Oral Diagnosis I Third Year

1. Oral Diagnosis-I
Review of chronic renal failure and dialysis
December 24, 2006
Dr. Suresh. C. S. BDS; MDS; MDSc (UK)

2. Chronic Renal Failure & Dialysis
“Overview”
 Kidney regulate fluid volume and acid
base balance of the plasma
 Excrete nitrogenous waste
 Synthesize erythropoietin, 1,25-
dihydroxycholecalciferol & renin
 Drug metabolism
 They are the target organs for
parathormone & aldosterone

3. Chronic Renal Failure & Dialysis
Definition
 End stage renal disease (ESRD) is a
bilateral progressive and chronic
deterioration of nephrons (the
functional unit of the kidney).
 The disease results in uremia and can lead to death.
 ESRD manifests when 50-75% of nephrons lose
function.

4. Chronic Renal Failure & Dialysis
Incidence & Prevalence
 In US, 8 million people have some form of kidney
disease, 360,000 have irreversible ESRD.
 Average dental practice of 2000 patients can expect
to have 2 patients with ESRD.
 ♂>♀.
 Age: 45-65.

5. Chronic Renal Failure & Dialysis
Etiology
 Diabetes mellitus 34%
 Hypertension 25%
 Chronic glomerulonephritis 16%
 Other causes like:
 Systemic lupus erythematosis
 AIDS, Etc

6. Chronic Renal Failure & Dialysis
Signs & Symptoms
 Patient appears ill & anemic
 Hemorrhagic episodes: ecchymosis,
petechiae, purpura and gingival or
mucous membrane bleeding (epistaxis)
 Cardiovascular manifestations include:
 Hypertension
 Congestive heart failure (shortness of breath, dyspnea on
exertion & peripheral edema)
 Pericarditis

7. Chronic Renal Failure & Dialysis
Signs & Symptoms (Cont.)
 Hyperpigmentation of the skin (retention of carotene-
like pigments normally excreted by the kidney)
 Gastrointestinal signs:
 Anorexia
 Nausea
 Vomiting
 Generalized gastroenteritis
 Peptic ulcer disease

8. Chronic Renal Failure & Dialysis
Signs & Symptoms (Cont.)
 Stomatitis manifested by oral
ulceration & candidiasis.
 Parotitis may be seen and a urine
like odor to the breath may be
detected.
 Uremic syndrome commonly causes malnutrition and
diarrhea.

9. Chronic Renal Failure & Dialysis
Medical Management
 The goals of treatment are to retard the progress of
disease and preserve the patient’s quality of life
 A conservative approach
 Involve decreasing the retention of nitrogenous
waste products
 Controling hypertension, fluids & electrolyte
imbalances
 Anemia associated with renal failure usually is
treated with the use of recombinant human
erythropoietin

10. Chronic Renal Failure & Dialysis
Medical Management (Cont.)
 Dialysis
 It is a medical procedure that artificially
filters blood
 It becomes necessary when the number of nephrons
diminishes too much.
 Every 2 or 3 days depending on need
 Usually 3 to 4 hours are required for each session

11. Chronic Renal Failure & Dialysis
Medical Management (Cont.)
 Drugs that are metabolized primarily
by the kidney should be avoided
 Abnormal bleeding is associated with
dialysis
 Bleeding tendency because of altered
platelets aggregation and decreased
platelets factor III
 5 years survival rate is 28%
 An alternative is renal transplantation

12. Chronic Renal Failure & Dialysis
Dental Management
 Patients under conservative care
 Consultation with patient’s physician
 If patient is in advance stages, dental care may
best be provided after physician’s consultation
and in a hospital like setting.
 Because of the potential for bleeding problems:
o Pretreatment screening for bleeding time and platelet
count.
o A hematocrit level and hemoglobin count should be
obtained to assess the status of anemia

13. Chronic Renal Failure & Dialysis
Dental Management (Cont.)
 If an orofacial infection exists, aggressive
management is necessary using culture and
sensitive tests and appropriate antibiotics
 Nephrotoxic drugs should be avoided
 Example: NSAID, Aspirin, and Tetracycline
require special dosage adjustments

14. Chronic Renal Failure & Dialysis
Dental Management (Cont.)
 Patients receiving dialysis
 Patients are at risk for infective endocarditis but the
reason(s) are not yet fully established.
 Infective endocarditis occurs in 2% to 9% of patients
receiving hemodialysis
 40% of patients on dialysis have congestive heart
failure
 Hemodialysis tends to aggravate bleeding tendencies
• Physical destruction of platelets
• Heparin usage

15. Chronic Renal Failure & Dialysis
Oral Complications & Manifestations
 Pallor of the oral mucosa secondary to anemia
 Red-Orange discoloration of the cheeks and
mucosa caused by pruritis and deposition of
carotene-like pigments
 Diminished salivary flow (parotid infections)
 Candidiasis (xerostomia)

16. Chronic Renal Failure & Dialysis
Oral Complications & Manifestations
(Cont.)
 Patients complain of an altered metallic
tastes.
 Uremic stomatitis.
 Petechiae and ecchymosis on the labial
and buccal mucosa, soft palate and
margins of the tongue as well as gingival
bleeding.
 Osseous changes of the jaws.