Oral health in liver transplant recipients
Year: 2013
Type: dissertation
Study design: Observational Study
Abstract: Liver transplantation (LT) is the treatment of choice for patients with severe liver disease. Quality of life of patients after LT may be comparable to that of the general population, but permanent immunosuppression poses a high risk for infections. Highly prevalent dental diseases not promptly treated may compromise LT outcome. All possible infectious foci, including dental infections, should thus be treated prior to LT. This thesis aimed to investigate how liver diseases and long-term immunosuppression after LT affect oral health and whether dental infections are associated with liver disease progression or with LT outcome. The study design was retrospective, cross-sectional, and observational. The study comprised 263 adult recipients of a LT between 2000 and 2006 at the Helsinki University Central Hospital, Finland. Of these patients, 212 (81%) had chronic liver disease, and all underwent dental examinations and treatment prior to LT. The study investigated the effect of differing liver disease etiology and severity on oral health status; the effect of dental infections on the progression of liver cirrhosis was further studied in a subgroup of 116 cirrhotic patients awaiting LT. Of the study patients, 51 (19%) had acute or subacute liver failure; these were further stratified by whether or not they received pretransplant dental treatment. Post-transplant systemic infectious complications were evaluated from the Finnish Liver Transplant Registry. After a minimum 2-year follow-up (median follow-up 6 years, range 2-11), all 84 eligible LT recipients were recruited for a new oral health examination according to a fixed protocol. A structured questionnaire was used to assess dry-mouth-related symptoms, with oral Candida cultivated, and salivary flow rates measured. The results were compared with those of 252 matched controls from a national health survey. Subjects were grouped according to liver disease etiology and type of immunosuppression. Dental health status of LT candidates varied depending on the etiology and severity of their liver disease. Alcohol cirrhosis patients (n=37) had significantly more tooth extractions before LT than did primary sclerosing cholangitis patients (n=54) (6 vs. 3, P less than 0.005). Poor liver function, as observed in higher Model for End-Stage Liver Disease (MELD) scores, associated with fewer teeth (21 vs. 25, 95%CI: -6.7-(-)1.4, P less than 0.005) and more tooth extractions (5 vs. 2, 95%CI: 1.6-4.2, P less than 0.001). Tooth extractions were often associated with severe complications such as bleeding. Several dental infections in cirrhotic patients associated with worsening of the liver disease as seen in the shorter time between diagnosis and LT operation. Post-transplant infection risk, especially sepsis, was higher in those acute liver disease patients who received no dental treatment before LT due to their more urgent need for LT compared with that of patients who had received dental treatment (OR=8.54, 95%CI: 1.82 40.1, P less than 0.05). This risk was independent of age, gender, etiology of acute liver failure, waiting-list time, MELD score, or level of immunosuppression. Compared with controls, chronic LT recipients had significantly more caries (1.2 vs. 0.5, P less than 0.005) and a higher prevalence of dysphagia (23% vs. 12%, P less than 0.05). They also had lower unstimulated salivary flow rates than did the acute LT recipients (0.3 ml/min vs. 0.6 ml/min, P less than 0.05). Oral mucosal lesions were significantly more frequent in LT recipients than in controls (43% vs. 15%, P less than 0.001). Drug-induced gingival overgrowth was the most common type of oral lesion, and its prevalence was significantly higher in chronic LT recipients than in their controls (16% vs. 1%, P less than 0.001). Simultaneous use of cyclosporine-A and calcium- channel blockers increased the overgrowth prevalence even further compared with the tacrolimus group (47% vs. 8%, P less than 0.05). Precancerous oral mucosal lesions occurred twice as often in chronic LT recipients as in controls (13% vs. 6%, Ns). Oral Candida count was positive in more than half the LT patients; use of steroids raised its prevalence to 70%. The need for dental treatment hence was high before the LT operation with differences in oral health between groups differing in liver disease etiology and severity. Among cirrhotic patients, several dental infections were reflected in the liver disease progression. Those patients who lacked dental treatment before LT showed an 8-fold risk for systemic infections after transplantation. Compared to controls, immunosuppressive and other xerogenic medications predisposed especially the chronic LT recipients to more dry-mouth-related symptoms and caries, and led to a higher risk for oral mucosal lesions, of which some were precancerous. Thus, both pre- and post-transplant dental treatments are highly important for these patients.
Source: Työväentutkimus Vuosikirja
Author: Jaana Helenius‐Hietala
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: green
OpenAlex ID: W913606338