Review Article

Oral manifestations in renal disease and its related complications

Shikha Handa1, Ginnia Bhayana2, Gaurav Atreja3.
1
Sr Lecturer, Department Of Pedodontics, MM College of dental science and research,
Mullana, 2Demonstrator, Department of Prosthodontics, Govt dental college Rohtak,
3
Reader, Department of Prosthodontics, MM College of dental science and research,
Mullana. Email: dratreja@yahoo.com

International Journal of Clinical Cases and Investigations. Volume 6 (Issue

5), 6:12, 1st October 2015.

Abstract
The systemic condition of patients with kidney failure has oral manifestations and
specific implications for dental treatment. Dental problems may compromise the
patient’s general health and hinder medical efforts to either maintain or replace vital
kidney functions. Specifically, the dentist must consider bleeding tendency, risk of
infection and medications before treating the patient. Oral and dental health has
served as a valuable indicator in measuring the prognosis of chronic kidney disease,
while, its role in diagnosing renal pathosis requires to be explored further.
Consultation with the nephrologist is essential before any dental treatment is carried
out, in order to determine the condition of the patient, define the best moment for
dental treatment, introduce the necessary pharmacological adjustments, or to
establish other important aspects for preventing complications in the dental clinic.
This manuscript reviews the characteristics of the disease, the existing therapeutic
options, and the considerations of relevance for the dental professional.

Keywords: Kidneys, Chronic renal disease, Dental Management

Introduction
The kidneys have a number of important functions: (a) Excretion of metabolic waste
products. (b) Electrolyte regulation through the control of sodium, potassium and
water excretion, and acid-base homeostasis. (c) Endocrine regulatory functions:
eicosanoids (prostaglandins, thromboxanes, leukotrienes, prostacyclins, etc.),
erythropoietin (EPO), the renin-angiotensin system, and vitamin D metabolism.
Renal failure is mostly due to the decrease in glomerular filtration rate (GFR). The
consequences are high blood pressure, weight loss, anaemia, neuropathy and
osteodystrophy.1Chronic renal disease (CRD), a progressive and irreversible decline

6 

   
in renal function, is the renal disease with the most implications in dentistry. CRF is
defined on the basis of a glomerular filtration rate (GFR) of less than 60 ml/min/1.73
m2, or by the evidence of renal damage (micro- or macroalbuminuria, persistent
hematuria, radiological anomalies) during a period of more than three months.2,3
Chronic renal failure (CRF) is characterized by a gradual reduction in the number of
functional nephrons.

Clinical manifestations
The early signs of chronic renal failure are subtle and may take long time before
people tend to notice any symptoms. The symptoms that can easily be detected
especially by the patient himself are increased urination, blood in the urine and urine
that is cloudy or tea-colored. Other symptoms aren’t obvious, but are a direct result
of the kidneys’ inability to eliminate waste and have to be clinically tested.

Oral manifestations Up to 90% of patients with renal insufficiency show oral signs
and symptoms in soft and hard tissues, some of them being a cause of the disease
itself and others deriving from the treatment of the pathology9.

Halitosis -The diminished function of the kidneys results in an increase in the levels
of urea in the blood and also in the saliva, where it will turn into ammonia. For this
reason, uremic individuals have a characteristic halitosis (uremic fetor). Apart from
urea, other factors possibly implied are the increase in the concentration of
phosphates and proteins and changes in the pH of saliva5,6 9.

Altered taste sensation- especially, sweet and acid flavours-. These can be due to
the high levels of urea, the presence of dimethyl- and trimethyl- amines, or low zinc
levels (due to the malabsorption derived from gastrointestinal disorders). Metallic
taste due to increased concentration of urea in saliva and its transformation into
ammonium.

Xerostomia (dry mouth)- as a result of the restriction in fluid intake, the side
effects of drugs (mainly antihypertensive agents), possible salivary gland alteration
(atrophy of minor salivary gland’s parenchyma), and oral breathing secondary to
lung perfusion problems.5,6,9

Uremic stomatitis- an uncommon clinical observation associated to uraemia. As

many as four types of uremic stomatitis have been described: erythemo-pultaceous,
ulcerative6,9,10,11, hemorrhagic and hyperkeratotic. The lesions are very painful and
most often appear on the ventral surface of the tongue and on the anterior mucosal
surfaces9. Clinically, it is characterized by the presence of erythematous lesions
which are localized or generalized. These lesions are covered by pseudomembranous
exudates that can be removed, leaving an intact or ulcerated mucosa. As there are
no histological pathognomonic signs of this manifestation, the definitive diagnosis
will be made combining clinical findings and excluding other diseases with the
histopathology12. It does not require a specific treatment and an involution will
usually occur after uraemia is restored (1); but in order to assist lesion healing, 10%
hydrogen peroxide gargles (1:1 in water), 4 times a day, can be recommended6.
These lesions are resistant to treatment for as long as the blood urea levels remain
7 

   
high10, and heal spontaneously within 2-3 weeks once the background renal disorder
has been resolved9,10.Gingival bleeding, petechiae and ecchymosis, also seen
resulting from platelet dysfunction and the effects of anticoagulants4,7,8 .

Gingival inflammation- There is some controversy in the literature in relation to

gingival inflammation in patients with CRF, since some studies report low incidences
of gingivitis -explained in terms of immune suppression and uraemia, which would
inhibit gingival inflammatory response to plaque accumulation – while other studies
report the opposite13.

Gingival hyperplasia secondary to drug treatment, which is one of the most widely,
documented oral manifestations in patients with renal failure. Such hyperplasia can
be induced by cyclosporine, and/or calcium channel blockers (nifedipine, amlodipine,
diltiazem, verapamil, etc.). The condition in turn is aggravated by the deficient oral
hygiene. A number of studies suggest that replacing cyclosporine with tacrolimus
may reduce the severity of gingival hyperplasia, and in any case thorough oral
hygiene is required 13,14,15. The problem also can increase in incidence and severity
when combining cyclosporine and nifedipine this suggesting an additive effect.
Hyperplasia mainly affects the labial surface of the interdental papilla, though greater
extensions can be affected - including the gingival margins and lingual and palatal
surfaces. Periodontal problems with important attachment loss, recesses and deep
pockets 13,16.

Enamel hypoplasia – Related to alteration in calcium and phosphorus metabolism.

Erosions on the surface of the teeth because of acidic regurgitation and vomiting
induced by uraemia. Pulp obliteration due to calcium and phosphorus metabolism.
Delayed eruption, changes in maxillary bone and these changes comprise bone
demineralization with trabeculation, cortical loss, giant cell radiotransparencies or
metastatic calcifications of the soft tissues. Increased risk of fracture when suffering
from chronic renal disease while doing other treatments such as extractions, tooth
mobility etc.

Caries- Diminished prevalence of caries due to urea which inhibits bacterial growth
and neutralizes bacterial plaque acids. Sometimes an antibacterial effect has been
attributed to the increase of the pH (due to urea hydrolization by saliva), which
suggests a protective function against caries. However, non- carious tooth tissue loss
is more prevalent in individuals with chronic renal disease than in the general
population. This may be due to nausea, oesophageal regurgitation, or induced
vomiting in bulimia nervosa (in patients who dislike the restrictive diet, which is
suggested as a part of the treatment)5. The majority of studies agree that there is a
greater incidence of periodontal disease, bone loss, recessions and deep periodontal
pockets17 with increase in formation of tartar due to increased level of urea in saliva.
Infections - Oral hygiene of patients receiving haemodialysis is usually poor, so
deposits of calculus and plaque may be increased. Treatment received by patients
with renal disease also produces oral clinical manifestations. In particular, lichenoid
disease may arise, associated with antihypertensive medication (diuretics, beta-
blockers).5,16 Kidney- transplanted patients are given a lifelong immunosuppressive
therapy, and therefore more susceptible to infections and to the development of
8 

   
malignant neoplasms. Where fungal infections are concerned, there are mainly
lesions related to Candida albicans. Various forms of candidiasis have been reported
in allograft recipients: pseudomembranous (1.9%), erythematous (3.8%), chronic
atrophic – also called prosthetic stomatitis (3.8%). It should be highlighted that
these figures may underestimate the increased susceptibility of immunosuppressed
allograft recipients to fungal infection, since systemic anti- fungal agents are
commonly prescribed prophylactically. The herpes group of viruses, in particular
cytomegalovirus (CMV) and herpes virus simplex (HSV), are frequently associated
with immunosuppresed organ transplant recipients. Mucosal ulceration is often
associated with CMV, having a predilection for the lateral borders of the tongue. Due
to this immunosuppresion, a reactivation of HSV, characterized by the onset of
recurrent, severe and long- standing infections. In the case of recurrent infections of
HSV in these patients, doses of 400 mg of acyclovir can be administered orally, 3
times a day during 10 days or more (usually, more than 2 weeks).

Malignization- effects of iatrogenic immune suppression that leads to tumours.

Treatment:
a) Conservative management. Such treatment aims to prevent or correct the
metabolic alterations and preserve the remaining renal functional capacity. The
measures include a high carbohydrate and low protein diet (though consensus is
lacking on this point), body weight control, treatment with antihypertensive drugs,
lipid lowering agents, vitamin D supplements, and correction of the anaemia with
erythropoietin.18,19
b) Renal replacement therapy is considered when conservative management fails
to be effective against the progression of renal deterioration, and comprises dialysis
and renal transplantation.
c) Prevention of infections. Infections are one of the most important causes of
morbidity and mortality in chronic renal failure. Vaccination is therefore potentially
very useful in patients of this kind, though such treatment is underused, since no
clear guidelines have been established, and vaccination response with the normal
doses and regimens may be limited.20

Prognosis: The life expectancy of patients on dialysis remains sombre

(approximately one-third that of the general population). The prognosis of individuals
with diabetes mellitus and/or hypertension is poorer than that of patients with
glomerulonephritis. The most common causes of death among patients with ESRF
are cardiovascular problems (about 50% of globalmortality) followed by infections
and malignization.21

Dental management of renal failure patients

Patients with renal failure require special considerations in relation to dental
treatment, not only because of the conditions inherent to the disease and its multiple
oral manifestations, but also because of the side effects and characteristics of the
treatments they receive.
9 

   
Consultation with the nephrologist provides information on the state of the disease,
the type of treatment, the best timing of dental management, or the medical
complications that may arise. Any modification of the usual medication used by the
patients or of other aspects of their treatment must first be consulted with the
nephrologist.

Close cooperation between medical and dental professionals is desirable in order to

improve the oral and general health of the patient, based on the creation of a dental
care program in the context of a multidiscipline approach to the disease.22
Prior to any invasive dental treatment, a complete blood count is to be obtained,
together with coagulation tests, in view of the possible haematological alterations.

It is essential to eliminate any infection in the oral cavity as soon as possible, with
the consideration of antibiotic prophylaxis when bleeding and/or a risk of septicaemia
is expected. Blood pressure is to be monitored before and during treatment, with the
administration of sedation to lessen anxiety.

Drug complications: The metabolism and elimination of certain drugs are altered in
situations of renal failure. In such cases dose adjustment or modification of the
dosing frequency is needed. The prescription of aminoglycoside antibiotics and
tetracyclines is to be avoided, because of their nephrotoxicity. Penicillins,
clindamycin and cephalosporins can be administered at the usual doses, and are the
antibiotics of choice – though the dosing interval should be prolonged. As regards
analgesics, paracetamol is the non-narcotic analgesic of choice in application to
episodic pain. Aspirin possesses antiplatelet activity, and as such should be avoided
in uremic patients. As regards the rest of nonsteroidal anti-inflammatory drugs
(indomethacin, ibuprofen, naproxen and sodium diclofenac), dose reduction or even
avoidance is indicated in the more advanced stages of renal failure, since they inhibit
prostaglandins and generate a hypertensive effect. Benzodiazepines can be
prescribed without the need of dose adjustments, though excessive sedation may
occur. The narcotic analgesics (codeine, morphine, fentanyl) are metabolized by the
liver, and so usually do not require dose adjustment.5,9,11

10 

   
Conclusion
The most important renal pathology in dentistry is CRD. Up to 90% of patients with
CRD show oral signs and symptoms, such as bleeding tendency, greater
susceptibility to infections and gingival overgrowth produced by cyclosporine.
Recognition of the oral manifestations of this disease is important, since they may be
indicators of the presence or extent of a specific disease and may therefore be useful
to the clinician in diagnosing the disorder, determining treatment requirements, or
assessing the prognosis of the disease in question. Dentists will probably see more
dialysis patients in the future, given the 10% to 15% annual growth in the incidence
of endstage renal disease. All parties must be knowledgeable about the treatment
priorities, operative concerns and precautions to be taken in this special population.

References
1. Thorman R, Neovius M, Hylander B. Clinical findings in oral health during
progression of chronic kidney disease to end stage renal disease in a Swedish
population. Karolinska Institute. Scand J Urol Nephrol. 2009; 43(2): 154-9.
2. Snyder S, Pendergraph B. Detection and evaluation of chronic kidney disease.
Am Fam Physician. 2005 Nov 1;72(9):1723-32.
3. Johnson DW, Usherwood T. Chronic kidney disease—management update.
Aust Fam Physician. 2005 Nov;34(11):915-23.
4. Davidovich E, Davidovits M, Eidelman E, Schwarz Z, Bimstein E.
Pathophysiology, therapy, and oral implications of renal failure in children and
adolescents: an update. Pediatr Dent. 2005 Mar-Apr;27(2):98-106.
5. Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and dental aspects of
chronic renal failure. J Dent Res. 2005 Mar; 84(3):199-208.
6. De la Rosa García E, Mondragón Padilla A, Aranda Romo S, Bustamante
Ramírez MA. Oral mucosa symptoms, signs and lesions, in end stage renal
disease and non-end stage renal disease diabetic patients. Med Oral Patol
Oral Cir Bucal. 2006 Nov 1;11(6):E467-73.
7. Kerr AR. Update on renal disease for the dental practitioner. Oral Surg Oral
Med Oral Pathol Oral Radiol Endod. 2001 Jul;92(1):9-16.
8. Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can
Dent Assoc. 2002 Jan;68(1):34-8.
9. De Rossi SS, Glick M. Dental considerations for the patient with renal disease
receiving hemodialysis. J Am Dent Assoc. 1996;127:211-9.
10. Antoniades DZ, Markopoulos AK, Andreadis D, Balaskas I, Patrikalou E,
Grekas D. Ulcerative uremic stomatitis associated with untreated chronic
renal failure: report of a case and review of the literature. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2006 May;101(5):608-13.
11. Gudapati A, Ahmed P, Rada R. Dental management of patients with renal
failure. Gen Dent. 2002 Nov-Dec;50(6):508-10.
12. Leão JC, Gueiros LA, Segundo AV, Carvalho AA, Barrett W, Porter SR. Uremic
stomatitis in chronic renal failure. Clinics (Sao Paulo).2005;60:259-62.
13. Davidovich E, Schwarz Z, 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 Oct;32(10):1076-82.

11 

   
 14. De la Rosa-García E, Mondragón-Padilla A, Irigoyen-Camacho ME,
Bustamante-Ramírez MA. Oral lesions in a group of kidney transplant
patients. Med Oral Patol Oral Cir Bucal. 2005 May-Jul;10(3):196-204.
15. Ciavarella D, Guiglia R, Campisi G, Di Cosola M, Di Liberto C, Sabatucci A, et
al. Update on gingival overgrowth by cyclosporine A in renal transplants. Med
Oral Patol Oral Cir Bucal. 2007 Jan 1;12(1):E19-25.
16. SobradoMarinho JS, Tomás Carmona I, Loureiro A, Limeres Posse J, García
Caballero L, Diz Dios P. Oral health status in patients with moderate-severe
and terminal renal failure. Med Oral Patol Oral Cir Bucal.2007 Aug
1;12(4):E305-10.
17. JoverCerveró A, Bagán JV, Jiménez Soriano Y, PovedaRoda R. Dental
management in renal failure: patients on dialysis. Med Oral Patol Oral Cir
Bucal. 2008;13:419-26.
18. Mandayam S, Mitch WE. Dietary protein restriction benefits patients with
chronic kidney disease. Nephrology (Carlton). 2006 Feb;11(1):53-7.
19. Navaneethan SD, Pansini F, Strippoli GF. Statins in patients with chronic
kidney disease: evidence from systematic reviews and randomized clinical
trials. PLoS Med. 2006 May;3(5):E123.
20. Dinits-Pensy M, Forrest GN, Cross AS, Hise MK. The use of vaccines in adult
patients with renal disease. Am J Kidney Dis. 2005 Dec;46(6):997-1011.
21. O’Seaghdha CM, Foley RN. Septicemia, access, cardiovascular disease, and
death in dialysis patients. Perit Dial Int. 2005 Nov-Dec;25(6):534-40.
22. Atassi F. Oral home care and the reasons for seeking dental care by
individuals on renal dialysis. J Contemp Dent Pract. 2002 May 15;3(2):31-41.

12