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.