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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 28  |  Issue : 1  |  Page : 2-6

Radiographic manifestations of teeth and jaw bones in chronic renal failure patients: A longitudinal study


1 Department of Oral Medicine and Radiology, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
2 Department of Oral and Maxillofacial Surgery, Babu Banarasi Das College of Dental Sciences, Lucknow, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Government Dental College and Research Institute, Bengaluru, Karnataka, India
4 Department of Oral and Maxillofacial Surgery, P.M.S. Dental College and Research Center, Thiruvananthapuram, Kerala, India
5 Department of Oral Pathology, M.N.R. Dental College and Hospital, Sangareddy, Telangana, India

Date of Web Publication8-Sep-2016

Correspondence Address:
Puja Rai
Department of Oral Medicine and Radiology, BBD College of Dental Sciences, Faizabad Road, Lucknow, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0972-1363.189980

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   Abstract 

Introduction: Chronic renal failure (CRF) is an important health problem worldwide with a tendency of annual progression. Renal failure could alter the balance of the stomatognathic system, thus conditioning the prevalence of oral diseases at its different stages. Researchers estimate that up to 90% of renal patients show oral manifestations and a wide range of bony anomalies accounting for 92% of the patients. Aims and Objectives: The aim and objective of this study was to evaluate radiographic manifestations in CRF patients and compare the findings between the stages of CRF. Materials and Methods: A longitudinal study on fifty CRF patients was conducted. Patients were divided into three stages depending on the severity of renal failure. Orthopantomograph was taken for all the subjects. Results: The study showed that 88% of the study group had positive radiographic findings. Stage IV renal failure patients had more severe manifestations as compared to Stages II and III. Conclusion: Majority of the patients had positive radiographic findings which can be one of the diagnostic markers in CRF patients.

Keywords: Chronic renal failure, jaw bones, orthopantomograph, pulpal calcifications, renal osteodystrophy


How to cite this article:
Rai P, Singh J, Khan M, Channaiah SG, Tharakan M, Erugula SR. Radiographic manifestations of teeth and jaw bones in chronic renal failure patients: A longitudinal study. J Indian Acad Oral Med Radiol 2016;28:2-6

How to cite this URL:
Rai P, Singh J, Khan M, Channaiah SG, Tharakan M, Erugula SR. Radiographic manifestations of teeth and jaw bones in chronic renal failure patients: A longitudinal study. J Indian Acad Oral Med Radiol [serial online] 2016 [cited 2019 Nov 14];28:2-6. Available from: http://www.jiaomr.in/text.asp?2016/28/1/2/189980


   Introduction Top


Chronic renal failure (CRF) can give rise to a wide spectrum of oral manifestations owing mainly to secondary hyperparathyroidism (HPT) complicating this disease. The term “CRF-associated mineral and bone disorders” comprises abnormalities in bone and mineral metabolism with or without extraskeletal calcification secondary to CRF pathophysiology. Researchers estimate that up to 90% of renal patients show oral manifestations such as increased calculus formation, high urea concentration in saliva, ammonia-like smell, xerostomia, oral bleeding and uremic stomatitis adding to patients debilitation, and many a times posing fatal complications.[1],[2] A wide range of bony anomalies has also been reported accounting for 92% of patients with CRF.[3] The commonly discovered alterations can be seen as partial or complete loss of the lamina dura, pulp calcifications and blurring of anatomic landmarks. Infrequently, clinically evident jaw enlargement or radiolucent brown tumors and abnormal bone remodeling after extraction may be seen.[4],[5]Radiographic alterations of the jaw bones in CRF are common and are the result of renal osteodystrophy (ROD) which are the spectrum of histologic changes that occur in bone architecture of patients with CRF. The kidney is the primary site for phosphate excretion and 1-α-hydroxylation of Vitamin D. CRF patients develop hyperphosphatemia as a result of inadequate 1,25 dihydroxyvitamin D levels that reflect reduced synthesis from parenchymal scarring. In addition, renal phosphate excretion is reduced. Together, both processes cause serum calcium levels to fall resulting in increased secretion of parathyroid hormone (secondary HPT). Changes in bone architecture can be caused by either a high-bone turnover state or a low-bone turnover state. Four types of bone phenotypes (ROD) can be diagnosed in CRF patients: Osteitis fibrosa cystica (high-bone turnover with secondary HPT), osteomalacia (low-bone turnover and inadequate mineralization, primarily related to diminished Vitamin D synthesis), adynamic bone disorder (low-bone turnover from excessive suppression of the parathyroid glands), and mixed osteodystrophy (with elements of both high- and low-bone turnovers).[5],[6]


   Materials and Methods Top


This study on radiographic manifestations of teeth and jaw bones in CRF patients was conducted in the Department of Oral Medicine and Radiology, Government Dental College and Research Institute and the Institute of Nephrourology, Victoria Hospital, Bengaluru, from November 2008 to July 2010. Fifty CRF patients were selected according to inclusion and exclusion criteria as the study group. The patients included in this study were explained about the details of the study procedure and written informed consent was obtained. CRF patients were divided into three subgroups: Stages III, IV, and V according to National Kidney Foundation's Dialysis Outcome Quality Initiative criteria. Stages I and II were not considered on account of the absence of clinical and laboratory findings of CRF.





  • Subgroup I - Patients with Stage III renal failure having glomerular filtration rate between 30 and 60 ml/min
  • Subgroup II - Patients with Stage IV renal failure having glomerular filtration rate between 15 and 30 ml/min
  • Subgroup III - Patients with Stage V renal failure having glomerular filtration rate <15 ml/min and on hemodialysis.


Fifty patients in the study group and 26 patients in the control group were then subjected to radiographic examination using orthopantomograph for evaluation of jaw bones and teeth changes. All panoramic radiographs were obtained using a panoramic Orthoslice 1000 C unit. The exposure and processing factors were standardized. The unit was operated at 8–10 mA and 60–80 kVp (depending on the subject density). Kodak T-Mat G panoramic film with Kodak Lanex medium intensifying screen was used for exposure setup. Exposed radiographs were processed according to the manufacturer's recommendations using an automatic processor. Interpretation of radiographs was done by two separate oral radiologists.

Statistical tests used

Chi-square test has been used to assess the association between categorical variables. For continuous variables, t-test/ANOVA has been used to find out significant differences if any. Level of significance is fixed at 5%.


   Results Top


In the present study, radiographic findings were found in 44 (88%) patients of the study group, alveolar bone loss was present in majority of patients i.e., 35 (70%). Pulpal calcification was present in 23 (46%) patients followed by widening of periodontal space in 19 (38%), blurring of anatomic landmarks in 16 (32%), osteosclerosis in 7 (14%) [Figure 1], alteration in bony trabeculae in 16 (32%), reduced bone density in 15 (30%), loss of lamina dura in 13 (26%) [Figure 2], and soft-tissue calcification in 1 (2%) patient [Figure 3] and [Graph 1]. Comparison of radiographic manifestations across the three stages of study group is represented in [Table 1] and between the study and control groups in [Table 2].
Figure 1: Chronic renal failure patients with osteosclerosis, pulp calcification, blurring of anatomic landmarks

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Figure 2: Chronic renal failure patients with generalized alveolar bone loss and generalized loss of lamina dura

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Figure 3: Chronic renal failure patients with multiple soft-tissue calcifications

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Table 1: Radiographic findings in stages of study group

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Table 2: Radiographic findings between study group and control group

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   Discussion Top


The present study showed radiographic changes (88%) in CRF patients and the results of our study are in accordance with Bras et al.,[7] Galili et al.,[8] and Damm et al.,[4] who discussed that radiographic alterations of the jaw bones in CRF are the result of ROD. Bone loss, blurring of anatomic landmarks and reduced bone density usually result due to rarefaction of maxilla and mandible secondary to ROD and secondary HPT. The compact bone of the jaws becomes thin and eventually disappears. This may be evident as loss of lower border of mandible, cortical margins of inferior alveolar canal, and partial or complete loss of lamina dura.

Davidovich,[9] Kansu et al.,[10] and Reddy et al.[11] in their studies stated that pulpal calcification is common in patients with end-stage renal disease. Handa et al.[12] also found that significantly higher percentage of CRF patients presented with pulp calcification than the controls. The direct correlation between pulp obliteration and duration of renal failure and dialysis suggests that pulp obliteration is related to disturbances in calcification processes and altered serum calcium-phosphate (Ca-P) ratio due to parathyroid disturbances in CRF patients. Metastatic calcification occurs when Ca-P exceeds 70 mg/dl. In fact, there is recently reported evidence on calcifications in other systems related to administration of calcium-containing phosphate binders in these patients.[9]

Blurring of anatomic landmarks 16 (32%), alteration in bony trabeculae 16 (32%), and reduced bone density 15 (30%) were the important findings in our study which is in accordance with the cases published by De Lacerda et al.[13] and Benmoussa.[14] Radiographic examination of a 38-year-old woman with osteodystrophy by De Lacerda et al. demonstrated a mixed radiolucent/radiopaque lesion in the mandible while in the maxilla, the tumor presented a ground glass appearance. A study on five patients by Triantafillidou et al.[15] with brown tumors of the jaws associated with primary or secondary HPT revealed that radiographically, brown tumors appear as well-demarcated uni- or multi-locular osteolytic lesions. In the mandible, the cortical bone is expanded and thinned. Brown tumors of the jaws occasionally result in root resorption and loss of the lamina dura, and may present as a space-occupying mass in the sinus. Their study concluded that primary or secondary HPT may be recognized by the presence of an osteolytic lesion with giant cells, a condition referred as brown tumor.


   Conclusion Top


The clinical and laboratory changes in CRF are mainly related to the kidney's inability to excrete breakdown products of body metabolism leading to increase in serum urea and creatinine levels, and inability to fulfill their endocrine functions leading to defect in calcium metabolism, hyperphosphatemia, hypocalcemia and resultant secondary HPT. These changes also cause various oral manifestations and radiographic findings which can be one of the diagnostic findings in renal failure patients. Early diagnosis and appropriate management of oral and radiographic manifestations can definitely improve patients' quality of life contributing to their general health.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
   References Top

1.
De Rossi SS, Glick M. Dental considerations for the patient with renal disease receiving hemodialysis. J Am Dent Assoc 1996;127:211-9.  Back to cited text no. 1
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2.
Hamid MJ, Dummer CD, Pinto LS. Systemic conditions, oral findings and dental management of chronic renal failure patients: General considerations and case report. Braz Dent J 2006;17:166-70.  Back to cited text no. 2
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3.
Proctor R, Kumar N, Stein A, Moles D, Porter S. Oral and dental aspects of chronic renal failure. J Dent Res 2005;84:199-208.  Back to cited text no. 3
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4.
Damm DD, Neville BW, McKenna S, Jones AC, Freedman PD, Anderson WR, et al. Macrognathia of renal osteodystrophy in dialysis patients. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:489-95.  Back to cited text no. 4
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5.
Chang JI, Som PM, Lawson W. Unique imaging findings in the facial bones of renal osteodystrophy. AJNR Am J Neuroradiol 2007;28:608-9.  Back to cited text no. 5
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6.
Thomas R, Kanso A, Sedor JR. Chronic kidney disease and its complications. Prim Care Clin Office Pract2008;35:329-44.  Back to cited text no. 6
    
7.
Bras J, van Ooij CP, Abraham-Inpijn L, Wilmink JM, Kusen GJ. Radiographic interpretation of the mandibular angular cortex: A diagnostic tool in metabolic bone loss. Part II. Renal osteodystrophy. Oral Surg Oral Med Oral Pathol 1982;53:647-50.  Back to cited text no. 7
    
8.
Galili D, Berger E, Kaufman E. Pulp narrowing in renal end stage and transplanted patients. J Endod 1991;17:442-3.  Back to cited text no. 8
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9.
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;32:1076-82.  Back to cited text no. 9
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10.
Kansu O, Ozbek M, Avcu N, Aslan U, Kansu H, Gençtoy G. Can dental pulp calcification serve as a diagnostic marker for carotid artery calcification in patients with renal diseases? Dentomaxillofac Radiol 2009;38:542-5.  Back to cited text no. 10
    
11.
Reddy MS, Kannan N, Patil R. Intra-oral periapical radiographic changes in patients with chronic renal failure – An observational study. J Res Adv Dent 2012;1:75-81.  Back to cited text no. 11
    
12.
Handa S, Bhayana G, Atreja G. Oral manifestation in renal diseases and its related complication. Int J Clin Cases Investig 2015;6:6-12.  Back to cited text no. 12
    
13.
De Lacerda JC, Gomes CC, Oliveira CS, Gomez RS. Osteodystrophy and brown tumour causing localised jaw enlargement. Oral Surg 2008;1:149-52.  Back to cited text no. 13
    
14.
Benmoussa L, Renoux M, Radoï L. Oral manifestations of chronic renal failure complicating a systemic genetic disease: Diagnostic dilemma. Case report and literature review. J Oral Maxillofac Surg 2015;73:2142-8.  Back to cited text no. 14
    
15.
Triantafillidou K, Zouloumis L, Karakinaris G, Kalimeras E, Iordanidis F. Brown tumors of the jaws associated with primary or secondary hyperparathyroidism. A clinical study and review of the literature. Am J Otolaryngol 2006;27:281-6.  Back to cited text no. 15
[PUBMED]    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2]



 

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