Case study: management of the kidney dialysis patient.

Introduction
The prevalence of diabetes in industrialized countries is on the rise. This appreciable rise of diabetic
patients will lead to an increased number of patients with end-stage renal disease (ESRD). These
patients will need dental management in general dental offices around the country. The number of
patients with kidney failure who require dialysis is growing by 10-15 percent annually, and most
commonly observed in the middle-aged to geriatric patient. Over the past five years, new patients
with kidney failure have averaged more than 90,000 annually. (1) With an aging population and rise
in life expectancy, clinicians in the general dental office should be aware of implications of renal
disease. The prevalence of people developing end-stage renal disease annually is estimated to be at
260,000. (1) Patients at highest risk for ESRD are diabetics, men, African-Americans, NativeAmericans, Asian-Americans and those with hypertension. There are over 70,000 patients on the
waiting list for a kidney transplant; only 17,000 will get a new kidney this year. (2) Patients with
ESRD are predisposed to a wide variety of dental problems, which may include periodontal disease,
xerostomia and premature tooth loss.
Implications
When addressing an ESRD patient in a dental office, the most important element in their treatment
plan should be to eliminate any possible active infection. Oral manifestations seen in ESRD patients
include stomatitis, candidiasis, xerostomia, gingivitis and periodontal disease. Patients may have an
ammonia-like odor of breath or an unpleasant metallic taste. Children are less prone to cavities,
although dental developmental abnormalities have been reported. (3) Teeth may be pathologically
mobile due to bone resorption or see severe erosion due to persistent vomiting or gastrointestinal
reflux. A triad of radiolucent jaw lesions, loss of lamina dura and demineralized (ground glass) bone
can be seen with renal osteodystrophy on panographs. Gingival overgrowth may be seen due to
immunosuppressive drugs (cyclosporine) if a kidney has been transplanted or if calcium channel
blockers are used to reduce the work load of the kidneys. (4) An increase in rate of calculus
formation may be seen due to serum imbalance of calcium phosphate. (5)
Periodontal diseases are a group of inflammatory diseases that affect the supporting tissues of the
dentition. Periodontitis can contribute to systemic inflammation in end-stage renal disease. ESRD
patients have a higher prevalence and severity of periodontal disease than the general population.
An ESRD patient with moderate to severe periodontal disease could have a total inflamed surface
area of 8-20 [cm.sup.2] depending on number of teeth affected, which is a large area to be inflamed
when a person is immunocompromised. (6) There are studies that show a positive association
between C-reactive proteins (CRP) (a serum inflammatory marker) and periodontal disease severity.
These serum inflammatory markers have also been robust predictors of cardiovascular mortality in
this ESRD population. Effective periodontal therapy may show a decrease in these CRP levels in
ESRD patients. (6-8)
Treatment
Meticulous daily oral hygiene by the patient is needed to remove subgingival plague and bacteria,
combined with professional local mechanical root debridement to remove calculus. For patients who

are not resolved after initial periodontal therapy and demonstrate good plaque control, surgical
pocket elimination may be indicated. Severe periodontal pocket formation not amenable to surgical
intervention will result in extraction of involved teeth. (3-5)
Clinical Management
ESRD patients on hemodialysis maintenance are medically
http://ritzytycoon4017.snappages.com/blog/2014/11/03/for-some-kidney-patients-home-dialysis-is-bet
ter complex, therefore close communication with the patient and nephrologist or physician is
essential. The medical history should be updated at each visit. Screen for the hepatitis B surface
antigen (HBsAg) or bleeding disorder before planning any surgery (bleeding time, platelet count,
hematocrit and hemoglobin). All universal precautions should be followed as incidence of hepatitis B
and C is higher among dialysis patients. (3,4) Withdraw anticoagulants for a short period only after
consultation with a nephrologist. Manage oral facial infections aggressively by obtaining a culture
specimen (for culture and sensitivity testing) and treat with appropriate antibiotics. Monitor blood
pressure closely and avoid compression of an arm with an arteriovenous graft or fistula. Invasive
dental procedures including root planing and extractions can result in transient bacteremia. The
American Heart Association guidelines should be followed and a medical consult regarding
premedication from each nephrologist should be obtained. (3) Perform dental treatment on nondialysis days to ensure absence of circulating heparin, which could lead to bleeding tendencies
during or after a procedure. There is a high prevalence of hypertension in ESRD patients, so be
careful when using local anesthetics containing vasoconstrictors and with dosage and administration
of drugs cleared through the kidneys. Drugs contraindicated are tetracycline, acyclovir,
acetaminophen, aspirin and NSAIDS. Lidocaine, narcotics (except Demerol) and diazepam can be
used safely in patients with renal failure. (4) Dose reduction is needed for aminoglycosides and
cephalosporins. To reduce dry mouth, recommend use of an alcohol-free mouth rinse or salivary
substitute. After a patient has received a kidney transplant, it is safe to resume regular dental visits
six to nine months after the transplantation, presuming no complications, or after the patient has
been cleared by the treating physician.
Treatment Modalities in Renal Disease
There are three medical treatment modalities for renal disease: a conservative approach where the
patient is watching diet and fluid intake, the patient has been placed on dialysis, or kidney
transplantation. (4)

Types of Dialysis

There are two types of dialysis a patient can be treated with: hemodialysis or peritoneal dialysis.
Hemodialysis is done around four hours a day, three times a week following a Monday, Wednesday,
Friday schedule or a Tuesday, Thursday, Saturday schedule. Hemodialysis is done through a fistula
or graft placed in a limb using two needles during dialysis; one needle draws the blood from the
artery section, and the other needle delivers the cleansed blood to the vein section after filtering.
Vascular access at dialysis is gained by an AV (arteriovenous) fistula, AV graft or shunt or venous
catheter. The AV fistula comprises an artery that is surgically grafted into a vein for access. An AV
graft or shunt is a synthetic tube implanted under the skin. The venous catheter is inserted into the
subclavian, internal jugular or femoral vein and advanced up to the heart until it reaches the
superior vena cava or right atrium. (9-11) Peritoneal dialysis uses the lining of the abdominal cavity:
the peritoneum. This type of dialysis is done daily, four times a day. There are no special dental
considerations in management of the peritoneal dialysis patient. (12)
Case Study
A 35-year-old African-American male presented to the Special Patient Care Clinic at the University of
Missouri, Kansas City School of Dentistry in September 2007. The patient has been on hemodialysis
since January 2001 and is starting the process for clearance to be placed on the transplant list at a
local hospital. Dental clearance is a priority before placement on the transplant list.
Medical History
Patient reports dialysis delivered through a fistula on the left lower forearm since 2001, delivered on
M-W-F schedule. A medical consult was requested with his primary care physician to determine if
the patient needed premedication. His physician suggested a premedication of 2 gms Amoxicillin one
hour prior to treatment following AHA guidelines. The patient reported taking the following
medications: Aciphex 20 mg as needed for acid reflux; Aspirin 81 mg; Benadryl 50 mg; Catapres .2
mg for hypertension; during hemodialysis, Epogen 2200 units IV, Fosrenol 1000 mg, Heparin 6000
units IV; Lisinopril 10 mg and Minoxidil 10 mg for hypertension; Mobic 7.5 mg to prevent bone
disease; Nephro-Vite one tablet daily; Normodyne 200 mg 2x/day; Sensipar 60 mg for
hyperparathyroidism in dialysis patients; Venofer 50 mg IV 1x/week; and Zemplar 7 mcg IV to
prevent secondary hyperparathyroidism. Patient reported no allergies.
Dental History
Approximately six years since his last dental treatment, the patient presents only for emergency
care. Patient reports pain off and on in posterior teeth, bleeding and sore gums when brushing, uses
a medium toothbrush and does not floss.
Initial Examination and Treatment Plan
Diagnosis, oral cancer screening, intra- and extra-oral examination, FMX and panoramic digital films
were completed (see Figure 1).
Treatment plan: Four quadrants SRP by a senior dental hygiene student (including six-week
evaluation prior to clearance for transplant)/OH instructions/rationale to lessen bacterial load when
on long-term dialysis, Dr. McCarville: Extraction #1, #2 DO, #3 OL, #14 OL, #16 MO, #17 O, #18
O, #19 DO, #20 DO, #21 DO and #31 DO.

Patient followed up for reevaluation at six weeks and healing nicely. At this point, the patient was
released for transplant surgery.
Conclusion
The number of patients with kidney failure and who require dialysis is growing 10-15 percent
annually, most commonly observed in the middle-aged to geriatric patient. Dentists and hygienists
alike need to feel comfortable treating ESRD patients because the most important element in the
treatment plan is to eliminate the risk of active infection. Close communication with the nephrologist
or physician is essential. ESRD patients are predisposed to periodontal problems, dental hygienists
are able to treat and help maintain the oral health in these compromised patients. Maintaining an
ESRD patient oral health greatly reduces their risk for infections during the transplant process.
References
(1.) Centers for Disease Control and Prevention. MMWR 2007; 56: 161-5.
(2.) National Kidney Foundation. US renal data system annual data report. Available at
www.kidney.org/. Accessed Mar. 2008.
(3.) Vesterinen M, Leivo T, Honkanen E, Lindqvist C. Oral health and dental treatment of patients
with renal disease. Quintessence Int 2007; 38: 211-9.
(4.) Sharma DCG, Pradeep AR. End stage renal disease and its dental management. NY State Dent J
2007; 73(1): 43-7.
[FIGURE 1 OMITTED]
(5.) Castillo A, Mesa F, Liebana J, et al. Periodontal and oral microbiological status of an adult
population undergoing haemodialysis: a cross-sectional study. Oral Diseases 2007; 13(2): 198-205.
(6.) Craig RG, Kotanko P, Kamer AR, Levin NW. Periodontal diseases--a modifiable source of
systemic inflammation for the end-stage renal disease patient on haemodialysis therapy? Nephrol
Dial Transplant 2007; 22(2): 312-5.
(7.) Borawski J, Wilezynske-Borawska M, Stokowaska W, Mysliwiec M. The periodontal status of predialysis chronic kidney disease and maintenance dialysis patients. Nephrol Dial Transplant 2007;
22(2): 457-64.
(8.) Bayraktar G, Kurtulus I, Duraduryan A et al. Dental and periodontal findings in hemodialysis

patients. Oral Diseases 2007; 13(4): 393-7.

(9.) Mayo Clinic. Kidneys and urinary tract. Hemodialysis and peritoneal dialysis: what's the
difference. Available at www.mayoclinic.com/health/hemodialysis/DA00093. Accessed Mar. 2008.
(10.) Williams RD. Living day-to-day with kidney dialysis; quality improvements continue for devices
and clinics; dialysis under scrutiny. US Food and Drug Administration. Available at
www.fda.gov/FDAC/features/1998/198_dial.html. Accessed Mar. 2008.
(11.) Burr RA. All about dialysis'. Diabetes Forecast 2003; 56(7): 70-2.
(12.) Raja K, Coletti D. Management of the dental patient with renal disease. Dent Clin N Am 2006;
50(4): 529-45.
By Kathryn M. Dockter, RDH, MS, and Kirstin McCarville, DDS
Kathryn M. Dockter, RDH, BS, MS, has over 30 years of experience in clinical practice, both in
general dentistry and periodontics. A graduate of the University of Missouri-Kansas City (UMKC)
School of Dentistry, she has a master's degree in Dental Hygiene Education and is a faculty member
in the Oncology Dental Support and Special Patient Care Clinic as Patient Care Clinical Manager at
UMKC School of Dentistry. Her areas of interest are oral oncology and tobacco cessation.
Kirstin McCarville BS, DDS, is a graduate of Creighton University Dental School She completed a
one year Advanced Education in General Dentistry Residency and a two-year Fellowship in Special
Patient Care with emphasis in treating oncology and transplant patients at UMKC School of
Dentistry. In August, she joined the faculty at Creighton University Dental School as an assistant
professor of prosthodontics and director of the Special Needs Clinic.
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