DARLENE WEST DDSINDIANA UNIVERSITY HOSPITALMARCH 7 2008MARCH 7, 2008

THE RENAL PATIENT:THE RENAL PATIENT:ORAL CONSIDERATIONS

OBJECTIVESOBJECTIVES

TO BECOME FAMILIAR WITH HOW CHRONIC TO BECOME FAMILIAR WITH HOW CHRONIC RENAL DISEASE EFFECTS ORAL HEALTH; WITH WHAT THE DENTAL PROFESSIONAL MIGHT FIND ON ORAL EXAMINATION

TO BECOME FAMILIAR WITH THE STRATEGIES USED BY DENTAL PROFESSIONALS TO IMPROVE ORAL HEALTH IN THE ESRD POPULATION

TO BE ABLE TO COUNSEL THE RENAL TO BE ABLE TO COUNSEL THE RENAL PATIENT/DIALYSIS PATIENT RE: NECESSARY CHANGES NEEDED IN DIET/ ORAL CARE TO IMPROVE ORAL HEALTH

THREE THINGS I KNOW:THREE THINGS I KNOW:

1 Th kid i th t ffi i t 1. The kidney is the most efficient “Waste treatment plant” created, until it no longer functionsuntil it no longer functions.

2. Eating wisely does not guarantee long life b t eating n isel ill long life but eating unwisely will likely facilitate a shortened life –especially in ESRD / CKDespecially in ESRD / CKD

3. The oral cavity is a good indicator for bothfor both.

#1

OVERVIEW: KIDNEYOVERVIEW: KIDNEY

ANATOMYANATOMY-2 bean shaped organsFist – size4 to 6 ounces

OVERVIEW: KIDNEYOVERVIEW: KIDNEY

FUNCTIONFUNCTION-Produce urine – 40 to 60 oz. per day

• Filter blood – 12 x per hourp• 2 gallons per hour• 200 quarts per dayBalance fluid contentsBalance fluid contentsBalance electrolytes

PhosphorusP t iPotassiumSodium

OVERVIEW: KIDNEYOVERVIEW: KIDNEY

FUNCTION-Produce RENIN – controls blood

pressureProduce ERYTHROPOITIN – signals gmarrow to produce red blood cellsActivate VITAMIN D – bone health

When kidneys no longer clean toxins and waste product from the blood and waste product from the blood and perform their functions to full capacity capacity . . .

Toxic Waste accumulates

ff ll

BONES

Toxic waste affecting all systems -

BONESSTONESABDOMINAL GROANSPSYCHIC MOANSFATIGUE OVERTONES

RESULT-RESULTCHEMICAL IMBALANCES

BONE CHANGESBONE CHANGESMUSCLE WEAKNESSGASTROINTESTINAL PROBLEMS

FLUID OVERLOAD↑BLOOD PRESSURE / HEART FAILURENAUSEA/ VOMITINGNAUSEA/ VOMITING

↓ RED CELL PRODUCTIONANEMIAFATIGUEFATIGUE

POOR NUTRITIONIMMUNO COMPROMISEIMMUNO COMPROMISE

#2

NUTRITION -NUTRITION

1992 – USDACENTER FOR NUTRITIONPOLICY AND PROMOTIONPOLICY AND PROMOTION

2005 Dietary Guidelines for Americansy

GRAINSVEGETABLESVEGETABLESFRUITSDAIRYMEAT AND BEANSOILS

DIETARY GUIDELINES with CKD?DIETARY GUIDELINES with CKD?

GRAINSVEGETABLESVEGETABLESFRUITSDAIRYMEAT AND BEANSOILS

DIETARY GUIDELINES AND CKDDIETARY GUIDELINES AND CKD

GRAINS – PHOSPHORUSGRAINS – PHOSPHORUSWHOLE GRAINS

VEGETABLES – PHOSPHORUSO O SPOTATOES

FRUITS – POTASSIUMAVOCADO, BANANAS,

DAIRY – POTASSIUM & PHOSPHORUSMILK, YOGURT

MEAT AND BEANS – POTASSIUM & MEAT AND BEANS – POTASSIUM & PHOSPHORUS

DRIED PEAS, NUTS, SEEDS, PROCESSED MEATSCHOCOLATE COLA CONTAIN BOTHCHOCOLATE, COLA – CONTAIN BOTH

J t h t d th h h CKD t?Just what do those who have CKD eat?

SUPPLEMENTAL MEDICATIONSSUPPLEMENTAL MEDICATIONS

PHOSPHATE BINDERSPHOSPHATE BINDERSERYTHROPOITINB VITAMINS AND FOLATEVITAMIN D

#3

PORTAL OF ENTRYPORTAL OF ENTRY

PREVENTIONPREVENTION

ORAL DISEASEORAL DISEASE

• CARIESTEETH CARIESTEETH

• PERIODONTAL DISEASESOFT TISSUE

• ALVEOLAR BONE LOSSBONES O O OSSBONES

ORAL DISEASEORAL DISEASE•CARIES•ENAMEL DEFECTS

TEETH •ENAMAL HYPOPLASIA•ENAMEL WEAR – ABRASION, ATTRITION AND EROSION

TEETH

•PERIODONTAL DISEASEMUCOSAL DISEASE

SOFT •MUCOSAL DISEASE•HERPES, CANDIDIASISTISSUE

•ALVEOLAR BONE LOSS•DYSTROPHIC CHANGESBONES •OSTEOPOROSIS, OSTEODYSTROPHYBONES

FORMULA FOR DENTAL CARIESFORMULA FOR DENTAL CARIES

TEETH

SUCROSESTEP MUTANS

STRATEGY FOR TREATMENT OF CARIES

CARIES REMOVALEXTRACTION VS. ENDODONTICS (ROOT CANAL)

AGGRESSIVE APPROACH TO ELIMINATE INFECTIONCARIES EXCAVATION AND RESTORATION

PREVENTIONFLUORIDE APPLICATIONDIET COUNSELING

CONCENTRATION ON ELIMINATION OF SUGARSSODAS, MINTS, LOZENGES, ADDED SUGARS

PATIENT EDUCATIONPATIENT EDUCATIONBRUSHING, FLOSSINGDAILY FLUORIDE APPLICATION @ HOME

PRESCRIPTION GELS AND PASTESPRESCRIPTION GELS AND PASTES

FORMULA FOR PERIODONTAL DISEASE

SOFT TISSUESSOFT TISSUES

ORAL FLUIDS

BACTERIAL FLUIDSTOXINS

STRATEGY FOR TREATMENT OF PERIODONTAL DISEASEPERIODONTAL DISEASE

EXTRACTION OF TEETH WITH POOR PROGNOSIS

PERIODONTAL THERAPY/ DEBRIDEMENTREMOVAL OF BACTERIAL DEBRISELIMINATION OF SOURCE OF INFECTION ABOVE AND BELOW THE GINGIVAL TISSUESFREQUENT RECALL EXAMS AND CLEANING

PATIENT EDUCATIONDISEASE EDUCATIONBRUSHING FLOSSINGBRUSHING, FLOSSINGUSE OF DISINFECTANT RINSES

SEVERE PERIODONTITISWITH FURCATION INVOLVEMENT NONRESTORABLE

CARIOUS TEETH

RENAL PATIENTRENAL PATIENT

CHEMICAL IMBALANCESCHEMICAL IMBALANCESBONE CHANGESMUSCLE WEAKNESSGASTROINTESTINAL PROBLEMSGASTROINTESTINAL PROBLEMS

FLUID OVERLOAD↑BLOOD PRESSURE / HEART FAILURENAUSEA/ VOMITING

↓ RED CELL PRODUCTIONANEMIAANEMIAFATIGUE

POOR NUTRITIONIMMUNO COMPROMISEIMMUNO COMPROMISE

PERIODONTAL DISEASE

IMMUNE

CARIES

IMMUNE COMPROMISE

INFECTIONINFECTION

CONSIDERATIONS FOR THOSE WITH KIDNEY DISEASE

Th J l f Cli i l P i d t l The Journal of Clinical Periodontology reported that

“ l i h kid di d . . . “people with kidney disease and those on dialysis are more likely to ha e pe iodontal disease and othe have periodontal disease and other oral health problems than the general population ” population.

Because people with kidney disease have weakened immune systems they are more weakened immune systems, they are more susceptible to infections.

The inflammation caused by periodontal disease is a risk factor for cardiovascular didisease.

CASE #1CASE #1

27 YEAR OLD AA FEMALE 27 YEAR OLD AA FEMALE PMH:

JUVENILE POLYSYSTIC KIDNEY DISEASE JUVENILE POLYSYSTIC KIDNEY DISEASE SEIZURE D/OHTNHTNASTHMAACID REFLUX

PE: BP 138/81 P 83 RAS

CASE #1CASE #1

ORAL FINDINGS:ORAL FINDINGS:GENERALIZED GINGIVAL ENLARGEMENTGENERALIZED GINGIVAL ERYTHEMAGENERALIZED GINGIVAL ERYTHEMAMILD TO MODERATE PLAQUE ACCUMULATIONGENERALIZED GINGIVAL BLEEDING WITH PROBINGGENERALIZED ENAMEL HYPOPLASIAGENERALIZED ENAMEL HYPOPLASIA

← GINGIVAL ENLARGEMENT

NORMAL

GINGIVAL ERYTHEMA

ENAMEL HYPOPLASIA

ENAMEL HYPOPLASIAENAMEL HYPOPLASIACHRONIC RENAL DISEASE IN THE FIRST YEAR OF LIFE IN THE FIRST YEAR OF LIFE IS ASSOCIATED WITH DEVELOPMENTAL DEFECTS OF ENAMELIN THE PERMANENT DENTITION

ENAMEL HYPOPLASIAENAMEL HYPOPLASIASTRIA CONINCIDE WITH TIME OF RENAL EPISODE

CASE #2CASE #2

54 YEAR OLD MALE54 YEAR OLD MALEESRD - 2° TYPE 1 DM / HTNHISTORY OF STROKE WITH R HISTORY OF STROKE WITH R HEMIPARESIS

CADCADHYPERCHOLESTEROLEMIAHYPOTHYROIDISMHYPOTHYROIDISMGLAUCOMA / RETINOPATHY

CASE #2CASE #2

ORAL FINDINGSORAL FINDINGS:EXTRAORAL: PALLOR WITH HYPERPIGMENTED SKIN HYPERPIGMENTED SKIN HAIRY TONGUEINTRAORAL:INTRAORAL:

GENERALIZED GINGIVAL RECESSIONSIGNIFICANT TOOTH WEAR DUE TO SIGNIFICANT TOOTH WEAR DUE TO ATTRITION, ABRASION, EROSIONMISSING TEETH

GINGIVAL RECESSION

HAIRY TONGUE

SIGNIFICANT LOSS OF ENAMELPALE ORAL TISSUES

CASE #3CASE #3

52 YEAR OLD AA FEMALE52 YEAR OLD AA FEMALEPMH:

ESRD ON HEMODIALYSISHTNDMCATARRACT L EYECATARRACT L EYEHX OF TRIPLE BYPASS WITH STENTHX OF GASTRIC ULCERSHYPOTHYROIDISMHYPOTHYROIDISMPERIPHERAL NEUROPATHYDEPRESSIONDVT L LEG

CASE #3CASE #3

ORAL FINDINGSORAL FINDINGS:EXTRAORAL – NO SWELLING APPARENT

SWELLING IN PAST ON L SIDESWELLING IN PAST ON L SIDE

INTRAORAL –UPPER DENTURE / NATURAL LOWER UPPER DENTURE / NATURAL LOWER TEETH IN POOR REPAIREVIDENCE OF PERIODONTAL DISEASEEVIDENCE OF CARIES

ROLLED GINGIVAL MARGINS RESULT OFPERIODONTAL INFECTION

TREATMENT:EXTRACTIONSPERIODONTAL SCALINGCARIES REMOVALUPPER DENTURE /LOWER PARTIALLOWER PARTIAL

CARIES

PERIAPICAL INFECTION

DENTAL MANAGEMENT CONSIDERATIONS

LABSLABSBLOOD PRESSURESBLOOD SUGARBLOOD SUGARPROPHYLACTIC ANTIBIOTIC COVERAGE

INFECTION IS A FREQUENT CAUSE OF MORBIDITY / MORTALITY IN PATIENTS RECEIVING / MORTALITY IN PATIENTS RECEIVING HEMODIALYSIS THERAPY

TREAT ON DAYS IN BETWEEN DIALYSISAGRESSIVELY ELIMINATE SOURCES OF INTRAORAL INFECTION

PERIODONTAL AND CARIOUSPERIODONTAL AND CARIOUS

CASE #4CASE #4

41 YEAR OLD CAUCASIAN FEMALE41 YEAR OLD CAUCASIAN FEMALEPMH:

HYPOPLASTIC KIDNEYS – TRANSPLANTHTNSTEROID INDUCED DMPARATHYROIDECTOMYBILATERAL HIP REPLACEMENT

CASE #4CASE #4

ORAL FINDINGSORAL FINDINGS:GENERALIZED INTRINSIC STAININGGENERALIZED ENAMEL HYPOPLASIAGENERALIZED ENAMEL HYPOPLASIALOCALIZED MILD GINGIVAL HYPERPLASIAHYPERPLASIASCALLOPING OF TONGUE

ENAMEL HYPOPLASIA

GINGIVAL HYPERPLASIA

RENAL OSTEODYSTROPHY

CASE #5CASE #5

43 YEAR OLD CAUCASIAN MALE43 YEAR OLD CAUCASIAN MALEESRD; TRANSPLANTED IN 1993TYPE 1 DMHTNCABG 2000HYPERCHOLESTEROLEMIAHYPERCHOLESTEROLEMIARETINOPATHY – R EYE ENUCLEATIONHX OF SKIN CANCER – MULTIPLE AREASLYMPHOMA OF COLON W/ RESECTION

1° DIAGNOSIS MADE WITH ORAL BIOPSY

IMMUNOSUPPRESSEDIMMUNOSUPPRESSED

CASE #5CASE #5

ORAL FINDINGS ORAL FINDINGS –LOCALIZED GINGIVAL ERYTHEMA SECONDARY TO CALCULUS SECONDARY TO CALCULUS ACCUMULATIONGENERALIZED SEVERE ENAMEL GENERALIZED SEVERE ENAMEL EROSIONRADIOGRAPHIC BONE LOSS

GINGIVAL RECESSIONGINGIVAL RECESSIONDUE TO BACTERIAL ACCUMULATION

SEVEREENAMEL EROSIONENAMEL EROSION

ENAMEL EROSIONENAMEL EROSION

SIGNIFICANT ISSUE RE: ORAL MORBIDITY-SIGNIFICANT ISSUE RE: ORAL MORBIDITYTOOTH LOSSSENSITIVITYVERTICAL DIMENSIONCARIES

AFFECTS >90% OF CKD PATIENTS

RELATED TO CHRONIC EMESISGERDGASTROPARESISGASTROPARESISNAUSEA RELATED TO DIALYSISCHEMICAL IMBALANCE

SEEMS NOT TO BE IMPROVED WITH MEDICATION

TREATMENT?TREATMENT?

ADDRESS NAUSEAADDRESS NAUSEASEEK TO DECREASE LOSS OF ENAMELENAMEL

DO NOT BRUSH RIGHT AFTER EPISODERINSE WITH BICARBONATE SOLUTION TO NEUTRALIZE ACID ENVIRONMENTDO NOT USE ABRASIVE TOOTHPASTESDO NOT USE ABRASIVE TOOTHPASTES

TARTAR CONTROLWHITENINGWHITENING

“. . . gnashing of teeth.”

h d h bl-Teeth are mentioned 41 times in the Bible “gnashing of teeth” 9 times in the New Testament

“Something is always going wrong with our teeth. They don't last anything like a lifetime, usually. y y g , yWhat chain of events in evolution should we thank for our mouthfuls of rotting crockery? “

- Kurt Vonnegut - Kurt Vonnegut,