Oral Diseases (2013) 19, 666672 doi:10.1111/odi.
12051
2012 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
All rights reserved
www.wiley.com
ORIGINAL ARTICLE
Periodontal inflammation in renal transplant recipients
receiving Everolimus or Tacrolimus preliminary results
O Pereira-Lopes1,2, B Sampaio-Maia2,3, S Sampaio2, P Vieira-Marques4, F Monteiro-da-Silva3,
AC Braga5, A Felino1, M Pestana2
1
Department of Oral Medicine and Oral Surgery, Faculty of Dental Medicine, University of Porto, Porto; 2Nephrology Research and
Development Unit (FCT-725), Faculty of Medicine, S~ao Jo~ao Hospital Center, University of Porto, Porto; 3Department of Basic
Medical and Dental Sciences, Faculty of Dental Medicine, University of Porto, Porto; 4Center for Research in Health Technologies
and Information Systems, Faculty of Medicine, University of Porto, Porto; 5Department of Production and Systems, University of
Minho, Porto, Portugal
OBJECTIVE: To compare oral health status between
renal transplant recipients (RTRs) receiving tacrolimus
(Tac) or everolimus (ERL) as immunosuppressive
therapy.
DESIGN: This study is a cross-sectional study.
METHODS: Thirty-six RTRs receiving Tac and 22 RTRs
receiving ERL were included in the study. Age, gender,
time since transplant and pharmacological data were
recorded for both groups. Oral health status was
assessed through the evaluation of teeth, periodontal
parameters as well as saliva flow rate and pH.
RESULTS: RTRs receiving ERL were older than those
receiving Tac. No differences were found between
groups concerning oral hygiene habits, oral symptoms,
smoking habits, unstimulated and stimulated saliva flow
rate and pH, clinical attachment level or the number of
decayed, missing and filled teeth. However, RTRs
receiving ERL presented lower visible plaque index and
lower values for bleeding on probing when compared to
RTRs receiving Tac. In addition, RTRs receiving ERL
presented a gingival index varying from normal to mod-
erate inflammation whereas RTRs receiving Tac pre-
sented a gingival index varying from mild to severe
inflammation.
CONCLUSIONS: RTRs receiving ERL have lower
periodontal inflammation when compared to RTRs
receiving Tac.
Oral Diseases (2013) 19, 666--672
Keywords: oral health; periodontal disease; renal transplant
recipients; everolimus; tacrolimus; calcineurin inhibitors; mTOR
inhibitors
Correspondence: Benedita Sampaio-Maia, PhD, Faculty of Dental Medi-
cine, University of Porto, Rua Dr. Manuel Pereira da Silva, 4200-393
Porto, Portugal. Tel: +351 917411727, Fax: +351 220 901 101, E-mail:
bmaia@fmd.up.pt
Received 30 July 2012; revised 29 October 2012; accepted 18 November
2012
Introduction
Kidney disease is a worldwide public health problem asso-
ciated with an increased cardiovascular risk and all-cause
mortality. End-stage renal disease (ESRD) is dened by
the cessation of effective kidney function and the begin-
ning of renal replacement therapy, such as hemodialysis,
peritoneal dialysis, or kidney transplantation. The renal
replacement therapy of choice for ESRD is kidney trans-
plantation (Molony and Craig, 2009; Castillo et al, 2007;
Little et al, 2008). It is widely accepted that kidney trans-
plantation improves quality and length of life, and costs
less than dialysis (Molony and Craig, 2009; Al-Aradi
et al, 2009). However, kidney transplantation demands
immunosuppressant therapy to avoid renal transplant rejec-
tion (Civarella et al, 2007). The recent expansion in
immunosuppressive agents licensed for use in renal trans-
plant recipients (RTRs) has dramatically increased the
number of potential drug combinations available to the
clinician (Bjorn, 2004; Baz czkowska and Durlik, 2009).
Although calcineurin inhibitor (CNI) therapy (cyclosporine
A, tacrolimus) is necessary in the early post-transplant
phase to deliver sufcient immunosuppressive potency,
elimination, or minimization of CNI exposure may be nec-
essary in RTRs experiencing chronic CNI-related nephro-
toxicity. In these conditions, evidence has been gathered
suggesting that switching to an mTOR inhibitor (siroli-
mus, everolimus) may be effective (Bjorn, 2004;
Baz czkowska and Durlik, 2009).
Tacrolimus (Tac), also named FK-506, is a CNI intro-
duced as an immunosuppressive agent for use in organ
transplants in 1987 and has been used as primary therapy
after renal, hepatic, and cardiac transplantation (Wynn
et al, 2002; Attaphol et al, 2007; Spolidorio et al, 2006).
The mechanism of action is to suppress cellular immunity,
namely, inhibiting T-lymphocyte activation, possibly by
binding to an intracellular protein, FKBP-12. The FK506
FKBP12 complex binds to calcineurin, like the CsA
cyclophilin A complex, also resulting in inhibition of IL-2

transcription (Attaphol et al, 2007; Wynn et al, 2002).
Over the past few years, Tac has gained wider acceptance
as a rst-line immunosuppressant therapy for renal trans-
plantation (Sekiguchi et al, 2007).
Everolimus (ERL), also named RAD-001, is an mTOR
inhibitor with potent immunosuppressive and antiprolifera-
tive effects that is currently used as an immunosuppressant
to prevent rejection of organ transplants, namely in patients
experiencing chronic CNI-related nephrotoxicity (Bjorn,
2004; Baz czkowska and Durlik, 2009). Everolimus is a
derivative of sirolimus (SRL) and blocks growth factor
mediated proliferation of T cells, B cells, and vascular
smooth muscle cells. Lately, like CNIs, ERL acts on cellu-
lar response (Lebranchu et al, 2009; Bj orn, 2004). Everoli-
mus is also used in patients with renal cell cancer due to its
antitumor activity (Silva et al, 2010; Amato et al, 2009).
Oral health condition affects well-being and may con-
tribute to many serious conditions with repercussions in
overall health. Recently, oral infection has emerged as a
possible risk factor for cardiovascular diseases (CVD).
Among oral infections, periodontal infections are the lead-
ing cause, with studies reporting associations between
periodontal disease and CVD (Demmer and Desvarieux,
2006).
The oral health of RTRs can be affected by the oral
manifestations of the CKD (Castillo et al, 2007) as well
as by oral complications related with transplantation (Spo-
lidorio et al, 2006). Among oral complications in RTRs,
standout drug-induced gingival overgrowth, infections,
namely periodontitis, dental caries, candidiase, viral infec-
tion, and squamous cell carcinoma (Summers et al, 2007).
Although it is well recognized that oral complications
in RTRs may be related with the immunosuppressive ther-
apy used, there are few studies comparing the effects of
CNIs and mTOR inhibitors on oral health status in RTRs
(Spolidorio et al, 2006; Civarella et al, 2007; James et al,
2001; Hernandez et al, 2000; Chu et al, 2000; McKaig
et al, 2002). This is a matter of particular importance,
namely because CNIs and mTOR inhibitors may exert
opposed effects in cell proliferation.
The aim of the present study was to compare the oral
health status of RTRs receiving Tac or ERL as immuno-
suppressive therapy.
Subjects and methods
Subjects
Renal transplant recipients 1870 years old followed-up in
the post-transplant outpatient clinic of the Nephrology
Department of S. Jo~ao Hospital receiving Tac or ERL as
maintenance immunosuppressive regimen were included in
the study. All RTRs were taking corticosteroids (predni-
sone) and an antimetabolite (mycophenolate mofetil).
Patients with diabetes, active systemic infection and those
who possessed less than eight of the ten most anterior
teeth in the upper or lower dental arches were excluded.
On the basis of these criteria, the nal sample consisted of
58 subjects. The study was approved by the Ethics Com-
mittee of S. Jo~ao Hospital. All participants were recruited
voluntarily after receiving detailed information on the
Tacrolimus, Everolimus, and oral health
O Pereira-Lopes et al
667
study protocol, and written informed consent was obtained
in all cases. Data were collected from February 2009 to
May 2011. Demographic variables including age, gender,
literacy, body mass index, time since transplant and phar-
macological data were recorded for all subjects. One
examiner evaluated the oral health status of all patients.
The examiner was instructed and coached in the proper
use of the measurement instruments that would be later
used in the examination task, and the examiner performed
the examination task in a small sample of subjects (n = 5)
and repeated it in the following day. Identical results were
generated. To quantify the closeness between measure-
ments, the Kappa (j) statistic was used for nominal vari-
able. For quantitative measurements, the t-test for paired
samples was used. The results reveal no statistical signi-
cant differences between the two measures for a signi-
cance level of 5% (P > 0.05).
The oral examinations in all patients were performed
blinded to the transplantation status and immunosuppres-
sive treatment. Blood samples were collected on the morn-
ing of the oral examination after 12 h of overnight fasting.
The serum levels of the immunosuppressants were mea-
sured. Tacrolimus blood levels were measured using
chemiluminescent microparticle immunoassay (Abbott
Architect I System analyser, Abbott, IL, USA) whereas
ERL blood levels were measured using fluorescent polari-
zation immunoassay (Seradyn Innuor Certicann adapted
to an Abbott TDx Flx analyser, Abbott, IL, USA).
Glomerular ltration rate (GFR) was estimated using the
Cockcroft-Gault formula (Ferreira-Filho et al, 2011). An
online application was build for patients data collection
and storage. This included two-independent input forms:
one intended for the general characterization of clinical
and demographic data and the other for the oral evaluation
status. Data were stored in a common database, aggre-
gated and then exported for further statistical analyses.
Oral evaluation
Oral hygiene habits were assessed by asking the partici-
pants about the daily tooth-brushing habits and how often
the toothbrush was changed yearly. Oral symptoms were
evaluated by asking the participants whether they had the
feeling of a dry mouth during the day and whether they
had the feeling of a bad breath during the day. The gingi-
val index used was proposed by Loe and Silness in 1963
(Loe and Silness, 1963) and modied slightly in 1967
(Loe, 1967). It is dened as follows: 0 = normal gingiva;
1 = mild inammation, slight change in color, slight
edema, no bleeding on probing; 2 = moderate inamma-
tion, redness, edema, and glazing, bleeding on probing;
3 = severe inammation, marked redness and edema,
ulceration, tendency to spontaneous bleeding. Gingival
enlargement (GE) was measured per sextant using the Aas
Index (Aas, 1963). We have followed a visual index,
according to Greenberg (Greenberg et al, 2008), instead
of an approach based on alginate impressions to avoid
overburdening study participants who were receiving a
full-mouth periodontal examination. It is dened as fol-
lows: grade 0: no GE; grade I: slight or moderate GE;
Grade II: marked GE; Grade III: severe GE; grade IV:
very severe. Each sextant was graded according to the
Oral Diseases
 Tacrolimus, Everolimus, and oral health
O Pereira-Lopes et al

668
most severe site. A subject was classied as having GE receiving ERL than in those treated with Tac (Table 1).
when at least one interdental papilla with GE grade I was Dosages of prednisone and mycophenolate mofetil were
present in at least one sextant. equivalent in both groups (Table 1). Both serum creatinine
Oral hygiene was assessed using the Visible Plaque levels and GFR were similar between RTRs receiving Tac
Index (VPI) (Zhou et al, 2011) in four sites of each tooth and ERL (Table 1).
(mesio-buccal, mid-buccal, disto-buccal,and mid-lingual); The RTRs receiving ERL were older than those receiv-
the percentage of the examined sites with visible plaque ing Tac (Table 2). No signicant differences were
ranged from 0% to 100%. For each participant the number observed in gender, literacy, and body mass index
of decayed (D), missing (M), and lled (F) teeth was between the two groups (Table 2). The smoking habits,
recorded, and the DMFT index was calculated following both current and past did not differ signicantly between
the World Health Organization recommendations (Zhou the two groups (Table 2).
et al, 2011; WHO, 1997). In addition, a full-mouth peri- The oral health evaluation data are given in Tables 3
odontal examination was performed for all the teeth in the and 4. No signicant differences were observed in oral
oral cavity, excluding the third molars, using a dental mir- hygiene habits and oral symptoms between RTRs receiv-
ror, an explorer, and the Florida Probe (FP, Florida ing Tac or ERL. However, RTRs receiving ERL presented
Probe Company, Gainesville, FL, USA) introduced by a gingival index varying from normal to moderate inam-
Gibbs and co-workers (Gibbs et al, 1988; Barendregt mation, whereas RTRs receiving Tac presented a gingival
et al, 2006). The clinical attachment loss (CAL) and index varying from mild to severe inammation. No sig-
bleeding on probing (BOP) were assessed at six sites nicant differences were observed in the prevalence of GE
around each tooth (mesio-buccal, mid-buccal, disto-buccal, between the two groups. All RTRs presenting GE were
mesio-lingual, mid-lingual,and disto-lingual). Clinical within grade 1, showing at least one sextant with GE.
attachment loss was expressed as the distance in mm from Also, RTRs receiving ERL present median VPI and
the cemento-enamel junction to the bottom of the gingival BOP values signicantly lower than those found in RTRs
pocket [15], whereas BOP was scored positive if a site receiving Tac. No signicant differences were found
bled after pocket probing within the time interval used for regarding CAL between the studied groups. In addition,
the buccal and lingual measurements of a quadrant. both unstimulated and stimulated saliva, ow rate, and
Additionally, whole saliva was collected in a quiet pH, did not differ between the two groups.
room over 5 min, between 8:00 and 12:00 AM to mini-
mize the circadian rhythm effects, and at least 2 h after
Table 1 Renal history of renal transplant recipients medicated with
eating, tooth brushing, mouth washing, or smoking. Sali- Tacrolimus (Tac) and Everolimus (ERL)
vary secretion was stimulated with parafn pellets (Ivoclar
vivadent, NY, USA), and the participants were asked to Tac ERL
spit into a sterile tube. The total amount collected over a n = 36 n = 22 P
5-min period was registered, enabling the salivary ow
rates (ml/min) to be calculated. The salivary pH was Renal history
Time after 16.5 (36.6  45.5) 119 (119.8  46.9) < 0.001
measured immediately after saliva collection using a pH transplant
indicator paper (5.08.0, Duotest, Germany). (months)
Pretransplant 35.5 (37.6  24) 20.5 (22  22.6) 0.169
Statistical analysis dialysis
The statistical analysis was performed using IBM SPSS vintage
(months)
version 19.0 (Statistical Package for Social Sciences, New Serum 1.49 (1.66  1.17) 1.60 (1.83  0.76) 0.218
York, NY, USA). The categorical variables were described creatinine
through absolute and relative frequencies (%) and ana- levels (mg/dl)
lyzed by chi-square independence test. Continuous vari- Glomerular 54 (56.5  23.45) 50 (54.29  24.29) 0.568
ltration
ables were described using mean  standard deviation rate (mL/min)
(s.d.) and analyzed by t-test when following a normal dis- Immunosupressor
tribution. When continuous variables did not follow a nor- therapy
mal distribution, they were described using median Dosage 5 (6  3) 2.0 (2  1)
(mean  standard deviation) and analyzed by Mann (mg/day)
Blood level 8.21  2.39 7.27  1.85
Whitney test. The decision rule is used to detect statisti- (ng/ml)
cally signicant evidence for probability values (value of Prednisone
the proof test) < 0.05. Dosage 5 (7.75  4.78) 5 (5.47  1.64) 0.265
(mg/day)
Mycophenolate
Results mofetil
Dosage 1125 (1240  381.4) 1000 (1090  373.5) 0.630
A total of 58 RTRs receiving Tac (n = 36) or ERL (mg/day)
(n = 22) were included in the study. The Tac and ERL
daily dosages and corresponding blood levels are given in Tacrolimus and Everolimus dosage and subjects blood levels. Prednisone
dosage and mycophenolate mofetil dosage.
Table 1. The previous time on hemodialysis did not differ Values are presented as median (mean  standard deviation) except
between the two groups of RTRs (Table 1). However, the blood levels presented as mean  standard deviation. Testing of group
time after transplant was signicantly higher in RTRs differences by MannWhitney U-Test.

Oral Diseases
 Tacrolimus, Everolimus, and oral health
O Pereira-Lopes et al

669
In the present study, gingival tissues in RTRs receiving
Discussion
Tac presented more severe clinical signs of inammation
The main goal of this study was to compare oral health than RTRs receiving ERL. Given that healthy gingival
status in RTRs receiving Tac or ERL. This study shows tissues are an efcient peripheral defense of the periodon-
that, in comparison with RTRs receiving Tac, the RTRs tium (Schroede and Listgarten, 1997), the presence of more
receiving ERL present lower visual plaque index, bleeding severe inammation could ultimately affect the peripheral
on probing, and gingival inammation. Given that BOP defense of the periodontium. However, it is known that the
and VPI are related with periodontal and gingival inam- presence of gingivitis alone cannot predict the development
mation, our results suggest that RTRs receiving ERL are of periodontitis in an individual (Klaus et al, 1985).
better protected for the development of periodontal inam- In the present study, the RTRs receiving ERL presented
mation in comparison with RTRs receiving Tac. a lower BOP score in comparison with RTRs receiving
Globally, the studied population presented low oral Tac. Bleeding on probing is accepted as a sign that
hygiene habits that may explain the high visual plaque enables the detection of hidden-from-view periodontal
index found. The low education level of this population inammation (Armitage, 2004). According to Lindhe and
may condition these ndings. It is known that patients co-workers (Lindhe et al, 2003), BOP percentages reect
with low literacy levels have important problems access- a summary of the patients: 1) ability to perform proper
ing the healthcare system, understanding recommended plaque control, 2) host response to the bacterial challenge,
treatments, and following the instructions of providers and 3) compliance. The percentage of sites with BOP rep-
(Horowitz and Kleinman, 2008). resent an objective inammatory parameter which can be
used to evaluate the presence of periodontal disease and
Table 2 Age, gender, literacy, body mass index, and smoking habits
the risk of disease progression (Lindhe et al, 2003). In
among renal transplant recipients receiving Tacrolimus (Tac) and Everoli- addition, BOP reects decreased collagen density,
mus (ERL) increased blood vessel density and fragility, and a reduc-
tion in epithelial thickness and integrity (Nesse et al,
Tac ERL P 2008). Thin, fragile, or even discontinuous pocket epithe-
n = 36 n = 22 lium may serve as an entrance for oral bacteria into the
Age (years) 39  9 50  11 < 0.001# systemic circulation. Furthermore, BOP is characterized
Gender 0.171* by a dense inltration of inammatory cells in periodontal
Male 19 (52.8) 16 (72.7) tissues (Lindhe et al, 2003). These inammatory cells,
Female 17 (47.2) 6 (27.3) which have a key role in the pathogenesis of periodontitis,
Literacy 0.947*
Sixth grade 10 (66.7) 6 (66.7)
also may play a role in eliciting a systemic inammatory
Higher than sixth grade 5 (33) 3 (33) response or cross-reactivity (Nesse et al, 2008).
Body mass index 23.6  3.6 24.7  3.7 0.491# If we compare our results with those of other studies that
Smoking habits evaluated oral health in similar populations, our BOP scores
Current smoking 16 (44) 6 (29) 0.267* may seem low. However, one should mention that our
Past smoking 19 (53) 11 (52) 1.000*

Values are presented as number (%) except age and body mass index
presented as mean  standard deviation. Testing of group differences by
#
t-test or *Fishers exact test.
Table 4 Teeth evaluation, periodontal evaluation, and salivary evaluation
of renal transplant recipients receiving Tacrolimus (Tac) and Everolimus
(ERL)

Table 3 Oral hygiene habits, oral symptoms, gingival index, and gingi- Tac n = 36 ERL n = 22 P
val enlargement in renal transplant recipients receiving Tacrolimus (Tac)
and Everolimus (ERL) Teeth evaluation
Visible plaque index 100 (92  21) 87 (82  23) 0.048
Tac n = 36 ERL n = 22 P Decayed 2 (3  4) 1 (3  3) 0.138
Missing 0 (1  2) 1 (5  5) 0.077
Oral hygiene habits Filled 4 (6  6) 6 (7  5) 0.317
Daily tooth brushing < 2 15 (46.9) 5 (26.3) 0.235 DMFT index 10 (11  7) 12 (11  6) 0.641
times per day Periodontal evaluation
Change toothbrush < 4 10 (27.8) 11 (50) 0.101 Bleeding on probing 8 (15  20.7) 2 (5.5  9.6) 0.015
times per year Clinical attachment 2.6 (2.8  0.6) 2.8 (2.9  0.7) 0.600
Oral symptoms level
Dry mouth 20 (62.5) 10 (55.6) 0.765 Salivary evaluation
Bad breath 18 (56.3) 14 (73.7) 0.247 Unstimulated saliva 0.4 (0.43  0.33) 0.34 (0.41  0.27) 0.902
Gingival index 0.032a ow rate (ml/min)
Normal 0 2 (9.1) Unstimulated saliva 7.4 (7.11  0.46) 7.4 (7.2  0.61) 0.201
Mild inammation 10 (28.5) 6 (27.3) pH
Moderate inammation 17 (48.6) 14 (63.6) Stimulated saliva 1.32 (1.59  0.9) 1.28 (1.51  0.9) 0.624
Severe inammation 8 (22.9) 0 ow
Gingival enlargement 4 (11.1) 2 (9.1) 1.000 rate (ml/min)
Stimulated saliva 8.0 (7.72  0.4) 8.0 (7.8  0.27) 0.764
Values are presented as n (%). Testing of group differences by chi-square pH
test. a Given that four cells (50,0%) have expected count < 5 and the
minimum expected count is 0.77, the conditions of applicability of chi- Values are presented as median (mean  standard deviation). Testing of
square test were not satised. group differences by MannWhitney test.

Oral Diseases
 Tacrolimus, Everolimus, and oral health
O Pereira-Lopes et al
670
results of BOP scores are presented as median because the
values did not follow a normal distribution. When we pres-
ent our results of BOP scores as mean  standard deviation,
the values for the Tac and ERL groups are similar to those
of other studies (James et al, 2001; Greenberg et al, 2008).
Previous data have shown that CNIs induce angiogenesis
by the production of cytokines, whereas the mTOR inhibi-
tors prevent replication of cancer cells and tumor angiogen-
esis (Guba et al, 2004; Ulricha et al, 2008; Flechner, 2007).
Angiogenesis contributes to inammation. New blood ves-
sels may contribute to maintain the chronic inammatory
state by transporting inammatory cells to the site of inam-
mation and by supplying nutrients and oxygen to the prolif-
erating inamed tissue (Jackson et al, 1997). In these
conditions, the host inammatory response in periodontitis
leads to soft- and hard-tissue destruction (Deo and Bhon-
gade, 2010). Therefore, one can hypothesize that RTRs
receiving ERL may be more protected for the development
of periodontal disease in comparison with RTRs receiving
Tac, due to the distinct effects of the two immunosuppres-
sants on angiogenesis.
Renal transplant recipients receiving ERL were older
than those receiving Tac. This nding is in agreement
with previous observations (Spolidorio et al, 2006;
McKaig et al, 2002) and is related with the fact that Tac
is the CNI used in our and other transplant units in RTRs
younger than 45 years, whereas in RTRs older than 45
cyclosporine A is the CNI used. The time after transplant
was also higher in RTRs receiving ERL than in those
receiving Tac. This is an expected nding principally
because Tac is a rst-step immunosuppressive therapy
used in the early post-transplant phase, whereas ERL is as
second-step immunosuppressant used in RTRs switched
from CNIs due to chronic CNI-related nephrotoxicity.
Herein, RTRs receiving ERL have longer time after
transplant and are older than those receiving Tac. These
two ndings may be important confounders, however it was
very difcult to select a sample with no differences regard-
ing age and time after transplant as explained previously.
Because it is known that oral complications related to
drug therapy are associated to the time after transplant and
that the process of aging may contribute to higher severity
of periodontal disease, the nding that RTRs receiving
ERL were older and presented less periodontal inamma-
tion further reinforces the view that ERL may be endowed
with protective effects on periodontal disease.
On the other hand, RTRs receiving ERL were longer
exposed to the anti-inammatory effect of prednisone,
although its concentration did not differ between RTRs
receiving Tac and those receiving ERL.
Another interesting nding was that no differences were
observed regarding smoking habits among the three
groups. This nding is particularly relevant because previ-
ous data showed that smoking represents a risk factor for
periodontal disease. Additionally, in smokers the signs
and symptoms of both gingivitis and chronic periodontitis,
mainly gingival redness and BOP, are masked by the
dampening inammation seen in smokers when compared
to non-smokers [83]. Hence, we can conclude that the
lower BOP scores in RTRs receiving ERL were not
affected by the smoking habit, as confounder.
Oral Diseases
Renal transplant recipients receiving Tac had higher
BOP and VPI in comparison with ERL group. These
results suggest that RTR receiving Tac presents higher
oral microbial colonization and periodontal inammation
and may then be more susceptible to oral infection.
Dental plaque accumulation is known to be associated
with several factors such as oral hygiene habits, salivary
ow rate, and saliva composition. Despite the differences
found in VPI among all studied groups, no differences
were observed regarding oral hygiene habits and salivary
ow rate. However, saliva composition was not evaluated.
Given that drug therapy alters saliva composition (Pink
et al, 2009; Smith and Hamilton, 1981) and saliva modu-
lates the adhesion of microorganisms to the oral tissue sur-
faces and plays a fundamental role in maintaining the
physical-chemical integrity of tooth enamel by modulating
remineralization and demineralization process (De Almeida
et al, 2008; Lagerlof and Oliveby, 1994), one can hypothe-
size that Tac may affect salivary composition and function,
unbalancing the oral equilibrium and fostering growth of
oral microorganisms and dental plaque accumulation.
An unsatisfactory plaque accumulation for RTRs receiv-
ing Tac was evidenced by a higher percentage of sites
with visible plaque. This may initiate an inammatory
process in gingiva, leading to environmental changes
which could foster further growth of pathogenic species
(Bogren et al, 2007). Bacterial colonization and growth on
supra- and sub-gingival tooth surfaces causes chronic
inammation in periodontal tissues (Asikainen et al, 2010;
Nibali et al, 2007). Periodontitis is an asymptomatic infec-
tion that causes local impairment during its lengthened
progression, but it may also be associated with increased
risk for non-oral infections as well as to pro-inammatory
host responses linked to systemic diseases, namely
cardiovascular diseases (Asikainen et al, 2010). Therefore,
our results suggest that adequate pre- and post-transplant
oral health care may be particularly recommended for
RTR receiving Tac in order to prevent these related
comorbidities.
As a cross-sectional study, the present study has limita-
tions related with the fact that one can only suspect a drug
effect. To test the hypothesis and fully evaluate this drug
effect, further studies such as interventional trial or animal
experiment design are advised.
Conclusion
It is concluded that RTRs receiving ERL have lower peri-
odontal inammation when compared to RTRs receiving Tac.
Clinical relevance
Scientic rationale for the study
In current literature, there is a lack of information about
the oral health repercussion of CNIs (Tac) vs mTOR
inhibitors (ERL).
Principal ndings
Renal transplant recipients receiving ERL present lower
bleeding on probing, visible plaque index, and gingival
inammation than RTRs receiving Tac.

Practical implications
Adequate pre- and post-transplant oral health care is rec-
ommended for renal transplant recipients, mainly those
receiving Tac.
Acknowledgement
This research was supported by the Nephrology Research and
Development Unit (FCT-725) of Faculty of Medicine, University
of Porto, Portugal.
The authors also acknowledge the kind assistance of the
nurses Maria Ferreira and Elsa Lopes of post-transplant outpa-
tient clinic of the Nephrology Department of S~ao Jo~ao Hospital
Center.
Author contributions
B Sampaio-Maia designed the clinical study and the laboratory
approach. O Pereira-Lopes performed the clinical oral evaluation.
S Sampaio selected the patients and collected the clinical data.
O Pereira-Lopes, B Sampaio-Maia and F Monteiro-Silva per-
formed the laboratory procedures. O Pereira Lopes, B Sampaio-
Maia, P Vieira-Marques and A Braga performed the data proces-
sing and statistical analysis. O Pereira-Lopes, B Sampaio-Maia,
S Sampaio, A Felino, M Pestana were all involved in results dis-
cussion. O Pereira-Lopes, B Sampaio-Maia, A Felino and M
Pestana wrote the manuscript.
Conict of interest
No funding or potential conict of interest to mention.
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