case report

Introduction:

            My
patient, initials PF and chart number 565203, is an 88-year-old female who came
to the dental clinic with a personal aid. She presented with a wide variety of
medical conditions for which a medical consult was obtained; revealing that the
patient had chronic kidney disease. A comprehensive exam was performed on her
which included periapical radiographs of her remaining teeth and periodontal
probing to evaluate the stability of the teeth. After evaluation and a consult
with the periodontist, it was determined that the patient had generalized
moderate chronic periodontitis with localized severe at teeth # 8 and 31. Her
proposed treatment was scaling and root planning which was started at her next
visit.

            This paper will look to determine if there is an association
between kidney disease and periodontitis. A literature review will be performed
on three articles to determine if kidney disease has an effect on the long term
success of SRP treatment. A PICO question will be provided and there will be an
analysis of the articles to aid in the treatment decision of this patient.

            Periodontal
disease is a group of inflammatory diseases that affects the gingivae and
alveolar bone surrounding the teeth. There is a progression of the disease that
begins with gingivitis and advances to periodontitis. “Gingivitis
is a common and mild form of gum disease that causes irritation, redness and
swelling (inflammation) of your gingiva. Periodontitis is a serious gum
infection that damages the soft tissue and destroys the bone that supports your
teeth. (Mayo Clinic, 2017)” Both of these diseases are caused by an accumulation of
plaque on the teeth, especially below the gingival margin. Plaque formation is caused by the colonization and
multiplication of microbial species in the oral cavity. Once the disease progresses to periodontitis it is
irreversible and cannot be cured only managed. It is important to receive
treatment for periodontal disease early because the progression of the disease
leads to a reduction in bone level which could lead to a number of dental
problems.

            There
are a number of causes that contribute to the development of periodontal
disease ranging from certain microbiology to pathophysiology. The views on
microbiology range between the specific and non-specific plaque hypothesis. “The Specific
Plaque Hypothesis proposes the concept that out of the diverse microflora found
in the oral cavity, only specific species are responsible for the formation and
aggravation of oral cavities. (Young)” The hypothesis gives credit to a group
of bacteria called the red group that are responsible for causing periodontal
disease. “This group includes the bacteria P. gingivalis, T. forsythia, and T.
denticola. (Craig, 2016)” The non-specific plaque hypothesis is stated as
follows, “The disease is the outcome of the overall activity of the total
plaque microflora. (Young)” There is a progression of bacteria in the mouth
from health to disease. The normal flora begins as gram positive aerobes and as
disease progresses, the flora progresses to gram negative anaerobes. The
thought is that the periodontal disease is created by metabolic byproducts of
the gram negative anaerobes. “Currently
periodontitis is believed to result from a specific mixed anaerobic infection
in disease susceptible individuals. 
However, most periodontal therapies are targeted at non-specifically
reducing the plaque mass. (Craig, 2016)”

            As the
plaque begins to accumulate on the teeth the patient will present with
gingivitis. This is caused by an inflammatory response against the plaque
buildup. If the plaque is not removed in a timely manner the disease will
progress to periodontitis. Only genetically susceptible individuals will
progress to periodontitis. There was a study done in Sri Lanka where laborers
aged 14-46 were followed for 15 years. The laborers received no dental care
except for emergency treatment. They were then placed into three groups based
on the level of attachment loss. The results of the study are as followed: “11%
had no periodontitis, 81% had mild to moderate periodontitis, and 8% had severe
periodontitis. (Craig, 2016)” An important distinguishing quality between
gingivitis and periodontitis is attachment loss associated with periodontitis.
“This is the measurement of the
position of the soft tissue in relation to the cemento-enamel junction (CEJ)
that is a fixed point that does not change throughout life. (Fritz, 2013)” It
is this measurement that will allow practitioners to classify patients with
mild, moderate, or severe periodontitis. As the level of plaque builds there
will be an increase in inflammatory mediators leading to a higher level of
inflammation. It is the inflammation that causes destruction of the underlying
bone and periodontal ligaments. This creates a pocket that allows more plaque,
bacteria, and food to get trapped in, further perpetuating the problem.

            Periodontitis presents with a number of symptoms that are
usually the same between individuals. Early on the patient will have inflamed
gingiva. This will present as red and puffy gums that may bleed upon brushing
or chewing hard food. As the level of plaque and bacteria build, the patient
may start to experience bad breath, halitosis, and a metallic taste. As the
disease progresses there will be recession of the gums which can create the
appearance of longer crowns. “Even
when clinically healthy, gingiva has a constant stream of PMNs migrating from
the vasculature and into the sulcus in response to an IL-8 gradient secreted
from gingival epithelial cells. (Craig, 2016)” It is these immune cells that
will respond to the built up plaque and begin destroying the underlying bone.
As this happens the teeth will gain mobility and they can eventually begin to
fall out.

            Current
methods for diagnosing periodontitis are mostly based off of clinical
measurements. The main method would be periodontal probing and evaluation of
radiographs for bone loss. Periodontal probing involves measuring the gingival
margin in relation to the CEJ. If the gingival margin is apical, or below the
CEJ, that means that there is recession. This is the amount of bone loss there
is around the given tooth. The classification of periodontitis is based off of
the amount of bone loss. “Mild periodontits: 1-2 mm CAL (clinical attachment
loss), moderate: 2-4mm CAL, and severe: 5+ mm CAL. (Loomer, 2016)”  The gingival margin can also be coronal, or
above the CEJ. This would indicate inflammation of the gums leading to swelling
and is more indicative of gingivitis. “Supplemental quantitative and qualitative assessments of the gingival
crevicular fluid and subgingival microflora can potentially provide useful
information about the patient’s periodontal disease. (Periodontol, 2004)” This
would include testing for certain inflammatory mediators or the specific
microflora that is associated with the red group, as mentioned above. This
could be useful for determining the duration of treatment and placing the
patient on a maintenance program.

            Prevention
is the most important method of controlling periodontitis. This includes brushing
twice a day with fluoridated toothpaste and regular flossing to clean in
between teeth. It is important to notice the signs of gingivitis and to receive
treatment from a dental professional before it progresses to periodontitis.
Once the disease progresses to periodontitis it can only be managed. “The aim of treatment for periodontitis
is to prevent damage to bones and connective tissue surrounding the teeth.
(Smith, 2017)” The types of treatment can be classified based on surgical and
non-surgical techniques. “For mild to moderate cases of periodontitis, it is
often possible to treat it using minimally invasive dental procedures, without
the need for surgery. (Smith, 2016)” These non-surgical techniques usually
consist of scaling and root planning. Scaling is the removal of plaque coronal
to the CEJ. This is done to try and minimize the inflammatory response to the
adjacent structures. Root planning is the smoothing of the root surface apical
to the CEJ. A smooth surface makes it harder for plaque to adhere to the
surface and prevents additional buildup. “This can also help to remove the
byproducts of bacterial infection, which can cause inflammation and delay
healing. (Smith, 2017)” Systemic antibiotics are not typically used to treat
periodontitis due to poor blood flow to the affected tissue. An exception is
the presence of an abscess or systemic infection, which is usually indicated by
the presence of a fever. “Topical antibiotics in a mouth rise or gel may be
recommended, depending on the cause and extent of infection. (Smith, 2017)”

Clinical Question:

            This case report looks to answer the question, “Is there a difference in the treatment
of periodontal disease in patients who have kidney disease compared to those in
the absence of kidney disease?” This question can be broken down into a PICO
format that describes the population, intervention, control, and outcome of the
studies. For this question the population was adult human population with
kidney disease. The intervention or treatment would be any periodontal
treatment. The control was adult human population without kidney disease, and
the outcome was the long term periodontal health. The articles selected for
this review came from the PubMed database using the search terms periodontal
disease and kidney disease. The rest of the review will focus on summarizing
and analyzing the articles to come up with an appropriate treatment plan for my
patient.

 

Description of Patient:

            My patient, initials PF and chart number
565203, is an 88-year-old African American female. She presented with symptoms
of dementia and a personal aid that she is completely dependent on. While
collecting her social history she revealed that her last dental visit was in
2014. She brushes twice daily but never flosses, but she does use a fluoride
containing mouthwash. She presented with a wide variety of medical diseases.
They included Diabetes, diverticulitis, a colostomy bag, glaucoma, cataracts,
hypertension, and renal failure. The renal failure does not require her to
receive dialysis. After hearing about all of these conditions I sent her to get
a medical consult before continuing with treatment. The medical consult
revealed that she had an HbA1c of 6.6 which is on the higher side, but doesn’t require
antibiotic prophylaxis. It also revealed a long list of medications that she is
currently taking.

            The first thing done at the comprehensive exam was taking
vitals. Her blood pressure was 149/79 and her pulse was 72 beats per minute.
Her blood pressure readings put her in stage I hypertension. My modifications
to dental treatment would include limiting the amount of epinephrine used and
avoiding intravascular injection of local anesthetic. During the comprehensive
exam we took periapicals of all of her remaining teeth. They showed severe
amounts of bone loss and calculus on the surfaces of her teeth. We also filled
out the perio chart which had probing depths ranging from 3-7 mm. These two
factors were used in creating a diagnosis for the patient of generalized
moderate chronic periodontitis with localized severe at teeth # 8 and 31.

            The major risk factor leading to her periodontitis is her
inability to adequately maintain her oral hygiene. After the first visit I
demonstrated the proper way to brush and had her demonstrate it back. She was
unable to properly brush her teeth so I explained to the aid that she will need
help brushing and flossing. I suggested the use of interproximal brushes since
they are easier to use than floss.

Conclusion:

            This report looked to answer the question, “Is there a difference in the treatment
of periodontal disease in patients who have kidney disease compared to those in
the absence of kidney disease?” After analysis of three studies I would alter
my treatment for the above patient. I would place this patient in a higher risk
and more frequent recalls. I would also advise the patient to seek treatment
for her kidney disease since it was shown that improvement of kidney function
can improve periodontal health. There is a mutualistic relationship between
reducing kidney and periodontal disease. Improving one will decrease the
systemic inflammation improving the other.