Severe periodontitis associated with chronic kidney disease.

The data on Indian population with regard to severity/prevalence of chronic periodontitis in association with chronic kidney disease (CKD) is scarce. We are describing an interesting case of severe periodontitis associated with CKD. The patient had unusual inflammatory gingival overgrowth which persisted even after treatment. By describing this case we want to highlight our current lack of understanding with regard to etiopathogenesis of periodontal disease in CKD patients and need for further research in this area.

INTRODUCTION

Chronic kidney disease (CKD), also known as chronic renal disease, is a progressive loss in renal function over a period of months or years. It is defined by National kidney foundation of USA as – “Kidney damage or glomerular filtration rate <60 mL/min/1.73 m2 for more than three months”. CKD is classified into stage one to five based on glomerular filtration rate and stage five CKD is also called as end-stage renal disease.

Many studies have reported increased prevalence and severity of periodontal disease in patients with CKD.[1-3] A recent study by Messier et al. has reported higher extent of periodontal bone loss in dialysis patients, but there was a lack of a dose-response association between bone loss and CKD stage which underscores the complex relationship between the two conditions.[4] CKD patients have higher levels of traditional systemic inflammatory markers (IL-6 and C-reactive protein) and of pro-hepcidin, which along with parameters of clinical severity and probing depth, decrease after periodontal treatment.[5] Though the literature on Indian population in this regard is very scarce, one study has shown higher prevalence of periodontal disease in CKD patients.[6]

This case report describes a case of severe periodontal destruction in a patient of CKD with unusual inflammatory gingival overgrowth.

CASE REPORT

A 35 year old female patient presented to Dental Department, Vardhman Mahaveer Medical College and Safdarjang Hospital, New Delhi, with chief complaint of mild pain and swelling in mandibular molars on both side. Her medical records revealed that she was suffering from stage four CKD. She was non-diabetic, non-hypertensive and cause of CKD was not established. She was not taking any drug which is known to cause gingival overgrowth.

Clinical examination

On intraoral examination, she had bilateral periodontal abscess in relation to first mandibular molars, with deep periodontal pockets and pus discharge [Figures 1 and 2]. OPG revealed severe angular bone loss in relation to 36 and 46, and external root resorption of mesial root of 46 [Figure 3].

Figure 1

Periodontal abscess in relation to 46 regions

Figure 2

Periodontal abscess in relation to 36 regions

Figure 3

Initial OPG of patient showing bone loss in 36 and 46 regions

Initial treatment

Abscess was drained under local anesthesia through periodontal pocket, and copious irrigation with CHX was done. Oral hygiene instructions were given and phase I therapy was started. Patient was recalled after one week. Opinion of nephrologists was also sought regarding dental treatment.

Recall visits

After one week there was no pus discharge, but inflammatory gingival overgrowth persisted. Considering the medical condition of the patient and nephrologist's opinion, it was decided to manage the case non-surgically. Full mouth scaling and root planing was completed. Combination of Amoxycillin and Metronidazole was given for seven days (after dose adjustment in consultation with nephrologists). Patient was recalled every month for scaling and root planing.

The response to therapy was poor, inflammatory gingival overgrowth persisted in both the molars [Figures 4 and 5], there was bleeding on probing, but no pus discharge.

Figure 4

One month post-operative (46 region)

Figure 5

One month post-operative (36 region)

After six months, the patient's CKD deteriorated to stage 5 and was put on haemodialysis twice a week. Though non-surgical periodontal therapy was being continued with monthly recalls, OPG revealed rapid periodontal destruction in 36 and 46 [Figure 6] as compared previous OPG taken six months back [Figure 3]. The inflammatory gingival overgrowth persisted in both the molars.

Figure 6

OPG after six months showing rapid bone destruction in 36 and 46 regions

DISCUSSION

The studies of periodontal status in adults with chronic kidney disease (CKD) performed in the past 10 years are scarce, especially on Indian population. Moreover, most of these studies focused patients on maintenance hemodialysis.[1-37-9] This case report highlights the severe periodontal disease in patient who was followed from pre-dialysis stage to stage five. Two notable findings in this case report draw special attention. First, the unusual inflammatory gingival overgrowth in mandibular molar regions which has not been reported previously in CKD patients. Second, the poor response to therapy and rapid periodontal destruction despite the regular non-surgical periodontal intervention. Both these unusual findings highlight our current lack of understanding with regard to etiopathogenesis of periodontal disease in CKD patients.

Though the factors associated with CKD responsible for increased prevalence/severity of periodontal disease are not completely understood, they may include hyposalivation and xerostomia, impaired immunity and wound healing, alveolar bone destruction due to renal osteodystrophy, bleeding diathesis, diabetes mellitus, malnutrition and a state of general disability impairing oral hygiene.[1011] Increase in levels of serum osteocalcin and/or GCF osteocalcin in CKD patients may also explain the effect of CKD on periodontal disease, by its effect on bone metabolism.[12] Morphological examinations of gingival specimens from chronic hemodialysis patients show peculiar and extensive degenerative changes in the area of epithelial cells, which are not observed in subjects with periodontitis but without renal failure.[13] Some studies also suggest that periodontitis may contribute to systemic inflammatory burden in CKD patients on hemodialysis maintenance therapy.[14]

The exacerbation of periodontal disease, as patient goes from pre-dialysis phase to dialysis phase, which was seen in this case report, has also been reported by other investigators.[215]

The CKD patient with periodontitis is medically complex and presents the dental practitioner with several challenges in the management of their periodontal condition. Accordingly, close communication between the dentist and nephrologist is essential to optimize periodontal management. Among the factors which may complicate the treatment include high prevalence of anemia, clotting deficiencies, hypertension, diabetes and renal osteodystrophy in such patients.

Through this case report we want to attract attention of investigators and motivate them to perform research related to periodontal disease in CKD patients and its effective management. This will not only improve understanding of this complex issue, but will also help thousands of such patients suffering from CKD with periodontal disease.