Q u i n t e s s e n c e I n t e r n at i o n a l

Clinical oral findings in dialysis

and kidney-transplant patients
Acir José Dirschnabel, DDS, MS1/Alessandra de Souza Martins, DDS1/
Shirley Aparecida Gonçalves Dantas, DDS1/
Marina de Oliveira Ribas, DDS, MS, PhD1/
Ana Maria Trindade Grégio, MS, PhD1/
Luciana Reis de Azevedo Alanis, DDS, MS, PhD1/
Sérgio Aparecido Ignácio, MS, PhD1/
Paula Cristina Trevilatto, DDS, MS, PhD1/
Rafaela Wassoler Casagrande, DDS2/
Antonio Adilson Soares de Lima, DDS, MS, PhD3/
Maria Ângela Naval Machado, DDS, MS, PhD3

Objectives: Oral lesions secondary to chronic renal failure or related to immunosuppressive

therapy after transplant are reported in the literature, but their prevalence is still obscure.
The aim of this study was to investigate oral clinical findings in patients undergoing renal
dialysis and renal transplant recipients. Method and Materials: Forty-six patients treated
with dialysis (DL), 33 kidney-transplant (KT) patients, and 37 control (C) patients were
examined intraorally. Oral clinical findings were diagnosed and treated. Results: The results
showed that 95.6% (44/46) of the DL group, 93.9% (31/33) of KT patients, and 56.7%
(21/37) of the control group presented at least one pathological entity in the oral mucosa.
A high prevalence of oral lesions, such as saburral tongue and xerostomia, was found
in the DL and KT groups. Certain oral lesions demonstrated a predisposition toward one
type of group, such as a higher prevalence of metallic taste in the DL group and gingival
overgrowth in the KT group. Conclusion: The prevalence of oral lesions was significantly
higher in renal patients (DL and KT groups). The most prevalent oral clinical findings were
saburral tongue and xerostomia for both groups. Metallic taste was more prevalent in the
DL group. Although geographic tongue was more frequent in KT patients and melanin
pigmentation in the control group, the number of lesions was low for all groups. In addition,
gingival overgrowth was more prevalent in the KT group; however, the difference was not
significant (P = .06). (Quintessence Int 2011;42:127–133)

Key words: cyclosporine, dialysis, immunossuppressor drugs, kidney transplant,

oral lesions, prevalence

Chronic renal failure results from the pro-
gressive and chronic deterioration of neph-
rons, with a concomitant decline in the
Center for Health and Biological Sciences, School of Dentistry,
1
glomerular filtration rate, which demands
extrarenal blood filtering techniques (dialy-
sis or hemodialysis) or other therapies
(such as renal transplants).1 Kidney trans-
plants are considered the most efficient

Pontifícia Universidade Católica do Paraná, Curitiba, Paraná, renal replacement therapy for a significant
Brasil. number of patients with end-stage renal
Dental Health Service, Fundaçãão Pro-Renal, Curitiba, Paraná,
2 disease.
Brasil. End-stage renal disease patients
Department of Stomatology, Faculty of Dentistry, Universidade
3
undergoing hemodialysis and immunosup-
Federal do Paraná, Curitiba, Paraná, Brasil.
pressed organ-transplanted patients are
Correspondence: Dra Maria Ângela Naval Machado, more prone to develop pathologic condi-
Department of Stomatology, Faculty of Dentistry, Universidade
tions in the oral cavity.2–5 A wide range
Federal do Paraná, Rua José Cadilhe nº 892, CEP: 80620-240,
Curitiba–PR, Brasil. Email: man.machado@ufpr.br of oral signs and symptoms, such as

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Q u i n t e s s e n c e I n t e r n at i o n a l
Dirschnabel et al
dry mouth, change of taste, and mucosal
pallor, has been reported in end-stage
renal disease patients.6 In addition, some
reports have been published on the salivary
composition changes and dental calcu-
lus formation in end-stage renal disease
patients undergoing hemodialysis.7 In addi-
tion, oral infections such as candidosis,
recurrent herpes, and hairy leukoplakia
have also been reported as consequences
of drug-induced immunossuppression.2,3
Immunosuppressant therapy is required
to minimize the risk of allograft rejection.
Cyclosporin is one of the immunosuppres-
sors used against rejection of kidney grafts,
which may be administered alone or in
combination with other drugs (azathioprine
and prednisolone).3 Gingival overgrowth
secondary to cyclosporine therapy associ-
ated or not with calcium channel blockers
(nifedipine and amlodipine) is the most
reported oral manifestation of transplant
patients. 8–10
Also, there have been a few
reports on squamous cell carcinoma and
Kaposi sarcoma appearing within areas of
gingival enlargement.3
However, studies about the prevalence
of oral lesions in end-stage renal disease
patients undergoing hemodialysis and kid-
ney-transplant patients are still scarce. Dental
professionals must be aware of the most fre-
quent oral manifestations of hemodialysis and
transplant patients to ensure correct manage-
ment of such patients.
Due to the progressive increase in the
number of patients treated with hemodialy-
sis and/or renal transplantation each year, it
is important to know the prevalence of the
oral lesions in this specific population. Thus,
the purpose of this study was to investigate
oral lesions and other clinical findings in
renal hemodialysis patients and kidney-
transplant recipients.
Method and Materials
A transversal descriptive study was con-
ducted in 116 individuals, comprising 46
patients undergoing hemodialysis (DL) and
33 kidney-transplant recipients (KT) from
Fundaçáo Pro-Renal (Curitiba-PR), and 37
healthy control patients (C) of the Dental
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Clinics of Pontifícia Católica Universidade
do Paraná (PUCPR).
Approval for this study was obtained
from the Ethics Committee in Research at
PUCPR. All subjects signed a consent form
to participate in the study.
Oral evaluations were carried out by a sin-
gle investigator at the Pro-Renal Foundation.
Any necessary biopsies of lesions were
conducted at the Dental School of PUCPR
and sent to the Laboratory of Pathology for
histopathologic diagnoses.
Pregnant women and smokers were
excluded from this study.
The patients’ data were collected based
on a protocol including demographic par-
ticularities (sex and age), disease history
(including time and frequency of dialysis),
and time elapsed from transplantation. The
intraoral examination was performed based
on World Health Organization (WHO) cri-
teria.11 The oral mucosa was evaluated to
identify lesions and their locations. Oral
lesions were diagnosed using established
standard criteria on a clinical basis. Patients
were aware of their lesions and were treated
as necessary.
Descriptive statistical analysis, including
means and standard deviations of each oral
lesion, were performed. The Student t test
(P < .05) was used for intragroup analysis to
detect significant differences in the number
of oral lesions in relation to the period of
time (greater or less than 12 months) from
the beginning of hemodialysis in the DL
group and after transplant therapy in the KT
group (Table 1). The chi-square test (P <
.05) was used to compare the prevalence
of oral lesions and their distribution among
groups (Table 2).
Results
Forty-six patients (23 males and 23 females)
under hemodialysis with a mean age of 47.97
years (standard deviation 13.97, range 14 to
78); 33 (13 males and 20 females) kidney-
transplant patients with a mean age of 37.15
years (standard deviation 10.10, range 19 to
57); and 37 (12 males and 25 females) control
patients with a mean age of 39.56 years (stan-
dard deviation 18.22, range 16 to 81) were

evaluated. A total of 116 individuals took part
in this study.
There was no statistically significant
difference in the number of oral lesions
occurring in the first year of hemodialysis
treatment compared to a period longer
than 1 year (P < .05) in the DL group
(Table 1). The mean time of therapy for the
dialysis group was 38.09 months. There
was no statistically significant difference
in the number of oral lesions occurring in
the first year for kidney-transplant groups
compared to longer than 1 year (P < .05) in
the KT group (Table 1). The mean time of
therapy after kidney transplant was 38.03
months.
Table 2 presents the comparison of the
number of oral findings between the DL and
C and between the KT and C groups. Table
3 shows the prevalence of oral clinical find-
ings in the C, DL, and KT groups. It was
found that 95.6% (44/46) of the DL group,
93.9% (31/33) KT, and 56.7% (21/37) of the
C group showed at least one pathologic
entity in the oral mucosa, which indicates
that renal patients (in hemodialysis or trans-
planted) had two times as many oral clinical
findings than the C group.
The most prevalent oral clinical findings
were saburral tongue (Fig 1) and xerostomia
for the DL and KT groups (Table 3). Metallic
taste was statistically more prevalent in the
DL group. Geographic tongue (Fig 1) was
more frequent in the KT group, although
the number of findings was small. Melanin
pigmentation was more prevalent in the C
group, but the number of clinical findings
was also small. Although the prevalence of
gingival overgrowth (Fig 2) was higher in the
KT group, the difference was not statistically
significant (P = .06). Candosis and inflam-
matory fibrous hyperplasia (Fig 3) were
prevalent in all age groups; however, there
was no statistically significant difference
among them.
Discussion
The present study aimed to evaluate the
clinical oral findings prevalent in subjects
undergoing hemodialysis and kidney-trans-
plant patients.
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Q u i n t e s s e n c e I n t e r n at i o n a l
Dirschnabel et al
Table 1 No. of oral lesions in relation to period of time
from beginning of hemodialysis or after
kidney transplant for dialysis (DL) and
kidney-transplant (KT) groups
Group (n) Time (mo) Mean (± SD) of oral lesions
DL
16 < 12 2.25a (± 1.69)
30 > 12 1.83a (± 1.05)
KT
10 < 12 2.30b (± 0.67)
23 > 12 1.83b (± 1.03)
Student t test (P < .05). Means followed by the same letters do not differ
statistically; n, number of patients; analysis intergroups.
Table 2 No. of oral findings for dialysis (DL),
kidney-transplant (KT), and control (C) groups
Group n Mean (± SD)
DL 33 1.97 (± 1.30)*
KT 46 1.93 (± 0.93)*
C 37 1.02 (± 1.19)
Mann Whitney U test (P < .05); n, number of patients per group.
*Statistically significant difference in comparison with the control group (refer-
ence group).
The period of time from the beginning of
hemodialysis (1 year or more) did not affect
the frequency of oral lesions in DL group;
the same results were observed for KT
group after transplantation.
In the present study, one of the most
prevalent clinical oral findings was saburral
tongue in the DL (37.0%) and KT (42.4%)
groups. Saburral tongue generally is associ-
ated with poor hygiene12,13 and is scarcely
mentioned in kidney-transplant and dialysis
patients.12 Those authors found a preva-
lence of 22.2% of saburral tongue in 90
kidney-transplant patients.12 A high preva-
lence of xerostomia was also found for
both groups, DL (28.2%) and KT (30.3%).
Symptoms of xerostomia can arise in many
individuals receiving hemodialysis6,7 due to
restricted fluid intake (decreased urinary
output) and adverse effects of therapy.14 In
129
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Dirschnabel et al

Table 3   No. and distribution (%) of oral findings in dialysis (DL), kidney-transplant
(KT), and control (C) groups

DL (n = 46) KT (n = 33) C (n = 37)

Oral findings n % n % n %
Saburral tongue 17* 37.0 14* 42.4 1 3.0
Fissured tongue 3 6.5 3 9.1 2 5.4
Geographic tongue 1 2.2 4* 12.1 0 0.0
Inflammatory fibrous hyperplasia 9 19.5 3 9.1 4 10.8
Xerostomia 13* 28.2 10* 30.3 0 0.0
Hyperkeratosis 4 8.7 0 0.0 1 2.7
Gingival overgrowth 0 0.0 5 15.2 1 2.7
Melanin pigmentation 0* 0.0 1 3.0 3 6.5
Argirosis 1 2.2 1 3.0 1 2.7
Leukoplakia 0 0.0 3 9.1 0 0.0
Mandibular or palatal torus/exostosis 4 8.7 2 6.1 5 13.5
Candidosis 8 10.8 5 15.2 4 17.0
Metallic taste 13* 28.2 2 6.1 0 0.0
Leukoeritroplakia 0 0.0 1 3.0 1 2.7
Leukoedema 0 0.0 1 3.0 0 0.0
Herpes simplex infection 1 2.2 2 6.1 1 2.7
Pigmented nevus 0 0.0 1 3.0 0 0.0
Hairy tongue 0 0.0 1 3.0 1 2.7
Peripheral giant cells lesions 0 0.0 0 0.0 1 2.7
Hemangioma 3 8.1 0 0.0 3 6.5
Mucocele 1 2.1 0 0.0 1 2.7
Dental abnormalities 2 4.3 2 6.1 0 0.0
Traumatic fibroma 2 4.3 0 0.0 0 0.0
Chewing lesions 2 4.3 3 9.1 0 0.0
Papilloma 1 2.1 0 0.0 1 2.7
Actinic cheilitis 1 2.1 0 0.0 1 2.7
Burning mouth 0 0.0 0 0.0 1 2.7
Petechias 1 2.1 0 0.0 0 0.0
Mucosal pallor 1 2.1 0 0.0 2 5.4
Fordyce granules 0 0.0 0 0.0 1 2.7
Central giant cells lesion 0 0.0 0 0.0 1 2.7
Paracoccidiodidomicosis 0 0.0 0 0.0 1 2.7
Traumatic ulcers 0 0.0 0 0.0 2 5.4
Double lip 0 0.0 0 0.0 1 2.7
Total of lesions 91 64 38
Subjects with lesions 44 95.6 31 93.9 21 56.7

*Statistically significant difference; chi-square test (P < .05).

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Dirschnabel et al

Fig 1    (left) Clinical aspect of saburral and geographic tongue in a

kidney-transplant patient.
Fig 2   (center) Clinical view of gingival overgrowth in a kidney-
transplant patient.
Fig 3    (right) Clinical aspect of inflammatory fibrous hyperplasia and
candidosis in a patient undergoing hemodialysis.

kidney-transplant patients, xerostomia may A higher frequency and severity of oral

be directly associated with antihyperten-
sive therapy.15 One prevalent lesion in DL
group was metallic taste (28.2%), which is
probably related to anemia and retention of
uremic toxins.14 Another prevalent lesion in
KT group (12.1%) was geographic tongue,
which may have a genetic basis, although
its etiology remains unknown.16 Melanin pig-
mentation was observed in a higher num-
ber in the C group (6.5%). It is a condition
generally associated with race and is an
ordinary oral finding in Brazilian populations
and does not seem to be related to disease
status. The KT group showed a prevalence
of 15.2% of gingival overgrowth, maybe
because these patients were taking cyclo-
sporine for more than 9 months. The preva-
lence of gingival overgrowth in individuals
taking cyclosporine is variable, with a wide
range from 6% to 85%.3,6,17,18 These studies
vary largely in different populations, accord-
ing to drug dosage, plasma concentration
of cyclosporine, duration of therapy, dental
plaque levels, and measurement of gingival
overgrowth.9,10,17
Immunosuppressed transplant patients
are more susceptible to oral infections,
especially of viral or fungal nature.12,19,20
lesions have been observed in renal
patients.3 In this study, a low prevalence
of lesions of viral nature was observed and
consisted of herpes simplex and papil-
loma infection. The clinical lesions caused
by herpes simplex infection are evident
when the patient presents erosions, ulcer-
ations, or crust preceded by blistering. The
low prevalence of those lesions may not
have been observed as it is a transitory
condition. In addition, the use of effective
antiherpetic therapy can reduce the fre-
quency of herpes simplex infection in renal
allograft recipients.6 Candida infection was
prevalent in all groups. Oral candidosis is
usually associated with local and systemic
predisposing factors. Local factors include
hyposalivation, denture wear, and poor oral
hygiene. Systemic factors include diabetes
mellitus, pernicious anemia, AIDS, immuno-
suppressive or radiation therapy, antibiot-
ics, corticosteroids, psychotropic drugs,
and smoking.21–23 It is extremely rare to find
a case of oral candidosis, in which one
or more of these factors cannot be identi-
fied. Candidosis is a common oral finding
in general populations, especially in den-
ture wearers.24 However, candida infection

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Q u i n t e s s e n c e I n t e r n at i o n a l
Dirschnabel et al
in kidney-transplant patients is becoming
more common due to the increasing use
of immunosuppressive drugs2,14; in hemo-
dialysis patients, it is frequently observed
because of dehydration due to the restric-
tion of fluid intake that causes dry mouth.4,5
The prevalence of orofacial manifesta-
tions in hemodialysis and kidney-transplant
subjects differs among authors depending
on the study and patient-selection crite-
ria.2,19,25
Evaluated parameters in a Brazilian pop-
ulation suggest defective oral health status
in chronic kidney disease patients undergo-
ing different modalities of treatment.26 In this
study, the prevalence of oral lesions was
doubled in patients belonging to DL and KT
groups, indicating that dental practitioners
must pay close attention to this particularly
susceptible population. Thus, supportive
oral programs must be implemented to
allow early diagnosis and treatment of the
oral lesions that increase morbidity in these
patients.
Conclusion
The prevalence of oral lesions was signifi-
cantly higher in renal patients (DL and KT).
The most prevalent oral clinical findings
were saburral tongue and xerostomia for
both groups. Metallic taste was most preva-
lent in the DL group. Although geographic
tongue was most frequent in kidney-trans-
plant patients, and melanin pigmentation
in the control group, the number of lesions
was low for all groups. In addition, gingival
overgrowth was more prevalent in the KT
group; however, the difference was not
significant.
Acknowledgments
Alessandra de Souza Martins and Shirley Aparecida
Gonçalves Dantas were supported by PIBIC- PUCPR/
CNPq.
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