Immune & Transplant
Dental Management of Patients with Heart / lung / liver transplant
Proceed with physician coordination, labs & precautions
Heart / lung / liver transplant: a stable immunosuppressed patient can usually undergo invasive care with the precautions below and appropriate blood tests.
Emergency vs routine management
If EMERGENCY — what to do
- • Contact the transplant team the same day — oral infection is a serious risk in immunosuppressed patients; treat the source promptly.Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
- • Before invasive treatment obtain a recent FBC: ANC ≥ 1.0 × 10⁹/L and platelets ≥ 50 × 10⁹/L are generally needed for outpatient surgery.Ref: Elad S et al. MASCC/ISOO Clinical Practice Guidelines for oral care / mucositis in cancer therapy. Support Care Cancer 2015–2020
- • Avoid clarithromycin/erythromycin and azole antifungals (fluconazole, miconazole) — they sharply raise tacrolimus/ciclosporin/sirolimus levels. Use amoxicillin (or azithromycin with caution) and topical nystatin.Ref: Stockley's Drug Interactions (current edition)
- • If on corticosteroids, assess the need for stress-dose cover.Ref: Woodcock T et al. Guidelines for the management of glucocorticoids during the peri-operative period (AAGBI/SfE). Anaesthesia 2020;75:654–663
If ROUTINE — what to do
- • Within 6 months of transplant or during rejection: emergency care only, coordinated with the transplant team.Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
- • After stabilisation: routine care with transplant-team liaison; antibiotic cover only if advised by the team.Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
- • Monitor gingival overgrowth (ciclosporin/tacrolimus) and oral lesions (candidiasis, HSV, hairy leukoplakia).Ref: Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
Clinical precautions
- • Coordinate with the transplant / treating physician before invasive care
- • Antibiotic prophylaxis is NOT routinely required for immunosuppression alone — decide case-by-case with the treating physician for invasive/surgical procedures. If indicated: Amoxicillin 2 g orally 1 hour before (adult); if penicillin-allergic, Clindamycin 600 mg or Azithromycin/Clarithromycin 500 mg orally 1 hour before.
- • Meticulous infection control; treat any active oral infection promptly
- • Avoid nephrotoxic NSAIDs; adjust drug doses to renal function
- • Calcineurin inhibitors (tacrolimus, ciclosporin): avoid drugs that raise their levels — azole antifungals (fluconazole) and macrolides (erythromycin, clarithromycin); avoid NSAIDs (additive nephrotoxicity). Ciclosporin can cause gingival overgrowth.
- • Local haemostatic measures
Information & tests to request
- • Months since transplant — Immunosuppression is most intense in the first 3–6 months (and while treating rejection). We defer elective invasive dental care during this window.
- • Absolute neutrophil count — ANC (x10⁹/L) — A full blood count checks for neutropenia (infection risk). We wait for ANC ≥1.0 (ideally ≥2.0) before invasive care; if <1.0 we defer or treat in a hospital setting.
- • Daily prednisolone-equivalent dose (mg) — This patient's condition/therapy is commonly associated with long-term corticosteroids, which can suppress the adrenal response to surgical stress. Enter the daily dose (0 if none) to determine whether supplementary stress-dose cover is needed.
At a glance by procedure
Initial assessment before lab results or timing details are entered.
| Procedure | Initial assessment |
|---|---|
| Examination / radiographs | ROUTINE Routine non-invasive care with precautions |
| Supragingival scaling / polish | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
| Deep scaling / subgingival RSD (subgingival calculus) | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
| Root canal treatment | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
| Simple extraction (1–3 teeth) | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
| Surgical / bony extraction | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
| Implant placement | MODIFY / CAUTION Proceed with physician coordination, labs & precautions |
References
- Transplant patients — dental management (BSDH / BSOM)
- AHA 2021 (endocarditis prophylaxis only if a specific cardiac indication exists)
- Little JW, Miller CS et al. Dental Management of the Medically Compromised Patient, 10th ed., Elsevier 2023
- Elad S et al. MASCC/ISOO Clinical Practice Guidelines for oral care / mucositis in cancer therapy. Support Care Cancer 2015–2020
- Stockley's Drug Interactions (current edition)
- Woodcock T et al. Guidelines for the management of glucocorticoids during the peri-operative period (AAGBI/SfE). Anaesthesia 2020;75:654–663
Related guides
This guide supports — and does not replace — professional clinical judgment. Always consider the individual patient and consult the treating physician when indicated.