Chemotherapy:
Hypodontia
Root abnormalities
Amelogenesis imperfecta
Microdontia of bicuspid teeth
Tendency toward thinning of roots with an enlarged pulp chamber
Radiotherapy Short:
Damage to epithelial surfaces
Mucositis
Intraoral soft tissue ulceration
Taste disorders
Oralpharyngeal mucositis
Radiotherapy Long:
Xerostomia
Caries
Root tip blunting and shortening
incomplete calcification of teeth
premature closure of apices
delayed or arrested tooth development
comprised trismus
abnormal occlusal relationships
facial deformities
Tuesday, January 19, 2010
Stuff we already Know by Dan and Joanne
Dan Boboia & Joanne Lewis
Chemotherapy Long term:
Hypodontia
Root abnormalities
Amelogenesis imperfecta
Microdontia of bicuspid teeth
Tendency toward thinning of roots with an enlarged pulp chamber
Radiotherapy Short:
Damage to epithelial surfaces
Intraoral soft tissue ulceration
Taste disorders
Oralpharyngeal mucositis
Radiotherapy Long:
Xerostomia
Caries
Root tip blunting and shortening
incomplete calcification of teeth
premature closure of apices
delayed or arrested tooth development
comprised trismus
abnormal occlusal relationships
facial deformities
Chemotherapy Long term:
Hypodontia
Root abnormalities
Amelogenesis imperfecta
Microdontia of bicuspid teeth
Tendency toward thinning of roots with an enlarged pulp chamber
Radiotherapy Short:
Damage to epithelial surfaces
Intraoral soft tissue ulceration
Taste disorders
Oralpharyngeal mucositis
Radiotherapy Long:
Xerostomia
Caries
Root tip blunting and shortening
incomplete calcification of teeth
premature closure of apices
delayed or arrested tooth development
comprised trismus
abnormal occlusal relationships
facial deformities
Oral Complications in Children with Cancer
Dan Boboia 1/22/10 Lit. Review
Title: Oral Complications in Children with Cancer
Author: Childers et al
Main Purpose: To determine the incidence of oral complications in 214 pediatric patients with cancer at Children’s Hospital of Alabama.
Methods / Results: Final study sample comprised 214 pediatric cancer patients; median age was 6 years; Incidence of each oral complication is given in table 1. Incidence of ulcers ranked highest, followed by gingivitis. Children with sarcomas had more ulcers and Candida infections then those with leukemia. There was a 5 x higher rate of gingivitis then in patients with sarcoma. Candida infections in children with solid tumors were four times more then in patients with leukemia.
Conclusion:
Oral complications are a frequent cause of morbidity in children with cancers. There are also certain cancers in which certain oral complications are seen more often. Prevention could be more effective my identifying the risk groups and developing treatment strategies.
Title: Oral Complications in Children with Cancer
Author: Childers et al
Main Purpose: To determine the incidence of oral complications in 214 pediatric patients with cancer at Children’s Hospital of Alabama.
Methods / Results: Final study sample comprised 214 pediatric cancer patients; median age was 6 years; Incidence of each oral complication is given in table 1. Incidence of ulcers ranked highest, followed by gingivitis. Children with sarcomas had more ulcers and Candida infections then those with leukemia. There was a 5 x higher rate of gingivitis then in patients with sarcoma. Candida infections in children with solid tumors were four times more then in patients with leukemia.
Conclusion:
Oral complications are a frequent cause of morbidity in children with cancers. There are also certain cancers in which certain oral complications are seen more often. Prevention could be more effective my identifying the risk groups and developing treatment strategies.
Thursday, January 14, 2010
Dental Management of the Renal Transplant Patient
Department of Pediatric Dentistry
Lutheran Medical Center
Name: Craig Elice Date: January 15, 2010
Article title: Dental Management of the Renal Transplant Patient
Author(s): Rhodus NL, Little JW
Journal: Compend Contin Educ Dent
Volume (number): 14(4)
Month, Year:
Major topic: Renal Transplant, dental management
Type of Article: Review of Literature
Main Purpose: The article reviewed the indications, process, systemic and oral complications and management of dental patients receiving a kidney transplant
Findings: Indications for renal transplant include chronic renal disease or end-stage renal disease (ERSD). Along with the deterioration of the nephrons comes hypertension, diabetes, congestive heart failure, infections, urinary tract obstructions, hypercalcemia and elevated potassium which all require medical management. Problems managing these issues leads to hemodialysis. Renal transplantation can free the patient from dialysis, but has a host of problems along with it such as graft rejection, chronic immunosuppression, susceptibility to infections, and poor wound healing. Oral complications may include gingivitis, desquamation, and ulceration of the oral mucosa. Oral candidiasis, and HSV I are common. Cyclosporine, azathioprine, prednisone and ALG are common immunosuppressive medications which have many adverse effects. Cyclosporine can cause severe kidney and liver changes, hypertension,, anemia, and bleeding problems as well as gingival hyperplasia, hirsutism, and various cancers of the skin. Azithioprine causes bone marrow suppression increasing the risk of infection and excessive bleeding from anemia, thrombocytopenia, and leucopenia. ALG also causes hemolysis, leukopenia, thrombocytopenia, and tumor development as well as infections. Prednisone acts as an anti-inflammatory agent which has side effects including hypertension, diabetes mellitus, osteoporosis, impaired healing and psychoses. Dental management focuses on elimination of infection by restoring or extracting teeth and disease prevention such as good oral hygiene, antimicrobial mouthwashes, and professional dental cleanings and fluoride applications. Consultation with the physician is important to determine degree of renal dysfunction and the need for antibiotics to prevent infective endocarditis. The need for antibiotics is controversial and is best determined by a physician consult. The dentist should avoid drugs metabolized or excreted by the kidney. Management of these patients can be divided into two phases. The first phase occurs immediately posttransplant when complications and rejection are most likely. Only emergency dental care is provided, while routine dental care is contraindicated. The second phase a.k.a. the stable phase often requires antibiotic prophylaxis. Due to the altered oral flora, the type of antibiotic is uncertain. Patients are at increased risk of infections from the environment therefore infection control procedures are necessary. Patients are susceptible to HBV, HIV, CMV, Epstein Barr, etc. In addition to post-operative infections, the dentist must be wary of risks of excessive bleeding and adverse reactions to physical and emotional stress. Anticoagulants and high doses of prednisone are common medications. If the level of anticoagulation is greater than 2 and a half times the normal PT, the medication dosage should be reduced. Depending of the procedure, it may take 3-4 days of reduced dosage to improve the PT. Avoidance of drugs metabolized or excreted by the kidneys is important. Local anesthetics and antibiotics like penicillin, erythromycin, amoxicillin, and clindamycin are generally safe. Aminoglycosides and tetracycline should not be prescribed as well as aspirin and phenacetin. Analgesics like acetaminophen, codeine, are safe. Patients taking steroids need a physician consult to determine the necessity for a change in dose. Patients on a chronic 5mg dose of prednisone may need to double or triple their normal dose the morning of, and 1 hour preop. Taking a patients blood pressure prior to dental treatment is probably good practice because one of the side effects of cyclosporine is hypertension. Signs of over-immunosuppression include recurrent HSV infections, herpes zoster, candidiasis, large slow to heal aphthous ulcers and infrequently lymphoma, Kaposi’ sarcoma, and hairy leukoplakia.
Key points/Summary: Medical consultation is necessary to establish the following: current status of patient, degree of immunosuppression and if graft rejection is present, need for prophylactic antibiotics, need for steroid supplementation, need to alter anticoagulation dosage, presence of hypertension, current status of renal function, and medications that should be avoided. Dental management should focus on removal of infection and good dental health through oral hygiene practices, cleanings, and fluoride.
Assessment of article: Good article but I think it is dated.
Lutheran Medical Center
Name: Craig Elice Date: January 15, 2010
Article title: Dental Management of the Renal Transplant Patient
Author(s): Rhodus NL, Little JW
Journal: Compend Contin Educ Dent
Volume (number): 14(4)
Month, Year:
Major topic: Renal Transplant, dental management
Type of Article: Review of Literature
Main Purpose: The article reviewed the indications, process, systemic and oral complications and management of dental patients receiving a kidney transplant
Findings: Indications for renal transplant include chronic renal disease or end-stage renal disease (ERSD). Along with the deterioration of the nephrons comes hypertension, diabetes, congestive heart failure, infections, urinary tract obstructions, hypercalcemia and elevated potassium which all require medical management. Problems managing these issues leads to hemodialysis. Renal transplantation can free the patient from dialysis, but has a host of problems along with it such as graft rejection, chronic immunosuppression, susceptibility to infections, and poor wound healing. Oral complications may include gingivitis, desquamation, and ulceration of the oral mucosa. Oral candidiasis, and HSV I are common. Cyclosporine, azathioprine, prednisone and ALG are common immunosuppressive medications which have many adverse effects. Cyclosporine can cause severe kidney and liver changes, hypertension,, anemia, and bleeding problems as well as gingival hyperplasia, hirsutism, and various cancers of the skin. Azithioprine causes bone marrow suppression increasing the risk of infection and excessive bleeding from anemia, thrombocytopenia, and leucopenia. ALG also causes hemolysis, leukopenia, thrombocytopenia, and tumor development as well as infections. Prednisone acts as an anti-inflammatory agent which has side effects including hypertension, diabetes mellitus, osteoporosis, impaired healing and psychoses. Dental management focuses on elimination of infection by restoring or extracting teeth and disease prevention such as good oral hygiene, antimicrobial mouthwashes, and professional dental cleanings and fluoride applications. Consultation with the physician is important to determine degree of renal dysfunction and the need for antibiotics to prevent infective endocarditis. The need for antibiotics is controversial and is best determined by a physician consult. The dentist should avoid drugs metabolized or excreted by the kidney. Management of these patients can be divided into two phases. The first phase occurs immediately posttransplant when complications and rejection are most likely. Only emergency dental care is provided, while routine dental care is contraindicated. The second phase a.k.a. the stable phase often requires antibiotic prophylaxis. Due to the altered oral flora, the type of antibiotic is uncertain. Patients are at increased risk of infections from the environment therefore infection control procedures are necessary. Patients are susceptible to HBV, HIV, CMV, Epstein Barr, etc. In addition to post-operative infections, the dentist must be wary of risks of excessive bleeding and adverse reactions to physical and emotional stress. Anticoagulants and high doses of prednisone are common medications. If the level of anticoagulation is greater than 2 and a half times the normal PT, the medication dosage should be reduced. Depending of the procedure, it may take 3-4 days of reduced dosage to improve the PT. Avoidance of drugs metabolized or excreted by the kidneys is important. Local anesthetics and antibiotics like penicillin, erythromycin, amoxicillin, and clindamycin are generally safe. Aminoglycosides and tetracycline should not be prescribed as well as aspirin and phenacetin. Analgesics like acetaminophen, codeine, are safe. Patients taking steroids need a physician consult to determine the necessity for a change in dose. Patients on a chronic 5mg dose of prednisone may need to double or triple their normal dose the morning of, and 1 hour preop. Taking a patients blood pressure prior to dental treatment is probably good practice because one of the side effects of cyclosporine is hypertension. Signs of over-immunosuppression include recurrent HSV infections, herpes zoster, candidiasis, large slow to heal aphthous ulcers and infrequently lymphoma, Kaposi’ sarcoma, and hairy leukoplakia.
Key points/Summary: Medical consultation is necessary to establish the following: current status of patient, degree of immunosuppression and if graft rejection is present, need for prophylactic antibiotics, need for steroid supplementation, need to alter anticoagulation dosage, presence of hypertension, current status of renal function, and medications that should be avoided. Dental management should focus on removal of infection and good dental health through oral hygiene practices, cleanings, and fluoride.
Assessment of article: Good article but I think it is dated.
Renal disease
Resident’s Name: Joanne Lewis Date: January 15, 2010
Chapter 23: Renal Disease (The Handbook of Pediatric Dentistry)
Definitions:
Renal Insufficiency – damage past the point of compensation; impaired ability to maintain the internal invironment.
Renal Failure – reduction in glomerular filtration rate; normal homeostasis cannot be maintained.
End-Stage Renal Disease (ESRD) – chronic, irreversible, progressive disease; most common causes are diabetes mellitus, hypertension and chronic glomerulonephritis.
Medical Treatment of ESRD:
Dialysis – peritoneal dialysis or hemodialysis
Renal Transplantation
Oral Manifestations of ESRD
- Malodor
- Metallic taste
- Xerostomia
- Glossitis
- Increased deposition of calculus
- Low caries
- Tooth erosion (due to vomiting)
Prophylactic Antibiotics Prior to Dental Treatment
AHA guidelines do not address prophylactic antibiotic use in ESRD and renal transplant patients. In patients with recent placement of a shunt (<6>
Dental Management During Renal Therapy and Before Transplantation
Stabilize or eliminate existing and potential sources of oral infection.
OH training.
Radiographic exam to look for changes in bone.
Xerostomia? Taking any meds high in sucrose?
Consult with physician.
More aggressive treatment (ext. vs. pulp therapy/endo) may be indicated – dental infections during immunosuppression can have significant impact on medical therapy.
Ortho – only if OH is excellent.
Extractions – at least 7-10 days prior to transplant.
Dental care should be done soon after dialysis; avoid the day before dialysis.
Dental Management After Transplantation
Defer all elective procedures during immunosuppression periods.
Increased risk of oral malignancy – monitor.
Ortho – may start or resume after at least a 2 year disease-free survival.
Factors affecting cyclosporine-induced gingival overgrowth in pediatric renal transplant recipients.
Resident: Adam J. Bottrill
Date: 15JAN10
Region: Providence
Article title: Factors affecting cyclosporine-induced gingival overgrowth in pediatric renal transplant recipients.
Author(s): Karpinia, Katherine DMD et al.
Journal: Pediatric Dentistry
Page #s: pp. 450-455
Year: 1996
Major topic: Cyclosporine-induced gingival overgrowth
Minor topic(s): Pediatric renal transplant patients
Type of Article: Summary of research
Main Purpose: To study the occurrence of gingival overgrowth in children after kidney transplantation and to investigate the relationship of gingival overgrowth (GO) to medical and dental parameters.
Overview of method of research: 49 transplant patients taking cyclosporine were evaluated for a number of different characteristics.
Key points in the article discussion:
A. General
1. CsA is used with organ recipients to prevent graft rejection.
2. Taken via oral or IV.
3. absorbed by gut and metabolized by the liver enzymes of the cytochrome P450 system.
4. Blood CsA levels >200 ng/mL is associated with various side effects.
5. GO first reported in 1983.
6. Recently reported that adults with >400 ng/mL have significantly greater risk of GO.
7. Though much has been reported on adults with CsA associated GO, not much out there on children and adolescents.
B. Hypothesis:
1. The immunosuppressant drug CsA, as used in pediatric renal transplant patients, contributes to the clinical manifestation of GO.
2. Specific aims:
a. document the presence of GO in children with kidney transplants via exam
b. associate documented GO with blood trough levels of CsA
c. document the gingival health status of subjects exhibiting GO, compared with subjects without GO
d. detect relationships between medication and GO
C. Method:
1. 1992-1993: 49 subjects from 5.9-18.6 y.o.
2. 19 received cadaveric kidneys and 30 had living relative donors
3. All subjects were allowed routine dental care.
4. Inclusion Criteria
a. Hx of kidney transplant
b. CsA immunosuppressive therapy
5. Exam
a. CsA levels
b. Plaque and calculus (present vs not present)
c. Gingival index (normal, mild, moderate, severe)
d. Gingival width
e. Probing depth
f. Gingival overgrowth (present or not, per tooth)
D. Results and Discussion
1. Overall, subjects’ OH was fair. No subject was completely plaque-free.
2. This study found that 77.5% of pediatric patients meeting inclusion criteria exhibited GO at exam.
3. All those on CsA >3mo showed GO
4. In contrast with recent reports, this study found the prevalence of GO in children larger than recently reported adult CsA-induced GO.
5. This papillary and marginal GO yielding firm, nodular, or granular growth has been found with CsA, phenytoin, sodium valproate, primidone, CCB’s nifedipine, verapamil, diltiaze and nitrendipine.
6. GO frequency was NOT significantly associated with plaque, gingival index, calculus OR CsA levels.
7. The single most critical factor in GO occurrence was increased TIME of CsA therapy.
Assessment of article: Keep in mind these results are based on very specific inclusion criteria. Shenanigans?... you decide.
Date: 15JAN10
Region: Providence
Article title: Factors affecting cyclosporine-induced gingival overgrowth in pediatric renal transplant recipients.
Author(s): Karpinia, Katherine DMD et al.
Journal: Pediatric Dentistry
Page #s: pp. 450-455
Year: 1996
Major topic: Cyclosporine-induced gingival overgrowth
Minor topic(s): Pediatric renal transplant patients
Type of Article: Summary of research
Main Purpose: To study the occurrence of gingival overgrowth in children after kidney transplantation and to investigate the relationship of gingival overgrowth (GO) to medical and dental parameters.
Overview of method of research: 49 transplant patients taking cyclosporine were evaluated for a number of different characteristics.
Key points in the article discussion:
A. General
1. CsA is used with organ recipients to prevent graft rejection.
2. Taken via oral or IV.
3. absorbed by gut and metabolized by the liver enzymes of the cytochrome P450 system.
4. Blood CsA levels >200 ng/mL is associated with various side effects.
5. GO first reported in 1983.
6. Recently reported that adults with >400 ng/mL have significantly greater risk of GO.
7. Though much has been reported on adults with CsA associated GO, not much out there on children and adolescents.
B. Hypothesis:
1. The immunosuppressant drug CsA, as used in pediatric renal transplant patients, contributes to the clinical manifestation of GO.
2. Specific aims:
a. document the presence of GO in children with kidney transplants via exam
b. associate documented GO with blood trough levels of CsA
c. document the gingival health status of subjects exhibiting GO, compared with subjects without GO
d. detect relationships between medication and GO
C. Method:
1. 1992-1993: 49 subjects from 5.9-18.6 y.o.
2. 19 received cadaveric kidneys and 30 had living relative donors
3. All subjects were allowed routine dental care.
4. Inclusion Criteria
a. Hx of kidney transplant
b. CsA immunosuppressive therapy
5. Exam
a. CsA levels
b. Plaque and calculus (present vs not present)
c. Gingival index (normal, mild, moderate, severe)
d. Gingival width
e. Probing depth
f. Gingival overgrowth (present or not, per tooth)
D. Results and Discussion
1. Overall, subjects’ OH was fair. No subject was completely plaque-free.
2. This study found that 77.5% of pediatric patients meeting inclusion criteria exhibited GO at exam.
3. All those on CsA >3mo showed GO
4. In contrast with recent reports, this study found the prevalence of GO in children larger than recently reported adult CsA-induced GO.
5. This papillary and marginal GO yielding firm, nodular, or granular growth has been found with CsA, phenytoin, sodium valproate, primidone, CCB’s nifedipine, verapamil, diltiaze and nitrendipine.
6. GO frequency was NOT significantly associated with plaque, gingival index, calculus OR CsA levels.
7. The single most critical factor in GO occurrence was increased TIME of CsA therapy.
Assessment of article: Keep in mind these results are based on very specific inclusion criteria. Shenanigans?... you decide.
Dental Considerations for the patient w/ Renal disease receiving hemodialysis 1/15/10
Murphy January 15, 2010
Article Title: Dental Considerations for the patient w/ Renal disease receiving hemodialysis
Authors: DeRossi DMD, Scott. Michael Glickman, DMD
Journal: JADA
Volume: Jan 1996
Major Topic: Renal Disease and its dental complications
Minor Topic: Renal Disease treatments and complications
Type of Article: Review of disease/treatment options
Main Purpose: Review of how to treat a patient receiving dialysis
Overview of Method of Research: Review of current (1996) literature for dental management of pt’s w/ renal disease.
Findings: About 8 million people in the US are affected by some type of kidney disease. ESRD is a chronic, progressive disease that causes the destruction of nephrons, the kidney’s functional unit. Once destroyed, nephrons do not regenerate. Some things to think of when treating a patient with kidney disease include excessive bleeding, hypertension, anemia, drug intolerance and synergism, increased susceptibility to infection, and various oral manifestations. With renal failure, many of the changes that occur happen over a period of time and are ameliorated by different types of treatment, from dietary changes, to transplants, to medications, to dialysis. There are two types of dialysis, peritoneal dialysis which is essentially ambulatory treatment, and hemodialysis, which is done in the hospital, and is much more common in the US than peritoneal dialysis. Arteriovenus shunts and fistulas are often placed to allow access to the patient’s bloodstream. During treatment, pt’s receive anticoagulants to facilitate blood exchange and to maintain patency.
Around 90% of patients with renal disease show some type of oral manifestation. Patients may complain of/have
-bad breath/metallic breath
-xerostomia
-mucosal pallor
-uremic stomatitis
-painful ulcerations on the ventral tongue surface and anterior mucosal surfaces
-decrease in caries(due to the inhibition of bacteria from highly uremic saliva…very common in children)
-erosion from frequent regurg.
One oral sign that becomes more evident as the late stage of disease approaches is renal osteodystrophy. The increase in urinary excretion of phosphates decrease urine calcium excretions, causing exaggerated release of calcium from bone. This can present as a
-ground glass appearance of bone
-loss of lamina dura
-radiolucent giant cell lesions
-bone loss
-metastatic soft tissue calcifications
-tooth mobility/tooth drift
-malocclusion
-enamel hypoplasia
-pulp stones/calcification
-delayed/altered eruption
Patients on peritoneal dialysis don’t pose any contraindications to dental tx. Hemodialysis pt’s however, do.
Key Point/Summary
Things to consider….
Before Tx
-consult w/ nephrologists for recent coag values and possible AB coverage
-eval hyper/hypotension
-do not take BP in same arm that access is in
-Find out underlying cause of RD
-Obtain CBC to eval for anemia
-Determine presence f uremic symptoms
-Get X-Rays to eval for osteodystrophy
-Determine type of vascular access
-Determine dialysis cycle
-Consider AB coverage and anti anxiety meds
-Review the meds the pt is taking and assess any oral implications(nifedipine)
During TX
-Thorough exam
-eliminate all infection
-use adjunctive hemostatic aids
-make sure pt is comfy
-allow pt breaks to move around
After Tx
-use post procedure hemostatic agents
-review home care
-possible xerostomia therapy
-post op AB
-adjust meds for RD dosage
Patients are best treated on the morning after they receive dialysis. The MOST important thing to keep in mind with these patients is the risk of infection. The mortality rate with these patients is high due to their lowered immune response…45%. ANY dental procedure that may produce bleeding should be covered w/ AB’s….yes you too Dr. Adam!! The best AB to use is vancomycin, but it’s wicked expensive and isn’t practical. Other options are amox 3g PO 1 hour before proc., or clinda 300mg PO 1 hour pre op, the 150mg 6 hours after initial dose.
Assessment of article: Lots of relevant good info on RD. Having a close family member who lived with it for almost 11 years, I know how tough it can be…on everyone. Try to be aware of not only the patients, but also their caregivers and family as well. It sucks. No other way to say it.
Article Title: Dental Considerations for the patient w/ Renal disease receiving hemodialysis
Authors: DeRossi DMD, Scott. Michael Glickman, DMD
Journal: JADA
Volume: Jan 1996
Major Topic: Renal Disease and its dental complications
Minor Topic: Renal Disease treatments and complications
Type of Article: Review of disease/treatment options
Main Purpose: Review of how to treat a patient receiving dialysis
Overview of Method of Research: Review of current (1996) literature for dental management of pt’s w/ renal disease.
Findings: About 8 million people in the US are affected by some type of kidney disease. ESRD is a chronic, progressive disease that causes the destruction of nephrons, the kidney’s functional unit. Once destroyed, nephrons do not regenerate. Some things to think of when treating a patient with kidney disease include excessive bleeding, hypertension, anemia, drug intolerance and synergism, increased susceptibility to infection, and various oral manifestations. With renal failure, many of the changes that occur happen over a period of time and are ameliorated by different types of treatment, from dietary changes, to transplants, to medications, to dialysis. There are two types of dialysis, peritoneal dialysis which is essentially ambulatory treatment, and hemodialysis, which is done in the hospital, and is much more common in the US than peritoneal dialysis. Arteriovenus shunts and fistulas are often placed to allow access to the patient’s bloodstream. During treatment, pt’s receive anticoagulants to facilitate blood exchange and to maintain patency.
Around 90% of patients with renal disease show some type of oral manifestation. Patients may complain of/have
-bad breath/metallic breath
-xerostomia
-mucosal pallor
-uremic stomatitis
-painful ulcerations on the ventral tongue surface and anterior mucosal surfaces
-decrease in caries(due to the inhibition of bacteria from highly uremic saliva…very common in children)
-erosion from frequent regurg.
One oral sign that becomes more evident as the late stage of disease approaches is renal osteodystrophy. The increase in urinary excretion of phosphates decrease urine calcium excretions, causing exaggerated release of calcium from bone. This can present as a
-ground glass appearance of bone
-loss of lamina dura
-radiolucent giant cell lesions
-bone loss
-metastatic soft tissue calcifications
-tooth mobility/tooth drift
-malocclusion
-enamel hypoplasia
-pulp stones/calcification
-delayed/altered eruption
Patients on peritoneal dialysis don’t pose any contraindications to dental tx. Hemodialysis pt’s however, do.
Key Point/Summary
Things to consider….
Before Tx
-consult w/ nephrologists for recent coag values and possible AB coverage
-eval hyper/hypotension
-do not take BP in same arm that access is in
-Find out underlying cause of RD
-Obtain CBC to eval for anemia
-Determine presence f uremic symptoms
-Get X-Rays to eval for osteodystrophy
-Determine type of vascular access
-Determine dialysis cycle
-Consider AB coverage and anti anxiety meds
-Review the meds the pt is taking and assess any oral implications(nifedipine)
During TX
-Thorough exam
-eliminate all infection
-use adjunctive hemostatic aids
-make sure pt is comfy
-allow pt breaks to move around
After Tx
-use post procedure hemostatic agents
-review home care
-possible xerostomia therapy
-post op AB
-adjust meds for RD dosage
Patients are best treated on the morning after they receive dialysis. The MOST important thing to keep in mind with these patients is the risk of infection. The mortality rate with these patients is high due to their lowered immune response…45%. ANY dental procedure that may produce bleeding should be covered w/ AB’s….yes you too Dr. Adam!! The best AB to use is vancomycin, but it’s wicked expensive and isn’t practical. Other options are amox 3g PO 1 hour before proc., or clinda 300mg PO 1 hour pre op, the 150mg 6 hours after initial dose.
Assessment of article: Lots of relevant good info on RD. Having a close family member who lived with it for almost 11 years, I know how tough it can be…on everyone. Try to be aware of not only the patients, but also their caregivers and family as well. It sucks. No other way to say it.
Oral changes associated with end-stage liver disease and liver transplantation: implications and dental management
Kris Hendricks January 15, 2010
Article Title: Oral changes associated with end-stage liver disease and liver transplantation: implications for dental management.
Authors: W. Kim Seow, R.W> Shepherd, T.H. Ong
Journal: Journal of Dentistry for Children
Volume: Nov-Dec 1991
Major Topic: Liver Disease and its dental complications
Minor Topic: Oral Pathology
Type of Article: Informative with Case studies
Main Purpose: The study investigates a group of children with end-stage liver disease with particular reference to the oral manifestations of the disease, as well as the complications associated with liver transplantation.
Overview of Method of Research: Review of current (1991) literature for medical and dental live disease management in children. Case study also.
Findings:
- All patients presented with enamel defects and some degree of gingival and enamel staining.
- Good oral hygiene lessens gingival hypertrophy in post-transplant patients
- High concentration topical fluoride applications are not recommended due to compromised metabolism
- Postoperative antibiotic coverage with Pen VK is recommended due to weakened immune system.
- Bleeding tests must be performed prior to any surgical treatment and all deficiencies should be treated prior to or during procedures, including IV infusion of fresh frozen plasma and Vit. K.
- Special anesthetic consideration due to decreased liver function. Usually isoflurane is the general anesthetic of choice.
Key Point/Summary
- End-stage liver disease causes nutrition deficiences due to poor absorption of fats and fat soluble vitamins such as A,D,E,K
- Vit. K deficiencies lead to bleeding tendencies
- Osteopenia, and rachitic skeletal changes as a result of poor vit D metabolism
- Transplant is the preferred treatment
- Post-transplant patients are usually immuno-suppressed with cyclosporin ( at least they were 20 years ago)
- Oral manifestations are green staining on teeth, enamel hypoplasia, gingival staining and cyclosporin induced gingival hypertrophy.
- Histologic and anatomical studies reveal that post-transplant enamel formation is normal. For example a tooth root may be stained and malformed until transplanation and then continue in a normal fashion thereafter.
- In this sample, gingival staining often continued post-transplant, even when billirubin levels were well controlled.
- Gingival hypertrophy increased with time after cyclosporin treatment.
Assessment of article: Good article. May be outdated, but it was interesting and informative without taking it beyond the scope of what a dentist needs to know.
Tuesday, January 12, 2010
The dental status of children with chronic renal failure
Resident: Hencler
Date: 01/15/2009
Article title: The dental status of children with chronic renal failure (CRF)
Author(s): Wolff, Stark, Sarnat, Binderman, Eisenstein, Drukker
Journal: The International Journal Of Pediatric Nephrology
Volume #6; Number 2; Page #127-132
Year: 1985
Major topic: Dental status and CRF
Type of Article: Clinical observation
Main Purpose:
Investigate the dental status of children with CRF to determine the prevalence and range of changes in dental structures and correlating these changes with metabolic disturbances, secondary to the uremic state, known to affect bone structure and development.
Overview of method of research:
Examined 30 children between 3-17 year old, 18 boys and 12 girls. Patients were divided into three groups according to their therapeutic regimens: (1) 15 on conservative therapy (2) 9 children on dialysis (3) 6 children who had undergone successful kidney transplantation. Eleven had primary dentition, 7 mixed, and 12 with permanent dentition. Hospital charts were reviewed for clinical and laboratory data. Every patient was evaluated for eruption age, enamel hypoplasia or hypocalcification, intrinsic staining, caries rate, gingival condition, and oral hygiene.
Findings:
• Dental Age and Eruption Age: Results demonstrate delay in both dental and eruption age for the 3 groups. Although some degree of retardation was found in both dental parameters, the delay in eruption was minimal, whereas retardation of dental age approached that in bone age.
• Enamel Defects: Location of the enamel defects clearly corresponded to the age at which renal function deteriorated and substantial biochemical disturbances occurred, namely, acidosis, hypocalcemia, hyperphosphatemia, and a rise in alkaline phosphate. There was a high incidence of enamel defects found in the CRF patients in this study.
• Intrinsic Discoloration: Found in the teeth of 9 patients. All cases of discoloration were found in parts of the teeth that developed postnatally. Discoloration was diffuse.
• Oral Hygiene and Gingival Condition: The patients in this study were compared to healthy patients with regards to OH and the gingiva. The authors found that both the OH and gingival indices were both higher for CRF patients in this study when compared to healthy patients.
• Caries: Measuring DMFT and comparing to healthy children, the results demonstrate a marked “protective” effect of CRF, especially in the younger age groups. The authors found a very low caries prevalence.
• Changes in the Jawbones: Absence of lamina dura (LD) was found in 6 and 3 showed loss of cortical borders of the mandibular canal (CBMC) and ground glass appearance of the bone structure. Radiographic changes were most frequent in the dialysis group.
Key points in the article discussion:
The 30 children with CRF clearly differed from a normal childhood population in all dental parameters examined. It appears that in CRF, development of the teeth is less sensitive to metabolic disturbances than that of bone. The degree of retardation was found to be a function of age at onset and duration of CRF and possibly also of steroid therapy in transplanted patients. The patients in this study had a very high incidence of enamel defects, in the form of hypoplasia and hypocalcification. Although the enamel defects have been attributed to hypocalcemia and Vit D deficiency, the authors were unable to relate them to any specific biochemical disturbance or therapeutic regimen. The increased incidence to staining with increasing severity of renal failure seems to be caused by pigments excreted by the kidneys. The poor condition of the gingiva in CRF patients appears to result from poor OH and high incidence of calculus. Poor OH reflects chronic ill health and tendency of parents to be more lax with these children. Reduced caries prevalence in uremic patients is surprising because to the poor OH and commonly recommended dietary regimens (low protein and high carb) for CRF patients. 4 explanations are as follows: (1) most of these patients suffer from anorexia and probably consume less food between meals reducing caries risk, (2) Recommended high fat diet reduce surface tension of the enamel that may lower plaque formation, (3) High salivary phosphate concentration found in uremia may facilitate remineralization of potential carious lesions, and (4) most importantly, the high salivary concentration of urea. Urea and it’s degradation products are both bacteriocidal and alkaline and is a highly effective agent for the prevention of caries. Radiographic changes of the jawbones are known to accompany other bone changes in CRF. Absence of the dental LD has been described in uremic patients. In dialysed patients, loss of LD was more common than loss of CBMC, whereas in transplanted patients the reverse was true because the LD is part of the liable alveolar bone whereas CBMC on the other hand belongs to the more stable basal bone. A ground glass appearance of jawbones is a finding of calcium metabolism disorders and hyperparathyroidism. The lower incidence of this finding in this study may reflect a shorter period of renal failure.
Summary of conclusions:
This study demonstrates that the metabolic defects associated with CRF do affect the development and structure of the teeth and alveolar bone. The nature and extent of these changes are a function of the age of onset of CRF and it’s duration. Despite low caries incidence, the finding of poor OH and resultant gingival changes suggests need for counseling and OHI. Antibiotic prophylaxis is very important when treating patients taking immunosuppressive treatment following kidney transplantation.
Assessment of article:
Good article, relevant to the pediatric dentist. Children with CRF will require special dental management including possible antibiotic prophylaxis and consults with PCP and nephrologists.
Date: 01/15/2009
Article title: The dental status of children with chronic renal failure (CRF)
Author(s): Wolff, Stark, Sarnat, Binderman, Eisenstein, Drukker
Journal: The International Journal Of Pediatric Nephrology
Volume #6; Number 2; Page #127-132
Year: 1985
Major topic: Dental status and CRF
Type of Article: Clinical observation
Main Purpose:
Investigate the dental status of children with CRF to determine the prevalence and range of changes in dental structures and correlating these changes with metabolic disturbances, secondary to the uremic state, known to affect bone structure and development.
Overview of method of research:
Examined 30 children between 3-17 year old, 18 boys and 12 girls. Patients were divided into three groups according to their therapeutic regimens: (1) 15 on conservative therapy (2) 9 children on dialysis (3) 6 children who had undergone successful kidney transplantation. Eleven had primary dentition, 7 mixed, and 12 with permanent dentition. Hospital charts were reviewed for clinical and laboratory data. Every patient was evaluated for eruption age, enamel hypoplasia or hypocalcification, intrinsic staining, caries rate, gingival condition, and oral hygiene.
Findings:
• Dental Age and Eruption Age: Results demonstrate delay in both dental and eruption age for the 3 groups. Although some degree of retardation was found in both dental parameters, the delay in eruption was minimal, whereas retardation of dental age approached that in bone age.
• Enamel Defects: Location of the enamel defects clearly corresponded to the age at which renal function deteriorated and substantial biochemical disturbances occurred, namely, acidosis, hypocalcemia, hyperphosphatemia, and a rise in alkaline phosphate. There was a high incidence of enamel defects found in the CRF patients in this study.
• Intrinsic Discoloration: Found in the teeth of 9 patients. All cases of discoloration were found in parts of the teeth that developed postnatally. Discoloration was diffuse.
• Oral Hygiene and Gingival Condition: The patients in this study were compared to healthy patients with regards to OH and the gingiva. The authors found that both the OH and gingival indices were both higher for CRF patients in this study when compared to healthy patients.
• Caries: Measuring DMFT and comparing to healthy children, the results demonstrate a marked “protective” effect of CRF, especially in the younger age groups. The authors found a very low caries prevalence.
• Changes in the Jawbones: Absence of lamina dura (LD) was found in 6 and 3 showed loss of cortical borders of the mandibular canal (CBMC) and ground glass appearance of the bone structure. Radiographic changes were most frequent in the dialysis group.
Key points in the article discussion:
The 30 children with CRF clearly differed from a normal childhood population in all dental parameters examined. It appears that in CRF, development of the teeth is less sensitive to metabolic disturbances than that of bone. The degree of retardation was found to be a function of age at onset and duration of CRF and possibly also of steroid therapy in transplanted patients. The patients in this study had a very high incidence of enamel defects, in the form of hypoplasia and hypocalcification. Although the enamel defects have been attributed to hypocalcemia and Vit D deficiency, the authors were unable to relate them to any specific biochemical disturbance or therapeutic regimen. The increased incidence to staining with increasing severity of renal failure seems to be caused by pigments excreted by the kidneys. The poor condition of the gingiva in CRF patients appears to result from poor OH and high incidence of calculus. Poor OH reflects chronic ill health and tendency of parents to be more lax with these children. Reduced caries prevalence in uremic patients is surprising because to the poor OH and commonly recommended dietary regimens (low protein and high carb) for CRF patients. 4 explanations are as follows: (1) most of these patients suffer from anorexia and probably consume less food between meals reducing caries risk, (2) Recommended high fat diet reduce surface tension of the enamel that may lower plaque formation, (3) High salivary phosphate concentration found in uremia may facilitate remineralization of potential carious lesions, and (4) most importantly, the high salivary concentration of urea. Urea and it’s degradation products are both bacteriocidal and alkaline and is a highly effective agent for the prevention of caries. Radiographic changes of the jawbones are known to accompany other bone changes in CRF. Absence of the dental LD has been described in uremic patients. In dialysed patients, loss of LD was more common than loss of CBMC, whereas in transplanted patients the reverse was true because the LD is part of the liable alveolar bone whereas CBMC on the other hand belongs to the more stable basal bone. A ground glass appearance of jawbones is a finding of calcium metabolism disorders and hyperparathyroidism. The lower incidence of this finding in this study may reflect a shorter period of renal failure.
Summary of conclusions:
This study demonstrates that the metabolic defects associated with CRF do affect the development and structure of the teeth and alveolar bone. The nature and extent of these changes are a function of the age of onset of CRF and it’s duration. Despite low caries incidence, the finding of poor OH and resultant gingival changes suggests need for counseling and OHI. Antibiotic prophylaxis is very important when treating patients taking immunosuppressive treatment following kidney transplantation.
Assessment of article:
Good article, relevant to the pediatric dentist. Children with CRF will require special dental management including possible antibiotic prophylaxis and consults with PCP and nephrologists.
Monday, January 11, 2010
A review of liver transplantation for the dentist and guidelines for dental management
LUTHERAN MEDICAL CENTER
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 1/15/10
Article title: A review of liver transplantation for the dentist and guidelines for dental management
Author(s): Glassman et all
Journal: Special Care in Dentistry
Volume #; Number; Page #s): 13:2
Year: 1993
Introduction : The major goal of dental intervention before and after liver transplantation is the prevention of bacteremia from an oral source that could lead to systemic infection. In addition there are many pre- and post-transplant issues that should be addressed in order for the dentist to properly and safely render treatment.
Dental Protocol prior to liver transplant:
• Obtain proper medical dental history
• Prioritize dental problems. Those most likely to cause pain, bleeding, infection, or bacteremia in the next 12 months should receive the highest priority.
• PT/PTT, platelet count, and bleeding time should be known prior to performing any procedures which will cause bleeding. A PT time less then 16 seconds requires no transfusions, anything higher will. Platelet count less then 50,000 will require platelet replacement. In additition, minimize bleeding through topical hemostatic agents, pressure packs, etc. Swallowed blood is also an issue because it’s a source of protein that may not be easily metabolized
• Acites – contact physician regarding use of AB prophylaxis or refer to AHA guidelines
• Caution when using drugs such as acetaminophen, local anesthetics, narcotics, etc. since most are metabolized by the liver
Dental protocol after liver transplant:
• Obtain all current medical history
• Thorough dental exam
• Prioritize dental problems. Those most likely to cause pain, bleeding, infection, or bacteremia in the next 12 months should receive the highest priority.
• AB prophylaxis when necessary
• Steroid supplementation when appropriate
• OH procedures; stress use of floss to prevent cyclosporine induced gingival hyperplasia and other dental pathology. Remove local irritants
• Caution when using drugs such as acetaminophen, local anesthetics, narcotics, etc. since most are metabolized by the liver
Dental Residency Program
Literature Review Form
Resident: Boboia Date: 1/15/10
Article title: A review of liver transplantation for the dentist and guidelines for dental management
Author(s): Glassman et all
Journal: Special Care in Dentistry
Volume #; Number; Page #s): 13:2
Year: 1993
Introduction : The major goal of dental intervention before and after liver transplantation is the prevention of bacteremia from an oral source that could lead to systemic infection. In addition there are many pre- and post-transplant issues that should be addressed in order for the dentist to properly and safely render treatment.
Dental Protocol prior to liver transplant:
• Obtain proper medical dental history
• Prioritize dental problems. Those most likely to cause pain, bleeding, infection, or bacteremia in the next 12 months should receive the highest priority.
• PT/PTT, platelet count, and bleeding time should be known prior to performing any procedures which will cause bleeding. A PT time less then 16 seconds requires no transfusions, anything higher will. Platelet count less then 50,000 will require platelet replacement. In additition, minimize bleeding through topical hemostatic agents, pressure packs, etc. Swallowed blood is also an issue because it’s a source of protein that may not be easily metabolized
• Acites – contact physician regarding use of AB prophylaxis or refer to AHA guidelines
• Caution when using drugs such as acetaminophen, local anesthetics, narcotics, etc. since most are metabolized by the liver
Dental protocol after liver transplant:
• Obtain all current medical history
• Thorough dental exam
• Prioritize dental problems. Those most likely to cause pain, bleeding, infection, or bacteremia in the next 12 months should receive the highest priority.
• AB prophylaxis when necessary
• Steroid supplementation when appropriate
• OH procedures; stress use of floss to prevent cyclosporine induced gingival hyperplasia and other dental pathology. Remove local irritants
• Caution when using drugs such as acetaminophen, local anesthetics, narcotics, etc. since most are metabolized by the liver
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