|Year : 2012 | Volume
| Issue : 2 | Page : 91-94
Endodontic management of patient with established chronic kidney disease undergoing hemodialysis
Navin Mishra, Naseem Shah, Ajay Logani, Isha Narang
Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research, All India Institute of Medical sciences, New Delhi, India
|Date of Web Publication||6-Mar-2013|
Department of Conservative Dentistry and Endodontics, Centre for Dental Education and Research,All India Institute of Medical sciences, New Delhi - 110 029
Source of Support: None, Conflict of Interest: None
Chronic kidney disease is associated with progressive deterioration of renal function resulting in reduced glomerular filtration rate. Multiple drugs used for its management invariably alter the common oral manifestations associated with the disease. The patients require special considerations for endodontic management because of increased tendency towards bleeding episodes, odontogenic infections and drug interactions. The present case report describes the comprehensive endodontic management in a patient of chronic renal disease taking plethora of medications.
Keywords: Chronic kidney disease, uremia, immunosuppressant
|How to cite this article:|
Mishra N, Shah N, Logani A, Narang I. Endodontic management of patient with established chronic kidney disease undergoing hemodialysis. Saudi Endod J 2012;2:91-4
|How to cite this URL:|
Mishra N, Shah N, Logani A, Narang I. Endodontic management of patient with established chronic kidney disease undergoing hemodialysis. Saudi Endod J [serial online] 2012 [cited 2020 Jan 26];2:91-4. Available from: http://www.saudiendodj.com/text.asp?2012/2/2/91/108159
| Introduction|| |
Endodontic management in patients with complex medical conditions is an arduous task even for skilled clinicians. Such medically compromised patients are often referred to dental specialist. Thus, thorough knowledge of the common medical complexities, their implications and multiple drug interactions play an important role in overall management of such patients.
Renal failure is characterized as diminution of excretory function of the kidneys, leading to retention of nitrogenous waste products of metabolism like blood urea nitrogen, uric acid, and creatinine. The most fundamental categorization is as acute kidney failure (AKF) and chronic kidney disease (CKD).  AKF refers to sudden and usually reversible loss of renal function developing over a period of days or weeks characterized by an increase in plasma creatinine level greater than 200 micromole per liter.  Heart failure, fluid loss, renal stones, urinary tract infections, etc., are the important causes of acute kidney failure. Chronic renal disease also known as CKD is classified in 5 stages, on basis of decreasing glomerular filtration rate (GFR). Stage 1 is the mildest form (GFR > 90 ml/min), while stage 5 (GFR < 30 ml/min) a severe form with poor life expectancy. Stage 5 CKD is termed as established chronic kidney disease and is synonymous with the now outdated terms end-stage renal disease (ESRD) or chronic renal failure (CRF).  The main causes of CKD are diabetes mellitus, hypertension, glomerular disease, certain drugs toxicity like NSAIDS, aspirin, amphotericin B, gentamycin, etc.  It has wide spectrum of oral manifestations affecting both hard and soft tissues of the oral cavity like xerostomia, paleness of the mucosal membrane, uremic stomatitis, gingival bleeding, gingival hyperplasia, periodontal infections, oral candidiasis, and osteoporosis of jaw bones.  The frequent occurrence of this disease and paucity of knowledge amongst dental practitioners may hinder the successful management of such cases. This case report describes the successful endodontic management of the patient with chronic kidney disease who was undergoing hemodialysis 3 days in a week and was awaiting kidney transplant.
| Case Report|| |
A 28-year-old male reported to the department of conservative dentistry and endodontics, All India Institute of Medical Sciences (AIIMS) New Delhi, with the chief complaint of continuous throbbing radiating type of pain in the left lower region since 1 week. He had a history of hypertension induced chronic kidney disease and was awaiting transplant. Extra oral examination showed no significant changes apart from pallor. Intraoral examination showed deep occlusal caries with swelling in the mucobuccal fold in respect to tooth # 37, which was tender on palpation and percussion. Ventral surface of tongue, oral mucous membrane showed marked redness, which was very painful and xerostomia was noted. Periodontal evaluation showed no abnormality. Radiographic examination from horizontal and 20 degree mesial and distal angulations showed caries involving the pulp with periapical pathology [Figure 1]. The endodontic diagnosis of acute apical abscess was made. Informed consent was obtained. Inferior alveolar nerve block with 2% lignocaine solution with 1:100,000 adrenaline (Lignox 2% A; Indoco Remedies Ltd, Mumbai, India) was given. Under rubber dam isolation access opening was made through Endo access kit and single canal was located and the pus was drained through the canal.
Copious irrigation was done using 2.5% sodium hypochlorite and 0.9% saline (Vensons India, Bangalore, India) and working length taken by 3 rd generation apex locator. Biomechanical preparation was done with circumferential filing by 0.2 taper files and the canals were dried with paper points (Dentsply, Maillefer) and calcium hydroxide dressing was given. The access was sealed with Cavit G (3M ESPE, Seefeld, and Germany) for 1 week. Patient was prescribed amoxicillin with clavulanic acid 1.5 gram once a day for 7 days, paracetamol 500 mgs if needed, artificial saliva rinse (oralube) 4 times a day, topical anesthetic benzocaine before each meal and multivitamins. Patient was recalled after 8 days, i.e. a day after dialysis and patient symptoms were resolved. Canals were then obturated by warm gutta-percha vertical compaction technique using AH plus (Dentsply Maillefer) sealer. Tooth #37 was restored with silver amalgam over the underlying light cure glass ionomer base. Patient was evaluated radiographically and clinically after 1 year posttransplant and the expected healing was seen [Figure 2].
| Discussion|| |
Patients with renal failure require special considerations in relation to endodontic treatment, not only because of the conditions inherent to the disease, but also because of the side effects and characteristics of the treatments they receive. Because of increased tendency towards bleeding episodes, odontogenic infections and drug interactions endodontic management differs from other dental treatment. Managing medically complex endodontic patient is a team effort hence, close cooperation between nephrologists and dental specialist is desirable in order to improve the oral and general health of the patient.  The recording of complex medical and drug histories should be norm for dental practitioners. The risk associated with multiple-drug therapy in chronic kidney disease is a challenge for our understanding of clinical pharmacology and adverse drug interactions especially in dental settings.
The present case was in stage 5 of chronic kidney disease having xerostomia and uremic stomatitis. Xerostomia can be due to restriction in fluid intake or because of antihypertensive agents,  hence an artificial saliva substitute was prescribed. Uremic stomatitis is an uncommon complication of uremia that may occur as a result of advanced renal failure.  These oral lesions are painful and most often seen on the anterior mucosal surface and tongue. These lesions are not amenable to any treatment as long as the blood urea levels remain high,  and heal spontaneously after functionality of kidneys is restored hence, in the present case a palliative treatment with topical benzocaine ointment was prescribed before meals. In such patients all potential infectious foci from the oral cavity should be eliminated as they are poorly controlled due to depressed immune system and require prophylactic antibiotic coverage to curtail local or distant spread.  The metabolism and elimination of certain drugs are altered in renal failure hence, dose adjustment or modification of the dosing frequency is required. The prescription of aminoglycoside, fluoroquinolones and tetracyclines should be avoided because of their nephrotoxicity. Penicillins (except phenoxymethyl penicillin and flucloxacillin), clindamycin and cephalosporin's can be administered at the usual doses, and are the antibiotics of choice but dose adjustments are made according to the severity of declining GFR with dosing interval of 24 h in stage 5 CKD,  hence in the present case amoxicillin with clavulanic acid 1.5 gram was prescribed once a day for 7 days. Paracetamol is the analgesic of choice and no dose adjustment is required, while aspirin and other non-steroidal anti-inflammatory drugs should be avoided since they aggravate gastrointestinal irritation and possesses antiplatelet activity, which increases the chances of bleeding in such patients.  Propionic acid derivatives like ibuprofen, aryl acetic acid derivative like diclofenac sodium, or a preferential cox 2 inhibitor like nimesulide should be avoided in the more advanced stage of CKD, since they inhibit prostaglandins resulting in raised blood pressure and cerebrovascular accidents. 
These patients have bleeding tendencies due to uremia [Table 1] and hemodialysis.  Dental treatment should commence on a day after dialysis, to ensure the absence of circulating heparin.  Such patients should undergo complete blood count and coagulation profile tests before initiating the surgical endodontics and nerve blocks in nonsurgical root canal therapy. In the present case, coagulation profile and other routine blood test were near normal range. Desmopressin either through intravenous/intranasal have proven to be effective during bleeding episodes. Tranexamic acid can be used as an oral rinse or can be given through oral route in a dose of 500 mgs twice a day to control bleeding in such patients.  Local anesthetics like lidocaine are generally safe and can be administered in their usual dose and anesthesia can be achieved through infiltration, while nerve block is generally not advised unless deemed necessary because of bleeding tendencies. In the present case, IANB was given because coagulation profile tests were in a normal range and in condition of acute periapical abscess infiltration anesthesia does not work well, especially in molar regions on account of thick buccal cortical plate. Regarding conscious sedation, midazolam is preferable to diazepam because of risk of thrombophlebitis. It is also important that in the first 6 months after transplantation, any elective dental treatment should be avoided.  In the present case, endodontic treatment was done before transplant and patient was recalled for follow-up after 1 year and expected healing was seen.
| Conclusion|| |
The prevalence of chronic kidney disease is high and over 1 million people worldwide are alive on dialysis or with a functioning graft.  Incidence of CKD has doubled in the last 15 years. These patients have wide systemic and oral manifestation; hence dental management is complicated even for an astute clinician. The main difficulties encountered in these patients are bleeding tendencies, infections, and drug interactions hence with a team effort and well supervised treatment protocols, dental treatment can be made effective and safe.
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[Figure 1], [Figure 2]