This document discusses the management of dental patients suffering from end stage renal disease (ESRD). It begins by covering the physiology of the kidneys and causes of ESRD. Signs and symptoms of chronic renal failure that can appear in the oral cavity are described. Medical management focuses on conservative care to control symptoms as well as dialysis. Dental management for patients receiving conservative care or dialysis emphasizes consultation with physicians, modified treatment plans to avoid nephrotoxic drugs, infection control, and postoperative monitoring of vitals. The goals are to restore oral health and eliminate infection sources.

1. Dr. Savita sahu
I yr Post Graduate
Oral and Maxillofacial Surgery
Sri Siddhartha Dental College
MANAGEMENT OF DENTAL PATIENT SUFFERING
FROM END STAGE RENAL DISEASE (ESRD)

2. CONTENT
• PHYSIOLOGY
• About ESRD
• MEDICAL MANAGEMENT
• DENTAL MANAGENT

3. PHYSIOLOGY OF KIDNEY
• ROLE IN HEMOSTASIS (excretion of urea, uric acid, creatinine, bilirubin)
• HEMOPOIETIC FUNCTION
• ENDROCRINE FUNCTION (renin, 1,25 dihydrocholecalceferol, PG)
• REGULATION OF BP (renin)
• REGULATION OF CALCIUM LEVEL (1,25 dihydrocholecalceferol, )

4. END STAGE RENAL DISEASE ( ESRD)
• It refers to bilateral, progressive chronic deterioration of nephron, the
functional unit of kidney.
• Nephrons is deterioration leads to ESRD through successive laboratory and
clinical stages.
• 1st stage- diminished renal reserve
-mildly elevated creatinine level(0.5-1.5 mg/dl)
-GFR ↓(inulin=125mg/dl)

5. • 2nd stage- RENAL INSUFFICIENCY- GFR is mild –moderate
- Nitrogen products begin to accumulate
• RENAL FAILURE-excretory
-endocrine functioning detoriates
-metabolic
-inability to perform homeostasis

6. ETIOLOGY
• COMMON- diabetes mellitus D.M
• hypertension H.T
• GLOMERULONEPHRITIS
• OTHERS INCLUDE-
• polycystic kidney disease, systemic lupus erythematosus, neoplasm, and
acquired immunodeficiency syndrome (AIDS) nephropathy.

7. PATHOPHYSIOLOGY
Various diseases affect different segment of nephron at first
↓
Eventually entire nephron is affected
↓
Compensatory hypertrophy
↓
Maintains normal functioning (until 50-75% of nephron are destroyed)
↓
Compensatory mechanism are over whelmed , uremia appears
↓
Morphological changes leading to end stage kidney is marked

8. • Loss of glomerular filtration function that results in build up of nonprotein
nitrogen compounds in the blood, mainly urea, is called azotemia.
• Level of azotemia is measured as blood urea nitrogen (BUN).
• Azotemia results in metabolic acidosis
• In later stages it causes anorexia, vomiting, fatigue
• Hyperventilation of patient occurs
• In patient with ESRD+ acidosis- adaptive mechanism is already failed leading
to serious consequences like- sepsis, febrile illness

9. • ELECTROLYTE DISTURBANCES- sodium depletion
- hyperkalemia
-increase in azotemia
-urine output decreases
-acid base balance deteriorates
-hematological abnormalities occur
• CVS- congestive heart failure
pulmonary edema
hypertension

10. RENAL OSTEODYSTROPHY

11. SIGN AND SYMPTOMS

13. ORAL MANIFESTATIONS OF CHRONIC RENAL FAILURE
• Pallor of oral mucosa
• Xerostomia
• Pigmentation of oral mucosa
• Parotid infections
• Dysgeusia
• Candidiasis
• Petechiae and ecchymosis of oral mucosa
• Enamel hypoplasia
• Osteodystrophy (radiolucent jaw lesions)
• Uremic stomatitis*

14. LABORATORY FINDING
• Kidney function test
• Creatinine clearance
• Serum creatinine
• GFR

16. MEDICAL MA NAGEMENT
• A) CONSERVATIVE MANAGEMENT
• i) decreased retention of nitrogen compound and controlling H.T., fluid and
electrolyte
• Ii) secondary hyperparathyroidism is treated with low phosphate diet
• iii) avoidance of nephrotoxic drugs or agent metabolised in kidney.

17. NEPHROTOXIC DRUGS
• Tetracycline
• Vancomycin
• Streptomycin
• Gentamycin
• Acylovir
• Acetaminophen
• Phenacetine
• NSAIDS
• Aspirin
• Antihistamine
• phenobarbitones

18. DECREASED DOSES
• CEPHALOSPORINS
• PENICILLINS
• AMPICILLIN
• METRONIDAZOLE
• ACYLOVIR
• PARACETAMOL
• BENZODIAZPINE

19. NORMAL DOSE
• CLOXACILLIN
• ERYTHROMYCIN
• MINOCYCLINE
• CODIENE
• DIAZEPAM
• LIDOCAINE

20. • DIALYSIS – it is the medical procedure to artificially filter the blood .
• it is done when the creatinine >3 mg/dl
• It provides only 15 % of normal renal function
• Prone to infection (viral)

21. DENTAL MANAGEMENT-PATIENT UNDER CONSERVATIVE CARE
1) Consult with physician regarding physical status and level of control
2) Avoid dental treatment if disease is unstable
3) Screen for bleeding disorder before surgery (bleeding time, platelet count,
hematocrit, hemoglobin)
4) Monitor blood pressure closely
5) Pay meticulous attention to good surgical technique
6) Avoid nephrotoxic drugs (acetaminophen in high doses, acyclovir, aspirin,
nonsteroidal antiinfl ammatory drugs)
7) Adjust dosage of drugs metabolized by the kidney
8) Aggressively manage orofacial infections with culture and sensitivity tests and
antibiotics
9) Consider hospitalization for severe infection or major procedures Consider
corticosteroid supplementation as indicated

22. • RECEIVING HEMODIALYSIS- Same as conservative care recommendations
• Beware of concerns of arteriovenous shunt
• Consult with physician about risk for infective endarteritis or endocarditis
• Avoid blood pressure cuff and IV medications in arm with shunt
• Avoid dental care on day of treatment (especially within first 6 hours
afterward); best to treat on day after
• Consider antimicrobial prophylaxis.
• Consider corticosteroid supplementation as indicated
• Assess status of liver function and presence of opportunistic infection in
these patients because of increased risk for carrier state of hepatitis B and C
viruses and human immunodeficiency virus (HIV)

23. • 1) dental treatment should be done 1 day after haemodialysis , coz the
patient is usually fatigue on that date
• 2)major surgery is performed on the day after end of week of haemodialysis
treatment to provide time for clot retraction before the dialysis is resumed.
• 3)heparin dose can be decreased during the 1st haemodialysis after surgery.
• 4) can administer protamine sulphate if immediate care is needed to block
the heparin.
• 5) regular test for HIV, HBV

24. • 6) Haemodialysis removes some drug from circulation , shorten the effect,
therefore care should be taken while prescribing the medicine
The dialysis of drug depend of 4) factor
i) Molecular weight
ii) Protein binding- uremia decreases the protein binding
iii) Volume of drug distribution- Lipid drug not dialysed.
iv) Endogenous drug clearance (LFT,KFT)

25. TREATMENT PLAN MODIFICATION
• The goals of dental care for patients receiving conservative treatment for
ESRD are to restore the mouth to the healthiest condition possible and to
eliminate possible sources of infection.
• Recall appointments should be frequent when salivary flow rates are
diminished to reduce the development of oral infections and periodontal
disease.
• Once an acceptable level of oral hygiene has been established, no
contraindication exists to routine dental care.

26. THANK YOU