DENTA PATIENT WITH RECEIVING H SCOT 5. DE ROSS! O.M.0; MICHAEL GLICK, Dane ‘s technology and medicine advanee, dentists increasingly will be asked to treat patients with complex medical condi- ) tions ' Among these is end-stage renal disease, or ESRD It is be- lieved that about 8 million peo- ple in the United States are af fected by some type of kidney disease; the number of patients who received treatment for ESRD is estimated to be close to 260,000 in 1995, while more than 47,000 die annually of chronic, progressive, inrevers- ible kidney failure ’ Patients afflicted by this medical condi- tion can visit a general dentist's office with number of poten. tial problems that can affect their oral health care. Particu- larly, there are concerns with excessive bleeding, hyperten- sion, anemia, drug intolerance and synergism, increased sus- practitioner's management con- ceptibility to infection and vari siderations and propose a new ous oral manifestations associ-_| treatment protocol ated with the disease itself and | with hemodialysis treatment | Protocols for the dental man. | agement of these patients have been suggested; however, ad- vances in our understanding of ‘An increasing number of Ameri- ans are tiving with end-stage renal disease. This discase has ‘many implications for dentistry, ia terms of oral manifestations and management of afflicted patients. The authors present pertinent information to help dentists treat Patients who exhibit the oral ‘and systemic manifestations of Fenal disease, from the onset of renal impairment through hemodialysis. renal disease and its sequelae necessitate an updated ap- Proach. In this article, we dis. cuss the basis for the dental ETIOLOGY anD paTHO- PHYsioLoay | ESRD is a chronic, progressive | disease that is characterized by the destruction of nephrons, the Com Coy PRACTICE CONSIDERATIONS FOR THE RENAL DISEASE EMODIALYSIS Kidney’s funetional unit.'* Dia- betes, pyelonephritis. glomeru lonephritis, nephrosclerosis. polycystic kidney disease and collagen vascular disease are among the leading causes of this destruction ‘It is impor. tant to ascertain if'an underly. ing disease is present since such a disease, in itself, may influ- ence dental management The nephron consists of a glomerulus (filtering fannel) and tubule The estimated 1 million nephrons per kidney help filter waste from the blood. modulate the excretion of salts and water from the body and allow the kidney to perform its excretory, metabolic and en- docrine functions.** Once de- stroyed, the nephrons do not re- generate However, the kidney attempts to compensate via hy- pertrophy of the remaining fonetional nephrons; normal renal function is maintained until approximately half of the ‘nephrons are destroyed. At this point, the kidney's compensa- ; | tory mechanisms are over- whelmed, and signs and symp. toms of renal failure begin to JADA, Vol 127. Fobruary 1998 211SSSA AAA SSS ESS rer or 5 5 5 5 5 4 4 > 4 3 > t + 4 LINICAL PRACTICE i TABLE 1 LABORATORY COMPONENT NORMAL LABORATORY RANGE SYMPTOMATIC RENAL FAILURE Glomerular filtration rate” 100-150 miL/min. <10 mL/min ‘Grea ‘Clearance 85-125 mi/min. (female) 97-140 mL/min. (male) 10-60 mL/min, (moderate renal failure) <10 mL/min. (severe renal failure) Serum creatinine 06-120 me/aL, 25 mu/al. Blood urea nitrogen | 8 meal >50 mg/L Soran caleiom 36108 meal Depressed ‘Serum phosphate 2-45 malate | Blevated Serum potassium 3.86 mma { Elevated * Most nepirlogists we creatinine clearance to oases glomerviar filtration rate Thus, OFR values are not away readily availble ‘manifest themselves.'"* ‘Asa gradual and progressive process, renal failure can be de- | seribed in successive laboratory | and clinical stages (Table 1). | Diminished renal reserve. | This represents decreased kid- | ney function without clinical | manifestations or symptoms. In. fact, a lower creatinine clear- ance is often the only observ \ able change. Creatinine is a | poorly metabolized breakdown product of muscle; daily produe- | tion is proportional to muscle | mass and is constant for a given | individual. Since creatinine in | the urine derives primarily from that filtered by the glom erulus, it is a good indicator of \ glomerular function ** A creati- nine elearance test assesses kid- ney funetion by comparing the amount of creatinine in the | blood with the amount excreted | in the urine over a 24-hour peri- od. As the nephron population continually declines, the glom- erular filtration rate also de- clines, while the blood urea ni- trogen, or BUN, level rises.’”* These changes reflect the kid- 212 JADA, Vol 127, February 1996 noys’ decreased ability to filter and exerete certain toxic sub- stanees from the bloodstream Renal insufficiency. Kid. ney funetion is mildly to moder- ately diminished, resulting in symptomatic evidence of renal failure; there is evidence of im- paired ability to maintain the internal environment, including mild accumulation of nitrogen produets in the blood, decreased ability to concentrate the urine and mild anemia Renal failure. Kidney func tion has deteriorated to th point of chronic abnormalities in the internal environment, in- | dluding azotemia, metabolic aci- | dosis, hypocalcemia and hyper- | phosphatemia as well as } isosthenuria and nocturia Uremic syndrome. Thi | represents a number of clinical | signs and symptoms that ap- | pear in the individual with re- | nal failure (Figure 1). Uremic syndrome primarily results from the retention and accumulation | of excretory products and the di- minished endocrine and metabol- | ic functions of the kidney. Many of these systemic signs of renal failure and uremia can be important to the dental prac- titioner, particularly hemato logic changes, changes in bone metabolism and alterations in immune status? MEDICAL MANAGEMENT OF THE PATIENT WITH RENAL FAILURE. With chronic renal failure, many of the gradual and pro- gressive changes are corrected by treatments ranging from di- etary changes to renal replace- ment.** With mild and early renal insufficiency, conservative therapy such as alterations in diet can minimize the effects of | kidney failure and perhaps slow | disease progression "" Patients | often receive sodium bicarbon- | ate to reduce acidosis, vitamin | D supplements to treat hypocal- | comia and high carbohydrate/ low protein diets to minimize the toxie nitrogenous products produced by the metabolism of | protein.” With advanced dis- | ease, such as renal failure, | greater measures such as dialy-sis must be taken Dialysis is an_ | | artificial means of removing ni- , togenous and other toxic prod- ' ucts of metabolism from the | blood. For many patients, dialy- | sis isa hfesaving intervention | that has significantly reduced " the mortality of this once-fatal | disease | ‘There are two types of dialy- | ba at ne cna ncn, Perera era § : CLINICAL PRACTIC Ess 1 Nausea, vomiting, anorexia, am- | monte tanec and Scout stoning Us, parotitie, esophagitis, gases tis, gastrointostinal beadine Headaches, peripheral neuropa- | thy; paralyate, myoclonic jerks. | seizure, aaterixie Solero, asteree Normocytic-normachromie ane. mia, coagulation defect. increased Susceptibility to infection. de. greased erythropoietin production, lymphocytopenia Gastrointestinal Neuromuscular Hematotogic- Immunologie sis: peritoneal and hemodialy- sis In peritoneal dialysis, ac- cess to the body is achieved via | Bcatheter through the abdomi- nal wall into the peritoneum. A || dialysate from a bag attached to the eatheter passes into the cav- | Renal osteodystrophy (asteomala- cia, osteoporosis, Uatcosclerosin) secondary hyperparathyroidism, impaired groweh/developmen loss of libide and sexual function, |_amenorrhoa, Atrial hypertension, congestive heart failure, cardiomyopathy. Cardiovascular brane serves to filter out waste | Dermatorogic | ity, where the peritoneal mem- | | tas Vow www esos sere kidneys, Recent data from the US. Renal Data System esti- mate that in 1995, 188,000 peo- ple underwent dialysis treat: ments, including at least 155,000 people undergoing hemodialysis * Patients undergoing hemodialy- sis receive these treatments in outpatient centers for approxi- mately three to four hours a day, three times per week. ‘Today, renal transplantation is the treatment of choice for patients with irreversible kid- ney failure. However, the use of transplantation is limited to the availability of organs. Trans- Plantations are being performed with increasing success; approx- imately 70,000 transplant pa- tients are alive today, with a five-year renal survival rate of more than 60 percent '* The ; dental management of patients 1 Who have undergone transplan- tation is beyond the scope of | this article from the local vessels. This pro- cess, often called continuous ambulatory peritoneal dialysis, or CAPD, or continuous cyclic peritoneal dialysis, or CCPD, is }Aslower process than hemodi alysis and is less often used for long-term treatment."'" How. ever, peritoneal dialysis offers } _ patients greater mobility be- }| 2 Sane hae nt depen n 3 cumbersome machines, and it is |.) : becoming more common, consti , tuting approximately 20 percent ) ' ofall dialysis therapy ) Arteriovenous shunts and fis- tulas are commonly used to ac- cess the patient's bloodstream ‘in hemodialysis *" The artificial ) | kidney, known as the dialyzer, | containe semipermeable mem. |” ° branes that allow the passage of > | excess fluid and wastes. During treatments, patients are given anticoagulants in the form of 1e- “9 | gional or systemic heparin to fa. 23 | cilitate blood exchange and to maintain access patency *™ Al- % | though hemodialysis is impor- “9 | tant in fluid and electrolyte bal- | ance, in addition to blood filtering, these treatments do not provide the same degree of health as normally functioning > ORAL MANIFESTATIONS ) Several changes occur in the > r = a 3 Pericarditis, nrrhythmi Figure 1. Systemic manifestations of renal fi Pallor, hyperpigmontation, occhy- mosis, uremic frost. pruritis. Freddie! “brown nail bods oral cavity that are associated with chronic renal failuie and uremia Researchers estimate that up to 90 percent of renal patients will show oral symp- toms.’ With renal insufficiency and uremia, patients may com- plain of a bad odor and metallic taste in the mouth. This is due to the high urea content in s: liva and its subsequent break down to ammonia Patients also complain of dry mouth and often are prone to retrograde parotitis; these complications are believed to result from a combination of direct gland involvement, chemical inflam- mation, dehydration and mouth breathing.” Perhaps the most common oral finding is pallor of the mucosa secondary to the anemia commonly seen in pa- tients with renal failure who are . undergoing hemodialysis." | _Uremic stomatitis is often a | clinical finding in cases of ad- " vanced disease. There are two ; forms of this stomatitis; often, they correspond with an acute JADA, Vol 127, Februmy 1996 2131 errr rn wwe VUUUUEVUEVVVUU UU EVO dO NEY YY Se sess [NICAL PRACTICE | | | | rise in BUN levels. The erythe- | mopultaceous form is character- ized by red, burning mucosa covered with a gray exudate and pseudomembrane; the ulcerative form is characterized by frank ulceration with red- ness and a pultaceous cover~ ing" The exact etiology of | uremic stomatitis remains un- mown, but itis suspected to be | a chemicallike burn or a loss of | the tissue's resistance to normal | and/or traumatic influences | These lesions are commonly | painful and most often appear | on the ventral tongue and ante- | rior mucosal surfaces. These le- { sions usually heal spontaneously, with resolution of the underlying uremia and lowering of BUN Hevels"* | White patches often associat- + ed with the skin, called “uremic frost,” can occasionally be seen intraorally. This uremic frost | results from remaining wrea crystals left on epithelial sur- faces following perspiration and { saliva evaporation " Since | these patients often require high-carbohydrate and low-pro “tein diets to minimize the nitro- gen products produced by the metabolism of protein, severe caries would be expected. How- ever, the caries index is often noticeably lover in these pa- | tients. This low caries rate is | attributed to the inhibition of | plaque and bacteria by higher | lovels of salivary urea" This | finding is most apparent in chil ‘ dren, despite their high sugar | intalke and less-than-adequate \ oral hygiene. Also, some patients may have severe ero- sion of the dentition due to fre quent regurgitation, resulting | from the nausea associated with | hemodialysis treatments? Other oral manifestations of renal disease are related to | 1 214 JADA, Vol 127, February 1998 | renal osteodystrophy. These manifestations become appar- ent in late-stage disease, even with dialysis treatments” Meta- bolic renal osteodystrophy re- sults from disorders in calctum | and phosphorus metabolism, | abnormal vitamin D metabo- [lism and increased parathyroid | activity, Calcium absorption in ' the intestines is diminished early in renal failure because | the kidneys cannot convert vita- | min D to its active form. There j is also a corresponding reten- tion of phosphate, which ulti- | mately leads to decreased se- rum calcium levels This is associated with compensatory hyperactivity of the parathyroid glands, leading to increased uri- nary excretion of phosphates, decreased urine calcium excie- tion and exaggerated release of calcium from bone *"* ‘The manifestations of meta- bolic renal osteodystrophy and compensatory hyperparathy- roidism of the mandible and maxilla include bone demineral- ization, decreased trabecula- tion, “ground-glass” appear- ance, loss of lamina dura, radio- lucent giant cell lesions and metastatic soft-tissue caleifica~ tions"! In addition, with such bone loss, it is not uneom- mon for patients to have spon- taneous fractures of the jaws from trauma as well as to be at "risk of fracture during oral and periodontal surgical procedures Other dental findings in re- nal osteodystrophy include tooth mobility, malocclusion, enamel hypoplasia and pulp stones. Tooth mobility and drift- ing have been documented in \ such patients without appreci- ' able pathological periodontal | defects ® Enamel hypoplasia in ' the form of white or brown dis | coloration is commonly seen in | those patients whose renal dis- | ease began at a young age In fact, the hypoplastic areas on permanent teeth often corre- | spond to the age at onset of ad- | vanced renal failure.’® Abnor- j mal bone healing following | dental extractions has been re- ported”; radiographically, this | manifests as a failure of the | 1amina dura to resorb and the | deposition of sclerotic bone | around the socket. The litera~ ture has also documented pul | pal narrowing and calcification ‘as well as delayed or altered eruption "7" Tt is important to recounize that with the increased avail- ability and use of dialysis, and ultimately renal transplanta- tion, many of the oral maniles- tations of renal failure and wre- mia are less commonly seen However, since signs and symp- toms of renal disease can be seen intraorally, the dentist, if aware of these problems. ean play an important role in the di- agnosis, overall health and treatment of the patient DENTAL MANAGEMENT CONSIDERATIONS: Patients with uremia and renal failure who are undergoing hemodialysis require special consideration, most importantly with regard to risk of excessive bleeding, risk of infection and medications used (Figure 2) Pa- tients with CAPD do not pose any contraindications to dental treatment other than in eases of | acute peritoneal infections; | therefore, this article will focus | on the treatment of patients re- ; ceiving hemodialysis Hematologic conditions that | most commonly affect the pa | tient with uremia and renal failure are excessive bleeding | and anemia‘ Bleeding ten-3 on LPT PSSST PAA LLL LDL PLES EPA EAE wee wo t wwe | dencies in these patients are at- tributed to a combination of fac- tors, including anticoagulants used with hemodialysis therapy and vascular access mainte- nance.‘ Mechanical trauma to platelets during dialysis treatments can reduce the total platelet number up to 17 per- cent in some cases, although this alone is not clinically sig- nificant.'2* Often, these pa- tients have reduced platelet counts, decreased platelet adhe- siveness, increased prostacyclin activity, decreased availability of platelet factor 3 and in- creased capillary fragility, all of which can lead to increased loss of blood ‘The increased hemorrhagic tendency in uremia can be exac- erbated by anemia. It is be- lieved that low hematocrit lev- els commonly found in uremic patients negatively influence the rheological component of platelet—vessel-wall interac- tion.'* Gingival hemorrhages, ulcerations and petechial and eechymosislike lesions are often, reported in these patients and jure commonly seen intraorally * Peritoneal dialysis and hemo- dialysis correct many of the hematologic dysfunctions asso ciated with uremia and renal failure Carl and Wood” suggested that patients receive dental treatment just before undergo- ing hemodialysis since they are free of anticoagulants at that time and at decreased risk of bleeding. However, since hep- arinization during dialysis treatment does not usually pro- duce clinically significant resid- ual bleeding and the effects of heparin only last approximately three to four hours after infu- sion, the risk of excessive bleed- ing because of anticoagulation Before treatment TConsule with pationt’s nephrologist for recent coagula. phylaxis fon walues and to discuss administration ofantibious pro | ‘= Evaluate patient for hypertension and/or hypotension Tj Avoid use of the arm with vascular access for injection || of medication and/or use of blood preceace eae | TyPgtermine underlying causes of renal failure (for exam || ple, diabetes can affect provision of care) || = Have a complote blood coll count performed to evaluate || patient for anemia: recard slsin bleeding tise Tr indicated, institute appropriate hemostatic agente Such as desmoprensin acetate or conjugaved extronen || mPetermine prosence of uremic symptoms (avigabiity, | nausea. vomiting, lothargy, pruritic) || pt Obtain dental radiographs to determine manifestations | of osteodystrophy: = Determine the type of vascular access |= Determine the time of dialysis (dialysis cycle; dental | ffeatmont is indicated on the day afte: dialvais UTDHave routine hepatitis B surface antigen testing por formed: tests should include liver function tesun pra thrombin time and partial thromboplastin Line th casas of liver damage = Consider antibiotic prophylaxis = Consider anti-anxiety pertensive patients dative premedication for hy- During treatment Rerform thorough intraoral examination for presence of oral manifestations = Ager = Use aa Burgerios sively eliminate all intraoral sources of infaction netive homoutatic aids for oral and periodontal = Place patient f comfortable. noneramped position Allow the patient us walk or stand ascasionally during Tong procedures After treatment = Use post-procedural hemostatic agents — Encourage good oral home care i Institute therapy for xerostemia it i Use postoperative antibiotien for patients undersoing severoly traumatic procedures T Avoid use of respiratory depressant drugs in pationts with severe anemia oo Adjust dosages uf medications a renal impairment Figure 2. Dental evaluation and management of patients receiving hemodisiveia. is minimal '"*" A case report and quantitative changes in i by Buckley and colleagues ' platelets, rather than to hep- , Shows that postoperative bleed- arinization Also, a platelet » ing following oral surgical pro- count and a complete blood cell cedures in these patients is | count can serve as important ' most often related to qualitative | parameters for the dental prac. JADA, Yol 127, Februmry 1986 215 CLINICAL PRACTIC Een |VUVwweeoeose ss coms |NICAL PRACTICE | one, swith regard to manag | ing bleeding and anemic condi- | tions. Adjunctive hemostatic i measures should be used as \ often as possible in at-risk pa- |tionts A synthetic analogue of | the anti-diuretic hormone vaso- ‘ pressin, 1-deamino-8-D-argi ‘ nine vasopressin, has been sug- \ gested in the management of | severe bleeding in patients with | renal failre, boosting the cong, talant effects of von Willebrand's | factor and resulting in de- | creased bleeding times for up to four hours ** Conjugated estrogen can be used for long-term hemostasis, swith effects lasting up to two weeks” Tranexamic acid, an anti-fibrinolytic in the form of a mouthrinse, has been shown to significantly reduce operative and postoperative bleeding *"* In addition, meticulous surgical | technique; good primary closure; and local hemostatic aids, such ‘as microfibrillar collagen and oxidized regenerated cellulose, help to reduce bleeding ass0- ted with oral surgery and | periodontal procedures and | should be used as frequently as \ possible |” Because of anemia, respira- | tory depressant drugs such as nareoties should be used with caution ‘Phe risle of infection is also a | concern with uremic patients in | renal failure. Primarily, al- | tered cellular immunity in chro- | nic systemic uremia along with malnutrition resulting from protein-restricted diets lead to | an immunodeficient state." | Patients are more susceptible to bacterial infection because of | their protein malnutrition, \ | which leads to a diminished abil- | | ity to produce antibodies | Both oral diseases and dental ! manipulation create bacterem- I 216 JADA, Val 127, February 1996 ias that may lead to significant | morbidity and potential mortal- ity in patients with renal failure and those receiving dialysis." Periodontal disease, endodonti- cally involved teeth, oral ulcers and dental procedures all can serve as a means of entry for microorganisms into the blood- stream. Therefore, itis vital that every effort be made to eliminate oral sources of infee- | tion. Good home oral care, fre- | quent and aggressive oral health maintenance and regular Infection is a frequent cause of morbidity and mortality in patients receiving hemodialysis therapy. | | \ ( use of anti-fungal and antimi- crobial mouthrinses are effec: tive means to reduce the risk of dentally induced infections in these patients "" Infectious endocarditis is not | q rare complication in regularly dialyzed patients; it occurs in 2.7 percent of patients during maintenance hemodialysis and in 9 percent of those who have fan infection of a vascular access ‘ site "® With this increased risk, there has been some discussion in the literature about the need | for antimicrobial coverage for ' dental procedures to reduce the | chance of septicemia and endo- | carditis." Researchers thought | that patients undergoing dialy- | sis were at risk of endarteritis | from dentally induced bactere- ‘mias that ean be a source of in- fectious emboli leading to endo- carditis.” *" These patients es for hemodialysis in the form of external cannulas or arterio- | venous fistulas and shunts *"" commonly have vascular access | However, more recent evidence suggests a host of factors that can potentially lead to endo- carditis in these patients." Overall, infection is a frequent | cause of morbidity and mortal- | ity in patients receiving hemo- dialysis therapy." Mortality \ associated with infective endo- carditis is very high—45 per cent. Streptococeus viridans ac | Seants for 17 percent of eases of | infective endocarditis in patients | with chronic renal failure." |” According to Manton and | Midda, patients with arterio- venous shunts are at greater risk of infection following dental manipulation than patients with eannula and fistula access sites ‘Phe authors recommend antibiotic coverage for patients | with shunts who undergo inva sive dental procedures." Naylor and colleagues also suggested antimicrobial premedication for patients undergoing dental pro- cedures that induce mucosal bleeding to prevent vascular ac- cess infections, bacteremia and infective endocarditis * Itis clear that patients with chronic renal failure who re- ceive hemodialysis have an in- creased susceptibility to the de- velopment of infective endo- carditis, This infection more commonly affects abnormal car~ diac valves; however, there is a hhigh incidence of infective endo- | carditis in patients receiving | dialysis who have no evidence of preexisting cardiac valve dam- | age.” Manton and Midda specu- Jated that changes in fluid vol- | ume and hemodialysis itself | affect heart behavior, creating | smechanical stresses” that may | play a role in the development | of infective endocarditis. * Thus, | antibiotic prophylaxis prior to dental cate needs to focus on | preventing infective endocardi-‘ 4 qmocecscsccse OTOP ODIO FPP LLL righ v wr tis. The American Heart Associ- ation’s protocol for prevention of infective endocarditis should be used, but modified according to | the severity of renal failure | (Figure 8° The drug of choice | is vancomycin infused during | dialysis. Because of the renal | impairment, this antibiotic will | protect the patient for up to | seven days.“ However, insur- | ance reimbursement for van- | comycin prophylaxis for dental | procedures may not be avail- | able, thus limiting the patient's ‘access to this therapy. Because of changes in fluid volume, salt retention and the presence of shunts and fistulas, patients commonly are affected by certain cardiovascular condi- tions Specifically, congestive heart failure and pulmonary hy- pertension can be seen in pa- tients with renal failure." Often, hypertension in patients with renal disease leads to ath- erosclerosis, with significant cerebral, coronary and periph. eral vascular effects" Although patients are often treated with antihypertensive medications, dentists should take precau- tions to avoid excessive stress in the dental chair that could ele- vate systolic pressure.'* Den- tists should monitor blood pres- sure before and during treat- ment as well as administer seda- tive premedication to reduce anxiety in patients with renal failure who receive dialysis." {Many patients receive anti- hypertensive medications, in- | cluding nifedipine, a calcium | channel blocker known to in- duce gingival hyperplasia. Con- versely, hypotension resulting from fluid depletion and adre- | nal insufficiency is a common side effect and complication of | hemodialysis treatment, occur- ring in 20 to 80 percent of dialy- [= Vancomycin (1.0 6) infused over one hour during dialy- sis the day before dental treatment TL Amoxicillin (3.0 g per mouth) one hour before the den- tal procedure; a second dose is not needed ‘j_Exythromycin ethylouccinate (B00 mg) or erythromycin stearate (10g by mouth) two hours before the dental pre. cedure, then one-half the dose six hours after the initial dose [JE Clingamycin (300 mg by mouth) one hour before the Soze Elective dental proce- dures should be per- formed on the day after dialysis treat- ment when the pa- tient is best able to tolerate treatment. i | | sis sessions." However, not all | ofthe complications are benign; stroke, angina, myocardial in- farction and arrhythmias have | been documented as possible | side effects of dialysis-induced hypotension * Therefore, elec tive dental procedures should ! be performed on the day after dialysis treatment when the pa- tient is best able to tolerate treatment Apart from serving as a po- | tential site for infection, arterio- venous access sites must not be jeopardized; blood pressure monitoring is prudent, but the affected arm should never be used for the intravenous or intramuscular injection of any medications, nor should the cir- culation be impeded by a blood pressure cuff" In addition, pa- tients should not be kept in cramped positions in the dental chair and should be allowed to stand or walk occasionally to minimize the risk of access ob- struction.” dental procadure, then 150 mg six hours afver the initial Figure 3. Suggested changes for bacterial endocarditis prophylaxis for patients receiving hemodialyaie, Because patients undergoing dialysis are exposed to a large number of tranefusions and | blood exchanges, as well as renal failure-related immuno- | suppression, the literature sug- "gests that they are at greater risk of hepatotropie viral infee- ' tions such as hepatitis B and C, tuberculosis and human im- | munodeficiency virus. "These patients should be encouraged to undergo periodic testing for hepatitis infectivity" and HIV antibody “" For patients with liver damage, the dentist should evaluate the results of liver fanetion tests and potential | bleeding tests (that is, pro- | thrombin time, partial thrombo- plastin time) bofore extracting teeth and performing periodon- ‘tal surgery. ‘The incidence of tu- berculosis in pationts with renal disease has been reported “tobe up to 10 times greater than that in the general popula- | tion * This increased incidence is probably a result of dimin- | ished cellular immunity in pa- ' tients with chronic renal fail- | ure However, extrapulmonary ‘tuberculosis was seen in the majority of cases, and therefore | it doos not represent a trans- | mission risk via aerosolized droplets in a dental setting | Pharmacotherapeutics repre- | sent a final consideration for patients with renal disease who | receive dialysis. Most drugs are JADA, Vol 127, February 1996 217 CLINICAL PRACTICE ssaweal es, aN L-SANSARLAAAS ond i é A a q — CLINICAL PRACTICE TABLE 2 MIAINTENANCE DOSE INTERVALS (1 Ce A ena twofold increase in the elimination half-life of a drug removed from the DRUG NORMAL RENAL. | MODERATE RENAL | SEVERE RENAL, 2 FUNeTION FAILURE SS FAILUNE body solely vie ' aaencienes renal excretion | Seperate 3 7 ou partaly elimi 1 Cephalexin 8 6 6-12 nated by the kid- | Sitinmvein 3 ; Donyeyeline asad Peer aaee ney, the change in Erythromycin 6 6 6 plasma half-lives eee 7 7 tat | should be corre- Belracyeline é Avoid use Avoid use | spondingly i W340 Biers 285 | io Dantes i ‘Analgesice | can avoid the ex- Reotaminophen = ce ae cessive accumula- fepirin 4 £8 qveid use | tion of drugs in 1 fobproten é ee void uss | aprotee : pvSizace | SESKESES | patients with 1sccl ancethetice | renal failure pri- | iiocaine) [Normal amount | Normal amount_| Normal amount) jnaily by length LL ‘Narcotics ening the interval a asine! Sooo eee between doses ac- i Geameacce 7 | cording to the de- Mere eee gree of elimina: ' Propoxyphene i | tion impairment —— 7 aitivaxares Table 2 lists dose ——a ; —, = | intervals for some [Rentobarbia 2 3 | Bhenoburvieal & 3 atc —|_of the drugs com. | Secobarbital 8 | monly prescribed i Benzodiazepines i in dentistry Ghiordiazeponide 3 Baz as concLusion Diazepam \ 5 3 3 - The goal of dental i — treatment in pa- Boxamernanone T ¢ 6 | 93 | tients with renal | Biphoniiydranine a Se a aa Diphentyd 33 iscase should be [Prednisone | 22 | the early and fire- quent evaluation. | atleast partially excreted via | Prescribing medications for | of the oral cavity for the source the kidney; therefore, dimin- | patients with renal failure who of infection Early detection of ished renal function alters the _ are undergoing hemodialysis, oral pathologies will permit | drug volume of distribution, poses a challenge to dentists swift correction with minimal metabolism, rate of elimination | and bioavailability.” The | plasma half-lives of agents elim- | inated in the urine are often. greatly prolonged in patients with renal failure and effective- ly reduced by dialysis. Even with those drugs metabolized by the liver, the renal failure to ex- crete metabolites can lead to in- creased incidence of toxicity." 218 JADA, Vol 127, February 1998 ‘The therapeutic regimen must __/ need for extensive dental treat- be maintained within a narrow | ment. Strong preventive mea- range, avoiding toxicity at one _| sures also can minimize the fend and sub-therapeutic dosing | need for extensive dental care. at the other ‘Some drugs are __| ‘The dentist must be aware of nephrotoxic in themselves, and _; the ramifications of renal dis- the added strain these drugs _| ease (including its underlying place on already damaged kid- | causes) and hemodialysis on neys must be avoided. A 60 per- | dental treatment. Specifically, cent drop in creatinine clear- _| the dentist must consider bleed: | ance theoretically represents a _| ing tendency, risk of infectionwe ‘ i v wc KAR ed vee se oo f ij a pee. 7 x2 | and medications before treating | the patient. Clearly, this sys- | temic disease has consequences | that affect the oral cavity in | more ways than just the loss of function, esthetics and comfort. ' The renal patient's dental prob- ‘Jems can compromise his or her general health and hinder med- ical management. Therefore, the dentist is @ pivotal provider in the overall health care of pa- + tients with this disease. » 1 Cahn $C Renal disease In: Lyn MA, Brightman Vd, Greenberg DIS, edx Buckets ‘ral medicioe 9th ed Phiadeipio: Lipa ut eT 509 12 US Renal Daa System, USRDS 1995. ‘anmual data ropore. Bethea. Sid; Natienol Institutes ef Healt, Natoma Institute af Di shotes an Dizstive and Kidnov Diseeae Apel 1985, 1 Disorders ofthe kidney nd urinary tract ns Iseloachr BS. Brauneld Ey Wilson JD. al-ads Harr’ principles ef internal tedieine J2th et New Vor: HeGraw i 9Lt2sa-ane 4 Levine D2 Care ofthe real patient nt ol Philedsiphia: Saunders; 1991.399-210 5 Rabees JA Ethlogy and pathology Uf pelos Ant Kidney Bi 109478 6 Wiliams W Peststreptoaeesl gmer lonephritis: how inporane 38 cause of throne renal disease? Traneplant Pr 1957-21Spplemert 2072100 7 Lenin SP Diseases af the kidney nd ststurbances in electrolyte metabo i Rose LF Have D, eds Internal medicine fr dentistry Zoe ed St Lauiss Mosby Year Bonk; 1003519.91 3 Tesch of Pappor clinical nepealngy tnd ed Bescon: Lit, Brown F867 107 9 Lov) HAY Dental consideration forthe patient rescving dali for rena lure Spee Core Dentist 098,604-6 10 Enjnee TL. Justak 73, Bonnett WA Achieving oral healt n patente with real Sire and renal transplants JADA 1986219; aie 11 Wostbrock SD Dental managemen of patients reevinghemadiahyae sd Kine Fransplants JADA 1av896:16¢8 12 Grete. Mesingor E, Stich A Dawe lw protsin dit really slow dv te rate Drogeasion oehronic renal fice? Bled Pont t990:7338 13 Mitch WE. Natrtion ad th kidney Boston: Lite, rw, a@e-243-62 1 dameson MD, Wiegmana TB Principles {see and complications et hemadilyis Nd | Chin Nera Are 1960.79 46-59 115 Gabriel RAorbiity and motility of | lne-trm haemodityse a soviow Soe | Mel tostr7.0seo1 16 Sewell 3B Dental care fr patents with | tena file and renal treaaplants JADA ez i0Kna | “ir'Can W Wood Rts The dena patient | with chrone renal failure Quintessence Int | | ssr6:t9.15, 18 Hovinga J. Roodveets AP. Gailord J Some findings ia patente with ueaomie stom aii, Malefae Sarg 19760128-7 19, Sampson F, Molster F de Dontl com plietiona inthe end stage of ena daease Gon Dent 193432:297-8 20 Molpus WM, Pritchard RS, Walker CW, Fitarondaiph FL ‘The eadiogeaphespeeteum af renal extoodytrophyAm Fem Phyo epicaatsi 21 Carl W Chranie renal dsnge end hy- pexparathyoidism: Dental manifestations ‘and management Compend Contin Eve Dent 1s67 89607708 22. Fishman MC, Hofman AR, Kavenor RD. Thalee MS. Renal divonse In: Medicine 8rd ed. Philadephia: Lippincse 1991-159.92 23 Rabelink 1. Zwoginga dd, Keomane HA, Sima JJ Thromboria a hemertacis in renal dis Kidney tnt 09446397 96, 24 Schiller GI. Berkewon SA, Homatlogie ‘aspects of renal inslficeney Blo fv Tasos 25 Roger SD. Par J, Tucker 8. Rain AB, Baker LI Kovacs IB Camporizon of haemo. ale activin baemedialyas and porto fol dali pation with roel techaigoe Temonatomery Nephron 1902625228 25, Buckley DJ, Darett AP Kvtiod. Stow: set JH. Control o bleeding in svery uremic Datients undessoig oral eurgery Oral Sarg Oral Ned Oral Patol ve68:61546:9 21 Dobkin JP ler ME, Seige) NE epicomia in patients on eran emo sis Ann Intorn Med 10798838 33 "28, Mannuet PM. Romina G, Pasir Lombardi fy Mesa G Zimmerman T Deo ' nie:Dssrgninevasapresinsharens bleeds ing tina uremia N Engl Neo 1800308012 439 Liu Vk. Roufld RE. Navewn SC ‘reat ‘ment of uracmie bloding with senjugeed ov {Wogan Lancet 198422 Be M0 Sindee Pedersen 8 Stenbjery S.Eiet of Joel antibrnoltietreatinent wth ran ‘mic acid in hamephien underging ora ‘argury J Oral Nile Surg 186 44702-7 {aT Sindet Pedoreen 5. Rarmetom G Bern sil, Dlombuck N Hemostanie fle of a. ‘examie aid mouthwash in anticanguiant Irented patonts undergoing orl surgery N Engl J Mea 1080;320:840.9 32 Diced VB, Soinidl, Demes PN. Braua TW’ Mane mont of tho oral and maxillofacial wirgery pa. ene wish end-stage ronal disease Or Maxiltse Surg 199250:1207-12 ‘3, Goldman Df. Vanherweghem dL, Bact- il nections in chronic Romesialyen pa tient: epiderialgie und pathophyialagie as: peeta Adv Nephrol 1000;10318-92 ‘3 Koslow RA, Zllnor SR Taibetin in pa | tents on meintetance hemadialysi Lancet wsiaarti78, 35 Keano WF, Shapiro FL, RajL Ine. dlnce and type af infections secorring n A ‘ranie homodilyss paints Trans Am Soe ‘Anu Tatera Organs 1977.25:1.7 ‘36 Chatenowa L, JungorsP, Desearops Latecha B fenmunclgi considerations ofthe ‘uromie nd dlalyod pationt Kidney ft tontasiSupplement 1502.6 | “37 Naylor GD, Hall BH, Terezhalmy GT. ‘The patint with chronic renal faiare whois Sndaring dali or rena ennsplaneaton ‘nother consideration for antimierbal peo | Bhylauis: Oral Surg Oral Med Oral Patho $98898:116-21 ‘6, Fayo JT. ONeol R Dental eapansibility forthe medicelly eompromined patent J Oral Mee lomiasis2.6 S30 Heard BJ. Staples AB, Crowns AW ‘Te dental patint with renal cease! preea- ‘Sons and guidlines JADA 197B96928 ‘10 Levnard A, Rai 1, hopire FL Bates al endeenritis in regulate ditvzed patents Kidney in 107209.22 ‘Reid CL. Rahimtona SH nective endo arts in homie renal fallen: The are ‘nd renal eiseae, Now York: Churchill Li Ingle: 1964189208 “22 Mantan SL. Midda M1 Rona! fire ant the dental patient: 4 eautionary (le Be Dent | W'gssi160'385-00 49. Dajori AS. Bis AL. Chung ft at Prevention of bsstral endocarditis recom ‘mondations by he American Heart Arc “fiom ARIA 1880-2642819-92 "Tobin BE, Montes B. Mooketice BKC En: i deca a haemolysis patonts vith sy ternediewace J Dial 197827581 {5 DelS Hepotiiz Crus infection in hemodiniyeed patents ond kidney allogra, | fecpents Ade Nephrol 199522491590, “06, Reser IW, Shapiro WD, Porush JO) The | insdence and opdemiology of human iron tficaay viru infection ih 20 pics fronted in an innorsityhomodiaeaa center ‘nod Kidney Dis 1999:162831 7 Baltimore Boston Callatoraive Study Graup Hutnan imunodetcieney virus infec: tion in hemadiaiyi patients Arch Invern ‘ea 1988:148617-9, "5 Mitel & Tuberculosis in patients an ‘maintenance dialysis Am J Kidney Dis 199 tasre-82 49 Bennet WM Drugs and ronal disease 2nd ed, New York: Churchill Livingstone 198626-65 is Bernstein JB, Stanley DE. Cheice ofa | ines, pinemacokineti and dove adjust | ments in acute and ehroni onal Eslore Med | Glin Nor Are 1900:-1058-73, 51 Fernoger TV, Whelton Pk, Klag MU Risk of Kidney flloe ssseated withthe vse of etaminophen, asprin and nansterail Sabinlammatory deage N'Engl dS Mod soi ar 1675.9 52 Neldle EA. Yagola JA. ede Pharmacla- iprand therapies for denis. rd ed St outs Mosby-Yeor Book: 1980571 JADA, Vol 127, February 1996 219 a GLIAL PRAT