|Year : 2017 | Volume
| Issue : 2 | Page : 69-73
Knowledge and attitude of dental students about oral health considerations in patients with renal problems
Ujwala Rohan Newadkar, G Lalit Chaudhari
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra, India
|Date of Web Publication||8-Jun-2017|
Ujwala Rohan Newadkar
Department of Oral Medicine and Radiology, ACPM Dental College, Dhule, Maharashtra
Source of Support: None, Conflict of Interest: None
Aim: The aim of this study was to assess the knowledge and attitude of undergraduate dental students about oral health considerations in patients with renal problems. Materials and Methods: A cross-sectional, quantitative study was conducted based on a questionnaire containing 15 questions about prevention, clinical aspects, and attitudes toward oral health considerations in patients with renal problems. One hundred and thirty-three undergraduate dental students between the third and final years were enrolled in the study. The statistical significance was measured using Pearson's Chi-square test. Results: There was a predominance of females (58.65%). Interrelationship between dental and medical problems such as chronic kidney disease (CKD) has been noticed in most of the students (92.48%), and uremic stomatitis is the most commonly (68.66%) observed terminology among them. Other oral manifestations were reported by 48% of students from all three groups. However, students did not have enough knowledge regarding the dental management of these patients. Conclusions: Students have a good knowledge of the etiology of oral health consideration in patients with renal problems and are apparently alert in their examinations. The clinical aspects of the oral health consideration in such patients, however, are not so clear.
Keywords: Chronic kidney disease, dialysis, oral health, periodontitis
|How to cite this article:|
Newadkar UR, Chaudhari G L. Knowledge and attitude of dental students about oral health considerations in patients with renal problems. SRM J Res Dent Sci 2017;8:69-73
|How to cite this URL:|
Newadkar UR, Chaudhari G L. Knowledge and attitude of dental students about oral health considerations in patients with renal problems. SRM J Res Dent Sci [serial online] 2017 [cited 2022 Aug 13];8:69-73. Available from: https://www.srmjrds.in/text.asp?2017/8/2/69/207651
| Introduction|| |
Poor oral health in patients with chronic kidney disease (CKD) is an important problem but is often ignored. Signs of poor oral health and dentition should be an alarm also at early stages of CKD. Oral manifestations that have been reported in CKD patients include an ammonia-like odor resulting from a high urea content, gingivitis, xerostomia, mucosal pallor, tooth mobility, malocclusion, and a greater risk of dental erosion due to frequent regurgitation. Primary preventive measures for patients undergoing dialysis for kidney failure have previously been overshadowed by concerns about more urgent health problems. Dental health appears to be yet another area where attention has been lacking. Thorough knowledge of the oral changes in such patients is essential to diagnose the underlying disease and to take precautions to avoid the bacteremia and prevent complications. The aim of the present study was to assess the knowledge and attitude of undergraduate dental students about oral health considerations in patients with renal problems.
| Materials and Methods|| |
A cross-sectional, quantitative study was conducted between May and July 2014. The 150 participants were third to final year undergraduate dental students. A questionnaire [Appendix 1 [Additional file 1]] containing ten questions about clinical aspects and attitudes toward oral health considerations in patients with renal problems was distributed. The students received the questionnaire after agreeing to participate and giving written informed consent. The questionnaire was not used for graduation purposes, and the students were not compelled to fill it out. The SPSS Version 18.0 software (SPSS Inc., Chicago, IL, USA) was used, and the statistical significance was measured using Pearson's Chi-square test with significance level α of 5%. For this test, students were divided into three groups: 1 (3rd year), 2 (4th year I semester), and 3 (4th year II semester).
| Results|| |
One hundred and seventy questionnaires were applied and 150 were returned (75.14%), 50 from each group. There was a predominance of females (58.65%) in the sample. Interrelationship between dental and medical problems such as CKD has been noticed in most of the students (92.48%), and uremic stomatitis is the most commonly (68.66%) observed terminology among them. Other oral manifestations were reported by 48% of students from all three groups [Table 1]. Most of the students reported regularly conducting a thorough examination of the oral cavity (78%). However, students did not have enough knowledge regarding the dental management of these patients [Table 2]. About 84% of students were unaware of the investigations to be advised in patients undergoing dialysis. Two of the ten variables showed differences between the students: treatment modalities for renal disorders (Pearson's Chi-square, P = 0.03) and dental management of such patients (Pearson's Chi-square, P = 0.02).
|Table 1: Response of the participants regarding the oral manifestations of renal diseases|
Click here to view
|Table 2: Response of the participants regarding the dental management of patients with renal diseases|
Click here to view
| Discussion|| |
The National Kidney Foundation defined CKD as kidney damage for three or more months associated with structural or functional abnormalities of the kidney, with or without decreased glomerular filtration rate. Estimates of the global burden of disease indicate that diseases of the kidney and urinary tract account for approximately 830,000 deaths and 18,467,000 disability-adjusted life years annually, ranking them 12th among causes of death (1.4% of all deaths) and 17th among causes of disability (1.0% of all disability-adjusted life years). More than thirty oral signs and symptoms in patients with chronic renal failure have been reported, some of which commonly seen are calculus, high urea concentration in saliva, ammonia-like smell, xerostomia, oral bleeding, stomatitis, pale gingivae, drug-induced gingival hyperplasia, loss of lamina dura, maxillary and mandibular radiolucent lesions, abnormal bone remodelling after extraction, enamel hypoplasia, delayed tooth eruption pattern, low caries prevalence, dental erosion, sensitivity to percussion and mastication, tooth mobility, and malocclusion.,
Renal disease has become important in dentistry due to the growing number of patients who, as a result of renal dialysis or transplantation, survive renal failure. Aspects of renal disease affecting dental management are heparinization before dialysis, possible hepatitis B or C carriage after chronic dialysis, permanent venous fistulae susceptible to infection, secondary hyperparathyroidism, immunosuppressive treatment for nephritic syndrome or transplant patients, oral lesions due to drugs, particularly for immunosuppression, low doses or withholding of many drugs: for example, some cephalosporins and tetracyclines, and oral lesions of chronic renal failure. Dialysis is an artificial means of removing nitrogenous and other toxic products of metabolism from the blood. Dialysis leads to systemic alterations and oral complications. This study revealed that majority of the dental students were aware of these oral manifestations. Henceforth, they always carried a thorough examination of the oral cavity of such known cases.
Most of the CKD patients on dialysis suffer from gingivitis and periodontitis. Dental erosion is seen as a result of frequent regurgitation, tooth mobility and drifting of teeth are commonly seen, orange–red color of the mucosa due to carotenes such as material deposition and metastatic calcification in the perioral area is also reported. Oral and cutaneous hyperpigmentation in renal patients is due to the inability of the kidney to excrete excess beta-melanocyte-stimulating hormone, the accumulation of which results in the stimulation of melanocyte at the basal layer of oral epithelium. Uremic stomatitis is a complication associated with uremia and occurs in advanced renal failure with blood urea nitrogen levels above 300 mg/mL. Xerostomia occurs due to restriction in fluid intake, the side effects of drugs (fundamentally antihypertensive agents), direct salivary gland alteration, salivary gland atrophy, and fibrosis.
Candidiasis is seen as patients lose the ability to fight infections. Candidiasis is more frequent in transplant patients because of generalized immunosuppression. Other oral manifestations of renal disease are related to renal osteodystrophy (RO), a common condition which is considered as a dysfunctional mineral homeostasis. Radiographic features of RO in mandible or maxilla are bone demineralization, loss of trabeculation, ground glass appearance, total or partial loss of lamina dura, abnormal socket healing, giant cell lesions or brown tumors, and metastatic calcifications., The patients are at increased risk of fracture during dental treatments, such as extractions. In this study, majority of the students in Group 3 reported regarding these things.
This study revealed that students did not have enough knowledge regarding the dental management of these patients. Dentists should avoid the excessive stress that could elevate the systolic blood pressure. Drugs that are directly nephrotoxic should be avoided. Drugs excreted mainly by the kidney may have undesirably enhanced or prolonged activity if doses are not lowered. Drug therapy may need to be adjusted, depending on the degree of renal failure, the patient's dialysis schedule, or the presence of a transplant. Except in emergency, such drugs should be prescribed only after consultation with the renal physician. Students in the Group 1 had adequate knowledge regarding the pharmacological aspect than that of other groups.
Antibiotic prophylaxis, typically with vancomycin, has been recommended before invasive dental procedures  although this recommendation is contrary to guidelines of the British Society for Antimicrobial Chemotherapy. This study revealed that students were not aware of the various investigations to be advised for the patients undergoing dialysis. Before any invasive dental treatment, a complete blood count is to be obtained, together with coagulation tests, in view of the possible hematological 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 septicemia is expected. Blood pressure is to be monitored before and during treatment, with the administration of sedation to lessen anxiety. Hemodialysis predisposes to blood-borne viral infection, such as hepatitis virus. In such patients, dentists should perform liver function tests before extractions and minor oral surgical procedures. Patients on hemodialysis often have reduced platelet counts, platelet adhesiveness, and availability of platelet factor 3, as well as increased prostacyclin activity and capillary fragility, all of which lead to greater blood loss. Dental treatment is best carried out on the day after dialysis when there has been maximal benefit from dialysis and the effect of the heparin has worn off. The hematologist should be first consulted. Should bleeding be prolonged, desmopressin may provide hemostasis for up to 4 h. If this fails, cryoprecipitate may be effective, has a peak effect at 4–12 h, and lasts up to 36 h. Conjugated estrogens may aid in hemostasis: the effect takes 2–5 days to develop but persists for 30 days. Arteriovenous shunts should not be jeopardized, and the affected arm should never be used for intravenous or intramuscular injection. Patients should not be kept in cramped positions in the dental chair and should be allowed to stand or walk occasionally to minimize the risk of access obstruction.
Promoting good dental hygiene reduces the risk of oral infections. Awareness should be raised among patients undergoing dialysis, their nephrologists, and their dentists about the need for primary dental prevention.
It is the responsibility of the dental schools to ensure the formation of a generalist with solid technical, scientific, humanistic, and ethical knowledge, aimed at promoting health and emphasizing the philosophy of prevention of prevalent oral diseases. Although postgraduation is important for the activity in this field, graduation is essential and must ensure that students have the relevant basic knowledge on prevention and early diagnosis of various oral manifestations of systemic disorders.
| Conclusions|| |
Dental surgeons with their immense research are making a considerable contribution to the general health and well-being of humankind suffering from oral health-related problems due to chronic renal failure. Students have a good knowledge of the etiology of oral health consideration in patients with renal problems and are apparently alert in their examinations. The clinical aspects of the oral health consideration in such patients, however, are not so clear. It is necessary to implement the clinical suspicion of oral health considerations in patients with renal problems throughout the undergraduate course to enable awareness and early diagnosis. Close collaboration between the dentist and nephrologist is required in the treatment of patients with chronic renal disease.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Akar H, Akar GC, Carrero JJ, Stenvinkel P, Lindholm B. Systemic consequences of poor oral health in chronic kidney disease patients. Clin J Am Soc Nephrol 2011;6:218-26.
Tozoglu U, Keles M, Unal D, Uyanik A. Cytological analysis of the oral cells of chronic renal failure patients: A cytomorphometric study. Turk J Med Sci 2012;42:1443-8.
Klassen JT, Krasko BM. The dental health status of dialysis patients. J Can Dent Assoc 2002;68:34-8.
Levey AS, Eckardt KU, Tsukamoto Y, Levin A, Coresh J, Rossert J, et al.
Definition and classification of chronic kidney disease: A position statement from kidney disease: Improving global outcomes (KDIGO). Kidney Int 2005;67:2089-100.
Dirks J, Remuzzi G, Horton S, Schieppati A, Rizvi SA. Diseases of the kidney and the urinary system. In: Jamison DT, Breman JG, Measham AR, Alleyne G, Claeson M, Evans DB, et al
., editors. Disease Control Priorities in Developing Countries. 2nd
ed. Washington, DC: World Bank; 2006. p. 695-706.
Kho HS, Lee SW, Chung SC, Kim YK. Oral manifestations and salivary flow rate, pH, and buffer capacity in patients with end-stage renal disease undergoing hemodialysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;88:316-9.
Hamid MJ, Dummer CD, Pinto LS. Systemic conditions, oral findings and dental management of chronic renal failure patients: General considerations and case report. Braz Dent J 2006;17:166-70.
Cawson RA, Odell EW. Renal disease. In: Parkinson M, Taylor A, Hewat C, editors. Essential of Oral Pathology and Oral Medicine. 8th
ed. London: Elsevier Ltd.; 2008. p. 415-16.
Mozaffari PM, Amirchaghmaghi M, Mortazavi H. Oral manifestations of renal patients before and after transplantation: A review of literature. DJH 2009;1:1-6.
Kauzman A, Pavone M, Blanas N, Bradley G. Pigmented lesions of the oral cavity: Review, differential diagnosis, and case presentations. J Can Dent Assoc 2004;70:682-3.
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;11:E467-73.
Agarwal SK, Srivastava RK. Chronic kidney disease in India: Challenges and solutions. Nephron Clin Pract 2009;111:c197-203.
Olivas-Escárcega V, Rui-Rodríguez Mdel S, Fonseca-Leal Mdel P, Santos-Díaz MA, Gordillo-Moscoso A, Nernández-Sierra JF, et al.
Prevalence of oral candidiasis in chronic renal failure and renal transplant pediatric patients. J Clin Pediatr Dent 2008;32:313-7.
Kerr AR. Update on renal disease for the dental practitioner. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:9-16.
Gudapati A, Ahmed P, Rada R. Dental management of patients with renal failure. Gen Dent 2002;50:508-10.
Fletcher PD, Scopp IW, Hersh RA. Oral manifestations of secondary hyperparathyroidism related to long-term hemodialysis therapy. Oral Surg Oral Med Oral Pathol 1977;43:218-26.
Antonelli JR, Hottel TL. Oral manifestations of renal osteodystrophy: Case report and review of the literature. Spec Care Dentist 2003;23:28-34.
Scully C, Cawson RA. Genitourinary and renal disease. In: Parkinson M, editor. Medical Problems in Dentistry. 5th
ed. New Delhi: Elsevier Ltd.; 2005. p. 115-22.
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.
De Rossi SS, Glick M. Dental considerations for the patient with renal disease receiving hemodialysis. J Am Dent Assoc 1996;127:211-9.
[Table 1], [Table 2]