This document discusses complications of organ transplantation including issues related to immunosuppression, rejection, and drug side effects. It notes that excessive immunosuppression increases infection risk while rejection causes organ failure. Major immunosuppressant drugs like azathioprine, cyclosporine, and prednisone are associated with side effects like infections, hypertension, diabetes, and cancer. Special complications for transplanted organs include graft-versus-host disease, an immune response against the donor organ. Dental management of transplant patients requires consideration of infection risk and adverse drug reactions during screening, treatment planning, and post-transplant care.

1. CHAPTER 21
Organ and Bone Marrow Transplantation

2. Complications
• Complications associated with organ
transplantation generally consist of :
1. technical problems involving the surgical
procedure
2. problems related to immunosuppression
3. special problems specific to the organ
transplanted

3. Immunosuppression
• Excessive immunosuppression increases the risk for infection and must be avoided.
• signs :
Infections
delayed healing
Hypertension
Diabetes
 Addison’s disease-type reactions
 cushingoid features (e.g., edema, ascites, buffalo hump, moonfacies)
 increased susceptibility to infection
Weakness
fatigue

4. Rejection
• Rejection ---« signs and symptoms of organ failure.
• Organ biopsy is used to confirm the rejection reaction (Figure
21-9).
• evidence of acute rejection -----« increase dosage of the
immunosuppressive agents.
• Chronic rejection occurs insidiously and is progressive.
• It cannot be reversed with intensified therapy.
• Chronic rejection ----« organ failure.
• Classic evidence of chronic rejection is found by biopsy.

5. Drug Side Effects
• A major side effect of azathioprine is bone marrow suppression with resulting leukopenia,
thrombocytopenia, and anemia.
• These changes greater risk for infection and excessive bleeding.
• Cyclosporine has replaced azathioprine.
• Cyclosporine side effects:
 severe kidney and liver changes hypertension- bleeding –anemia
 potentiate renal injury caused by other agents.
 gingival hyperplasia
 hirsutism
Gynecomastia
cancers of the skin and cervix

6. • Antithymocyte globulin (ATG) and ALG both act as lymphocyte-selective immunosuppressants.
• side effects :
 fever
Hemolysis
Leukopenia
Thrombocytopenia
tumor development
increased risk for infection

7. Prednisone side effects :
hypertension
diabetes mellitus
Osteoporosis
impaired healing
mental depression
Psychoses
increased risk for infection
 adrenal gland suppression.

8. cancers
• Immunosuppressed patients exhibit an increased incidence of certain cancers.
• 6% various forms of cancer.
• Cancers commonly seen in the general population (carcinomas of lung, breast, prostate,
and colon) show no change in occurrence in immunosuppressed patients.
• two types of cancer found commonly increased frequency :
squamous cell carcinoma of the skin
carcinomas of the uterine cervix

9. • Cancers that are uncommon in the general
population but that occur with increased
frequency in immunosuppressed patients are
Lymphomas
lip carcinomas
Kaposi sarcoma
carcinomas of the kidney
 carcinomas of the vulva and perineum

10. Special Organ Complications
• involve:
 heart
 bone marrow
GVHD is an important and often lethal complication
of allogenic BMT
 Acute GVHD :
 first 3 months after transplantation
mucosal, skin, liver, gastrointestinal tract involvement
Intraorally there are nonspecific mucosal ulcers and
palatal mucoceles. (Figures 21-10 to 21-12).

11. • Chronic GVHD :
occurs later (often after day 100)
 characterized by skin changes similar to those in scleroderma, sicca syndrome, malabsorption, and
features of autoimmunity.

12. DENTAL MANAGEMENT
• Pretransplant Medical Considerations :

13. Posttransplantation Medical Considerations:
(1) immediate posttransplantation period:
first 3 months after
immunosuppressive therapy
(2) stable posttransplantation period
 (3) chronic rejection period.

14. (2) stable posttransplantation period

15. TREATMENT PLANNING CONSIDERATIONS
• Pre transplantation Patients

16. Post transplant Patients
Immediate Post transplantation Period.
Stable Post transplantation Period.
Risk of Infection.
Viral Infections.
Excessive Bleeding.
Adverse Reaction to Stress.
Hypertension.
Chronic Rejection Period.

17. Oral Complications and Manifestations
• Oral findings that may indicate over
immunosuppression include :
Mucositis
herpes simplex infections
herpes zoster
CMV infection
Candidiasis
large and slow-to- heal aphthous ulcers and other
ulcerations
unusual alveolar bone loss
 on occasion
Lymphoma
Kaposi sarcoma
squamous cell carcinoma of the lip
hairy leukoplakia.