The United States Organ Transplant System: Update and Dental Treatment Considerations

Cher Thomas, RDH and I met during unusual circumstances about 20 years ago and became fast friends. We had both registered for an educational weekend at the Speaking and Consulting Network, a premiere organization for dental speakers and consultants in dentistry. We’d never met and even though it’s not always easy to share a hotel room with a complete stranger, I found Cher to be easygoing and fun. In fact, one year, we were invited by Philips Oral Healthcare for a weekend of fun in Vegas and ended up getting up on stage and dancing in front of a large audience. I won’t go into a lot of detail, let’s just say that it wasn’t fun for me to watch a video of myself with a Sonicare electric toothbrush, dancing around the stage. Cher was a better dancer than me and I tried to hide from the camera.

The first night of our weekend was a ton of fun sharing stories about our backgrounds and conversation flowed naturally. The following morning, Cher asked me to help her open her foil pill packs, and I watched as she lifted a huge rectangular plastic box from her luggage. The box was a pill organizer and at the time, Cher was taking a total of 40 different medications. It was then that I learned that Cher was a kidney transplant recipient and she started educated me about the various medications she takes to thrive.

Remarkably, Cher has beaten the odds. She just celebrated her 24th year as a transplant recipient, and she tells me she knows people who have maintained their transplant for more than 40 years.

Since then, Cher continues to educate me about transplant recipients, especially kidney transplantation, and I am always eager to learn more about solid organ transplants. She has dedicated most of her career to the dental care of renal transplant patients. When we first met, it was estimated that 1 in 10 people had chronic kidney disease (CKD). It is now estimated to be 1 in 7 people. As this chronic illness becomes more and more prevalent, it is obvious there are some barriers to care. When a patient applies to be an organ transplant recipient, several tests are performed. Many are tissue typing and the medical and mental stability of the patient. Each transplant center has a long list of criteria and once all the tests are completed the patient’s case is presented to an organ transplant board for consideration.

A recent CNN headline I saw about the United States government planning to overhaul the organ transplant system was a good excuse to get in touch with Cher once again. I decided to ask her some questions and will share what I’ve learned. In addition, I’ll review some pertinent information for dental care professionals to ask organ transplant patients before proceeding with a dental treatment plan.

• What’s wrong with the United States organ transplant system and why is it being overhauled? The newly reported overhaul includes strategies to modernize the system to “shorten wait times, address racial inequities, and reduce the number of patients who die while waiting,” according to The New York Times.¹ The United Network for Organ Sharing (UNOS) oversees the database that matches potential organ recipients with potential donors. Within each region are Organ Procurement Organizations (OPO). These organizations are not-for-profit organizations responsible for recovering deceased donor for transplant. There are currently 56 OPOs in the United States. OPOs are certified by Centers for Medicare & Medicaid Services (CMS). It is CMS that assesses their performance levels. July 10, 2019, executive order 13879 was issued to increase access to kidney transplantation. At that time, the efficiency of OPOs and barriers to transplantation began to be assessed.
• Is a dental exam required before a patient can undergo solid organ transplantation? Yes–all potential sources of infection must be removed or treated prior to transplant. Immediately after transplant, patients are at the highest level of immunosuppression and are at the highest risk of sepsis and/or acute rejection. Rejection can be activated to an untreated infection; therefore, even oral infection can prove deadly or be the cause of losing an organ.
• Do dental insurance companies pay for dental care prior to organ transplantation and why are dental benefits important for these recipients? Yes! Dental insurance companies do pay for oral care; however, we have not seen a noticeable change in the dental coverage for many patients. Unfortunately, many people (as in the general population) lack dental coverage. To be listed on the UNOS database, a potential recipient has to satisfy every requirement by the individual transplant center–including to have a dental exam and all potential infection treated. If a patient cannot get either, they cannot be listed. If they cannot be listed, then they will never get a transplant and will continue with Medicare coverage for dialysis. The price comparison for transplant surgery is around $100,000 versus the average cost of dialysis per year at $90,000. It makes a lot of sense/cents to transplant.

Preparing for Dental Treatment: Organ Transplant Patients

I’ve previously written about factors to be considered before starting dental treatment, but it never hurts to review major points:

1. When performing invasive dental procedures, always consult with the patient’s physician about antibiotic prophylaxis. Before treating a prospective transplant recipient, obtain and review medical and dental histories. Perform a non-invasive oral examination until you talk to the patient’s physician.² Allow more time for a comprehensive new patient exam if you are in the habit of rushing patients through the initial exams.
2. If the patient presents with an active oral infection, such as an abscessed tooth or purulent periodontal infection, administer systemic antibiotics after consulting with the patient’s physician.²
3. Excessive bleeding can be a problem in organ transplant patients and can be caused by medications and/or organ dysfunction. Bleeding potential must be discussed with the patient’s physician. Read the National Institute of Dental and Craniofacial Research (NIDCR) dental management section about organ transplant patients while preparing for treatment.²
4. Before organ transplant: all active oral disease should be treated because post operative immunosuppression decreases a patient’s ability to resist systemic infection. The NIDCR dental management section as referenced above goes into detail about treating active oral disease.²
5. After organ transplant: except for emergency oral care, dental treatment should be avoided for at least 3 months following organ transplantation. Once the graft has stabilized (typically 3-6 months post-surgery) patients can be treated in a dental office with proper precautions.² There are a lot of side effects from immunosuppressive drugs and these are among the most common oral health problems affecting transplant recipients. Once you receive a list of the patient’s medications, make sure you become familiar with adverse effects.

Expanding Dental Coverage for Transplant Recipients

Under the physician fee schedule final rule for 2023, CMS recently issued a decision to expand medically necessary dental procedures in Medicare.³ CMS reports that the final rule creates a process to identify additional dental services that are integral to the success of other covered medical services. Elimination of infection before an organ transplant will begin to be covered in 2023.3 Covered dental services include: oral exams relating to renal transplant surgery, wiring of teeth, reduction of jaw fractures, extraction of teeth in preparation for radiation treatment of neoplastic disease and dental splints for covered treatment of certain medical conditions. For kidney transplant patients, the new rule matters because it expands preventive and diagnostic dental exams covered under Medicare Part B.³

References:

1. Sheryl S. U.S. Organ Transplant System, Troubled by Long Wait Times, Faces an Overhaul. New York Times. March 22, 2023. Accessed May 9, 2023. https://www.nytimes.com/2023/03/22/us/politics/organ-transplants-biden.html

2. NIDCR. Dental Management of Organ or Stem Cell Transplant. Accessed May 9, 2023. https://www.nidcr.nih.gov/sites/default/files/2017-09/organ-stem-cell-transplant-mouth.pdf

3. Expanding Dental Coverage is a Win for Transplant Recipients. National Kidney Foundation. November 15, 2022. Accessed May 9, 2023. https://www.kidney.org/newsletter/advocacy/expanding-dental-coverage-win-transplant-recipients