The periodontal problems and management of the renal transplant patient

Oral Health in Children with Chronic Kidney Disease, Hemodialysis, and Renal Transplantation: A Comprehensive Narrative Review of the Oral Manifestations and Dental Implications

Chronic kidney disease (CKD) in children presents multifaceted challenges, impacting various aspects of health, including oral health. This narrative review provides a comprehensive synthesis of literature focusing on the oral health status of pediatric CKD patients, encompassing oral manifestations, dental considerations, and management challenges associated with hemodialysis and kidney transplantation. A comprehensive search strategy was employed, utilizing databases such as PubMed, Scopus, Web of Science, and Google Scholar, to identify relevant literature on oral manifestations in children with CKD, including those undergoing hemodialysis or renal transplantation. Search terms were carefully selected to capture studies examining enamel hypoplasia, dental caries, delayed tooth eruption, gingival diseases, periodontal diseases, radiographic alterations, craniofacial development, dry mouth, and changes in the oral mucosa. Our narrative review meticulously selected articles through a systematic process. Ultimately, 12 studies meeting the inclusion criteria were included in the review. Relevant data from each included study were independently extracted and synthesized, focusing on oral manifestations and their implications in pediatric CKD patients. The synthesized findings were organized and presented in a structured manner within the review article, considering their clinical implications and informing recommendations for dental management of children with CKD. This article highlights the importance of a coordinated effort between nephrologists, dentists, and other healthcare professionals in providing holistic care for pediatric CKD patients. A comprehensive understanding of the oral health status of these children, along with proactive dental management strategies, contributes to improved overall health outcomes and a better quality of life. This review aims to serve as a valuable resource for the oral healthcare providers involved in the care of pediatric CKD patients.

Effect of end-stage renal disease on oral health in patients undergoing renal dialysis: A cross-sectional study

Aims and Objectives:

To evaluate the effect of chronic renal failure on oral health in renal dialysis patients. To assess and improvise awareness of staff regarding oral health care of the patients in hemodialysis unit.

Materials and Methods:

A cross-sectional questionnaire survey and oral health examination study were conducted on 206 end-stage chronic renal failure patients (stage V) who were undergoing renal dialysis in Guntur city. The study included the questionnaire form and modified WHO proforma to record their oral health status. Oral examination was done in American Dental Association (ADA) type III method by using mouth mirror and community periodontal index (CPI) probe. Questionnaire survey was conducted among the nursing staff in the hemodialysis unit.

Results:

Mean age of the study subjects was 46.79 ± 12.78 years; 81.1% were males and 18.9% were females. Candidiasis (8.3%) was the most frequently seen oral mucosal condition in these subjects. Majority of the subjects (44.2%) showed periodontal diseases (CPI score 3: Pocket depth of 4-5 mm). Caries prevalence of 56.3% was seen in this study group. Higher incidence of hepatitis C was significantly associated with higher duration of dialysis. There was very little awareness among the nursing staff regarding dental care.

Conclusion:

There is greater deterioration of periodontal health among dialysis patients with chronic renal disease. Awareness regarding dental care is very less among patients undergoing renal dialysis. These patients should be monitored carefully to maintain their oral health. Awareness must be increased among dialysis patients and nursing staff about the need for primary prevention of dental diseases.

Oral and salivary changes in patients with end stage renal disease (ESRD): a two year follow-up study

OBJECTIVES

To compare oral health, salivary flow rate, xerostomia and thirst in end stage renal disease (ESRD) patients remaining on dialysis treatment and after renal transplantation.

DESIGN

Longitudinal observation.

SETTING

ESRD patients recruited from dialysis centres in Amsterdam, The Hague and Utrecht, The Netherlands.

METHOD

At baseline and after two years, salivary flow rates, xerostomia and thirst were determined in 43 ESRD patients. The number of decayed missing filled teeth/surfaces (DMFT/DMFS) was recorded, and periodontal status assessed.

RESULTS

After renal transplantation (n = 20), the salivary flow rate increased significantly from UWS = 0.30 +/- 0.21 ml/min to 0.44 +/- 0.29 ml/min (p <0.001) and the level of xerostomia and thirst decreased. After two years, the percentage of bleeding on probing in dialysis patients (n = 23) decreased from 29.5 +/- 25.4% to 10.3 +/- 12.3%, (p <0.05). No differences in DMFT and DMFS were observed between dialysis and renal transplant patients.

CONCLUSIONS

DMFT, dental plaque, gingival bleeding and periodontal indices did not change remarkably after two years, comparing dialysis and renal transplant patients. Renal transplantation enhances salivary flow and decreases symptoms of xerostomia and thirst, and hence enhances the potential to improve the quality of life of affected individuals.

Gastrointestinal complications in renal transplant recipients

Gastrointestinal complications are frequent in renal transplant recipients and can include oral lesions, esophagitis, peptic ulcer, diarrhea, colon disorders and malignancy. Oral lesions may be caused by drugs such as cyclosporine and sirolimus, by virus or fungal infections. Leukoplakia may develop in patients with Epstein-Barr virus (EBV) infection. The commonest esophageal disorder is represented by fungal esophagitis usually caused by candida. A number of patients may suffer from nausea, vomiting and gastric discomfort. These disorders are more frequent in patients treated with mycophenolate mofetil (MMF). Peptic ulcer is more rare than in the past. Patients with a history of peptic ulcer are particularly prone to this complication. Other gastroduodenal disorders are caused by cytomegalovirus (CMV) and herpes simplex infection. Diarrhea is a frequent disorder which may be caused by pathogen microorganisms or by immunosuppressive agents. The differential diagnosis may be difficult. Colon disorders mainly consist of hemorrhage, usually sustained by CMV infection, or perforation which may be caused by diverticulitis or intestinal ischemia. Colon cancer, anal carcinoma, and EBV-associated lymphoproliferative disorders are particularly frequent in transplant recipients. A particular gastric lymphoma called mucosa-associated lymphoid tissue (MALT) lymphoma may develop in renal transplant patients. It usually responds to the eradication of Helicobacter pylori.

Risk factors for gingival overgrowth in patients medicated with ciclosporin in the absence of calcium channel blockers

OBJECTIVES

This study investigates the effect of a range of potential risk factors on the severity of gingival overgrowth in transplant patients medicated with ciclosporin in the absence of any calcium channel blockers.

MATERIALS AND METHODS

One hundred dentate solid organ transplants medicated with ciclosporin (but not calcium channel blockers or phenytoin) were recruited for the study. Demographic, pharmacological and periodontal data were recorded and gingival overgrowth assessed from stone models.

RESULTS

Univariate analysis identified the duration of transplant, papilla bleeding index, creatinine serum concentration, azathioprine and prednisolone dosage as risk factors for overgrowth severity. Multivariate modelling, excluding the periodontal parameters, gave a predictive model that included dosages of ciclosporin, azathioprine, prednisolone and weight (p<0.0001, adjusted-R2=19%). Adding the periodontal variables strengthened the model (p<0.0001, adjusted-R2=34.5%).

CONCLUSION

The explanatory models in this study contain a number of variables that moderate inflammation (azathioprine and prednisolone) or are markers of it (papilla bleeding index). Dosage of each of the three immunosuppressants was identified as a risk factor for the severity of gingival change. This observation appears to have been masked by the effects of the calcium channel blockers in earlier studies.

Immunolocalization of collagenase (MMP-1) and stromelysin (MMP-3) in the gingival tissues of organ transplant patients medicated with cyclosporin

Cyclosporin-induced gingival overgrowth results from a disturbance in the homeostatic balance in the gingival tissues which is characterised by both an increase in the number of fibroblasts and in the volume of the extracellular matrix. Whilst the accumulation of the collagenous matrix is well recognised, little attention has been paid to the role of the degradative enzymes in the development of this condition in vivo. The matrix metalloproteinases MMP-1 (collagenase) and MMP-3 (stromelysin) were immunolocalized using specific polyclonal and monoclonal antisera in gingival specimens from 18 patients with drug-induced gingival overgrowth and 6 control subjects. A positive granular pattern of MMP-1 staining was seen in the vast majority of fibroblasts in specimens from drug-free controls throughout the connective tissue. This was in marked contrast to the findings in overgrown tissue, where positive cytoplasmic staining was shown by only a small number of fibroblasts. Where fibroblast staining occurred in overgrown tissue, the intracellular pattern was the same as in the drug free tissue. Positive staining was, however, largely confined to a small number of fibroblasts in the lamina propria of the outer gingival mucosa and even in this region there were areas that showed little or no fibroblast staining. This apparent cessation of collagenase production by many of the fibroblasts in gingival overgrowth supports the hypothesis that perturbation of collagenase activity is responsible for the disturbance in the homeostatic balance, which is pivotal to this condition.

Periodontitis associated with chronic renal failure: a case report

Chronic renal disease is associated with well-documented impairments in polymorphonuclear leucocyte (PMN) function. PMNs are important in defending the periodontium against plaque infections. This report discusses a case of periodontitis in a patient with chronic renal failure. It presents treatment provided and 1-year follow up. It shows that periodontal infections in patients with depressed PMN function could still be managed successfully with standard periodontal treatment emphasizing plaque control.

Dental attendance patterns in renal transplant recipients

OBJECTIVES

Renal transplant recipients (RTR) represent a large and growing population of individuals on potent immunosuppressant therapy who are at significantly greater risk of developing lip and oral mucosal disease, including lip cancer. The aims of this study were to determine the proportion of RTR receiving regular dental treatment, the dental services they used, and the relationship between the prevalence of lip and intraoral lesions and dental attendance.

DESIGN

The lip and oral mucosa of 159 RTR and 160 controls were examined. Subjects were asked questions about frequency of dental attendance and which service they used.

RESULTS

57.9% RTR attended a dentist regularly compared with 51.3% controls. Among the RTR who attended a dentist regularly, 54.3% visited their general dental practitioner, and 45.6% attended a dental hospital for treatment. This was significantly different from controls where 92.7% of regular attenders used their general dental practitioner (P < 0.001). Although the prevalence of oral lesions in RTR (54.7%) was more than twice as many as controls (19.4%), no significant difference was observed between RTR regular dental attenders and non-attenders.

CONCLUSIONS

This study indicates a clear need for oral health care and screening to be focused on RTR.