Oral Health in Solid Organ Transplantation: An Integrative Review

Rosso, Julia Galato; Dantas, Elaine Maria Guara Lôbo; Galato, Dayani

doi:10.53855/bjt.v29i1.764_PORT

ABSTRACT

After transplantation, patients start taking immunosuppressants to prevent rejection of the transplanted organ. This alters the immune system, making patients more susceptible to infections and diseases of the oral cavity. This necessitates dental care and monitoring both before and after transplantation. This study aimed to describe the main oral manifestations, and the care required for oral health after solid organ transplantation. Materials and methods: This article is an integrative literature review. The following databases were used for the search: Medline through Pubmed; Academic Search Premier through Ebsco and Web of Science (Main Collection Clarivate Analytics/Thomson Reuters), using the terms ‘Organ Transplantation’ and (‘Oral Health’ or ‘dental care’ or ‘Dental health’) as descriptors. A total of 278 papers were identified in the databases, of which 39 were duplicates, leaving 239 for analysis of titles and abstracts. Of these, 220 were excluded and 18 were selected for full-text reading. Of the remaining 16, seven were included in this review. The location of the studies was mainly in Asia and Europe, and they were published between 2007 and 2021. The studies involved kidney, liver, lung and heart transplants and the main types of immunosuppressive drugs were tacrolimus, cyclosporine, mycophenolate, sirolimus and glucocorticoids. The number of patients observed ranged from 19 to 418. The oral health of transplant patients is worse than that of the general population. Periodontal disease, tooth decay and various types of infection were commonly observed due to low immunity, which is why the progression of diseases tends to be faster. Ideally, all oral health conditions should be treated before transplantation. However, this approach is not always feasible, so it is necessary to follow up these patients in the dental clinic. However, this scenario is not the reality found in the findings, several treatments were not carried out and after the transplant these patients do not have periodic follow-up in the dental office, thus observing how the oral health of these patients is often neglected. Transplant patients are more susceptible to dental problems such as periodontal disease, caries and various infections. However, this is not always feasible, so these patients need to be followed up in a dental practice. However, several treatments were not carried out.

Descriptors
Organ Transplantation; Oral Health; Immunossupressive Agents

RESUMO

Após a realização do transplante, os pacientes passam a fazer uso de imunossupressores, visando à prevenção da rejeição do órgão transplantado. Essa terapia medicamentosa altera o sistema imunológico do paciente, deixando-o mais suscetível às infecções e doenças da cavidade oral, sendo, assim, necessário o acompanhamento e tratamento odontológico tanto antes quanto após o transplante. Nesse sentido, tem-se como objetivo descrever as principais manifestações orais e os cuidados necessários com a saúde bucal após o transplante de órgãos sólidos. Trata-se de uma revisão integrativa de literatura. Para a pesquisa, foram utilizadas as bases de dados Medical Literature Analysis and Retrieval System Online (Medline) por meio do PubMed, Academic Search Premier por meio da Ebsco e Web of Science (Coleção Principal Clarivate Analytics/Thomson Reuters), adotando como descritores os termos “Organ Transplantation” and (“Oral Health” or “dental care” or “Dental health”). Foram identificados 278 trabalhos nas bases de dados; destes, 39 estavam duplicados, restando 239 para análise de títulos e resumos, dos quais 18 foram selecionados para leitura de texto completo, sendo sete incluídos na presente revisão. Os estudos foram realizados predominantemente na Ásia e na Europa, sendo publicados entre 2007 e 2021. Os estudos envolviam transplantes de rim, fígado, pulmão e coração, e os principais tipos de medicamentos imunossupressores foram tacrolimus, ciclosporina, micofenolato, sirolimus e glicocorticoides. O número de pacientes observados variou entre 19 e 418. A saúde bucal dos pacientes transplantados apresenta piores condições quando comparada à população em geral. Doenças periodontais, cárie e diversos tipos de infecções foram comumente observadas devido à baixa imunidade; por conta disso, a progressão das doenças tende a ser mais rápida. É importante tratar todas as condições relacionadas à saúde bucal antes do transplante. No entanto, essa abordagem nem sempre é viável, e logo se mostra necessário o acompanhamento desses pacientes no consultório odontológico após o procedimento. Todavia, esse cenário não é a realidade encontrada nos achados: diversos tratamentos não foram realizados, e após o transplante esses pacientes não têm acompanhamento periódico no consultório odontológico, o que representa uma negligência quanto à saúde bucal deles. Os transplantados estão mais suscetíveis a problemas odontológicos, como doença periodontal, cárie e infecções diversas. Sendo assim, é essencial a sensibilização dos pacientes e das equipes assistenciais para o acompanhamento odontológico.

Descritores
Transplante de Órgãos; Saúde Bucal; Imunossupressores

INTRODUCTION

Solid organ transplantation (SOT) was one of the greatest medical advances of the last century, enabling thousands of people to access this replacement therapy. In addition to advances in surgical techniques, the development of immunosuppressive drugs made it possible to reduce the risk of transplant rejection and, consequently, increase the survival of transplant recipients¹.

However, even when the use of immunosuppressive medications is necessary, the situation is not without risk; in addition to predisposing patients to adverse reactions, it also makes them more susceptible to infections. For this reason, and to monitor the clinical course, these patients require periodic follow-up by healthcare team professionals, including the dentist²^-⁴.

Oral health is crucial to the success of the transplant, and the opinion of the responsible professional is required before the procedure can be performed, as an oral source of infection could progress rapidly—for instance, leading to sepsis in an immunosuppressed patient³. In this regard, before transplantation, recipients are advised to seek dental care to address oral health issues and prevent them from progressing to systemic infection. However, depending on the type of transplant and the patient's health status, such pre-procedure care may be very limited and insufficient due to the urgency of the case³.

After the transplant, some patients require follow-up visits to complete specific procedures, such as tooth extractions and periodontal treatment⁵. Furthermore, they must undergo more frequent dental check-ups and maintain rigorous oral hygiene, given that immunosuppression increases susceptibility to oral pathologies—rendering these patients more prone to developing infections (fungal, bacterial, and viral), periodontal diseases, carious lesions⁶, or even malignant oral lesions⁷.

In this context, this article aims to describe the main oral manifestations and the necessary oral health care following solid organ transplantation.

MATERIALS AND METHODS

This is an integrative literature review. The study addressed the research question: "What are the main oral health issues following solid organ transplantation?" Based on the review's findings, key care measures were identified that transplant recipients should adopt to maintain oral health during immunosuppression.

The search was conducted in the Medical Literature Analysis and Retrieval System Online (Medline) database via PubMed, Academic Search Premier via EBSCO, and Web of Science (Core Collection, Clarivate Analytics/Thomson Reuters), using the strategies presented in Table 1.

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Table 1
Search strategies adopted in the research conducted in the databases.

The search was conducted on July 9, 2024, with no time limits applied. Articles identified via the search strategy were included, while review articles, clinical trials (as they represent controlled experiments rather than the usual clinical application of the practice), and non-observational studies were excluded; articles addressing other health issues, hematopoietic stem cell transplantation, or pediatric patients (incorrect population) were also excluded. Furthermore, texts in languages other than the target language—such as French and German—were excluded.

To assist in the document review process, files resulting from the searches were imported into the Rayyan^® software. Initially, duplicate documents were identified; subsequently, titles and abstracts were analyzed independently by two researchers. Following this analysis, a consensus meeting was held to determine which articles would proceed to the full-text analysis stage.

Data were extracted from the selected articles by one researcher and reviewed by a second. The results were organized into two tables: one characterizing the studies—including data on the study location, objective, type of study, type of solid organ transplant undergone by participants, number of subjects, and the immunosuppressive regimen used—and a second detailing the described dental problems (specific issues and observed frequencies), whether regular dental follow-up was reported, the description of oral hygiene assessments, and records of immunosuppressant-induced gingival hyperplasia.

Article quality was assessed using the Newcastle-Ottawa Scale (NOS), which is recommended for observational studies. The criteria (maximum of 8 points) were as follows: random sampling (1 = yes, 0 = no); impartial sampling (1 = yes, 0 = no); well-described study participants (1 = yes, 0 = no); sample size (1 = ≥300 subjects, 0 = <300 subjects); assessment of dental problems via clinical diagnosis by a qualified professional (1 = yes, 0 = no); impartial outcome assessment (1 = yes, 0 = no); response rate (1 = ≥70%, 0 = <70%); and statistical analysis (1 = appropriate statistical test, 0 = no description or inappropriate test).

As this was a literature review study, evaluation by a Research Ethics Committee involving human subjects was not required.

RESULTS

A total of 278 studies were identified in the databases; of these, 39 were duplicates, leaving 239 for title and abstract screening. Of these, 220 were excluded for not fitting the proposed topic, and 18 were selected for full-text reading. However, three could not be located in full; the authors were contacted but did not respond within two weeks. Of the remaining 16, 7 were included in this review (Fig. 1).

Figure 1
Flowchart of the process for including articles in the review on oral health and care for solid organ transplant recipients.

The quality assessment of the included studies is presented in Table 2.

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Table 2
Quality assessment of the studies included in the review on oral health in solid organ transplantation using the Newcastle-Ottawa Scale.

Table 3 presents a description of the included studies, noting that they were conducted primarily in Asia and Europe and published between 2007 and 2021. The studies involved kidney, liver, lung, and heart transplants and the main types of immunosuppressive medications. The number of patients observed ranged from 19 to 418.

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Table 3
Characterization of studies included in the systematic review on oral health and care in patients undergoing solid organ transplantation

Table 4 presents the main oral manifestations and the dental treatments described. Patients exhibit a high need for periodontal and restorative dental treatment, including endodontic procedures and extractions, as well as for treatment of bacterial, viral, or fungal infections—the latter exemplified by Candida albicans. Among patients wearing prosthetic appliances, a significant percentage had stomatitis. Dental attendance among transplant patients was irregular, and oral hygiene quality was reported as poor in the majority of cases—which is evidenced by the fact that the demand for necessary dental treatments, even before transplantation, remained largely unaddressed. Furthermore, Table 4 provides data on drug-induced gingival hyperplasia, which is significant in the context of pharmacovigilance regarding immunosuppressive therapy.

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Table 4
Dental needs and their treatments described in the studies included in the systematic review on oral health and care for solid organ transplant recipients.

One of the studies, Kwak et al.¹³, evaluated post-transplant mortality: among the 418 patients observed, 15 kidney recipients and 1 liver recipient died. Of these, seven died from sepsis, with three having oral infections identified before transplantation. However, it was not possible to associate oral manifestations with the clinical outcome of these patients.

DISCUSSION

The included studies were of moderate quality, with limitations primarily in sampling and statistical analyses. According to these studies⁸^-¹⁴, patients undergoing SOT are subjected to immunosuppressive therapy to prevent graft rejection and ensure the survival of the transplanted organ. Although beneficial, these medications promote significant changes in both systemic and local immune responses, increasing susceptibility to opportunistic infections. In addition to modulating the immune response, some immunosuppressants may alter salivary flow and composition, reduce salivary antimicrobial factors, and promote changes in gingival morphology—factors that contribute to biofilm accumulation on the tooth surface. These microbial communities attached to surfaces are responsible for many oral diseases, such as dental caries and periodontitis¹⁵; furthermore, immunosuppression itself increases the predisposition to tumour development¹⁶.

Biofilms, which are organized communities of microorganisms, may also promote carcinogenesis by stimulating chronic inflammatory responses, increasing the release of pro-inflammatory cytokines and reactive oxygen species, and contributing to drug resistance¹⁷^,¹⁸. Furthermore, the presence of biofilms in the tumour microenvironment can further reduce the effectiveness of the immune system and limit the therapeutic effects of antibiotics and anti-inflammatory drugs. Moreover, bacterial resistance associated with biofilms can hinder the treatment of oral diseases¹⁸.

When associated with poor oral hygiene, these mechanisms can significantly increase the risk of developing infectious diseases in this population⁸^,¹⁰.

Prevalence of periodontal diseases

A high prevalence of periodontal disease was found in almost all studies⁶^,⁸^,⁹^,¹¹^-¹⁴. Notably, in the study by Ziebolz et al.⁹, none of the evaluated patients had a healthy periodontal condition. This poor periodontal health highlights the high frequency of inflammatory changes in periodontal tissues among SOT patients. These findings are corroborated by several other studies included in this review⁶^,⁸^,¹¹^-¹⁴, which demonstrate high indices of gingival inflammation and dental biofilm accumulation. As previously discussed, biofilm, a microbial community attached to a surface, significantly affects oral health. Periodontitis, caries, and peri-implantitis are infectious oral diseases in which oral biofilms play a causal role¹⁹ and affect more than just oral health, having social and psychological impacts¹⁹^,²⁰. These changes may be related to visible oral alterations, such as advanced dental caries and edentulism, which negatively influence self-perception and social interactions¹⁹^, ²⁰.

Periodontal disease poses a risk to SOT patients, as it can promote alveolar bone loss and act as a chronic focus of infection13. The presence of oral bacterial biofilms triggers chronic inflammatory responses in the host, which may result in tissue-destructive events and favour the proliferation of microorganisms such as Porphyromonas gingivalis (P. gingivalis) and Streptococcus mutans (S. mutans)¹³^,¹⁹^-²¹.

Tooth loss is one of the most severe consequences of periodontal disease, which occurs as the condition progresses without proper treatment. In advanced stages of periodontitis, the tooth may reach a degree of irreversible mobility, resulting in the loss of periodontal support²⁰. Furthermore, microbial proliferation in dental biofilm contributes to the development of caries. When this lesion progresses without timely diagnosis and treatment, it may reach the dental pulp, necessitating endodontic treatment to maintain the tooth. This scenario was observed in the study by Guggenheimer et al.³, in which 32% of the observed patients presented with severe dental diseases, as well as in other studies²²^,²³.

Beyond the direct clinical repercussions, oral health also impacts functional aspects such as speech, mastication, and well-being, reducing quality of life levels in this population⁶.

Gingival hyperplasia

Immunosuppressants used after SOT are associated with several alterations in the oral cavity, as demonstrated by the findings⁸^,⁹^,¹¹. Among the most frequently reported is drug-induced gingival overgrowth⁶^,⁸^,⁹^,¹¹^,¹⁴, especially associated with the use of cyclosporine. The prevalence of this condition ranges from 20% to 76% among patients²⁴. The incidence and severity of the disease depend on genetic predisposition, local factors, and habits such as smoking and alcohol consumption⁶. Furthermore, the poor oral hygiene observed in most individuals leads to worsening gingival inflammation. In some cases, even after surgical procedures such as gingivoplasty, gingival overgrowth may recur if oral hygiene quality does not improve⁸.

The findings also provide data on other immunosuppressants that may be associated with similar manifestations. There are reports of gingival overgrowth associated with the use of sirolimus⁹; however, the literature still lacks sufficient studies consistently establishing an association between this medication and gingival overgrowth.

Clinical consequences and opportunistic infections

A study points out the high need for surgical interventions in these patients, such as the removal of root debris, treatment of peri-implantitis and tooth extractions¹⁴. These conditions may represent foci of infection in the oral cavity that, if left untreated, could progress to health complications, as these patients are more susceptible to opportunistic infections due to immunosuppression associated with SOT⁹^,²⁵.

Among opportunistic infections, candidiasis was the most commonly reported oral lesion in immunosuppressed patients¹⁰. Due to the compromised immune system, the fungus C. albicans finds the opportunity to establish itself and proliferate, causing oropharyngeal candidiasis. Patients may also develop deep fungal infections, such as mucormycosis, which presents with necrotic, invasive lesions. This condition has a mortality rate ranging from 65% to 70% in SOT patients²⁴.

Viral infections are also frequently observed and are typically related to human herpesviruses and varicella-zoster virus, with incidence in the SOT patient group ranging from 7.6% to 10.8%, thus higher than that in the general population²⁶. Odontogenic infections are, in almost all cases, polymicrobial, and the latter may have a periodontal or endodontic origin²⁴^,²⁷.

In addition to infections, inflammatory lesions of the oral mucosa are also common. Mucositis affects between 60% and 80% of SOT patients²⁴; in this context, conditions such as mucositis and denture stomatitis can impair speech, food intake, or even medication administration. This occurs due to symptoms such as pain in the oral mucosa, burning sensation, and dryness in the oral cavity⁸. Golecka et al.⁸ demonstrated that patients who used oral prostheses, especially acrylic ones, in combination with immunosuppressive therapy, created conditions for the development of denture stomatitis. Furthermore, they described that low salivary flow and gingival overgrowth may be factors that aggravate the inflammatory condition⁸ – in which case, the healthcare team must be attentive to advise patients on oral hygiene habits, necessary care for the prosthesis, and the ideal treatment to alleviate oral symptoms.

Risk of potentially malignant lesions

Immunosuppressed patients are more predisposed to developing neoplasms, including malignant lesions in the lip region²⁸^,²⁹ and the oral cavity ²⁹. Epidemiological studies indicate that transplant recipients present a significantly higher incidence compared to the general population²⁸^-³⁰. According to a review conducted by Huo et al.³⁰, involving 72 cohorts and over 2 million SOT patients, the risk of developing oral cancer was 3.60 (95% CI: 2.79–4.69), while for lip cancer it was 34.69 (95% CI: 26.82–44.86), when compared to individuals without SOT.

The literature suggests that this increase is related to multiple factors, including prolonged immunosuppression; the use of certain medications, such as cyclosporine and azathioprine; and environmental factors, especially chronic exposure to ultraviolet radiation (sun exposure)²⁸. Furthermore, other risk factors, such as smoking and alcohol consumption, may contribute to the development of neoplasms in the oral region²⁹.

In this context, it is important to highlight that immunosuppression can reduce the immune surveillance capacity against neoplastic cells, thereby favouring the development and progression of tumors³⁰. Thus, performing periodic clinical examinations of the oral cavity is fundamental for the early diagnosis of potentially malignant lesions in these patients.

Preventive measures and the importance of regular dental follow-up

The findings of this review highlight a high need for dental treatment both before and after transplantation⁸^,⁹^,¹¹^-¹³. However, two studies demonstrated that many patients do not receive adequate dental care throughout the transplant process⁹^,³¹.

Ideally, pre-transplant dental assessment should prioritize comprehensive oral health management rather than merely providing clearance for the surgical procedure. However, such treatments are often compromised, as the patient's underlying health status and the urgency of transplantation frequently limit the time available for necessary dental interventions⁹. Furthermore, transplant surgeons are often concerned about the risk of patient deterioration following invasive dental procedures—such as periodontal surgery and extractions—thereby favouring the postponement of these treatments until the post-transplant period¹³. This, in part, accounts for the poor oral health status of SOT patients observed in the studies included in this review. Additionally, inadequate patient education and poor adherence to preventive practices further contribute to this scenario.

The severity of the oral conditions presented by these individuals highlights the extent to which oral health is neglected in the SOT patient population. The need for dental treatment is evident both before and after transplantation; however, the majority of these treatments remain unaddressed⁹^,³¹.

The oral health of SOT patients may reflect a neglect of treatment during the organ waiting period, often exacerbated by a lack of information and guidance regarding oral hygiene. Studies have observed poor oral hygiene quality among these individuals—a situation that could be improved by greater investment of time and resources in patient education and motivation. It is the role of the dental surgeon to teach proper brushing techniques, instruct patients on the care of prosthetic appliances, and provide information regarding the oral risks associated with immunosuppressive therapy, all to enhance patient well-being. Furthermore, it is essential to motivate patients to prioritize and maintain their oral health by adhering to recommended treatments and ensuring regular dental follow-ups⁸.

It has been observed that untreated oral manifestations may lead to deterioration in the patient's overall health status⁸. Therefore, a reorganization of pre-transplant patient care pathways is required, with a specific treatment focus on promoting comprehensive oral health. Furthermore, regular post-transplant follow-up at the dental office is essential for maintaining oral health and reinforcing proper oral hygiene practices.

In this context, the need for immunosuppression in these individuals renders them more prone to dental biofilm accumulation and, consequently, to dental and periodontal diseases. Therefore, reinforcing hygiene habits and ensuring regular follow-up is essential. Furthermore, a recently published review by Olsson et al.²⁵ suggests that oral health—specifically infections—may be associated with post-transplant complications in solid organ recipients.

It is worth noting that the studies included in this review were conducted predominantly in Asia and Europe, contexts that present significant differences in access to dental treatment compared to Brazil. The findings demonstrate that access to dental care remains a major challenge across regions worldwide. In several Asian and European countries, dental benefits provided by public health systems are limited to specific treatments or age groups. Furthermore, many dental services require out-of-pocket payments from patients or are entirely self-funded. In many countries, routine dental visits are also limited to only one annual check-up³²^-³⁴.

Beyond financial barriers stemming from out-of-pocket payments, patients may face physical and geographical obstacles to accessing services. Inequalities in the utilization of dental care are frequently associated with factors such as income, educational level, and migration status, resulting in the lack of adequate dental follow-up for many individuals during the pre- and post-transplant periods³²^-³⁴.

Furthermore, healthcare strategies exhibit distinct characteristics across countries. In Brazil, there is a greater emphasis on health promotion, prevention, and education, prioritizing interventions before the onset of disease³⁵^-³⁶. In contrast, many other countries show a predominance of a curative care model, where interventions primarily occur after the establishment of the condition³²^-³⁴.

In the Brazilian context, the implementation of the National Oral Health Policy, through the Brasil Sorridente (Smiling Brazil) program, has significantly expanded dental coverage within the Unified Health System (Sistema Único de Saúde - SUS), facilitating greater population access to both basic and specialized services. However, despite these observed advances, the literature indicates that access to dental care in Brazil remains unequal, particularly in regions of higher social vulnerability and in remote locations³⁶. Thus, although the Brazilian landscape shows significant progress compared with certain countries in Asia and Europe, limitations persist in the continuity of dental care and the comprehensive monitoring of these patients. This context highlights the need to strengthen public policies focused on dental care for individuals who have undergone solid organ transplantation.

The limitations of this review include the number of databases searched (three) and the search algorithm used, which may have contributed to the exclusion of studies that could have enriched our findings. Nevertheless, the dissemination of these results aims to raise awareness among transplant teams regarding the oral healthcare of patients with SOT, which is particularly relevant given Brazil's prominent global position in the number of transplants performed and the role of its public healthcare system in this care.

CONCLUSION

It can be concluded that patients with SOT require special attention to their oral health due to their immunosuppressed state and the low oral hygiene standards identified in the included studies. There is a predisposition to several oral manifestations, including periodontal disease, caries, gingival hyperplasia, and denture stomatitis, as well as bacterial, fungal, and viral infections. Consequently, oral hygiene education and periodic monitoring by the healthcare team are essential, which should include dental care to ensure the quality of these patients' oral health. However, the absence of Brazilian studies in this research underscores the need for further studies in this area.

ACKNOWLEDGEMENT

To the University of Brasília and the Catholic University of Brasília for their support in conducting this study.

DECLARATION OF USE OF ARTIFICIAL INTELLIGENCE TOOLS
The authors used ChatGPT (OpenAI) exclusively for language editing of the manuscript. The authors reviewed the entire content and assume full responsibility for the final version.
FUNDING
Not applicable.

DATA AVAILABILITY STATEMENT

All data were generated/analyzed in this article.

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²⁰ Gasner NS, Schure RS. Doença periodontal. StatPearls. 2026. [acesso em 2025 nov 21]. Disponível em: https://www-ncbi-nlm-nih-gov.translate.goog/books/NBK554590/?_x_tr_sl=en&_x_tr_tl=pt&_x_tr_hl=pt&_x_tr_pto=tc
» https://www-ncbi-nlm-nih-gov.translate.goog/books/NBK554590/?_x_tr_sl=en&_x_tr_tl=pt&_x_tr_hl=pt&_x_tr_pto=tc
²¹ Kurtzman GM, Horowitz RA, Johnson R, Prestiano RA, Klein B. The systemic oral health connection: biofilms. Medicine. 2022 nov; 101 (46): e30517. https://doi.org/10.1097/MD.0000000000030517
» https://doi.org/10.1097/MD.0000000000030517
²² Lopes-Delphino KL, Reia VCB, Sampaio MML, Vargas REM, Santos PSS, Freitas SAJ Filho. Impacto da saúde bucal na qualidade de vida em receptores de transplante renal: série de casos. Braz J Transplant. 2025; 28: e2425. https://doi.org/10.53855/bjt.v28i1.678_PORT
» https://doi.org/10.53855/bjt.v28i1.678_PORT
²³ Betancur-Quintero S, Buitrago-Vásquez S, Londoño-Grajales JA, Londoño-Cuello W, Martínez-Delgado CM, Zuluaga-Valencia GA. Estado de salud periodontal de pacientes trasplantados renales y calidad de vida asociada. Estudio exploratorio. Odontol Sanmarquina. 2020 feb; 23 (1): 27-33. https://doi.org/10.15381/os.v23i1.17504
» https://doi.org/10.15381/os.v23i1.17504
²⁴ Waring E, Villa A. Oral manifestations of immunodeficiencies and transplantation medicine. Atlas Oral Maxillofac Surg Clin N Am. 2017 sep; 25 (2): 105-111. https://doi.org/10.1016/j.cxom.2017.04.003
» https://doi.org/10.1016/j.cxom.2017.04.003
²⁵ Olsson J, Hunfjörd S, Braun O, Häggman-Henrikson B, Ljunggren A. Impact of oral infection on organ transplantation: a systematic review. J Evid-Based Dent Pract. 2024 dec; 24 (4):102035. https://doi.org/10.1016/j.jebdp.2024.102035
» https://doi.org/10.1016/j.jebdp.2024.102035
²⁶ Kwon DE, Lee HS, Lee KH, La Y, Han SH, Song YG. Incidence of herpes zoster in adult solid organ transplant recipients: a meta-analysis and comprehensive review. Transpl Infect Dis. 2021 jun; 23 (4): e13674. https://doi.org/10.1111/tid.13674
» https://doi.org/10.1111/tid.13674
²⁷ Melo HSS, Melo REVA. Infecções de origem odontogênica: uma revisão de literatura. Arch Health. 2021 jul; 2 (4): 853-856. [acesso em 2025 nov 21]. Disponível em: https://ojs.latinamericanpublicacoes.com.br/ojs/index.php/ah/article/view/506
» https://ojs.latinamericanpublicacoes.com.br/ojs/index.php/ah/article/view/506
²⁸ Laprise C, Cahoon EK, Lynch CF, Kahn AR, Copeland G, Gonsalves L, et al. Risk of lip cancer after solid organ transplantation in the United States. Am J Transplant. 2019 jan; 19 (1): 227-237. http://dx.doi.org/10.1111/ajt.15052
» https://doi.org/10.1111/ajt.15052
²⁹ Öhman J, Rexius H, Mjörnstedt L, Gonzalez H, Holmberg E, et al. Oral and lip cancer in solid organ transplant patients – a cohort study from a Swedish Transplant Centre. Oral Oncol. 2015 feb; 51 (2): 146-150. http://dx.doi.org/10.1016/j.oraloncology.2014.11.007
» https://doi.org/10.1016/j.oraloncology.2014.11.007
³⁰ Huo Z, Li C, Xu X, Ge F, Wang R, Wen Y, et al. Cancer risks in solid organ transplant recipients: results from a comprehensive analysis of 72 cohort studies. Oncoimmunology. 2020 nov; 9 (1):1848068. https://doi.org/10.1080/2162402X.2020.1848068
» https://doi.org/10.1080/2162402X.2020.1848068
³¹ Magliocca KR, Harris DB, Schain DC. Cutaneous and oral mucosal lesions in a cardiac transplant recipient. J Am Dent Assoc. 2012 jun; 143 (6): e25-e28. https://doi.org/10.14219/jada.archive.2012.0244
» https://doi.org/10.14219/jada.archive.2012.0244
³² Winkelmann J, Gómez Rossi J, Schwendicke F, Dimova A, Atanasova E, Habicht T, et al. Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach. BMC Oral Health. 2022 mar; 22: 65. https://doi.org/10.1186/s12903-022-02095-4
» https://doi.org/10.1186/s12903-022-02095-4
³³ Tchicaya A, Lorentz N. Socioeconomic inequalities in the non-use of dental care in Europe. Int J Equity Health. 2014 jan; 13: 7. https://doi.org/10.1186/1475-9276-13-7
» https://doi.org/10.1186/1475-9276-13-7
³⁴ GBD 2021 Oral Disorders Collaborators. Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2025 mar; 405 (10482): 897-910. https://doi.org/10.1016/S0140-6736(24)02811-3
» https://doi.org/10.1016/S0140-6736(24)02811-3
³⁵ Freire DEWG, Freire AR, Lucena EHG, Cavalcanti YW. Acesso em saúde bucal no Brasil: análise das iniquidades e não acesso na perspectiva do usuário, segundo o Programa de Melhoria do Acesso e da Qualidade da Atenção Básica, 2014 e 2018. Epidemiol Serv Saúde. 2021; 30(3):e2020444. https://doi.org/10.1590/S1679-49742021000300016
» https://doi.org/10.1590/S1679-49742021000300016
³⁶ Santos LPS, Lima AMFS, Chaves SCL, Vilela DMOC, Valente APPC, Rossi TRA. Política de Saúde Bucal no Brasil: transformações e rupturas entre 2018-2021. Cien Saúde Colet. 2023 maio; 28 (5): 1575-1587. https://doi.org/10.1590/1413-81232023285.14002022
» https://doi.org/10.1590/1413-81232023285.14002022

Edited by

Section editor:
Ilka de Fátima Santana F. Boin https://orcid.org/0000-0002-1165-2149

Publication Dates

Publication in this collection
07 Aug 2026
Date of issue
2026

History

Received
22 Nov 2025
Accepted
01 July 2026

Este é um artigo publicado em acesso aberto (Open Access) sob a licença Creative Commons Attribution, que permite uso, distribuição e reprodução em qualquer meio, sem restrições desde que o trabalho original seja corretamente citado.

[1] ¹ Holt CD. Overview of immunosuppressive therapy in solid organ transplantation. Anesthesiol Clin. 2017 sep; 35 (3):3 65-380. https://doi.org/10.1016/j.anclin.2017.04.001
» https://doi.org/10.1016/j.anclin.2017.04.001

[2] ² Elalouf, A. Infections after organ transplantation and immune response. Transpl Immunol. 2023 apr; 77: 101798. https://doi.org/10.1016/j.trim.2023.101798
» https://doi.org/10.1016/j.trim.2023.101798

[3] ³ Guggenheimer J, Eghtesad B, Stock DJ. Dental management of the (solid) organ transplant patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2003 apr; 95(4): 383-389. https://doi.org/10.1067/moe.2003.150
» https://doi.org/10.1067/moe.2003.150

[4] ⁴ Lee AY, Jeong J, Heo K-N, Park S, Ah Y-M, Han JM, et al. Complications associated with immunosuppressive agents in solid organ transplant recipients: a nationwide analysis. J Clin Med. 2025 may; 14 (10): 3602. https://doi.org/10.3390/jcm14103602
» https://doi.org/10.3390/jcm14103602

[5] ⁵ Abed H, Burke M, Shaheen F. The integrated care pathway of nephrology and dental teams to manage complex renal and postkidney transplant patients in dentistry: a holistic. Saudi J Kidney Dis Transpl. 2018 jul; 29(4): 766-774. [acesso em 2025 nov 21]. Disponível em: https://journals.lww.com/sjkd/fulltext/2018/29040/the_integrated_care_pathway_of_nephrology_and.2.aspx
» https://journals.lww.com/sjkd/fulltext/2018/29040/the_integrated_care_pathway_of_nephrology_and.2.aspx

[6] ⁶ Pejcic A, Djordjevic V, Kojovic D, Zivkovic V, Minic I, Mirkovic D, et al. Effect of periodontal treatment in renal transplant recipients. Med Princ Pract. 2014; 23 (2): 149-153. https://doi.org/10.1159/000357274
» https://doi.org/10.1159/000357274

[7] ⁷ Santos PSS, Sarmento DJS, Romão EA. Lesões orais malignas tardias após transplante renal. Braz J Transplant. 2023; 26(1): e0623. https://doi.org/10.53855/bjt.v26i1.485_PORT
» https://doi.org/10.53855/bjt.v26i1.485_PORT

[8] ⁸ Golecka M, Mierzwińska-Nastalska E, Ołdakowska-Jedynak U. Influence of oral hygiene habits on prosthetic stomatitis complicated by mucosal infection after organ transplantation. Transplant Proc. 2007 nov; 39 (9): 2875-2878. https://doi.org/10.1016/j.transproceed.2007.09.018
» https://doi.org/10.1016/j.transproceed.2007.09.018

[9] ⁹ Ziebolz D, Hraský V, Goralczyk A, Hornecker E, Obed A, Mausberg RF. Dental care and oral health in solid organ transplant recipients: a single center cross-sectional study and survey of German transplant centers. Transpl Int. 2011 sep; 24 (12): 1179-1188. https://doi.org/10.1111/j.1432-2277.2011.01325.x
» https://doi.org/10.1111/j.1432-2277.2011.01325.x

[10] ¹⁰ Keerthi M, Reddy GS, Shekar PC, Chandra KLP, Kumar KK, Reddy BVR. A study on isolation, identification, and antifungal susceptibility of various oral candidal species in renal transplant patients. J Dr NTR Univ Health Sci. 2015 jul-sep; 4(3): 170-175. https://doi.org/10.4103/2277-8632.165399
» https://doi.org/10.4103/2277-8632.165399

[11] ¹¹ Schmalz G, Wendorff H, Berisha L, Meisel A, Widmer F, Marcinkowski A, et al. Association between the time after transplantation and different immunosuppressive medications with dental and periodontal treatment need in patients after solid organ transplantation. Transpl Infect Dis. 2018 jan; 20 (2): e12832. https://doi.org/10.1111/tid.12832
» https://doi.org/10.1111/tid.12832

[12] ¹² Schmalz G, Garbade J, Sommerwerck U, Kollmar O, Ziebolz D. Oral health-related quality of life of patients after solid organ transplantation is not affected by oral conditions: results of a multicentre cross-sectional study. Med Oral Patol Oral Cir Bucal. 2021 jul; 26 (4): e437-e444. https://doi.org/10.4317/medoral.24277
» https://doi.org/10.4317/medoral.24277

[13] ¹³ Kwak E-J, Kim D-J, Choi Y, Joo DJ, Park W. Importance of oral health and dental treatment in organ transplant recipients. Int Dent J. 2020 dec; 70 (6): 477-481. https://doi.org/10.1111/idj.12585
» https://doi.org/10.1111/idj.12585

[14] ¹⁴ Moest T, Lutz R, Jahn AE, Heller K, Schiffer M, Adler W, et al. Oral health of patients suffering from end-stage solid organ insufficiency prior to solid organ re-transplantation: a retrospective case series study. BMC Oral Health. 2021 oct; 21: 1-9. https://doi.org/10.1186/s12903-021-01908-2
» https://doi.org/10.1186/s12903-021-01908-2

[15] ¹⁵ Jovičić O, Mandić J, Mandinić Z, Čolović A. Oral changes in patients before and after transplantation of solid organs and hematopoietic stem cells. Srp Arh Za Celok Lek. 2021; 149 (5-6): 381-386. https://doi.org/10.2298/sarh190909106j
» https://doi.org/10.2298/sarh190909106j

[16] ¹⁶ Patini R, Cordaro M, Marchesini D, Scilla F, Gioco G, Rupe C, et al. Is systemic immunosuppression a risk factor for oral cancer? A systematic review and meta-analysis. Cancers. 2023 jun;15 (12): 3077. https://doi.org/10.3390/cancers15123077
» https://doi.org/10.3390/cancers15123077

[17] ¹⁷ Mivehchi H, Eskandari-Yaghbastlo A, Bahrami PP, Elhami A, Faghihinia F, Nejati ST, et al. Exploring the role of oral bacteria in oral cancer: a narrative review. Discov Oncol. 2025 feb; 16: 242. https://doi.org/10.1007/s12672-025-01998-2
» https://doi.org/10.1007/s12672-025-01998-2

[18] ¹⁸ Gupta A, Bhattacharya D, Elayaperumal S, Sivamani Y, Lahiri D, Nag M. Biofilms: a cause for the development of cancer: a review. Microbe. 2025 mar; 6: 100236. https://doi.org/10.1016/j.microb.2025.100236
» https://doi.org/10.1016/j.microb.2025.100236

[19] ¹⁹ Abebe GM. Oral biofilm and its impact on oral health, psychological and social interaction. Int J Oral Dent Health. 2021; 7: 127. https://doi.org/10.23937/2469-5734/1510127
» https://doi.org/10.23937/2469-5734/1510127

[20] ²⁰ Gasner NS, Schure RS. Doença periodontal. StatPearls. 2026. [acesso em 2025 nov 21]. Disponível em: https://www-ncbi-nlm-nih-gov.translate.goog/books/NBK554590/?_x_tr_sl=en&_x_tr_tl=pt&_x_tr_hl=pt&_x_tr_pto=tc
» https://www-ncbi-nlm-nih-gov.translate.goog/books/NBK554590/?_x_tr_sl=en&_x_tr_tl=pt&_x_tr_hl=pt&_x_tr_pto=tc

[21] ²¹ Kurtzman GM, Horowitz RA, Johnson R, Prestiano RA, Klein B. The systemic oral health connection: biofilms. Medicine. 2022 nov; 101 (46): e30517. https://doi.org/10.1097/MD.0000000000030517
» https://doi.org/10.1097/MD.0000000000030517

[22] ²² Lopes-Delphino KL, Reia VCB, Sampaio MML, Vargas REM, Santos PSS, Freitas SAJ Filho. Impacto da saúde bucal na qualidade de vida em receptores de transplante renal: série de casos. Braz J Transplant. 2025; 28: e2425. https://doi.org/10.53855/bjt.v28i1.678_PORT
» https://doi.org/10.53855/bjt.v28i1.678_PORT

[23] ²³ Betancur-Quintero S, Buitrago-Vásquez S, Londoño-Grajales JA, Londoño-Cuello W, Martínez-Delgado CM, Zuluaga-Valencia GA. Estado de salud periodontal de pacientes trasplantados renales y calidad de vida asociada. Estudio exploratorio. Odontol Sanmarquina. 2020 feb; 23 (1): 27-33. https://doi.org/10.15381/os.v23i1.17504
» https://doi.org/10.15381/os.v23i1.17504

[24] ²⁴ Waring E, Villa A. Oral manifestations of immunodeficiencies and transplantation medicine. Atlas Oral Maxillofac Surg Clin N Am. 2017 sep; 25 (2): 105-111. https://doi.org/10.1016/j.cxom.2017.04.003
» https://doi.org/10.1016/j.cxom.2017.04.003

[25] ²⁵ Olsson J, Hunfjörd S, Braun O, Häggman-Henrikson B, Ljunggren A. Impact of oral infection on organ transplantation: a systematic review. J Evid-Based Dent Pract. 2024 dec; 24 (4):102035. https://doi.org/10.1016/j.jebdp.2024.102035
» https://doi.org/10.1016/j.jebdp.2024.102035

[26] ²⁶ Kwon DE, Lee HS, Lee KH, La Y, Han SH, Song YG. Incidence of herpes zoster in adult solid organ transplant recipients: a meta-analysis and comprehensive review. Transpl Infect Dis. 2021 jun; 23 (4): e13674. https://doi.org/10.1111/tid.13674
» https://doi.org/10.1111/tid.13674

[27] ²⁷ Melo HSS, Melo REVA. Infecções de origem odontogênica: uma revisão de literatura. Arch Health. 2021 jul; 2 (4): 853-856. [acesso em 2025 nov 21]. Disponível em: https://ojs.latinamericanpublicacoes.com.br/ojs/index.php/ah/article/view/506
» https://ojs.latinamericanpublicacoes.com.br/ojs/index.php/ah/article/view/506

[28] ²⁸ Laprise C, Cahoon EK, Lynch CF, Kahn AR, Copeland G, Gonsalves L, et al. Risk of lip cancer after solid organ transplantation in the United States. Am J Transplant. 2019 jan; 19 (1): 227-237. http://dx.doi.org/10.1111/ajt.15052
» https://doi.org/10.1111/ajt.15052

[29] ²⁹ Öhman J, Rexius H, Mjörnstedt L, Gonzalez H, Holmberg E, et al. Oral and lip cancer in solid organ transplant patients – a cohort study from a Swedish Transplant Centre. Oral Oncol. 2015 feb; 51 (2): 146-150. http://dx.doi.org/10.1016/j.oraloncology.2014.11.007
» https://doi.org/10.1016/j.oraloncology.2014.11.007

[30] ³⁰ Huo Z, Li C, Xu X, Ge F, Wang R, Wen Y, et al. Cancer risks in solid organ transplant recipients: results from a comprehensive analysis of 72 cohort studies. Oncoimmunology. 2020 nov; 9 (1):1848068. https://doi.org/10.1080/2162402X.2020.1848068
» https://doi.org/10.1080/2162402X.2020.1848068

[31] ³¹ Magliocca KR, Harris DB, Schain DC. Cutaneous and oral mucosal lesions in a cardiac transplant recipient. J Am Dent Assoc. 2012 jun; 143 (6): e25-e28. https://doi.org/10.14219/jada.archive.2012.0244
» https://doi.org/10.14219/jada.archive.2012.0244

[32] ³² Winkelmann J, Gómez Rossi J, Schwendicke F, Dimova A, Atanasova E, Habicht T, et al. Exploring variation of coverage and access to dental care for adults in 11 European countries: a vignette approach. BMC Oral Health. 2022 mar; 22: 65. https://doi.org/10.1186/s12903-022-02095-4
» https://doi.org/10.1186/s12903-022-02095-4

[33] ³³ Tchicaya A, Lorentz N. Socioeconomic inequalities in the non-use of dental care in Europe. Int J Equity Health. 2014 jan; 13: 7. https://doi.org/10.1186/1475-9276-13-7
» https://doi.org/10.1186/1475-9276-13-7

[34] ³⁴ GBD 2021 Oral Disorders Collaborators. Trends in the global, regional, and national burden of oral conditions from 1990 to 2021: a systematic analysis for the Global Burden of Disease Study 2021. Lancet. 2025 mar; 405 (10482): 897-910. https://doi.org/10.1016/S0140-6736(24)02811-3
» https://doi.org/10.1016/S0140-6736(24)02811-3

[35] ³⁵ Freire DEWG, Freire AR, Lucena EHG, Cavalcanti YW. Acesso em saúde bucal no Brasil: análise das iniquidades e não acesso na perspectiva do usuário, segundo o Programa de Melhoria do Acesso e da Qualidade da Atenção Básica, 2014 e 2018. Epidemiol Serv Saúde. 2021; 30(3):e2020444. https://doi.org/10.1590/S1679-49742021000300016
» https://doi.org/10.1590/S1679-49742021000300016

[36] ³⁶ Santos LPS, Lima AMFS, Chaves SCL, Vilela DMOC, Valente APPC, Rossi TRA. Política de Saúde Bucal no Brasil: transformações e rupturas entre 2018-2021. Cien Saúde Colet. 2023 maio; 28 (5): 1575-1587. https://doi.org/10.1590/1413-81232023285.14002022
» https://doi.org/10.1590/1413-81232023285.14002022

Database	Strategy
Medline	"organ transplantation"[All Fields] AND ("oral health"[All Fields] OR "dental care"[All Fields] OR "dental health"[All Fields])
Academic Search Premier	("organ transplantation") AND ("oral health" OR "dental care" OR "dental health")*
Web of Science	("organ transplantation") AND ("oral health" OR "dental care" OR "dental health") (All Fields)

Reference	Itens
	Selection*				Comparability*	Exposure*	Total (score)
	Random sample	Impartial sample	Well-described study participants	Sample size	Assessment performed by a dental professional	Impartial outcome assessment	Response rates	Statistical test
^{Golecka et al., 2007} ⁸	0	1	1	0	1	1	1	0	5
^{Ziebolz et al., 2011} ⁹	0	1	1	0	1	1	0	1	5
^{Keerthi et al., 2015} ¹⁰	0	1	1	0	1	1	1	1	6
^{Schmalz et al., 2018} ¹¹	0	1	1	0	1	1	1	1	6
^{Schmalz et al., 2021} ¹²	0	1	1	0	1	1	1	1	6
^{Kwak et al., 2020} ¹³	0	1	1	1	1	1	1	0	6
^{Moest et al., 2021} ¹⁴	0	1	1	0	1	1	1	0	5

Reference	Study location	Study objective	Study type	Type of transplantation	Number	Immunosuppressive regimen adopted
^{Golecka et al., 2007} ⁸	Poland	Assessment of oral hygiene habits, as well as the condition of prosthetic appliances and natural teeth post-SOT.	Case-control study	Liver Kidney	30 (cases)/30 (controls)	Did not describe
^{Ziebolz et al., 2011} ⁹	Germany	To obtain information regarding dental care, oral hygiene behaviours, and oral health status before and after SOT.	Cross-sectional study	Heart Liver Kidney	20	Tacrolimus, cyclosporine, mycophenolate, glucocorticoids, and sirolimus
^{Keerthi et al., 2015} ¹⁰	India	To determine the prevalence of Candida albicans oral colonization in renal transplant recipients.	Case-control study	Kidney	30 (cases)/50 controls	Did not describe
^{Schmalz et al., 2018} ¹¹	Germany	To investigate the association between post-transplant time and different immunosuppressive regimens with the need for periodontal treatment in patients post-SOT.	Cross-sectional study	Liver Lung Kidney	196	Tacrolimus, cyclosporine, mycophenolate, glucocorticoids, and sirolimus
^{Schmalz et al., 2021} ¹²	Germany	To assess the oral health-related quality of life in patients post-SOT.	Cross-sectional study	Heart Liver Lung	169	Tacrolimus, cyclosporine, mycophenolate, glucocorticoids, and sirolimus
^{Kwak et al., 2020} ¹³	South Korea	To investigate which dental treatments were deemed necessary pre-transplant and to retrospectively determine the frequency with which these treatments were actually performed in patients post-SOT.	Cross-sectional study	Liver Kidney	418	Mostly tacrolimus, glucocorticoids, and antimetabolites (mycophenolate) or mTOR inhibitors (sirolimus)
^{Moest et al., 2021} ¹⁴	Germany	To assess the need for surgical and conservative dental therapy in patients post-SOT who are awaiting a new SOT.	Case series study	Heart Liver Kidney	19	Tacrolimus, cyclosporine, mycophenolate, glucocorticoids, sirolimus, azathioprine, and belatacept

Reference	Types of dental problems	Regular dental check-ups	Oral hygiene assessment	Drug-induced gingival hyperplasia
^{Golecka et al., 2007} ⁸	57% of patients required periodontal treatment, 67% presented with active caries lesions, and 20% required treatment for denture stomatitis.	Not described.	85% exhibited inadequate oral hygiene.	It was observed that in patients using cyclosporine with poor oral hygiene, gingival overgrowth recurred even after gingivoplasty
^{Ziebolz et al., 2011} ⁹	Need for dental and periodontal treatment (pre- and post-SOT).	45% of patients after transplantation and 60% before transplant.	The post-transplant group exhibited poor oral hygiene.	Two patients were receiving cyclosporine and an antihypertensive calcium channel blocker, such as nifedipine, and two were receiving sirolimus.
^{Keerthi et al., 2015} ¹⁰	Susceptibility to fungal infections – Candida	Not described.	Not described.	There were no reports.
^{Schmalz et al., 2018} ¹¹	A need for dental treatment was observed in 44% of patients, and periodontal treatment in 76%.	77% of patients after transplantation.	Exhibited insufficient oral hygiene conditions.	The influence of immunosuppressive medications was considered to be of low relevance to oral health parameters.
^{Schmalz et al., 2021} ¹²	High need for periodontal and dental treatment	Not described.	Worsened Oral Health-Related Quality of Life (OHRQoL) compared to the control group.	There were no reports.
^{Kwak et al., 2020} ¹³	Requirement for periodontal treatment, restorative treatment, endodontic treatment, extractions, implants, and prosthetic rehabilitation among the observed patients.	14.6% of liver transplant patients and 11.5% of kidney transplant patients.	Exhibited inadequate oral hygiene conditions (worse in liver transplant recipients).	There were no reports.
^{Moest et al., 2021} ¹⁴	68.4% (13 cases): need for conservative and/or surgical treatment; 52.6% (10 cases): need for conservative treatment; 36.8% (7 cases): surgical intervention; 21.1% (4 cases): need for conservative and surgical treatment.	Not described	Not described.	A case of a patient taking cyclosporine is reported.