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Principles governing the prosthodontic treatment of patients with cardiac transplants
J'ANDA C L I N I C A L
R E P O R T S
Principles governing the prosthodontic treatment of patients with cardiac transplants J o h n J. D . C arp en d ale, BDSc, M S D R o la n d W . D ykem a, D D S , M S D C arl J. A ndres, D D S , M S D C harles J. G ood acre, D D S , M S D
A s th e s u r v iv a l ra te o f p a tie n ts w ith cardiac transplants im proves, it is m ore likely th at dentists w ill have to provide extensive dental care and it is im portant to k n o w th e sp e c ia l p re c a u tio n s th a t m u s t be ta k e n w h en tre a tin g th ese p a tie n ts. In th is report on the p ro sth o d o n tic treatm en t o f a p a tie n t w ith a c a rd ia c tr a n s p la n t a n d an u n s ta b le m e d ic a l h isto ry, sp e c ific d e n ta l m a n a g em en t gu idelin es are proposed. T he tre a tm e n t illu stra tes an a lte rn a tiv e to com plex an d prolon ged restorative treat m ent fo r p atien ts w ith com prom ised p o st transplant recovery.
rth o to p ic heart tran sp lan tatio n is used to treat term inal m yocar d ia l d ise a se th a t c a n n o t be corrected by o th e r m edical or therapy. Recent m ajor advances in cardiac tra n s p la n ta tio n have led to d ecreasing m ortality and have helped m any patients to retu rn to nearly unrestricted physical activity. T h e In tern atio n al H eart T ra n s p la n t R e g istry re p o rts a w o rld w id e 1year survival rate of 80%, a n d a 6-year survival rate of 40% for patients w ho
O
received tr a n s p la n ts sin c e 1978.1 T h e introduction, in December 1983, of low dosage, trip le -d ru g im m u n o su p p ressiv e th e ra p y , of c y c lo s p o rin ( im m u n o s u p pressant), azathioprine (im m unosuppres s a n t) a n d p r e d n is o n e ( s te ro id )23 has caused a great im provem ent in actuarial survival an d a dram atic decrease in the in c id e n c e o f r e je c tio n a n d se rio u s infections. Most organism s listed as the cause of term inal infections in patients receiving
tra n sp la n ts o ccur en d o g e n o u sly in the m o u th . Because the m o u th has a diverse eco sy ste m , d if fe r in g p o p u la tio n s of m icro o rg an ism s exist in d en tal p laq u e, the g in g iv a l crevice, th e d orsal surface of the tongue, an d saliva. R o u tin e dental procedures are usually p o stp o n e d u n til m a in te n a n c e levels of im m u n o su p p re ssa n ts are reached.4 T h e regim en u su ally recom m ended includes a c o m b in a tio n of c y c lo s p o r in A a n d prednisone w ith antithym ocyte g lo b u lin
Table 1 ■ Guidelines for the dental management of patients with cardiac transplants. 1. If p ossible, com plete a den tal e x a m in a tio n a n d p ro p h y la x is before the tr a n s p la n t an d immunosuppressive drug therapy. 2. Consult the physicians and surgeons regarding health stability and drug therapy. 3. M onitor the patient’s drug therapy and gingival response closely. 4. Use prophylactic antibiotics as recommended and adhere to strict infection control procedures. 5. Elim inate all existing and potential sources of infection. 6. P erform frequent o ral prop h y lax es and counsel the p a tie n t reg ard in g the im p o rtan c e of m eticulous oral hygiene. 7. Do not schedule extensive p ro sth o d o n tic treatm ent u n til the p a tie n t’s m edical co n d itio n su rg ica lhas stabilized. 8. Extensive prosthodontic treatment may be provided if the patient has returned to unrestricted levels of physical activity. 9. Schedule patients’ appointm ents when they are well rested and under low levels of stress. 10. Use careful soft tissue management during all restorative procedures to preserve tissue integrity. 11. Prostheses should be durable, easily cleaned, and cover as little soft tissue as possible. 12. Be aware of the patient’s post-transplant physical and psychological vulnerabilities. 13. Schedule frequent (at least every 3 months) post-placem ent ap p o in tm en ts for prophylaxis, and evaluation of oral hygiene and the soft tissue response to any prostheses.
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u sed to tre a t r e je c tio n e p iso d e s. C yc lo sp o rin A has caused g in g iv a l h y p e r p lasia an d perioral hyperesthesia in about 30% of p a tie n ts ta k in g th e d ru g . T h e hy p eresth esia u su a lly d isa p p ea rs a few days after therapy is b egun.5 G eneralized f ib ro u s h y p e r p la s ia of th e g in g iv a is in d is tin g u ish a b le from the h y p erp lasia caused by p h e n y to in (D ila n tin , P arkeDavis) an d occurred in six of 18 patients in a study by W ysocki a n d others.6
T re a tm e n t of th is h y p erp la sia involves the rem oval of irritan ts before the start of cyclosporin A therapy. H y p erp la sia can also develop in the absence of local irritants. A gingivectom y is required w henever sig n ifican t h y p er p la s ia o cc u rs. A lth o u g h h y p e r p la s ia recurs, its frequency has n ot been estab lished. M cG raw a n d o th e rs7 have su g g ested a c o r r e la tio n b etw e en g in g iv a l overgrow th induced by cyclosporin A
Fig 1 ■ Anterior view of maxillary and m an d ib u la r teeth in occlusion.
Fig 2 ■ Occlusal view of m a x illa ry arch show ing wear on the m axillary incisors and canines.
Fig 3 ■ Occlusal view of m a n d ib u la r arch show ing wear on the m a n d ib u la r incisors and canines.
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an d the role of d ental p laq u e as a local b a c te ria l re se rv o ir. D e lilie rs a n d c o w o rk e rs8 h av e n o tic e d , fro m e x p e r im e n ta l d a ta , a re v e rs ib ility o f th e problem after d isco n tin u atio n of the drug, su g g e stin g th a t in d iv id u a l h y p e rse n si tiv ity is p ro b a b ly th e m o st ac ce p ta b le e x p la n a tio n o f g in g iv a l h y p e r p la s ia induced by cyclosporin A. T h e p ro p h y la c tic use of a n tib io tic s to p rev en t bacterem ias has been tra d i tionally recom m ended for patien ts receiv in g o rgan tran sp lan ts w ith conventional im m u n o su p p ressan ts. O ne p ap e r9 in d i ca te d th a t n o t a ll tr a n s p l a n t c e n te rs a d v o c a te c h e m o p r o p h y la x is w h en p a tie n ts are b e in g tre a te d w ith cy clo sporin A.9 T h e risk of developing resistant b acteria was discussed as b ein g greater th an the risk of infection associated w ith transient bacterem ias. D iscussion of steroid m anagem ent w ith th e p a t i e n t ’s p h y s ic ia n is im p o r ta n t. A lth o u g h m a n y p a tie n ts are a lre a d y receiv in g su fficie n t steroids to p rev en t com plications, corticosteroid levels may need to be in creased in th o se p a tie n ts w h o suffer a h ig h stress level because of a dental p h o b ia .9 Initially, there w as a lack of data on recip ien ts of h ea rt tra n s p la n ts ’ p ercep tio n s of th e ir q u a lity of life. In m o re re c e n t stu d ies by L o u g h a n d o th e rs ,10 89% of resp o n d e n ts rated th e ir q u a lity of life as good to excellent. Principles of dental management
Several b asic p rin c ip le s fo r th e d en tal m a n a g e m e n t of im m u n o s u p p re s s e d p a tie n ts a p p ly to p a tie n ts re c e iv in g cardiac transplants. —W hen possible, a dental exam ination a n d p ro p h y la x is s h o u ld be p erfo rm ed before the tran sp lan t a n d the b eg in n in g of im m unosuppressive d ru g therapy. T h is p ro ce d u re is h e lp fu l in e s ta b lis h in g a baseline for n o rm al gingival h ealth an d appearance, an d perm its rem oval of local gingival irritan ts before b eg in n in g im m u n o suppressant therapy. —T h e atte n d in g p h y sician s an d su r geons should be consulted reg ard in g d ru g m a n ag e m en t a n d the d e te rm in a tio n of w h e n th e p a t i e n t ’s h e a lth s ta tu s w ill p erm it dental treatm ent. —P ro p h y la c tic a n tib io tic s sh o u ld be used w hen recom m ended. —T h e risk of infection w ill be decreased by strict adherence to infection co n tro l procedures. —A ll e x istin g a n d p o te n tia l sources of infection should be elim inated.
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— Oral p ro p h y la x es sh o u ld be p er form ed at 3-m on th in tervals or m ore frequently, if necessary, for control of hyperplasia. —C o u n selin g the p atien t regarding m eticu lo u s oral h y g ien e to prevent medical com plications is important. —Frequent appointm ents are necessary for evaluation of oral care and reinforce ment o f proper hygiene. In addition to these basic principles, there are items that should be considered when prosthodontic therapy is required. —Prosthodontic treatment should be individually determined by the patient’s medical status at the time of treatment. —Extensive prosthodontic treatment procedures sh ould be postp oned until the p a tien t’s m edical con d ition is sta bilized and maintenance levels of im m u nosuppressants have been reached. —If a patient’s medical condition has been stable for some time and that patient has returned to u nrestricted p h ysical activity levels, extensive prosthodontic treatment may be provided. —T he patient’s post-transplant phys ical and p sych o lo g ica l vu ln erab ilities sh o u ld be considered, and alternative interim treatment planned if a change in the p atien t’s m edical status occurs. However, because of the patients’ gen erally p o sitiv e fee lin g s regard in g the q u a lity o f their liv es, care m ust be exercised in presenting treatment plans that reflect changes made as a result of their overall health. —If an interim prosthesis is required, it should be durable, easy to clean and m aintain, and n onirritating to tissues susceptible to cyclosporin-A hyperplasia. It sh o u ld cover as little soft tissue as possible, resist functional force during potentially extended service periods of wear, fulfill esthetic requirements, and preserve the rem aining tooth structure. —P a tien ts’ ap poin tm ents sh ould be scheduled when they are well rested and under low levels of stress. P rolon ged appointm ents should not be scheduled until the patient has returned to unre stricted physical activity. —Soft tissue trauma should be m in imized during all procedures. Although this is a rou tin e req u irem en t in all situations, it is of m onum ental im por tance for those patients in whom minor tissu e traum a co u ld resu lt in lifethreatening in fection or contribute to transplant rejection. —Frequent ap poin tm ents sh ould be sch ed u led to evalu ate the soft tissu e response to any prosthesis and to detect
any em erging oral irritations related to a prosthesis.
Patient treatment report T he follow in g patient treatment report demonstrates some of the principles used in the p ro sth o d o n tic treatm ent of a patient with a cardiac transplant. A 58-year-old m ale sought treatment because his teeth were wearing away and he had sensitivity in his anterior teeth when chewing. T he medical history showed that the p atien t had u nd ergone cardiac trans plantation 6 months before h is first dental visit. T he transplant was the result of ischemic cardiomyopathy w ith Class IV angina. At the p a tie n t’s in itia l d ia g n o stic appointm ent, he reported taking pred nisone (steroid), imuran (anticoagulant), and cyclosporin (im m unosuppressant), and appeared to be doing well, with no restrictions in activity. The patient was fo llo w in g a p rescribed lo w -fa t, low cholesterol diet and a formalized cardiac rehabilitation program. T h e tran sp lan t center in d ica ted no major contraindications to dental treat ment, provided the patient received the A m erican H eart A sso c ia tio n ’s recom mended antibiotic coverage. The patient’s post-transplant recovery and transplant acceptance were carefully m onitored by the tran sp lan t center w ith particu lar attention to any evidence of rejection. T he patient’s dosage of prednisone had been reduced since he show ed a satis factory rate of recovery. T h e c lin ic a l e x a m in a tio n show ed m oderate to severe a ttr itio n of the maxillary and mandibular incisors and canines (Fig 1-3). T he fo llo w in g teeth were m issing: the third m olars in all four quadrants, the maxillary right first m olar, the m a n d ib u la r rig h t second premolar and the m andibular left first and second molars. Generally good oral hygiene and no dental caries were noted. Areas of gingival hyperplasia were evident in the in terp apillary g in g iv a between the four m a x illa ry in ciso rs. At the diagnostic appointment, alginate impres sion s were made for d ia g n o stic casts, w h ich were later a rticu la ted u sin g a facebow record and m axillom andibular relation records. D iagn ostic tooth preparations were m ade and fu ll co n to u r w ax patterns d evelop ed on the m o u n ted casts to determ ine the m ost appropriate tooth forms and occlusal relationships. The
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preferred treatm ent plan included tw o three-unit fixed partial dentures to replace a mandibular right second premolar and maxillary right first molar, respectively. Single crown restorations were planned for a ll rem aining m axillary and m an d ibular teeth. R estoration of the four m axillary incisors required endodontic treatment and post and cores. A Kennedy Class II rem ovable partial denture was planned for the mandibular arch. A 2m m in crease in the o cc lu sa l vertical dim ension was required to permit proper form and function. A heat-polymerized clear acrylic resin o cc lu sa l d evice w as fabricated at the altered vertical d im en sio n to evaluate the patient’s ability to accept the change, to reduce the se n sitiv ity on the w orn anterior teeth during function, and to ev a lu a te oral h y g ien e ad eq uacy and g in g iv a l response w hen the teeth and soft tissue were covered. Postplacement inspections were accom p lished at 2-week intervals to evaluate these aspects and to perform any necessary occlusal adjustments. During this time, the patient experienced significant fluc tuations in his health. Because o f this instability in his recovery, it was decided to adopt an alternative treatment plan rather than embark on a protracted oral rehabilitation. T h e decision was based on many actual or potential problems. T h e p a tie n t’s m ed ica l c o n d itio n w as unstable at the scheduled time of treat ment and the greater number of lengthy appointm ents required by the original treatment plan w ould increase his level of stress. Furthermore, an oral infection m ight develop from the extensive number and type of requ ired p ro sth o d o n tic procedures and p rod uce a p ro lo n g ed bacteremia that could contribute to the p a tie n t’s u n stab le h ea lth , and h in d er recovery. Periodontal health could also be n eg a tiv ely a ffected by the p r o sth o d o n tic procedures because of a com promised healing ability. In view of these problems, alternative treatm ent p la n s that were o r ig in a lly considered were reevaluated. A removable prosthesis overlying the m axillary teeth was a rea so n a b le in terim treatm ent alternative. T he partial overdenture was selected because: —it provided the least com p licated, fastest m eth od o f r e h a b ilita tin g the p a tien t on an in terim basis u n til h is medical status stabilized, —ex istin g restorations were in good condition, —the anterior teeth w ould be covered
Carpendale-Others : PROSTHODONTIC TREATMENT OF PATIENTS WITH CARDIAC TRANSPLANTS ■ 519
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to red u c e w ear an d se n sitiv ity d u r in g chew ing, and —the m a n d ib u lar teeth were generally in b etter c o n d itio n th a n the m ax illa ry teeth w ith less m agnitude of wear. M o u n te d d ia g n o stic casts w ere used to survey the m axillary arch to find the m o st d esira b le p a th o f p la c e m e n t a n d to d e te rm in e if an y te eth w o u ld need c o n to u r m odifications. U ndercuts, su it able for prosthesis retention, were noted
o n the facial surfaces of teeth num bers 3 an d 14, w ith fu rth e r re te n tio n b ein g p ro v id ed by the in tim ac y in fit of the overdenture fram ew ork an d the contours of the su p p o rtin g teeth. T o reduce unnecessary tissue coverage, a horsesh o e-ty p e m a jo r co n n e c to r was selected. All m axillary teeth were covered by the fram ew ork w ith labial extensions o n th e a n te rio r teeth to acco m m o d ate resin veneers for im proved appearance.
Fig 4 ■ Finished m ax illa r y in ter im p r o s thesis.
T h e s e e x te n s io n s te rm in a te d 0.5 m m coronally to the m arg in al gingiva. T h e occlusal surfaces of the prosthesis were form ed in acrylic resin. Resin was used b ec au se o f its a d ju s ta b ility , ease of fabrication an d replacem ent, an d favor able wear characteristics w hen o p p o sin g p artially w orn n atu ra l teeth. A rem ovable p artial denture fram ew ork was designed a n d a b ase m e ta l c a s tin g m ade. E le c trochem ical e tc h in g 11 of the base m etal was used to bond the resin to the m etal because interocclusal space was lim ited. T h e m aster cast an d fram ew ork were m ounted o n an articu lato r at the chosen v e rtic a l d im e n s io n . T h e a p p r o p r ia te shade of re sin v en e erin g m a te ria l was a p p lie d to th e etch e d fra m ew o rk , th e p r o s th e s is w as f in is h e d a n d p o lis h e d (F ig 4), a n d th e r e q u ir e d in tr a o r a l adjustm ents were com pleted. P o stp lacem en t a p p o in tm e n ts show ed g o o d p a t ie n t a c c e p ta n c e , g o o d o ra l hygiene, a n d ad eq u ate ap p earan ce (Fig 5,6). After 1 year, the resin show ed good in te g r ity a n d a r e a s o n a b le p e r io d of service can be anticipated. T h e p a tie n t’s h ealth has become m ore stable, so a more definitive treatm ent p lan involving total d en tal reh a b ilita tio n is cu rren tly b eing contem plated. Conclusion
Fig 5 ■ Intraoral view of maxillary prosthesis in place.
A treatm ent m odality has been presented for a p a tie n t w h o h as ju s t u n d e rg o n e c a rd ia c t r a n s p l a n ta tio n a n d is no w e x p e rie n c in g c o m p ro m ise d p o s t- tr a n s p la n t recovery. T h e treatm ent is suggested as a n a lte rn a tiv e to co m p lex a n d p r o longed restorative treatm ent at this stage of recovery. P rinciples are presented that govern the dental m anagem ent of patients w ith cardiac transplants. -----------------------J Ü O A -----------------------
Fig 6 ■ Anterior view
Dr. Carpendale is a graduate student; Dr. Dykema is professor emeritus; Dr. Andres is director, graduate p ro sth o d o n tic s; an d Dr. G o odacre is c h a irm an , departm ent of prosthodontics, In d ian a University S chool of D entistry, 1121 W M ichigan St, In d i anapolis, IN 46202. Address requests for reprints to Dr. Goodacre.
w ith interim prosthesis in place sh ow in g im proved appearance.
1. Kay M P, E lcom be SA, O ’F allo n MW. T h e in tern atio n a l h eart tra n sp la n t registry —the 1984 report. J Heart T ransplant 1985;4:290-2. 2. Bolman RM, Elick B, Olivari M T, Ring WS, Arentzen CE. Im proved im m u n o su p p ressio n for heart transplantation. J Heart T ransplant 1985;4:315-
8. 3. Andreone PA, Olivari MT, Elick B. Reduction of infectious com plications follow ing heart trans plantation with triple-drug imm unotherapy. J Heart T ransplant 1986;5:13-9.
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4. Sowell SB. Dental care for patients with renal failure and renal transplants. JADA 1982; 104:1717. 5. Daley TD, Wysocki GP. Cyclosporin therapy; its significance to the periodontist. J Periodontol 1984;55:708-12. 6. Wysocki GP, Gretzinger HA, Laupacis A, Ulan RA, Stiller CR. Fibrous hyperplasia of the gingiva: a side effect of cyclosporin A therapy. O ral Surg Oral Med Oral Pathol 1983;55:274-8.
7. M cGaw T , Lam S, C oates J. C yclo sp o rin induced gingival overgrowth: correlation w ith dental plaq u e scores, gin g iv itis scores, an d cyclosporin levels in serum an d saliva. O ral S urg O ral Med Oral Pathol 1987;64:293-7. 8. D eliliers G L , S antoro F, P o lli N, B runo E, F u m a g a lli L, R isc io tti E. L ig h t a n d electron microscopic study of cyclosporin A-induced gingival hyperplasia. J Periodontol 1986;57:771-5. 9. Harms KA, Bronny AT. Cardiac transplantation;
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dental considerations. JADA 1986;112:677-81. 10. L ough ME, L indsey AM, S h in n JA, Stotts NA. Im pact of sym ptom frequency and sym ptom distress on self-rep o rted q u a lity of life in h eart transplant recipients. Heart L ung 1987;16:193-200. 11. Zurasky JE , D uke ES. Im p ro v ed ad h esio n of d en tu re acrylic resin s to base m etal alloys. J Prosthet Dent 1987;57:520-4.
Comment Where medicine has taken us? Advances in m edicine have m ade it p o ssible for p a tie n ts w ith end-stage diseases of the heart, liver, and kidneys to receive organ transplants. T h e lo n g term survival after m ajo r o rgan trans p la n tatio n has greatly im proved since the first k idney tr a n s p la n t in 1953, the first liver tran sp lan t in 1963, and the first heart tran sp lan t in 1967. T h e lo n g -te rm su rv iv al of k id n ey tra n s p la n t p a tie n ts is n o w g re a te r th a n 80%. H ea rt tra n s p la n t p a tie n ts have a greater th an 80% 1-year survival rate an d m ore than 50%, a 5-year survival rate. T hese patients, in ever-increasing n u m b e rs , are n o w se e k in g d e n ta l treatm ent. Cyclosporine, alo n g w ith an tith y m ocyte g lo b u lin a n d c o rtic o ste ro id s, are used to suppress the im m une system of the organ recipient. W ith o u t these drugs, the tran sp lan ted organ w ould be rejected. However, these drugs have several im p o rta n t side effects: increased incidence of hyperten sio n , increased risk for infection, increased incidence of m a lig n a n t tu m o rs su c h as ly m p h o m a a n d K ap o si’s sarco m a, p o o r w o u n d h e a lin g , in c re a se d ris k fo r excessive b le e d in g (th ro m b o c y to p e n ia ), a n d th e p o te n tia l fo r a d re n a l cortical suppression w hich may m ake it difficult for the p atien t to deal w ith stressful surgical procedures. Because m o st tr a n s p la n t p a tie n ts m u s t be tra n s fu s e d w ith b lo o d d u r in g th e im p lan ta tio n of the new organ, they also are at increased risk for hepatitis B an d non-A, non-B hepatitis. M any physicians recom m end a n ti biotic prophylaxis for invasive dental p ro c e d u re s fo r th e ir p a tie n ts w ith transplants. T h e rationale is to prevent infection in the im m u n e suppressed
p a tie n t. O th e r p h y sic ia n s state th a t rou tin e an tib io tic p ro p h y lax is is not needed an d in fact sh o u ld be avoided because of the problem of developing resistant organism s to the antibiotics used for p ro p h y la x is. P a tie n ts w ith such resistan t o rg an ism s co u ld then develop future infections w hich w ould be d iffic u lt to m a n ag e . T h ese p h y sicians w ould prefer th at their patients receive d en tal care w ith o u t p ro p h y lax is an d if in fec tio n does develop, it can be treated w ith ap p ro p riate local a n d sy stem ic m e a su re s . T h e la tte r view point becomes m ore ap p ro p riate w hen the m o u th is free of infection. T h e den tist sh o u ld co n su lt w ith the p a tie n t’s p h y sic ia n for g u id a n c e in this area. It is im p o rta n t th at current, effective infectious disease co n tro l procedures be a basic p a rt of all dental practices. T h is is m ost im p o rta n t w hen treating p a tie n ts w ith tr a n s p la n ts . T h e s e p atien ts m ust be p rotected from the transm ission of infectious agents from th e d e n tis t, d e n ta l sta ff, a n d o th e r patients. In ad dition, the d ental staff m e m b ers m u s t be p ro te c te d fro m possible tran sm issio n of HBV , nonA, non-B h ep a titis or, in rare cases, H IV fro m th e p a t ie n t w ith th e transplant. T h e possible effect on d en tinogene sis o f h ig h s te ro id lev els u sed to m anage patients w ith tran sp lan ts has been re p o rte d o n several occasions. T h e report by N asstrom a n d others, as p u b lis h e d in O ral Surgery, O ral M edicine, Oral P athology in 1985 has been the m ost referenced study regard in g this possible effect. Several p ro b lem s o c c u r w ith th e in te r p r e ta tio n of this study. First, only 29 of the
51 p a tie n ts in th e stu d y h a d r a d io graphs to show the appearance of the p u lp cham ber before steroid therapy w as in itia te d . W h e n th e a u th o r s re p o rte d n a rro w in g in 14 of th e 19 p atients in the renal tran sp lan t g ro u p they did n o t indicate how m any had before an d after film s w ith n arrow ing, an d how m any h ad before an d after film s w ith o u t n arro w in g . Secondly, the rela tio n sh ip of age a n d d en tin o g en esis in th e p a tie n ts stu d ie d w as n o t re p o rte d . T h e ag es o f p a tie n ts in th e ir stu d y ra n g e d fro m 1 to 61 years, w ith a m ean age of ab o u t 35. F in ally , th e p o ssib le effect of ren a l osteodystrophy on dentinogenesis was n o t discussed. T h e two papers d ealin g w ith these p ro b le m s d e m o n stra te th e necessity for d en tists to be aw are of th e need to m anage p atien ts w ith tra n sp la n ts safely an d effectively a n d to be aw are of the possible effect of h ig h steroid dosages on dentinogenesis. T h e p ap er concerning the p atien t w ith systemic lu p u s erythem atosus (SLE) also raises th e issu e o f a n tib io tic p r o p h y la x is for prevention of infective endocarditis (IE). A recen t re p o rt in d ic a te d th a t n o n b acterial th ro m b o tic en d o card itis occurs in a b o u t 50% of th e p a tie n ts w ith S L E . T h e in c id e n c e o f IE in p atients w ith SLE is ab o u t 1%. T h u s, p atien ts w ith SLE m ay be a t sig n if ic an t risk for IE a n d are can d id ates fo r a n tib io tic p r o p h y la x is b e fo re dental treatm ent. T h e d en tist sh o u ld c o n s u lt th e p a t i e n t ’s p h y s ic ia n to confirm the need for p ro p h y lax is in these patients.
Jam es W. L ittle, DMD, MSD
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Principles governing the prosthodontic treatment of patients with cardiac transplants J o h n J. D . C arp en d ale, BDSc, M S D R o la n d W . D ykem a, D D S , M S D C arl J. A ndres, D D S , M S D C harles J. G ood acre, D D S , M S D
A s th e s u r v iv a l ra te o f p a tie n ts w ith cardiac transplants im proves, it is m ore likely th at dentists w ill have to provide extensive dental care and it is im portant to k n o w th e sp e c ia l p re c a u tio n s th a t m u s t be ta k e n w h en tre a tin g th ese p a tie n ts. In th is report on the p ro sth o d o n tic treatm en t o f a p a tie n t w ith a c a rd ia c tr a n s p la n t a n d an u n s ta b le m e d ic a l h isto ry, sp e c ific d e n ta l m a n a g em en t gu idelin es are proposed. T he tre a tm e n t illu stra tes an a lte rn a tiv e to com plex an d prolon ged restorative treat m ent fo r p atien ts w ith com prom ised p o st transplant recovery.
rth o to p ic heart tran sp lan tatio n is used to treat term inal m yocar d ia l d ise a se th a t c a n n o t be corrected by o th e r m edical or therapy. Recent m ajor advances in cardiac tra n s p la n ta tio n have led to d ecreasing m ortality and have helped m any patients to retu rn to nearly unrestricted physical activity. T h e In tern atio n al H eart T ra n s p la n t R e g istry re p o rts a w o rld w id e 1year survival rate of 80%, a n d a 6-year survival rate of 40% for patients w ho
O
received tr a n s p la n ts sin c e 1978.1 T h e introduction, in December 1983, of low dosage, trip le -d ru g im m u n o su p p ressiv e th e ra p y , of c y c lo s p o rin ( im m u n o s u p pressant), azathioprine (im m unosuppres s a n t) a n d p r e d n is o n e ( s te ro id )23 has caused a great im provem ent in actuarial survival an d a dram atic decrease in the in c id e n c e o f r e je c tio n a n d se rio u s infections. Most organism s listed as the cause of term inal infections in patients receiving
tra n sp la n ts o ccur en d o g e n o u sly in the m o u th . Because the m o u th has a diverse eco sy ste m , d if fe r in g p o p u la tio n s of m icro o rg an ism s exist in d en tal p laq u e, the g in g iv a l crevice, th e d orsal surface of the tongue, an d saliva. R o u tin e dental procedures are usually p o stp o n e d u n til m a in te n a n c e levels of im m u n o su p p re ssa n ts are reached.4 T h e regim en u su ally recom m ended includes a c o m b in a tio n of c y c lo s p o r in A a n d prednisone w ith antithym ocyte g lo b u lin
Table 1 ■ Guidelines for the dental management of patients with cardiac transplants. 1. If p ossible, com plete a den tal e x a m in a tio n a n d p ro p h y la x is before the tr a n s p la n t an d immunosuppressive drug therapy. 2. Consult the physicians and surgeons regarding health stability and drug therapy. 3. M onitor the patient’s drug therapy and gingival response closely. 4. Use prophylactic antibiotics as recommended and adhere to strict infection control procedures. 5. Elim inate all existing and potential sources of infection. 6. P erform frequent o ral prop h y lax es and counsel the p a tie n t reg ard in g the im p o rtan c e of m eticulous oral hygiene. 7. Do not schedule extensive p ro sth o d o n tic treatm ent u n til the p a tie n t’s m edical co n d itio n su rg ica lhas stabilized. 8. Extensive prosthodontic treatment may be provided if the patient has returned to unrestricted levels of physical activity. 9. Schedule patients’ appointm ents when they are well rested and under low levels of stress. 10. Use careful soft tissue management during all restorative procedures to preserve tissue integrity. 11. Prostheses should be durable, easily cleaned, and cover as little soft tissue as possible. 12. Be aware of the patient’s post-transplant physical and psychological vulnerabilities. 13. Schedule frequent (at least every 3 months) post-placem ent ap p o in tm en ts for prophylaxis, and evaluation of oral hygiene and the soft tissue response to any prostheses.
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u sed to tre a t r e je c tio n e p iso d e s. C yc lo sp o rin A has caused g in g iv a l h y p e r p lasia an d perioral hyperesthesia in about 30% of p a tie n ts ta k in g th e d ru g . T h e hy p eresth esia u su a lly d isa p p ea rs a few days after therapy is b egun.5 G eneralized f ib ro u s h y p e r p la s ia of th e g in g iv a is in d is tin g u ish a b le from the h y p erp lasia caused by p h e n y to in (D ila n tin , P arkeDavis) an d occurred in six of 18 patients in a study by W ysocki a n d others.6
T re a tm e n t of th is h y p erp la sia involves the rem oval of irritan ts before the start of cyclosporin A therapy. H y p erp la sia can also develop in the absence of local irritants. A gingivectom y is required w henever sig n ifican t h y p er p la s ia o cc u rs. A lth o u g h h y p e r p la s ia recurs, its frequency has n ot been estab lished. M cG raw a n d o th e rs7 have su g g ested a c o r r e la tio n b etw e en g in g iv a l overgrow th induced by cyclosporin A
Fig 1 ■ Anterior view of maxillary and m an d ib u la r teeth in occlusion.
Fig 2 ■ Occlusal view of m a x illa ry arch show ing wear on the m axillary incisors and canines.
Fig 3 ■ Occlusal view of m a n d ib u la r arch show ing wear on the m a n d ib u la r incisors and canines.
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an d the role of d ental p laq u e as a local b a c te ria l re se rv o ir. D e lilie rs a n d c o w o rk e rs8 h av e n o tic e d , fro m e x p e r im e n ta l d a ta , a re v e rs ib ility o f th e problem after d isco n tin u atio n of the drug, su g g e stin g th a t in d iv id u a l h y p e rse n si tiv ity is p ro b a b ly th e m o st ac ce p ta b le e x p la n a tio n o f g in g iv a l h y p e r p la s ia induced by cyclosporin A. T h e p ro p h y la c tic use of a n tib io tic s to p rev en t bacterem ias has been tra d i tionally recom m ended for patien ts receiv in g o rgan tran sp lan ts w ith conventional im m u n o su p p ressan ts. O ne p ap e r9 in d i ca te d th a t n o t a ll tr a n s p l a n t c e n te rs a d v o c a te c h e m o p r o p h y la x is w h en p a tie n ts are b e in g tre a te d w ith cy clo sporin A.9 T h e risk of developing resistant b acteria was discussed as b ein g greater th an the risk of infection associated w ith transient bacterem ias. D iscussion of steroid m anagem ent w ith th e p a t i e n t ’s p h y s ic ia n is im p o r ta n t. A lth o u g h m a n y p a tie n ts are a lre a d y receiv in g su fficie n t steroids to p rev en t com plications, corticosteroid levels may need to be in creased in th o se p a tie n ts w h o suffer a h ig h stress level because of a dental p h o b ia .9 Initially, there w as a lack of data on recip ien ts of h ea rt tra n s p la n ts ’ p ercep tio n s of th e ir q u a lity of life. In m o re re c e n t stu d ies by L o u g h a n d o th e rs ,10 89% of resp o n d e n ts rated th e ir q u a lity of life as good to excellent. Principles of dental management
Several b asic p rin c ip le s fo r th e d en tal m a n a g e m e n t of im m u n o s u p p re s s e d p a tie n ts a p p ly to p a tie n ts re c e iv in g cardiac transplants. —W hen possible, a dental exam ination a n d p ro p h y la x is s h o u ld be p erfo rm ed before the tran sp lan t a n d the b eg in n in g of im m unosuppressive d ru g therapy. T h is p ro ce d u re is h e lp fu l in e s ta b lis h in g a baseline for n o rm al gingival h ealth an d appearance, an d perm its rem oval of local gingival irritan ts before b eg in n in g im m u n o suppressant therapy. —T h e atte n d in g p h y sician s an d su r geons should be consulted reg ard in g d ru g m a n ag e m en t a n d the d e te rm in a tio n of w h e n th e p a t i e n t ’s h e a lth s ta tu s w ill p erm it dental treatm ent. —P ro p h y la c tic a n tib io tic s sh o u ld be used w hen recom m ended. —T h e risk of infection w ill be decreased by strict adherence to infection co n tro l procedures. —A ll e x istin g a n d p o te n tia l sources of infection should be elim inated.
CLINICAL
— Oral p ro p h y la x es sh o u ld be p er form ed at 3-m on th in tervals or m ore frequently, if necessary, for control of hyperplasia. —C o u n selin g the p atien t regarding m eticu lo u s oral h y g ien e to prevent medical com plications is important. —Frequent appointm ents are necessary for evaluation of oral care and reinforce ment o f proper hygiene. In addition to these basic principles, there are items that should be considered when prosthodontic therapy is required. —Prosthodontic treatment should be individually determined by the patient’s medical status at the time of treatment. —Extensive prosthodontic treatment procedures sh ould be postp oned until the p a tien t’s m edical con d ition is sta bilized and maintenance levels of im m u nosuppressants have been reached. —If a patient’s medical condition has been stable for some time and that patient has returned to u nrestricted p h ysical activity levels, extensive prosthodontic treatment may be provided. —T he patient’s post-transplant phys ical and p sych o lo g ica l vu ln erab ilities sh o u ld be considered, and alternative interim treatment planned if a change in the p atien t’s m edical status occurs. However, because of the patients’ gen erally p o sitiv e fee lin g s regard in g the q u a lity o f their liv es, care m ust be exercised in presenting treatment plans that reflect changes made as a result of their overall health. —If an interim prosthesis is required, it should be durable, easy to clean and m aintain, and n onirritating to tissues susceptible to cyclosporin-A hyperplasia. It sh o u ld cover as little soft tissue as possible, resist functional force during potentially extended service periods of wear, fulfill esthetic requirements, and preserve the rem aining tooth structure. —P a tien ts’ ap poin tm ents sh ould be scheduled when they are well rested and under low levels of stress. P rolon ged appointm ents should not be scheduled until the patient has returned to unre stricted physical activity. —Soft tissue trauma should be m in imized during all procedures. Although this is a rou tin e req u irem en t in all situations, it is of m onum ental im por tance for those patients in whom minor tissu e traum a co u ld resu lt in lifethreatening in fection or contribute to transplant rejection. —Frequent ap poin tm ents sh ould be sch ed u led to evalu ate the soft tissu e response to any prosthesis and to detect
any em erging oral irritations related to a prosthesis.
Patient treatment report T he follow in g patient treatment report demonstrates some of the principles used in the p ro sth o d o n tic treatm ent of a patient with a cardiac transplant. A 58-year-old m ale sought treatment because his teeth were wearing away and he had sensitivity in his anterior teeth when chewing. T he medical history showed that the p atien t had u nd ergone cardiac trans plantation 6 months before h is first dental visit. T he transplant was the result of ischemic cardiomyopathy w ith Class IV angina. At the p a tie n t’s in itia l d ia g n o stic appointm ent, he reported taking pred nisone (steroid), imuran (anticoagulant), and cyclosporin (im m unosuppressant), and appeared to be doing well, with no restrictions in activity. The patient was fo llo w in g a p rescribed lo w -fa t, low cholesterol diet and a formalized cardiac rehabilitation program. T h e tran sp lan t center in d ica ted no major contraindications to dental treat ment, provided the patient received the A m erican H eart A sso c ia tio n ’s recom mended antibiotic coverage. The patient’s post-transplant recovery and transplant acceptance were carefully m onitored by the tran sp lan t center w ith particu lar attention to any evidence of rejection. T he patient’s dosage of prednisone had been reduced since he show ed a satis factory rate of recovery. T h e c lin ic a l e x a m in a tio n show ed m oderate to severe a ttr itio n of the maxillary and mandibular incisors and canines (Fig 1-3). T he fo llo w in g teeth were m issing: the third m olars in all four quadrants, the maxillary right first m olar, the m a n d ib u la r rig h t second premolar and the m andibular left first and second molars. Generally good oral hygiene and no dental caries were noted. Areas of gingival hyperplasia were evident in the in terp apillary g in g iv a between the four m a x illa ry in ciso rs. At the diagnostic appointment, alginate impres sion s were made for d ia g n o stic casts, w h ich were later a rticu la ted u sin g a facebow record and m axillom andibular relation records. D iagn ostic tooth preparations were m ade and fu ll co n to u r w ax patterns d evelop ed on the m o u n ted casts to determ ine the m ost appropriate tooth forms and occlusal relationships. The
REPORTS
preferred treatm ent plan included tw o three-unit fixed partial dentures to replace a mandibular right second premolar and maxillary right first molar, respectively. Single crown restorations were planned for a ll rem aining m axillary and m an d ibular teeth. R estoration of the four m axillary incisors required endodontic treatment and post and cores. A Kennedy Class II rem ovable partial denture was planned for the mandibular arch. A 2m m in crease in the o cc lu sa l vertical dim ension was required to permit proper form and function. A heat-polymerized clear acrylic resin o cc lu sa l d evice w as fabricated at the altered vertical d im en sio n to evaluate the patient’s ability to accept the change, to reduce the se n sitiv ity on the w orn anterior teeth during function, and to ev a lu a te oral h y g ien e ad eq uacy and g in g iv a l response w hen the teeth and soft tissue were covered. Postplacement inspections were accom p lished at 2-week intervals to evaluate these aspects and to perform any necessary occlusal adjustments. During this time, the patient experienced significant fluc tuations in his health. Because o f this instability in his recovery, it was decided to adopt an alternative treatment plan rather than embark on a protracted oral rehabilitation. T h e decision was based on many actual or potential problems. T h e p a tie n t’s m ed ica l c o n d itio n w as unstable at the scheduled time of treat ment and the greater number of lengthy appointm ents required by the original treatment plan w ould increase his level of stress. Furthermore, an oral infection m ight develop from the extensive number and type of requ ired p ro sth o d o n tic procedures and p rod uce a p ro lo n g ed bacteremia that could contribute to the p a tie n t’s u n stab le h ea lth , and h in d er recovery. Periodontal health could also be n eg a tiv ely a ffected by the p r o sth o d o n tic procedures because of a com promised healing ability. In view of these problems, alternative treatm ent p la n s that were o r ig in a lly considered were reevaluated. A removable prosthesis overlying the m axillary teeth was a rea so n a b le in terim treatm ent alternative. T he partial overdenture was selected because: —it provided the least com p licated, fastest m eth od o f r e h a b ilita tin g the p a tien t on an in terim basis u n til h is medical status stabilized, —ex istin g restorations were in good condition, —the anterior teeth w ould be covered
Carpendale-Others : PROSTHODONTIC TREATMENT OF PATIENTS WITH CARDIAC TRANSPLANTS ■ 519
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to red u c e w ear an d se n sitiv ity d u r in g chew ing, and —the m a n d ib u lar teeth were generally in b etter c o n d itio n th a n the m ax illa ry teeth w ith less m agnitude of wear. M o u n te d d ia g n o stic casts w ere used to survey the m axillary arch to find the m o st d esira b le p a th o f p la c e m e n t a n d to d e te rm in e if an y te eth w o u ld need c o n to u r m odifications. U ndercuts, su it able for prosthesis retention, were noted
o n the facial surfaces of teeth num bers 3 an d 14, w ith fu rth e r re te n tio n b ein g p ro v id ed by the in tim ac y in fit of the overdenture fram ew ork an d the contours of the su p p o rtin g teeth. T o reduce unnecessary tissue coverage, a horsesh o e-ty p e m a jo r co n n e c to r was selected. All m axillary teeth were covered by the fram ew ork w ith labial extensions o n th e a n te rio r teeth to acco m m o d ate resin veneers for im proved appearance.
Fig 4 ■ Finished m ax illa r y in ter im p r o s thesis.
T h e s e e x te n s io n s te rm in a te d 0.5 m m coronally to the m arg in al gingiva. T h e occlusal surfaces of the prosthesis were form ed in acrylic resin. Resin was used b ec au se o f its a d ju s ta b ility , ease of fabrication an d replacem ent, an d favor able wear characteristics w hen o p p o sin g p artially w orn n atu ra l teeth. A rem ovable p artial denture fram ew ork was designed a n d a b ase m e ta l c a s tin g m ade. E le c trochem ical e tc h in g 11 of the base m etal was used to bond the resin to the m etal because interocclusal space was lim ited. T h e m aster cast an d fram ew ork were m ounted o n an articu lato r at the chosen v e rtic a l d im e n s io n . T h e a p p r o p r ia te shade of re sin v en e erin g m a te ria l was a p p lie d to th e etch e d fra m ew o rk , th e p r o s th e s is w as f in is h e d a n d p o lis h e d (F ig 4), a n d th e r e q u ir e d in tr a o r a l adjustm ents were com pleted. P o stp lacem en t a p p o in tm e n ts show ed g o o d p a t ie n t a c c e p ta n c e , g o o d o ra l hygiene, a n d ad eq u ate ap p earan ce (Fig 5,6). After 1 year, the resin show ed good in te g r ity a n d a r e a s o n a b le p e r io d of service can be anticipated. T h e p a tie n t’s h ealth has become m ore stable, so a more definitive treatm ent p lan involving total d en tal reh a b ilita tio n is cu rren tly b eing contem plated. Conclusion
Fig 5 ■ Intraoral view of maxillary prosthesis in place.
A treatm ent m odality has been presented for a p a tie n t w h o h as ju s t u n d e rg o n e c a rd ia c t r a n s p l a n ta tio n a n d is no w e x p e rie n c in g c o m p ro m ise d p o s t- tr a n s p la n t recovery. T h e treatm ent is suggested as a n a lte rn a tiv e to co m p lex a n d p r o longed restorative treatm ent at this stage of recovery. P rinciples are presented that govern the dental m anagem ent of patients w ith cardiac transplants. -----------------------J Ü O A -----------------------
Fig 6 ■ Anterior view
Dr. Carpendale is a graduate student; Dr. Dykema is professor emeritus; Dr. Andres is director, graduate p ro sth o d o n tic s; an d Dr. G o odacre is c h a irm an , departm ent of prosthodontics, In d ian a University S chool of D entistry, 1121 W M ichigan St, In d i anapolis, IN 46202. Address requests for reprints to Dr. Goodacre.
w ith interim prosthesis in place sh ow in g im proved appearance.
1. Kay M P, E lcom be SA, O ’F allo n MW. T h e in tern atio n a l h eart tra n sp la n t registry —the 1984 report. J Heart T ransplant 1985;4:290-2. 2. Bolman RM, Elick B, Olivari M T, Ring WS, Arentzen CE. Im proved im m u n o su p p ressio n for heart transplantation. J Heart T ransplant 1985;4:315-
8. 3. Andreone PA, Olivari MT, Elick B. Reduction of infectious com plications follow ing heart trans plantation with triple-drug imm unotherapy. J Heart T ransplant 1986;5:13-9.
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4. Sowell SB. Dental care for patients with renal failure and renal transplants. JADA 1982; 104:1717. 5. Daley TD, Wysocki GP. Cyclosporin therapy; its significance to the periodontist. J Periodontol 1984;55:708-12. 6. Wysocki GP, Gretzinger HA, Laupacis A, Ulan RA, Stiller CR. Fibrous hyperplasia of the gingiva: a side effect of cyclosporin A therapy. O ral Surg Oral Med Oral Pathol 1983;55:274-8.
7. M cGaw T , Lam S, C oates J. C yclo sp o rin induced gingival overgrowth: correlation w ith dental plaq u e scores, gin g iv itis scores, an d cyclosporin levels in serum an d saliva. O ral S urg O ral Med Oral Pathol 1987;64:293-7. 8. D eliliers G L , S antoro F, P o lli N, B runo E, F u m a g a lli L, R isc io tti E. L ig h t a n d electron microscopic study of cyclosporin A-induced gingival hyperplasia. J Periodontol 1986;57:771-5. 9. Harms KA, Bronny AT. Cardiac transplantation;
REPORTS
dental considerations. JADA 1986;112:677-81. 10. L ough ME, L indsey AM, S h in n JA, Stotts NA. Im pact of sym ptom frequency and sym ptom distress on self-rep o rted q u a lity of life in h eart transplant recipients. Heart L ung 1987;16:193-200. 11. Zurasky JE , D uke ES. Im p ro v ed ad h esio n of d en tu re acrylic resin s to base m etal alloys. J Prosthet Dent 1987;57:520-4.
Comment Where medicine has taken us? Advances in m edicine have m ade it p o ssible for p a tie n ts w ith end-stage diseases of the heart, liver, and kidneys to receive organ transplants. T h e lo n g term survival after m ajo r o rgan trans p la n tatio n has greatly im proved since the first k idney tr a n s p la n t in 1953, the first liver tran sp lan t in 1963, and the first heart tran sp lan t in 1967. T h e lo n g -te rm su rv iv al of k id n ey tra n s p la n t p a tie n ts is n o w g re a te r th a n 80%. H ea rt tra n s p la n t p a tie n ts have a greater th an 80% 1-year survival rate an d m ore than 50%, a 5-year survival rate. T hese patients, in ever-increasing n u m b e rs , are n o w se e k in g d e n ta l treatm ent. Cyclosporine, alo n g w ith an tith y m ocyte g lo b u lin a n d c o rtic o ste ro id s, are used to suppress the im m une system of the organ recipient. W ith o u t these drugs, the tran sp lan ted organ w ould be rejected. However, these drugs have several im p o rta n t side effects: increased incidence of hyperten sio n , increased risk for infection, increased incidence of m a lig n a n t tu m o rs su c h as ly m p h o m a a n d K ap o si’s sarco m a, p o o r w o u n d h e a lin g , in c re a se d ris k fo r excessive b le e d in g (th ro m b o c y to p e n ia ), a n d th e p o te n tia l fo r a d re n a l cortical suppression w hich may m ake it difficult for the p atien t to deal w ith stressful surgical procedures. Because m o st tr a n s p la n t p a tie n ts m u s t be tra n s fu s e d w ith b lo o d d u r in g th e im p lan ta tio n of the new organ, they also are at increased risk for hepatitis B an d non-A, non-B hepatitis. M any physicians recom m end a n ti biotic prophylaxis for invasive dental p ro c e d u re s fo r th e ir p a tie n ts w ith transplants. T h e rationale is to prevent infection in the im m u n e suppressed
p a tie n t. O th e r p h y sic ia n s state th a t rou tin e an tib io tic p ro p h y lax is is not needed an d in fact sh o u ld be avoided because of the problem of developing resistant organism s to the antibiotics used for p ro p h y la x is. P a tie n ts w ith such resistan t o rg an ism s co u ld then develop future infections w hich w ould be d iffic u lt to m a n ag e . T h ese p h y sicians w ould prefer th at their patients receive d en tal care w ith o u t p ro p h y lax is an d if in fec tio n does develop, it can be treated w ith ap p ro p riate local a n d sy stem ic m e a su re s . T h e la tte r view point becomes m ore ap p ro p riate w hen the m o u th is free of infection. T h e den tist sh o u ld co n su lt w ith the p a tie n t’s p h y sic ia n for g u id a n c e in this area. It is im p o rta n t th at current, effective infectious disease co n tro l procedures be a basic p a rt of all dental practices. T h is is m ost im p o rta n t w hen treating p a tie n ts w ith tr a n s p la n ts . T h e s e p atien ts m ust be p rotected from the transm ission of infectious agents from th e d e n tis t, d e n ta l sta ff, a n d o th e r patients. In ad dition, the d ental staff m e m b ers m u s t be p ro te c te d fro m possible tran sm issio n of HBV , nonA, non-B h ep a titis or, in rare cases, H IV fro m th e p a t ie n t w ith th e transplant. T h e possible effect on d en tinogene sis o f h ig h s te ro id lev els u sed to m anage patients w ith tran sp lan ts has been re p o rte d o n several occasions. T h e report by N asstrom a n d others, as p u b lis h e d in O ral Surgery, O ral M edicine, Oral P athology in 1985 has been the m ost referenced study regard in g this possible effect. Several p ro b lem s o c c u r w ith th e in te r p r e ta tio n of this study. First, only 29 of the
51 p a tie n ts in th e stu d y h a d r a d io graphs to show the appearance of the p u lp cham ber before steroid therapy w as in itia te d . W h e n th e a u th o r s re p o rte d n a rro w in g in 14 of th e 19 p atients in the renal tran sp lan t g ro u p they did n o t indicate how m any had before an d after film s w ith n arrow ing, an d how m any h ad before an d after film s w ith o u t n arro w in g . Secondly, the rela tio n sh ip of age a n d d en tin o g en esis in th e p a tie n ts stu d ie d w as n o t re p o rte d . T h e ag es o f p a tie n ts in th e ir stu d y ra n g e d fro m 1 to 61 years, w ith a m ean age of ab o u t 35. F in ally , th e p o ssib le effect of ren a l osteodystrophy on dentinogenesis was n o t discussed. T h e two papers d ealin g w ith these p ro b le m s d e m o n stra te th e necessity for d en tists to be aw are of th e need to m anage p atien ts w ith tra n sp la n ts safely an d effectively a n d to be aw are of the possible effect of h ig h steroid dosages on dentinogenesis. T h e p ap er concerning the p atien t w ith systemic lu p u s erythem atosus (SLE) also raises th e issu e o f a n tib io tic p r o p h y la x is for prevention of infective endocarditis (IE). A recen t re p o rt in d ic a te d th a t n o n b acterial th ro m b o tic en d o card itis occurs in a b o u t 50% of th e p a tie n ts w ith S L E . T h e in c id e n c e o f IE in p atients w ith SLE is ab o u t 1%. T h u s, p atien ts w ith SLE m ay be a t sig n if ic an t risk for IE a n d are can d id ates fo r a n tib io tic p r o p h y la x is b e fo re dental treatm ent. T h e d en tist sh o u ld c o n s u lt th e p a t i e n t ’s p h y s ic ia n to confirm the need for p ro p h y lax is in these patients.
Jam es W. L ittle, DMD, MSD
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