[MUSIC] Let's turn our attention now to the dental management of the transplant patient. Transplant patients are often medically compromised patients and they pose significant risks, both to themselves as well as concerns to the practicing dentist. What I'd like to do in discussing a transplant patient is to divide up the transplantation period, to those patients that present to you pre-transplant, and what the dentist should be thinking about in managing or in seeing these patients, as well as the post-transplant considerations that you have as a dentist. And in the post-transplant dental considerations, we'll divide up that time from the immediate post-transplant period through a stable post-transplant period and also, if in fact, post-transplant that organ is slowly starting to chronically reject. In the pre-transplant period, patients will be coming to their dentists and often being consulted by transplant centers to once again eliminate dental infection prior to that transplant placement. The dentist must be mindful however, that these are significantly ill patients with end organ damage. So before any dental treatment is initiated, a medical consultation is required. In addition, one should consider postponing elective dental treatment based upon their underlying medical condition. Remember, these are significantly ill patients. Dentists often, once again are consulted to rule out acute dental alveolar or dental infections, as well as rule out potential dental infectious sources. They're often asked to stabilize the oral disease. Occasionally they're even asked to remove sources of chronic infection that may lead to acute complications within the transplant process and immediately post-transplant. If, in fact, treatment is necessary prior to transplant, a medical consultation with the transplant team can help determine the medical risk:benefit ratio. So one must obtain appropriate lab information and supplemental inflammation as needed. And they need to become acquainted with specific management issues, based upon that particular organ which has significant disease. And they may need to employ special precautions prior to any type of treatment in preparing somebody for an organ transplant. How about post-transplant. We will be seeing patients after they've had their transplant and once again I'd like to divide this up into the immediate transplant period, the stable period after the organ is functioning correctly, and during the time where chronic rejection may be setting in. Immediately after transplant, elective dental treatment is typically not recommended. Emergency treatment is and should be performed only with medical consultation and consideration of specific management needs. During the period of time when the organ is fully functioning and integrated, we consider this the stable period and elective treatment should and will be performed, once again after medical consultation with the transplant team. The dentist must understand issues of immunosuppression. Oral mucosal disease related to that immunosuppression or sometimes related to the medications given for the transplant itself must be diagnosed and treated. Evaluate oral hydration and salivary flow. Occasionally patients will need supplements to treat their oral cavity and eliminate the dryness. The dentist must also be mindful that the patient in a stable period may be on high dose glucocorticosteroids and may require a steroid boost prior to dental surgical procedure. Some consideration must also begin for antibiotic prophylaxis during the immune suppressed period of time. This will be directly related to the level of immunosuppression and should be discussed with the transplant team prior to even routine dental procedures. Once again, the organ that gets transplanted often will be functioning to an appropriate level. However, occasionally the organ may not be at 100%. So the dentist again must consider specific management needs based upon the functioning of the organ that had been transplanted. Lastly, during the chronic rejection period, I think of these patients as the most difficult to treat dentally. That is because they are often immunosuppressed with various medications, and their organ is again starting to fail. It's advised to the dentist that only emergency treatment be performed on these patients. In fact, if patients need treatment during this period, close consultation with a transplant team is absolutely necessary. I referenced earlier that oral mucosal diseases need to be evaluated in the transplant patient. And that is because of the level of immunosuppression. These patients tend to be more susceptible to bacterial infections, some that we recognize very easily, and others that may not be overly recognizable on a quick cursory examination. These patients are also susceptible to various viral infections and fungal infections. Once again, often this will be directly related to the level of immunosuppression. Later on, in a transplant process when a patient has been on immunosuppression for quite some time, they are at risk of developing a post-transplant related lymphoproliferative disease. We often think of this as a lymphoma. Some of these lesions may be seen in the oral cavity. And once again any lesion that's persistent for greater than two to four weeks needs to be aggressively diagnosed. Dry mouth, I alluded to earlier is also a significant concern in many post-transplant patients. Once again, this is often related to medications but, in fact, could also be related to end organ function, particularly with the kidney. Dry mouth is one of those conditions in which the dentist plays a significant role in improving the patient's quality of life post-transplant. Dry mouth also leads to an increased amount of dental decay. A dentist should consider, in absence of saliva, placing patients on supplemental fluoride to help preserve their dentition. Another condition associated with a post-transplanted patient and often directly related to dryness in the mouth is a superficial mucocele. Occasionally, we can see the thickening of the salivary flow through the minor salivary glands pooling submucosally, that is, just underneath the surface, leading to a superficial mucocele. As you can see, taking care of patients during the pre-transplant through the post-transplant period, for the dentist, is often a very, very difficult task. And the dentist really needs to keep very close consultation with the transplant team, or the transplant physician.
