1996;127;211-219JADA SS De Rossi and M Glickrenal disease receiving hemodialysisDental considerations for the patient with

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U

D AL SIDEIOI r

PATIENTWVITH RENAL DISEASE

RECEIVING HEMODIALYSISSCOTT S. DE ROSSI, D.M.D.; MICHAEL GLICK, D.M.D.

Os technology and medicinea vance, dentists increasinglywill be asked to treat patientswith complex medical condi-tions.1 Among these is end-stagerenal disease, or ESRD. It is be-lieved that about 8 million peo-ple in the United States are af-fected by some type of kidneydisease; the number of patientswho received treatment forESRD is estimated to be close to260,000 in 1995, while morethan 47,000 die annually ofchronic, progressive, irrevers-ible kidney failure.2 Patientsafflicted by this medical condi-tion can visit a general dentist'soffice with a number of poten-tial problems that can affecttheir oral health care. Particu-larly, there are concerns withexcessive bleeding, hyperten-sion, anemia, drug intoleranceand synergism, increased sus-ceptibility to infection and vari-ous oral manifestations associ-ated with the disease itself andwith hemodialysis treatment.Protocols for the dental man-agement of these patients havebeen suggested; however, ad-vances in our understanding of

An increasing number of Ameri-

cans are living with end-stage

renal disease. This disease has

many implications for dentistry, in

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

renal disease, from the onset of

renal impairment through

hemodialysis.

renal disease and its sequelaenecessitate an updated ap-proach. In this article, we dis-cuss the basis for the dentalpractitioner's management con-siderations and propose a newtreatment protocol.

ETIOLOGY AND PATHO-PHYSIOLOGY

ESRD is a chronic, progressivedisease that is characterized bythe destruction of nephrons, the

kidney's functional unit.'4 Dia-betes, pyelonephritis, glomeru-lonephritis, nephrosclerosis,polycystic kidney disease andcollagen vascular disease areamong the leading causes ofthis destruction.37 It is impor-tant to ascertain if an underly-ing disease is present since sucha disease, in itself, may influ-ence dental management.

The nephron consists of aglomerulus (filtering funnel)and tubule. The estimated 1million nephrons per kidneyhelp filter waste from the blood,modulate the excretion of saltsand water from the body andallow the kidney to perform itsexcretory, metabolic and en-docrine functions.34 Once de-stroyed, the nephrons do not re-generate. However, the kidneyattempts to compensate via hy-pertrophy of the remainingfunctional nephrons; normalrenal function is maintaineduntil approximately half of thenephrons are destroyed. At thispoint, the kidney's compensa-tory mechanisms are over-whelmed, and signs and symp-toms of renal failure begin to

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TABLE I

LABORATORY COMPONENT NORMAL LABORATORY RANGE SYMPTOMATIC R NAL FILURE

Glomerular filtration rate* 100-150 ml-/min. <10 mi./min.

Creatinine cleaance 85-1256 iLmin. (female) 10-50 mL/min. ( date

97-140 mL/min. (male) <10 mL/min. (severe renal

Seruxm creatinine 0.6-1.20 mg/dL >15 mg/dL

Blood urea itrogen 8-18 mg/dL 0 mg/dL

Serum calcium 8.5-10.5 mg/d1L Depressed

Serumfp ph f2evated

Serum potassiuxm 3.8-5 mmEq/fL Elevated

* Most nephrologists use creatinine clearance to assess glomerular filtration rate. Thus, GFR values are not always readily available.

manifest themselves.3'4'6As a gradual and progressive

process, renal failure can be de-scribed in successive laboratoryand clinical stages (Table 1).Diminished renal reserve.

This represents decreased kid-ney function without clinicalmanifestations or symptoms. Infact, a lower creatinine clear-ance is often the only observ-able change. Creatinine is apoorly metabolized breakdownproduct of muscle; daily produc-tion is proportional to musclemass and is constant for a givenindividual. Since creatinine inthe urine derives primarilyfrom that filtered by the glom-erulus, it is a good indicator ofglomerular function.3 8 A creati-nine clearance test assesses kid-ney function by comparing theamount of creatinine in theblood with the amount excretedin the urine over a 24-hour peri-od. As the nephron populationcontinually declines, the glom-erular filtration rate also de-clines, while the blood urea ni-trogen, or BUN, level rises.378These changes reflect the kid-

neys' decreased ability to filterand excrete certain toxic sub-stances from the bloodstream.Renal insufficiency. Kid-

ney function is mildly to moder-ately diminished, resulting insymptomatic evidence of renalfailure; there is evidence of im-paired ability to maintain theinternal environment, includingmild accumulation of nitrogenproducts in the blood, decreasedability to concentrate the urineand mild anemia.Renal failure. Kidney func-

tion has deteriorated to thepoint of chronic abnormalitiesin the internal environment, in-cluding azotemia, metabolic aci-dosis, hypocalcemia and hyper-phosphatemia as well asisosthenuria and nocturia.Uremic syndrome. This

represents a number of clinicalsigns and symptoms that ap-pear in the individual with re-nal failure (Figure 1). Uremicsyndrome primarily results fromthe retention and accumulationof excretory products and the di-minished endocrine and metabol-ic functions of the kidney.

Many of these systemic signsof renal failure and uremia canbe important to the dental prac-titioner, particularly hemato-logic changes, changes in bonemetabolism and alterations inimmune status.9'-'

MEDICAL MANAGEMENTOF TIHE PATIENT WITHRENAL FAILURE

With chronic renal failure,many of the gradual and pro-gressive changes are correctedby treatments ranging from di-etary changes to renal replace-ment.34 With mild and earlyrenal insufficiency, conservativetherapy such as alterations indiet can minimize the effects ofkidney failure and perhaps slowdisease progression."2'1' Patientsoften receive sodium bicarbon-ate to reduce acidosis, vitaminD supplements to treat hypocal-cemia and high carbohydrate/low protein diets to minimizethe toxic nitrogenous productsproduced by the metabolism ofprotein.'2", With advanced dis-ease, such as renal failure,greater measures such as dialy-

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sis must be taken. Dialysis is anartificial means of removing ni-trogenous and other toxic prod-ucts of metabolism from theblood. For many patients, dialy-sis is a life-saving interventionthat has significantly reducedthe mortality of this once-fataldisease.

There are two types of dialy-sis: peritoneal and hemodialy-sis. In peritoneal dialysis, ac-cess to the body is achieved viaa catheter through the abdomi-nal wall into the peritoneum. Adialysate from a bag attached tothe catheter passes into the cav-ity, where the peritoneal mem-brane serves to filter out wastefrom the local vessels. This pro-cess, often called continuousambulatory peritoneal dialysis,or CAPD, or continuous cyclicperitoneal dialysis, or CCPD, isa slower process than hemodi-alysis and is less often used forlong-term treatment.3'4"4 How-ever, peritoneal dialysis offerspatients greater mobility be-cause they are not dependent oncumbersome machines, and it isbecoming more common, consti-tuting approximately 20 percentof all dialysis therapy.2'4"14

Arteriovenous shunts and fis-tulas are commonly used to ac-cess the patient's bloodstreamin hemodialysis.4"4 The artificialkidney, known as the dialyzer,contains semipermeable mem-branes that allow the passage ofexcess fluid and wastes. Duringtreatments, patients are givenanticoagulants in the form of re-gional or systemic heparin to fa-cilitate blood exchange and tomaintain access patency.4"4 A1l-though hemodialysis is impor-tant in fluid and electrolyte bal-ance, in addition to bloodfiltering, these treatments donot provide the same degree ofhealth as normally functioning

Oastrointestlnal Nausea, vomiting, anorexia, am-monia taste arnd breath, stomati-tis, parotites, esophagtis, gastri-

_________________ tis, gastrointestinal bleeding

Neuromuscular Headaches, peripheral neuropa-thy, paralysisB, myoclonic jerks,seizure, asterixis

Hemetlogic-0 V0 Norxncytic-normochromic ane-Immunolog1c mia,m coagulation deect, increased

usceptibibty Xto infecton, de-creassed erythr it production,ymp

Endocrine- Rexnal osteodystrophy (osteomala-metabolic cia, osteoporosis, osteosclerosis),

secondary hyperparathyroidism,impaired growth/development,loss of libido and sexual fuinction,amenorrhea

Cerd4iovascuar A l hyprtension, congestive-heartfailure, caiomyopathy,pericarditis, arrhythmias

Dermatologic Pallor, hyperpigmentation, ecchy-mosis, uremic frost, pruritis,reddish-brown nail beds

Figure 1. Systemic manifestations of renal failureluremia.

kidneys. Recent data from theU.S. Renal Data System esti-mate that in 1995, 188,000 peo-ple underwent dialysis treat-ments, including at least 155,000people undergoing hemodialysis.'Patients undergoing hemodialy-sis receive these treatments inoutpatient centers for approxi-mately three to four hours a day,three times per week.

Today, renal transplantationis the treatment of choice forpatients with irreversible kid-ney failure. However, the use oftransplantation is limited to theavailability of organs. Trans-plantations are being performedwith increasing success; approx-imately 70,000 transplant pa-tients are alive today, with afive-year renal survival rate ofmore than 60 percent.12 Thedental management of patientswho have undergone transplan-tation is beyond the scope ofthis article.

ORAL MANIFESTATIONS

Several changes occur in the

oral cavity that are associatedwith chronic renal failure anduremia. Researchers estimatethat up to 90 percent of renalpatients will show oral symp-toms.7 With renal insufficiencyand uremia, patients may com-plain of a bad odor and metallictaste in the mouth. This is dueto the high urea content in sa-liva and its subsequent break-down to ammonia. Patients alsocomplain of dry mouth andoften are prone to retrogradeparotitis; these complicationsare believed to result from acombination of direct glandinvolvement, chemical inflam-mation, dehydration and mouthbreathing.'0 Perhaps the mostcommon oral finding is pallor ofthe mucosa secondary to theanemia commonly seen in pa-tients with renal failure who areundergoing hemodialysis.'0"15,'6

Uremic stomatitis is often aclinical finding in cases of ad-vanced disease. There are twoforms of this stomatitis; often,they correspond with an acute

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rise in BUN levels. The erythe-mopultaceous form is character-ized by red, burning mucosacovered with a gray exudateand pseudomembrane; theulcerative form is characterizedby frank ulceration with red-ness and a pultaceous cover-ing.11"16-18 The exact etiology ofuremic stomatitis remains un-known, but it is suspected to bea chemicallike burn or a loss ofthe tissue's resistance to normaland/or traumatic influences.These lesions are commonlypainful and most often appearon the ventral tongue and ante-rior mucosal surfaces. These le-sions usually heal spontaneously,with resolution of the underlyinguremia and lowering ofBUNlevels.7",8

White patches often associat-ed with the skin, called "uremicfrost," can occasionally be seenintraorally. This uremic frostresults from remaining ureacrystals left on epithelial sur-faces following perspiration andsaliva evaporation.'8 Sincethese patients often requirehigh-carbohydrate and low-pro-tein diets to minimize the nitro-gen products produced by themetabolism of protein, severecaries would be expected. How-ever, the caries index is oftennoticeably lower in these pa-tients. This low caries rate isattributed to the inhibition ofplaque and bacteria by higherlevels of salivary urea.9"16" 9 Thisfinding is most apparent in chil-dren, despite their high sugarintake and less-than-adequateoral hygiene. Also, somepatients may have severe ero-sion of the dentition due to fre-quent regurgitation, resultingfrom the nausea associated withhemodialysis treatments.9

Other oral manifestations ofrenal disease are related to

renal osteodystrophy. Thesemanifestations become appar-ent in late-stage disease, evenwith dialysis treatments.20 Meta-bolic renal osteodystrophy re-sults from disorders in calciumand phosphorus metabolism,abnormal vitamin D metabo-lism and increased parathyroidactivity. Calcium absorption inthe intestines is diminishedearly in renal failure becausethe kidneys cannot convert vita-min D to its active form. Thereis also a corresponding reten-tion of phosphate, which ulti-mately leads to decreased se-rum calcium levels. This isassociated with compensatoryhyperactivity of the parathyroidglands, leading to increased uri-nary excretion of phosphates,decreased urine calcium excre-tion and exaggerated release ofcalcium from bone.20-22

The manifestations of meta-bolic renal osteodystrophy andcompensatory hyperparathy-roidism of the mandible andmaxilla include bone demineral-ization, decreased trabecula-tion, "ground-glass" appear-ance, loss of lamina dura, radio-lucent giant cell lesions andmetastatic soft-tissue calcifica-tions.1"916"19-21 In addition, withsuch bone loss, it is not uncom-mon for patients to have spon-taneous fractures of the jawsfrom trauma as well as to be atrisk of fracture during oral andperiodontal surgical procedures.

Other dental findings in re-nal osteodystrophy includetooth mobility, malocclusion,enamel hypoplasia and pulpstones. Tooth mobility and drift-ing have been documented insuch patients without appreci-able pathological periodontaldefects.2' Enamel hypoplasia inthe form of white or brown dis-coloration is commonly seen in

those patients whose renal dis-ease began at a young age. Infact, the hypoplastic areas onpermanent teeth often corre-spond to the age at onset of ad-vanced renal failure.9"2' Abnor-mal bone healing followingdental extractions has been re-ported2'; radiographically, thismanifests as a failure of thelamina dura to resorb and thedeposition of sclerotic bonearound the socket. The litera-ture has also documented pul-pal narrowing and calcificationas well as delayed or alterederuption.9,'6""92'

It is important to recognizethat with the increased avail-ability and use of dialysis, andultimately renal transplanta-tion, many of the oral manifes-tations of renal failure and ure-mia are less commonly seen.However, since signs and symp-toms of renal disease can beseen intraorally, the dentist, ifaware of these problems, canplay an important role in the di-agnosis, overall health andtreatment of the patient.

DENTAL MANAGEMENTCONSIDERATIONS

Patients with uremia and renalfailure who are undergoinghemodialysis require specialconsideration, most importantlywith regard to risk of excessivebleeding, risk of infection andmedications used (Figure 2). Pa-tients with CAPD do not poseany contraindications to dentaltreatment other than in cases ofacute peritoneal infections;therefore, this article will focuson the treatment of patients re-ceiving hemodialysis.

Hematologic conditions thatmost commonly affect the pa-tient with uremia and renalfailure are excessive bleeding

4,15,23,24 -and anemia.' Bleeding ten

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dencies in these patients are at-tributed to a combination of fac-tors, including anticoagulantsused with hemodialysis therapyand vascular access mainte-nance.4'2324 Mechanical traumato platelets during dialysistreatments can reduce the totalplatelet number up to 17 per-cent in some cases, althoughthis alone is not clinically sig-nificant.4'23'25 Often, these pa-tients have reduced plateletcounts, decreased platelet adhe-siveness, increased prostacyclinactivity, decreased availabilityof platelet factor 3 and in-creased capillary fragility, all ofwhich can lead to increased lossof blood.2326

The increased hemorrhagictendency in uremia can be exac-erbated by anemia. It is be-lieved that low hematocrit lev-els commonly found in uremicpatients negatively influencethe rheological component ofplatelet-vessel-wall interac-tion.427 Gingival hemorrhages,ulcerations and petechial andecchymosislike lesions are oftenreported in these patients andare commonly seen intraorally.26Peritoneal dialysis and hemo-dialysis correct many of thehematologic dysfunctions asso-ciated with uremia and renalfailure.

Carl and Wood17 suggestedthat patients receive dentaltreatment just before undergo-ing hemodialysis since they arefree of anticoagulants at thattime and at decreased risk ofbleeding. However, since hep-arinization during dialysistreatment does not usually pro-duce clinically significant resid-ual bleeding and the effects ofheparin only last approximatelythree to four hours after infu-sion, the risk of excessive bleed-ing because of anticoagulation

Before treatment

~ Consult with patient's nephrologist for recent coagula-tion vralues and to discLuss administration of antibiotic pro-phylaxis

~ E-valuate patient for hypertension and/or hypotension- A-void use of the arm with vascular access for injectionof medication and/or use of blood pressuxre cuff

~ Determine uinderlying caLuses of renal failuzre (for exam-ple, diabetes cana affect provrision of care)- Havre a complete blood cell couint performed to evaluatepatient for anremia; record skin bleeding time- If inadicated, institute appropriate hemostatic agents,sLuch as desmopressin acetate or conLjugated estrogen- Determine presence of uiremic symptoms (fatigability,nausea, vomiting, lethargy, pruritis)- Obtain dental radiographs to determine manifestationsof osteodystrophy~ Determine the type of vascLular access

- Determine the time of dialysis (dialysis cycle); dentaltreatment is indicated on the day after dialysis

~ Have roLutine hepatitis B s-urface antigen testing per-formed; tests should inclLude liver fuinction tests, pro-thrombin time and partial thromboplastin time in cases ofliver damage- Consider antibiotic prophylaxis

~ Consider anti-anxiety, sedative premedication for hy-pertensivre patients

During treatment

~ Perform thorouigh initraoral examinatiorn for presernce oforal manifestations-Aggressively eliminate all intraoral souirces of infection

Use adjunctivre hemostatic aids for oral and periodontalsurgeries

~ Place patient in comfortable, noncramped position- Allow the patient to walk or stand occasionally duringlong procedures

After treatment

Use post-procedural hemostatic agernts~ Encourage good oral home care- Instituite therapy for xerostomia if indicated- Use postoperative antibiotics for patiernts iundergoinigseverely traumatic procedures

~ Avroid uise of respiratory depressant drugs irn patientswith severe anremia

~ Adjuist dosages of medications according to the extent ofrenal impairment

Figure 2. Dental evaluation and management of patients receivinghemodialysis.

is minimal.414"427'28 A case reportby Buckley and colleaguesshows that postoperative bleed-ing following oral surgical pro-cedures in these patients ismost often related to qualitative

and quantitative changes inplatelets, rather than to hep-arinization.26 Also, a plateletcount and a complete blood cellcount can serve as importantparameters for the dental prac-

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titioner with regard to manag-ing bleeding and anemic condi-tions.23 Adjunctive hemostaticmeasures should be used as

often as possible in at-risk pa-

tients. A synthetic analogue ofthe anti-diuretic hormone vaso-

pressin, 1-deamino-8-D-argi-nine vasopressin, has been sug-

gested in the management ofsevere bleeding in patients withrenal failure, boosting the coag-

ulant effects ofvon Willebrand'sfactor and resulting in de-creased bleeding times for up tofour hours.23'28

Conjugated estrogen can beused for long-term hemostasis,with effects lasting up to twoweeks.29 Tranexamic acid, ananti-fibrinolytic in the form of amouthrinse, has been shown tosignificantly reduce operativeand postoperative bleeding.303'In addition, meticulous surgicaltechnique; good primary closure;and local hemostatic aids, suchas microfibrillar collagen andoxidized regenerated cellulose,help to reduce bleeding asso-

ciated with oral surgery andperiodontal procedures andshould be used as frequently as

possible.'0'26'32Because of anemia, respira-

tory depressant drugs such as

narcotics should be used withcaution.

The risk of infection is also a

concern with uremic patients inrenal failure.33 Primarily, al-tered cellular immunity in chro-nic systemic uremia along withmalnutrition resulting fromprotein-restricted diets lead toan immunodeficient state.27336Patients are more susceptible tobacterial infection because oftheir protein malnutrition,which leads to a diminished abil-ity to produce antibodies.27'34'35

Both oral diseases and dentalmanipulation create bacterem-

ias that may lead to significantmorbidity and potential mortal-ity in patients with renal failureand those receiving dialysis.'10"637Periodontal disease, endodonti-cally involved teeth, oral ulcersand dental procedures all canserve as a means of entry formicroorganisms into the blood-stream. Therefore, it is vitalthat every effort be made toeliminate oral sources of infec-tion. Good home oral care, fre-quent and aggressive oralhealth maintenance and regular

IInfection is a frquent

cause of morbidity andmortality in patientsreceving hemodialysistherapy.

use of anti-fungal and antimi-crobial mouthrinses are effec-tive means to reduce the risk ofdentally induced infections inthese patients.9"6'3739

Infectious endocarditis is nota rare complication in regularlydialyzed patients; it occurs in2.7 percent of patients duringmaintenance hemodialysis andin 9 percent of those who havean infection of a vascular access

site.404' With this increased risk,there has been some discussionin the literature about the needfor antimicrobial coverage fordental procedures to reduce thechance of septicemia and endo-carditis.37 Researchers thoughtthat patients undergoing dialy-sis were at risk of endarteritisfrom dentally induced bactere-mias that can be a source of in-fectious emboli leading to endo-carditis.9"6'37 These patientscommonly have vascular access-es for hemodialysis in the formof external cannulas or arterio-venous fistulas and shunts.4"4

However, more recent evidencesuggests a host of factors thatcan potentially lead to endo-carditis in these patients.41Overall, infection is a frequentcause of morbidity and mortal-ity in patients receiving hemo-dialysis therapy.'1535 Mortalityassociated with infective endo-carditis is very high-45 per-

cent. Streptococcus viridans ac-

counts for 17 percent of cases ofinfective endocarditis in patientswith chronic renal failure.4'

According to Manton andMidda, patients with arterio-venous shunts are at greaterrisk of infection following dentalmanipulation than patientswith cannula and fistula access

sites.42 The authors recommendantibiotic coverage for patientswith shunts who undergo inva-sive dental procedures.42 Naylorand colleagues also suggestedantimicrobial premedication forpatients undergoing dental pro-

cedures that induce mucosalbleeding to prevent vascular ac-

cess infections, bacteremia andinfective endocarditis.37

It is clear that patients withchronic renal failure who re-

ceive hemodialysis have an in-creased susceptibility to the de-velopment of infective endo-carditis. This infection morecommonly affects abnormal car-

diac valves; however, there is ahigh incidence of infective endo-carditis in patients receivingdialysis who have no evidence ofpreexisting cardiac valve dam-age.40 Manton and Midda specu-lated that changes in fluid vol-ume and hemodialysis itselfaffect heart behavior, creating"mechanical stresses" that mayplay a role in the developmentof infective endocarditis.42 Thus,antibiotic prophylaxis prior todental care needs to focus on

preventing infective endocardi-

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tis. The American Heart Associ-ation's protocol for prevention ofinfective endocarditis should beused, but modified according tothe severity of renal failure(Figure 3).43 The drug of choiceis vancomycin infused during

dialysis. Because of the renalimpairment, this antibiotic willprotect the patient for up toseven days.40"' However, insur-ance reimbursement for van-comycin prophylaxis for dentalprocedures may not be avail-able, thus limiting the patient'saccess to this therapy.

Because of changes in fluidvolume, salt retention and thepresence of shunts and fistulas,patients commonly are affectedby certain cardiovascular condi-tions. Specifically, congestiveheart failure and pulmonary hy-pertension can be seen in pa-

tients with renal failure.3'4,14415Often, hypertension in patientswith renal disease leads to ath-erosclerosis, with significantcerebral, coronary and periph-eral vascular effects.'5 Althoughpatients are often treated withantihypertensive medications,deiitists should take precau-tions to avoid excessive stress inthe dental chair that could ele-vate systolic pressure.16 Den-tists should monitor blood pres-

sure before and during treat-ment as well as administer seda-tive premedication to reduceanxiety in patients with renalfailure who receive dialysis.'6'32Many patients receive anti-

hypertensive medications, in-cluding nifedipine, a calciumchannel blocker known to in-duce gingival hyperplasia. Con-versely, hypotension resultingfrom fluid depletion and adre-nal insufficiency is a commonside effect and complication ofhemodialysis treatment, occur-

ring in 20 to 30 percent of dialy-

Figure 3. Suggested changes for bacterial endocarditis prophylaxisfor patients receiving hemodialysis.

IElective dental proce-dures should be per-

formed on the dayafter dialysis treat-ment when the pa-tient is best able totolerate treatment.

sis sessions.'4 However, not allof the complications are benign;stroke, angina, myocardial in-farction and arrhythmias havebeen documented as possibleside effects of dialysis-inducedhypotension.4 Therefore, elec-tive dental procedures shouldbe performed on the day afterdialysis treatment when the pa-tient is best able to toleratetreatment.

Apart from serving as a po-

tential site for infection, arterio-venous access sites must not bejeopardized; blood pressuremonitoring is prudent, but theaffected arm should never beused for the intravenous or

intramuscular injection of anymedications, nor should the cir-culation be impeded by a bloodpressure cuff.4"14 In addition, pa-

tients should not be kept incramped positions in the dentalchair and should be allowed tostand or walk occasionally tominimize the risk of access ob-struction."6

Because patients undergoingdialysis are exposed to a largenumber of transfusions andblood exchanges, as well as

renal failure-related immuno-suppression, the literature sug-

gests that they are at greaterrisk of hepatotropic viral infec-tions such as hepatitis B and C,tuberculosis and human im-munodeficiency virus.45 Thesepatients should be encouragedto undergo periodic testing forhepatitis infectivity'6 and HIVantibody.46'47 For patients withliver damage, the dentist shouldevaluate the results of liverfunction tests and potentialbleeding tests (that is, pro-

thrombin time, partial thrombo-plastin time) before extractingteeth and performing periodon-tal surgery. The incidence of tu-berculosis in patients withrenal disease has been reportedto be up to 10 times greaterthan that in the general popula-tion.48 This increased incidenceis probably a result of dimin-ished cellular immunity in pa-

tients with chronic renal fail-ure.39 However, extrapulmonarytuberculosis was seen in themajority of cases, and thereforeit does not represent a trans-mission risk via aerosolizeddroplets in a dental setting.

Pharmacotherapeutics repre-

sent a final consideration forpatients with renal disease whoreceive dialysis. Most drugs are

JADA, Vol. 127, February 1996 217

- Vancomycin (1.0 g) infused over one hour during dialy-sis the day before dental treatment- Amoxicillin (3.0 g per moutth) one hour before the den-tal procedure; a second dose is not n-eeded- Erythromycin ethylsuccinate (800 mg) or erythromycinstearate (1.0 g by mouth) two hours before the dental pro-cedure, then one-half the dose six hours after the initialdose- Clindamycin (300 mg by mouth) one hour before thedental procedure, then 150 mg six hours after the initialdose

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at least partially excreted viathe kidney; therefore, dimin-ished renal function alters thedrug volume of distribution,metabolism, rate of eliminationand bioavailability.344950 Theplasma half-lives of agents elim-inated in the urine are oftengreatly prolonged in patientswith renal failure and effective-ly reduced by dialysis. Evenwith those drugs metabolized bythe liver, the renal failure to ex-crete metabolites can lead to in-creased incidence of toxicity.51

Prescribing medications forpatients with renal failure whoare undergoing hemodialysisposes a challenge to dentists.The therapeutic regimen mustbe maintained within a narrowrange, avoiding toxicity at oneend and sub-therapeutic dosingat the other.4 Some drugs arenephrotoxic in themselves, andthe added strain these drugsplace on already damaged kid-neys must be avoided. A 50 per-cent drop in creatinine clear-ance theoretically represents a

twofold increase* in the elimination

half-life of a drugremoved from the

ILIIRSm C-; body solely viarenal excretion.For drugs only

9-12?0g, , partially elimi-612is00 00E nated by the kid-12-24 ney, the change in*E S R; plasma half-lives

12-16; should be corre-oid Xle spondinglyery 0 less.51,52 Dentists

can avoid the ex-cessive accumula-

*oid use tion of drugs inoiUdf- Ch patients with

renal failure pri-marily by length-ening the interval

4 S 0- nCSbetweendoses ac-

4i ,'', cording to the de-4-6 00 0_F gree of elimina-4 tion impairment.

Table 2 lists dose777it: intervals for some

8-1fff0t 0-0 of the drugs com-8ff- Xt---;s monly prescribed

in dentistry.8-12 Xv CONCLUSION

The goal of dentaltreatment in pa-

6 g 0 0tients with renal9S-12:0SP;S.12 disease should be

the early and fre-quent evaluation

of the oral cavity for the sourceof infection. Early detection oforal pathologies will permitswift correction with minimalneed for extensive dental treat-ment. Strong preventive mea-sures also can minimize theneed for extensive dental care.The dentist must be aware ofthe ramifications of renal dis-ease (including its underlyingcauses) and hemodialysis ondental treatment. Specifically,the dentist must consider bleed-ing tendency, risk of infection

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CLINICAL PRACTICE

and medications before treatingthe patient. Clearly, this sys-temic disease has consequencesthat affect the oral cavity inmore ways than just the loss offunction, esthetics and comfort.The renal patient's dental prob-lems can compromise his or hergeneral health and hinder med-ical management. Therefore,the dentist is a pivotal providerin the overall health care of pa-tients with this disease. .

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Fitzrandolph FL. The radiographic spectrumof renal osteodystrophy. Am Fam Phys1991;43:151-8.21. Carl W. Chronic renal disease and hy-

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RD, Thaler MS. Renal disease. In: Medicine.3rd ed. Philadelphia: Lippincott; 1991:159-92.23. Rabelink TJ, Zwaginga JJ, Koomans

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Saini J, Demas PN,Braun TW. Manage-

Dr. De Rossi was a

senior dental stu-

dent at the time thisarticle was pre-

pared. He is cur-

rently an oral

medicine resident,University of Penn-

sylvania School of

Dental Medicine,Philadelphia.

Dr. Glick is the di-rector, Infectious

Disease Program,and associate pro-

fessor, Departmentof Oral Medicine,University of Penn-

sylvania School of

Dental Medicine,4001 Spruce St.,Philadelphia, Pa.

19104. Address

reprint requests to

Dr. Glick.

ment of the oral and maxillofacial surgery pa-tient with end-stage renal disease. J OralMaxillofac Surg 1992;50:1207-12.

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dence and type of infections occurring in 445chronic hemodialysis patients. Trans Am SocArtif Intern Organs 1977;23:41-7.

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for the medically compromised patient. J OralMed 1984;39:152-6.

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carditis in chronic renal failure. In: The heartand renal disease. New York: Churchill Liv-ingstone; 1984:189-208.42. Manton SL, Midda M. Renal failure and

the dental patient: a cautionary tale. Br DentJ 1986;160:388-90.

43. Dajani AS, Bisno AL, Chung KJ, et al.Prevention of bacterial endocarditis: recom-mendations by the American Heart Associa-tion. JAMA 1990;264:2919-22.

44. Tobin M, Montes M, Mookerjee BK. En-docarditis in haemodialysis patients with sys-temic disease. J Dial 1978;2:75-84.

45. Pol S. Hepatitis C virus infection inhemodialyzed patients and kidney allograftrecipients. Adv Nephrol 1995;24:315-30.

46. Reiser IW, Shapiro WB, Porush JG. Theincidence and epidemiology of human immun-odeficency virus infection in 320 patientstreated in an inner-city hemodialysis center.Am J Kidney Dis 1990;16:26-31.

47. Baltimore-Boston Collaborative StudyGroup. Human immunodeficiency virus infec-tion in hemodialysis patients. Arch InternMed 1988;148:617-9.48. Mitwalli A. Tuberculosis in patients on

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tibiotics, pharmacokinetics, and dose adjust-ments in acute and chronic renal failure. MedClin North Am 1990;4:1059-73.51. Perneger TV, Whelton PK, Klag MJ.

Risk of kidney failure associated with the useof acetaminophen, aspirin, and nonsteroidalantiinflammatory drugs. N Engl J Med1994;331: 1675-9.52. Neidle EA, Yagiela JA, eds. Pharmacolo-

gy and therapeutics for dentistry. 3rd ed. St.Louis: Mosby-Year Book; 1989:5-71.

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