work of various expert sources and the clinical experience of the authors of this article.

➤ After consultation with the medical team members, consider switching from cyclosporin to tacrolimus for significant resolution or complete regression of the gingival enlargement. ²⁶

➤ Advise the patient to follow an oral hygiene program prior to transplant surgery.⁸⁴ Oral hygiene instructions should include:

√ Extra soft brush for sensitive teeth

√ Chlorhexidine 0.12% mouth rinse BID^78,85,86

√ Mild toothpastes with low abrasive qualities and no added whitening or tartar control products which can be irritating in a dry mouth

√ Non-alcohol containing mouthwashes

➤ Conduct quadrant scaling and root planing⁵⁶ to possibly help resolve the inflammation, which may eliminate the need for surgery;⁸⁷ at least 12 months of oral hygiene, subgingival scaling, and periodontal maintenance therapy is most effective in resolving the infl ammation.⁸⁸

➤ Perform microbial culture and antibiotic sensitivity test to best determine that the etiology is bacterial and not fungal, since Candida hyphae have been found in the gingival lesions as previously pointed out.

➤ Freqeuntly monitor saliva and gingival crevicular fluid for active HCMV infection; this may reduce the risk of transplant complications due to HCMV infection.⁶⁷

➤ Use caution when prescribing an antibiotic due to potential nephrotoxicity. ^2,78

➤ For slight to moderate gingival enlargement, use systemic antibiotics. If treated early, condition responds well to azithromycin 250-500 mg/per day for 3-5 days.^89-91 Azithromycin may lead to amelioration or complete regression of the gingival overgrowth and the duration of the effects may be 3 months to 2 years.⁹⁰ Another study contradicted the findings stating that azithromycin and/or metronidazole do not really cause regression of the overgrowth but act on the concomitant bacterial infection and gingival inflammation.⁹²

➤ For bleeding on probing or cyclosporine A-induced gingival overgrowth, use azithromycin-containing toothpaste (85 mg of azithromycin per gram of toothpaste).⁹³

➤ If Candida is identified, use topical antifungal medications. Regimens include clotrimazole troche 10 mg ( 1 troche slowly dissolved in mouth five times a day for 14 consecutive days), and nystatin oral suspension 5 ml ( 1 teaspoon — hold in mouth for 2 minutes and swallow) QID. ²

➤ For angular cheilitis, use nystatin ointment (applied to the lesion) QID until healing occurs. ²

➤ For xerostomia, use over-the-counter (OTC) moisturizing toothpaste, alcohol-free, anti-bacterial mouthwash,

sugar-free gum to stimulate salivary flow, mouth moisturizing gel or mouth spray, synthetic saliva-aqueous solution, or prescriptions for 1.1% neutral sodium fluoride toothpaste, 0.63% stannous fluoride rinse concentrate, or 0.4% stannous fluoride gel to minimize the potential for root caries in the adult patient. ^2,76

➤ Children with chronic renal failure (CRF) have significantly lower isolation frequency of Streptococcus mu-tans,⁹⁴ but it significantly increases 3 months post transplant.⁹⁴ Caries may become more significant in children post-transplant. Use fluoride rinses or at-home fluoride application trays if necessary.

➤ For gingival enlargement, scalpel or laser excision is necessary if the excess tissue is unsightly and/or interferes with mastication, speech or oral care. ²⁶ The classical surgical approach has been gingivectomy, however an alternative periodontal flap approach has also been suggested, ¹¹ to limit the large denuded connective tissue wound seen in the gingivectomy. This alternative approach minimizes post operative pain and bleeding, permits healing by primary intention,⁹⁵ and possibly prevents or limits the overzealous healing or faster cell proliferation of the injured connective tissue especially when plaque control is difficult after surgeries and the tissue regrowth may easily recur. Recurrence rate of severe cyclosporine A-induced gingival enlargement after surgery is about 40% within 18 months.⁹⁵ (Figure 3.) The recurrence rate was found to be higher in younger patients with greater existing gingival inflammation and who are poorly compliant to the recommended maintenance visit schedule.⁹⁵ Regular re-motivation and professional care at frequent recalls after periodontal surgery is important.⁹⁶

➤ To minimize the risk of adrenal crisis in individuals who have taken large doses of corticosteroids ( 10 mg prednisolone daily during the preceding 3 months) and are undergoing surgical procedures (including extractions of more than one tooth), appropriate corticosteroid cover should be administered. ^42,78

➤ Biopsy of the excised tissues is recommended due to the risk of epithelial dysplasias, lymphoproliferative diseases and carcinomas reported in organ transplant recipients.⁹⁷

 

Conclusion Although advances in immunosuppressive regimens, surgical techniques, organ preservation, and overall management of transplant recipients have improved graft and patient survival, infectious complications remain a major obstacle. Bacterial, fungal, and viral infections are implicated after transplant surgery as causes for organ rejection. Recognition of infection as a serious complication following solid organ transplantation supports