renal failure

1. Renal failure
By. Mohamed elsayed tolba

2. 1. Introduction
2. Epidemiology
3. Etiopathogenesis
4. Clinical manifestations
5. Oral manifestations
5.1. Soft tissue
5.2. Hard tissue
6. Medical management
7. Role of the pediatric dentist

3. Introduction
Kidneys are vital organs for maintaining a stable internal environment
(homeostasis).
Renal failure can be congenital or acquired condition and prevalence ranges
from 39 to 56 million children universally.
Acute renal failure is rapidly progressive loss of renal function characterized by
sudden and important reduction in glomerular filtration rate (GFR) lasting for
hours up to days.

4. Etiology of acute renal failure

5. Chronic renal failure is a progressive and irreversible decline in the total number
of functioning nephrons, which causes a decline in the glomerular filtration rate.
Nephrotic syndrome is a common chronic disorder that is characterized by
alterations of the glomerular capillary wall, resulting in protein loss through the
urine.
End-stage renal failure (ESRF) is the stage when renal replacement therapy by
dialysis or transplantation is required.

6. Epidemiology
There is limited information on the epidemiology of CRD in the pediatric
population. Because this disease is often asymptomatic in its early stages, it is
both underdiagnosed and underreported.
The estimated incidence of ESRF in childhood, either due to a congenital or
acquired condition, is 10–12 cases per 1 million children, with a prevalence
varying from 39 to 56 million children.

7. Etiopathogenesis
The kidney performs four essential functions:
• excretion of metabolites, particularly urea.
• regulation of blood volume and electrolyte concentration.
• regulation of erythrocyte production in the bone marrow by secreting
erythropoietin.
• participation in calcium homeostasis through hydroxylation of vitamin D3 into
active or inactive metabolites.
Any pathology involving renal function would be expected to have serious
pleiotropic effects.

8. Clinical manifestations
Clinical signs and symptoms of renal failure are collectively termed as
uremia.
Uremia is a state of intoxication that involves multiple extrarenal systems,
such as the bone, heart, vasculature, and lungs
Uremia causes suppression of lymphocytic responses, dysfunction of
granulocytes, and suppression of cell-mediated immunity.

9. Oral manifestations
 Soft tissue
Reduced erythropoietin and the resultant anemia lead to pallor of the oral mucosa.
Platelet aggregation is altered during uremia. This situation, combined with the use of
heparin and other anticoagulants in hemodialysis, leads patients to become
predisposed to ecchymosis, petechiae, and hemorrhages in the oral cavity.

10. Stomatitis, mucositis, and glossitis can cause pain and inflammation of the
tongue
and oral mucosa.
Altered taste sensations, dysgeusia, as well as bacterial and candidiasis
infections can develop due to the underlying renal disease.

11. A common oral symptom of CRF is the sensation of a dry mouth, which may be
caused by restricted fluid intake (necessary to accommodate the reduced excretory
capacity of the kidney), adverse effects of drug therapy, and the low salivary flow
rate.
Patients also suffer from odorous breath (uremic breath) and sensations of
metallic tastes in the mouth (uremic fetor).
Uremic fetor occurs as a result of a high salivary concentration of urea, which is
converted to ammonia
Additional possible causes are increased phosphate and protein concentrations,
as well as changes in salivary pH.

12. Gingival inflammation has been reported to be due to plaque accumulation
and poor oral has hygiene.
Attention been given to general medical care, prolonged hospitalization,
and hypoplastic teeth as causes of high plaque scores in these patients.
However, the frequency of gingival inflammation is low because the
immunosuppression and uremia associated with renal disease alter the
inflammatory response to bacterial plaques in gingival tissue.
Pallor caused by anemia can also mask inflammatory signs in the gingiva.

13. Another manifestation of CRD is gingival enlargement secondary to drug
therapy or transplantation.
Gingival enlargement chiefly affects the labial interdental papillae
Gingival overgrowth (GO) is assumed to be related to the following:
 alteration of the fibroblast metabolism by cyclosporine and or its
metabolites.
 increasing protein synthesis, collagen, extracellular matrix formation.

14. Other problems related to gingival over growth are:
 disagreeable appearance leads to psychological trauma to the patient.
 eruption teeth will be delayed or ectopic eruption of teeth and problems of speech.
Cytomegalovirus infections are common post-transplant Candidiasis and herpes virus
infection are common due to prolonged immunosuppression.

15. Lichenoid reactions are medicine associated; drug induced oral hairy leukoplakia
(OHL).
Epstein-Barr virus can be seen in primary infection of oropharynx where the virus
gets latent in epithelium and gets reactivated upon immunosuppressant manifesting
itself as OHL and tongue lesions.
Increased risk of virus related to malignaization such as Kaposi sarcoma or non-
Hodgkin’s lymphoma.
Xerostomia is generally due to fluid restriction and medium induced along with
salivary gland dysfunction.

16. Reddish brown discoloration has been reported in developing dentition along with delayed
eruption of tooth.
Severe erosions have been seen on the lingual surface of the teeth due to frequent
vomiting induced by uremia, regurgitations and dialysis associated nausea and
medications.
Elevated salivary pH, decreased salivary magnesium, and high levels of salivary
urea and phosphorus lead to precipitation of calcium-phosphorus and calcium
oxalate, and, thus, dental calculus formation.

17. White patches of the skin, called ‘‘ uremic frost ’’ can occasionally be seen intraorally.
Uremic frost results from the formation of urea crystal on the epithelial surfaces after
perspiration and saliva evaporation.

18.  Hard tissue
Disruptions during the histodifferentiation, apposition, and mineralization
stages of tooth development result in tooth structure abnormalities.
In children with renal disease, incidence rates of enamel hypoplasia range from
31% to 83%, depending on the racial, ethnic, nutritional, and socio-economic
statuses of the child’s family/parent.
In patients with renal disease, the risk of caries formation is increased by poor
oral hygiene and a carbohydrate-rich diet.
Nevertheless, the incidence of dental caries appears to be low in these
patients, owing to the presence of highly buffered and alkaline saliva due to
elevated urea and phosphate concentrations.

19. Manifestations of metabolic renal osteodystrophy and compensatory
hyperparathyroidism include :
 demineralization, decreased trabeculation, and a ‘‘ground-glass’’ appearance
of bone,
 decreased cortical bone thickness, loss of lamina dura, radiolucent giant cell
lesions.
 maxillary brown tumors, enlargement of the skeletal base, and metastatic
soft-tissue calcification.
 Patients have an increased risk of jaw fracture due to trauma or oral surgery.

20. Other dental findings include :
Narrowing or calcification of the tooth pulp chamber, tooth mobility,
malocclusion, enamel hypoplasia, pulp stones, and abnormal bone healing after
dental extraction.
Radiographically, osteodystrophy manifests as a failure of the lamina dura to
resorb and the deposition of sclerotic bone around the socket.

21. Medical management
Medical management of renal disease depends on the stage of disease and
clinical status of the patient.
Management may include dietary changes, administration of sodium bicarbonate
to reduce acidosis, and correction of systemic complications.

22. Role of the pediatric dentist
Close collaboration between the dentist and pediatric nephrologist is required
in the treatment of children with CRD.
Before any surgery, renal patients should undergo a detailed oral assessment,
and any necessary dental treatment should be carefully planned and
performed.
In any situation consultation with nephrologist is mandatory at all the time.

23. Prophylactic antibiotic therapy as these patients a very prone to infection.
Penicillin, clindamycin and cephalosporin are usually indicated. History
should be taken regarding the allergies of penicillin.
Avoid nephrotoxic drugs such as tetracycline or streptomycin.
Due to poor GI resorption antibiotic should administer by IM route.

24. Procedure indicated under antibiotic
1. prophylaxis
2. Extractions
3. Placement of orthodontic Bracket
4. Periodontal treatment, Calculus removal
5. Endodontic procedure
6. Periapical surgery
7. Reimplantation
8. Implants

25. Local anaesthesia used should be of amide type:
such as lidocaine , xylocaine because of their resorption potential of the
liver.
As per analgesics, paracetamol the drug of choice,
nonsteroidal anti inflammatory drugs should be adjusted or avoided in
case of advance renal failure.
Benzodiazepines of narcotic analgesic are metabolized via liver so does
not require dose adjustments.
Administration of relative analgesia to reduce anxiety.
For dialysis patients, Provide treatment on no dialysis days.
Consult nephrologist for heparin dose adjustment.

26. For dialysis patients:
1. At each visit patient medical history and medication list should be
checked.
2. Carry out dental treatment of hemodialysis patients on non dialysis days
to ensure absence of circulating heparin.
3. Prefer use of local anasthetics with reduced epinephrine in all dialysis
patients.
4. Withhold anticoagulants for a period of time agreed upon with the
nephrologist.

27. 5. Be aware that meticulous local haemostatics measures, including
mechanical pressure, packing, suturing and topical thrombin, may be
required, given the platelet dysfunction that often occurs in patients with
renal failure.
6. Desmopressin controls severe bleedings.
7. Conjugated estrogen achieves longer haemostasis.

28. 8. Tranexamic acid for oral rinse
9. Lidocaine, narcotics (except meperidine) and diazepam can be used
safely in patients with renal failure. Dose adjustment is needed for
aminoglycosides and cephalosporin.
Tetracycline is generally not recommended in patients with end-stage
renal failure. Most of the nephrologists agree to the use of nonsteroidal
antiinflammatory drugs, as dialysis patients usually have little
salvageable renal function.

29. For patients of renal transplant:
Evaluation and eliminate the foci of infection before transplant.
All the elective dental procedures should be avoided frst 6 months post renal
transplant.
Prophylactic antibiotic therapy is mandatory.
A recommended dose of 25 mg of hydrocortlume via IV route before the
procedure.
Uremic stomatitis can be treated with 10% hydrogen peroxide gargles
(1:1 in water) 4 times a day, can be recommended.

30. Immunosuppressive therapy is given lifelong.
For candida infection, systemic anti- fungal agents are commonly prescribed
prophylactically.
In the case of recurrent infections of HSV in these patients, doses of 400 mg
of acyclovir can be administered orally, 3 times a day during 10 days or more
(usually, more than 2 weeks).
Gingivectomy is indicated for gingival overgrowth to improve functional
discomfort and aesthetic alteration

31. Stress - reduction guidelines
Patient’s physician should be consulted, to determine the need for additional
steroids.
Patient should obtain proper rest the night before treatment and should
reduce work and social obligations the day of treatment.

32. Dialysis patients should be scheduled in the morning the day after dialysis therapy,
when the patient’s health is best suited for dental treatment.
Appointments should be kept short.
Barbiturates, benzodiazepines, meperidine, and chloral hydrate can usually be used
in normal amounts.
Nitrous oxide oxygen therapy is an excellent anxiolytic regimen accepted well by
patients with renal disease

33. Chair position
Sit the patient in the semi reclined position or in a position that is most
comfortable.
Provide breaks during treatment, as needed.
Local anesthesia can be used safely in the majority of patients with renal
diseases.
Administer immoral anesthetics slowly, with aspiration.

34. Antibiotic guidelines
Culture and sensitivity testing is recommended whenever oral infection is
present.
Antibiotic prophylaxis should be provided to the dialysis patient with an AV
fistula to protect against endarteritis and endocarditis
Total antibiotic dosage should be reduced. Consultation with the physician to
determine dosage and frequency of administration is advised.

35. Oral penicillin can be used without problems as long as patients are not
hypersensitive to the drug.
Tetracycline should be avoided. Doxycycline or minocycline should be substituted.
Aminoglycosides (gentamycin, streptomycin, tobramycin) are nephrotoxic and should
not be prescribed.
Cephalosporins may be nephrotoxic and should be used with caution.

36. Infection control
Antibiotic prophylaxis and oral antimicrobial rinses should be considered.
Gloves, masks, and eye protection is mandatory.
Aseptic protocol must be followed.
Contact with blood. saliva, and aerosols should be minimized by using a
rubber dam and high velocity evacuation, while limiting the use of rotary
hand pieces.

37. Cross-contamination is reduced by wrapping objects subject to touch and
providing for all instruments required in a single sterile package.
Contaminated instruments should be cleaned of all bodily fluids before
sterilization.
Contaminated disposable supplies should be discarded in labeled
biohazardous bags.
Surfaces should be cleaned and disinfected with the appropriate disinfectant
agents.
Instruments should be sterilized by autoclaving, dry heat, or ethylene oxide
gas.

38. Hemorrhagic dental procedures
Avoid hemorrhagic procedures with in the frst 8 hours after hemodialysis.
Provide prophylactic antibiotic to prevent infection.
Obtain preoperative complete blood count (RBC), differential, bleeding time,
PT.
Give attention to good surgical technique and closure.
To prevent bleeding after minor surgery, use microiibrillar collagen, topical
thrombin, stents.
Consider desmopressin or cryoprecipitate for major surgical procedures.
Avoid “needle sticks”, but if they occur, the patient should be screened for
HBAg and HIV.