6. Transplantation Medicine

Question 1

Transplantation medicine
• Organ transplantation is the effective restoration of vital organ functions in end-stage organ disease

• Underlying principles:
– Immunology of proper donor and recipient ____
– Immunosuppressive therapy for ____ and management of graft rejection

• Comprehensive dental ____ prior to transplantation reduces risks of infections
• Post-transplantation oral health considerations
– Immunosuppressive ____
– ____-term immunosuppression
– Complications of ____
• Dental risk assessment and dental planning vital

Answer 1

matching
preventation

screening
medications
long
graft-versus-host disease (GVHD)

Question 2

Organ Procurement and Transplantation Network U.S. Department of Health & Human Services

Just by sitting here, in just ____ minutes someone in the country will have end stage organ disease and need a transplant. So they will be added to the waiting list. By the end of today, about ____ people will have undergone organ tissue or cell transplant. When someone is listed as an organ donor, they have the ability to help ____ people.

Answer 2

10
95
8

Question 3

WHY? Look at how many candidates are on the waiting list. ____ total.
Notes ____ and liver are high. Why is kidney #1? (couldn’t hear, but he hints kidney disease is common), indirectly hepatitis, BUT IMPORTANTLY: Kidney is high because these people don’t die immediately so people can wait on ____. 2 kidneys they can live on ____. Even if both are affected, they can stay on dialysis a long time.
____- lots of alcohol abuse, hepatitis.

Answer 3

113,000
kidney
dialysis
one
liver

Question 4

When you get organ transplant, they are able to survive. Within the first year, ____% survival. For kidney its ____%! High percent they will survive and live longer, even in the 90’s after 3 years for adult and pediatric patients. Good chance you will have patients needing or have received organ transplantations.

Answer 4

70-90

96.7

Question 5

Classification/Types of Transplantation

Graft: A transplanted cell, tissue or organ

Based on type of tissue transplanted
• ____ organ/tissue transplantation (virtually all ____ of organs/tissues)
• ____ transplantation (____ components)

A graft is any cell tissue or organ that is transplanted from one site to another.
What are they types? Based on the type of tissue: Solid organ transplant (heart, liver kidney). Almost all types of organs and tissues can be transplanted.
Hematopoietic cell transplantation is the transplant of bone marrow components for whatever reason they may be needed.

Answer 5

solid
types
hematopoietic cell
bone marrow

Question 6

Classification/Types of Transplantation

Based on genetic relations of tissue to recipient
• ____ transplantation: a graft to and from one’s self (____)

• ____ transplantation: a graft from one identical twin (identical genetic make-up) to another (____)

The other one is based on the genetic relations. For example, if you have a graft from one side of the mouth to the other (self to self) thats autologous transplantation. Also would be when you take then fibula to the jaw. From one part of the body to the other. This is an autograft.
Isogenic or syngeneic is transplant form identical ____. Easy to do because of identical genetic make up. High probability that this will work.
Allogenic transplantation: donor to a non identical recipient. Members of the same ____. Mr. Smith to Mr. Jones. Xenograft from one ____ to another. Monkey to human. All these are important terms. Most used is allogenic.

Answer 6

autologous
autograft

isogeneic or syngeneic
isograft

twin
species
species

Question 7

Classification/Types of Transplantation
Based on genetic relations of tissue to recipient
• ____ transplantation: a graft from donor to a non-genetically identical recipient (____)
• ____ transplantation: a graft from donor of one specie to recipient of another specie (____)

Answer 7

allogeneic
allograft
xenogeneic
xenografts

Question 8

Indications for transplants

This chart emphasizes the need for organ transplantation. Many indications: ____ or something more limited.

Long list. He reads a few of them like ____ transplantation (from one person to someone with a tumor)

TAKE A LOOK PLAYA

Answer 8

multi organ transplantation

allogenic

Question 9

Transplantation antigens: MHC Major Histocompatibility Complex (MHC)

• 1967: Discovery of the human MHC revolutionized organ transplantation
• Histocompatibility antigens are tissue ____ antigens
• Induce immune response in a genetically dissimilar (____) recipient – Rejection
• 1968: WHO Nomenclature Committee designated the leukocyte antigens controlled by the closely linked human MHC genes as ____.
• Genes (>200) that encode histocompatibility antigen reside in the MHC region on the ____ arm of human ____
• The genes and their encoded cell-surface and soluble protein products are divided into 3 classes (____) based on tissue ____, ____, and ____.
• All share important roles in immune function

These antigens are very important. They are the Major Histocompatibility Complex also called hemoleukocyte antigens. Discovered in 1967 and they changed everything. Every cells have something different on their surface that allows the cell to be “self.” They do some sort of immune reaction when taken from one person to another then genetically dissimilar. These genes are close to HLA (human leukocyte antigen) so they use both terms.

MHC region on chromosome 6. three types based on distribution, structure and function

Answer 9

cell-surface
allogeneic
HLA
short
chromosome 6
I, II, and III
distribution
structure function

Question 10

The Human Leukocyte Antigen System

Looking at chromosome six we can see the MHC region. There you have three classes where III is between
1 and 2. Different genetic regions or loci responsible for immune reaction or histocompatibility. HLA ____ are really the important ones for transplant medicine.

Important to know they’re on the short arm of chromosome #6.

Answer 10

2 and 1

Question 11

The Human Leucocyte Antigen System
Class I MHC antigens
• Present on all ____ cells and red blood cells
• Composed of ____ chain protein encoded by genes of the HLA-A, HLA-B, or HLA-C loci on chromosome 6 and associated noncovalently with ____, encoded by a gene on chromosome ____

Class II MHC antigens
• Expressed only on ____ which include B lymphocytes, activated ____ lymphocytes, monocytes, ____, Langerhans cells, dendritic cells, endothelium, and ____ cells.
• Heterodimer composed of noncovalently associated ____ chains proteins encoded by genes of the ____ region
Klein and Sato, N Engl J Med. 2000 Sep 7;343(10):702-9.

Class III MHC genes
• Located between the ____ and ____ loci
• Determine the structure of ____, C4, and ____ in the complement system

Class I are on all nucleated cells and red blood cells and are labeled A B and C that are associated with the class I. Looks at the structure on the right: Its a heterodimer that is associated with a macro globulin (?), just FYI
Class II also a heterodimer. But only present on the antigen presenting cells. Also another heterodimer. HLA = D (Dq Dp Dr, etc) All of these must be matched together to be a good match.

Class III is less important. Located between B and D on the chromosome 6. Involved in complement activation

Answer 11

nucleated
heavy
B2-microglobulin
15

antigen presenting cells (APC)
T
macrophages
epithelial
alpha and beta
HLA-D

HLA-B
HLA-D
C2
factor B

Question 12

Transplantation antigens: MHC Class I

Every ____ has these antigens on their surface (all nucleated cells and RBCs)

Answer 12

cell

Question 13

Transplantation antigens: MHC Class II

Class II MHC self-marker protein: present only in ____ cells

Class II is only on APCs. Antigen presenting cells process anything ____. They digest and put them in the lysosome and put them on the surface so they become antigenic so antibodies can be produced against them. APCs are also nucleated so they will express class I as well as class II.

Answer 13

antigen presenting cells

foreign

Question 14

Transplantation antigens: ABO system

ABO Compatibility
• Less important than ____ compatibility in graft survival.

• ABO incompatibility: rejection of primarily vascularized grafts (____)
• ABO blood group antigens are highly expressed on kidney and cardiac grafts (especially patients with blood group ____ antigen)
• Preformed naturally occurring antibodies to blood group substances are present in ____ recipients
• Can be tempered with ____ therapies

Also considered is the ABO (but less important) especially when it comes to ____ transplants. This is easily tempered by immunosuppressive medication. No match, transplant will still go on because this can always be suppressed but still something to look at.

Two tests are done to test matches. ____ is the DNA typing to see what antigens are expressed by the donor. All the calculations are done especially of class I and II to see if the match would work. If a perfect match, the match would go on.

Answer 14

HLA
kidney and heart
substances
mismatched
immunosuppressive
vascularized
HLA

Question 15

Donor-Recipient Matching

Pairing of donors to recipients: Two laboratory tests

1. ____: determination of HLA antigens on donor and recipient leukocytes
2. ____: measures response of immunocompetent cells from the recipient to donor cell antigens (or donor immune response to recipient cell antigen for HCT)

Functional test is when they take the cells of the donor and recipient to see if there is a reaction. Especially important with hematopoietic stem cell transplantation.

Answer 15

serologic or DNA typing

functional test

Question 16

Graft rejection

What if there’s not a good graft. ____ will be 100%, will not be rejected.
But taking from B to A and don’t match the HLA, the graft will be ____ by host immunity.
Someone from B to donate to someone with complex A and B will still be ____ because only B genes are going in.
If we take someone with complex A and B and put in someone with B it will ____ because of the A.

Highly complex… Match and keep a record. Better with ____ but still need to match HLA. Can match with non family with same HLA and perhaps trade with another persons relative.

Answer 16

autograph
destroyed
accepted
reject

relatives

Question 17

Graft Rejection

1. Donor antigen reacts with recipient ____ cell receptors: T cell response
2. Recipient APC: activates ____ cell response
3. Production of ____, lymphokines: activation of cytotoxic T cells, B cells and NK cells, macrophage activation
4. Direct ____ damage
5. Damage to ____ endothelium of graft
6. Graft ____
7. In HCT: mature lymphocytes in graft can react with recipient antigen = ____

Graft rejection will activate a cells response. APC will realize it is foreign and activate the T cell to release cytokines. Activation of B cells and NK cells that will target the tissues and destroy the endothelium of the graft to destroy the grafts access to blood flow leading to rejection.

GVHD- lymphocytes in the graft can react with the host cells. We will talk more about this soon.

Answer 17

T
T
cytokine
tissue
vascular
rejection
GVHD

Question 18

Graft Rejection
1. End-organ damage: re-manifestation of the various ____ of the specific nonfunctioning organ.
2. Clinical presentation (organ specific):
• Increased ____ (rejection of liver),
• Decreased metabolism of medications (rejection of liver/kidney)
• Complete ____ and death (rejection of lung/heart).
3. Need for re-____ to prevent death (except for kidney failure)

HLA matching is VERY important. Graft rejection will happen when this goes wrong. Kidney is put in and if rejected will go back to the disease state that initially became the indications for the graft. Clinical presentation will vary.

If kidney, inability to metabolize medication. Lung and heart, this is life threatening leading to organ failure and death. Take out the organ and retransplant immediately to avoid death.

Answer 18

complications
bleeding tendency
organ failure
transplantation

Question 19

Graft rejection

Hyperactive
• Common in ____ organ rejection
• Occurs within ____ hours of surgical anastomosis
• Mediated by ____ antibodies and complements
• Requires ____ graft removal

Acute rejection
• Mediated by ____ cells and antibodies
• Occurs within first ____ days after transplantation
• Responds to high-dose ____ and antilymphocyte therapies

Chronic rejection
• ____ and insidious
• Primarily ____ mediated
• ____ but ____ cell-mediated toxicity resulting in vascular
endothelial damage of transplanted organ
• Generally ____ even with immunosuppressive medications

Answer 19

solid
48
preformed
immediate

T
90
steroids

slow
antibody
continuous
muted
irreversible

Question 20

Immunosuppressive medications

• ____ are used a lot because they can temper the action of the antigen presenting cells and T cells.
• Calcineurin inhibitors like ____ are used to block the activation of T cells
• ____ are mTOR inhibitors that block the proliferation of T cells.
• This cartoon is showing that these medications are actually tempering the activation or activity of T cells

Answer 20

steroids
cyclosporine and tacrolimus
sirolimus and everolimus

Question 21

“I’m not going to go over this long list. This is for you to study.”
Lists all the medications that are used. Shows the classification and indications for each
____ is highly used as a broad acting immunosuppressant. Also used after organ transplantation for ____ action to prevent rejection.
All drugs have their ____ and nephrotoxic side effects. Also shows dental implications for each

____ is involved in gingival hyperplasia.
____ medications are antagonized.
____ is known to called pyogenic granuloma-like lesions ____ inhibitors are associated with aphthous lesions or ulceration

Answer 21

cyclosporine
prophylactic
hepatoxic

cyclosporine
P450
tacrolimus
MTOR

Question 22

• Steroids have a lot of ____. When patients are on steroids, need to know all the different side effects of corticosteroids.

Answer 22

side effects

Question 23

Corticosteroids
Corticosteroid Side-Effect Profile
• Induces \_\_\_\_
• Induces muscle weakness
• Induces osteoporosis
• Alters fat metabolism and distribution
• Induces \_\_\_\_
• Induces electrolyte imbalances
• Induces central nervous system effects, including psychological changes 
• Induces \_\_\_\_ changes—cataracts, glaucoma
• Aggravates high blood pressure
• Aggravates congestive heart failure
• Aggravates \_\_\_\_ disease
• Aggravates underlying infectious processes (e.g. tuberculosis)
• Suppresses the pituitary-adrenal axis, resulting in adrenal atrophy
• Suppresses the stress response

• This is a list of the side effects of corticosteroids
• Patients on long-term corticosteroids are susceptible to developing ____, myopathies, muscle weakness
• Patients might be taking additional medications like parathyroid hormone or bisphosphonates which will
also affect how you treat your patients dentally.
• Patients might have ____ deposition, puffiness, hyperlipidemia, electrolyte imbalance, psychotic effect,
cataracts, high blood pressure, peptic ulcer

• All these are things you have to be concerned about with patients on immunosuppressants, especially ones taking corticosteroids.
• ____ infections (like tuberculosis) can be re-activated by these meds.
• ____ is important. These drugs suppress the stress response

Answer 23

diabetes
hyperlipidemia
ocular
peptic ulcer

DM
fat
chornic
stress

Question 24

Hematopoietic Cell Transplantation

• Autologous HCT: no ____ required
• Allogeneic HCT:
– Requires “conditioning” with cytotoxic ____ or radiation
– To eradicate residual ____ prior to infusion of the hematopoietic stem cells
– Donor T cells react against and kill residual tumor cells to induce a ’____’ effect (GVT)

• Most of the things we talked about apply more to organ transplantation. How let’s look at hematopoietic cell transplantation.
• Autologous HCT: from self to self, does to need immunosuppression. Blood is taken out and re-____ back into the same person.
• Allogeneic HCT: requires a conditioning regimen. The patient is given some form of chemo or radiation (especially patients with leukemia) to kill the tumor cells before they transplant the stem cells.
• The goal is to eradicate the tumor so when the stem cells are transplanted, they have the ability to kill any residual tumor cells (Graft vs Tumor effect)

Answer 24

immunosuppression
chemotherapy
tumor
graft-v-tumor

infused

Question 25

Complications of Hematopoietic Cell Transplantation

• Associated with allogeneic HCT
– Intensive ____ and/or radiation (conditioning regimen)
– Cytotoxic effect to kill the residual malignant cells (Graft vs. Tumor effect)
– Administration of immunosuppressive

• Infections

• End-organ damage (pre-transplant conditioning regimen)
– ____ often used to reduce direct organ toxicity

• Graft vs. Host Disease(GVHD)

• This method has complications. Chemo and radiation make the patient susceptible to stress and immunosuppression. The cytotoxic effect on the malignant cells would also affect the patient. The combination of immunosuppressive agents would affect the patient.
• Patient is susceptible to ____. If you do dental treatment, there could be infection afterwards
• When patients have end organ damage, they need to do reduced intensity conditioning so you don’t
cause too much damage to the organ.

Answer 25

chemotherapy
reduced intensity conditioning (RIC)

infection

Question 26

Graft vs. Host Disease (GVHD)

A clinical syndrome resulting from immunologic attack by donor ____
T cells on recipient tissues either directly or through exaggerated inflammatory responses following allogeneic HCT

Three etiological requirements for GVHD.
• Graft contains immunologically ____ cells
• Host expresses tissue antigens ____ to the graft
• Host incapable of ____ the donor graft (due to ____ and
immunosuppressive regimens)

GVHD affects the entire ____ system, including the mouth, as well as the ____ and the ____
Can be lethal and requires intensive immunosuppressive therapy.
Mucosal ____ in GVHD: entry port for other infectious pathogens.

• The immunocompetent cells from the donor now attack the host cells. They recognize the host cells as
antigenic cells.

◦The graft must be immunocompetent. Graft must be from someone who does not have the tumor
◦Host must have some kind of antigen that is foreign that the transplanted stem cell can recognize as foreign. Patients are usually on immunosuppressive drugs so their cells cannot even fight the
graft. Yon’t don’t want the recipient cells to attack the graft, so you suppress the host immune response
• The graft recognizes the host tissue as foreign and starts destroying it
• This manifests in the mouth and GI system (mucosal areas), skin and liver

Answer 26

immunocompetent

competent
foreign
rejecting
myelosuppressive

gastrointestinal
skin
liver
ulcerations

Question 27

Acute and chronic oral graft vs. host disease

Acute GvHD
- prominent ____

Chronic GvHD

• ____ ulceration
• lichenoid hyperkeratosis
• ____ lower lip changes
• GVDH can cause mucosal ulcerations which are very painful
• In the mouth, these ulcerations can be sources of infection
• Patient with acute GVHD. Extensive mucosal ulceration with crusting of the lips
• If patients are able to overcome the first phase, they can get to the second phase where it is chronic.
• Chronic: ____ like lesions on the mucosal surfaces

Answer 27

lip crusting
pseudomembranous
hyperkeratotic

lichen-planus

Question 28

GVHD

Another patient w GVHD. Ulcerations and additional secondary infection of ____

• Extensive ____ on both sides of the tongue.
• This is very uncomfortable. Broad based mucosal ____ with pseudomembranous surfaces
• On the buccal mucosa, extensive ulceration

Answer 28

candidiasis

ulceration
ulcerations

Question 29

Superficial mucocele

• Patients with GVHD are also susceptible to ____ because of the attack on ____ salivary glands.
• The ducts get blocked, so the saliva that gets excreted gets deposited into the tissue. Leads to formation of superficial mucoceles.
• This is part of GVHD

Answer 29

superficial mucoceles

minor

Question 30

Dental Management Of The Transplant Patient - General Principles

Risk assessment
• Medical history status – \_\_\_\_ specific
• Indications for transplantation
• Pertinent labs: e.g. \_\_\_\_/anticoagulation,
infection/CBC with diff, ANC
• Transplantation schedule and timeline

• •
You need to be able to assess the risks involved
If you know the organ that is being transplanted, you need to think what the pathological effects will be on the patient.
◦For liver transplant, think of ____, ____ of drugs, etc ◦Whatever the effects are, they are organ specific

• •
Patients will be susceptible to infection, so need to do the pertinent labs before treatment
Find out from the physician what the plan of treatment is. Need to know if you have the chance to treat or prepare the patient before the transplantation takes place.

Answer 30

organ
bleeding

bleeding
metabolism

Question 31

Dental Management Of The Transplant Patient - General Principles
• Pre Transplant Dental Considerations
• Post Transplant Dental Considerations 
– \_\_\_\_ post transplant period
– \_\_\_\_ post transplant period
– \_\_\_\_ rejection period

• Risk assessment: need a thorough history and thorough evaluation of the patient
• Divide stages into pre-transplant and post-transplant.
• Post transplant period is divided into immediate, stable and chronic periods.
• The general principles will be to think about what will affect your dental treatment before and after
◦For after, will it be immediately after, when the patient is stable, or when the patient is actually rejecting the graft.

Answer 31

immediate
stable
chronic

Question 32

Pre-Transplant Medical Considerations

1. Specific organ ____
2. ____ side effects
3. ____
4. ____

• ____
• Cirrhosis
• Chronic obstructive pulmonary disease (COPD)
• Coronary heart disease
• ____
• Diabetes
• Hepatitis
• ____
• Idiopathic pulmonary fibrosis
• Polycystic kidney disease
• Short gut syndrome

What are the indications for the transplant? Go through all the medical problems the patient has and see if any of them need to be managed or will interfere with your dental treatment
• If patient has diabetes, they are susceptible to ____. Hepatitis means liver damage and clotting/ bleeding problems. Hypertension means you have to monitor their blood pressure during treatment
◦These all depend on the ____ organ damage.

• Specific organ complications need to be identified.
• Patients will be on a lot of medications (ex. Immunosuppressives). Consider side effects of these drugs
• Consider any kind of rejection that may take place. How will this affect your dental planning

Answer 32

complications
medication
immunosuppression
rejection

cystic fibrosis
hypertension

infection
end

Question 33

Dental Management: Pre-Transplant Patient

Pre-transplant dental screening and clearance
• Comprehensive dental and oral ____ prior to transplant-recommended
• To reduce risk of infections in immediate period of immunosuppression

• These are different considerations before the transplant.
• Any kind of infection has to be treated. Caries and periodontal disease have to be taken care of.
• Do elective dental treatment to reduce the risk of ____.
• If there is some periodontal problem after the patient gets immunosuppressed, it can get exacerbated

Answer 33

evaluation

infections

Question 34

Dental Management: Pre-Transplant Patient

Pre transplantation considerations

1. Significantly ill patient with ____ damage
2. Medical consultation ____
3. Consider postponing ____ treatment
4. Dental consultation prior to anticipated transplantation
   • Rule out acute dental ____ sources, stabilize oral disease
   • Remove sources of ____ infection that may lead to acute complications within the
   transplant process and immediate post-transplant period
5. Perform ____ treatment; this will require consultation with transplantation physician to determine medical risk: benefit ratio
   • Obtain laboratory information/supplemental information as needed: CBC, PT, PTT, INR, metabolic panel, liver function tests, other organ specific panels
   • Be acquainted with specific management issues (e.g., blood products, prophylactic antibiotics, alternate medication regimens due to organ failure) that may need to be employed if treatment is rendered

Summary of considerations: What are the issues with respect to the end organ? Would you need to consult with a physician to plan the dental treatment? Or are these elective treatments that can wait until after the transplant? Work with the physician to figure this out.

• Key point: You don’t want to leave any source of ____ because after the patient is immunosuppressed, the infection will be aggravated. Reduce and source of infection and stabilize the patient as much as possible. If there are small caries that can be treated, do it.
• Remember that you need to work with the ____ to get the current labs.
• If patient is susceptible to infection, you have to consider perioperative ____ coverage to prevent
infection.

Answer 34

end-organ
required
elective
infectious
chronic

necessary

infection
physician
antibiotics

Question 35

Dental Management: Post-Transplant Patient

Post-transplant dental care (3 phases)
• ____ post transplant period
• ____ graft period
• ____ rejection period

• Summary of what will happen post transplant
• Immediate: Consult with ____ and keep oral ____ regime going on. Only do ____
procedures, defer all elective treatment.
• Stable: continue with oral ____ measures because patient is immunosuppressed. ____ all indicated dental conditions. Monitor the labs

• Chronic: if patient is undergoing rejection, work with physician so if there is any odontogenic infection, you can ____ it at that time.

Answer 35

immediate
stable
chronic

physician
hygiene
emergency

hygiene
treat

treat

Question 36

Dental Management: Post-Transplant Patient
Post-transplantation considerations

• Immediately after transplant
– No ____ dental treatment performed
– ____ treatment only with medical consultation and consideration of specific management needs

• Stable period after functioning transplant
– ____ treatment may be performed after medical consultation with the transplantation physician
– Issues of immunosuppression must be recognized
– Oral mucosal disease must be diagnosed and treated
– Evaluate oral ____ and salivary flow: supplement or treat with sialagogues as needed
– Supplemental corticosteroids (steroid boost) may be necessary
– Consideration for antibiotic prophylaxis due to immune suppression.
• Two grams of oral ____ or 600mg of ____ are suggested one hour prior to invasive dental care
• Consideration of specific management needs

• Chronic rejection period
– Only ____ treatment

• In summary, no ____ treatment during immediate transplant period.
• You can do elective treatment when the patient is ____
• When rejection is taking place, only do ____ treatment

Answer 36

elective
emergency

elective
hydration
amoxicillin
clindamycin

emergency

elective
stable
emergency

Question 37

Dental Management Considerations in the Transplant Patient

1. Pre transplant dental screening and clearance
2. To reduce risks of ____ complications
3. Long term immunosuppressive therapy (rejection, GVHD)
4. Perform basic oral care-maintain good oral ____
5. Reduce risk of local inflammation and infection
6. ____ with soft tooth brush and fluoride paste twice a day
7. Flossing daily
8. Daily ____ gluconate oral rinses
9. Soak prosthesis in disinfectant solutions
10. Prophylactic ____- for perioperative coverage

• Another slide saying the same thing all over again.
• Physicians like to send patients to dentists to evaluate before the transplant. Sometimes there is not
enough time, but you want to see the patient at least ____ weeks before the transplant so you can do any dental treatment you need to do. If you have to do an extraction, there should be enough time for healing before their transplant.
• Reduce any risk of ____ because the patient is going to be immunosuppressed

• Teach them to do the basic oral care/hygiene. Prescribe some kind of peridex or antimicrobial for them. Teach them how to brush with a soft brush. Teach them how to floww
• Apply fluoride to prevent caries when they are immunosuppressed (allows for more microbial proliferation).
• If they have dentures, teach them how to soak them in disinfectant to prevent dentures from being a source of infection

Answer 37

infection
hygiene
toothbrushing
chlorhexidine
antibiotics

2
infection

Question 38

Oral Complications in the Transplant Patient
• \_\_\_\_
• Medication-related oral complications 
• \_\_\_\_ overgrowth
• Pyogenic granuloma
• \_\_\_\_ inhibitor-associated stomatitis 
• Orofacial granulomatosis-like lesions 
• Oral hairy \_\_\_\_
• Oral infections
• \_\_\_\_
• Secondary malignancy

• Specific complications that patients have during transplantation
• Oral mucositis is ____ of the mucosa.
• Medication complications. Ex. Gingival ____ from immunosuppressive like cyclosporine
• MTOR inhibitors can cause ____ ulcerations
• Infections like GVHD

Answer 38

oral mucositis
gingival
mTOR
leukoplakia
GvHD

inflammation
overgrowth
aphthous

Question 39

Medication-induced oral dryness

• Patient with generalize oral ____ due to medication.
• This is a difficult patient to treat.
• Patient cannot ____ as wide as possible. Entire mucosa is dry and sloughing off
• Any attempt to treat this patient will probably cause ____ off of the mucosa. Have to manage this
____ before you can do any treatment.

Answer 39

dryness
open
slough
first

Question 40

Bacterial Infections

Bacterial infections
(usually during ____ period of solid organ transplantation)
Types vary with each specific organ.
• Includes gram-____ and gram-____ bacterial species
• Drug-resistant bacterial infections
– ____ skin infections
– upper and lower respiratory infections (____)
– ____

• Patients may be susceptible to all kinds of infection.
• Gingival ____ because of immunosuppressant drugs
• Infections from all kinds of gram positive or negative bacteria.
• If the normal standard antibiotics are not covering the infection, then you need to do ____ or sensitivity
testing to identify the particular antibiotic that will take care of the infection.

Answer 40

early postoperative

positive
negative
staphylococcal
pneumonia
tuberculosis

swelling
culture

Question 41

Viral Infections
• HSV infections usually occur at ____ weeks after organ transplantation
• CMV infections usually occur at ____ months after transplantation,
• VZV infections - usually between ____ months post- transplantation
• Other viral agents, including adenovirus, hepatitis B and C viruses, EBV, and human parvovirus B19

• Herpes simplex virus, CMV, varicella zoster infections can occur via re-activation of the virus
• HSV occurs within the first 6 months
• CMV and VZV occur much later.
• Other viral agents can be EBV or human parvovirus B19
• These are viral re-____ that can occur when the patient is immunosuppressed

Answer 41

2 to 6
1 to 6
2 and 10
reactivations

Question 42

Viral infections

• You may need to take a ____ and do ____ culture to identify the kind of viral infection the patient has

Answer 42

biopsy

viral

Question 43

Fungal Infections

• Susceptibility to local and systemic fungal infections 
– \_\_\_\_ species
– Aspergillus,
– \_\_\_\_,
– Fusarium,
– \_\_\_\_

• Invasive ____ infections (usually ____ in the transplantation process)
• Systemic fungal infections are often difficult to treat in the immunosuppressed patient and require systemic ____

• Most of the time, the infection is candida. But because of the immunosuppressive nature, other fungal infections like aspergillosis can occur.
• Could also be C. Neoformans, fusarium or trichosporon.
• These are unusual final infections that you don’t see in normal people, just ____
individuals

Answer 43

candida
cryptococcus neoformans
trichosporon

fungal
later
antifungal

immunosuppressed

Question 44

Fungal infections

• Extensive fungal infections.
• These are unusual so it tells you the patient is ____ because of the rapid spread of infection

Answer 44

immunosuppressed

Question 45

Hyperplastic candidiasis

• Extreme case of ____ candidiasis in an immunosuppressed individual
• ____, and hyperplastic
• If you take a biopsy and do a culture, it will show that it is a ____ infection

Answer 45

hyperplastic
thick
fungal

Question 46

Parasitic Infections

• Parasitic infections caused by ____i, and others can be seen in immunosuppressed transplant recipients

• If patients have a parasite, a parasitic infection can be ____
• Depends on the patients history.
• Toxoplasma Gondi is a common one that has been found in immunosuppressed individuals

Answer 46

toxoplasma gondi

reactivated

Question 47

Immunosuppression Related Cancer

• ____ carcinomas of the skin
• ____ (mostly B-cell lymphomas including post-transplant lymphoproliferative disorders (PTLDs)
– ____ virus in PTLDs
– PTLDs have been treated with decreased immunosuppression, ____ agents, conventional chemotherapy, ____, and IFN-α therapy.
• Kaposi’ssarcoma
– ____implicated in Kaposi’s sarcoma

•
• • •
Because of the immunosuppression, some of the immune surveillance that prevents cancer development can be attenuated
Patients can develop cancers like SCC of the skin, lymphomas in general
EBV virus has been associated with lymphoma.
Kaposi sarcoma is due to herpes virus infection.

•
Immunosuppressive medication tempers down the immune surveillance and allows cancer to develop.

Answer 47

squamous cell
lymphomas
EBV
antilymphocytic
radiotherapy
human herpes virus (HHV8)

Question 48

Immunosuppression realted cancer

____ carcinoma of skin

____

• Patient that developed SCC of the skin after being on long term ____ medication
• Lymphoma in the ____ tissue in a patient that has been immunosuppressed for a long time.

Answer 48

squamous cell
lymphoma
immunosuppressive
soft

Question 49

• In summary, know the medications for transplant, know the genotyping, know the medications that are involved and their side effects. Know the dental management and what you would do if a patient was sent to your practice for clearing and evaluation before a transplantation

Answer 49

yay