Renal medicine dentally relevant questions

Question 1

What to consider when prescribing drugs to a chronic renal failure patient? (give drug examples)

Answer 1

Altered rate of elimination of renally excreted drugs, therefore accumulation (opiates)
Altered protein binding: reduced binding of acidic drugs (phenytoin) and increased binding of alkali drugs (lignocaine)
Nephrotoxic drugs may worsen renal failure (gentamicin, NSAIDs)

Question 2

When treating a patient with uraemia, what should be considered?

Answer 2

Increased bleeding time and bruising
Normal platelet count but disrupted function due to increased urea
[Bleeding time improved with EPO/dialysis]

Question 3

What antibiotic prophylaxis is given to a haemodialysis patient prior to dental treatment?

Answer 3

IV vancomycin and gentamicin

Question 4

What immunosuppression drugs are taken for transplant patients? and what are there functions?

Answer 4

Prednisolone
Azathioprine - blocks lymphocyte and neutrophil proliferation
MMF/mycophenolate mofetil - blocks lymphocyte proliferation
Cyclosporin - calcineurin inhibitor which blocks T cell activation and therefore IL2 production
Tacrolimus - same as cyclosporin but more potent
Sirolimus/rapamycin - inhibit IL2 mediated signal transduction pathways

Question 5

What is the dental side effect of cyclosporin and tacrolimus?

Answer 5

Gum hypertrophy

Question 6

What are the dental side effects of sirolimus/rapamycin?

Answer 6

Delayed wound healing and stomitits

Question 7

What is the triple therapy for renal transplant patients? (3 different versions)

Answer 7

Prednisolone, azathioprine, tacrolimus
Prednisolone, MMF, tacrolimus
Prednisolone, MMF, sirolimus

Question 8

What are the 2 main dental concerns with nephrological problems?

Answer 8

Gum hypertrophy and caries

Question 9

Who is oral facial digital syndrome seen in?

Answer 9

X-lined dominant, therefore lethal in males

Females affected have cysts similar to ADPKD (autosomal dominant polycystic kidney disease)

Question 10

What are the abnormalities seen in oral facial digital syndrome?

Answer 10

Extra renal manifestations
Cranio-facial abnormalities and oral manifestations:
- Facial milia (very small bumps/cysts on skin surface)
- Cleft palate
- Dental abnormalities
- Bifid/lobulated tongue
Limb and skeletal abnormalities:
- Limb abnormalities
- Brachydactyly - shortened toes and fingers
- Syndactyly - 2/more digits fused together
- Clinodactyly - curved digits

Question 11

What time of day is best to treat a dialysis patient on heparin? and why?

Answer 11

Day after dialysis as heparin will have worn off and dialysis peaked

Question 12

Patient with renal transplant on immunosuppressants is increased risk of oral infections, name a few.

Answer 12

Candidiasis
HSV
Zoster virus

Question 13

What prophylaxis is given to transplant patients to prevent viral infections?

Answer 13

Low dose aciclovir

Question 14

What disease is indicated with rampant periodontal disease with good OH?

Answer 14

Diabetes

Question 15

How is homeostasis impaired in Chronic kidney disease?

Answer 15

Impaired platelet adhesiveness
Decreased vWF
Decreased thromboxane
Increased prostaglandin --> vasodilation 
Taking heparin

Question 16

What is the appearance of a patient on steroids coming in to visit the dentist?

Answer 16

Moon face 
Oedema
Bone pain = osteodystrophy - may seem like TMD if in jaw
Oral ulceration and infection increased
Gingival hyperplasia with cyclosporin

Question 17

What is sialosis?

Answer 17

Neoplastic or infective swelling of major salivary glands, esp. parotid

Question 18

Why should a renal disease patient be told not to swallow their blood following an extraction?

Answer 18

If blood is swallowed this causes a heavy protein load, losing renal reserve, therefore stopping renal function

Question 19

What drugs should be avoided when prescribing to patient with renal disease?

Answer 19

Gentamycin - nephrotoxic
Erythromycin contraindicated in transplant pt taking ciclosporin - reaching toxic levels
NSAIDs - avoid in mild kidney impairment
Tetracyclines should be avoided except doxycline

Question 20

What drugs should be reduced in dosage when prescribing to patient with renal disease?

Answer 20

Aciclovir
Amoxicillin 
Ampicillin 
Cefalexin 
Erythromycin

Question 21

In acute kidney injury, potassium levels rise to a dangerous level, what drugs can be given to lower this?

Answer 21

Ca resonium - rectal paste
Glucose and insulin infusions IV

Both remove potassium from the blood stream

Question 22

What are presenting symptoms of jaundice?

Answer 22

Yellow skin/ sclera
Dark urine/ pale stool
Last to present - intractable itch

Question 23

What is Charcot’s triad? and what can these symptoms indicate?

Answer 23

Fever
Pain
Jaundice

Indication of obstructive jaundice