Being prepared to treat patients with renal disease.
The American adult patient is getting older. By the year 2040, older adults will make up 21 percent of the U.S. population and of that group, people aged 85 and older will make up the most rapidly growing segment of this particular group. (1)
These individuals and others who are medically compromised require special treatment modifications, and the dental assistant is in the forefront of screening and coordinating many aspects of patient care.
Chronic renal failure, dialysis, and organ transplantation
The kidneys are responsible for fluid and electrolyte balance, production of red blood cells, drug excretion, removal of bodily wastes, and maintenance of calcium in our bones. When the kidneys fail, a domino effect occurs that affects the other major body systems. Diabetes, high blood pressure, and various kidney disorders are the main causes of end stage renal disease. End stage renal disease is when body systems are so compromised that critical life systems can only be maintained through dialysis or renal transplantation. Death will result if no treatment is given at this stage. Chronic renal disease, end stage renal disease, dialysis, and organ transplantation warrant special dental considerations.
Diabetes is the number one risk factor for renal disease. When reviewing the medical history of a diabetic patient, it is very important to ask leading questions to find out how well the disease is controlled. The dental assistant, while reviewing the health history with the diabetic patient, should ask the following questions:
1. When were you diagnosed with diabetes?
2. Have you noticed any trouble with wound healing?
3. Are your glucose levels controlled through insulin or diet?
4. Do you check your insulin levels at home and if you do, how often do you monitor the level of insulin?
5. How often do you see your primary physician and what are your A1c levels? (Hemoglobin A1c is a protein related to blood sugar intolerance. A normal level of A1c is less than seven. For more information on the A1c test, go to: http://www.ndep.nih.gov/diabetes/pubs/KnowNumbers_Eng.pdf).
6. Does your health care provider recommend that you follow a certain diet?
7. Does your weight fluctuate?
8. Do you exercise on a regular basis and, if so, tell me what type and how often?
9. Have you eaten this morning? Have you taken your meds as normal today?
10. Have you ever had a diabetic crisis? What were the initial symptoms?
Once these questions have been asked, detailed written notes (in ink) should be made and presented to the dentist. These patients require thorough documentation.
High blood pressure is the number two cause of renal disease. The American Heart Association guideline for normal blood pressure is 120/80 mm Hg for adults. (2) Blood pressure that stays between 120-139/80-89 mm Hg for adults is considered prehypertension and above this level at 140/90 mm Hg for adults or higher is considered high (hypertension). (2) Renal disease affects other body systems, too, including patients with no prior history of high blood pressure who suddenly develop renal disease-associated hypertension.
Another important point about patients with renal disease is the possible adverse side effects of medications they are taking. Renal disease patients are sometimes taking Prednisone or Imuran and either one of these drugs can elevate blood sugar levels and/or blood pressure.
End stage renal disease occurs when kidney function declines to 10 percent. When the kidneys fail, fluids accumulate, and blood pressure increases. Electrolytes become unbalanced, leaving patients susceptible to cardiac distress. Impurities build up in the blood causing uremia. Calcium balances are disturbed and bone density is affected. Dialysis is needed to maintain life.
Understanding dialysis types
Hemodialysis is the type of dialysis with which most people are familiar. In order to remove excess fluid and remove deadly body toxins that have built up, the patient's blood must be filtered artificially. Normally, patients attend dialysis sessions three times a week, for 3-5 hours each session.
Dialysis patients should not have routine dental procedures on their dialysis session days. Heparin, a blood thinner, is used during dialysis sessions and makes the patient susceptible to excessive bleeding. Only emergency dental treatment is to be performed on dialysis days.
Keep in mind that dialysis patients should only be scheduled for dental appointments on their "off" days.
Patients are on strict fluid restrictions to limit fluid buildup. Regardless, on their "off" days, patients will often show signs of fluid buildup that may result in elevated blood pressure. Often "normal" blood pressures are difficult to obtain in dialysis patients regardless of hypertensive medications.
Dialysis patients have a higher risk of hepatitis infection. The dental assistant should follow personal protective equipment guidelines.
Finally, hemodialysis patients are susceptible to bacterial infections at their dialysis access site. This access, called a graft or fistula, is usually placed in the forearm.
In order to prevent blood clots, blood pressure should NEVER be taken in the graft/fistula arm.
This access appears as a very large, raised artery in the arm (see Figure 1). However, if a patient has had problems with the graft, a temporary access may be located in the neck or a permanent graft may be located in the leg. With any dialysis patient, the dental assistant should question the patient regarding the location of their graft(s) and decide where it is safe to place the blood pressure cuff. Since the graft site is susceptible to infection, antibiotic premedication is necessary for any invasive dental procedure that will result in bleeding.
[FIGURE 1 OMITTED]
The other type of dialysis is peritoneal dialysis. This type of dialysis purifies the blood through osmosis rather than filtration. A catheter is surgically placed in the abdomen and inserted into the peritoneal cavity. The lining of the cavity allows the blood impurities to diffuse through the lining. The cavity is drained several times a day or at night with a machine.
Peritoneal dialysis patients are not at high risk for infection and are not premedicated on the basis of dialysis alone. Other factors that would require antibiotic premedication must be present and are determined according to the American Heart Association Guidelines for Premedication. The dental assistant should verify that the patient has never been treated with hemodialysis and does not have a graft. In this case, blood pressure may be taken in any location.
Medical consultation is necessary
With the possibility of multisystem involvement, systemic diseases, an elevated risk of bleeding, a high risk of cardiac episodes, and possible need for antibiotic premedication, a medical consult with the primary care physician is necessary regardless of the method of dialysis.
Most patients you will see with renal disease will have advanced disease because kidney damage goes unnoticed in the early stages when there usually aren't any alarming symptoms. Only when the kidney damage is more extensive does the problem become apparent and patients undoubtedly require drastic treatment measures like dialysis or renal transplantation.
Kidney transplantation frees people from dependence on dialysis and these patients have a better chance of enjoying life more fully and living longer. Many scientific breakthroughs in surgical techniques and immunosuppressive therapy for transplant recipients permit more individuals to undergo these treatment modalities. Kidney transplantation is by far the most frequent and successful of all solid organ transplants and kidney transplant recipients can lead normal lives for many decades.
Dental assistants are the ideal auxiliaries to greet these special needs patients and ask the aforementioned pertinent medical history questions before the dentist meets and examines the patient. Copy these questions and keep them in a file folder along with other file folders on special needs patients and you'll be prepared to interact with these individuals should the opportunity present itself. Patients with renal disease will greatly appreciate your interest in their condition and will respect your impressive command of the subject.
(1.) Little JW. Special medical concerns in the dental management of older adults. General Dentistry, 2004; 52(2):152.
(2.) American Heart Association: http://www.americanheart.org/
National Kidney Foundation: http://www.kidney.org/
Procter & Gamble, dentalcare.com: http://dental care.com/soap/intermed/dialysis.htm
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|Author:||Slim, Lynne Hollister|
|Publication:||The Dental Assistant|
|Date:||May 1, 2005|
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