Year : 2009 | Volume
: 20 | Issue : 1 | Page : 20--29
Oral lesions in Saudi renal transplant patients
Maha Ali Al-Mohaya1, Azmi Mohammad-Ghaleb Darwazeh2, Salih Bin-Salih3, Waleed Al-Khudair4,
1 Oral Medicine Clinic, Riyadh Armed Forces Hospital, Riyadh, Saudi Arabia
2 Department of Oral Medicine and Surgery, Jordan University of Science and Technology, Irbid, Jordan
3 Department of Medicine King Abdulaziz Medical City, Riyadh, Saudi Arabia
4 Department of Surgery, King Abdulaziz Medical City, Riyadh, Saudi Arabia
Maha Ali Al-Mohaya
Consultant of Oral Medicine, Riyadh Armed Forces Hospital, P.O. Box 7897, Riyadh 11159
Renal transplantation has evolved as the best treatment option for patients with endstage renal disease. Different oral problems arise in these patients, either as a direct consequence of drug-induced immunosuppression or pharmacokinetics. To determine the prevalence of intra-oral lesions in a group of medically stable Saudi renal transplant patients (RTP) and to identify possible risk factors, in comparison with age and sex-matched healthy control subjects (HCS), we studied 58 RTP and 52 HCS. All subjects had a thorough oral examination and oral lesions were diagnosed according to the clinically accepted criteria. Gingival overgrowth (GO), erythematous candidiasis (EC) and hairy leukoplakia (HL) were diagnosed in RTP with prevalence of 74.1%, 15.5%, and 8.6%, respectively. The severity of the gingival overgrowth significantly correlated with the use of cyclosporine and nifedipine combination therapy, serum cyclosporine, and serum creatinine level. In conclusions, the finding of our study strongly propose that RTP should undergo routine and regular comprehensive oral examination, and any suspicious lesion must be investigate and treated.
|How to cite this article:|
Al-Mohaya MA, Darwazeh AM, Bin-Salih S, Al-Khudair W. Oral lesions in Saudi renal transplant patients.Saudi J Kidney Dis Transpl 2009;20:20-29
|How to cite this URL:|
Al-Mohaya MA, Darwazeh AM, Bin-Salih S, Al-Khudair W. Oral lesions in Saudi renal transplant patients. Saudi J Kidney Dis Transpl [serial online] 2009 [cited 2021 Jan 24 ];20:20-29
Available from: https://www.sjkdt.org/text.asp?2009/20/1/20/44702
Renal transplantation has evolved as the best treatment option for patients with end-stage renal disease. During the last two decades, a significant progress has been achieved in graft and patient survival after renal transplantation. In part, this was attributed to improved surgical and tissue matching techniques, and to advances in the anti-rejection drug therapy. , The increase in the number and life expectancy of renal transplant patients (RTP) has an impact on oral and dental health services. Different oral and dental problems arise in these patients, most of which develop as a direct consequence of drug-induced immunosuppression or pharmacokinetics. ,,
Gingival overgrowth (GO) is a well recognized side effect of cyclosporine and calcium channel blockers, , and both drugs are extensively used by RTP. The prevalence of GO among RTP receiving both cyclosporine and calcium channel blocker is believed to be greater than in those receiving only cyclosporine. ,,
Amongst the different types of severe systemic infections following renal transplantation are those caused by fungi which carry a high mortality rate. , Oral candidiasis in RTP has been rarely studied in comparison with other immunosuppressed patients such as those with HIV/AIDS. 
Due to prolonged immunosuppression, RTP are expected to be more liable to oral candidiasis compared with the immunocompetant subjects, but data in this regard are limited. 
Hairy leukoplakia (HL) was first described in 1984, and at that time it appeared to be limited to HIV seropositive patients.  Subsequent case reports have confirmed that this lesion occurs also in immunosuppressed HIV seronegative patients; , however, studies on its prevalence in RTP are sparse. ,
Prevalence of oral lesions in the Saudi renal transplant population is largely unknown. Therefore, the aim of this study was to determine the prevalence of intra-oral lesions in a group of medically stable RTP, and to identify possible risk factors that may be associated with the development of these lesions, in comparison with age and sex-matched healthy control subjects (HCS).
Patients and Methods
Fifty eight consecutive RTP, who had successful kidney transplant for at least 6 months, were recruited from the out-patient Renal Transplant Clinic at King Abdulaziz Medical City (KAMC). The control subjects constituted of 52 apparently healthy, age and sex-matched individuals and were recruited from the out-patient clinic at the College of Dentistry, King Saud University, Riyadh, Saudi Arabia. All control subjects were attending for routine dental treatment. Participants were asked to sign an informed consent form which was approved by the local ethical committee.
The demographic data for each subject were recorded [Table 1]. Thorough oral and peri-oral examination was performed by the principal investigator (MAM). Oral lesions, when present, were diagnosed according to the history and the clinically accepted criteria.  Lesions with doubtful clinical diagnosis were biopsied. Criteria for diagnosis of oral lesions were as follows:
Gingival overgrowth (GO)
GO was diagnosed and scored according to Angelopoulos and Goaz.  Score 0: no GO [Figure 1]; Score 1: mild GO covering only the gingival one third of the tooth crown or less [Figure 2]; Score 2: moderated GO extending up to the middle of the crown [Figure 3]; Score 3: severe GO covering more than one half of the crown [Figure 4].
Hairy leukoplakia (HL)
The diagnosis of HL was made according to the criteria proposed by Ecclearinghouse.  An asymptomatic whitish gray lesion on the lateral margins of the tongue which is not removable and may exhibit vertical corrugation was diagnosed clinically as HL [Figure 5].
Erythematous candidiasis (EC) was diagnosed according to the Ecclearinghouse  presumptive criteria as red areas located on the dorsum of the tongue or palate [Figure 6]. The clinical diagnosis was confirmed by microscopic demonstration of candidal hyphae or blastospores in the smear and by positive growth of Candida colonies from swabs collected from clinically infected area and cultured on Sabouraud's agar plates. Candida species were identified using serum germ tube formation test and the commercially available yeast identification system API 20C AUX  (bioMerieux, Marcyl, Etiole, France).
Other intra-oral lesions were diagnosed according to the criteria described by Pindborg. 
Blood investigations for RTP included blood urea nitrogen (BUN) levels, serum creatinine level, serum cyclosporine levels, and fasting blood glucose levels.
A total of 58 RTP (36 male and 22 female) and 52 HCS (34 male and 18 female) participated in the study. The mean age of RTP was 39.2 years (SD 12.8) ranging from 16 to 62 years, and of the HCS 37.1 years (SD 11.6) ranging from 16 to 60 years. The mean duration of transplant was 51.6 months (SD 31.9) ranging from 7 to 125 months. The source of renal transplant was cadaver in 39 (67.2%) patients, living non-related donor in 10 (17.2%) and living related donor in 9 (15.5%) RTP. None of the subjects was fully edentulous or using removable dentures. The RTP (except two patients) were all on combination of immunosuppressant agents. All RTP were taking the prednisolone, while 56 (96.6%) were on cyclosporine and 37 (63.8%) were on calcium channel blockers.
A total of 97 oral lesions or conditions were diagnosed in RTP compared to 38 lesions diagnosed in HCS. [Table 2] shows the oral findings in both groups.
GO was the most frequently encountered lesion in RTP where it was diagnosed in 74.1% of the patients, while none of the HCS had clinically evident GO (p= 0.000). Forty-one (95.3%) patients with GO were on cyclosporine, while 32 (74.4%) were on calcium channel blocker (either nifedipine or amlodipine). The prevalence of GO among RTP who were medicated by both cyclosporine and calcium channel blocker (30/35 cases; 85.7%) was significantly higher (p= 0.006) than those who were on cyclosporine alone (11/21(52.4%) cases).
All cases of RTP with severe GO were on combination of cyclosporine and calcium channel blockers. A total of six out of nine (66.7%) patients with moderate GO were on both medications. On the other hand, only 2/9 (22.2%) patients who were on cyclosporine alone had moderate GO, while none had severe GO [Table 3]. No significant difference was detected between RTP with GO and those without GO in respect to age, gender, teeth brushing, Miswak use, smoking, dental status or duration of transplantation.
The statistical analysis showed no significant difference in the mean values of the blood investigations among RTP with and without GO except for serum cyclosporine level, which was significantly higher in patients with GO (mean 180± 55 ng/mL) compared with those without GO (mean 140 ± 40.4 ng/mL, p= 0.01) [Table 4].
One way ANOVA test has shown that RTP with severe GO had significantly higher mean of serum creatinine level than those with mild GO (194 v.s. 141 µmol/L, p= 0.01). Similarly, the mean fasting blood glucose levels were significantly higher in RTP with severe GO than in those without GO (7.3 v.s. 5 mmol/L, p= 0.03).
The second most frequently diagnosed oral lesion in RTP was erythematous candidiasis (EC), which was diagnosed in 9 (15.5%) RTP, while Candida-associated angular cheilitis was diagnosed in only one (1.7%) patient who had concomitantly EC. C. albicans was isolated from five lesions (55.6%), while C. dubliniesis and C. famata each was isolated from two lesions (22.2%). None of the HCS had oral candidiasis. The prevalence of EC in RTP was significantly higher than in HCS (p= 0.002). Seven (77.8%) cases of EC were located on the dorsum of the tongue, while the remaining 2 (22.2%) cases were on the dorsum of the tongue as well as on the hard palate. The prevalence of EC was not related to age, gender, smoking, teeth brushing or duration of transplantation. Eight out of 33 (24.2%) RTP who were not using Miswak have shown clinical and microbilogical evidence of EC, and this was significantly higher than 1/25 (4.0%) of RTP who were using Miswak and developed EC (p= 0.04) [Table 5].
HL was diagnosed in 5 (8.6%) RTP, but was not observed in any HCS (p= 0.04). All lesions were present bilaterally on the lateral border of the tongue. No significant difference could be detected in the mean values of blood investigations between RTP with HL and those without. Due to small number of patients with HL, no attempt was made to investigate the possible correlation with other variables such as medications, age, and gender.
It is generally believed that RTP exhibit an increased prevalence of oral lesions that could be related either to the patient's medications or to their immunosuppressive state. However, with exception of GO, little is known about the prevalence of intra-oral lesions in RTP. ,
The prevalence of clinically evident GO among RTP of this study (74.1%) is within the range of 25%-81% of drug-induced GO previously reported by other studies, ,,,,,3,, but higher than 22% reported in RTP by KING et al.  The wide range in the reported prevalence of druginduced GO in RTP could be related to intrinsic variations in population samples such as genetic differences, standards of oral hygiene, the dose and duration of treatment and the criteria used to quantify the gingival enlargement. ,
The pathogenesis of the drug-induced GO is still a subject of investigation. The results of recent studies have indicated that cyclosporine affects signaling molecules in gingival fibroblasts inducing an increase in AP-1, IL-6, and TGF-beta1 activity, which all increase the expression of fibrinogenic molecules and promote GO. , Stereological studies have shown that cyclosporine-induced GO represent altered composition of gingival tissue characterized by increased thickness of epithelium, blood vessels, and non-collagenous matrix in the connective tissue. , In addition, the suppression of T cell function in the gingival tissues by cyclosporine therapy can result in an increase of human papillomavirus infection, adding to the proliferative activity of cyclosporine. 
The data from this study have shown that RTP on a combination of therapy (cyclosporine and calcium channel blocker) had remarkably higher incidence and severity of GO when compared with those who were on cyclosporine alone, which was observed by others. ,, However, the reasons are still not precisely determined. A common pharmacodynamic feature of both drugs is their action on calcium hemostasis. Calcium channel blockers are calcium antagonists, and cyclosporine is known to lower the cytosolic free calcium. The synthesis and release of collagenases and other metalloproteinases from gingival fibroblasts are calciumdependent processes. Consequently, the intake of these drugs may lead to an impairment of collagenase synthesis and/or release, which may result in impaired collagenolysis.  The imbalance between collagen production and breakdown may be one of the mechanism(s) that may contribute to the development of GO in RTP. Theoretically, the combined inhibitory effects of both drugs on calcium-dependent collagenase production may explain the qualitative and quantitative increase in gingival overgrowth observed in patients on combination of therapy. Flynn et al  have demonstrated that therapeutic combination of cyclosporine A and nifedipine could induce gingival edema synergistically secondary to increased sulfated-glycosaminoglycan (sGAG) synthesis by gingival fibroblasts.
Unfortunately, we were unable to evaluate the prevalence of GO among RTP who were taking calcium channel blocker alone due to very few number of patients taking this medication only (two patients). However, the relationship between drug pharmacokinetic variables and the prevalence and severity of GO remains a matter of debate. Some studies suggest that a serum threshold concentration of cyclosporine is necessary to induce gingival changes. ,,,,
The present study found that the mean concentration of serum cyclosporine among RTP with GO was significantly higher than that in patients without GO. Recent studies have shown that the conversion of RTP medicated with cyclosporine to other immunosuppressive agents such as tacrolimus resulted in resolution or improvement of GO. , Additionally, we showed that RTP with severe GO had higher level of serum creatinine than those with mild GO. It is well known that elevation of serum creatinine concentration is an indicator of renal function impairment. Such elevation might be predisposed by cyclosporine-induced nephrotoxicity. 
It is widely accepted that hyperglycemia is associated with biological alterations, which predispose to periodontal disease.  The present study has shown that blood glucose concentration in RTP with severe GO was significantly higher than that in patients without GO. Whether higher blood glucose level in RTP acts as a co-factor contributing to the development or severity of GO in those patients needs further study.
Few case reports have documented malignant changes in drug-induced GO. ,, Therefore, oral health care providers dealing with RTP should be aware of this possibility and any suspicious lesion should be referred for histopathologic examination.
Oral candidiasis has been described in anecdotal reports of RTP. ,, However, with exception of few studies, ,, the prevalence of oral candidiasis in RTP remains to be determined. In our study patients, EC was diagnosed in 15.5% of the patients, while none of the control subjects had oral candidal infection. However, no correlation could be detected between EC and age, gender, or smoking habit. Moreover, the development of EC was not related to lack of oral hygiene practice in term of teeth brushing, which may suggest that oral candidiasis was related mainly to immunosuppressive agents per se than any other factor. Our observation that RTP who used Miswak as an oral hygiene tool had significantly lower prevalence of oral candidiasis may suggest an antifungal effect of Miswak, which has been demonstrated by some recent in vitro studies. 5,,
Over the past two decades, several reports described fungal infections in immunocompromised patients, such as organ transplant patients, caused by Candida species other than albicans. , Among our RTP, C. famata and C. dubliniesis were responsible for infection in 44.5% of the cases.
It is strongly believed that HL is associated with the presence of Epstein-Barr virus (EBV).  The prevalence of HL in HIV-infected patients ranges between 9% and 20% (51-54%). King et al  reported HL in 8.6% of RTP, which is not far away from 11.3% among our RTP. This finding supports the view that HL is not specific to HIV infection but is a general manifestation of immunosuppression.
The emergence of HL in HIV-infected patients is regarded as a marker for progression to AIDS. ,,,, The clinical significance of HL in RTP is difficult to interpret at this stage, but may be regarded as a marker of a significant overimmunosuppression.
It is well known that immunosuppressive therapy increases the risk of malignancy. , Despite the fact that RTP are usually maintained on long-term powerful immunosuppressive therapy, the incidence of intra-oral malignancy appears low. As RTP survive longer, we may witness an increase in the incidence of intra-oral malignancy in patients on long-term immunosuppressive therapy. Nevertheless, kidney transplant recipients are at high risk to develop other malignancies such as Kaposi's sarcoma, cancer of the uterine cervix, gastric cancer, basal cell carcinoma and non-Hodgkin's lymphoma.  None of these lesions were encountered among our study patients, possibly due to the relatively small sample size.
The other intra-oral lesions observed among RTP in this study were not believed to be associated either with renal transplantation or immunosuppression. In addition, their prevalence was not significantly different from that in HCS.
We conclude that the findings of the present study suggest RTP should undergo routine and regular comprehensive oral examination, and any suspicious lesion must be investigated and treated. In addition, RTP should be routinely screened for oral candidiasis, and identified lesions treated with appropriate antifungal therapy. Strict oral hygiene and care are emphasized in RTP.
|1||Abecasis M, Barlett ST, Collins AJ, et al. Kidney transplantation as primary therapy for end-stage renal disease: a National Kidney Foundation/Kidney Disease Outcomes Quality Initiative (NKF/KDOQITM) conference. Clin J Am Soc Nephrol 2008;3(2):471-80.|
|2||Peddi VR, Whiting J, Weiskittel PD, Alexander PD, Alexander JW, First MR. Characteristics of long-term transplant survivors. Am J Kidney Dis 1998;32(1):101-6.|
|3||de la Rosa-Garcia E, Mondragon-Padilla A, Irigoyen-Camacho ME, Bustamante-Ramirez MA. Oral lesions in a group of kidney transplant patients. Med Oral Patol Oral Cir Bucal 2005;10(3):196-204.|
|4||Marsot-Dupuch K, Quillard J, Meyohas MC. Head and neck lesions in the immunocompromised host. Eur Radiol 2004;14(Suppl 3): E155-67.|
|5||Seymour RA, Thomason JM, Nolan A. Oral lesions in organ transplant patients. J Oral Pathol Med 1997;26(7):297-304.|
|6||Lima RB, Benini V, Sens YA. Gingival overgrowth in renal transplant recipients: a study concerning prevalence, severity, periodontal, and predisposing factors. Transplant Proc 2008; 40(5):1425-8.|
|7||Thomason JM, Seymour RA, Ellis JS, et al. IdIatrogenic gingival overgrowth in cardiac transplantation. J Periodontol 1995;66(8):742-6.|
|8||de Oliveria Costa F, Diniz Ferreira S, De Miranda Cota LO, Da Costa JE, Aguiar MA. Prevalence, severity, and risk variables associated with gingival overgrowth in renal transplant subjects treated under tacrolimus or cyclosporin regimens. J Periodontol 2006;77(6): 969-75.|
|9||Radwan-Oczko M, Boratynska M, Klinger M, Zietek M. Risk factors of gingival overgrowth in kidney transplant recipients treated with cyclosporine A. Ann Transplant 2003;8(4):57-62.|
|10||King GN, Healy CM, Glover MT, et al. Prevalence and risk factors associated with leukoplakia, hairy leukoplakia, erythematous candidiasis and gingival hyperplasia in renal transplant recipients. Oral Surg Oral Med Oral Pathol 1994;78(6):718-26.|
|11||Badiee P, Kordbacheh P, Alborzi A, Zeini F, Mirhendy H, Mahmoody M. Fungal infections in solid organ recipients. Exp Clin Transplant 2005;3(2):385-9|
|12||Paya CV. Fungal infections in solid organ transplantation. Clin Infect Dis 1993;16(5):677-88.|
|13||Samaranayake LP. Oral mycoses in HIV infection. Oral Surg Oral Med Oral Pathol 1992; 73(2):171-80.|
|14||Golecka M, Oldakowska-Jedynak U, Mierz - winska-Nastalska E, Adamczyk-Sosinska E. Candida-associated denture stomatitis in patients after immunosuppression therapy. Transplant Proc 2006;38(1):155-6.|
|15||Greenspan D, Greenspan JS, Conant M, Petersen V, Silverman S, De Souza Y. Oral 'hairy' leukoplakia in male homosexuals: Evidence of association with both papillomavirus and a herpes-group virus. Lancet 1984; 2:831-4.|
|16||Itin P, Rufli T, Rudlinger R, et al. Oral hairy leukoplakia in a HIV-negative renal transplant patient: a marker for immunosuppression? Dermatologica 1988;177(2):126-8.|
|17||Syrjanen S, Laine P, Niemela M, Happonen RP. Oral hairy leukoplakia is not a specific sign of HIV infection but related to immuno-suppression in general. J Oral Pathol Med 1989;18(1): 28-31.|
|18||Pindporg JJ. Atlas of diseases of the oral mucosa. Copenhagen: Munksgaard; 1992.|
|19||Angelopoulos AP, Goaz PW. Incidence of diphenylhydantoin gingival hyperplasia. Oral Surg Oral Med Pathol 1972;34:898-906.|
|20||EC-CLEARINGHOUSE on oral problems related to HIV infection and WHO Collaborating Center on oral manifestation of the immunodeficiency virus. Classification and diagnostic criteria for oral lesions in HIV infection. J Oral Pathol Med 1993;22(7):289-91.|
|21||Schuffenecker I, Freydiere A, De Nontclos H, Gille Y. Evaluation of four commercial systems for identification of medically important yeasts. Eur J Clin Microbiol Infect Dis 1993;12(4):255-60.|
|22||Tyldesley WR, Rotter E. Gingival hyperplasia induced by cyclosporine-A. Br Dent J 1984; 157(9):305-9.|
|23||Thomson JM, Seymour RA, Ellis JS. Risk factors for gingival overgrowth in patients medicated with ciclosporin in the absence of calcium channel blockers. J Clin Periodontol 2005;32(3):273-9.|
|24||Daley TD, Wysocki GP, Day C. Clinical and pharmacological correlations in cyclosporininduced gingival hyperplasia. Oral Surg Oral Med Oral Pathol 1986;62(4):417-21.|
|25||Seymour RA, Smith DG, Rogers SR. The comparative effects of azathioprin and cyclosporin on some gingival health parameters of renal transplant patients: a longitudinal study. J Clin Periodontol 1987;14(10):610-3.|
|26||Pernu HE, Pernu LM, Huttunen KR, Nieminen PA, Knuttila ML. Gingival overgrowth among renal transplant recipients related to immunosuppressive medication and possible local background factors. J Periodontol 1992;63(6): 548-53.|
|27||McGaw T, Lam S, Coates J. Cyclosporininduced gingival outgrowth: Correlation with dental plaque scores, gingivitis scores and cyclosporin levels in serum and salvia. Oral Surg Oral Med Oral Pathol 1987;64(3):293-7.|
|28||Chae HJ, Ha MS, Yun DH, et al. Mechanism of cyclosporine-induced overgrowth in gingiva. J Dent Res 2006;85(6):515-9|
|29||Bostrom A, Bharath H, Saulewicz A, Narayan AS. Cyclosporin A affects signaling events differentially in human gingival fibroblast. J Dent Res 2005;84(6):532-536.|
|30||Hyland PL, Traynor PS, Myrillas TT, et al. The effects of cyclosporin on the collagenolytic activity of gingival fibroblasts. J Periodontol 2003;74(4):437-45.|
|31||Wondimu B, Reinholt FB, Modeer T. Stereologic study of cyclosporine-induced gingival overgrowth in renal transplant patients. Eur J Oral Sci 1995;103(4):199-206.|
|32||Bustos DA, Grenon MS, Benitez M, De Boccardo G, Pavan JV, Gendelman H. Human papillomavirus infection in cyclosporineinduced gingival overgrowth in renal allograft recipients. J Periodontol 2001;72(6):741-4.|
|33||Torrezan PR, Andrade Sobrinho J, Denardin OV, Rapoport AC. Cyclosporine induced gingival hyperplasia in kidney transplants. Rev Assoc Med Bras 2005;51(4):200-5.|
|34||King GN, Fullinfaw R, Higgins TJ, Walker RG, Francis DM, Wiesenfeld D. Gingival hyperplasia in renal allograft recipients receiving cyclosporin A and calcium antagonists. J Clin Periondontol 1993;20:286-93.|
|35||Thomason JM, Seymour RA, Rice N. The prevalence and severity of cyclosporin and nifedipine-induces gingival overgrowth. J Clin Periodontol 1993;20(1):37-40.|
|36||Flynn JC, Henderson JS, Johnson RB. Synergism between nifedipine and cyclosporine A on the incorporation of [35S] sulfate into human gingival fibroblast cultures in vitro. J Periodontal Res 2006;41(4):316-21.|
|37||Walker RG, Cottrell S, Sharp K, et al. Conversion of cyclosporine to tacrolimus in stable renal allograft recipients: Quantification of effects on the severity of gingival enlargement and hirsutism and patient-reported outcomes. Nephrology 2007;12(6):607-14.|
|38||Thorp M, Demottos A, Bennett W, Barry J, Norman D. The effect of conversion from cyclosporine to tacrolimus on gingival hyperplasia, hirsutism and cholesterol. Transplantation 2000;69(6):1218-20.|
|39||Bobadilla NA, Gaba G. New insights into the pathophysiology of cyclosporine nephrotoxicity. Am J Physiol Renal Physiol 2007;293(1):F2-9.|
|40||Karjalainen KM, Knuuttila ML. The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1996;23:1060-7.|
|41||Rolland SL, Seymour RA, Wilkins BS, Parry G, Thomason JM. Post-transplant lymphoproliferative disorders presenting as gingival overgrowth in patients immunosuppressed with ciclosporin: a report of two cases. J Clin Periodontol 2004;31:581-5.|
|42||Qunibi WY, Akhtar M, Ginn E, Smith P. Kaposi's sarcoma in cyclosporine-induced gingival hyperplasia. Am J Kidney Dis 1988;11 (4):349-52.|
|43||Varga E, Tyldesley WR. Carcinoma arising in cyclosporin-induced gingival hyperplasia. Br Dent J 1991;171(1):26-7.|
|44||Romano C, Ghilardi A, Carcagni MR, De Aloe GA. Case of oral erosive candidosis in a kidney transplant patient. Mycoses 2004;47(11-12):524-6.|
|45||Al-Mohaya MA, Darwazeh AM, Al-khudair W. Oral fungal colonization and oral candidiasis in renal transplant patients: the relationship to Miswak use. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93(4):455-60.|
|46||al-Bagieh NH, Idowu A, Salako N. Effect of aqueous extract of miswak on the in vitro growth of Candida albicans. Microbios 1994;80 (323):107-13.|
|47||Abu Alsamh D, Al-bagieh N. ABU. A study of the antimicrobial activity of the miswak ethanolic extract in vitro. Biomed Lett 1996;53:225-38.|
|48||Wingard JR, Merz WG, Rinaldi MG, Johnson TR, Karp JE, Saral R. Increase in Candida krusei infection among patients with bone marrow transplantation and neutropenia treated prophylactically with fluconazole. N Engl J Med 1991;325(18):1274-7.|
|49||Vazques JA, Dembry LM, Sanchez V, et al. Nosocomial Candida glabrata colonization: an epidemiologic study. J Clin Microbiol 1998;36 (2):421-6.|
|50||Wurapa AK, Luque AE, Menegus MA. Oral hairy leukoplakia: a manifestation of primary infection with Epstein-Barr virus? Scand J Infect Dis 1999;31(5):505-6.|
|51||Nokta M. Oral manifestations associated with HIV infection. HIV/AIDS Rep 2008;5:5-12.|
|52||Greenspan JS, Greenspan D. Oral hairy leukoplakia: diagnosis and management. Oral Surg Oral Med Oral Pathol 1989;67(4):396-403.|
|53||Thompson SH, Charles GA, Craig DB. Correlation of oral disease with the Walter Reed staging scheme for HIV-1-seropositive patients. Oral Surg Oral Med Oral Pathol 1992;73(3): 289-92.|
|54||Barr CE, Lopez MR, Rua-Dobles A, Miller LK, Mathur-Wagh U, Turgeon LR. HIV-associated oral lesions: immunologic, virologic and salivary parameters. J Oral Pathol Med 1992;21 (7):295-8.|
|55||Katz MH, Greenspan D, Westenhouse J, et al. Progression to AIDS in HIV-infected homosexual and bisexual men with hairy leukoplakia and oral candidiasis. AIDS 1992;6(1):95-100.|
|56||Makitie AA, Lundberg M, Salmela K, Kyllonen L, Pukkala E. Head and neck cancer in renal transplant patients in Finland. Acta Otolaryngol 2008;2:1-4.|
|57||King GN, Healy CM, Glover MT, et al. Increased prevalence of dysplastic and malignnant lip lesions in renal transplant recipients. N Engl J Med 1995;332(16):1052-7.|
|58||Vatazin AV, Prokopenko EI, Shcherbakova EO, Pasov SA, Ivanov IA, Kazantesva IA. Malignant tumors in patients with kidney transplants. Urol Nefrol (Mosk) 2000;5:11-5.|