1. BY: DR HINA ADNAN Renal disease and dental care

2. RENAL DISEASE People whose kidneys do not function properly occasionally receive dialysis, a process that uses a machine to "clean" the blood.

3. Renal disease and dental care People with renal problems may have a bad taste in their mouths, which occurs because the kidneys are not removing urea from the blood. Skeletal changes also can occur because the body cannot absorb calcium properly. People with kidney problems can lose bone from their jaws and their teeth may become loose and painful. Many symptoms and complications of renal disease can affect dental treatment. These include anorexia, anemia, hypertension and heart disease, as well as dry mouth (Xerostomia), periodontal (gum) disease, loose teeth, tooth loss and inflammation of the mouth and salivary glands. Some of these symptoms are caused by the disease and some are caused by medications and other treatment regimens used for kidney diseasedry mouth(gum) disease

4. If you are on dialysis, dental treatment should occur within 24 hours of dialysis. People with shunts may be taking a blood thinner, which can increase the risk of bleeding and hemorrhage. Because of the shunt, they may be at higher risk of bacterial endocarditis and should take antibiotics prior to dental treatment under a physician's guidance

5. End stage renal failure is a life threatening condition. The kidneys regulate fluids, excrete nitrogenous waste, synthesise vitamin D and erythropoietin (EPO), maintain acid-base homeostasis regulate mineral and electrolyte balance and regulate the metabolism and excretion of drugs. All of these things can affect dental treatment due to the resulting abnormalities. Dialysis patients are heparinized and so in order to avoid abnormal bleeding tendencies, treatment should be carried out the day after dialysis. For the transplant patient only emergency treatment should be carried out within the first three months after transplantation. It is also suggested that transplant recipients should receive antibiotic prophylaxis prior to dental treatment.

6. Dental Drugs Few of the drugs used in dentistry are likely to cause complications. Topical fluoride applications need to be used carefully and it is recommended that systemic fluorides are avoided The use of aspirin and other non-steroidal anti- inflammatory drugs (NSAIDS) is contraindicated in the renal patient as excretion is delayed. Analgesics that can be safely used include codeine and dihydrocodeine

7. Local anaesthetics appear safe unless there is a severe bleeding tendency. Although local anaesthetic is metabolised by the liver, it is excreted via the kidney and large amounts of local anaesthetic should be avoided.

8. Oral Health The main oral health problem experienced by renal patients is xerostomia. This is as a result of several factors which include multiple medication, restricted intake of fluids and diabetes, which many renal patients suffer from. Xerostomia may also predispose the patient to caries, mucositis and oral infection as the protective factors in saliva are not present.

9. Dialysis patients may form calculus more rapidly than healthy individuals possibly due to high salivary urea and phosphate levels. Elevated parathyroid hormone synthesis is also common in ESRF which causes accelerated bone loss. This may also exacerbate periodontal disease. Transplant patients who are immunosuppressed often experience a change in oral flora. This can predispose the patient to oral candidiasis. In addition cyclosporine and calcium channel blockers are known to contribute to gingival hyperplasia, which is exacerbated by poor oral hygiene.

10. Conclusion These patients require special attention with regard to bleeding tendencies, risk of infection, xerostomia and multiple medication use. When treating these patients it is also good to keep in mind that some may be pre-occupied with the treatment of their renal disease and have a tendency to neglect preventive oral health measures. Patients may also experience stress in trying to comply with the extensive dietary restrictions and medication programs, which may also contribute to anxiety and aversion to further preventive instruction. In addition to good oral health promotion, there is an increased need for collaboration between the dental and medical professions to provide safe and appropriate dental care for these patients.