapy be considered in children with significant changes to facial appearance.

Cyclosporin A-induced gingival overgrowth in renal transplant patients

BACKGROUND

The incidence of gingival overgrowth (GO) associated with the use of cyclosporin A (CsA) is controversial. In the present study, we determined the incidence of GO in Brazilian renal transplant patients treated with CsA and the possible associations between periodontal and pharmacological variables.

METHODS

The test group consisted of 20 renal transplant patients, and the control group included 20 non-transplant patients. Periodontal conditions were evaluated based on the plaque index (PI), gingival index (GI), probing depth (PD), and the rate of gingival overgrowth, together with pharmacological variables (daily CsA dose and duration of treatment).

RESULTS

A significant difference in PI (P < 0.0001) and PD (P < 0.0001) was observed between groups, while GI (P = 0.15) did not differ significantly. Using the Pearson correlation coefficient, a significant correlation was observed not only between GI (P < 0.001; r = 0.8141) and GO, but also for PD (P < 0.001; r = 0.866) and GO. The other correlations were not statistically significant.

CONCLUSIONS

We conclude that GO induced by CsA may vary according to the individual sensitivity of each patient and may or may not be correlated with other local factors (periodontal variables).

Oral fungal colonization and oral candidiasis in renal transplant patients: the relationship to Miswak use

OBJECTIVES

The aim of this study was to determine and compare the prevalence of oral candidal colonization and oral candidiasis in a group of medically stable renal transplant patients (RTPs) and age and sex-matched healthy control (HC) subjects.

STUDY DESIGN

The oral cavities of 58 RTPs and 52 HC subjects were clinically examined for the presence of oral candidiasis. Oral fungal colonization was determined by using the concentrated oral rinse technique.

RESULTS

Prevalence of oral fungal colonization was not significantly higher in RTPs than in HC subjects (74.1% vs 59.6%, respectively; P =.1), but the density of growth was significantly higher in RTPs (P <.0017). Oral candidiasis was diagnosed in 15.5% of RTPs but in none of HC subjects (P =.002). RTPs who used a chewing stick (Miswak: Salvadora persica ) for oral hygiene had a significantly lower prevalence of oral candidiasis (P =.04) compared with other RTPs.

CONCLUSIONS

RTPs are at high risk of developing oral candidiasis. More clinical investigations are needed to determine the antimycotic effect of Miswak. Regular oral screening is recommended for RTPs.

Resolution of oral ulcerations after decreasing the dosage of tacrolimus in a liver transplantation recipient

Oral ulcers have may possible causes, including immunosuppression and drug therapy. Severe cases of oral ulceration merit special consideration because the ulcers may become large enough to alter the quality of life of the patient. The present case involves a male patient who in 1994 received an orthotopic liver transplantation because of alcoholic cirrhosis. The initial immunosuppressive regimen was induced with tacrolimus (4 mg/d) and prednisone (20 mg/d). Ten months after orthotopic liver transplantation, the patient complained of multiple recurrent oral ulcers, dysphagia, and severe oral pain, which did not respond to any of the treatments over a 3-year period. Approximately 3(1/4) years after these unresponsive ulcers appeared, the reduction of the oral dosage of tacrolimus resulted in the total remission of the ulcers. A retrospective analysis demonstrated that appearance of the ulcers coincided with a dose of 9 mg/d of tacrolimus (whole blood levels of 12 ng/mL); the ulcers did not disappear until the dose was reduced to 4 mg/d (whole blood level of 6.6 ng/mL).

Severe oral manifestations of chronic graft-vs.-host disease

BACKGROUND

Graft-vs.-host-disease, or GVHD, is the main cause of morbidity in patients who have received bone marrow transplants. Chronic GVHD, or cGVHD, occurs 100 days or more after the transplant procedure and may take the form of various oral manifestations.

CASE DESCRIPTION

A 23-year-old woman received an allogeneic bone marrow transplant. Although prophylactic therapy was provided, the patient developed cGVHD. Appropriate therapy was initiated, and it received a good clinical response at all sites affected by cGVHD, except in the oral cavity. The patient received complete symptomatic relief through revised systemic therapy, improved oral hygiene, use of topical medications and a monitored diet.

CLINICAL IMPLICATIONS

Effective intervention by dentists is an important part of increasing treatment effectiveness and improving quality of life in patients who received bone marrow transplants.

Reduction of severe gingival overgrowth in a kidney transplant patient by replacing cyclosporin A with tacrolimus

Side effects of certain drugs such as cyclosporin A (CsA) and phenytoin may induce gingival overgrowth which in some instances become unacceptable to the patient because esthetic, functional, and other effects. Use of these drugs is related to important medical situations, such as organ transplantation and control and withdrawal of the drugs is contraindicated. Tacrolimus is an immunosuppressant used to prevent graft rejection in organ transplant patients and has been shown to cause fewer oral side effects than CsA. This report deals with a case of probable synergism between the use of CsA and phenytoin which caused an intense gingival overgrowth in a kidney transplant patient. A treatment protocol including very thorough oral hygiene, scaling and root planing, clorhexidine digluconate rinses (0.12%), and substituting CsA with tacrolimus is described. Response to treatment after 6 months of tacrolimus use was excellent with almost complete reversion of the gingival enlargement. One-year follow-up demonstrated a stable gingival situation. The successful substitution of CsA with tacrolimus provides great expectations for the management of CsA-related gingival enlargement.

Cyclosporin A and hydroxycyclosporine (M-17) affect the secretory phenotype of human gingival fibroblasts

The responsiveness of human gingival fibroblast populations to cyclosporin A (CsA) and its principal metabolite, hydroxycyclosporine (M17), was evaluated in cell culture. Gingival fibroblasts exhibited a dose-dependent accumulation and bell-shaped distribution of dansylated CsA. A 100-fold excess of non-labeled CsA prevented the accumulation of the fluorescent probe in the fibroblasts. Both CsA (400 ng/ml) and M17 (100 ng/ml) stimulated mean gingival fibroblast cell number to 23.2% and 36.7% above controls, and reduced mean collagen production by 37.7% and 37.4% below controls, respectively; however, neither CsA nor M17 affected mean protein production in comparison to control cultures. Analyses of responses to CsA and M17 by ligand-accumulating and non-accumulating fibroblasts sorted out from the parent cultures did not provide consistent interstrain responses either by cells representing the upper quartile of fluorescence or cells representing the bottom quartiles of fluorescence. These data demonstrate that CsA is accumulated by gingival fibroblasts and that CsA and M17 are potent modulators of gingival fibroblast phenotype.