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,