```markdown THE UNIVERSITY OF WESTERN AUSTRALIA | Oral Health Centre of Western Australia Renal disease and nutritional deficiencies Bobby Joseph Associate Professor 2026 ``` Bobby Joseph Associate Professor 2026 # Learning objectives - To be familiar with the oral manifestations of chronic renal failure - To understand the dental management of renal patients undergoing dialysis - To know the oral complications of renal transplant - To understand the significance of nutrition in maintaining oral health and the integrity of the oral mucous membrane Upon completion of this section, students should be able to: - Demonstrate familiarity with the oral manifestations of chronic renal failure. - Understand the dental management protocols for renal patients undergoing dialysis. - Identify the oral complications associated with renal transplants. - Recognize the significance of nutrition in maintaining oral health and the integrity of the oral mucous membrane. ```html <table> <tr> <td>Left Kidney (in cross-section)</td> </tr> <tr> <td>Diaphragm</td> </tr> <tr> <td>Pelvis of Kidney</td> </tr> <tr> <td>Renal Arteries (red) & Veins (blue)</td> </tr> <tr> <td>Inferior Vena Cava</td> </tr> <tr> <td>Descending Aorta</td> </tr> <tr> <td>Adrenal Gland</td> </tr> <tr> <td>Right Kidney</td> </tr> <tr> <td>Ureters</td> </tr> <tr> <td>Bladder</td> </tr> </table> ```  #### Anatomical Structures of the Renal System - **Left Kidney (in cross-section)** - **Right Kidney** - **Adrenal Gland** - **Diaphragm** - **Pelvis of Kidney** - **Renal Arteries (red) & Veins (blue)** - **Inferior Vena Cava** - **Descending Aorta** - **Ureters** - **Bladder** A detailed anatomical diagram showing the human kidneys, adrenal glands, and associated blood vessels. The diagram includes a cross-section of the left kidney, highlighting the renal pelvis, and labels key structures such as the inferior vena cava, descending aorta, renal arteries (red), renal veins (blue), ureters, and bladder. The right kidney is shown in its anatomical position with the adrenal gland above it. # Functions of kidney - Elimination of waste products, particularly urea - Excretion of metabolites and drugs - Regulation of blood volume and electrolyte concentration - Regulation of RBC production in the bone marrow by secreting erythropoietin - Participation in calcium homeostasis and synthesize vitamin D, renin and prostaglandins - Elimination of waste products, particularly urea - Excretion of metabolites and drugs - Regulation of blood volume and electrolyte concentration - Regulation of RBC production in the bone marrow by secreting erythropoietin - Participation in calcium homeostasis and synthesize vitamin D, renin and prostaglandins ```markdown # Renal disease - Renal disease is of great significance in general dental practice - Dental management needs to be modified to prevent complications - Oral changes occur - Chronic renal failure - Result of medical management ``` #### Significance in Dental Practice - Renal disease is of great significance in general dental practice. - Dental management needs to be modified to prevent complications. - Oral changes occur due to: - Chronic renal failure - Results of medical management # Renal disorders - Patients with kidney disorders are seen in dental practice due to improvements in medical care leading to prolonged life expectancy - Essential to have a working knowledge on renal disorders to provide appropriate and safe dental care - Oral changes as a result of chronic renal failure - Dental management modified to prevent complications #### Clinical Overview - Patients with kidney disorders are seen in dental practice due to improvements in medical care leading to prolonged life expectancy. - It is essential to have a working knowledge of renal disorders to provide appropriate and safe dental care. - Oral changes occur as a result of chronic renal failure. - Dental management must be modified to prevent complications. # Dental aspects of renal diseases - Renal function - Chronic renal failure: oral manifestations - Renal patient undergoing dialysis: dental management - Renal transplant patients: oral complications 7 #### Key Areas of Dental Concern - Renal function assessment - Chronic renal failure: oral manifestations - Dental management of renal patients undergoing dialysis - Oral complications in renal transplant patients Points of relevance in the history of a patient with a renal disorder - History of diabetes mellitus - Chronic renal failure (CRF) - Related bony disorders - Anaemia - Dialysis - type - how often - presence of A-V fistula - Transplant - when - associated medication including steroids - Susceptibility to infections/recent history of repeated infection (dental or generalised) #### Relevant Medical History for Renal Patients - History of diabetes mellitus - Chronic renal failure (CRF) - Related bony disorders - Anaemia - Dialysis details: - Type of dialysis - Frequency - Presence of A-V fistula - Transplant history: - Date of transplant - Associated medication (including steroids) - Susceptibility to infections or recent history of repeated infections (dental or generalised) # Chronic renal failure (CRF) - Progressive kidney damage - Early CRF: patient notice a need to urinate frequently at night (nocturia) - Notice uncharacteristically poor appetite - Adult CRF leads to hypertension and uraemia - CRF can affect diverse body systems #### Progression of Chronic Renal Failure (CRF) - CRF involves progressive kidney damage. - Early symptoms include nocturia (frequent urination at night). - Patients may notice an uncharacteristically poor appetite. - Adult CRF leads to hypertension and uraemia. - The condition can affect diverse body systems. # Chronic renal failure - Irreversible deterioration in renal function - Plasma creatinine persistently exceeds 300µmol/l (normal range 80-120µmol/l) - Low glomerular filtration rate persisting over 3 months (normal 120ml/min) #### Diagnostic Indicators - Irreversible deterioration in renal function. - Plasma creatinine persistently exceeds 300µmol/l (normal range: 80-120µmol/l). - Low glomerular filtration rate (GFR) persisting over 3 months (normal: 120ml/min). # Clinical features of chronic renal failure: a systemic approach ## Cardiovascular - Hypertension - Congestive cardiac failure - Atheroma ## Gastrointestinal - Anorexia, nausea, vomiting - Peptic ulcer ## Neurological - Lassitude - Headaches - Tremor - Sensory disturbances #### Systemic Clinical Features **Cardiovascular** - Hypertension - Congestive cardiac failure - Atheroma **Gastrointestinal** - Anorexia, nausea, vomiting - Peptic ulcer **Neurological** - Lassitude - Headaches - Tremor - Sensory disturbances ```markdown - **Dermatological** - Itching - Hyperpigmentation - **Haematological/Immunological** - Bleeding tendency - Anaemia - Susceptibility to infection - **Metabolic “Uraemia”** - Thirst - Nocturia/polyuria - Electrolyte disturbances - Secondary hyperparathyroidism ``` #### Additional Systemic Features **Dermatological** - Itching - Hyperpigmentation **Haematological/Immunological** - Bleeding tendency - Anaemia - Susceptibility to infection **Metabolic "Uraemia"** - Thirst - Nocturia/polyuria - Electrolyte disturbances - Secondary hyperparathyroidism # Oral manifestations of CRF - Dry mouth - Mucosal ulceration - Bacterial & fungal plaques - Pallour of the mucosa - Oral purpura - Giant cell lesions (osteolytic lesions in jaws) - White plaques (uraemic stomatitis)   - Dry mouth - Mucosal ulceration - Bacterial & fungal plaques - Pallor of the mucosa - Oral purpura - Giant cell lesions (osteolytic lesions in jaws) - White plaques (uraemic stomatitis) A close-up photograph showing a mucosal ulceration on the inner lip, with an arrow pointing to the affected area and the label 'ulceration' indicating the condition. A photograph of the oral cavity displaying purpura, with an arrow and label pointing to the purplish discoloration on the mucosal surface, illustrating a symptom of CRF. # Uraemia - Presence of excessive amounts of urea, nitrogenous waste compounds in the blood - Causes kidney failure - Results in nausea, vomiting, lethargy, drowsiness - Treatment may require haemodialysis #### Uraemia Overview - Defined as the presence of excessive amounts of urea and nitrogenous waste compounds in the blood. - Results from kidney failure. - Clinical symptoms include nausea, vomiting, lethargy, and drowsiness. - Treatment may require haemodialysis. # Uraemic stomatitis - Due to markedly elevated levels of urea and other nitrogenous wastes in the blood stream - Clinically seen as white plaques on the buccal mucosa, floor of mouth and tongue - Pain and unpleasant taste and burning sensation in the mouth - Odour of ammonia or urine in the patient’s breath - Clinical appearance can mimic oral hairy leukoplakia - Caused by markedly elevated levels of urea and other nitrogenous wastes in the bloodstream. - **Clinical Presentation:** - White plaques on the buccal mucosa, floor of the mouth, and tongue. - Pain, unpleasant taste, and burning sensation. - Odour of ammonia or urine on the breath. - **Differential Diagnosis:** Clinical appearance can mimic oral hairy leukoplakia. ```markdown Types of uraemic stomatitis 1. Ulcerative 2. Haemorrhagic 3. Non-ulcerative, pseudomembranous 4. Hyperkeratotic White lesions ```   #### Classification of Uraemic Stomatitis 1. Ulcerative 2. Haemorrhagic 3. Non-ulcerative, pseudomembranous 4. Hyperkeratotic (White lesions) The title 'Types of uraemic stomatitis' is displayed at the top of the page in a large, dark font, indicating the main subject of the content. A numbered list of four types of uraemic stomatitis is presented: 1. Ulcerative, 2. Haemorrhagic, 3. Non-ulcerative, pseudomembranous, and 4. Hyperkeratotic. A bracket on the right side groups the third and fourth types under the label 'White lesions'. ```html <table> <thead> <tr> <th colspan="2">Uraemic stomatitis</th> </tr> </thead> <tbody> <tr> <td><strong>Ulcerative</strong><br>Painful superficial ulcers covered by a pseudomembrane</td> <td><strong>Non-ulcerative</strong><br>Painful diffuse oedematous erythema and thick greyish pseudomembrane</td> </tr> </tbody> </table> ```   #### Clinical Subtypes - **Ulcerative:** Characterized by painful superficial ulcers covered by a pseudomembrane. - **Non-ulcerative:** Characterized by painful diffuse oedematous erythema and a thick greyish pseudomembrane. A photograph showing ulcerative uraemic stomatitis with painful superficial ulcers covered by a pseudomembrane, characterized by dark, necrotic lesions on the oral mucosa. A photograph depicting non-ulcerative uraemic stomatitis, featuring painful diffuse oedematous erythema and a thick greyish pseudomembrane on the tongue. # Osseous lesions - Loss of lamina dura - Osteoporosis - Osteolytic areas (renal osteodystrophy) - Secondary hyperparathyroidism - Abnormal bone repair after extractions - Renal disease patients screened for bone disease before implant placement   - Loss of lamina dura - Osteoporosis - Osteolytic areas (renal osteodystrophy) - Secondary hyperparathyroidism - Abnormal bone repair after extractions - **Note:** Renal disease patients should be screened for bone disease before dental implant placement. Two dental radiographs showing osseous lesions: one depicting loss of lamina dura and osteolytic areas, and the other showing a bone lesion with possible secondary hyperparathyroidism, both related to renal osteodystrophy. A histological image of bone tissue showing abnormal bone repair after extractions, with cellular and structural changes indicative of osseous lesions. # Orofacial features of renal osteodystrophy: tooth and periodontium - Delayed eruption - Enamel hypoplasia - Loss of lamina dura - Widening of the periodontal ligament - Severe periodontal destruction - Tooth mobility - Drifting - Pulp calcifications - Pulp narrowing #### Effects on Tooth and Periodontium - Delayed eruption - Enamel hypoplasia - Loss of lamina dura - Widening of the periodontal ligament - Severe periodontal destruction - Tooth mobility - Drifting - Pulp calcifications - Pulp narrowing ```markdown Dialysis - Remove metabolites by exposing the patient’s blood across a semi-permeable membrane to a hypotonic solution - Essential if renal function worsens to end-stage renal disease (ESRD) ``` #### Dialysis Mechanism - Removes metabolites by exposing the patient’s blood across a semi-permeable membrane to a hypotonic solution. - Essential if renal function worsens to end-stage renal disease (ESRD). ```markdown Dialysis - Haemodialysis > arteriovenous shunt necessary - Continuous ambulatory peritoneal dialysis (CAPD) > no hospitalization required - Continuous cyclic peritoneal dialysis (CCPD) > machine does the exchanges at night ``` #### Types of Dialysis - **Haemodialysis:** Requires an arteriovenous (A-V) shunt. - **Continuous Ambulatory Peritoneal Dialysis (CAPD):** No hospitalization required. - **Continuous Cyclic Peritoneal Dialysis (CCPD):** A machine performs exchanges at night. ```markdown Dental management of haemodialysed patients: some important considerations - Impaired excretion of drugs by kidney - Bleeding tendency - Heparinization prior to dialysis - A-V shunts susceptible to infection - Anaemia - Increased carriage of Hepatitis B & C - Hypertension ```  #### Dental Management of Haemodialysed Patients - Impaired excretion of drugs by the kidney. - Bleeding tendency. - Heparinization prior to dialysis. - A-V shunts are susceptible to infection. - Anaemia. - Increased carriage of Hepatitis B & C. - Hypertension. A photograph showing an arterio-venous fistula on a patient's arm, labeled with an arrow pointing to the site. This image illustrates a common vascular access method for haemodialysis patients, which is relevant to the dental management considerations listed in the surrounding text. The optimum time for renal patients to undergo dental procedures is 12-24 hours post-haemodialysis #### Timing of Treatment The optimum time for renal patients to undergo dental procedures is 12-24 hours post-haemodialysis. # Renal transplant patients - Side-effects of immunosuppressive regimes - Pose a no: of dental & management problems - Cyclosporin : A nephrotoxic drug!!! - Nifidepine : hypertension in renal patients - Patients face side-effects from immunosuppressive regimes. - Presents several dental and management challenges. - **Cyclosporin:** A nephrotoxic drug. - **Nifedipine:** Used for hypertension in renal patients. # Oral complications of renal transplantation - Drug induced gingival overgrowth - Bacterial & fungal plaques - Increased incidence of oral malignancy (cyclosporin) reported - Oral candidosis - Herpes simplex infections (secondary) - Drug-induced gingival overgrowth - Bacterial & fungal plaques - Increased incidence of oral malignancy (reported with cyclosporin) - Oral candidosis - Secondary herpes simplex infections ```html <table> <tr> <td><img src="https://i.imgur.com/5ZjKQ7l.jpg" alt="Gingival overgrowth"></td> <td><img src="https://i.imgur.com/4mQ0Z8E.jpg" alt="Carcinoma of gingiva"></td> </tr> <tr> <td><img src="https://i.imgur.com/9QfLh8W.jpg" alt="Herpes simplex"></td> <td><img src="https://i.imgur.com/7VXqGnU.jpg" alt="Oral candidosis"></td> </tr> </table> ```     #### Clinical Presentations - Gingival overgrowth - Carcinoma of the gingiva - Herpes simplex - Oral candidosis A clinical photograph showing gingival overgrowth, characterized by swollen, pink, and enlarged gums surrounding the teeth, with a normal tooth structure visible beneath. A clinical photograph of carcinoma of the gingiva, displaying a lesion on the gum tissue with a dark, irregular, and possibly necrotic area adjacent to the teeth. A clinical photograph illustrating herpes simplex infection, showing multiple small, fluid-filled vesicles on the inflamed mucosal surface of the mouth. A clinical photograph of oral candidosis, depicting a white, curd-like, and textured lesion on the tongue, characteristic of fungal infection. ```markdown Immunosuppressive therapy 1. Cyclosporin 2. Combined cyclosporin and nifedipine 3. Tacrolimus-less gingival enlargement? 4. Corticosteroids ``` #### Common Immunosuppressive Agents 1. Cyclosporin 2. Combined cyclosporin and nifedipine 3. Tacrolimus (may result in less gingival enlargement) 4. Corticosteroids # Disorders related to immunosuppression - Lymphoma - Skin cancers - Hairy leukoplakia - Leukoplakia - Kaposi’s sarcoma ## Skin cancer ## Leukoplakia ## Hairy leukoplakia ## Kaposi’s sarcoma     #### Associated Pathologies - Lymphoma - Skin cancers - Hairy leukoplakia - Leukoplakia - Kaposi’s sarcoma A close-up photo of skin cancer on the face, showing a red, irritated lesion with a rough texture, labeled 'Skin cancer'. A photo of leukoplakia inside the mouth, displaying a white, irregular patch on the oral mucosa, labeled 'Leukoplakia'. A photo of hairy leukoplakia on the tongue, showing a white, corrugated lesion, labeled 'Hairy leukoplakia'. A photo of Kaposi's sarcoma in the mouth, displaying red-purple lesions on the gums and palate, labeled 'Kaposi's sarcoma'. # Prescribing for patients with renal disease - Many drugs prescribed by dentists are excreted by kidneys - Failure to excrete drug or metabolites lead to toxicity - Nephrotoxic drugs should be avoided e.g. gentamycin - Drugs may require dose reduction 29 - Many drugs prescribed by dentists are excreted by the kidneys. - Failure to excrete drugs or metabolites leads to toxicity. - Nephrotoxic drugs (e.g., gentamicin) should be avoided. - Drugs may require dose reduction. ```html <table> <thead> <tr> <th>Drug</th> <th>Caution</th> </tr> </thead> <tbody> <tr> <td><b>Antibiotics</b><br>Amoxicillin, ampicillin</td> <td>Reduce dose, rash more common</td> </tr> <tr> <td><b>Erythromycin</b></td> <td><b>Contraindicated</b> in patients who had kidney transplant</td> </tr> <tr> <td><b>Tetracyclines</b></td> <td><b>Avoid</b>; use of doxycycline or minocycline if necessary (avoid excessive doses)</td> </tr> <tr> <td></td> <td>Doxycycline increases plasma-cyclosporin concentration</td> </tr> <tr> <td><b>Antifungals</b><br>Amphotericin<br>Fluconazole<br>Miconazole</td> <td>Increases plasma-cyclosporin concentration</td> </tr> <tr> <td><b>Antiviral</b><br>Acyclovir</td> <td>Reduce dose</td> </tr> </tbody> </table> ```  #### Antibiotic and Antifungal Considerations - **Amoxicillin, ampicillin:** Reduce dose; rash is more common. - **Erythromycin:** Contraindicated in patients who have had a kidney transplant. - **Tetracyclines:** Avoid; use doxycycline or minocycline if necessary (avoid excessive doses). Doxycycline increases plasma-cyclosporin concentration. - **Antifungals (Amphotericin, Fluconazole, Miconazole):** Increases plasma-cyclosporin concentration. - **Acyclovir:** Reduce dose. A table listing various drug categories and their associated cautions, including antibiotics (e.g., amoxicillin, erythromycin), antifungals (e.g., amphotericin, fluconazole), and antivirals (e.g., acyclovir). The table provides specific cautions such as dose reduction, contraindications, and interactions with cyclosporin. ```html <table> <thead> <tr> <th>Drug</th> <th>Caution</th> </tr> </thead> <tbody> <tr> <td><strong>Analgesics</strong></td> <td></td> </tr> <tr> <td>Aspirin</td> <td>Avoid (sodium, water retention; deterioration in renal function; risk of gastric hemorrhage)</td> </tr> <tr> <td>Ibuprofen, diflunisal</td> <td>Avoid if possible/use lowest effective dose, monitor renal function</td> </tr> <tr> <td>Dihydrocodeine, pethidine</td> <td>Reduce dose/ avoid (increased and prolonged effect, increased cerebral sensitivity)</td> </tr> <tr> <td><strong>Other Drugs</strong></td> <td></td> </tr> <tr> <td>Carbamazepine</td> <td>Reduces plasma-cyclosporin concentration</td> </tr> <tr> <td>Nitrazepam, temazepam</td> <td>Start with small doses (increased cerebral sensitivity)</td> </tr> <tr> <td>Povidone-iodine</td> <td>Avoid regular application to inflamed or broken mucosa</td> </tr> <tr> <td>Ephedrine</td> <td>Avoid (CNS toxicity)</td> </tr> </tbody> </table> ```  #### Analgesic and Other Drug Considerations - **Aspirin:** Avoid (causes sodium/water retention, deterioration in renal function, and risk of gastric hemorrhage). - **Ibuprofen, diflunisal:** Avoid if possible; use lowest effective dose and monitor renal function. - **Dihydrocodeine, pethidine:** Reduce dose or avoid (increased/prolonged effect and cerebral sensitivity). - **Carbamazepine:** Reduces plasma-cyclosporin concentration. - **Nitrazepam, temazepam:** Start with small doses due to increased cerebral sensitivity. - **Povidone-iodine:** Avoid regular application to inflamed or broken mucosa. - **Ephedrine:** Avoid due to CNS toxicity. A table listing various drugs and associated cautions. The table is divided into two columns: 'Drug' and 'Caution'. Under 'Drug', it lists categories such as 'Analgesics' and 'Other Drugs', with specific drug names like Aspirin, Ibuprofen, Carbamazepine, and Ephedrine. The 'Caution' column provides specific warnings for each drug, such as avoiding Aspirin due to sodium retention and gastric hemorrhage risk, or reducing the dose of Dihydrocodeine due to increased cerebral sensitivity. The table is presented with a clear structure, using bold text for headers and organized content for readability. Autosomal dominant polycystic kidney disease (ADPKD) - Common genetic disease- 1 in every 800 people - Mostly teenagers & young adults affected - Kidneys enlarge, fill up the abdomen - Lumbar pain, haematuria, hypertension - High levels of circulating ammonia - Breath smells of urine - Treatment: dialysis or renal transplantation  - Common genetic disease (1 in 800 people). - Mostly affects teenagers and young adults. - **Clinical Features:** - Kidneys enlarge and fill the abdomen. - Lumbar pain, haematuria, and hypertension. - High levels of circulating ammonia. - Breath smells of urine. - **Treatment:** Dialysis or renal transplantation. Two oval-shaped photographs showing enlarged kidneys with multiple cysts, illustrating the effects of autosomal dominant polycystic kidney disease (ADPKD). The images depict the characteristic appearance of the kidneys with numerous fluid-filled sacs, consistent with the condition described in the surrounding text. # Kidney tumours ## Wilms’ tumour - Common in children - Age 1-4 years - 6-7% of all childhood cancers - Mutation of WT 1 gene ## Renal cell carcinoma - 85% of all malignancies - Incidental mass - No symptoms - Haematuria - Abdominal pain - Smokers increased risk #### Wilms’ Tumour - Common in children (ages 1-4 years). - Accounts for 6-7% of all childhood cancers. - Associated with mutation of the WT 1 gene. #### Renal Cell Carcinoma - Accounts for 85% of all renal malignancies. - Often presents as an incidental mass. - **Symptoms:** Haematuria, abdominal pain, or no symptoms. - Smokers have an increased risk. # Case-study A 45-year-old male patient with a history of chronic renal failure presents with severe toothache. He undergoes regular haemodialysis. He looks very tired and has come directly from the renal dialysis unit. O/E there is a grossly carious maxillary first molar that requires extraction. There is no associated soft tissue swelling but you notice white plaques on the tongue and buccal mucosa. These do not wipe off and the patient reports that ‘they come and go’. 1. How would you manage the dental extraction of this patient? 2. What is the most likely diagnosis of the white plaques on the patient’s oral mucosa? #### Clinical Scenario A 45-year-old male with chronic renal failure on regular haemodialysis presents with severe toothache. He appears tired post-dialysis. Examination reveals a grossly carious maxillary first molar requiring extraction. No soft tissue swelling is present, but non-wipeable white plaques are noted on the tongue and buccal mucosa, which the patient says "come and go." **Discussion Questions:** 1. How would you manage the dental extraction of this patient? 2. What is the most likely diagnosis of the white plaques on the patient’s oral mucosa? # Answers **Q1.** Extraction carried out at least 12 hrs post haemodialysis Recent FBC to exclude thrombocytopaenia Established protocol for preoperative antibiotic prophylaxis? If there is none consult renal unit Routine LA must be employed Suture the wound, insert haemostatic gauze and check there is no postoperative bleeding Patient may have tendency to bleed after extraction **Q2.** White plaques likely to be uraemic stomatitis No treatment required If the plaques rub off – candida > Antifungal agent: fluconazole Culture and sensitivity of microorganisms indicate the therapy of choice #### Case Study Answers **Management of Extraction (Q1):** - Perform extraction at least 12 hours post-haemodialysis. - Obtain a recent Full Blood Count (FBC) to exclude thrombocytopaenia. - Consult the renal unit regarding preoperative antibiotic prophylaxis protocols. - Use routine local anaesthesia (LA). - Suture the wound, insert haemostatic gauze, and monitor for postoperative bleeding due to potential bleeding tendencies. **Diagnosis of White Plaques (Q2):** - Likely diagnosis: Uraemic stomatitis. - No treatment is required for these plaques. - **Differential:** If plaques rub off, consider Candida. Treatment: Antifungal agent (e.g., fluconazole). Culture and sensitivity should guide therapy. ```markdown 1. Renal patients may have impaired drug excretion. Drugs used in dental sedation and GA should be used with caution and in consultation with a physician 2. Renal disease influences the use of NSAIDS and some antimicrobials in dentistry 3. Bleeding tendency due to platelet dysfunction 4. Dental treatment should be carried out on the day after dialysis 5. The surgically created arterio-venous fistula **should not** be used for venepuncture by the dentist 6. Kidney transplant patients may need corticosteroid cover 7. Bleeding tendency if anticoagulated 8. Gingival hyperplasia if taking cyclosporin 9. Prone to infection due to immunosuppression Summary ``` #### Summary of Dental Considerations for Renal Patients 1. Renal patients may have impaired drug excretion. Drugs for sedation and GA should be used with caution in consultation with a physician. 2. Renal disease influences the use of NSAIDs and certain antimicrobials. 3. Platelet dysfunction may cause a bleeding tendency. 4. Dental treatment should ideally be carried out the day after dialysis. 5. Surgically created arterio-venous fistulas **should not** be used for venepuncture by the dentist. 6. Kidney transplant patients may require corticosteroid cover. 7. Anticoagulation therapy may increase bleeding risk. 8. Cyclosporin use may lead to gingival hyperplasia. 9. Immunosuppression makes patients prone to infection. # Nutritional deficiencies - Nutrition is defined by the W.H.O as “intake of food considered in relation to the body’s dietary needs” - Malnutrition can significantly affect oral health - Poor oral health in turn can result in malnutrition - Dietary recommendation for intake both macro and micronutrients differ for the population sub-type - Nutritional deficiencies can lead to - Disease progression through altered tissue homeostasis - Reduced resistance to microbial biofilm - Decrease in tissue healing Nutrition is defined by the W.H.O as the "intake of food considered in relation to the body’s dietary needs." #### Impact of Nutrition on Oral Health - Malnutrition can significantly affect oral health. - Poor oral health in turn can result in malnutrition. - Dietary recommendations for intake of both macro and micronutrients differ for various population sub-types. #### Consequences of Nutritional Deficiencies Nutritional deficiencies can lead to: - Disease progression through altered tissue homeostasis. - Reduced resistance to microbial biofilm. - Decrease in tissue healing. ```html <table border="1" class="dataframe"> <thead> <tr style="text-align: left;"> <th>Vitamin deficiencies</th> <th>Systemic effects</th> <th>Oral effects</th> </tr> </thead> <tbody> <tr> <td>Vitamin A</td> <td>Night blindness<br>Xerophthalmia</td> <td>Decreases epithelial tissue development; may contribute to leukoplakia/cancer</td> </tr> <tr> <td>Vitamin B1 (Thiamine)</td> <td>Neuritis, cardiac failure</td> <td>Cracked lips?</td> </tr> <tr> <td>Vitamin B2 (Riboflavin)</td> <td>Dermatitis</td> <td>Angular stomatitis, glossitis</td> </tr> <tr> <td>Vitamin B3 (Niacin)</td> <td>Dermatitis, CNS disease</td> <td>Glossitis, stomatitis and gingivitis</td> </tr> <tr> <td>Vitamin B12</td> <td>Pernicious anaemia</td> <td>Glossitis, aphthae</td> </tr> <tr> <td>Folic acid</td> <td>Macrocytic anaemia</td> <td>Glossitis, aphthae</td> </tr> <tr> <td>Vitamin C</td> <td>Scurvy (purpura, delayed wound healing, bone lesions in children</td> <td>Gingival swelling and bleeding</td> </tr> <tr> <td>Vitamin D</td> <td>Rickets</td> <td>Hypocalcification of teeth</td> </tr> </tbody> </table> ```  | Vitamin Deficiencies | Systemic Effects | Oral Effects | | :--- | :--- | :--- | | Vitamin A | Night blindness, Xerophthalmia | Decreases epithelial tissue development; may contribute to leukoplakia/cancer | | Vitamin B1 (Thiamine) | Neuritis, cardiac failure | Cracked lips? | | Vitamin B2 (Riboflavin) | Dermatitis | Angular stomatitis, glossitis | | Vitamin B3 (Niacin) | Dermatitis, CNS disease | Glossitis, stomatitis and gingivitis | | Vitamin B12 | Pernicious anaemia | Glossitis, aphthae | | Folic acid | Macrocytic anaemia | Glossitis, aphthae | | Vitamin C | Scurvy (purpura, delayed wound healing, bone lesions in children) | Gingival swelling and bleeding | | Vitamin D | Rickets | Hypocalcification of teeth | A table titled 'The effects of vitamin deficiencies' that lists various vitamin deficiencies, their systemic effects, and their oral effects. The table includes vitamins A, B1 (Thiamine), B2 (Riboflavin), B3 (Niacin), B12, Folic acid, C, and D, detailing associated health issues such as night blindness, neuritis, dermatitis, scurvy, and rickets, along with oral manifestations like cracked lips, glossitis, and gingival bleeding. Vitamin A - Nutrient important for vision, growth, cell division, reproduction and immunity - Has antioxidant properties - Found in many foods such as, spinach, dairy products, liver - Other sources of food rich in beta-carotene (green leafy vegetables, carrots) - What the research says: - Acne (large doses no effect) - Macular degeneration (reduce risk by 25%) - Cancer (lung, prostate unclear) - Measles (reduce death) Vitamin A is a nutrient important for vision, growth, cell division, reproduction, and immunity. It possesses antioxidant properties. #### Dietary Sources - Found in many foods such as spinach, dairy products, and liver. - Other sources rich in beta-carotene include green leafy vegetables and carrots. #### Research Findings - **Acne:** Large doses have shown no effect. - **Macular degeneration:** May reduce risk by 25%. - **Cancer:** Effects on lung and prostate cancer remain unclear. - **Measles:** Shown to reduce death rates. # Vitamin A deficiency - Severe effects on secretory epithelium (rats) - Columnar cells become squamous and keratinised - Dental development is severely affected - No evidence in humans for such changes - Treatment of keratotic plaques (leukoplakia) with retinoids (Vitamin A derivatives) - Drugs have toxic side effects - Epidemiological studies suggested low Vitamin A intake is associated with oral and other cancers #### Effects of Deficiency - Severe effects on secretory epithelium (observed in rats). - Columnar cells become squamous and keratinised. - Dental development is severely affected. - Note: There is no evidence in humans for these specific cellular changes. #### Clinical Applications and Studies - Treatment of keratotic plaques (leukoplakia) with retinoids (Vitamin A derivatives). - Retinoid drugs have toxic side effects. - Epidemiological studies suggest low Vitamin A intake is associated with oral and other cancers. # Riboflavin deficiency - Result from malabsorption syndrome - In severe cases: angular stomatitis, painful red fissures at the angles of mouth - Glossitis (tongue becomes magenta in colour and granular) - Resolution follows after administering riboflavin (5 mg 1 tds) #### Riboflavin (B2) Deficiency - Often results from malabsorption syndrome. - **Severe cases:** Angular stomatitis, characterized by painful red fissures at the angles of the mouth. - **Glossitis:** The tongue becomes magenta in color and granular. - **Treatment:** Resolution follows after administering riboflavin (5 mg 1 tds). # Nicotinamide deficiency (pellagra) - Affects the skin, GI tract, nervous system - Weakness, loss of appetite, changes in mood - Glossitis - Tip and lateral margins of tongue, red, swollen - Dorsum of tongue coated with thick, greyish fir - Gingival margins are red, swollen, ulcerated #### Nicotinamide (B3) Deficiency (Pellagra) - Affects the skin, GI tract, and nervous system. - General symptoms include weakness, loss of appetite, and changes in mood. #### Oral Manifestations of Pellagra - **Glossitis:** The tip and lateral margins of the tongue appear red and swollen. - **Tongue Appearance:** The dorsum of the tongue is coated with thick, greyish fur. - **Gingiva:** Gingival margins are red, swollen, and ulcerated. # Aetiology of Vit B12 deficiency - **Autoimmune**: Pernicious anemia is an autoimmune condition in which antibodies to intrinsic factor are produced - **Malabsorption**: Parietal cells in the stomach produce intrinsic factor; therefore, any patient with a history of gastric bypass surgery may be at risk for developing a B12 deficiency - **Dietary Insufficiency**: vegans #### Aetiology of Vitamin B12 Deficiency 1. **Autoimmune:** Pernicious anemia is an autoimmune condition in which antibodies to intrinsic factor are produced. 2. **Malabsorption:** Parietal cells in the stomach produce intrinsic factor; therefore, any patient with a history of gastric bypass surgery may be at risk for developing a B12 deficiency. 3. **Dietary Insufficiency:** Observed in vegans. # Folic acid deficiency - Result from malnutrition, anticonvulsant therapy, pregnancy, alcoholism - Women advised to take folic acid supplements for reducing risk of neural tube defects - Also, may reduce risk of orofacial clefts #### Folic acid deficiency - Can result from malnutrition, anticonvulsant therapy, pregnancy, and alcoholism. - Women are advised to take folic acid supplements to reduce the risk of neural tube defects. - Supplementation may also reduce the risk of orofacial clefts. - Vitamin B12 and folic acid deficiency - Glossitis - Raw beefy tongue <img src="https://i.imgur.com/8XzZQ9L.jpg" alt="Glossitis and Raw beefy tongue images side by side"/> <img src="https://i.imgur.com/8XzZQ9L.jpg" alt="Glossitis and Raw beefy tongue images side by side"/>  #### Combined B12 and Folic Acid Deficiency Oral manifestations include: - Glossitis - Raw beefy tongue Two side-by-side photographs showing the effects of vitamin B12 and folic acid deficiency on the tongue. The left image displays glossitis with a smooth, red, and shiny tongue, while the right image shows a raw beefy tongue with a similar appearance, illustrating the clinical presentation of these deficiencies. # Vitamin D deficiency - Vitamin D obtained mainly from exposure to sunlight and diet - Rich source of Vitamin D is fish liver oils - Causes rickets during skeletal development - In severe cases induce defective tooth mineralization - Associated with higher prevalence of periodontitis and gingival inflammation - Also, may be linked osteonecrosis of jaws - Linked to oral cancer development? Vitamin D is obtained mainly from exposure to sunlight and diet. A rich source of Vitamin D is fish liver oils. #### Clinical Implications of Deficiency - Causes rickets during skeletal development. - In severe cases, induces defective tooth mineralization. - Associated with a higher prevalence of periodontitis and gingival inflammation. - May be linked to osteonecrosis of the jaws. - Potentially linked to oral cancer development. ```markdown # Vitamin C deficiency - Scurvy, once common among crews of sailing ships - Rarely seen today - Cases still occur in elderly, neglected and younger patients with markedly restricted diet - Skin manifestations include capillary fragility, spontaneous bruising - Oral manifestations - Friable, swollen, bleeding gingiva - Marked false pocketing - Mobility of teeth ``` Vitamin C deficiency leads to Scurvy, which was once common among crews of sailing ships. #### Prevalence and Risk Groups - Rarely seen today. - Cases still occur in elderly, neglected, and younger patients with markedly restricted diets. #### Manifestations - **Skin:** Capillary fragility and spontaneous bruising. - **Oral:** - Friable, swollen, bleeding gingiva. - Marked false pocketing. - Mobility of teeth. Iron deficiency - Symptoms - Fatigued, listless and weak - Short of breath, dizzy and light-headed - Struggling to concentrate - Getting infections - Decreased libido - Oral findings - Depapillated atrophic tongue - Glossodynia (burning sensation) - Candidiasis/ angular cheilitis - Aphthous-like ulcers  #### Systemic Symptoms - Fatigued, listless, and weak. - Short of breath, dizzy, and light-headed. - Struggling to concentrate. - Increased susceptibility to infections. - Decreased libido. #### Oral Findings - Depapillated atrophic tongue. - Glossodynia (burning sensation). - Candidiasis / angular cheilitis. - Aphthous-like ulcers. A close-up photo of a depapillated atrophic tongue, showing a smooth, red, and shiny surface with loss of papillae, which is a common oral finding in iron deficiency. The image is positioned next to a list of symptoms and oral findings related to iron deficiency. Iron deficiency - Glossitis - Smooth, depapillated tongue <img src="https://i.imgur.com/7QZ8X.png" alt="Image of a red, smooth tongue with visible glossitis." /> <img src="https://i.imgur.com/9QZ8X.png" alt="Image of a smooth, depapillated tongue." />   #### Tongue Manifestations - Glossitis - Smooth, depapillated tongue A close-up photo of a red, smooth tongue showing signs of glossitis, associated with iron deficiency as indicated by the surrounding text. A close-up photo of a smooth, depapillated tongue, illustrating the clinical appearance of glossitis due to iron deficiency. Anorexia nervosa Anorexia nervosa - Food avoidance - Underweight - Distorted body image - Fear of obesity - Medical conditions: renal failure, liver dysfunction, dehydration, depression - Patients come to the clinic due to general nutritional deficiencies (stomatitis) - Parotid gland swelling - Acid erosion of dental hard tissues #### Anorexia Nervosa - **Characteristics:** Food avoidance, being underweight, distorted body image, and fear of obesity. - **Associated Medical Conditions:** Renal failure, liver dysfunction, dehydration, and depression. #### Oral and Clinical Findings - Patients often present to the clinic due to general nutritional deficiencies (e.g., stomatitis). - Parotid gland swelling. - Acid erosion of dental hard tissues. # Bulimia - Affect roughly 2% of young adult women - Binge eating alternating with self-induced vomiting or purging - Associated with psychiatric or psychological problems - Normal body weight - Frequent vomiting and misuse of laxatives cause potassium depletion - Hypokalaemia predisposes to myocardial instability - Oesophageal and dental hard tissue erosions common #### Bulimia - Affects roughly 2% of young adult women. - Characterized by binge eating alternating with self-induced vomiting or purging. - Associated with psychiatric or psychological problems. - Patients typically maintain a normal body weight. #### Medical and Dental Complications - Frequent vomiting and misuse of laxatives cause potassium depletion. - **Hypokalaemia:** Predisposes the patient to myocardial instability. - **Erosion:** Oesophageal and dental hard tissue erosions are common. 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