Oral and Dental Aspects of Chronic Renal Failure

SRI REZEKI

Oral and Dental Aspects of Chronic Renal Failure

R. Proctor, N. Kumar, A. Stein, D. Moles, and S. Porter

CRF : Progressiv decline in renal function associated with reduced glomerular filtration rate (GFR). Signs : Pallor due to anemia, brown discoloration of the nails, scratch marks due to pruritus, signs of fluid overload, hypertension, flow murmurs, bruising due to platelet abnormality, confusion, coma, renal osteodystrophy Symtoms : Pruritus, lethargy, anorexia, nausea, vomiting, diarrhea, poor concentration,leg cramps, ankle edema, dyspnea, insomnia, loss of libido.

Oral and Dental Aspects of Chronic Renal Failure

R. Proctor, N. Kumar, A. Stein, D. Moles, and S. Porter

Treatment : dyalisis (hemodyalisis & peritoneal dyalisis), renal ransplantation

Oral manifestation of CRF

OH individuals receiving hemodialysis can be poor Xerostomia in many individuals receiving hemodialysis Oral Malodor/ bad taste : ammonia Mucosal lesion : white parhes and/or ulceration, lichen planus-like disease, oral hairy leukoplakia, Uremic stomatitis

Oral manifestation of CRF

Oral infections : candidosis, viral infection Dental anomalies : delayed eruption of permanent teeth, enamel hypoplasia,calcification of the pulp chamber of teeth, although patients may have xerostomia no increased risk of cervical caries (porter et al., 2004), loss of non-carious tooth tissue. Bone lesions

Oral manifestation of CRF

Oral manifestation of CRF

Dental Management of Patients with CRF

Untreated dental infectons in immunosuppressed individualsmorbidity & transplant rejection (Greenberg & Cohen,1977) detailed assessment & provision of good dental care following the diagnosis of CRF. Regular clinical review important! Oral complications of renal disease (Bottomley et al., 1972) Regular, nonsurgical, periodontal treatment is indicated (Bottomley et al., 1972; Potter&Wilson, 1979; Naugle et al., 1998)

Dental Management of Patients with CRF

Individuals receiving dialysis have unmet restorative dental need (Potter & Wilson 1979; Naugle et al., 1998) Pre-transplant oral care was not meticulous no evidence that poor OH or consequent significantly affects the morbidity or mortality associated with CRF (Klassen & Krasko 2002). Report : Severe local & systemic spread of odontogenic infection in renal transplant recipient (Reyna et al., 1982; Wilson et al., 1982)

Dental Management of Patients with CRF

Bleeding tendency anti-coagulants or platelet dysfunction dental treatment on the day following dyalisis (Stewart, 1967; Dobkin et al.,1978; Precious et.al.,1981; Sowell,1982; Mannucci et al.,1983; Buckley et.al., 1986; Eschbach & adamson, 1989; Jameson & Wiegmann, 1990; De Rossi & Glick, 1996; Naylor & Fredericks, 1996) practical solution since the patients will still be in the hospital.

Dental Management of Patients with CRF

Minimize the risk of adrenal crisis in individuals who have taken large doses of corticosteroid & undergoing major surgical procedures corticosteroid cover (Seymour et al.,1994)large doses were used: up to 200mg hydrocortisone (in the past) Recent guidline lower physiological doses :25 mg i.v hydrocortisone preoperatively (Nicholson et al., 1998) Impaired renal function result in high blood levels of drugs or their metabolites (Perneger et al., 1994) reduce dosage of many drugs

B r i t i s h N a t i o n a l F
m u l a r y

B r i t i s h N a t i o n a l F
m u l a r y

2002

Dental Management of Patients with CRF

Infective Endocarditis or infection of vascular access site antibiotic prophylaxis prior to dental prosedure recommended for individuals receiving renal dialysis & allografts (Levy,1988; Hay et al., 1992; Hall et al., 1994; Naylor and Fredericks 1996; Werner and Saad, 1999). Do not recommend antibiotic prophylaxis for individuals with renal disease who require dental procedures that are likely to give rise to a bacterimia (The British Society for Antimicrobial Chemotherapy (BSAC) guidelinesSimmons, 1993)

Dental Management of Patients with CRF

Good oral health lowers the risk of oral infection lowers septicemia, endocarditis, or endarteritis at site of dialysis access no simple answer to the need for antibiotic prophylaxis for bacterimia-producing dental procedures in patients with CRF (Klassen & Krasko., 2002). Drug-induced GE substitute another drug (Khocht & Schneider, 1977) may not always be possible. Meticulous OH can lessen any plaque related ggval disease, but there may still be some drug-associated GE (Oettinger-Barak et al., 2000).

Dental Management of Patients with CRF

The use of antimicrobial agents (Nash & Zaltzman, 1998; Wirnsberger et al.,1998), such as metronidazole (Wong et al., 1994) to lessen GEincrease the cyclosporin concentrationnephrotoxicity (Seymour et al., 1997) GEinterferes with mastication, speech, or oral carescalpel or laser excision reccurent especially when OH inadequate (Seymour et al., 1994; Hall 1997)The need for long-term effective plaque control & consideration of additional anti-plaque measure such as topical chlorhexidine gluconate or triclosan preparations.

Systemic Conditions, Oral Findings and Dental Management of CRF patients : General Considerations & Case Report
Mahmud Juma Abdalla Abdel HAMID Claus Dieter DUMMER Loureno Schmidt PINTO

Case Report A 35-year-old Caucasian female was referred to our clinic for dental treatment. She had a medical history of moderate renal function loss since 1991 and DM and hypertensive crises since the age of 13, which were controlled exclusively with diet. The patient needed hospitatalization in several occasions due to uremia, metabolic acoidosis & hypertensive crisis, being diagnosed with CRF & starting hemodialysis. Diabetic nephropathy was established as an etiologic factor for CRD & she was trensferred to continuous ambulatory peritoneal dialysis (CAPD)

Systemic Conditions, Oral Findings and Dental Management of CRF patients : General Considerations & Case Report
Mahmud Juma Abdalla Abdel HAMID Claus Dieter DUMMER Loureno Schmidt PINTO

She is currently undertaking 4 hour hemodialysis session, 3x/weeks using a polytetrafluoroethylene prosthesis as an iv fistula in the left arm. Complication due to DM such as amaurosis & peripheral vascular problems Painful symptomatology in the anterior region of the mandible. Pain on chewing & sensitivity to thermal stimuli. IO clinical exam mobility of some teeth, generalized loss of insertion, deep periodontal pockets, furcation lesion, ggval bleeding & heavy metal plaque deposit throughout the mouth (Fig. 1).

Systemic Conditions, Oral Findings and Dental Management of CRF patients : General Considerations & Case Report
Mahmud Juma Abdalla Abdel HAMID Claus Dieter DUMMER Loureno Schmidt PINTO

The panoramic radiograph revealed accentuated bone loss at the alveolar crest compromising bone support, radiopaque images between the teeth suggestive of interproximal calculus & periapical abscesses associate with some teeth (Fig.2). Almost all teeth were severely destroyed and/or periodontally compromised The patient & her family were clarified about her oral conditions decision : full mouth tooth extraction & subsequent prosthetic rehabilitation

Systemic Conditions, Oral Findings and Dental Management of CRF patients : General Considerations & Case Report
Mahmud Juma Abdalla Abdel HAMID Claus Dieter DUMMER Loureno Schmidt PINTO

Before exo : Medical consent was obtained Routine laboratory tests were done The surgical procedure were scheduled in blocks under general anesthesia. Post operative course was uneventful 5 months after extraction the panoramic radiographic control did not show radiographic alterations suggestive of bone malformation (Fig.3)

Discussion

Uremia Central Nervous System loss of memory, illusion, slurred, speech depression, low concentration, coma, asterixis, epilepsy, & can also associated with development of metabolic acidosis & hyperkalemia. Uremia Gastrointestinal system nausea, vomits,peptic ulcers & metallic taste in the mouth and cause dermatological alterations such as pallor, pruritus, and calcium deposition in tissue Decreased erythropoietin production anemia Changes in leukocyte prod lymphocytopenia Abnormal pletelet adhesion & aggregationm (vWf defect) decreased of Pf III & alteration in protrombin metabolismHemostasis problems

Discussion

Changes in bone metabolism are common If renal disease develops during growth phasedelayed growth or rickets (renal osteodystrophy), delayed tooth eruption & sexual maturity. Renal disease CHF associated to pulmonary edema, ascites, arrhytmias, arteriosclerosis, myocardiopathy & pericarditis. Severe CRF Hypertention

Discussion

Alterations in the oral cavity : calculus, High concentration of anemia in saliva Uremic stomatitis & candida infections Ro alteration in mx & mb, loss of lamina dura,radioluscent lesions & abnormal postextraction bone healing The treatment proposed for patient CRF depend on stage of the renal disease.

Ucerative Uremic stomatitis associated with untreated CRF : Report of case & review of the literature

Although uremic stomatitis occurs in the patients ESRF, we report a case of a patient who exhibited ulcerative form of uremic stomatitis related to the sudden relaps of uremia. Woman, 83 y.o . Complain:xerostomia, unpleasant metal taste, mouth burning. Loss of appetite, dysphagia, dyspepsia, nausea, vomiting, abdominal pain, constipation, loss of weight over a period of the preceding 2 months Decreased of dialy urination the prev 15 day Med history : heart failure, arthritis,asthma, hysterectomy, renal complaints, repeated urological infection from t he age 30. CRF was also diagnosed 3 years before. 1 year ago she had the same oral lesion, which last for 3 month & resolved after a treatment that was prescribed by physician

Ucerative Uremic stomatitis associated with untreated CRF : Report of case & review of the literature

IO exam : extensive ulcerative lesion involving the anterior dorsal surface of the tongue covered by thick yellowish crust. The mucosa of the ventral surface of the tongue was homogenous and smoothly white. The remaining lingual mucosa was reddish & atropic. Part of hard palate mucosa was mildly red & thin whitish line, present on the left buccal mucosa The cervical lymph node were not papable, there was no fever.

DENTAL CONSIDERATIONS FOR THE PATIENT

WITH RENAL DISEASE RECEIVING HEMODIALYSIS

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