GMDC: dental correlations

lecture given 5/18/2026

what are the oral manifestations of end stage renal disease?

halitosis, gingival bleeding, ANUG, uremic stomatitis, parotid inflammation and enlargement

how is end stage renal disease treated? (specifically in the US)

hemodialysis (most popular), peritoneal dialysis, transplant

when is dialysis started?

volume overload, refractory acidosis, refractory hyperkalemia

creatinine is chronically high with low clearance, BUN is high

hemodialysis

removal of toxins and excess fluids is accomplished via extracorporeal circulation of blood through a dialyzer

tx usually performed 3x a week for 3-4 hrs

vascular access is established via an AV fistula, vascular graft, or indwelling vascular catheter

peritoneal dialysis

placement of a catheter into the abdominal cavity which facilitates filtration through the drainage of toxins

intermittent: frequent exchanges of dialysate, usually 3x per week for 10-12 hrs, less commonly used, can be in dialysis center

CAPD: 4 exchanges of dialysate per day, usually performed by the patient at home

CCPD: utilizes a programmed machine that performs the dialysate exchanges during the night

what is the survival rate 1 yr after starting dialysis, and 5 yrs after?

70-79%

40%

renal transplant

lack of available donors, living donor, cadaver (67%)

life long immune suppressive medications to prevent graft rejection

what should the coordination of care btwn dentist and physician be for a pt with ESRD?

what is the underlying cause?

recent coagulation values?

timing of the dental visit (when do they do dialysis)?

how should you manage dental patients with ESRD?

provide dental treatment the day after dialysis

avoid treatment immediately after due to the potential for prolonged bleeding tendencies from the residual effect of heparin used during dialysis

do not take BP on arm with AV fistula

summary of dental treatment modifications for the pt undergoing hemodialysis

AV shunt not to be used for venipunctures or for the administration of medications

the arm with the AV shunt should not be used for measuring BP

with pts heparinized during hemodialysis, any invasive procedures should occur 24 hrs after dialysis

no antibiotic prophy needed for AV fistula (but some nephrologists may recommend)

which of the following is true regarding a patient with ESRD, who is undergoing hemodialysis?

a) hemodialysis is the least used treatment for ESRD in the US

b) the patient commonly undergoes hemodialysis for 5 to 7 days a week

c) the patient may have been started on hemodialysis because the Cr is chronically elevated above 20mg/dL

d) the catheter for hemodialysis is placed into the abdominal cavity

c) the patient may have been started on hemodialysis because the Cr is chronically elevated above 20mg/dL

if you need to anesthetize a pt with ESRD, what anesthetic should you use?

lidocaine- amide local anesthetic that is metabolized in the liver, and is primarily excreted along with its metabolites through the kidney / slightly less than 10% of lidocaine is excreted unchanged

pts with SEVERE renal impairment may be unable to remove from their blood- so it is a relative contra-indication

what meds should be avoided in ESRD pts?

nephrotoxic meds, NSAIDs

a __% drop in creatinine clearance theoretically represents a _fold increase in the elimination half-life of a drug removed from the body solely via renal excretion

50, 2

what are complications associated with advanced renal disease?

uremia- can be fatal if not treated

failing kidney does not excrete sodium properly, which results in fluid retention, edema, hypertension, and cardiovascular disease

inability to eliminate nitrogenous waste products

decreased erythropoietin production and a propensity toward bleeding due to decreased platelet aggregation and adhesiveness results in anemia

host defenses may be compromised due to decreased production of WBCs, nutritional deficiencies, and immunosuppressive therapy

bone disorders (renal osteodystrophy) resembling hyperparathyroidism may be noted in the skeleton

oral complications

which of the following would not be considered a oral manifestation of advanced renal disease?

a) halitosis

b) multiple fibromas

c) uremic stomatitis

d) ANUG

b) multiple fibromas

COPD

has an insidious onset

usually presents in the 5th or 6th decade of life, complaints of excessive cough, sputum production, and SOB

symptoms have often been present for an average of 10 years

most patients have smoked at least 20 cigarettes per day for 20 or more years before the onset of symptoms

blue bloater

predominately with chronic bronchitis

bluish tinged skin color from peripheral cyanosis secondary to chronic hypoxemia and hypercarbia

peripheral edema

tachycardia, tachypnea, and chronic cough with production of large amounts of sputum

pink puffers

perdominately emphysema

a cachectic appearance, but pink skin color

dyspnea manifested by pursed lip breathing and use of accessory muscles of respiration

what management is needed for dental treatment of COPD pts?

efforts must be directed towards the avoidance of anything that could further depress respiration

since pts with COPD often have coexisting heart disease (congestive heart failure and/or hypertension), these conditions must be addressed

assess pts current clinical status- consult w the pts physician as needed, presence and severity of symptoms, results of current spirometry, ABG

place pt in a semi-supine or upright chair position for treatment

use of local anesthesia is not contraindicated

if pt has CV side effects secondary to meds you may need to limit vasoconstrictor

use of pulse oximeter to determine O2 saturation, could be beneficial

for severe COPD, rubber dam may be problematic

nitrous oxide is contraindicated or must be used with caution in patients with emphysema and/or severe COPD

if sedative medications are required, low dose oral benzos may be used

narcotic analgesics and barbituates are used with caution because they are respiratory depressants

use of macrolide antibiotics may result in elevated serum theophylline levels

assess the risk for adrenal suppression (present or past steroid usage)

which of the following is associated with a patient with COPD, demostrating bronchitis?

a) the patient is usually cachectic in appearance

b) patient usually presents with pink skin

c) presents with a barrel chest

d) cyanosis is common

d) cyanosis is common

how should you evaluate a COPD pt?

determine the presence of factors that may exacerbate COPD (upper respiratory infection)

check BP and pulse- increased could be due to toxic reactions or overdose of a sympathomimetic or anticholinergic bronchodilator or methylxanthines

consider dental treatment of high risk pts in a special care facility like hospital clinic

what are signs and symptoms of asthma?

vary with severity of the disease but may include wheezing, tachycardia, tachypnea, accessory muscle usage with breathing, paradoxical abdominal and diaphragmatic movement on inspiration, pulsus paradoxus (a fall of systolic blood pressure of > 10mgHH during the inspiratory phase)

what is the dental significance for the patient with asthma?

specific oral conditions have been related to the use of asthma medications- xerostomia, increased caries, oral pharyneal candidiasis

the direct effect of medications may also be manifested by soreness of the oral mucosa

what meds are used to treat asthma?

inhaled b2 agonist- albuterol

inhaled corticosteroids- beclomethasone

systemic corticosteroids- prednisone

mast cell stablizers- cromolyn

methylxanthines- theophylline

anticholinergics- ipratropium bromide

leukotriene modifiers- montelukast

what dental management is needed for pts with asthma?

optimal asthma control is desirable before dental treatment

ASA and NSAIDs should be avoided in asthmatics (samter’s triad including nasal polyps)

opiates can induce histamine release

macrolide antibitoics increase theophylline levels

sulfite preservatives can precipitate asthmatic attacks

which of the following oral conditions is not associated with the use of asthma meds?

a) xerostomia

b) decreased caries rate

c) oral pharyngeal candidiasis

d) soreness of the oral mucosa

b) decreased caries rate

when should you request a medical consult on a pt with a history of asthma?

poorly controlled asthma (frequent exacerbations, recent hospitalizations)

use of oral corticosteroids

FEV1 <60% predicted

patient does not know what medication they are taking for asthma and is unable to provide this info

uncertainty about stabolity of their condition

cystic fibrosis

autosomal recessive disorder of exocrine glands primarily affecting the respiratory and GI tract

characterized by abnormally thick secretions from mucous glands, pancreatic insufficiency COPD, and an increase in the concentration of electrolytes in sweat

predominate age- infants, children, and young adults

what is the etiology and pathogenesis of CF?

chromosome mutation reults in abnormalities in chloride transport and water flux across the surface of epithelial cells

this affects various organs and causes damage to exocrine tissue

the consequences are recurrent pneumonia, bronchiectasis, atelectasis, diabetes mellitus, biliary cirrhosis, cholelithiasis, intestinal obstruction, and increased risk for GI malignancies

what systems are involved in CF?

GI

pulmonary- hacking cough, viscous scretions, rapid respiratory rate, frequent infections

sterility

salt depletion and head exhausion occur frequently in warm climates

what is the dental significance of CF?

major and minor salivary glands are involved

electrolyte, enzyme, and total protein in saliva are altered

drying of nasal and maxillary sinus mucosa contributes to chronic mouth breathing

anterior open bite and enamel hypoplasia have been noted

stable angina

attacks of chest pain are limited duration and are predictably induced by exertion

the pain is usually relieved by decreasing the cardiac metabolic demand or by nitroglycerine

unstable angina

attacks occur more frequently and produce more severe symptoms than those with stable angina- occur with progressively less activity and may occur at rest

variant angina (prinzmetal’s)

coronary artery spasm appear to be an important mechanism

chest pain occurs at rest and is associated with ST segment deviation on ECG

patients tend to be younger than pts with chronic or unstable secondary to coronary artery disease, and may not exhibit classic coronary risk factors

attacks usually occur in the early morning and most frequently resolve spontaneously

if prolonged, may result in MI, dysrhythmias or death

how should you manage pts with angina?

need to classify the severity of angina, and rule out unstable angina or angina that has become progressively more severe

any changes in medication

pt monitoring- pretreatment, BP and pulse throughout

stress reduction

ensure adequate oxygenation

use of pretreatment nitrates?

establish profound local anesthesia

are vasoconstrictors contraindicated in pts with angina?

not absolute, but dose should be limited

what are the clinical presentations/physical findings of angina?

substernal chest pain/pressure/tightness, pain in the mandible/neck/left shoulder or arm/epigastric/back

may be brought on by physical activity, stress, cold exposure, or a large meal

how many total doses of nitroglycerine can you give?

3, 5 min apart

MONA for suspected MI

call 911

morphine- or sub nitrous

oxygen

nitroglycerine

ASA

what are significant cardiovascular pathologies that you need to be aware of when your pt has a history of MI?

congestive heart failure, dysrhythmias, angina pectoris, valvular disease

what are are factors that present a continued risk of MI?

hypertension, hyperlipidemia, diabetes mellitus, smoking

what are specific dental management considerations for pts with previous MI?

appropriate pt monitoring, stress reduction measures, ensure adequate oxygenation, use of pretreatment nitrates, establish profound local anesthesia, ensure adequate post treatment pain control

when is prophy antibiotics suggested for cardiac pts?

prosthetic cardiac valve or material

previous, relapse, or recurrent IE

CHD

cardiac transplant recipients who develop cardiac valvulopathy

prosthetic cardiac valve material- presence of cardiac prosthetic valve, transcatheter implantation of prosthetic valve, cardiac valve repair with devices including annuloplasty/rings/clips, left ventricular assist devices or implantable heart

previous, relapse, or recurrent IE

CHD- unrepaired cyanotic congenital CHD, including palliative shunts and conduits, completely repaired congenital heart defect with prosthetic material or device during the first 6 mo after procedure, repaired CHD with residual defects at the site of or adjacent to the site of a prosthetic patch or prosthetic device, surgical or transcatheter pulmonary artery valve or conduit placement such as melody valve or contegra conduit

when is prophy antibiotics NOT suggested for cardiac pts?

implantable electronic devices such as a pacemaker or similar devices

septal defect closure devices when complete closure is achieved

peripheral vascular grafts and patches including those used for hemodialysis

coronary artery stents or other vascular stents

CNS ventriculoatrial shunts

vena cava filters

pledgets

what procedures is antibiotic prophy suggested for?

all dental procedures that involve manipulation of gingival tissue or periapical region of teeth or perforation of oral mucosa

what procedures is antibiotic prophy NOT suggested for?

anesthetic injections though non-infected tissue, taking x-rays, placing remo or ortho appliances, adjustment of ortho appliances, placement of ortho brackets, shedding of primary teeth, bleeding from trauma to the lips or oral mucosa

antibiotic prophy for pts?

2g amoxicillin

antibiotic prophy for pts allergic to penicillin?

cephalexin 2g

azithromycin or clarithromycin 500mg

doxycycline 100mg

what is the clinical presentation/physical findings of a pt with bulimia nervosa?

recurrent episodes of binge eating

feeling of lack of control over eating

regularly engaging in either self-induced vomiting, use of laxatives/diuretics, strict dieting or fasting, or vigorous exercise to prevent weight gain

presistent over concern with body shape and weight

preoccupation with weight and food, history of weight fluctuation, dizziness, thirst, syncope, hypokalemia, postural signs of volume depletion, parotitis, scars on dorsum of the hand

which of the following cardiac conditions require prophy antibiotics to prevent infective bacterial endocarditis?

a) a pt with a cardiac pacemaker

b) a pt with a coronary artery stent

c) a pt with a prosthetic cardiac valve

d) a pt wiht a vena cava filter

c) a pt with a prosthetic cardiac valve

dental management for a pt with an eating disorder includes all of the following except:

a) one should recognize signs and symptoms of eating disorders

b) you should remain non-judgemental

c) avoid asking the pt additional questions related to their oral condition, so as not to upset the pt

d) recommend regular professional oral exams

c) avoid asking the pt additional questions related to their oral condition, so as not to upset the pt