**4. Association between chronic renal failure and periodontal disease**

Based on several studies, CRF and periodontal disease can have reciprocal effects (Fig. 3). CRF and renal therapy can greatly influence the dental management of renal patient. Moreover, chronic adult periodontitis can contribute to the overall systematic inflammatory burden and may therefore influence the management of the end-stage renal disease (ESRD) patient on hemodialysis maintenance therapy (Craig, 2008).

#### **4.1 Possible association of chronic renal failure with periodontal disease**

CRF can cause several changes that influence oral conditions such as decreased salivary flow rate, increase salivary urea level and calculus accumulation (Torres et al., 2010). CRF may have an effect on the periodontal status of an individual through several possible mechanisms.


The results showed that the subjects in the OG had a higher number of progressive sites for additional attachment loss than the subjects in the NOG. This three-year longitudinal study clearly demonstrated that BMD is a risk factor for periodontal disease progression in an elderly population. In addition, according to our findings on linkage with BMD, there are some systemic factors that contribute to both loss of bone mass and periodontal disease progression (Kshirsagar, 2005). Systemic factors of bone remodeling may also modify the local tissue response to periodontal disease. The BMD of the mandible is affected by the mineral status of the skeleton and also by diseases that cause generalized bone loss (Davidovich, 2005). The mouth and face are highly accessible parts of the body, and reflect changes that occur internally. For the clinician, the mouth and face provide physical signs and symptoms of local and generalized disease. During routine oral examinations, periodontal disease including maxillary/mandibular general bone loss may be diagnostic of early osteoporotic changes in the skeleton. Some systemic factors of bone remodeling also

Osteoporosis and low renal function contribute to loss of bone mass. We were able to identify a weak but clear relationship between CAL and S-OC. There was a significant association between CAL and 24-hour creatinine clearance, which is a renal function marker**.** These findings suggest that S-OC is a valid marker of bone turnover when evaluating periodontal disease. It has been assumed that S-OC is associated with not only bone turnover but also low renal function. Periodontal conditions, including bone metabolism, may be affected by low renal function. The systemic bone metabolism, which might be

modify the local tissue response to periodontal disease.

affected by low renal function, is associated with periodontal disease.

patient on hemodialysis maintenance therapy (Craig, 2008).

mechanisms.

(Craig, 2008).

reduced oral hygiene (Craig, 2008).

**4. Association between chronic renal failure and periodontal disease** 

**4.1 Possible association of chronic renal failure with periodontal disease** 

Based on several studies, CRF and periodontal disease can have reciprocal effects (Fig. 3). CRF and renal therapy can greatly influence the dental management of renal patient. Moreover, chronic adult periodontitis can contribute to the overall systematic inflammatory burden and may therefore influence the management of the end-stage renal disease (ESRD)

CRF can cause several changes that influence oral conditions such as decreased salivary flow rate, increase salivary urea level and calculus accumulation (Torres et al., 2010). CRF may have an effect on the periodontal status of an individual through several possible

a. A major clinical consequence of CRF is uremic syndrome (uremia). This condition leads to an immune dysfunction possibly caused by defects in lymphocyte and monocyte function, which in turn may increase the rate of gingival inflammation

b. Several studies have found an increasing level of plaque formation, calculus, gingival inflammation and also decreasing saliva excretion, which can be considered together as reduced oral hygiene (Yoshihara et al., 2007). The intense psychological and time demands that are associated with hemodialysis in patients with ESRD may account for

Fig. 4. The mechanism between low renal function and periodontal disease.

c. CRF has an important effect on vitamin D metabolism (Yoshihara et al., 2007). Since vitamin D is metabolized in the liver and kidney, the presence of CRF will automatically disturb vitamin D metabolism. Vitamin D is metabolized by kidney to its active metabolite, 1,25-dihydroxyvitamin D3. This substance subsequently interacts with vitamin D nuclear receptor in the intestine, bone and kidney. The functions of this substance are to regulate bone metabolism, immune response and also cell proliferation and differentiation. Regarding bone metabolism, vitamin D controls the availability of calcium phosphate by regulating the excretions of hormones such as the parathyroid hormone (PTH) (Souza et al., 2007). CRF may disrupt the regulation of PTH which may leads to hyperparathyroidism condition and increased rate of bone disease (Yoshihara et al., 2007). Vitamin D also contributes in the synthesis of bone matrix proteins such as type-I collagen, alkaline phosphatase, osteocalcin and osteopontin (Souza et al., 2007). Osteocalcin may exist in the circulating blood and undergo local accumulation in some parts of the body. Osteocalcin has been postulated to have a role in both bone resorption and mineralization and is currently considered the most specific marker of osteoblast function. The serum level of this protein is considered to be a marker of bone formation. Serum osteocalcin is presently considered a valid marker of bone turnover

Relationships Among Renal Function, Bone Turnover and Periodontal Disease 83

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when resorption and formation are coupled and a specific marker of bone formation when formation and resorption are uncoupled (Bullon et al., 2005). Osteocalcin has also been found in the gingival crevicular fluid (GCF). Several studies found an increased level of serum osteocalcin in subjects with CRF. Moreover, the level of GCF osteocalcin was found to be significantly associated with periodontal disease, since there was an association with pocket depth, clinical attachment level and bleeding on probing (Bullon et al., 2005). Therefore, it might be reasonable to explain an effect of CRF on periodontal disease by its effect on bone metabolism (especially alveolar bone) which is specifically marked by the level of serum osteocalcin and/or GCF osteocalcin.

#### **4.2 Possible association of periodontal disease with chronic renal failure**

Periodontal disease may have an effect on CRF and also the treatment of CRF. Periodontal disease may have an effect on CRF through several possible mechanisms.


On the other hand, there are also some studies which failed to find the type of correlations mentioned above (Kitsou et al., 2000; Marakoglu et al., 2003; Duran et al., 2004; Bots et al., 2006). It is acknowledged that differences in research design, measurement methods instruments used, and other factors may have resulted in different findings. Therefore, it is still relevant and reasonable to execute further research using a more sophisticated and well-designed method to elucidate the relationship between CRF and periodontal disease.
