transplantation are prone to infection, bleeding, and delayed healing due to leucopenia
and thrombocytopenia. However, the majority of children awaiting liver
transplantation due to biliary atresia are of a very young age and have not experienced
dental caries, though their teeth may have intrinsic green staining due to biliverdin
deposition in the developing dental tissues. This is a time when intensive oral hygiene
instruction and preventive advice and therapy are of paramount importance in helping
to minimize later potential oral problems. Before any invasive dental procedures are
undertaken, consultation with the child's physician is vital in order to establish the
extent of the organ dysfunction and its repercussions. Prophylactic antibiotics will
probably be required in patients with cardiac problems and depressed white blood cell
counts. Any significant alterations in bleeding times and/or coagulation status must be
checked. There are also certain drugs that should be avoided inpatients with end-stage
liver or kidney disease.
16.8.2 Immediate post-transplant period
Drugs prescribed to prevent graft rejection have several side-effects. Azathioprine
results in leucopenia, thrombocytopenia, and anaemia; hence, children in this
immediate post-transplant phase may be even more prone to infections and
haemorrhage than before. Cyclosporin (Neoral) and Tacrolimus are largely replacing
azathioprine but these may cause severe kidney and liver changes leading to
hypertension and bleeding problems. Cyclosporin is also associated with gingival
enlargement. Steroids are prescribed at this time with the risk of adrenal suppression.
Full supportive dental care is required and children complain of nausea and may
develop severe oral ulceration. Routine oral hygiene procedures can become difficult
but the use of chlorhexidine as a mouthwash, spray, or on a disposable sponge,
together with local anaesthetic preparations is helpful.
16.8.3 Stable post-transplant period
Once healing has occurred and any acute graft rejection been brought under control
then routine dental treatment can be undertaken. Reinforcement of all preventive
advice and liaison with the child's dietitian may be helpful as many patients are still
on high carbohydrate supplementation. Steroid therapy is discontinued in children
with liver transplants after 3 months but may be continued for longer periods than this
in those with other organ transplants. Antifungal prophylaxis is usually given in the
first few months after transplantation to prevent oral candidal infections. Dental
problems, apart from oral ulceration and those associated with immunosuppression
and bleeding tendencies, include delayed eruption and exfoliation of primary teeth
and ectopic eruption of permanent teeth. These are related to the gingival overgrowth
associated with cyclosporin and nifedipine medication (1111HFig. 16.9).
Key Points
Transplant immunosuppression:
- leucopenia;
- thrombocytopenia;
- gingival enlargement.