Dental management in renal failure / dental implant courses

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INTRODUCTION
 functional units called NEPHRONS
 Composed Of A Glomerule And Tubule.
 Interconnected Capillaries Contained
Within A Cup-like Sac Bowman’s Capsule
 Proximal Convoluted Tubule-loop Of Henle-distal
Convoluted Tubule-collector Duct

FUNCTIONS
 Excretion of metabolic waste products.
 Electrolyte regulation
 Endocrine regulatory functions
 Metabolic functions
 Control of blood pressure

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CLASSIFICATION
 Acute Renal Failure (ARF)
sudden and important reduction in Glomerular
Filtration Rate (GFR) lasting for hours or days
 Causes
 pre-renal
 intrinsically renal
 post-renal

PRE RENAL INTRINSIC POST RENAL
Gastrointestinal losses Acute tubular necrosis Urethral obstruction
Cardiovascular failure Severe cortical
necrosis
Bladder obstruction
Liver failure Severe acute
glomerulonephritis
Bladder rupture
Burns with fluid
sequestration
Vasculitis Bilateral ureteral
obstruction
Bleeding Malignant hypertension
Excessive perspiration Allergic interstitial
nephritis

CHRONIC RENAL FAILURE
 Gradual reduction in the number of functional nephrons
 terminal or end-stage renal failure (ESRF)
 Causes
 Chronic immune glomerulopathy
 Hypertensive nephrosclerosis
 Chronic tubulointerstitial diseases
 Metabolic diseases (e.g., diabetes mellitus)
 Congenital and hereditary renal processes (e.g., renal polycystic
disease)

Chronic renal failure
 Glomerular Filtration Rate -<60
ml/min/1.73 m2
 Micro- Or Macroalbuminuria
 Persistent Hematuria
 Radiological Anomalies
 Period Of More Than Three Months

 Uremia
 increased levels of acute phase proteins, certain
cytokines, and even macrophages.
 Endocrine Functions Impaired
 Extra-renal Multiorgan Disease

 Men
 Most Frequent Causes
 diabetes mellitus( 40-60% )
 arterial hypertension(15-30%)
 Glomerulonephritis(10%)
 renal polycystosis(2-3%)
 E.S.R.F.
 hyperfunction of the remaining functional nephrons
 systemic and intra-renal hypertension
 proteinuria,

DIAGNOSIS
 Glomerular Filtration Rate
 Creatinine Clearance
 Quantify Proteinuria
 Immunoglobulins

CLINICAL MANIFESTATIONS
 Generalized Paleness
 Brown Hyperpigmentation Of The Nails And Skin
 Retention Of Dietary Pigments
 Skin Excoriations Produced By Intense Generalized Itching
 Accumulation Of Calcium And Phosphate Microcrystals

 Arterial hypertension most common
complication
 Dyspnea
 Gastrointestinal alterations
 Anorexia
 nausea and vomiting associated to the uremia
 G.I. Bleeding

 Impaired hemostasis
 platelet dysfunction
 Anticoagulants
 diminished platelet adhesion
 increase in prostacyclin activity
 lesser availability of platelet factor 3,
 Increased capillary fragility

 Susceptibility to infection
 Decrease in cellular immune function
 Chemotactic defects induced by uremia
 Second most common reason for death
 alterations in mineral metabolism
 Renal osteodystrophy,
 Skeletal defects
 fractures, pain
 joint and periarticular calcifications

 C.N.S. manifestations
 Restlessness
 apathy
 Insomnia
 Endocrine-metabolic Alterations
 hypoparathyroidism
 retarded growth
 Diminished libido
 Erectile dysfunction in males
 Infertility in women

Oral manifestations
 Bad odour
 Metallic Taste
 increased concentration of urea in saliva
and its posterior transformation into
ammonium

xerostomia
 Restriction In Fluid Intake
 Side Effects Of Drugs
 Possible Salivary Gland Alteration
 Oral Breathing Secondary To Lung Perfusion
Problems

Uremic stomatitis
 Four Types
 erythemo-pultaceous,
 ulcerative
 Hemorrhagic
 Hyperkeratotic
 painful
 ventral surface of the tongue and on the anterior mucosal surfaces
 resistant to treatment-blood urea levels remain high
 Heal spontaneously within 2-3 week

Gingival bleeding and inflammation
 Petechiae and ecchymosis
 platelet dysfunction
 Effects of anticoagulants
 Hyperplasia
 secondary to drug treatment
 Cyclosporine,calcium channel blockers
 labial surface of the interdental papilla,
 gingival margins and lingual and palatal surfaces

 Periodontal problem
 attachment loss
 deep pockets
 Enamel hypoplasia
 alterations in calcium and phosphorus metabolism
 affect primary and permanent dentition
 Severe erosions on the lingual surfaces of the teeth
 frequent regurgitation and vomiting induced by uremia
 Medication
 Nausea associated to dialysis

 Pulp obliteration
 Delays or alterations in eruption
 Changes in maxillary bone
 increased risk of fracture during extractions
 Tooth mobility
 Malocclusion
 crowding,
 pulp chamber calcifications
 Temporomandibular joint problems

 A diminished prevalence of caries
 protective effect on the part of urea
 which inhibits bacterial growth
 neutralizes bacterial plaque acids

INFECTIONS
 Candidiasis
 Cytomegalovirus (CMV)
 first months after transplantation
 prolonged immune suppression
 human herpesvirus 8

Mucosal lesions
 Lichenoid reactions
 Oral hairy leukoplakia
 medication
 drug-induced immune suppression
Malignancy
 increased susceptibility to epithelial dysplasia and
carcinoma of the lip
 iatrogenic immune suppression
 Kaposi’s sarcoma or non-Hodgkin lymphoma

Conservative
 prevent or correct the metabolic alterations
 Preserve the remaining renal functional capacity.
 high carbohydrate and low protein diet
 body weight control
 treatment with antihypertensive drugs,lipid
lowering agents
 vitamin D supplements
 correction of the anemia with erythropoietin

Dialysis and renal
transplantation
 Artificial Mechanism That Clears Blood
Of Nitrogen Waste And Other Toxic
Products Of Metabolism
 Two modalities
 Peritoneal dialysis (PD)
 hemodialysis (HD)

PERITONIAL
 Access to the body is gained through a
catheter placed in the abdominal wall and
inserted in the peritoneum.
 The dialysate (sterile electrolyte solution) is
introduced through the catheter
 peritoneal membrane filters the blood
waste products via an osmotic mechanism

 blood filtration is carried out by a machine (dialyzer)
equipped with a semipermeable membrane
 allows passage of the excess fluids and waste
products
 three days a week
 an artificial permanent vascular access is placed in
the form of a catheter or surgically performed
arteriovenous fistula

Heparin
 To facilitate blood cycling through the dialyzer,
 Measuring permeability of the vascular access.

Renal transplantation
 Treatment of choice in patients with irreversible
renal failure
 Immunosuppressive therapy must be provided
to avoid acute rejection
 All transplant patients, with the exception
identical twin, require life-long
immunosuppressive therapy

 Prevention of infections
 Vaccination
 Prognosis
 prognosis of individuals with diabetes mellitus and/or
hypertension is poorer
 Most common causes of death
 cardiovascular problems (about 50% of global
 mortality)
 infections
 malignization

Dental Management
 Consultation with the Nephrologist
 State of the disease
 Type of treatment
 Best timing of dental management
 Medical complications that may arise
 Any modification of the usual medication used

 Multidiscipline approach
 Complete blood count, together with coagulation
tests
 Eliminate any infection in the oral cavity as soon as
possible
 Antibiotic prophylaxis
 Blood pressure is to be monitored
 Administration of sedation

Drugs
 Aminoglycoside and tetracyclines is to be avoided,
 Nephrotoxicity
 Penicillins, clindamycin and cephalosporins
 antibiotics of choice
 Paracetamol
 Analgesics
 Avoid aspirin
 Benzodiazepines can be used

On Dialysed Patients..
 Provide Dental treatment on non-dialysis days,
 To ensure the absence of circulating heparin, which has a half-
life of about four hours
 To prevent increased risk of bleeding
 Complete blood count and coagulation tests
 Local haemostatic measures
 Mechanical compression,
 Sutures
 Tranexamic acid - or administered via the oral route at a dose
of 10-15 mg/kg body weight a day distributed in 2-3 doses

 Antibiotic coverage
 2 g of amoxicillin via the oral route one hour
before the dental procedure.
 Clindamycin 600 mg via the oral route, one hour
before the intervention
 Protection against transfusion infections
 Universal precautions
 vaccinations

On transplant patients…
 Conduct dental evaluation prior to renal transplantation
 To eliminate the existing infectious foci.
 Teeth offering an uncertain prognosis are to be removed
 Prophylactic antibiotic treatment
 supplementary dose of corticosteroids
 Stress
 25 mg of hydrocortisone via the intravenous route, before the
intervention
 Avoid elective dental treatment-6 months

 . ~


Dental management in renal failure / dental implant courses

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