.................... ...............................................
Paul Glassman, DDS, Christine Wong, DDS, Robert Gish, MD
A review of liver transplantation for the dentist
and guidelines for dental management
The number of recipients of liver
transplants has grown rapidly in the
last few years and is likely to con-
tinue to do so in the future. The
dentist should be prepared to see
individuals who are contemplating or
have had liver transptants.
The major goal of dental interven-
tion, before and after liver transplan-
tation, is the prevention of
bacteremia from an oral source that
could lead to systemic infection. In
addition, pre-transplant medical
conditions of concern to the dentist
include poor drug metabolism,
bleeding disorders, poor wound
healing, and an inability to metabolize
s wall0 wed blood. Post-transplant
dental treatment must take into
consideration immunosuppressive
drugs and the potential for infections.
Dental treatment should include a
thorough dental examination, elimina-
tion of dental problems that could
cause medical problems, and an
intensive preventive dentistry pro-
gram to minimize the occurrence of
dental disease.
74 Special Care in Dentistry, Vol 13 No 2 1993
uman organ transplantation
has become an accepted
treatment modality for a
variety of acute and chronic illnesses
in the last half of this century. The
American Council of Transplantation
defines a "successful" transplant as
one in which there is normal organ
function one year after the transplant
procedure. By this definition, the first
successful organ transplant was a
kidney transplant performed in 1954
by Drs. Harrison and Murray at the
Peter Bent Brigham Hospital in
Boston.' The first human liver trans-
plant was attempted by Starzl at the
University of Colorado in 1963. That
patient and six others who had
transplants over the next four years
died within 30 days of surgery.2 The
first clinically successful liver trans-
plant was performed by Starzl in
1967.3
The first attempts at liver trans-
plantation were performed with
heterotopic grafts in which extra liver
tissue was grafted alongside a dis-
eased organ. This procedure has now
been largely replaced by orthotopic
liver transplants in which the diseased
liver is removed and a new liver graft
is p l a ~ e d . ~
In the last 20 years, there have been
a number of advances that have led to
a dramatic increase in the number of
organ transplants performed in the
United States. These advances
include breakthroughs in tissue
typing, transportation solutions, and
immunosuppressive drugs. Often
cited as the most significant contribu-
tion to this area was the development
of cyclosporine (Sandimmune3 in the
mid-1970'~.~,~<~ The use of this drug,
along with advances in surgical
management, has been associated
with an increase in the one-year post-
transplant survival rate of 25% prior
to cyclosporine to 60%-80%at the
present time.*
In the last 10 years, the number of
transplanted livers has increased
steadily. In 1967, the United Network
for Organ Sharing was formed as a
national organ procurement and
transplantation network. Statistics
compiled by that organization show
that in 1982 there were 62 liver
transplants performed in the United
States. In 1985, there were 602, and in
1989,2188 livers were transplanted.
As of December, 1990, there were 1206
people waiting for liver transplant
proceduresP The practicing dentist is
becoming more likely to encounter an
individual in his/her practice who
may be contemplating, or who has
already had, a liver transplant proce-
dure.
The authors are associated with the
liver transplant service at California
Pacific Medical Center (CPMC)in San
Francisco, which is a major west coast
transplant center. The Center per-
formed 110 liver transplants in 1992,
with 2/3 of those being in adults. The
dental protocols suggested in this ar-
ticle have been the result of collabora-
tion with the CPMC transplant team.
This article will provide a review
of liver transplantation for the dentist.
Information will be presented on the
indications for liver transplant, the
selection process, the surgery itself,
and the mechanism and implications
of immunosuppression. In addition,
dental considerations will be dis-
cussed, and protocols preseqed for
dental management of patient's pre-
and posttransplantation.

Indicationsfor transplantation
Liver transplantation is an option
for patients with acute liver failure or
progressive and irreversible chronic
liver damage when there is no alterna-
tive medical therapy.’O The principle
indications for liver transplants in
adults include various causes of
chronic liver disease and fulminant
hepatic failure, as listed in Table 1.”
In children, the most common indica-
tion for liver transplantation is
extrahepatic biliary atresia.12
Selection and surgery
Potential liver transplant patients
are medically evaluated in order to
establish a well-supported diagnosis,
determine the severity of the illness,
and identify relative or absolute
contraindications, as listed in Table
2.” The goal of the selection process is
to identify patients who have a higher
likelihood of survival for one year
with a liver transplant than without
one. Currently, only about 50% of
individuals who are considered for
transplant actually undergo the
procedure nationally”, although this
number is 95% at CPMC.
Potential donors are individuals
who have suffered brain injury and
have met the criteria for brain death.
They should have no history of
malignancy other than primary brain
tumor, and no history of liver disease,
excessive alcohol consumption, or
other diseases that can affect liver
function. Cardiopulmonary function
of the donor is maintained until the
liver is removed. The liver is trans-
planted immediately or as soon
thereafter as po~sible.’~
The donor and recipient are
generally matched for ABO blood
group ~ompatibility’~, and for liver
size. Organ preservation solutions are
now available that will allow a donor
liver to be kept for 18-24 h o ~ r s ’thus
~,
allowing donors to be utilized from
distant geographical areas.
The three phases of the transplant
surgery are the donor hepatectomy,
the recipient hepatectomy, and the
implantation of the new liver.” After
the diseased liver is removed, the
patient is maintained by a Veno-Veno
bypass. The new liver is implanted by
Table 1. Principle indications for liver transplantation in adults.
Chronic Liver Disease Primary biliary cirrhosis
Primary sclerosingcholangitis
Cryptogenic cirrhosis
Cirrhosis from idiopathic(autoimmune) chronic active hepatitis
Cirrhosis from viral hepatitis (B, D, non A non B)
Alcoholic liver disease
Bud-Chiari syndrome (HepaticVein Thrombosis)
Hepatocellular carcinoma
Misce11aneou s
Fulminant Hepatic Failure Viral hepatitis (A, B, D, non A non 8)
Drug and toxic hepatic injury
Fulminant Wilson’s disease
Reye‘s syndrome
Massive hepatic trauma
Adapted from Munoz SJ, Friedman LS. Liver transplantation. Med Clin NA 73:lOll-39,1989.
Table 2. Contraindications to liver transplantation.
Absolute Extrahepatic hepatobiliary malignancy
Active sepsis outside the hepatobiliary tree
Severe cardiopulmonarydisease
Acquired immunodeficiency syndrome (AIDS)
Thrombosis of the portal and superior mesenteric veins
Adult Respiratory Distress Syndrome
Relative Age greater than 60 years
Hypoxemia due to intrapulmonary right-to-left shunt
HIV positivity without clinical AIDS
HBsAG positivity
Portal vein thrombosis (superiormesenteric vein must be patent)
Prior complex hepatobiliary surgery
Active alcoholism or drug abuse
-
Inabilitv to understand the magnitude of the undertaking
-
Adapted from Munoz SJ,Friedman LS. Liver transplantation. Med Clin NA 731011-39,1989.
successive anastomosis of the hepatic other aspects of the immune system to
artery, inferior and superior vena function, significantly reducing
cavae, portal vein, and bile duct. serious or fatal bacterial infections and
Retransplantation due to failure of the lowering the overall incidence of
graft is necessary in 5% to 25% of infecti~n.’~,’~
patients.l6 Cyclosporine is a lipid-soluble
decapeptihe derived fiom soil fungi.
immunosuppressive therapy Corticosteroidsand other immuno-
Immunosuppression is vital to the suppressive drugs suppress all
prevention of postoperative graft immunocompetent cells and thereby
rejection. The introduction of hinder the patient’s ability to combat
cyclosporine has dramatically im- infe~ti0n.l~ The mechanism of action
proved the survival rate for liver of cyclosporine, however, is much
transplant recipients. It selectively more selective. It is able to provide
prevents graft rejection while allowing protection against graft rejection
Special Care in Dentistry, Vol13 No 2 1993 75
Table 3. Side-effects of cyclosporine.
Nephrotoxicity
Hypertension
Tremors, nightmares, insomnia
Hepatotoxicity
Hirsutism
Fibrous breast tissue
Gingival swelling
Diarrhea, nausea, vomiting
Infection
Malignancy
Adapted from Munoz SJ, Friedman LS. Liver
transplantation. Med Clin NA 73:lOll-39,
1989.
selectively. It does this in part be-
cause it inhibits the proliferation and
activation of helper/inducer T cells
and cytotoxic T cells while having no
effect on generation or activation of
suppressor T cells.20It also does not
cause bone marrow suppression and
has minimal effect on B cell function.
Cyclosporine does not affect mature
cytotoxic T cells, which expIains why
it prevents graft rejection but is not
useful in its treatment.” The side-
effects of cyclosporine are listed in
Table 3. The side-effect of gingival
enlargement will be discussed below.
Cyclosporine interacts with a number
of other drugs, some of which are
listed in Table 4. Cyclosporine has a
delayed effect of inducing malignant
neoplasms, including non-Hodgkin’s
lymphomas and Kaposi’s sarcoma.
Because of this, many centers now
rely on a triple immunosuppressive
regimen of lower doses of
cyclosporine, prednisone, and
azathioprine.”
Prednisone is a potent anti-inflam-
matory corticosteroid that acts as a
non-selective immunosuppressant by
affecting several levels of the immune
response. Corticosteroids in large
doses are used initially in the treat-
ment of acute rejection. The major
problem with corticosteroids is the
high frequency of associated bacterial,
viral, and fungal infections.
Azathioprine (Imuran9 is a purine
antimetabolite that suppresses hyper-
sensitivities of the cell-mediated type
and causes variable alterations in
76 Special Care in Dentistry, Voi 13 No 2 1993
Table 4. Examples of cyclosporine drug
interactions.
Increase the blood level of cyclosporine
Ketoconazole
Erythromycin
Cimetidine
Decrease the blood level of cyclosporine
Dilantin
Rifampin
Septra/ Bactrim
Increase the risk of nephrotoxicity
Septra/Bactrim
Nonsteroidal anti-inflammatorydrugs
Adapted from Munoz SJ, Friedman LS. Liver
transplantation. Med Clin NA 73:lOll-39,
1989.
antibody production.21Its side-effects
include bone marrow suppression,
stomatitis, hepatitis, malignancy, and
infection. Like cyclosporine, it
interacts with Ketaconazole@,Erythro-
mycin, Cimetidinea, and other drugs.
It is now routinely used in combina-
tion with cyclosporine, especially in
patients with underlying renal or
hypertensive disease, to avoid dose-
related cyclosporine toxicity.”
Another drug used in immunosup-
pression of the post-liver transplant
patient is Antilymphocyte Globulin.
These are a group of antibody prepa-
rations made by injecting an animal
with an antigenic substance such as
human lymphocytes. A more selec-
tive antibody that is now being
prepared is OKT3. This is a murine
monoclonal antibody that is directed
against the T3-antigen receptor on the
human T cell membrane. It interferes
with the antigen recognition process
and the activation and proliferation of
mature lymphocytes. These prepara-
tions can be useful along with steroids
in the treatment of acute rejections,
although some patients develop
antimurine antibodies to them.22
A new drug that is being investi-
gated for use in liver transplant
patients is FK506. It is a macrolide
found in Streptornyces tsukubaensis. It
suppresses T-cell-mediated immunity
in a manner similar to cyclosporine.
FK506 was first used in 1989 to rescue
chronically rejecting livers in patients
with such poor renal function that
cyclosporine could not be used. It
appears to produce a rapid convales-
cence, low steroid requirements, early
discharge from the hospital, and the
elimination of early graft fai1u1-e.~~
FK506 appears in preliminary uncon-
trolled studies to have less
nephrotoxic and neurotoxic side-
effects than cyclosporine. Side-effects
that have bees observed include
nausea and insomnia.24
Medical complications
post4ransplantation
Patients are monitored closely after
liver transplantation. Liver function
tests and cyclosporine levels are
monitored, and abnormalities are
investigated thoroughly. Rejection
can be manifested by fever, increased
abdominal pain, increased ascites,
elevated liver function tests, increased
bilirubin, changes in the color of the
stool or urine, or changes in the bile.
If there is a suspicion of liver rejection,
a liver biopsy is performed to differ-
entiate rejection from other causes of
graft dysfunction.
Infection is the most frequent cause
of mortality and morbidity in liver
transplant patients. This is an ex-
tremely serious problem, since post-
operative infections have been found
to occur in up to 59% of patients and
to be the cause of death in 5%-16%.25,26
This is due to the impaired defense
mechanisms secondary to the liver
disease, the complexity and duration
of the transplant operation, and the
immunosuppressive drug therapy.
Early infections are caused by bacte-
ria, viruses, and other opportunistic
organisms. Cytomegalovirus (CMV)
infection is the most common viral
infection. More than 90% of infections
that occur later than 6 months after
transplant are bacterial.27It is for
these reasons that prophylactic
antibiotics are recommended after
liver transplantation, prior to dental
procedures that have the potential for
causing bacteremia. These recommen-
dations are described below.
Neuropsychiatric complications
include seizures among 10% to 40% of
patients.28Paresthesias and tremors
and seizures may be related to high
doses of cycl~sporine.~~
Renal insuffi-
ciency and hypertension are other
common medical problems following
liver tran~plantation.~~
Dental considerations prior
to liver transplantation
Pretransplantation dental consider-
ations are related mainly to the effects
of severe liver disease and the possi-
bility of transplantation. The primary
goal of dental intervention with
individuals contemplating a liver
transplantation is the prevention of
bacteremia from an oral source that
could lead to systemic infection.
Secondary goals are the elimination
and prevention of dental pain or
infection and dental disease that may
occur or progress before or after the
transplant procedure.
It is desirable to bring the patient’s
dental condition to optimal health
prior to the transplant procedure and
the initiation of immunosuppressive
therapy. This is not always possible,
however, due to the debilitating
effects of the patient’s underlying liver
disease or other systemic disease.
End-stage liver disease has several
consequences that are of concern to
the dentist. First, the liver’s ability to
metabolize drugs may become
severely impaired. Drugs such as
acetaminophen, narcotics, lidocaine,
procaine, mepivicaine, benzodiaz-
epines, barbiturates, erythromycin, or
ampicillin are all metabolized in the
liver. These drugs should be used by
the dentist only after consultation
with the patient‘s physician. Consid-
eration may be given to the use of
alternative drugs?’
An additional consideration with
impaired liver function is the possibil-
ity of bleeding disorders. This may
result from a decrease in coagulation
factors that are manufactured in the
liver, from a thrombocytopenia
caused by direct alcoholic bone
marrow suppression, hypersplenism,
or from increased fibrinolysi~.~~ A bleeding in individuals with severely
patient with one or more of these
disorders may require vitamin K,
fresh-frozen plasma, platelet transfu-
sion, or transfusion of other blood
components before dental treatment.
Appropriate tests include PT (pro-
thrombin time), PTT (partial thrombo-
Table 5. Dental protocol prior to liver transplant.
~~~ ~
1. Obtain medical information, including history, current conditions and treatment,and
anticipated treatment and problems.
2. Obtain a thorough dental history and perform a thorough dental examination,
including full-mouthradiographs.
3. Prioritize dental problems. Those most likely to cause pain, infection, or bacteremia
in the next 12 months should receive the highest priority. Work out the management
plan for dental treatment with medical input from the patient’sphysician.
4. If dental procedures, such as dental extractions, are contemplated that may cause
significant bleeding, the patient’s bleeding potential should be known. Appropriate
tests include PT (prothrombintime), PTT (partialthromboplastin time),platelet
count, and bleeding time. If there are coagulation problems, use the following
guidelines:
a. If the prothrombin time is less than 16 seconds, do not give transfusions. Provide
good surgical management and post-operative instructions.
b. If the prothrombin time is between 16 and 18 seconds and there is borderline
encephalopathy,give fresh-frozenplasma. With no encephalopathy,provide
good surgical management and post-operativeinstructions only.
C. If the prothrombin time is greater than 18 seconds, consider giving fresh-frozen
plasma.
d. If platelet count is inadequate(lessthan 50,000/mm3),considerplatelet replacement.
e. With any extraction, minimize swallowed blood by aggressive suctioning,and
good suturing and packing of extraction sites. Maintain pressure packs in the
operatory under close supervision until hemostasis has been obtained.
5. In the presence of ascites, use prophylactic antibiotics as recommended by the
patient‘s physician prior to dental procedures that are known to cause bacteremia.
The American Dental Association/American Heart Association regimen may be
utilized if the physician has no specific recommendations.
6. After dental treatment, as described above, institute an aggressive regimen of
preventive dental practices. See Table 6 for description.
plastin time), platelet count, and ammonia may result in hepatic
bleeding time. It is the authors’ encephalopathy and coma. This
experience that individuals without becomes an important issue for the
other abnormalities, in whom the PT dentist who is contemplating doing
is less than 1 1/2 times normal dental extractions or other dental
(normal is usually 12 seconds), have procedures that may cause bleeding,
only minimal post-operative bleeding since swallowed blood is a source of
problems. protein that may not be able to be
A complicating factor, in planning properly m e t a b ~ l i z e d Altered
.~~
for dental treatment that may cause protein metabolism also interferes
with proper healing3’
compromised liver function, is a The degree of alteration of protein
diminished ability to metabolize metabolism can be approximated by
proteins. Protein is converted to the degree of encephalopathy. Bor-
ammonia by the gut flora. The liver is derline encephalopathy is defined as
normally able to convert the ammonia poor memory, asterixis (an involun-
to inert urea. When this mechanism is tary flapping tremor consisting of
impaired, however, elevated levels of jerking movements of the hands, seen
Speclal Care In Dentistry, VollS No 2 1993 77
Table 6. Dental protocol after liver transplant. those aspects of the patient’s condition
that relate to the reasons for the
1. Obtain medical information, including history, current conditions and treatment, and
contemplated liver transplant. The
anticipated treatment and problems. patient’s ability to undergo diagnostic
2. If not performed prior to transplant, perform a thorough dental examination, and therapeutic dental procedures
including full-mouth radiographs, should also be assessed as discussed
above.
3. Prioritize dental problems. Those most likely to cause pain, infection,or bacteremia Next, a thorough dental history
within the next 12 months should receive the highest priority. Work out the manage- and examination with full-mouth
ment plan for dental treatment with medical input from the patient’s physician. radiographs should be performed. A
diagnosis of the patient’s dental
4. Use prophylactic antibioticsin immunocompromisedindividuals prior to dental problems should be prioritized.
procedures that are known to cause bacteremia. The American Dental Association/ Those conditions most likely to cause
American Heart Association regimen may be utilized if the physician has no specific pain, infection, or bacteremia in the
next year should receive the highest
recommendations. priority.
5. Consider steroid supplementationprior to major or stressful dental procedures in Dental treatment of the patient’s
individuals who have been on and are no longer on high-dose steroid therapy. dental problems should be carried out
with appropriate modifications made
6. Institute strict oral hygiene procedures, including the use of dental floss, following
to reflect the possible medical compli-
transplantationto prevent the occurrence of cyclosporine-inducedgingival cations described above. A protocol
hyperplasia and other dental pathology. If it has not been accomplished pre- has been developed in conjunction
operatively, remove local irritants and repair or replace defective restorationsor with the CPMC transplant team for
work-up and treatment of patients
appliances. Consider the use of anti-plaqueagents if adequate mechanical plaque prior to liver transplant. It is repro-
removal cannot be accomplished. duced in Table 5.
7. If gingival hyperplasia occurs in spite of the preventive measures just mentioned, Dental considerations after
discuss with the patient’s physician the possibility of reducing the patient’s dosage of liver transplantation
cyclosporineor eliminating its use altogether. Consider surgical removal for severe The medical issues of concern to
gingival hyperplasia that interferes with the patient’s ability to perform adequate the dentist change dramatically after a
successful liver transplant. The
plaque removal or interfereswith mastication.
problems associated pre-operatively
with a failing liver may be largely
gone. These issues are for the most
especially when the arms are ex- tis is a well-known complication of part replaced by concerns related to
tended and the hands dorsiflexed and cirrhosis with ascites, and bacteria the patient being on immunosuppres-
the fingers extended), and slight that are a part of the normal oral flora sive medications.
confusion. The presence of these have been cultured from ascitic f l ~ i d . 3 ~ The major goal of dental interven-
symptoms, which indicates beginning Therefore, antibiotic prophylaxis may tion after, as it is prior to, liver trans-
encephalopathy, means that the be indicated prior to dental treatment plant is the prevention of bacteremia
patient is at high risk from the pres- in individuals with this condition. from an oral source that could lead to
ence of swallowed blood in the GI The decision in an individual patient systemic infection. Secondary goals
The dentist must use extreme should be arrived at after consultation are the elimination and prevention of
caution in this situation to prevent with the patient’s physician. The dental pain or infection and treatment
post-operative bleeding. The authors American Dental Association/ of dental disease that may progress to
therefore recommend that, in patients American Heart Association regimen35 the point of causing pain or infection.
with borderline encephalopathy, may be utilized if the physician has no There is a great deal of variability
fresh-frozen plasma be given at PT’s specific recommendations. in the post-transplant patient’s ability
between 16 and 18 seconds, and that The dental work-up prior to liver to undergo dental procedures. With
good surgical management and post- transplant is generally agreed upon in individuals who are maintained
operative care be provided to prevent the two previous articles on this primarily on cyclosporine, there are
swallowing of blood. subject in the American dental litera- generally fewer problems with
Another issue of concern is ascites, t ~ r e .It~should
~ , ~ start
~ with the healing after dental interventions,
which is an accumulation of fluid in collection of medical data, including including extractions, than with the
the peritoneal cavity secondary to the patient’s medical history, current patient’s taking large doses of ste-
portal hypertension. It is apparent condition, and current and proposed roids.
clinically as a swelling of the abdo- medical and surgical treatment. There are no well-controlled
men. Spontaneous bacterial peritoni- Particular attention should be paid to studies of the necessity for or efficacy

78 Special Care in Dentistry, Vol 13 No 2 1993

of prophylactic antibiotics in
immunocompromised patients.
Svirsky and Saravia have recom-
mended ”during possible bacteremia-
inducing procedures, adherence to
American Heart Association regimen
for prophylactic antibiotic coverage”.36
Little and Rhodus, on the other hand,
differentiate between patients in good
dental health with no evidence of
graft rejection as not needing prophy-
laxis and patients with a need for an
increased dose of immunosuppres-
sants or those with active dental
infection as having indications for
prophylaxis.
As was mentioned earlier, infection
is the most frequent cause of mortality
and morbidity in liver transplant
patients. There is no evidence that the
distinctions made above between
patients in good dental health or those
needing additional doses of immuno-
suppressive medications correlate
with the risk of mortality and morbid-
ity from infection. Until such time as
these or other predictors of the risk of
systemic infection in post-transplant
patients can be demonstrated, the
authors of this article recommend the
use of prophylactic antibiotics prior to
dental treatments that may cause
systemic bacteremia in post-transplant
patients who are taking immunosup-
pressive medications. The American
Dental Association/American Heart
Association regimen35may be utilized
if the patient‘s physician has no
specific recommendations.
Another consideration for post-
transplant patients is that individuals
who have been, but are not currently,
on high doses of steroid may need
steroid supplementation prior to
lengthy or complicated dental proce-
dure~.~ This
’ decision should be made
in conjunction with the patient’s
physician.
A side-effect of cyclosporine that is
of significance to the dentist is gingi-
val hyperplasia. Some centers have
reported an incidence of hyperplasia
as high as 70%.38Clinically, the
hyperplastic tissue appears similar to
that induced by phenytoin sodium
(Dilantin9 and nifedipine
(Pro~ardia~).~’ Histologically, it
consists primarily of connective tissue
with elongated, thin rete pegs. In the
cyclosporine-inducedlesions, how-
ever, the connective tissue is more
vascular and contains a more promi-
nent inflammatory cell
It also appears that the incidence
and severity of the cyclosporine-
induced hyperplasia are related to
oral hygiene and local irritants as they
are with phenytoin. Treatment
consists of dental prophylaxis, oral
hygiene education, removal of local
irritants including repair or replace-
ment of defective restorations or
appliances, use of anti-plaque agents
when adequate mechanical plaque
removal cannot be achieved, and
surgical removal of the hyperplastic
tissue if it interferes with oral hygiene
procedures or mastication.
If the patient is not already on a
strict regimen of procedures designed
to prevent dental disease, such a
regimen should be instituted as soon
as possible after transplantation.
As with preoperative dental
intervention, treatment of the patient’s
dental problems should be carried out
with appropriate modifications made
to reflect the possible medical compli-
cations described above. A protocol
has been developed in conjunction
with the CPMC transplant team for
work-up and treatment of patients
after liver transplant. It is reproduced
in Table 6.
Summary
The number of recipients of liver
transplants has grown rapidly in the
last few years and is likely to continue
to do so in the future. The dentist
should be prepared to see individuals
who are contemplating or have had
liver transplants.
The major goal of dental interven-
tion, before and after liver transplant,
is the prevention of bacteremia from
an oral source that could lead to
systemic infection.
Pretransplant medical conditions
of concern to the dentist include poor
drug metabolism, bleeding disorders,
poor wound healing, an inability to
metabolize swallowed blood, and the
potential for bacteremia of dental
origin leading to systemic infections.
A thorough dental examination
should be performed prior to trans-
plant. Pretransplant dental treatment
Special Care in Dentistry, V o l 1 3 No 2 1993 79
should be prioritized to eliminate
dental problems that could cause
medical problems within the first
year.
Posttransplant dental treatment
must take into consideration immuno-
suppressive drugs and the potential
for infections. After liver transplanta-
tion, it is essential that an intensive
preventive dentistry program be
initiated to minimize the occurrence of
dental disease, including
cyclosporine-induced gingival
hyperplasia.
This article has presented a review
for the dentist of the disease processes
that lead to the necessity for a liver
transplant, the procedures involved in
the transplant, and dental guidelines
for managing patients before and after
a liver transplant.
Dr. Glassman is Associate Professor, Depart-
ment of Dental Practice, and Director of the
Advanced Education Program in General
Dentistry, at the University of the Pacific School
of Dentistry, 2155 Webster Street, San Francisco,
California 94115. Dr. Wong is Resident,
Advanced Education Program in General
Dentistry, University of the Pacific School of
Dentistry, San Francisco, California. Dr. Gish is
Medical Co-Director, Liver Transplant Program,
California Pacific Medical Center, San Fran-
cisco, California. Address correspondence to
Dr. Glassman.
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status, and future prospects for organ
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Kantorowitz JA, Moskowitz J, Rheinstein
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Evolution of liver transplantation.
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Orthotopic homotransplantation of the
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Cyclosporine: A new immunosupressive
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6. Starzl TE, Iwatsuki S, Shaw BW Jr, et al.
Orthotopic liver transplantation in 1984.
Transplant Proc 17250-8,1985.
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Hepatic retransplantation. Transplant
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