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science ISDH 2016 13 Background In most cases, renal replacement therapy is an indispensable life-sus- taining measure for patients with end- stage renal failure.1 Due to the often impaired general condition and possi- ble multiple medication intake, these patients must be classified as high- risk patients in the dental practice. In addition, these patients are often can- didates for transplantation, making regular diagnostics, demand-oriented therapy and, most of all, a risk-ori- ented prevention of oral diseases par- ticularly important with regard to transplantation. Anamnestic Specifics Patients on haemodialysis (HD), the most frequently-applied form of renal replacement therapy1 , are char- acterised by various special features (checklist). Due to underlying dis- eases such as diabetes mellitus and hypertension, as well as often a multi- ple medication intake, a large number of those patients is multimorbid. In addition, hypertension and the anti- coagulation by heparin (heparinisa- tion) have to be taken into account, as disregarding this factors may cause bleeding complications. Generally, the immune system of this group of pa- tients seems to be compromised, re- sulting in an increased proneness to infections.2 Consequences may in- clude systemic (e.g. infections) as well as oral diseases (caries, gingivitis and periodontitis).3 The longer dialysis is applied, the more the state of oral health decreases.4,5 In this regard, an increase in calculus formation, viral infections and erosions as well as hy- persalivation or xerostomia have be- come relevant.6–10 Furthermore, reduced salivation may cause mycotic infections (pre- dominantly candida albicans). Poten- tially, medication may influence the oral cavity, especially in form of drug-induced gingival overgrowth, caused for example by combined anti- hypertensive therapy by calcium- channel blockers (amlodipine or nifedipin). As a result, not only an in- creased risk for the formation or pro- gress of oral diseases, but also sys- temic complications are apparent. Oral-Health Management The time-consuming dialysis therapy puts considerable stress on patients, decreasing their quality of life significantly.11,12 As a result, oral health is reduced to a marginal status in the patient’s perception.13 Comple- mentary oral-hygiene measures (in- terdental brushes, florid gel) are of- ten neglected14–16 and the majority of the patients attends the dentist not regular check-up, but only in case of acute complaints.16 Therefore, the team of the dental practice should aim at sensitising and motivating pa- tients to assume more responsibility with respect to a control-oriented and preventative oral-health manage- ment. Specifics in Dental Treatment Especially an increased tendency to bleed caused by heparinisation as part of the dialysis procedure, but also a heightened risk for infections in the course of dental procedures must be mentioned. Moreover, many medications administered in the den- tal practice are metabolised by the kidneys.17 A potential nephrotoxicity of pharmaceutical drugs must there- fore be taken into account, for exam- ple tetracyclines, aminoglycosides and polypeptide antibiotics must be avoided or, if necessary, only be ad- ministered in small doses.18 In addi- tion, it is obligatory that the patient be informed about potential risks and his oral-health management be super- vised or prioritised. Furthermore, set- ting the treatment appointment on the day after (haemo)dialysis is of vi- tal importance.18 Necessity of an Individual and Risk-Oriented Prevention The long-term success of a pre- vention-oriented dental therapy, espe- cially of high-risk patients, depends on three main aspects: 1. Customised and continuing risk management (recall system), in- cluding informing the patient about the necessity of creating and main- taining oral health. 2. Extensive diagnostics (continuing diagnostic monitoring of teeth and periodontium) as well as monitor- ing reduced salivation and dis- eases of the oral mucosa (gingival overgrowth). 3. Prophylaxis/preventative meas- ures, combined with the motiva- tion and instruction of the patient and professional tooth cleaning, aiming at restoring/creating oral health. Independently from these as- pects, patients must be integrated in a structured and individually risk- oriented prevention concept. Gener- ally, this can be achieved without any additional ex- penditures in instru- ments and machin- ery. Please click the QR code for a possi- ble therapy scheme. Consequences for the Dental Practice HD patients must be informed about their status as high-risk pa- tients, as they are often unaware of this fact. Because these patients fre- quently are candidates for a kidney transplant, therapy as well as pre- und after-treatment of oral diseases at an early stage are essential (therapy scheme).19 Clinicians (general practi- tioner, internist, dentist) and patients must focus increasingly on an exten- sive exchange of information and in- terdisciplinary cooperation between dentists and nephrology/general practitioner. Likewise, all disciplines involved must consult in advance about drug administration and possi- ble antibiotic prophylaxis.20 In this re- gard, a detailed record of the patient’s medical and medication history is es- sential. Taking into account potential nephrotoxicity and well-defined indi- cations, drugs must always be admin- istered in reduced doses. Surgery must be conducted in a most atrau- matic way in order to avoid bleeding complications. Diabetes mellitus and a sufficient therapy of a possible renal hypertension must be considered es- pecially. Conclusion In particular, HD patients exhibit significant deficits regarding dental and oral health management. On the one hand, this entails the potential to improve the current situation as well as a duty for both patient and dental team. On the other hand, this can be seen as a chance to accompany and support the patient in a life-long, indi- vidually risk-oriented prevention in addition to creating a healthy oral sit- uation. For this, special treatment and prevention concepts should be estab- lished in the future. Anamnesis checklist for dialysis patients* – Which underlying disease has caused renal insufficiency? – Is the patient on the waiting list for a kidney transplant? – Has diabetes mellitus been diagnosed? If so, what is the HbA1c value? – Has hypertension been diagnosed? If so, has it been regulated by medica- tion? – How long has the patient been on and how often does he/she attend dia- lysis? – Administration of calcium-channel blockers (e.g. Nifedipin, Amlodipin)? – Immunosuppressive medication? – Have there been any complications? *Main factors in the anamnesis of HD patients especially, a complete anam- nesis remains mandatory. Kontakt | contact Gerhard Schmalz PD Dr Dirk Ziebolz Universitätsklinikum Leipzig Department für Kopf- und Zahnmedizin Poliklinik für Zahnerhaltung und Parodontologie Liebigstr. 10–14 04103 Leipzig, Germany gerhard.schmalz@ medizin.uni-leipzig.de Infos zumAutor (G. Schmalz) About the author Infos zum Autor (D. Ziebolz) About the author © wavebreakmedia/Shutterstock.com Literatur Literature Therapy scheme ISDH 201613