Hindawi

International Journal of Dentistry

Volume 2018, Article ID 9610892, 8 pages
https://doi.org/10.1155/2018/9610892

Review Article
Dental Care for Patients with End-Stage Renal Disease and
Undergoing Hemodialysis

Fulvia Costantinides ,1 Gaetano Castronovo ,1 Erica Vettori ,1 Costanza Frattini ,1

Mary Louise Artero,2 Lorenzo Bevilacqua ,1 Federico Berton ,1 Vanessa Nicolin,1
and Roberto Di Lenarda 1
1
Unit of Periodontology and Dental Hygiene, School of Dental Sciences, Department of Medical, Surgical and Health Sciences,
University of Trieste, Italy
2
Division of Nephrology and Dialysis, “Maggiore” University Hospital, Trieste, Italy

Correspondence should be addressed to Fulvia Costantinides; f.costantinides@fmc.units.it

Received 23 May 2018; Revised 11 September 2018; Accepted 2 October 2018; Published 13 November 2018

Academic Editor: Morenike O. Folayan

Copyright © 2018 Fulvia Costantinides et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
Chronic renal failure is a progressive disease characterized by a gradual destruction of nephrons and a consequent reduction of
kidney function. End-stage renal disease (ESRD) necessitates renal replacement therapy as peritoneal dialysis, hemodialysis, or
transplantation. Patients affected by ESRD or in hemodialysis are at risk for developing a number of comorbidities including
hypertension, anemia, risk of bleeding, susceptibility to infection, medication side effects, and oral manifestations associated with
the disease itself and with hemodialysis treatment. In this context, oral diseases represent a potential and preventable cause of poor
health outcomes in people with ESRD due to their relation to infection, inflammation, and malnutrition. The aim of this article
was to review ESRD and hemodialysis-associated manifestations and to describe the dental operative protocols for patients
awaiting kidney transplantation in light of the most recent literature.

1. Introduction systemic problems and treatment that may interfere with

clinical practice.
Oral health represents a potential determinant of health
outcomes in patients with end-stage renal diseases (ESRD). 2. Chronic Renal Disease:
Adults with ESRD have more severe oral diseases than the General Considerations
general population, and dental conditions such as caries,
periodontitis, and poor oral hygiene are associated with Chronic renal failure is a progressive disease characterized by
increased mortality. Oral pathologies are associated with a gradual destruction of nephrons and a consequent reduction
inflammation and malnutrition, which may accelerate of kidney function occurring over a few months or years [3].
cardiovascular events in ESRD [1]. Furthermore, in the As this process develops, the glomerular filtration rate (GFR)
context of kidney transplantation, infection from a dental falls while serum levels of urea rise. GFR is the rate at which
source is a potential threat for both organ transplant an ultrafiltrate of plasma is produced by glomeruli per unit
candidates and recipients since dental disease is a ubiqui- of time and is the best estimate of the number of functioning
tous condition and is also likely to be more severe and nephrons or functional renal mass [4]. Normal GFR
untreated in the transplant population [2]. values are approximately 120–130 mL/min/1.73 m2 and vary
The present work reviews the literature on general and according to age, gender, and body size [5]. All individuals
specific considerations regarding the dental treatment of with a GFR <60 mL/min/1.73 m2 for 3 months are classified as
ESRD patients in the pretransplant phase, considering the having chronic kidney disease, irrespective of the presence or
2 International Journal of Dentistry

absence of kidney damage. The reduction of GFR is usually deficiency ensues [10]. Erythropoietin synthesis is also de-
measured by creatinine clearance (CC), which gives an ac- creased, potentially leading to anemia. Furthermore, anemia
ceptable approximation of the value of GFR5. In clinical increases the hemorrhagic tendency in uremia due to
practice, the CC can be indirectly assessed through serum qualitative platelet dysfunction. Platelet dysfunction is due
creatinine (normal values 0.5–1.4 mg/dl) using several for- to both decreased platelet aggregation and impaired platelet
mulas such as Chronic Kidney Diseases Epidemiologic adhesiveness and is one of the main determinants of uremic
Collaboration (CKD-EPI) equation or the Modification of bleeding. This impairment is multifactorial and includes
Diet in Renal Disease (MDRD) equation. defects intrinsic to the platelet as well as abnormal platelet-
The progressive loss of renal function can be staged endothelial interaction. Uremic toxins and anemia also play
through clinical, instrumental, and laboratory findings in the a role. Correction of platelet dysfunction is desirable in
following. patients who are actively bleeding or who are about to
Stage 1: slightly diminished function—kidney damage undergo a surgical procedure (e.g., renal biopsy). Platelet
with normal or relatively high GFR (≥90 mL/min/1.73 m2). dysfunction in the uremic patient can be controlled with the
Kidney damage is defined as pathological abnormalities or administration of desmopressin, an analog of antidiuretic
markers of damage, including abnormalities in blood or urine hormone with little vasopressor activity, by the adminis-
tests, biopsy, or imaging studies. Stage 2: mild reduction in tration of conjugated estrogens, or infusion of cry-
GFR (60–89 mL/min/1.73 m2) with kidney damage. Stage 3: oprecipitate that can shorten the bleeding time in many
moderate reduction in GFR (30–59 mL/min/1.73 m2). Stage 4: uremic patients [11–13].
severe reduction in GFR (15–29 mL/min/1.73 m2)—prepa- The ESRD patient also presents an immunodeficient
ration for renal replacement therapy. Stage 5: established state caused by altered cellular immunity associated with
kidney failure or end-stage renal disease (ESRD) (GFR malnutrition, susceptibility to bacterial infection, and a di-
<15 mL/min/1.73 m2) requiring permanent renal replace- minished ability to produce antibodies [14].
ment therapy (RRT). A final consideration with respect to pharmacotherapy is
In 2004, KDIGO (Kidney Disease: Improving Global that most drugs are at least partially excreted via the kidney.
Outcomes) added a specification regarding the concomitant With renal dysfunction, the distribution, metabolism, bio-
presence of a replacement therapy using the letter “T” for availability, and rate of excretion of the drug are altered, and
transplanted patient and “D” for dialysis [6]. an adjustment of the dosage by amount or by frequency is
The two main causes of ESRD are hypertension and required [5].
diabetes mellitus, both of which have a deleterious impact on With advanced renal disease, aggressive measures such
the cardiovascular system and renal apparatus of the patients as dialysis must be taken. Dialysis is a life-saving in-
before and after transplantation. Particularly, cardiovascular tervention that has significantly prolonged life expectancy in
diseases (atherosclerosis) represent the main cause of death young patients. Hemodialysis is allowed by a machine
in renal transplant recipients. Other causes of ESRD are (dialyzer) that contains semipermeable membranes. These
glomerulonephritis, chronic pyelonephritic urologic disor- membranes permit the passage of excessive fluid and wastes.
ders, and autoimmune diseases [7]. The most common cause Arteriovenous shunts or fistulas achieve the access to the
of death in ESRD patients is cardiac arrest, followed by bloodstream. The continuous accumulation of toxic prod-
infection and malignancy [8]. ucts in ESRD requires that the patient undergoing hemo-
Treatment of chronic renal insufficiency includes dietary dialysis receive the treatment for approximately three-four
modifications and correction of systemic complications [8]. hours a day, three times a week. It is important to point out
ESRD, also known as the uremic syndrome, necessitates out that the efficiency of this process is much lower than
renal replacement therapy as dialysis or transplantation [4]. a functioning kidney, hence ESRD patients on hemodialysis
While stages 1 to 3 do not pose any contraindications for are in a constant state of kidney failure and hyperuremia.
routine dental treatment, patients with advanced kidney The constant presence of the uremic syndrome even in
disease (stages 4-5) require special considerations, most hemodialyzed patients has been forwarded as a primary
importantly regarding hypertension, anemia, risk of bleeding, contributor to the many systemic complications seen in
infection and medication used, and oral manifestations as- these patients.
sociated with the disease itself and with hemodialysis treat- Peritoneal dialysis (PD) offers greater independence;
ment [9]. access to the peritoneum is achieved by a catheter through
the abdominal wall into the peritoneum that serves as
3. ESRD and Dialysis a membrane able to filter the catabolic products from the
local vessels [9]. Although hemodialysis and PD correct
ESRD is characterized by diminished endocrine and met- many of the hematologic dysfunctions associated with
abolic functions of the kidney with subsequent retention and uremia, several issues already present in ESRD are exacer-
accumulation of toxic metabolites. The blood pressure is bated during the treatment. Hemodialysis requires the use of
increased due to fluid overload and production of vasoactive anticoagulant in the form of regional or systemic heparin to
hormones via the renin-angiotensin system, increasing the maintain access patency and facilitate the filtration of toxic
risk of developing congestive heart failure. As chronic blood compound such as urea through the dialysis mem-
kidney disease progresses, the ability to produce renal hy- brane [4]. Heparinization associated with mechanical
droxylated 1,25 vitamin D diminishes and 1,25 vitamin D trauma to platelets can reduce the total platelet number and
International Journal of Dentistry 3

increase hemorrhagic risk. This tendency is worsened by the hemodialysis generally have a poor objective periodontal
already present capillary fragility and anemia. Furthermore, status verified by mean CPITN (Community Periodontal
patients tend to have hypertension attributed to salt and Index of Treatment Needs), and deposit of calculus and
water retention and to activation of the rennin-angiotensin- plaque may be increased [5, 8, 22, 23]. Studies have shown
aldosterone [15, 16]. that dental care in patients undergoing hemodialysis is
Sudden death is the most common cause of death in neglected, and that they brush and floss infrequently [15].
dialyzed patients but also infection is a frequent cause of Results of a study by Naugle et al. suggested that 100% (n �
morbidity and mortality in patients receiving hemodialysis 45) of the individuals undergoing renal dialysis presented
therapy. Due to the vascular access, patients are at increased with some form of periodontal disease [24]. Moreover, di-
risk of endarteritis and endocarditis that occurs in about abetic nephropathic patients show deeper periodontal pockets
2.7% of patients during hemodialysis and in 9% of those who compared with ESRD nondiabetic patients [25]. Also, the
have an infection of the vascular access [17]. need for surgical treatment of periodontitis is significantly
higher in patients awaiting kidney transplant compared with
4. Oral Manifestations patients not undergoing organ transplantation [26]. Peri-
odontitis itself contributes to systemic inflammation and has
It has been estimated that 90% of chronic renal failure been associated with adverse hemodialysis outcomes in-
patients present oral symptoms. However, with the im- cluding mortality [27]. The accelerated periodontal disease
provements of hemodialysis technology many of the oral with pocket formation, gingival recession, and bone and tooth
manifestations of renal failure and uremia described below loss is due not only to inadequate oral hygiene and in-
are less commonly seen [4]. flammatory disease burden but also to renal osteodystrophy
Oral manifestations involve mucosal and glandular [5, 15].
tissues, the gingival and the periodontal apparatus, the Maxillary and mandibular bone tissue is interested by
maxillary and mandibular bone, and finally the dental status. renal osteodystrophy that results from disorders in calcium,
Primarily, in regard with the mucosal and glandular phosphorus, and vitamin D metabolism and from increased
involvement, the most common oral finding in dialyzed parathyroid activity. Oral manifestations of renal osteo-
patient is pallor of the mucosa due mainly to anemia (re- dystrophy include tooth mobility, malocclusion, pulp stones,
duced erythropoietin synthesis) [5, 15]. Bleeding tendency in enamel hypoplasia, bone demineralization, decreased tra-
these patients is sustained by alterations in platelet aggre- beculation of cancellous bone, decreased thickness of cor-
gation and renal anemia [15, 18]. Also, hemodialysis pre- tical bone, radiolucent giant cell lesions, jaw fracture
disposes to ecchymoses, petechiae, and hemorrhage in the (spontaneous or after dental procedures), and abnormal
oral mucosa [5, 19, 20]. bone healing after extraction [5, 9, 20]. To avoid hypo-
Xerostomia denotes the subjective sensation of dry mouth vitaminosis D and its consequences, it is therefore necessary
and is related to the overall volume status of the patients who to administer calcitriol or its analogs to compensate for the
are discouraged from drinking excess fluids and who are often compromised production of 1,25 vitamin D, which occurs in
prone to retrograde parotitis [9, 15, 20, 21]. In association with the later stages of chronic kidney disease (beyond stage 3) so
xerostomia, one third of hemodialyzed patients present that the classical functions of hormonal 1,25 vitamin D may
a characteristic halitosis called “uremic fetor” and a metallic be addressed [10].
taste due to high urea content in saliva and its breakdown in Finally, in regard with dental tissue involvement, a lower
ammonia [5, 9]. Also, the patient can perceive altered sweet rate of caries has been observed. This finding can be
and acid flavors due to high levels of urea in saliva and to the explained by the possible antibacterial effect of a higher urea
presence of dimethyl and trimethyl amines. A burning sen- concentration in saliva that inhibits plaque and bacteria
sation of lips and tongue and an enlarged tongue sensation development [9, 15]. The antibacterial effect has been at-
may be additional symptoms noted by dialyzed patients [5]. tributed to the increase of pH due to urea hydrolization by
An important problem is represented by uremic stomatitis, saliva, which suggests a protective function against caries
which is a relatively uncommon oral complication of un- [5, 16]. Dental erosions due to frequent regurgitation
known etiology [5, 18]. The lesions consist of localized or resulting from the nausea associated with hemodialysis
generalized erythematous areas covered by pseudomem- treatments and pulp narrowing and calcification are other
branous exudates that can be removed, leaving an intact or signs that the patient can present [4]. Enamel hypoplasia and
ulcerated mucosa. The lesions are commonly painful and delayed eruption can occur in children with chronic renal
most often appear on the ventral tongue and anterior mucosal diseases [5, 28].
surfaces. They usually heal spontaneously with resolution of The oral condition of patients with renal failure has been
the underlying uremia and after lowering of the blood urea described comprehensively in a recent meta-analysis by
nitrogen (BUN) level [9]. However, in order to promote the Ruospo et al. [29]. Authors clearly separated the prevalence
healing of the lesions, gargling with 10% hydrogen peroxide 4 of oral diseases in adults with ESRD, ESRD plus hemodi-
times a day can be recommended [5, 19]. Angular cheilitis has alysis, and transplantation and explored any association
been reported in more than 4% of patients receiving he- between oral disease and mortality. They found that DMFT
modialysis, and lichenoid disease may arise associated with indices were similarly high in adults with chronic kidney
antihypertensive medication [5, 8]. Secondarily, pointing the disease (CKD) stages 1–5 (18.7 [C.I. 95% 10.5–27.0]) and
attention on the periodontal health, patients undergoing those with CKD stage 5D (14.5 [C.I. 95% 12.7–16.3]), and the
4 International Journal of Dentistry

mean DMFT index increased with age but was not associated platelets count, hematocrit, and hemoglobin. In renal pa-
with gender or dialysis duration. Periodontitis affected tients taking warfarin, International Normalized Ratio (INR)
31.6% of adults with CKD stages 1–5 and 58% of patients in should be measured. Evidence-based medicine states that
dialysis. The prevalence of periodontitis in stage 5D was minor surgical procedure can be safely carried out without
unaffected by age, but increased with the proportion of adjustment for INR<4 although for INR>2.5, a consultation
women and duration of dialysis. The mean plaque index was with nephrologist is indicated [3, 31]. After the treatment,
1.14 and 1.62 in two population with CKD stages 1–5 and local hemostatic measures (compression, cold applications,
2.19 in kidney transplanted recipients. In stage 5D, the mean tranexamic acid, cellulose sponges, and sutures) can be used
plaque index was 1.9 and increased with age but was not in case of local hemorrhage and are generally sufficient to
influenced by gender or time treated with dialysis. Regarding obtain hemostasis.
mucosal diseases, ulcerations affected 8.6% of patients in
stage 5D and 1.3% of transplant recipients and candidiasis
5.2. Medications. Local anesthetics can be safely used be-
affected 22.2% of patients in stage 1–5, 19% of adults with
cause they have a hepatic elimination. Paracetamol remains
CKD in stage 5D, and 13.3% of kidney-transplanted patients.
the best choice for pain management, and also codeine can
The prevalence of oral candidiasis in stage 5 increased with
be used without modification of the dosages. Other anti-
age but not gender, time of dialysis, or geographical region.
inflammatory drugs such as ketoprofen, ibuprofen, or
Xerostomia was reported by 48.4% of patients in stage 5D;
naproxen could cause hypertension and worsen the bleeding
the mean stimulated predialysis salivary flow rate was
tendency. Aspirin is contraindicated because it increases
0.86 ml/min for CKD stage 5D whereas the mean unsti-
platelet dysfunction, the risk of gastric hemorrhage, and
mulated salivary flow rate was 0.22 ml/min.
contributes to the deterioration of renal function. In case of
doubts, the nephrologist or the personal physician should be
5. General Considerations for consulted.
Dental Management Patients who have been treated with high doses of
corticosteroids for a long time and or in stressful situations
Patients with renal disease in conservative medical treatment may require steroid supplementation prior to dental treat-
or with PD do not generally require special measures re- ment to avoid an episode of adrenal crisis [5]. Moreover, it is
garding dental treatment, apart from avoiding nephrotoxic suggested that dental sessions should take place in the
drugs (such as tetracyclines or aminoglycosides) and morning, in a quiet environment and that abrupt and un-
monitoring blood pressure during the procedures due to the expected movements be avoided during therapy [3].
frequent hypertension [5].
However, for hemodialysis patients, communication
with the nephrologist is highly recommended in order to 5.3. Antibiotic Prophylaxis and Therapy. Recent studies
know the stage of the pathology, the medications prescribed, pointed out the lack of scientific evidence to prescribe anti-
and comorbidities such as diabetes that negatively influence biotic prophylaxis for preventing infective endocarditis (IE) in
the homeostasis of these patients [5]. ESRD patients [15, 32]; ESRD or hemodialysis do not rep-
In diabetic dialysis patients, hypoglycemic agents and resent a criterion for IE prophylaxis. According to the
nutritional alterations can trigger hypoglycemia in the American Heart Association guidelines, antibiotic adminis-
background of diminished gluconeogenesis, reduced insulin tration remains indicated for patients suffering from con-
clearance by the kidney, and improved insulin sensitivity comitant cardiac comorbidities such as those with prosthetic
following initiation of renal replacement therapy. Detailed cardiac valve, previous IE, unrepaired cyanotic congenital
evaluation of antidiabetic regimen and nutritional patterns, heart disease (CHD), completely repaired congenital heart
patient education on self-monitoring of blood glucose, defect with prosthetic material or device during the first six
and/or referral to a diabetes specialist may reduce risk of months after the procedure, repaired CHD with residual
subsequent hypoglycemia [30]. defects at the site or adjacent to the site of a prosthetic patch or
Other important features to take into consideration are prosthetic device, and cardiac transplantation recipients who
drug intolerance and increased susceptibility to infection. develop cardiac valvulopathy [33]. Nevertheless, patients
affected by ESRD have an increased susceptibility to IE es-
pecially if they do not have a good control of the disease [34].
5.1. Risk of Bleeding. Dental treatment with risk of bleeding Furthermore, patients in hemodialysis can develop infections
should be postponed to nondialysis day since the antico- of the vascular access (endarteritis) that can become itself the
agulant effect of heparin is absent, the bloodstream is free source of bacteraemia, and thus they may benefit from an-
from toxic metabolites, and the patient is not debilitated by tibiotic prophylaxis, especially in the 6 months after the
the treatment. creation of the vascular access [35]. Due to these persisting
The administration of a heparin antagonist (protamine controversies, the best practice remains the discussion with
sulphate) can reduce the rate of bleeding in case of urgency. the patient’s nephrologist to evaluate, case by case, the in-
However, a persistent bleeding tendency remains due to dication for an antibiotic prophylaxis.
anemia and alteration in platelet aggregation and adhe- In the presence of an acute or re-exacerbated dental
siveness. A hematologic study before planning any invasive infection (periapical periodontitis, periapical, or periodontal
treatment can give information about coagulation times, abscess), a complete cycle of antibiotic therapy should be
International Journal of Dentistry 5

administered using nonnephrotoxic antibiotics and taking because of the persisting daily episodes of bacteraemia from
into consideration the CC because as renal function is re- the oral cavity. The spread of oral bacteria can be minimized
duced, the plasma levels of some drugs may be high or by the elimination of oral foci and by reducing the grade of
prolonged [4]. The CC test assesses glomerular function mucosal and gingival inflammation. A good control of oral
comparing the amount of creatinine in the blood with that hygiene and the absence of dental foci represent a funda-
eliminated in the urine over a day. Theoretically, a 50% drop mental step to receive a preemptive kidney transplant before
in CC represents a twofold increase in the half-life of a drug the patient needing dialysis, if medically suitable, thanks to
eliminated solely via renal excretion [9]. For this reason, a living donor. Also, an efficient dental treatment with
according to the degree of renal elimination of the drug, the maintenance of good oral hygiene is essential in the post-
interval between doses should be increased. transplant phase, especially by preventing the occurrence of
Penicillin and its derivatives, clindamycin and cepha- severe infections and consequently the survival of the
losporins are safer antibiotics for these patients [5]. Ami- transplanted organ. Furthermore, adequate plaque removal
noglycosides, tetracyclines, and polypeptide antibiotics and the treatment of gingivitis and periodontitis can avoid or
should be avoided because of their nephrotoxicity [4]. minimize gingival hypertrophy due to assumption of im-
munosuppressive drugs such as cyclosporine [41].
Besides the knowledge of general health aspects dis-
5.4. Psychological Aspect. Finally, it is extremely important to cussed above, the dental practitioner has to know the correct
remember the psychological aspect in treating ESRD or practical approach and the operative sequences to follow
hemodialyzed patients [4]. A poor quality of life and depression when treating renal patients. From the first appointment, it
have been associated with hemodialysis, and a reduction of is fundamental to impress upon the patient the importance
compliance should be expected in a higher percentage of of adequate oral health and explaining to them the possible
patients compared with general population [36, 37]. complications arising from untreated oral foci, both in the
However, it is debatable whether systemic alterations pre- and posttransplantation phases, and the possible oral
and general morbidity are casually associated with the worse side effects of taking future antirejection therapy [16, 42, 43].
dental and periodontal status or if the hemodialysis per se As already mentioned, an accurate medical history should
in combination with psychological factor may impact on be collected with particular reference to ESRD-related ill-
quality of life [38]. nesses, medications and their dosage, blood parameters,
Recently, Pakpour et al. investigated the oral health- timing, and type of dialysis performed. These aspects have to
related quality of life (OHRQoL) related to sociodemo- be directly discussed with the nephrologists when necessary
graphic variables, clinical findings, cognitive variables, oral [5, 44]. The dental exam consists of a noninvasive complete
health behaviours, and general health-related quality of life assessment of dental, periodontal, and mucosal tissues [9].
(GHRQoL) in ESRD patients undergoing hemodialysis [39]. Special care should be taken when positioning the patient,
Patients were matched with a healthy control group. Results avoiding compression of the arm with the vascular access for
showed that patients on hemodialysis had poor oral health hemodialysis [5]. All possible foci (periodontal and end-
status, OHRQoL, and GHRQoL compared to healthy sub- odontic lesions, residual roots, partially erupted and mal-
jects. Sociodemographic variables, oral health knowledge, positioned third molars, and peri-implantitis) and oral
hygiene attitudes, and GHRQoL predicted OHRQoL. pathologies (caries and mucosal lesions) have to be inter-
Conversely, Schmalz et al. did not find neither clinical cepted. Radiographs (orthopantomography and intraoral
nor statistical significant differences of Oral Health Impact x-rays) complete the diagnostic process both in dentate and
Profile (OHIP G14) between patients on hemodialysis and edentulous patients. Furthermore, a periodontal chart should
control group although ESRD patients exhibited worse oral be performed if periodontitis is suspected. The treatment plan
health [38]. This result highlights that the patient’s per- for periodontal disease must include the assessment of the
ception does not reflect the oral deficiencies and that edu- patient’s oral hygiene. Therapy of gingivitis and periodontitis
cation and motivation of these patients represent a focus in should consist primarily in accurate motivation and in-
oral health maintenance. struction for home oral hygiene, adapted and personalized to
the necessities of the patient. Mechanical removal of supra-
6. Operative Protocols and subgingival calculus should be performed with ultra-
sound devices and curettes.
An increased perception of the importance of oral health in Carious lesions must be recognized and when necessary
ESRD patients and transplant candidates has been observed pulp vitality should be tested. In the presence of pulp necrosis
in the scientific community in the last twenty years. Over and/or apical lesions, endodontic treatment, apicectomy, or
time, the dental protocols that have been proposed by extraction can be programmed. Generally, extractions are
various authors showed a growing attention to the psycho- recommended when conservative, endodontic, and peri-
logical aspect of the patient and to the importance of odontal treatments do not guarantee the complete resolution
maintaining good control of plaque and daily oral hygiene of the pathology [3, 4, 20]. Extraction of partially erupted and
[5, 6, 9, 16, 31, 40]. Due to the greatly increased incidence and malpositioned third molars is recommended to avoid peri-
severity of periodontitis in the hemodialysis population, the coronal infection especially in the early posttransplant period.
dentist should keep in mind that the lack of oral hygiene may In cases of peri-implantitis, surgical removal of the implant
put the patient at higher risk of local or disseminated infection should be performed. The surgery should be as atraumatic as
6 International Journal of Dentistry

FIRST ASSESSMENT
1.Explain extensively the aims of the dental treatment and discuss with the patient the importance of adequate oral health;
obtain a written informed consent.
2. Collect a complete medical history and, if necessary, contact the nephrologist to assess the grade of ESRD, ESRD-related
illnesses, timing, and type of dialysis.
3. Perform a noninvasive examination of dental, periodontal, and mucosal tissues. Complete the examination with
radiographs both in dentate and edentulous patients.
4. Recognize all possible foci (periodontal and endodontic lesions, residual roots, partially erupted and malposed third molars,
and peri-implantitis) and oral pathologies (caries and mucosal lesions).

Dental Foci Dental Foci

YES NO

DENTAL TREATMENT (General considerations)

1. Before any procedure that could lead to bleeding, a 15ml rinse of chlorhexidine 0.12% for 60 seconds is
recommended.
2. Antibiotic prophylaxis should be considered before surgery.
3. Dosage of pharmacologic therapies must be adapted to the creatinine clearance. In general, avoid
administration of aspirin and consider safe local anesthetic.
4. Organize the patient appointments on the day after hemodialysis.

Periodontal therapy Conservative- Oral surgery Prosthetic and

1. Take into account the endodontic therapy 1. Use an atraumatic orthodontic devices
assessment of the 1. Recognize carious technique to avoid the risk 1. Assess the adaptation
patient’s oral hygiene. lesions and proceed with of bone fractures. of removable prostheses
2. In cases of decayed tooth restoration. 2. Extract residual roots, to determine the necessity
periodontitis, perform a 2. Test pulp vitality on teeth with high mobility, of adjustment or
complete periodontal teeth with extensive and elements with substitution.
chart. caries. In presence of periodontal or endodontic 2. Check orthodontic
3. Proceed with the pulp necrosis and/or lesion that are not appliances and maintain
mechanical removal of apical lesions (diagnosed maintainable. them if they do not
supra-and subgingival by radiographs), proceed 3. Extract partially erupted interfere with oral
calculus with ultrasounds with the endodontic and malpositioned third hygiene (the removal of
devices and curettes. treatment. molars to avoid pericoronal orthodontic brackets is
4. Program surgical 3. Extraction is infection especially in the suggested just before
periodontal therapy when recommended when the early posttransplant period. transplantation).
indicated and only if a endodontic treatment 4. Treat peri-implantitis or 3. Instruct the patient
good prognosis is does not guarantee the perform the surgical regarding the correct
expected. Otherwise, complete resolution of the removal of unmaintainable cleaning and maintenance
proceed with extraction. pathology. implants. of the devices.
5. Motivate and instruct 5. Proceed with the biopsy
home oral hygiene. of suspected mucosal
lesions.

RECALL PROGRAM
1. Insert all patients in a strict recall program (frequency range of 3–6 months)
2. Repeat a complete noninvasive examination of the oral cavity and radiographs if the presence of new foci is suspected.
check prostheses and orthodontic appliances.
3. Treat the patients for new pathologies.

Figure 1: Flowchart for dental treatment of ESRD and hemodialyzed patients.

possible to avoid maxillo-mandibular fractures due to renal amount of oral bacteria that could reach the bloodstream.
osteodystrophy. In the presence of suspected mucosal lesions Adaptation of removable prostheses should be assessed to
that do not resolve in 7–10 days, a biopsy must be performed. determine the necessity of adjustment or substitution, and the
Before any procedure that could lead to bleeding (periodontal patient should be instructed regarding the cleaning and
chart, calculus removal with ultrasound, subgingival scaling, maintenance of the device [3].
extraction, and periodontal surgery) a 15 ml rinse of chlo- Orthodontic appliances can be maintained if they do not
rhexidine 0.12% for 60 seconds is recommended to reduce the interfere with oral hygiene. The removal of orthodontic
International Journal of Dentistry 7

brackets is indicated just before transplantation because the [2] J. Guggenheimer, B. Eghtesad, and D. J. Stock, “Dental
immunosuppressive therapy administered in the posttrans- management of the (solid) organ transplant patient,” Oral
plant period can induce gingival overgrowth that seems to be Surgery, Oral Medicine, Oral Pathology, Oral Radiology, and
much more accentuated in the presence of fixed appliances [3]. Endodontology, vol. 95, no. 4, pp. 383–389, 2003.
After the first cycle of dental therapy, it is crucial that all [3] E. A. Georgakopoulou, M. D. Achtari, and N. Afentoulide,
“Dental management of patients before and after renal
patients are included in a strict follow-up program to
transplantation,” Stomatologija, vol. 13, pp. 107–112, 2011.
maintain the results obtained and, above all, to maintain [4] A. Vasanthan and N. Dallal, “Periodontal treatment con-
a high level of compliance. The frequency of follow-up siderations for cell transplant and organ transplant patients,”
depends on the needs and motivation of the patient (3– Periodontol 2000, vol. 44, pp. 82–102, 2007.
6 months for effective plaque control) [45]. Since the patients [5] S. Martı́ Alamo, C. Gavaldá Esteve, and M. G. Sarrión Pérez,
undergo hemodialysis with a frequency of about three times “Dental considerations for the patient with renal disease,”
a week for approximately 2–4 hours per session (plus their Journal of Clinical and Experimental Dentistry, vol. 3,
other medical appointments), they could be psychologically pp. E112–E119, 2011.
affected and poorly compliant with respect to dental ap- [6] A. S. Levey, K. U. Eckardt, Y. Tsukamoto et al., “Definition and
pointments. For this reason, the education on the impor- classification of chronic kidney disease: a position statement
tance of oral health is crucial to maintain the best motivation from Kidney Disease: Improving Global Outcomes (KDIGO),”
of the patient. At each appointment, a review of medical Kidney International, vol. 67, pp. 2089–2100, 2005.
[7] S. L. Segelnick and M. A. Weinberg, “The periodontist’s role in
history is indicated and a complete noninvasive examination
obtaining clearance prior to patients undergoing a kidney
of the oral cavity should be repeated [15]. Radiographs must transplant,” Journal of Periodontology, vol. 80, pp. 874–877,
be performed if the presence of new foci is suspected. 2009.
It is important that this protocol is followed until the [8] R. Proctor, N. Kumar, A. Stein, D. Moles, and S. Porter, “Oral
patient undergoes renal transplantation. In fact, the ad- and dental aspects of chronic renal failure,” Journal of Dental
herence to periodic follow-up reduces the risk of oral in- Research, vol. 84, pp. 199–208, 2005.
fection just before the transplant and avoids the possibility of [9] S. S. De Rossi and M. Glick, “Dental considerations for the
losing the compatible organ because of an acute infection patient with renal disease receiving hemodialysis,” Journal of
from a dental source [15]. the American Dental Association, vol. 127, pp. 211–219, 1996.
Operative protocols from first access to follow-up visit [10] S. Williams, K. Malatesta, and K. Norris, “Vitamin D and
are summarized in Figure 1. chronic kidney disease,” Ethnicity & Disease, vol. 19, pp. S5–8-
11, 2009.
[11] P. M. Mannucci, G. Remuzzi, F. Pusineri et al., “Deamino-8-D-
7. Conclusion arginine vasopressin shortens the bleeding time in uremia,” New
England Journal of Medicine, vol. 308, no. 1, pp. 8–12, 1983.
CKD has become a major public health problem worldwide,
[12] J. A. Sloand and M. J. Schiff, “Beneficial effect of low-dose
and terminal stage of CKD, ESRD, requires renal re- transdermal estrogen on bleeding time and clinical bleeding in
placement therapy or kidney transplant [46, 47]. uremia,” American Journal of Kidney Diseases, vol. 26, no. 1,
The number of patients needing a kidney transplant is pp. 22–26, 1995.
increasing, and as this group of patients grows, its dental [13] P. A. Janson, S. J. Jubelirer, M. J. Weinstein, and D. Deykin,
needs will also increase. “Treatment of the bleeding tendency in uremia with cry-
It is important to coordinate with the nephrologist the oprecipitate,” New England Journal of Medicine, vol. 303,
dental intervention considering the possible deterioration of no. 23, pp. 1318–1322, 1980.
general conditions of the patient during and after the dental [14] E. J. Raubenheimer, C. E. Noffke, and H. D. Hendrik,
treatment. “Chronic kidney disease-mineral bone disorder: an update on
Patients have to be treated considering all issues cor- the pathology and cranial manifestations,” Journal of Oral
Pathology & Medicine, vol. 44, no. 4, pp. 239–243, 2015.
related to the kidney dysfunction and inserted in a strict
[15] J. T. Klassen and B. M. Krasko, “The dental health status of
follow-up program until transplantation. Early detection of
dialysis patients,” Journal of the Canadian Dental Association,
oral pathologies and strong preventive measures can min- vol. 68, pp. 34–38, 2002.
imize the need for extensive dental care [48]. The in- [16] A. Jover Cerveró, J. V. Bagán, Y. Jiménez Soriano, and
volvement of the patient is central to increase the motivation R. Poveda Roda, “Dental management in renal failure: pa-
for oral health. tients on dialysis,” Medicina Oral Patologia Oral y Cirugia
Bucal, vol. 13, pp. E419–426, 2008.
Conflicts of Interest [17] A. Leonard, L. Raij, and F. L. Shapiro, “Bacterial endocarditis
in regularly dialyzed patients,” Kidney International, vol. 4,
The authors declare that they have no conflicts of interest. pp. 407–422, 1973.
[18] J. C. Leão, L. A. Gueiros, A. V. Segundo, A. A. Carvalho,
References W. Barrett, and S. R. Porter, “Uremic stomatitis in chronic
renal failure,” Clinics, vol. 60, no. 3, pp. 259–262, 2005.
[1] S. C. Palmer, M. Ruospo, G. Wong et al., “Oral-D study [19] E. de la Rosa Garcı̀a, A. Mondragòn Padilla, S. Aranda Romo,
investigators. Dental health and mortality in people with and M. A. Bustamente Ramı̀rez, “Oral mucosa symptoms,
end-stage kidney disease treated with hemodialysis: a multi- signs and lesions, in end stage renal disease and non–end stage
national cohort study,” American Journal of Kidney Diseases, renal disease diabetic patients,” Medicina Oral Patologia Oral
vol. 66, pp. 666–676, 2015. y Cirugia Bucal, vol. 11, pp. E467–E473, 2006.
8 International Journal of Dentistry

[20] M. Dioguardi, G. A. Caloro, G. Troiano et al., “Oral mani- [35] A. M. Venkatesan, S. Kundu, D. Sacks, et al.,Society of
festations in chronic uremia patients,” Renal Failure, vol. 38, Interventional Radiology Standards of Practice Committee,
no. 1, pp. 1–6, 2015. “Practice guidelines for adult antibiotic prophylaxis during
[21] P. C. Fox, P. F. van der Ven, B. C. Sonies, J. M. Weiffenbach, vascular and interventional radiology procedures. Written by
and B. J. Baum, “Xerostomia: evaluation of a symptom with the Standards of Practice Committee for the Society of
increasing significance,” Journal of the American Dental As- Interventional Radiology and Endorsed by the Cardiovascular
sociation, vol. 110, no. 4, pp. 519–525, 1985. Interventional Radiological Society of Europe and Canadian
[22] J. S. Sobrado Marinho, I. Tomàs Carmona, A. Loureiro, Interventional Radiology Association [corrected],” Journal of
J. Limeres Posse, L. Carcià Caballero, and P. Diz Dios, “Oral Vascular and Interventional Radiology, vol. 21, no. 11,
health status in patients with moderate-severe and terminal pp. 1611–1630, 2010.
renal failure,” Medicina Oral Patologia Oral y Cirugia Bucal, [36] F. O. Finkelstein, K. L. Arsenault, A. Taveras, K. Awuah, and
vol. 12, pp. 305–310, 2007. S. H. Finkelstein, “Assessing and improving the health-related
[23] M. Dencheva, “Dialysis, renal transplantation and oral health quality of life of patients with ESRD,” Nature Reviews Ne-
many-sided nature of dental focal doctrine,” Biotechnology & phrology, vol. 8, no. 12, pp. 718–724, 2012.
Biotechnological Equipment, vol. 24, no. 2, pp. 1878–1881, 2010. [37] A. Reckert, J. Hinrichs, H. Pavenstädt, B. Frye, and G. Heuft,
[24] K. Naugle, M. L. Darby, D. B. Bauman, L. T. Lineberger, and “Prevalence and correlates of anxiety and depression in pa-
R. Powers, “The oral health status of individuals on renal tients with end-stage renal disease (ESRD),” Zeitschrift für
dialysis,” Annals of Periodontology, vol. 3, no. 1, pp. 197–205, Psychosomatische Medizin und Psychotherapie, vol. 59, no. 2,
1998. pp. 170–188, 2013.
[25] K. Nylund, J. H. Meurman, A. M. Heikkinen, E. Honkanen, [38] G. Schmalz, O. Kollmar, R. Vasko, G. A. Müller, R. Haak, and
M. Vesterinen, and H. Ruokonen, “Oral health in predialysis D. Ziebolz, “Oral health-related quality of life in patients on
patients with emphasis on periodontal disease,” Quintessence chronic haemodialysis and after kidney transplantation,” Oral
International, vol. 46, pp. 899–907, 2015. Diseases, vol. 22, no. 7, pp. 665–672, 2016.
[26] J. Rustemeyer and A. Bremerich, “Necessity of surgical dental [39] A. H. Pakpour, S. Kumar, B. Fridlund, and S. Zimmer, “A
foci treatment prior to organ transplantation and heart valve case-control study on oralhealth-related quality of life in
replacement,” Clinical Oral Investigations, vol. 11, no. 2, kidney disease patients undergoing haemodialysis,” Clinical
pp. 171–174, 2007. Oral Investigations, vol. 19, no. 6, pp. 1235–1243, 2015.
[27] A. V. Kshirsagar, R. G. Craig, K. L. Moss et al., “Periodontal [40] I. Saif, A. Adkins, V. Kewley, A. Woywodt, and V. Brookes,
disease adversely affects the survival of patients with end-stage “Routine and emergency management guidelines for the
renal disease,” Kidney International, vol. 75, no. 7, pp. 746– dental patient with renal disease and kidney transplant. Part
751, 2009. 2,” Dent Update, vol. 38, no. 4, pp. 250-251, 2011.
[28] E. Davidovich, M. Davidovits, E. Eidelman, Z. Schwarz, and [41] G. Castronovo, G. Liani, A. Fedon et al., “The effect of
E. Bimstein, “Pathophysiology, therapy and oral implications nonsurgical periodontal treatment on the severity of drug-
of renal failure in children and adolescents: an update,” Pe- induced gingival overgrowth in transplant patients,” Quin-
diatric Dentistry, vol. 27, pp. 98–106, 2005. tessence International, vol. 45, pp. 115–124, 2014.
[29] M. Ruospo, S. C. Palmer, J. C. Craig et al., “Prevalence and [42] G. Bayraktar, I. Kurtulus, A. Duraduryan et al., “Dental and
severity of oral disease in adults with chronic kidney disease: periodontal findings in hemodialysis patients,” Oral Diseases,
a systematic review of observational studies,” Nephrology vol. 13, no. 4, pp. 393–397, 2007.
Dialysis Transplantation, vol. 29, pp. 364–375, 2014. [43] N. R. Gautam, N. S. Gautam, T. H. Rao, R. Koganti, R. Agarwal,
[30] A. R. Gosmanov, E. O. Gosmanova, and C. P. Kovesdy, and M. Alamanda, “Effect of end-stage renal disease on oral
“Evaluation and management of diabetic and non-diabetic health in patients undergoing renal dialysis: a cross-sectional
hypoglycemia in end-stage renal disease,” Nephrol Dial study,” Journal of International Society of Preventive and
Transplant, vol. 31, pp. 8–15, 2016. Community Dentistry, vol. 4, no. 3, pp. 164–169, 2014.
[31] I. Saif, A. Adkins, V. Kewley, A. Woywodt, and V. Brookes, [44] A. Gudapati, P. Ahmed, and R. Rada, “Dental management of
“Routine and emergency management guidelines for the patients with renal failure,” General Dentistry, vol. 50,
dental patient with renal disease and kidney transplant. Part pp. 508–510, 2002.
1,” Dental Update, vol. 38, no. 3, pp. 185-186, 2011. [45] A. M. Xavier, K. Rai, and A. M. Hegde, “Preventative pro-
[32] P. B. Lockhart, B. Loven, M. T. Brennan, and P. C. Fox, “The tocols and management of oral pathologies in chronic kidney
evidence base for the efficacy of antibiotic prophylaxis in disease: an update,” Biological and Biomedical Reports, vol. 2,
pp. 1–9, 2012.
dental practice,” Journal of the American Dental Association,
[46] T. E. Matsha, Y. Y. Yako, M. A. Rensburg, M. S. Hassan,
vol. 138, no. 4, pp. 458–474, 2007.
A. P. Kengne, and R. T. Erasmus, “Chronic kidney diseases in
[33] W. Wilson, K. A. Taubert, M. Gewitz et al., “Prevention of
mixed ancestry south African populations: prevalence, de-
infective endocarditis: guidelines from the American Heart
terminants and concordance between kidney function esti-
Association: a guideline from the American Heart Association
mators,” BMC Nephrology, vol. 14, no. 1, p. 75, 2013.
Rheumatic Fever, Endocarditis, and Kawasaki Disease
[47] S. A. ElHafeez, D. Bolignano, G. D’Arrigo, E. Dounousi,
Committee, Council on Cardiovascular Disease in the Young,
G. Tripepi, and C. Zoccali, “Prevalence and burden of chronic
and the Council on Clinical Cardiology, Council on Car-
kidney disease among the general population and high-risk
diovascular Surgery and Anesthesia, and the Quality of Care
groups in Africa: a systematic review,” BMJ Open, vol. 8, no. 1,
and Outcomes Research Interdisciplinary Working Group,”
article e015069, 2018.
Circulation, vol. 116, no. 15, pp. 1736–1754, 2007, In press.
[48] U. Reyes, A. E. Spolarich, and P. P. Han, “A Comprehensive
[34] J. L. Gutiérrez, J. V. Bagán, A. Bascones et al., “Consensus
oral preventive care protocol for caring for the renal trans-
document on the use of antibiotic prophylaxis in dental
plant population,” Journal of Dental Hygiene, vol. 90,
surgery and procedures,” Medicina Oral Patologia Oral y
pp. 88–99, 2016.
Cirugia Bucal, vol. 11, pp. E188–205, 2006.
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