JOURNAL OF DENTISTRY AND DENTAL MEDICINE (ISSN:2517-7389)

Kidneys are vital organs for maintain a stable internal environment, prevalence of renal disease is increasing universally. Nephritic syndrome is a clinical manifestation of any glomerular lesion that causes more than 35 g of proteinuria/day. Chronic renal disease is defined as a progressive and irreversible decline in renal function associated with a reduced glomerular filtration rate. Common renal disorders seen in children include congenital nephropathies, nephrotic syndrome, chronic renal failure (CRF), glomerulonephritis, hydronephrosis, and multicystic renal dysplasia, which ultimately lead to end-stage renal disease (ESRD). Children usually show growth retardation, bleeding tendency due to capillary fragility and thrombocytopenia is positive, pale and anaemic. This article discuss about the etiology, clinical features and dental management of children with renal diseases. 

Children; Dental management; Oral health; Renal diseases

Kidneys play an important role in sustain physiologic balance; regaining homeostasis and fluid electrolyte acid-based balance, drug metabolism and elimination, blood pressure control through the renin-angio-tensin system, red blood cell production through erythropoietin production, and vitamin common renal disorders seen in children are nephritic syndrome, chronic renal failure, chronic pyelonephritis, chronic glomerulo nephritis which ultimately leads to end stage of renal failure [1].

Nephritic syndrome: it is a condition that indicates exogenous or endogenous glomerular injury. Acute nephritic syndromes occur most frequently in children and are classically associated with post streptococcal glomerulo nephritis, commonly preceded by a beta-hemolytic streptococcal oropharyngitis. Typically l-2 weeks after the pharyngitis. Since the advent of penicillin therapy, acute nephritic syndrome has been observed less frequently streptococcal pharyngitis [2].

The aetiology of this syndrome is unknown but there is a reasonable possibility that it is an autoimmune disease. The onset is often at the age of about 2 to 3 years and the duration may be months or years. There are glomerular changes and a loss of protein. Oedema is an important feature which recurs during the course of the disease and secondary anaemia may be present. These children are very susceptible to infection and upper respiratory infections are common. Exacerbations of the renal condition may occur on these occasions [3,4].

Clinical features over 50% cases are subclinical or mild, usually producing slightly abnormal renal function that lasts less than a week. Sudden onset characterized by fever malaise. Children are ill with concurrent findings of oedema, oliguria, azotemia, and dark or coffee ground color urine (hemnturia). The hypertension is usually mild to moderate and elevates the systolic blood pressure about 20 to 40 mmHg. When the blood pressure as markedly elevated and the oedema and electrolyte imbalance become persistent, nephritic syndrome can lead to convulsions. Congestive heart failure or cardiac arrythmias. Progressive cardio-respiratory symptoms include cough, dyspnea. orthopnea, edema, rules, and gallop rhythm [5].

Treatment by corticosteroid therapy has greatly changed the course of this disease. Its duration is much reduced and chances of complete recovery considerably improved. This therapy is likely to be intensive and prolonged and may be continuous or interrupted. The use of antibacterial agents has reduced the number of deaths due to infection.

Oral condition

Enamel hypoplasia occurs in some of the children with this condition, and there may be some degree of discoloration of the teeth by tetracyclines [6].

Dental treatment

In view of the prolonged nature of the disease and its relationship to infection, maintenance of dental health is of importance. In remission periods the patient leads a relatively normal life and dental treatment should be carried out regularly at that time. Dental sepsis should be eliminated including any teeth which are doubtful. Root canal therapy is contraindicated. All extractions should be done with suitable antibiotic cover and consultation with the physician in charge will be necessary to establish the existing state of the corticosteroid therapy and whether to supplement it General anaesthesia must be an in-patient procedure. Enamel hypoplasia is treated as necessary and the patient may seek improvement of the appearance of the permanent incisors when they are badly discoloured by frequent tetracycline therapy during the early years [7].

Oral manifestation and dental considerations

They develop persistent oropharyngitis that involves the tonsillar tissues, uvula, and 501% palate. lntensely painful pharyngeal erythema and areas of necrosis may be observed. Healing occurs 1 to 2 weeks after the initiation of penicillin therapy.

Dental care for the patient with nephritic syndrome should be delayed until acute symptoms resolve. Consultation with the physician is advised prior to commencing dental treatment, to determine the patient’s renal status [8].

Though most cases appear to be due to an ascending infection, there are some which are caused by a blood-borne infection of the coccal type from a distant focus. Recurrent or persistent infection results in scarring and loss of function of the kidney, but in some there is also a pre-existing obstructive lesion. Treatment is usually by prolonged courses of antibiotics or sulphonamides. Hypertension may be a feature.

Oral condition

There are no special dental features associated with this condition.

Dental treatment

This should be directed towards the elimination of septic foci and the maintenance of dental health.

• Extractions should be done under prophylactic cover, the choice of which should take into account previous or current therapy preferably in consultation with the patient’s physician [9].
  
• Postoperative bleeding may be a problem in cases with hypertension. General anaesthesia is generally contraindicated unless the patient can be admitted to hospital for it, but local anaesthesia is acceptable.
  
• Root canal therapy in a non-vital tooth is best avoided, though a vital extirpation may be acceptable if routine follow-up is certain [10].

This condition may follow either the acute type or the nephrotic syndrome in children or may have an insidious onset without demonstrable cause. There are often acute exacerbations following upper respiratory infections of B haemolytic streptococci and each attack causes further renal damage. Many of the glomeruli may be damaged, the tubules atrophic or cystic, and extensive scar tissue and other degenerative changes present. There may be complete failure at the time of puberty. The condition produces a significant state of fatigue and anaemia may be present. The prognosis is a downward one and death may follow cerebral damage or heart failure. Current types of treatment do not materially alter the prognosis, but modern development in transplant surgery may well change this. These patients are highly susceptible to infections and any measures which prevent this will prolong life and keep the patient in a better mental state [11].

Oral condition

There are no special dental features associated with this condition [12].

Dental Treatment

• Elimination of dental sepsis must be the first consideration and in view of the susceptibility to infection, any doubtful teeth are better removed. This must be done under antibiotic cover and consultation with the physician in charge is advisable.
  
• Local anaesthesia would be the method of choice and general anaesthesia should only be used as an in-patient procedure [13].
  
• Once the septic and doubtful teeth have been removed, dental health should be maintained.
  
• Treatment plans should be simple and not prolonged in view of the prognosis, but the patient should not be denied simple orthodontic treatment if desired.
  
• Such measures not only maintain good oral conditions but help to promote a hopeful attitude in the patient and root canal therapy is contraindicated [14]. 
  

It is also known as chronic kidney disease as it develops slowly, with few initial symptoms and is a long term result of irreversible acute disease or untreated disease progression. CRF is characterized by gradual reduction in the number of functional nephrons sufficient to produce alterations in the well-being and hampering the organ function. GRF rate falls less than 60 ML/min. Failure of kidney failure depend upon the degree of intoxication. Children nephritic syndrome is often caused by minimal change glomerulonephritis, that is, nephritic syndrome with minimal glomerular changes as seen by light microscopy [15-19] (Table 1). Etiolology of growth failure in children with chronic ranal failure in Figure 1 [20].

Clinical manifestations

Oedema is the most frequent complaint of patient seeking medical treatment, is usually localized to the lower extremeties, peri-orbital region, and abdominal wall, but infrequently [21-24]. It can involve the pericardial sac. left untreated edema may cause patients to complain that their legs feel cold, heavy, numb, and swollen. Lethargy, tiredness, muscle wasting, and hypertension. Frothy urine due to proteinuria and lipiduria. Reduced urine volume and increased thirst. “Muerke’s lines”, a transven white bands of the finger nails and toe nails are noted. Spontaneous thromboses due to increased platelet adhesion and aggregation as well as decreased levels of antithrombin III.

Oral manifestations

In children the periorbital edema can be severe enough to prevent the eyelids from opening. Although these features may be dramatic, after a short course of corticosteroid therapy, the oedema usually wanes [13,14].

Increased level of urea in the blood may lead to

• Nocturnal urination

Increased levels of phosphates may cause

• Muscular cramps

Accumulation of potassium may lead to

• Hyperkalemia

Increased production of erythropoietin ultimately resulting in anaemia that causes

• Weakness

Failure to remove excess fluids results in-

• Shortness of breaths due to overload on lungs

Polycystic kidney disease may give pain in the back or side due to accumulation of large, fluid cyst on kidney, Other symptoms include:

• Metallic taste in the mouth

Dental management

1. As these patients are likely to have hematologic alterations, CBC and coagulation test should be done: Before attempting any invasive procedures. Prophylactic antibiotic therapy as these patients a very prone to infection. Penicillin, clindamycin and cephalosporin are usually indicated. History should be taken regarding the allergies of penicillin
2. Due to poor GI resorption antibiotic should administer by IM route.
3. Local anaesthesia used should be of amide typo: such as lidocaine xylocaine because of their resorption potential of the liver
4. Paracetamol la the drug of choice [28,29]

Renal disease patients present a complex clinical problem with multi-system involvement, including several oral disturbances. Paediatric and general dentists should be aware of the severity of clinical manifestations related to CRF as well as the modem treatment possibilities and their repercussions on the lives of these children. Since the number of CRF children is constantly increasing, the need for dental treatment as an integral part in managing the CRF child is also rising. It is important for dentists to be familiar with this complex clinical problem, and its effect on the dental treatment, for provision of optimal dental care.

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