Renal Disease & Oral Implications Flashcards
learn renal disease
What is the caries rate of children with CKD?
Lower rate due to higher salivary buffering capacity (elevated salivary urea levels)
What are radiographic findings in patients with CKD (5)
1) Development Defects of Enamel (DDE)
2) Narrowing of the pulp chamber
3) Hypercementosis
4) Loss of Lamina Dura
5) Poor Bone Calcification (Ground glass)
What are soft tissue findings in patients with CKD?
1) Pallor of mucosa (anemia)
2) Increased prevalence of mucositis
What are commonly reported symptoms in patients with CKD?
1) Xerostomia
(decreased saliva due to poor fluid balance)
2) Uremic breath (high salivary [urea])
3) Metallic Taste
What multidisciplinary questions must you ask Nephrology?
1) Stage & Severity of Disease
2) Timing of dialysis & Hx transplant
3) Patient’s list of medications
4) Need for Dialysis, or Steroid Coverage
Recommended medications/anesthetics/sedation in CKD patients
1) Lidocaine (-amide)
2) Benzos OK
3) Paracetamol (Tylenol) for pain
When should you schedule hemodialysis patients for dental treatment?
1 day after dialysis
What is the medical profile of a patient undergoing kidney transplant?
1) Immunosuppressed forever
2) Corticosteroid (could use a boost to prevent adrenal crisis)
3) No tx first 6 months after transplant
What are dental problems observed with CKD drugs are associated with gingival overgrowth?
1) Gingival overgrowth (Cyclosporine
& Nifedipine)
2) Mucositis (sirolimus)
What sort of infections are most common post- kidney transplant?
Oral HSV
Tx 400mg acyclovir TID for 10-14days
Candidiasis
0.12% chlorhexide, Nystatin, Fluconazole
Oral cancer risk profile in CKD patients?
Increased Karposi sarcoma due to immune suppression
What are the main functions of the Kidneys?
Excretion of Metabolic Waste Products
Fluid & Electrolyte Regulation
pH Balance
Hormone Production and secretion
What hormones are produced by the kidneys?
EPO → RBC levels
Renin → affects Na+/K+ via RAAS system (blood pressure & fluid balance)
Prostaglandin → effects vasculature, inflammation, pain, healing
Angiotensin → activate Aldosterone (Na+ retain) –> BP regulation
What is Glomular Filtration Rate and what does it indicate?
nephron health
normal is 125mL/min
How is CKD determined?
Proteinuria (renal injury)
GFR < 60mL/min
Prevalence = 8 in 1 million
Etiology of CKD?
<5yo: Congenital abnormalities like Renal Hypoplasia, Dysplasia, or Obstructive Nephropathy
> 5yo: Acquired → glomerulonephritis, Alport syndrome, Polycystic Kidney Disease
Main causes of CKD among children:
Obstructive uropathy
Hypoplastic kidneys
Polycystic kidney disease
Childhood nephritic syndrome
Reflux nephropathy
How does kidney damage progress?
Hyperfiltration –> nephrons overworked
Proteinuria –> toxic
Hyperphosphatemia –> calcium deposits in renal vasculature
Clinical presentations of CKD
Edema, HTN, proteinuria,
Polyuria, failure to thrive, UTI
What lab values are expected in CKD?
Elevated blood urea nitrogen (BUN) & Serum Creatinine
Hyperphosphatemia
Elevation of uric acid
Hyperkalemia
Acidosis (low pH)
Hyponatremia
Hypocalcemia
Lab values Elevated in CKD?
Elevated blood urea nitrogen (BUN) & Serum Creatinine
Phosphate
Uric Acid
Potassium
Lab values decreased in CKD?
RBC (anemia, low EPO)
pH (acidosis)
Sodium
Calcium
How is CKD managed medically?
Bicarbonate (acidosis)
Fluid restriction (hyponatremia)
Growth Hormone (resistant)
What is renal osteodystrophy?
Bone disorder in CKD –> Osteitis fibrosa cystica (weak, cystic bone)
Cause: Low VitD (kidney) –> Low Ca2+ intake –> Hypocalcemia –> rebound PTH –> bone resorption
How is renal osteodystrophy treated?
Vitamin D supplementation
What other medications may CKD patient’s be on for anemia or HTN?
Anemia –> recombinant human factor
HTC –> ACEI
What type of dialysis do patients with end stage renal disease undergo?
after 50-75% nephrons destroyed
<5yo: peritoneal dialysis (66%)
>5yo: hemodialysis (33%)
Complications with hemodialysis
3x 4hours sessions every week
Provide 15% kidney function
Damage of platelet (possible thrombocytopenia)
CKD Dental concerns
1) Bleeding
2) Impaired drug excretion (if they have active metabolite)
3) Renal Osteodystrophy
CKD Dental Management
Medical consult to determine stability and control
CBC to screen bleeding disorder
Avoid nephrotoxic drugs
Aggressive tx of orofacial infections
CKD GFR values
Mild: 50-100mL/min
Moderate:10-50mL/min
Severe: <10mL/min
General Abx dosing guidelines for CKD
Azithromycin = no change
Other abx –> decrease dosing frequency or dosage
Avoid tetracycline, doxycycline OK
General analgesic guidelines for CKD
Mostly hepatic metabolism
Acet, Ibu OK q6-8h
General LA guidelines for CKD
Lidocaine is OK
General Oral Sedation guidelines for CKD
short term use NO problem
Diazepam
Triazolam
Dental Hemodialysis considerations
1) NO BP cuff on AV shunt
2) Dental treatment day after dialysis (heparin 1.5h 1/2 life)
3) Check liver function (Hep b, c, etc)
NO SBE NEEDED
Findings in renal failure (lessened with hemodialysis)
Pallor of mucosa (anemia)
Red-orange discoloration of mucosa (carotene-like pigments)
Xerostomia, parotid infections and candidiasis
Ammonia-like breath odor (high urea content)
Metallic taste
Uremic stomatitis (red, burning mucosa covered with gray exudates that may ulcerate) seen with high BUN levels
Petechiae and ecchymoses
Osseous changes – lytic bone lesions
Oral Manifestations Renal Failure –> Secondary HyperPTH
Brown tumour aka Palatal enlargement due to secondary hyperparathyroidism (recall, low calcium in blood –> PTH up)
Loss of trabelucae & lamina dura & ground glass appearance
Radiographic cystic lesions
Kidney Transplant Patients
Immunosuppressed for life!
Consult physician
Rx Chlorhexidine
Sx corticosteroid dosing
Avoid NSAID (increased bleeding w/ corticosteroids & nephrotoxic immunosuppressants)
Screen for head & neck cancers
