Dialysis and Dental Management

CHRONIC RENAL FAILURE, DIALYSIS AND DENTAL MANAGEMENT

This brief summary is meant only as a quick reference to provide dental practitioners with an overview of end stage renal disease, dialysis and dental management. It is not intended to be an inclusive discussion of this topic and should, therefore, be supplemented by more in-depth reading on the subject.

General Description. End-stage renal disease (ESRD) is a bilateral, progressive, and chronic deterioration of nephrons that results in uremia and ultimately leads to death. The rate of destruction and the severity of disease depend on the underlying causative factors, which are often unknown.

Epidemiology. Approximately 1.3 in 10,000 population develop ESRD annually; this rate is increasing by about 10 per cent per year, most rapidly in patients over age 65.

Etiology and clinical presentation. Some of the more common known causes of ESRD are diabetes, hypertension, glomerulonephritis, polycystic kidney disease, and systemic lupus erythematosus.

Its manifestations are seen in the cardiovascular, gastrointestinal, neuromuscular, hematologic, and dermatologic systems. Cardiovascular manifestations include hypertension, congestive heart failure, pericarditis. Gastrointestinal signs include anorexia, nausea, vomiting, generalized gastroenteritis, peptic ulcer disease, stomatitis, and candidiasis can also occur.

Patients may:

show mental slowness or depression
demonstrate muscular hyperactivity
experience hemorrhagic episodes, especially in the gastrointestinal tract
display pallor of the skin and mucous membranes (due to anemia)
display hyperpigmentation of the skin caused by the retention of carotene-like pigments normally excreted by the kidney

Conservative care. Conservative care attempts to decrease the retention of nitrogenous waste products and control fluids and electrolyte imbalances by dietary modification (protein restriction) and by closely monitoring fluid, sodium, and potassium intake. Calcium and vitamin D supplements are also prescribed.

Nephrotoxic drugs or agents that are metabolized principally by the kidney are avoided.

Dialysis. As more and more nephrons are destroyed, medical management of ESRD becomes inadequate and artificial filtration of the blood is required in the form of peritoneal dialysis or hemodialysis. Most patients are maintained by hemodialysis. The technique requires the surgical creation of a permanent arteriovenous fistula that is readily accessible to cannulation with a large-gauge needle. The patient is "plugged in" to the hemodialysis machine at the fistula site, and blood is passed through the machine, filtered, and returned to the patient. Treatments usually require 3 to 5 hours, and are performed every 2 or 3 days, depending on need.

Although hemodialysis is a lifesaving technique, there are complications associated with it. The risk of hepatitis B and C and AIDS is significant because patients have usually had multiple blood exposures. Infection of the arteriovenous fistula is also an ongoing concern and can result in septicemia, septic emboli, infective endarteritis, or endocarditis. The procedure itself causes platelet destruction, thereby aggravating already existing bleeding tendencies.

DENTAL MANAGEMENT

Medical considerations for patients under conservative care. Before dental care is provided to a patient under conservative management of ESRD, the patient's physician should be consulted. A joint decision should then be made as to the setting (inpatient or outpatient) in which this care can safely be provided. If ESRD is well-controlled, there is generally no problem in providing outpatient care. When rendering this care:

Order pretreatment screening for bleeding disorders (bleeding time, platelet count, hematocrit, hemoglobin).
Monitor blood pressure.
Pay meticulous attention to good surgical technique.
Use universal infection control procedures.

Medical considerations for patients receiving dialysis. The recommendations for managing a patient receiving hemodialysis are the same as those for managing a patient under conservative care, with a few additional considerations:

The surgically created arteriovenous fistula is potentially susceptible to infection (endarteritis) resulting from a dentally induced bacteremia and is a source of infectious emboli that can cause endocarditis. While both conditions are of low incidence, the patient's managing physician should determine whether or not to administer prophylactic antibiotics.
Hemodialysis patients must avoid dental care on the day of dialysis, when they could have bleeding tendencies. The best time for dental treatment is the day after hemodialysis.

Oral complications.

Pallor of the oral mucosa secondary to anemia.
Diminished salivary flow, resulting in xerostomia and parotid infections.
Patients frequently complain of a metallic taste, and the saliva may have a characteristic ammonia-like odor due to a high urea content.
In severe renal failure, a stomatitis may be present.
Loss of lamina dura.
Demineralized bone.
Localized radiolucent jaw lesions.

Potential Drug Interactions.

Of special concern are drugs that are primarily excreted by the kidney or that are nephrotoxic (tetracycline, acyclovir, acetaminophen, aspirin, and NSAlDs).
Certain drugs are removed during hemodialysis and, therefore, require an additional dose to be administered after hemodialysis.

PRIMARY REFERENCE

Little JW, Falace DA. Dental Management of the Medically Compromised Patient. 4th ed. St Louis, MO: Mosby Year Book, Inc; 1993: 248-257.

ADDITIONAL REFERENCE

Golden A, Powell DE, Jennings CD. Pathology: Understanding Human Disease. 2nd ed. Baltimore: Williams 8 Wilkins; 1985.