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Case study: management of the kidney dialysis patient.

Introduction

The prevalence of diabetes in industrialized countries is on the rise. This appreciable rise of diabetic patients will lead to an increased number of patients with end-stage renal disease (ESRD). These patients will need dental management in general dental offices around the country. The number of patients with kidney failure who require dialysis is growing by 10-15 percent annually, and most commonly observed in the middle-aged to geriatric patient. Over the past five years, new patients with kidney failure have averaged more than 90,000 annually. (1) With an aging population and rise in life expectancy, clinicians in the general dental office should be aware of implications of renal disease. The prevalence of people developing end-stage renal disease annually is estimated to be at 260,000. (1) Patients at highest risk for ESRD are diabetics, men, African-Americans, Native-Americans, Asian-Americans and those with hypertension. There are over 70,000 patients on the waiting list for a kidney transplant; only 17,000 will get a new kidney this year. (2) Patients with ESRD are predisposed to a wide variety of dental problems, which may include periodontal disease, xerostomia and premature tooth loss.

Implications

When addressing an ESRD patient in a dental office, the most important element in their treatment plan should be to eliminate any possible active infection. Oral manifestations seen in ESRD patients include stomatitis, candidiasis, xerostomia, gingivitis and periodontal disease. Patients may have an ammonia-like odor of breath or an unpleasant metallic taste. Children are less prone to cavities, although dental developmental abnormalities have been reported. (3) Teeth may be pathologically mobile due to bone resorption or see severe erosion due to persistent vomiting or gastrointestinal reflux. A triad of radiolucent jaw lesions, loss of lamina dura and demineralized (ground glass) bone can be seen with renal osteodystrophy on panographs. Gingival overgrowth may be seen due to immunosuppressive drugs (cyclosporine) if a kidney has been transplanted or if calcium channel blockers are used to reduce the work load of the kidneys. (4) An increase in rate of calculus formation may be seen due to serum imbalance of calcium phosphate. (5)

Periodontal diseases are a group of inflammatory diseases that affect the supporting tissues of the dentition. Periodontitis can contribute to systemic inflammation in end-stage renal disease. ESRD patients have a higher prevalence and severity of periodontal disease than the general population. An ESRD patient with moderate to severe periodontal disease could have a total inflamed surface area of 8-20 [cm.sup.2] depending on number of teeth affected, which is a large area to be inflamed when a person is immunocompromised. (6) There are studies that show a positive association between C-reactive proteins (CRP) (a serum inflammatory marker) and periodontal disease severity. These serum inflammatory markers have also been robust predictors of cardiovascular mortality in this ESRD population. Effective periodontal therapy may show a decrease in these CRP levels in ESRD patients. (6-8)

Treatment

Meticulous daily oral hygiene by the patient is needed to remove subgingival plague and bacteria, combined with professional local mechanical root debridement to remove calculus. For patients who are not resolved after initial periodontal therapy and demonstrate good plaque control, surgical pocket elimination may be indicated. Severe periodontal pocket formation not amenable to surgical intervention will result in extraction of involved teeth. (3-5)

Clinical Management

ESRD patients on hemodialysis maintenance are medically complex, therefore close communication with the patient and nephrologist or physician is essential. The medical history should be updated at each visit. Screen for the hepatitis B surface antigen (HBsAg) or bleeding disorder before planning any surgery (bleeding time, platelet count, hematocrit and hemoglobin). All universal precautions should be followed as incidence of hepatitis B and C is higher among dialysis patients. (3,4) Withdraw anticoagulants for a short period only after consultation with a nephrologist. Manage oral facial infections aggressively by obtaining a culture specimen (for culture and sensitivity testing) and treat with appropriate antibiotics. Monitor blood pressure closely and avoid compression of an arm with an arteriovenous graft or fistula. Invasive dental procedures including root planing and extractions can result in transient bacteremia. The American Heart Association guidelines should be followed and a medical consult regarding premedication from each nephrologist should be obtained. (3) Perform dental treatment on non-dialysis days to ensure absence of circulating heparin, which could lead to bleeding tendencies during or after a procedure. There is a high prevalence of hypertension in ESRD patients, so be careful when using local anesthetics containing vasoconstrictors and with dosage and administration of drugs cleared through the kidneys. Drugs contraindicated are tetracycline, acyclovir, acetaminophen, aspirin and NSAIDS. Lidocaine, narcotics (except Demerol) and diazepam can be used safely in patients with renal failure. (4) Dose reduction is needed for aminoglycosides and cephalosporins. To reduce dry mouth, recommend use of an alcohol-free mouth rinse or salivary substitute. After a patient has received a kidney transplant, it is safe to resume regular dental visits six to nine months after the transplantation, presuming no complications, or after the patient has been cleared by the treating physician.

Treatment Modalities in Renal Disease

There are three medical treatment modalities for renal disease: a conservative approach where the patient is watching diet and fluid intake, the patient has been placed on dialysis, or kidney transplantation. (4)

Types of Dialysis

There are two types of dialysis a patient can be treated with: hemodialysis or peritoneal dialysis. Hemodialysis is done around four hours a day, three times a week following a Monday, Wednesday, Friday schedule or a Tuesday, Thursday, Saturday schedule. Hemodialysis is done through a fistula or graft placed in a limb using two needles during dialysis; one needle draws the blood from the artery section, and the other needle delivers the cleansed blood to the vein section after filtering. Vascular access at dialysis is gained by an AV (arteriovenous) fistula, AV graft or shunt or venous catheter. The AV fistula comprises an artery that is surgically grafted into a vein for access. An AV graft or shunt is a synthetic tube implanted under the skin. The venous catheter is inserted into the subclavian, internal jugular or femoral vein and advanced up to the heart until it reaches the superior vena cava or right atrium. (9-11) Peritoneal dialysis uses the lining of the abdominal cavity: the peritoneum. This type of dialysis is done daily, four times a day. There are no special dental considerations in management of the peritoneal dialysis patient. (12)

Case Study

A 35-year-old African-American male presented to the Special Patient Care Clinic at the University of Missouri, Kansas City School of Dentistry in September 2007. The patient has been on hemodialysis since January 2001 and is starting the process for clearance to be placed on the transplant list at a local hospital. Dental clearance is a priority before placement on the transplant list.

Medical History

Patient reports dialysis delivered through a fistula on the left lower forearm since 2001, delivered on M-W-F schedule. A medical consult was requested with his primary care physician to determine if the patient needed premedication. His physician suggested a premedication of 2 gms Amoxicillin one hour prior to treatment following AHA guidelines. The patient reported taking the following medications: Aciphex 20 mg as needed for acid reflux; Aspirin 81 mg; Benadryl 50 mg; Catapres .2 mg for hypertension; during hemodialysis, Epogen 2200 units IV, Fosrenol 1000 mg, Heparin 6000 units IV; Lisinopril 10 mg and Minoxidil 10 mg for hypertension; Mobic 7.5 mg to prevent bone disease; Nephro-Vite one tablet daily; Normodyne 200 mg 2x/day; Sensipar 60 mg for hyperparathyroidism in dialysis patients; Venofer 50 mg IV 1x/week; and Zemplar 7 mcg IV to prevent secondary hyperparathyroidism. Patient reported no allergies.

Dental History

Approximately six years since his last dental treatment, the patient presents only for emergency care. Patient reports pain off and on in posterior teeth, bleeding and sore gums when brushing, uses a medium toothbrush and does not floss.

Initial Examination and Treatment Plan

Diagnosis, oral cancer screening, intra- and extra-oral examination, FMX and panoramic digital films were completed (see Figure 1).

Treatment plan: Four quadrants SRP by a senior dental hygiene student (including six-week evaluation prior to clearance for transplant)/OH instructions/rationale to lessen bacterial load when on long-term dialysis, Dr. McCarville: Extraction #1, #2 DO, #3 OL, #14 OL, #16 MO, #17 O, #18 O, #19 DO, #20 DO, #21 DO and #31 DO.

Patient followed up for reevaluation at six weeks and healing nicely. At this point, the patient was released for transplant surgery.

Conclusion

The number of patients with kidney failure and who require dialysis is growing 10-15 percent annually, most commonly observed in the middle-aged to geriatric patient. Dentists and hygienists alike need to feel comfortable treating ESRD patients because the most important element in the treatment plan is to eliminate the risk of active infection. Close communication with the nephrologist or physician is essential. ESRD patients are predisposed to periodontal problems, dental hygienists are able to treat and help maintain the oral health in these compromised patients. Maintaining an ESRD patient oral health greatly reduces their risk for infections during the transplant process.

References

(1.) Centers for Disease Control and Prevention. MMWR 2007; 56: 161-5.

(2.) National Kidney Foundation. US renal data system annual data report. Available at www.kidney.org/. Accessed Mar. 2008.

(3.) Vesterinen M, Leivo T, Honkanen E, Lindqvist C. Oral health and dental treatment of patients with renal disease. Quintessence Int 2007; 38: 211-9.

(4.) Sharma DCG, Pradeep AR. End stage renal disease and its dental management. NY State Dent J 2007; 73(1): 43-7.

[FIGURE 1 OMITTED]

(5.) Castillo A, Mesa F, Liebana J, et al. Periodontal and oral microbiological status of an adult population undergoing haemodialysis: a cross-sectional study. Oral Diseases 2007; 13(2): 198-205.

(6.) Craig RG, Kotanko P, Kamer AR, Levin NW. Periodontal diseases--a modifiable source of systemic inflammation for the end-stage renal disease patient on haemodialysis therapy? Nephrol Dial Transplant 2007; 22(2): 312-5.

(7.) Borawski J, Wilezynske-Borawska M, Stokowaska W, Mysliwiec M. The periodontal status of pre-dialysis chronic kidney disease and maintenance dialysis patients. Nephrol Dial Transplant 2007; 22(2): 457-64.

(8.) Bayraktar G, Kurtulus I, Duraduryan A et al. Dental and periodontal findings in hemodialysis patients. Oral Diseases 2007; 13(4): 393-7.

(9.) Mayo Clinic. Kidneys and urinary tract. Hemodialysis and peritoneal dialysis: what's the difference. Available at www.mayoclinic.com/health/hemodialysis/DA00093. Accessed Mar. 2008.

(10.) Williams RD. Living day-to-day with kidney dialysis; quality improvements continue for devices and clinics; dialysis under scrutiny. US Food and Drug Administration. Available at www.fda.gov/FDAC/features/1998/198_dial.html. Accessed Mar. 2008.

(11.) Burr RA. All about dialysis'. Diabetes Forecast 2003; 56(7): 70-2.

(12.) Raja K, Coletti D. Management of the dental patient with renal disease. Dent Clin N Am 2006; 50(4): 529-45.

By Kathryn M. Dockter, RDH, MS, and Kirstin McCarville, DDS

Kathryn M. Dockter, RDH, BS, MS, has over 30 years of experience in clinical practice, both in general dentistry and periodontics. A graduate of the University of Missouri-Kansas City (UMKC) School of Dentistry, she has a master's degree in Dental Hygiene Education and is a faculty member in the Oncology Dental Support and Special Patient Care Clinic as Patient Care Clinical Manager at UMKC School of Dentistry. Her areas of interest are oral oncology and tobacco cessation.

Kirstin McCarville BS, DDS, is a graduate of Creighton University Dental School She completed a one year Advanced Education in General Dentistry Residency and a two-year Fellowship in Special Patient Care with emphasis in treating oncology and transplant patients at UMKC School of Dentistry. In August, she joined the faculty at Creighton University Dental School as an assistant professor of prosthodontics and director of the Special Needs Clinic.
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Title Annotation:clinical feature
Author:Dockter, Kathryn; McCarville, Kirstin
Publication:Access
Geographic Code:1USA
Date:Nov 1, 2008
Words:1963
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