[Downloaded free from http://www.jisponline.com on Monday, February 25, 2019, IP: 36.79.47.

125]

Case Report

Severe periodontitis associated with

chronic kidney disease
Anurag Jain, Debipada Kabi

Department of Dentistry, Abstract:

Vardhaman Mahavir The data on Indian population with regard to severity/prevalence of chronic periodontitis in association with
Medical College and chronic kidney disease (CKD) is scarce. We are describing an interesting case of severe periodontitis associated
Safdarjang Hospital, with CKD. The patient had unusual inflammatory gingival overgrowth which persisted even after treatment. By
New Delhi, India describing this case we want to highlight our current lack of understanding with regard to etiopathogenesis of
periodontal disease in CKD patients and need for further research in this area.
Key words:
Chronic kidney disease, inflammatory gingival overgrowth, periodontitis

INTRODUCTION medical records revealed that she was suffering

from stage four CKD. She was non‑diabetic,

C hronic kidney disease (CKD), also known as

chronic renal disease, is a progressive loss in
renal function over a period of months or years. It
is defined by National kidney foundation of USA
Access this article online as  –  “Kidney damage or glomerular filtration
Website: rate  <60 mL/min/1.73 m2 for more than three
www.jisponline.com months”. CKD is classified into stage one to five
DOI: based on glomerular filtration rate and stage five
10.4103/0972-124X.107489 CKD is also called as end‑stage renal disease.
Quick Response Code:
Many studies have reported increased prevalence
and severity of periodontal disease in patients
with CKD.[1‑3] A recent study by Messier et  al.
has reported higher extent of periodontal bone
loss in dialysis patients, but there was a lack of
a dose‑response association between bone loss
and CKD stage which underscores the complex
relationship between the two conditions.[4] CKD
patients have higher levels of traditional systemic
inflammatory markers (IL‑6 and C‑reactive
protein) and of pro‑hepcidin, which along with
parameters of clinical severity and probing depth,
decrease after periodontal treatment.[5] Though the
literature on Indian population in this regard is very
scarce, one study has shown higher prevalence of
periodontal disease in CKD patients.[6]
Address for
This case report describes a case of severe
correspondence: periodontal destruction in a patient of CKD with
Dr. Anurag Jain, unusual inflammatory gingival overgrowth.
Department of
Dental, VMMC and CASE REPORT
Safdarjang Hospital,
New Delhi ‑ 110 029, India.
A 35 year old female patient presented to
E‑mail: dranuragjain@
indiatimes.com Dental Department, Vardhman Mahaveer
Medical College and Safdarjang Hospital,
Submission: 20‑12‑2010 New Delhi, with chief complaint of mild pain and
Accepted: 17‑08‑2012 swelling in mandibular molars on both side. Her
non‑hypertensive and cause of CKD was not
established. She was not taking any drug which
is known to cause gingival overgrowth.
Clinical examination
On intraoral examination, she had bilateral
periodontal abscess in relation to first mandibular
molars, with deep periodontal pockets and pus
discharge [Figures 1 and 2]. OPG revealed severe
angular bone loss in relation to 36 and 46, and
external root resorption of mesial root of 46
[Figure 3].
Initial treatment
Abscess was drained under local anesthesia
through periodontal pocket, and copious
irrigation with CHX was done. Oral hygiene
instructions were given and phase I therapy
was started. Patient was recalled after one
week. Opinion of nephrologists was also sought
regarding dental treatment.
Recall visits
After one week there was no pus discharge, but
inflammatory gingival overgrowth persisted.
Considering the medical condition of the
patient and nephrologist’s opinion, it was
decided to manage the case non‑surgically. Full
mouth scaling and root planing was completed.
Combination of Amoxycillin and Metronidazole
was given for seven days (after dose adjustment
in consultation with nephrologists). Patient was
recalled every month for scaling and root planing.
The response to therapy was poor, inflammatory
gingival overgrowth persisted in both the
molars [Figures 4 and 5], there was bleeding on
probing, but no pus discharge.

128 Journal of Indian Society of Periodontology - Vol 17, Issue 1, Jan-Feb 2013
[Downloaded free from http://www.jisponline.com on Monday, February 25, 2019, IP: 36.79.47.125]

Jain and Kabi: Chronic kidney disease

After six months, the patient’s CKD deteriorated to stage 5 and
was put on haemodialysis twice a week. Though non‑surgical
periodontal therapy was being continued with monthly recalls,
OPG revealed rapid periodontal destruction in 36 and 46
[Figure 6] as compared previous OPG taken six months back
[Figure 3]. The inflammatory gingival overgrowth persisted
in both the molars.
DISCUSSION
The studies of periodontal status in adults with chronic kidney
disease (CKD) performed in the past 10 years are scarce,
especially on Indian population. Moreover, most of these studies
focused patients on maintenance hemodialysis.[1‑3,7‑9] This case
report highlights the severe periodontal disease in patient who
was followed from pre‑dialysis stage to stage five. Two notable
findings in this case report draw special attention. First, the
unusual inflammatory gingival overgrowth in mandibular
molar regions which has not been reported previously in

Figure 1: Periodontal abscess in relation to 46 regions

Figure 2: Periodontal abscess in relation to 36 regions

Figure 3: Initial OPG of patient showing bone loss in 36 and

46 regions

Figure 4: One month post-operative (46 region)

Figure 5: One month post-operative (36 region) Figure 6: OPG after six months showing rapid bone destruction in 36 and 46 regions

Journal of Indian Society of Periodontology - Vol 17, Issue 1, Jan-Feb 2013 129
[Downloaded free from http://www.jisponline.com on Monday, February 25, 2019, IP: 36.79.47.125]
Jain and Kabi: Chronic kidney disease
CKD patients. Second, the poor response to therapy and
rapid periodontal destruction despite the regular non‑surgical
periodontal intervention. Both these unusual findings
highlight our current lack of understanding with regard to
etiopathogenesis of periodontal disease in CKD patients.
Though the factors associated with CKD responsible for
increased prevalence/severity of periodontal disease are not
completely understood, they may include hyposalivation
and xerostomia, impaired immunity and wound healing,
alveolar bone destruction due to renal osteodystrophy,
bleeding diathesis, diabetes mellitus, malnutrition and a state
of general disability impairing oral hygiene.[10,11] Increase in
levels of serum osteocalcin and/or GCF osteocalcin in CKD
patients may also explain the effect of CKD on periodontal
disease, by its effect on bone metabolism.[12] Morphological
examinations of gingival specimens from chronic hemodialysis
patients show peculiar and extensive degenerative changes in
the area of epithelial cells, which are not observed in subjects
with periodontitis but without renal failure.[13] Some studies
also suggest that periodontitis may contribute to systemic
inflammatory burden in CKD patients on hemodialysis
maintenance therapy.[14]
The exacerbation of periodontal disease, as patient goes from
pre‑dialysis phase to dialysis phase, which was seen in this
case report, has also been reported by other investigators.[2,15]
The CKD patient with periodontitis is medically complex and
presents the dental practitioner with several challenges in
the management of their periodontal condition. Accordingly,
close communication between the dentist and nephrologist
is essential to optimize periodontal management. Among
the factors which may complicate the treatment include high
prevalence of anemia, clotting deficiencies, hypertension,
diabetes and renal osteodystrophy in such patients.
Through this case report we want to attract attention of
investigators and motivate them to perform research related
to periodontal disease in CKD patients and its effective
management. This will not only improve understanding of this
complex issue, but will also help thousands of such patients
suffering from CKD with periodontal disease.
REFERENCES
1. Gavalda  C, Bagan  JV, Scully  C, Silvestre  FJ, Milian  MA,
130 Journal of Indian Society of Periodontology - Vol 17, Issue 1, Jan-Feb 2013
Jimenez Y. Renal hemodialysis patients: Oral, salivary, dental and
periodontal findings in 105 adult cases. Oral Dis 1999;5:299‑302.
2. Davidovitch E, Schwarz E, Davidovitch M, Eidelman E,
Bimstein  E. Oral findings and periodontal status in children,
adolescents and young adults suffering from renal failure. J Clin
Periodontol 2005;32:1076‑82.
3. Al‑Wahadni A, Al‑Omari MA. Dental diseases in a Jordanian
population on renal dialysis. Quintessence Int 2003;34:343‑7.
4. Messier MD, Emde K, Stern L, Radhakrishnan J, Vernocchi L,
Cheng B, et al. Radiographic Periodontal Bone Loss in Chronic
Kidney Disease. J Periodontol. 2012;83:602-11.
5. Bastos Jdo  A, Vilela  EM, Henrique  MN, Daibert Pde  C,
Fernandes LF, Paula DA, et al. Assessment of knowledge toward
periodontal disease among a sample of nephrologists and nurses
who work with chronic kidney disease not yet on dialysis. J Bras
Nefrol 2011;33:431‑5.
6. Bhatsange A, Patil SR. Assessment of periodontal health status in
patients undergoing renal dialysis: A descriptive, cross‑sectional
study. J Indian Soc Periodontol 2012;16:37‑42.
7. Naugle K, Darby ML, Bauman DB, Lineberger LT, Powers R. The
oral health status of individuals on renal dialysis. Ann Periodontol
1998;3:197‑205.
8. Atassi  F, Almas  K. Oral hygiene profile of subjects on renal
dialysis. Indian J Dent Res 2001;12:71‑6.
9. Chen LP, Chiang CK, Chan CP, Hung KY, Huang CS. Does
periodontitis reflect inflammation and malnutrition status in
hemodialysis patients? Am J Kidney Dis 2006;47:815‑22.
10. Klassen JT, Krasko BM. The dental health status of dialysis
patients. J Can Dent Assoc 2002;68:34‑8.
11. Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and dental
aspects of chronic renal failure. J Dent Res 2005;84:199‑208.
12. Yoshihara A, Hayashi Y, Miyazaki H. Relationships among
bone turnover, renal function and periodontal disease in elderly
Japanese. J Periodontal Res 2011;46:491‑6.
13. Yamalik N, Delilbasi L, Gulay H, Caglayan F, Haberal M,
Caglayan G. The histological investigation of gingiva from
patients with chronic renal failure, renal transplants, and
periodontitis: A light and electron microscopic study. J
Periodontol 1991;62:737‑44.
14. Rahmati MA, Craig RG, Homel P, Kaysen GA, Levin NW.
Serum markers of periodontal disease status and inflammation
in hemodialysis patients. Am J Kidney Dis 2002;40:983‑9.
15. Duran I, Erdemir EO. Periodontal treatment needs of patients with
renal disease receiving haemodialysis. Int Dent J 2004;54:274‑8.
How to cite this article: Jain A, Kabi D. Severe periodontitis
associated with chronic kidney disease. J Indian Soc Periodontol
2013;17:128-30.
Source of Support: Nil, Conflict of Interest: None declared.