Renal disease and the mouth

Dental management of patients with renal diseases or undergoing renal transplant

BACKGROUND

The kidneys carry out many essential processes. A reduced glomerular filtration rate is the primary cause of renal failure. Patients with chronic kidney disease are significantly increasing all around the world. Patients with varying degrees of renal disease will be seen on the dental chair, and the dentist must be aware of dental considerations when treating such patient. Dental clinicians should carefully evaluate the oral findings and general condition of the renal disease patient.

OBJECTIVE

To increase the awareness of dentists in the dental management of patients with renal diseases or undergoing renal transplant.

METHODS

This study reviews 56 articles searched on two databases PubMed and Google Scholar with English language.

CONCLUSION

Every dentist should be well-informed regarding dental considerations and oral manifestations when treating a patient with any renal disease. Simple treatment plan modification can prevent the evolution of mild to critical medical or dental complications in renal disease patients.

Association between periodontal inflamed surface area and systemic inflammatory biomarkers among pre-dialysis chronic kidney disease patients

Background

Several studies have shown an association between chronic kidney disease (CKD) and periodontitis. However, only few studies have quantified the burden of periodontal inflammation in pre-dialysis CKD patients. The aim of this study was to determine the association between periodontal inflamed surface area (PISA) and systemic inflammatory biomarkers among pre-dialysis CKD patients.

Materials and Methods

120 pre-dialysis CKD participants were recruited into this study. 60 participants constituted Group A (those with periodontitis) while 60 participants constituted Group B (those without periodontitis). Full periodontal examination was carried out in the participants for the estimation of PISA. Blood samples also collected to determine levels of high sensitivity C-reactive protein (hsCRP) and interleukin-6 (IL-6) in all participants. Independent t-test was used to compare means of PISA, hsCRP and IL-6 levels in the two groups. Pearson correlation analysis was used to determine association between PISA and (hsCRP and IL-6).

Results

The mean value of hsCRP was significantly higher in Group A compared to Group B (3.41 mg/L vs. 2.18 mg/L). PISA moderately correlated with hsCRP (r = 0.4, P < 0.01) in both groups. hsCRP also moderately correlated with IL-6 (r = 0.6, P < 0.001) in both groups.

Conclusion

This study demonstrates that there was an association between PISA and hsCRP. Increased hsCRP level in Group A revealed the inflammatory burden imposed by periodontitis.

Maximizing Oral Health Outcomes of Aboriginal and Torres Strait Islander People With End-stage Kidney Disease Through Culturally Secure Partnerships: Protocol for a Mixed Methods Study

BACKGROUND

Dialysis for end-stage kidney disease (ESKD) is the leading cause of hospitalization among Aboriginal and Torres Strait Islander individuals in Australia. Poor oral health is commonly the only obstacle preventing Aboriginal and Torres Strait Islander people with ESKD in Australia from receiving kidney transplant.

OBJECTIVE

This study aims to improve access, provision, and delivery of culturally secure dental care for Aboriginal and Torres Strait Islander individuals with ESKD in South Australia through the following objectives: investigate the facilitators of and barriers to providing oral health care to Aboriginal and Torres Strait Islander patients with ESKD in South Australia; investigate the facilitators of and barriers to maintaining oral health among Aboriginal and Torres Strait Islander people with ESKD in South Australia; facilitate access to and completion of culturally secure dental care for Aboriginal and Torres Strait Islander individuals with ESKD and their families; provide oral health promotion training for Aboriginal health workers (AHWs) at each of the participating Aboriginal Community Controlled Health Services, with a specific emphasis on oral health needs of patients with ESKD; generate co-designed strategies to better facilitate access to and provision of culturally secure dental services for Aboriginal and Torres Strait Islander people living with ESKD; and evaluate participant progress and AHW oral health training program.

METHODS

This collaborative study is divided into 3 phases: exploratory phase (baseline), intervention phase (baseline), and evaluation phase (after 6 months). The exploratory phase will involve collaboration with stakeholders in different sectors to identify barriers to providing oral health care; the intervention phase will involve patient yarns, patient oral health journey mapping, clinical examinations, culturally secure dental care provision, and strategy implementation workshops; and the evaluation phase will involve 6-month follow-up clinical examinations, participant evaluations of dental care provision, and AHW evaluation of oral health training.

RESULTS

Stakeholder interviews were initiated in November 2021, and participant recruitment commenced in February 2022. The first results are expected to be submitted for publication in December 2022.

CONCLUSIONS

Expected outcomes will identify the burden of oral disease experienced by Aboriginal and Torres Strait Islander people with ESKD in South Australia. Qualitative outcomes are expected to develop a deeper appreciation of the unique challenges regarding oral health for individuals with ESKD. Through stakeholder engagement, responsive strategies and policies will be co-designed to address participant-identified and stakeholder-identified challenges to ensure accessibility to culturally secure dental services for Aboriginal and Torres Strait Islander individuals with ESKD.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/39685.

Quality of Life in Patients with End-Stage Renal Disease Undergoing Hemodialysis

End-stage renal disease and hemodialysis therapy cause a number of changes, not only somatic but also psychosocial, including the patient’s perception and assessment of their quality of life. The literature describes predispositions to pathologies in the oral mucosa, craniofacial bones, teeth, and surrounding tissues in hemodialysis patients. This study aimed to determine the quality of life of hemodialysis patients in comparison with healthy subjects. The study group consisted of 200 subjects: the HD group (hemodialysis patients, n = 100) and the K group (control group, n = 100). General health and oral status were assessed using the following indices: plaque index, gingival index, probing depth, and clinical adhesion level. The WHOQOL-BREF survey was performed to determine both groups’ overall quality of life. The results showed lower values of assessed quality-of-life parameters in hemodialysis patients compared to the control group, especially in the somatic sphere. General diseases such as oral mycosis, osteoporosis, rheumatoid arthritis, and coronary-artery disease negatively impact the perceived quality of life. There are numerous indications for comprehensive psychological care of hemodialysis patients due to their poor psychosocial status.

Improved oral hygiene care and chronic kidney disease occurrence: A nationwide population-based retrospective cohort study

Oral diseases or poor oral hygiene have close connections with systemic inflammatory reaction, which is one of major mechanism in the development of chronic kidney disease (CKD). We conducted a research assuming that better oral hygiene care would be negatively related with the risk of developing new-onset CKD.From 2003 to 2004, a total of 158,495 participants from the Korean national health insurance data sharing service which provides health screening data including variables as age, sex, vascular risk factors, medication information, indicators regarding oral hygiene, and laboratory results. The diagnosis of CKD and vascular risk factors were defined according to the International Statistical Classification of Diseases and Related Health Problems codes-10th revision. The follow-up period for the study subject was until the occurrence of CKD, until death, or Dec 31, 2015.Approximately 13.3% of the participants suffered from periodontal disease, and 40.7% brushed their teeth at least three times a day. With a median of 11.6 (interquartile range 11.3-12.2) years' follow-up, the cohort included 3223 cases of incident CKD. The 10-year incidence rate for CKD was 1.80%. In multivariable analysis with adjustment for age, sex, demographics, vascular risk factors, blood pressure, and blood laboratory results, frequent tooth brushing (≥3 times a day) was negatively related to occurrence of CKD (hazard ratio: 0.90, 95% confidence interval [0.83-0.99], P  =  .043, P value for trend  =  .043).Participants with improved oral hygiene (≥3 times a day) have showed less risk of CKD. Additional interventional studies are in need to establish causative relationship between oral hygiene and risk of CKD.

Oropharyngeal and otorhinological changes in end stage renal patients undergoing hemodialysis

Background

The study aimed to assess oropharyngeal and otorhinolaryngological changes in end stage renal disease (ESRD) patients undergoing hemodialysis and correlate the findings to renal functions.

Material and Methods

This case-control study compared oral and otorhinolaryngological findings in 85 patients with (ESRD) on maintenance hemodialysis to age and sex matched 85 healthy controls. Frequencies of findings were calculated and compared and correlation between biochemical and the oral health parameters in case group was determined using T-test, chi-square and Pearson correlation test (significance were set at P<0.05).

Results

The frequency of oral signs and mucosal symptoms were significantly higher among ESRD compared to healthy controls. Dry mouth (34.12%), bad odour (32.94%), increased tongue coating (50.59%) and pale mucosa (45.88%) were the most commonly reported. Otorhinolaryngological findings was higher in cases than in controls, with otomycosis (10.59%) and allergic rhinitis (5.88%) being the most frequent findings. Serum creatinine and blood urea mean levels were higher in ESRD patients with oral and otorhinolaryngological findings compared to those without findings.

Conclusions

Oral and nasal manifestations in patients with ESRD on maintenance hemodialysis were significantly higher in comparison to healthy individuals and were related to their serum creatinine and blood urea mean levels. Key words:Chronic kidney disease, renal dialysis, Oral manifestation, nasal, case control, Egypt.

Oral health-related quality of life in adult patients with end-stage kidney diseases undergoing renal replacement therapy - a systematic review

Background

The oral health of patients undergoing renal replacement therapy (RRT) is insufficient. Poor oral health and its components can affect the oral health-related quality of life (OHRQoL) of these patients. The aim of this systematic review was to assess the OHRQoL of adult patients under RRT.

Methods

A systematic literature search was performed using the terms: dialysis OR “renal disease” OR kidney OR “renal failure” OR “kidney transplantation” OR hemodialysis OR “peritoneal dialysis” OR “renal replacement therapy” AND “oral health-related quality of life”, complemented by manual search. Clinical studies including adults (age ≥ 18 years) that were published between 2009 and 2019 were included in qualitative analysis.

Results

Twelve out of 20 studies were included in the qualitative analysis. The majority (11/12 studies) included patients undergoing haemodialysis (HD), with a sample size between 47 and 512 participants. Two studies included patients after kidney transplantation. Only one-quarter of the investigations included a healthy control group. The overall OHRQoL was found to be reduced. The majority of studies found relationships between OHRQoL and different oral health parameters. Furthermore, several relationships between OHRQoL and general quality of life as well as disease related parameters including age, gender, diabetes, blood parameters and dialysis duration were found. OHRQoL subscales psychological/psychosocial impairment and pain were predominantly affected.

Conclusions

Patients under RRT suffer from a reduced OHRQoL, which is potentially influenced by oral health and disease related parameters. Interdisciplinary dental care is needed and should consider both physical and psychosocial issues.

Oral manifestations of allograft recipients immediately before and after kidney transplantation

Objective: To identify the oral lesions of individuals with kidney disease immediately before and shortly after kidney transplantation, taking into account the immunosuppressive regimen, antiviral prophylaxis and type of transplantation.Methods: A prospective observational cohort study was carried from January 2017 to January 2018. Eighty individuals aged 18 years or older who were admitted for kidney transplantation were eligible to participate. Clinical data regarding medical history, immunosuppressive therapy, antiviral prophylaxis, laboratorial data and oral examination were performed by the same trained researcher, in three different moments: 24 hours before transplantation (1st time point), 15-20 days (2nd time point) and 45-60 days (3rd time point) after transplantation.Results: In the first, second and third time points, it was found that 3.7% (3/80), 23.7% (18/76) and 25.7% (19/74) of the participants showed oral soft tissue lesions. Ulcers and candidiasis were the most frequent oral lesions, and they were associated with the use of everolimus (p = .005) and azathioprine (p = .034), respectively. Less patients reported xerostomia after transplantation than before (p < .001).Conclusions: Oral lesions are common in the short term after renal transplantation and are particularly related to both toxicities of immunosuppressive drugs and immunosuppression.

Periodontal management of severe periodontitis and generalized gingival enlargement in a patient with chronic renal failure

Gingival enlargement is a common periodontal pathology seen in medically compromised patients. Although it is not the disease itself, certain medications used to treat these chronic diseases are known to precipitate the gingival enlargement. Periodontitis (PD) and gingival enlargement have been reported increasingly in patients with chronic renal failure. Severe enlargement is detrimental to esthetics and function while having a negative impact on the overall oral health-related quality of life. Treatment of such cases requires comprehensive periodontal management by a specialist, keeping in mind the medically compromised state of the patient. This report presents a case of severe PD with generalized gingival enlargement in a 45-year-old male who was a known case of Stage 4 chronic kidney disease, obstructive uropathy, and hypertension. Gingival enlargement was managed by gingivectomy and gingivoplasty. Six months' follow-up showed no sign of recurrence.

Health and oral health-related quality of life of children and adolescents with chronic kidney disease: a cross-sectional study

PURPOSE

The aim of this study was to evaluate if health and oral health status of children and adolescents with different stages of CKD are associated with their health-related quality of life (HRQoL), oral health-related quality of life (OHRQoL) and socioeconomic and demographic conditions.

METHODS

One hundred children and adolescents with CKD were age and gender matched to 100 individuals without CKD (mean age ± SD = 13.04 ± 2.57). Oral health was characterised by means of gingival bleeding index (GBI), plaque index (PI), the decayed, missing, and filled teeth (DMFT) index and the developmental enamel defect (DED) index. All children and adolescents answered two Peds QL^® instruments (general and oral health scales).

RESULTS

Comparing the mean scores of HRQoL and OHRQoL between groups, we observed that CKD group demonstrated worse perceptions when compared to non-CKD group. Multiple linear regression analysis with bootstrap estimation of variance (1000 replications) showed association between dental caries experience (p < 0.001), gingival inflammation (p < 0.001) and diagnosis of CKD (p = 0.027) with the OHRQoL and between physical and the emotional domain of HRQoL, when moderate/severe gingival inflammation and hypoplasia were present.

CONCLUSION

The implementation of public policies that contemplate the early dental preventive intervention in CKD children and adolescents should occur aiming to improve their oral health, once oral manifestations can directly affect the aspects of the HRQoL and OHRQoL of these individuals.

Can salivary creatinine and urea levels be used to diagnose chronic kidney disease in children as accurately as serum creatinine and urea levels? A case-control study

Background and aim: Children with chronic kidney disease (CKD) develop many metabolic changes in blood that often necessitate frequent biochemical analysis. Serum analysis is an invasive and painful procedure. It would be highly beneficial if a noninvasive alternative process to serum analysis in children were identified. Saliva can be collected noninvasively, repeatedly, and without the use of healthcare personnel. The aims of this study were to compare serum and salivary urea and creatinine levels in children with CKD and healthy controls, and to determine if salivary creatinine and urea levels can be used to diagnose CKD in children as accurately as serum creatinine and urea levels.

Materials and methods: This case–control study included 35 children with CKD and 28 healthy children as controls. Saliva and blood samples were collected for measurement of urea and creatinine levels. The urea and creatinine levels in serum and saliva in the CKD and control groups were compared using the independent samples Mann–Whitney U test. Correlations between the serum and salivary urea and creatinine levels were determined using Pearson’s correlation coefficient. Receiver operating characteristic analysis was used to assess the diagnostic performance of salivary creatinine and cutoff values were identified.

Results: In the CKD group, the mean salivary creatinine level was 0.45 mg/dL and the mean salivary urea level was 0.11 mg/dL, versus 28.83 mg/dL and 21.78 mg/dL, respectively, in the control group. Stage 4 and 5 CKD patients had a mean salivary urea level of 31.35 mg/dL, as compared to 17.78 mg/dL in the control group. Serum urea and creatinine, and salivary creatinine were significantly higher in the CKD patients (regardless of disease stage) than in the controls (p < .05). The salivary urea level was significantly higher in the stage 4 and 5 CKD patients than in the controls (p < .05). There was a positive correlation between serum and salivary creatinine. The area under the curve for salivary creatinine was 0.805. The cutoff value for salivary creatinine was 0.125 mg/dL, with a sensitivity of 82.9% and specificity of 78.6%.

Conclusions: Based on the positive correlation between the serum and saliva creatinine levels observed in the present study, we think saliva analysis could be used as a noninvasive alternative to blood analysis for diagnosing CKD in children.

Chronic Kidney Disease Linearly Predicts Outcomes After Elective Total Joint Arthroplasty

BACKGROUND

Kidney disease is associated with increased complications in total joint arthroplasty (TJA). The purpose of this study was to determine the association of kidney disease severity as measured by the chronic kidney disease (CKD) staging system with complications after TJA.

METHODS

A retrospective review of 12,308 primary TJAs (6361 hips and 5947 knees) from 2008 to 2013 was performed. The following preoperative variables were obtained from medical records: chemistry 7 panel, Elixhauser comorbidities, and demographic factors. CKD stages were defined based on estimated glomerular filtration rate (eGFR) in mL/min/1.73m(2): (1) 90+, (2) 60-89, (3A) 45-59, (3B) 30-44, (4) 15-29, and (5) <15. Multivariate analysis was performed to assess the independent influence of CKD stage on the aforementioned end points.

RESULTS

Patients with CKD stage greater than 2 demonstrated an increased odds of receiving transfusions (P = .001), length of stay >3 days (P = .010), acute kidney injury (P < .001), septic revisions (P = .002), and in-hospital complications (P < .001) compared with all patients with eGFR ≥60 when controlling for potential confounders. Only CKD stage 3A was significantly associated with septic revisions (90 days, P = .004; 2 years P = .002). In addition, the relationship between eGFR and the previously mentioned complications increased linearly rather than demonstrating a clear threshold at which the risk increased substantially.

CONCLUSION

Severe CKD is associated with increased transfusion, length of stay, and in-hospital complications; and complications increased linearly with disease severity. Surgeons should be cognizant of this increase when evaluating TJA patients with renal disease.

Association of dental and periodontal disease with chronic kidney disease in patients of a single, tertiary care centre in Thailand

BACKGROUND

Several studies have shown an association between oral diseases and chronic kidney disease (CKD), and regular oral care may be an important strategy for reducing the burden of CKD. The objective of this study was therefore to evaluate the association between dental and periodontal diseases in Thai patients with various stages of CKD.

METHODS

This was designed as a cross-sectional study and was performed between 2011 and 2012. The inclusion criteria were age >20 years and a diagnosis of CKD for at least 90 days. Data from medical records were collected, clinical oral examination was performed, and data were statistically analysed.

RESULTS

A total of 129 patients with different stages of CKD were included. Ninety-eight (76%) were men. The age range was 30-86 years. The Decay, Missing and Filling Tooth Index and the number of missing teeth were higher in the group with moderate CKD than in the control group (21 vs 17.5, p=0.045, 13 vs 8 p=0.01, respectively). Serum albumin levels decreased when estimated glomerular filtration rate (eGFR) was in decline (γ=0.33; p=0.002). Severe periodontitis was significantly higher in the 'more severe CKD group' (eGFR <60 mL/min/1.73 m(2)) than in the 'less severe CKD group' (eGFR 60-90 mL/min/1.73 m(2); 24% vs 9%, p=0.03). Severe periodontitis, eGFR <30 mL/min/1.73 m(2) and brushing teeth more than once a day were associated with hypoalbuminaemia (defined as <3.8 g/dL) (OR (95% CI) 5.88 (1.64 to 21.11), 5.80 (1.58 to 21.35) and 0.16 (0.05 to 0.60), respectively).

CONCLUSIONS

Severe periodontal diseases were more prevalent in patients with more severe CKD than in those with less severe CKD. The novel association of serum albumin levels with periodontal status was demonstrated in progressive stages of CKD. Dental intervention may be beneficial from the early stages of CKD.

Salivary creatinine and urea analysis in patients with chronic kidney disease: a case control study

Background

Many metabolic changes develop in patients with chronic kidney disease which often necessitate frequent biochemical analysis of blood. Saliva analysis as an alternative to blood has many advantages. The aims of this study were to evaluate levels of salivary creatinine and urea in patients with chronic kidney disease in comparison to healthy individuals; to determine correlation between salivary creatinine/urea and blood creatinine/urea and to evaluate the diagnostic potential of saliva.

Methods

A case control study, involving 50 patients with late stage chronic kidney disease and 49 healthy individuals as control. Blood and saliva samples were analyzed for urea and creatinine levels. Data are presented as median with interquartile range and compared using Independent Samples Mann Whitney U test. Correlation between plasma and salivary creatinine as well as urea was determined using Spearman’s correlation test. Receiver operating characteristics (ROC) analysis was done to determine the diagnostic ability of salivary creatinine and urea and cut-off values were established.

Results

Median salivary creatinine levels were 2.60 mg/dl and 0.20 mg/dl while median salivary urea levels were 92.00 mg/dl and 20.50 mg/dl in patients with chronic kidney disease and controls respectively. Salivary levels of creatinine and urea were significantly elevated in chronic kidney disease patients (p < 0.001). In addition, there was positive correlation between blood and salivary creatinine as well as urea levels. Total areas under the curve for salivary creatinine and urea were 0.97 and 0.89 respectively. Cut-off values for salivary creatinine and urea were 0.55 mg/dl and 27.50 mg/dl respectively which gave sensitivity and specificity of 94 % and 85 % for creatinine; as well as 86 % and 93 % for urea.

Conclusions

Findings of this study suggest that analysis of salivary creatinine and urea in patients with chronic kidney disease reflects their levels in blood. Hence, salivary creatinine and urea could be used as diagnostic biomarkers of chronic kidney disease.

Bidirectional Relationship between Chronic Kidney Disease & Periodontal Disease

Non communicable diseases (NCDs) affect the life of an individual in terms of mortality, morbidity and financial crises. Main NCDs are diabetes mellitus (DM), cardiovascular diseases (CVD), pulmonary diseases, osteoporosis and chronic kidney diseases (CKD). About 40% of the total deaths can be controlled by eliminating the risk factors for NCDs. Periodontitis have recently been labeled as an important potential risk factor for NCDs. CKD affect the oral health status of patients by inducing gingival hyperplasia, xerostomia, calcification of root canals and delayed eruption of teeth. Periodontitis increases systemic inflammatory burden leading to worsening of CKD which in turn has been has been found to negatively affect CKD of patients on hemodialysis therapy by altering their serum albumin and C-reactive protein levels. As hypoalbuminemia leads to increased mortality in CKD patients, it needs to be avoided by reducing systemic inflammatory burden in patients receiving HD therapy. Treating periodontal disease could be one factor that might decrease the systemic inflammatory burden and thereby improve quality of life of these patients.

Sources of Data: Data from descriptive, cross sectional and longitudinal studies published between 2000 and 2012 were included. Data searches based on human studies only.

Data Extraction: The key words, periodontitis, chronic kidney disease and hemodialysis, on MEDLINE, approximately 120 studies were identified. 35 of them were relevant to all three keywords. Most of them were cross sectional studies and total 7 clinical trials were identified regarding checking of serum levels after periodontal therapy with variable results.

Conclusion: Patients with CKD have higher prevalence of periodontal disease while non-surgical periodontal therapy has been indicated to decrease the systemic inflammatory burden in patients with CKD specially those undergoing HD therapy.

A retrospective case-control analysis of the outpatient expenditures for western medicine and dental treatment modalities in CKD patients in Taiwan

BACKGROUND

To determine if expenditures for dentistry (DENT) correlate with severity of chronic kidney disease (CKD).

METHODS

A total of 10,457 subjects were enrolled from January 2008 to December 2010, divided into three groups: healthy control (HC) group (n = 1,438), high risk (HR) group (n = 3,392), and CKD group (n = 5,627). Five stages were further categorized for the CKD group. OPD utilization and expenditures for western medicine (WM), DENT, and TCM (traditional Chinese medicine) were analyzed retrospectively (2000-2008) using Taiwan's National Health Insurance Research Database. Three major areas were analyzed among groups CKD, HR and HC in this study: 1) demographic data and medical history; 2) utilization (visits/person/year) and expenditures (9-year cumulative expenditure, expenditure/person/year) for OPD services in WM, DENT, and TCM; and 3) utilization and expenditures for dental OPD services, particularly in dental filling, root canal and periodontal therapy.

RESULTS

OPD utilization and expenditures of WM increased significantly for the CKD group compared with the HR and HC groups, and increased steadily along with the severity of CKD stages. However, overall DENT and TCM utilization and expenditures did not increase for the CKD group. In comparison among different CKD stages, the average expenditures and utilization for DENT including restorative filling and periodontal therapy, but not root canal therapy, showed significant decreases according to severity of CKD stage, indicating less DENT OPD utilization with progression of CKD.

CONCLUSIONS

Patients with advanced CKD used DENT OPD service less frequently. However, the connection between CKD and DENT service utilization requires further study.

Cemento-ossifying fibroma in a patient with end-stage renal disease

The presence of chronic renal disease (CRD) is a predisposing factor for the occurrence of soft and hard tissue lesions in the oral cavity. The cemento-ossifying fibroma (COF) is an uncommon benign fibroosseous lesion composed of fibrocellular component and calcified materials like cementum and woven bone. A 37-year-old female patient undergoing chronic haemodialysis reported to our institution with a complaint of slow growing, nontender swelling of mandible of 6-month duration. Computed tomography disclosed an ill-defined lesion showing thinning and expansion of buccal as well as lingual cortical plate with flecks of radiopacity in centre. Incision biopsy revealed histological characteristics consistent with cemento-ossifying fibroma. The lesion was excised under local anesthesia. The histopathological examination revealed irregularly shaped bone and cementum-like hard tissue calcifications contained within hypercellular fibrous tissue stroma, leading to a confirmation of the diagnosis of cemento-ossifying fibroma. This paper aims to provide light to the fact that the soft and hard tissues of the oral region may become susceptible to the development of pathological growths in case of some particular systemic conditions.

Amlodipine-Induced Gingival Hyperplasia in a Child: Case Report and a Review of the Literature

Objective:

To increase awareness of amlodipine-induced gingival hyperplasia in children, as well as review whether a dose-related relationship exists.

Case Summary:

A 9-year-old girl with a past medical history of membranous nephropathy and hypertension presented with failure to thrive and inability to gain weight. She had a history of allergy to enalapril. On admission, she was found to have gingival hyperplasia. A review of her medication profile found amlodipine and azathioprine to be possible agents for this adverse reaction. The child's mother noticed this adverse effect after an increase in amlodipine dosage. We recommended substituting the angiotensin receptor blocker losartan for amlodipine; however, the nephrologist feared a cross-reactivity with enalapril and decided to continue amlodipine therapy. A follow-up call after hospital discharge revealed that the patient could no longer eat by mouth and that her gums bled upon brushing.

Discussion:

We reviewed the possible role of azathioprine in causing our patient's gingival hyperplasia. Due to the timeliness of this occurrence and the possibility of a dose-related response, we selectively reviewed the literature associated with amlodipine in children. A PubMed search and subsequent review of the literature revealed 1 study in rats that showed a relationship between amlodipine dose/plasma concentration and gingival hyperplasia. In humans, this relationship was reported with other calcium channel blockers, but not with amlodipine and not in a child. The Naranjo probability scale revealed a possible adverse reaction of gingival hyperplasia associated with amlodipine.

Conclusions:

To our knowledge, this is the first report of a possible dose-related occurrence of gingival hyperplasia in a child receiving amlodipine.

Systemic consequences of poor oral health in chronic kidney disease patients

Changes in the oral cavity, such as periodontitis and other manifestations of poor oral health, are common in patients with chronic kidney disease (CKD) and may contribute to increased morbidity and mortality because of systemic consequences such as inflammation, infections, protein-energy wasting, and atherosclerotic complications. Poor oral health in CKD patients may thus represent an important, but often overlooked, problem. Several studies show that uremic patients have higher rates of decayed, missing, and filled teeth, loss of attachment, and periapical and mucosal lesions than the general population. The consequences of poor oral health may be more severe in CKD patients because of advanced age, common comorbidities such as diabetes, concurrent medications, and a state of immune dysfunction that may increase the risk for systemic consequences of periodontitis and other oral and dental pathologic conditions. Poor dentition and other signs of poor oral health should be an alarm clock also at early stages of CKD. However, it remains to be determined whether more successful management of poor oral health and periodontitis will reduce the risk of inflammation, infection, protein-energy wasting, and atherosclerotic complications in CKD patients. This review explores etiological factors and potential systemic consequences of poor oral health in CKD patients as well as possible preventive and therapeutic strategies.

Enhanced enzymatic activity of Candida species responsible for oral candidiasis in renal transplant recipients

Renal transplant recipients (RTRs) are regarded to be predisposed to oral candidiasis. This study was undertaken to evaluate the activity of hydrolytic enzymes in strains causing oral candidiasis in RTR. A total of 123 Candida albicans and 10 Candida krusei strains were isolated from 200 RTRs (39 RTRs suffered from symptomatic candidiasis, the remaining patients had no clinical symptoms of infection). All fungi were identified based on routine mycological procedures. Because of a small number of non-albicans strains, only C. albicans isolates were compared for enzymatic activity. The activity of 19 hydrolytic enzymes was assessed by API ZYM(®) test. The usage of mycophenolate mofetil was connected with higher ratio of clinically apparent oral candidiasis compared to immunosuppressive regimens without this drug (74.4% vs. 46.8%, respectively, P < 0.01). Candida albicans from RTRs showed higher enzymatic activity compared with strains from immunocompetent patients. Only two enzymes were found to be more active in C. albicans causing symptomatic candidiasis in RTRs (cystine arylamidase: P = 0.001, and α-fucosidase: P = 0.01) compared with saprophytic strains. Atrophic candidiasis showed higher activity of esterase lipase (C8) and α-mannosidase compared with the pseudomembraneous type. We suggest that the enhanced enzymatic activity is responsible for higher invasiveness of Candida residing in the oral cavity of RTRs.