Intraoral Periapical Radiographic Changes of Teeth and
Gingival bleeding2,6, Petechiae and Ecchymosis2 resulting from platelet dysfunction6,7 and the effects of anticoagulants7, Gingival hyperplasia secondary to drug treatment,9which in turn is aggravated by the deficient oral hygiene3, 9, 10. Periodontal problems include loss of periodontal ligaments, and formation of deep pockets11, 12, Enamel hypoplasia secondary to alterations in calcium and phosphorus metabolism2, which can affect both the primary and permanent dentition8. Severe erosions on the lingual surfaces of the teeth may occur due to frequent regurgitation and vomiting induced by uremia medication, and nausea associated to dialysis1, 7. Pulp obliteration2, possibly related to the alterations in calcium and phosphorus metabolism, Delays or alterations in eruption1,2. Changes in maxillary bone, secondary to renal osteodystrophy1,7comprising bone demineralization with trabeculation and cortical loss1, 2, 5, 7, giant cell radio transparencies or metastatic calcifications of the soft tissues1. The patients are also probably at increased risk of fracture during dental treatments such as extractions1, 5, tooth mobility1, 7, 8, malocclusion, crowding, pulp chamber calcifications1 and temporomandibular joint problems are also observed13.
Candidiasis is common among both transplant patients and subjects on dialysis5, 8. Cytomegalovirus (CMV) infection is frequent in the first months after transplantation2, Oral hairy leukoplakia (OHL) secondary to drug-induced immune suppression8,
9virus-related tumors such as Kaposi’s sarcoma8 or non-Hodgkin lymphoma8, 9. Skeletal changes resulting from chronic renal disease are collectively called renal osteodystrophy. It is widely accepted that acquired disturbance of the utilisation of vitamin D in both the intestines and bone tissue in chronic renal insufficiency results in hypocalcaemia and secondary hyperparathyroidism. In the roentgenogram the trabeculae of the spongy bone are not well defined and the density of the bone is generally decreased. Soft Radiographic alterations of the jaw bones in chronic renal disease are not uncommon and often represent as partial or complete loss of the lamina dura, thinning of the cortical plates, with the blurring of anatomic landmarks. In addition, trabecular pattern of the affected bone often assumes a ground-glass or salt and- pepper appearance16. As per the recent study the prevalence of CRF in India is 7852 cases per million population (p.m.p).15Considering the above back ground, this study is performed to examine the radiological changes of teeth and jaw bones in renal failure patients who are not undergoing dialysis.
OBJECTIVES OF THE STUDY
As a dental practitioner it is necessary to have a thorough understanding of special treatment considerations to be performed which can be effective and safe to these systemically compromised patients.
• To determine Intra Oral Peri Apical Radiograph (IOPA) changes in patients diagnosed with CRF who have not undergone dialysis.
• IOPA radiograph as an aid in assessing and predicting the prognosis of CRF.
METHODS AND MATERIALS
This is observational, case-control study and was conducted in the wing of Oral Medicine and Radiology at A.V. Super Specialty Dental Hospital. The study group was formed of 30 patients with modera-te- severe CRF: 22 men and 08 women; mean age = 64 ± 11 years; mean weight = 74.78 ± 4.60 kg; 42% had primary education, 37% secondary education and 21%
higher education. The 30 controls presented similar cha-racteristics with regard to sex (25 men and 5 women), age (mean age=60 ± 11 years), weight (mean weight = 75.50 ± 4.94 kg) and educational level (38%
had primary education, 35% secondary education and 27% higher education) and with no major systemic diseases. All the patients were drawn from outpatient department of A.V. Super Specialty Hospital, Hyderabad. Two Maxillofacial Radiologists performed the interpretation of IOPA radiographs.
RADIOGRAPHIC EXAMINATION OF PATIENT The selected sample were examined and subjected for clinical evaluation. The patient was made to sit comfortably on the physiological dental chair with artificial illumination. Detailed clinical history was noted followed by radiographic evaluation with the help of I.O.P.A.R in relation to 26, 27, 28 & 46, 47, 48.
MATERIALS
1. CCX Digital Trophy Trex Group – X-ray machine with specifications of 70 KVP, 8 mA, 0.16x/secs (Electronic x-ray timer), provided with a chair which could be elevated or brought down to adjust the vertical height.
2. IOPA Films- No. 2 (31 x 41 mm) (Kodak Dental Intra Oral E-Speed Film, Eastman Kodak Company, New York). No.0 (22 x 35 mm) (Kodak insight Super Polysoft Film, Eastman Kodak Company)
3. Lead apron, Sterile gloves, White adhesive plaster (Johnson and Johnson India Ltd)
EXPOSURE OF IOPA RADIOGRAPHS Patient was positioned upright in the chair with the back and head well supported. Positioned the dental chair low for maxillary and elevated for mandibular projections. Patient was draped by lead apron, where the x-ray unit is of 70 KVp, 8mA with the normal exposure time, then place the KODAK ,
29 Prasanth Venela 120-124.pmd 121 8/27/2012, 6:39 PM
E-Speed intra oral film of size 31x41mm, using snap- A- Ray intra oral film holder using Bisecting angle technique, where the position of film as close as possible to the lingual surface of the teeth, resting in the palate for maxillary with the horizontal angulation is at right angles to the buccal surfaces of teeth and vertical angulation of +20 degrees & in the floor of mouth for mandibular with the angulation of -5 degrees.
INTERPRETATION OF RADIOGRAPHS After exposure the films were processed in the dark room by manual visual processing method The processed and dried film was labelled and stored in a separate cover.The interpretation of IOPA radiographs was done in the dark room using radiographic view box and magnifying lens. The IOPA radiograph was mounted on the radiographic view box and criteria for Radiographic evaluation.
The results obtained in the present study were analysed using the SPSS version 16.0 statistical package for Windows. Chi-squared test were used to study the variables. Statistical significance was taken as a value of p<0.05. Odds ratio with 95% confidence interval was also calculated.
RESULTS
Of the 30 patients in the study group, 22 (73%) were in the initial stages of CRF and 08 (27%) were suffering moderate CRF and all the patients in the study group have not undergone for dialysis and were on pharmacological-dietary treatment. The following variables are presented for Maxillary bone changes in Table 1 and mandibular bone changes in Table 2 both for the patients and for the controls: the lamina dura in the maxillary bone showed changes in 93.3% of case
group where as 43.3% in control group, showing a tendency of statistical significance (p=<.0001). The changes were assessed in terms of entire lamina dura thickening or thinning completely or partially and its presence or absence. It is observed that in 33.3% of patients lamina dura was completely absent where as in controls it is only 3.3%. Significant change was observed in thinning of lamina dura in cases (60%) and in controls it was 26.6%. Similar changes were observed in the lamina dura of the mandible, 83.3% of the patients showed changes where as 33.3% of controls showed changes giving a tendency of statistical significance (p=0.0001). 86.6% of cases and 43.3% of controls showed changes in the pattern of trabeculation of maxilla providing the statistical significance (p=<0.001). Similar results were observed in mandibule (86.6% in cases and 10% in controls ; p=<0.0001).In maxilla 93.3% of patients showed changes in the radiographic density where as in controls only 20% have shown changes giving a statistical significance (p=<0.0001). But in case of mandibule, both controls and cases have shown less amount of changes in the overall radiographic density giving to statistical significance(40% in cases and 23.3%
of controls; p=0.1647). No significant difference was observed regarding the changes in pulp chamber (relative to age) of the maxilla in both cases and controls with no statistical significance (86.6% in patients and 70% in controls; p=0.117), Where as in case of mandible slight difference was observed in the pulp chamber when compared to maxilla. 63.3% of cases showed changes but whereas controls are 30%, giving no statistical significance (p= 0.0096). In case of changes in thickness of the lower border of the mandible significant changes were observed (73.3%
of cases and 20% of controls) giving a statistical significance(p=<0.0001).
Table 1. Table 2. Comparison of Radiographic changes in the Maxilla of Case group (n=30) and Control group (n=30)
Maxilla
Cases (CRF Control Odds ratio Statistical
patients) n (%) n (%) significance
Changes in Lamina Dura
Yes 28 (93.3) 13 (43.3) 18.3077 p=<.0001
No 2 (6.6) 17 (56.6)
Changes in Trabecular pattern
Yes 26 (86.6) 4 (13.3) 42.25 p=<.0001
No 4 (13.3) 26 (86.6)
Changes in overall radiographic density
Yes 28 (93.3) 6 (20) 56 p=<.0001
No 2 (6.6) 24 (80)
Changes in pulp chamber (relative to age)
Yes 26 (86.6) 21 (70) 2.785 p=0.117
No 4 (13.3) 9 (30)
Table 2. Comparison of Radiographic changes in the Mandible of Case group (n=30) and Control group (n=30):
Mandible
Cases (CRF Control Odds ratio Statistical
patients) n (%) n (%) significance
Changes in Lamina Dura
Yes 25 (83.3) 10 (33.3) 10 p=<.0001
No 5 (16.6) 20 (66.6)
Changes in Trabecular pattern
Yes 26 (86.6) 3(10) 58.5 p=<.0001
No 4 (13.3) 27 (90)
Changes in overall radiographic density
Yes 12 (40) 7 (23.3) 2.1905 p=0.1647
No 18 (60) 23 (76.6)
Changes in pulp chamber (relative to age)
Yes 19 (63.3) 9 (30) 4.03 p=0.0096
No 11 (36.6) 21 (70)
Changes in thickness of lower border of mandible
Yes 22 (73.3) 6 (20) 11 p=<.0001
No 8 (26.6) 24 (80)
DISCUSSION
Chronic renal failure alters bone metabolism by multiple mechanisms.Pathognomic radiologic findingsinclude the loss of the dental lamina, thinning of corticalbone in multiple locations, a coarsened trabecular pattern, and a “salt-and-pepper”
appearance of bone, particularly the skull.18,19,20 In this study, loss of Lamina dura was observed significantly in both the jaws in cases and negligible loss in control group ,the reason can be nonspecific instead of hyper/
hypoparathyroidism,as suggested in other studies21,22. This study correlates with the findings of study conducted by Indiana University Medical Center;
Indianapolis, USA that states that the triad of changes in lamina dura, trabecular pattern, and bone density alteration, although variable in relative appearance, frequently appear together23. The findings of this study find similarities with the findings of Veterans Administration Medical Center, Wood, Wis., USA in terms of delicate or absent trabecular patterns.22.The study also illustrated that changes in the size of pulp chamber in both the jaws in control as well as cases has no statistical significance and cannot be taken as diagnostic marker of the renal failure. This study also correlates with the overall granular or chalky white appearance associated with an increase in radiographic density as one of the most common alterations22.
ACKNOWLEDGEMENTS
We at A.V. Super specialty dental Hospital express our sincere gratitude to management, and administrative staff for rendering their support. We
are grateful to our colleagues involved in this program for planning, discussing the details and generalities in developing strategies for smooth implementation of the study.
REFERENCES
1. De Rossi SS, Glick M. Dental considerations for the patient with renal disease receiving hemodialysis. J Am Dent Assoc. 1996 Feb;127(2):
211-29.
2. 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.
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 Nov 1;11(6): E467-73.
4. 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.
5. Gudapati A, Ahmed P, Rada R. Dental management of patients with renal failure. Gen Dent. 2002 Nov-Dec; 50(6):508-510.
6. 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.
7. Klassen JT, Krasko BM. The dental health status of dialysis patients Can Dent Assoc. 2002 Jan;68(1):34-38.
29 Prasanth Venela 120-124.pmd 123 8/27/2012, 6:39 PM
8. Proctor R, Kumar N, Stein A, Moles D, Porter S.
Oral and dental aspects of chronic renal failure. J Dent Res 2005;84(3):199–208.
9. 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.
10. Ciavarella D, Guiglia R, Campisi G, Di Cosola M, Di Liberto C, Sabatucci A, et al. Update on gingival overgrowth by cyclosporine in Renal transplants. Med Oral Patol Oral Cir Bucal. 2007 Jan 1; 12(1):E19-25.Oct;32(10):1076-1082.
11. 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.
12. Sobrado Marinho 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):E305-310.
13. Bots CP, Poorterman JH, Brand HS, Kalsbeek H, Van Amerongen BM, Veerman EC, et al. The oral health status of dentate patients with chronic renal failure undergoing dialysis therapy. Oral Dis. 2006 Mar;12(2):176-180.
14. Roderick PJ, Jones I, Raleigh VS, McGeown M, Mallick N (1994). Population need for renal replacement therapy in Thames regions: ethnic dimension. Br Med J309:1111–1114.
15. Agarwal S.K, Dash S.C, Irshad M, Raju S, Singh R & Pandey R.M (2005).Prevalence of chronic renal failure in adults in Delhi, India. Nephrol.
Dial. Transplant 20 (8):1638-1642. doi:10.1093/
ndt/gfh855.
16. Göran Söderholm, Leif Lysell, ÅUke Svensson.
Changes in the jaws in chronic renal insufficiency and haemodialysis. Report of a case. J Clin Periodontol. 2005 Oct; 36-42.doi: 10.1111/j.1600- 051X.1974.tb01236.x
17. J. I. Chang, P.M. Som and W. Lawson (2005), Unique Imaging Findings in the Facial Bones of Renal Osteodystrophy. American Journal of Neuroradiology 28:608-609.
18. Bottomley WK, Cioffi RF, Martin AJ. Dental management of the patient treated by renal transplantation: preoperative and postoperative considerations. J Am Dent Assoc 1972; 85:
1330-1335.
19. Naylor GD, Fredericks MR. Pharmacologic considerations in the dental management of the patient with disorders of the renal system. Dent Clin North Amer 1996; 40:665-683.
20. Heard E Jr, Staples AF, Czerwinski AW. The dental patients with renal disease. Precautions and guidelines. J Am Dent Assoc 1978; 96:792-796.
21. Frankenthal S, Nakhoul F, Machtei EE, Green J, Ardekian L, Laufer D, Peled M. The effect of secondary hyperparathyroidism and hemodialysis therapy on alveolar bone and periodontium. J Clin Periodontol 2002; 29:479-483.
22. William H. Kelly, Michael K. Mirahmadi, James H. S. Simon, John T. Gorman. Radiographic changes of the jawbones in end stage renal disease. Elsevier Inc.1980 Oct; 372- 381.doi:10.1016/0030-4220(80)90423-5.
23. Charles E. Hutton. Intradental lesions and their reversal in a patient being treated for end-stage renal disease. Elsevier Inc 1985 Sep; 258- 261.doi:10.1016/0030-4220(85)90307-X