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| Year : 2015 | Volume
: 26
| Issue : 4 | Page : 678-683 |
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| Prevalence of oral lesions in kidney transplant patients: A single center experience |
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Sumita Kaswan1, Santosh Patil2, Sneha Maheshwari3, Richa Wadhawan4
1 Department of Conservative Dentistry and Endodontics, Jodhpur Dental College, Jodhpur National University, Jodhpur, Rajasthan, India
2 Department of Oral Medicine and Radiology, College of Dentistry, Aljoulf University, Sakaka, Aljoulf, Saudi Arabia
3 Dental College, Jodhpur National University, Jodhpur, Rajasthan, India
4 Department of Oral Medicine and Radiology, Jodhpur Dental College, Jodhpur National University, Jodhpur, Rajasthan, India
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| Date of Web Publication | 8-Jul-2015 |
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 Abstract | | |
Kidney transplant patients (KTPs) have a potential tendency to develop oral lesions due to the administration of immunosuppressive drugs, but their prevalence is still obscure. The aim of the present study was to investigate the oral clinical findings in a group of renal transplant patients in comparison with ageand sex-matched healthy controls (HCs). Three hundred KTPs who underwent transplantation at least six months earlier and 296 HCs were examined clinically for the presence of any oral lesions. Demographic and additional details regarding medications, systemic diseases and duration after transplantation were recorded. Statistical analysis was performed using the Chi-square test, with significance set at P <0.05. The prevalence of oral lesions in KTPs was 56.8% as compared with 29.7% in HCs. The most common lesion observed in KTPs was gingival overgrowth (21.8%), followed by candidiasis (17.1%). Coated tongue (15.9%), followed by leukoplakia (11.3%), were common in HCs. Both gingival hyperplasia and coated tongue were significantly related to poor oral hygiene (P <0.05), but were not significantly related to the immunosuppressive therapy (P >0.05). The findings of the present study indicate the need for a routine and regular oral health check-up, with emphasis on maintenance of oral hygiene for renal transplant patients.
How to cite this article:
Kaswan S, Patil S, Maheshwari S, Wadhawan R. Prevalence of oral lesions in kidney transplant patients: A single center experience. Saudi J Kidney Dis Transpl 2015;26:678-83 |
How to cite this URL:
Kaswan S, Patil S, Maheshwari S, Wadhawan R. Prevalence of oral lesions in kidney transplant patients: A single center experience. Saudi J Kidney Dis Transpl [serial online] 2015 [cited 2022 Mar 6];26:678-83. Available from: https://www.sjkdt.org/text.asp?2015/26/4/678/160128 |
| Introduction | |  |
Kidney transplantation is considered to be the best treatment option for patients with end stage renal disease and offers increased longevity and enhanced quality of life. Post-transplant health-care should include maintenance of the allograft and its function. The increase in the number as well as life expectancy of kidney transplant patients (KTPs) has an impact on oral health services. During the last two decades, significant progress has occurred in graft and patient survival rates after renal transplantation due to improved surgical and tissue-matching techniques, advances in anti-rejection drug therapy and a better surveillance and management of extra-renal risk factors. [1],[2] However, the immunosuppressive treatments necessary for these patients have a few shortand long-term side-effects, such as infection and increased risk of cardiovascular diseases and malignancy, which can be life-threatening to the patient. [3]
Different oral problems have been seen in these patients, either due to a direct consequence of drug-induced immunesuppression or pharmacokinetics. Gingival overgrowth is the most common side-effect of cyclosporine and calcium channel blockers, which are extensively used by the transplant patients. [4],[5] Because of prolonged immunosuppression, these patients are prone to higher chances of developing oral candidiasis compared with the immunocompetant subjects, but data in this regard are scarce. [2],[6] The prevalence of oral lesions in renal transplant patients in the Indian subcontinent is not known. Hence, the aim of the present study was to investigate the oral clinical findings in a group of KTPs in comparison with ageand sex-matched healthy controls (HCs) in the Indian population.
| Materials and Methods | | |
The study was performed on 300 KTPs (156 males, 144 females) from a renal transplant clinic who had received a successful transplant at least six months earlier and were on regular follow-up. Two-hundred and ninety-six ageand sex-matched healthy controls (158 males, 138 females) were recruited from the out patient department of the Jodhpur Dental College General Hospital. A written informed consent was obtained from all the patients. Ethical clearance was obtained from the Institutional Ethics Committee. All the patients were examined clinically for the presence of any oral lesions. Oral lesions were diagnosed clinically by the oral medicine specialist according to the clinically accepted criteria. [7] Biopsy was indicated in cases with a doubtful diagnosis and for suspected malignancy. Demographic and additional details regarding medications, systemic diseases and duration after transplantation were recorded. The observations were analyzed using the computer program SPSS 12 (SPSS Inc. Chicago, IL, USA). Statistical analysis was performed using the Chi-square test. P <0.05 was considered statistically significant.
| Results | | |
A total of 300 KTPs and 296 HCs were studied. The mean age of the KTPs was 38.5 ± 13.6 years and that of the HCs was 41.3 ± 12.5 years. The duration after kidney transplantation ranged from six months to 14 years. The prevalence of oral lesions in the KTPs was 56.8% as compared with 29.7% in the HCs [Table 1]. All the transplant patients (except four) were receiving immunosuppressive drugs, including prednisolone (99%), cyclosporine (98%), tacrolimus (72%), azathioprine (70%), sirolimus (72%), mycophenolate mofetil (86%) and calcium channel blockers (73%), among others (54%). One hundred and seventy oral lesions were observed in KTPs as compared with 89 lesions in HCs. The most common lesion observed in the KTPs was gingival overgrowth (21.8%), followed by candidiasis (17.1%). Pseudomembranous candidiasis (76%) was the most common lesion observed in KTPs. Smoker's palate was also common in the transplant patients (12.3%) as well as the control group (9.1%). Coated tongue (15.9%), followed by leukoplakia (11.3%), was more common in the HCs. The oral lesions in the KTPs were significantly higher than in the control group (P = 0.03). Gingival hyperplasia and candidiasis in the KTPs was significantly related to poor oral hygiene (P <0.05), but was not significantly related to the immunosuppressive therapy (P >0.05). The presence of coated tongue in the controls was also significantly related to poor oral hygiene practices (P <0.05) [Table 2]. The prevalence of gingival hyperplasia in the transplant patients was significantly higher than in the controls (P = 0.02). However, the greater prevalence of candidiasis in KTPs was not significantly higher than in the controls (P = 0.075). | Table 1: Prevalence of oral lesions diagnosed in kidney transplant patients and healthy controls.
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 | Table 2: Correlation of various administered drugs and poor oral hygiene to oral lesions
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| Discussion | | |
It has been largely believed that renal transplant patients have an increased chance of manifesting oral lesions due to their immunosuppressive health state and further because of the medications they receive after the transplant. To prevent rejection, KTPs need to take immunosuppressive therapy for an indefinite period; the common drugs include cyclosporine, azathioprine, cyclophosphamide and prednisolone. These drugs reduce the general immune response of the KTPs, increasing the patients' susceptibility to infections and the potential of developing lesions. [8] Gingival overgrowth is the most commonly known and discussed oral lesion in KTPs and little has been discussed about other oral lesions. [2],[9]
Earlier studies as mentioned in the literature have reported a wide variation in the frequency of occurrence of oral lesions in these patients. [2],[10],[11],[12],[13],[14],[15] King et al, [10] in their study, reported that the prevalence of oral lesions in the transplant patients (54.7%) was higher than that in the HC group (19.4%). They observed that KTPs have a significantly greater risk of gingival enlargement, oral candidiasis and hairy leukoplakia. Al-Mohaya et al [2] reported a higher prevalence of gingival enlargement (74.1%), coated tongue (22.4%) and erythematous candidiasis (15.5%) in KTPs. López-Pintor et al [14] also showed a higher prevalence of oral lesions (40%) in the transplant patients as compared with controls (23.4%). Dirschnabel et al [15] showed that 95.6% patients of the dialysis group, 93.9% of KTPs and 56.7% (21/37) of the control group presented at least one pathological entity in the oral mucosa. The present study reported a higher prevalence of 56.8% in KTPs when compared with a prevalence of 29.7% in HCs, similar to the abovementioned studies. The higher prevalence of oral lesions in KTPs was statistically significant (P = 0.03). The prevalence of oral lesions in KTPs in the present study was in line with the findings of King et al [10] but was higher than the findings of López-Pintor et al. [14]
Few researchers have shown the prevalence of oral lesions only in KTPs. Tyrzyk et al [12] reported a higher prevalence of fungal infections and leukoplakia in 30 KTPs treated with cyclosporine. Spolidorio et al [13] found a higher prevalence of oral lesions in 88 KTPs treated with cyclosporine when compared with 67 KTPs treated with FK-506. de la Rosa et al [11] observed that 60% of patients treated with cyclosporine had oral lesions. de Silva et al [8] observed that 81% of renal transplant patients were suffering from various oral diseases.
Gingival overgrowth was the most common lesion observed in KTP, similar to the findings of other studies as mentioned in the literature. [2],[8],[10] It is a synergistic effect of cyclosporine use in transplant patients. Its prevalence ranges from 22% to 77% according to the literature. [11],[16],[17] The present study reported a prevalence of 21.8% in KTPs, which is similar to the above-mentioned studies but lower than the findings of Al-Mohaya et al, [2] who reported a much higher prevalence of 74%. The reason of this wide variation could probably be attributed to the interference of some factors in the study design. Patients of the younger age group, higher cyclosporine levels and using calciumchannel blocker anti-hypertensive drugs have been reported to have a higher prevalence of gingival overgrowth. [11],[17],[18],[19] The results of the present study reported that overgrowth of the gingiva was associated with poor oral hygiene (P <0.05) but not to the immunosuppressive drug dose (P >0.05), similar to the study of King et al. [17] Also, patients with simultaneous consumption of cyclosporine and calcium channel blockers have shown increased frequency of gingival hyperplasia. [20] In another study by Thomason et al, [21] the KTPs had not received any calcium channel blockers and gingival overgrowth was seen in 16% of these patients. Improvement in the condition can be achieved by implementing proper tooth-brushing technique, topical povidone-iodine application and periodontal treatment. [11],[22] Also, tacrolimus, an immunomodulator drug that has replaced cyclosporine in some transplant procedures, has shown to have a significantly lower risk of inducing gingival hyperplasia. [11]
Oral candidiasis is an opportunistic infection that is associated with multiple risk factors. Previous studies [2],[10],[11],[23],[24] have shown a significantly higher prevalence in the KTPs than in HCs. The results of the present study were also in line with the above-mentioned studies. The prevalence of oral candidiasis in transplant patients varies from 9.4% to 46.7%. [2],[10],[11],[12],[23] Erythematous candidiasis is the most common form of candidiasis, as observed in other similar studies. [2],[10],[11] Golecka et al [6] have shown that renal transplant patients with dentures are more prone for denture candidiasis and angular cheilitis than control subjects with dentures. Thus, proper denture cleaning and adjustment are recommended for transplant patients to prevent this infection.
It is known that hairy leukoplakia is associated with the presence of immunodeficiency states and Epstein-Barr virus in human immunodeficiency virus (HIV)-infected patients. [2],[11] The prevalence of hairy leukoplakia in HIVinfected patients ranges between 9% and 20%. [11],[18],[22] King et al [10] and de la Rosa et al [11] reported the condition in 8.6% and 13% of renal transplant patients, respectively, which is higher than the findings of the present study (3.5%).
Infections related to herpes simplex virus (HSV) are also common in transplant patients. The prevalence of oral HSV infection in the KTPs in the present study was 2.3%, similar to the findings of López-Pintor et al [14] who reported a prevalence of 2.6%. Sometimes, oral HSV infections are more severe in KTPs than in non-immunocompromised patients. [25] Aphthous ulcers were observed in KTPs in only a few studies till date. [14]
Aphthous ulcers have been shown to be related to a high dose of immunosuppressive drugs, the withdrawal of corticoids and/or drug toxicity. [26] In this study, xerostomia was also identified in both the groups. This could be the result of use of antidepressants and diuretic agents, which are usually used in KTPs. The prevalence of lichen planus in KTPs was first reported by López-Pintor et al, [14] who reported a prevalence of 0.6% and 0.8% in KTPs and HCs, respectively. The present study reported a much higher prevalence of 6.5% and 5.6% in KTPs and HCs, respectively. It has been suggested by few researchers that topical immunosuppressive agents are an effective and secure treatment for lichen planus, which is similar to the drugs administered to the KTPs and hence they might not be the treatment of choice for lichen planus. [14],[27]
It is well known that immunosuppressive therapy increases the risk of malignancy. [2],[10] The incidence of malignancy ranges from 2.3% to 31%. [14] An increase in the incidence of intraoral malignancy in patients on long-term immunosuppressive therapy can be witnessed as the time elapses. Lip cancer was shown to be more frequent in males and elderly patients in a lengthy post-transplant follow-up. [14] Also, KTPs are at an increased risk for other malignancies such as Kaposi's sarcoma, uterine cervix cancer, gastric cancer, basal cell carcinoma and non-Hodgkin's lymphoma. [2],[28]
| Conclusion | | |
Solid-organ transplantation is the most accepted procedure for patients with irreversible organ failure, which is associated with different side-effects, and the necessary immunosuppression leads to increased rates of infection, malignancy and various other complications. The findings of the present study suggest that KTPs should undergo routine and regular comprehensive oral examination, to diagnose any suspicious lesion that can be treated in time. Also, oral hygiene maintenance programs are needed in KTPs to reduce the prevalence and severity of various oral complications.
Conflict of interest: None declared.
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Correspondence Address:
Santosh Patil
Department of Oral Medicine and Radiology, College of Dentistry, Aljoulf University, Sakaka, Aljoulf
Saudi Arabia
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DOI: 10.4103/1319-2442.160128 PMID: 26178537 
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