**1. Introduction**

72 Chronic Kidney Disease

Ojogwu L.I. The clinical assessment of heamodialysis machine in the management of kidney

Sanchez OP. Prevention and treatment of renal osteodystrophy in children with chronic

renal insufficiency and end stage renal diaseses; Semin Nepphrol 2001; 21 (5): 441-

failure. Nig. J.Biomedical Engineering 2001;(1):19-26.

50.

Chronic renal failure (CRF) is defined as a progressive decline in renal function associated with a reduced glomerular filtration rate. The most common causes are diabetes mellitus, glomerulonephritis and chronic hypertension (Proctor et al., 2004).

The clinical signs and symptoms of renal failure are collectively termed 'uremia'. CRF affects most body systems, and the clinical features are dependent upon the stage of renal failure and the systems involved.

Oral manifestations of CRF and related therapies:

a. Gingival enlargement

Gingival enlargement secondary to drug therapy is the most commonly reported oral manifestation of renal disease. It can be induced by cyclosporine and/or calcium channel blockers (Somacarrera et al*.*, 1994; Kennedy and Linden 2000).


Relationships Among Renal Function, Bone Turnover and Periodontal Disease 75

elderly people often experience periodontal destruction. Because bone loss is a common feature of periodontitis and osteoporosis, both diseases may share some common etiologic factors (Offenbacher, 1996). The final expression of periodontitis is governed by complex interactions among host, microbial and environmental factors occurring within an intricate

In addition, CRF is associated with marked disturbances of bone structure and metabolism, and there is a slowly progressive loss of renal function over months or years (Ruggeneti, 1998). A significant decrease in bone mineral density after transplantation is a serious finding (Huang & Sprague, 2009). It is well known that impaired renal function increases osteoclast activity leading to bone turnover, and this may influence bone metabolic parameters (Couttenye et al., 1999; Cirillo et al., 1998). There is a growing body of evidence indicating that impaired renal function is associated with disrupted regulation of vitamin D (Rix et al., 1999; Hamdy et al., 1995). Whereas some systemic factors that contribute to loss of bone mass and periodontal progression have been identified, we hypothesized that renal function is associated with bone metabolism, and thus is also associated with periodontal disease. To test this hypothesis, it is essential to evaluate the relationships among bone

We initiated a longitudinal interdisciplinary study on aging (the Niigata Study) in 1998 to examine the many links between oral health and general health and well being. In the present report, we reviewed the relationship between bone metabolism and periodontal disease, taking renal function into consideration, in elderly Japanese subjects from the

According to a registry of residents, questionnaires were sent to all 70-year-olds among the 4,542 inhabitants of Niigata City in Japan. Participants were informed of the purpose of the survey, and the overall response rate was 81.4%. After dividing the residents into groups of males and females, 600 individuals (the screened population) were randomly selected in order to have approximately the same number of male and female participants in the study. Follow-up surveys were carried out every year in June from1998 to 2008 (11 times in 10 years), using the same methods that were used at baseline. All subjects were Japanese and did not require special care for their daily activities. Since age influences bone metabolism, renal function and periodontal disease, subjects were restricted to 70 years old at baseline

In addition to a strict age requirement, other study inclusion criteria included the following: blood sugar < 140 mg/dL with no history of diabetes, more than 20 teeth remaining, nonsmokers, and no history of medication use for osteoporosis. There were 184 subjects among

We utilized data on bone mineral density (BMD) of the heel, which we measured using an ultrasound bone densitometer (Fig. 1, Achilles Bone DensitometerTM, Luner Corporation,

cellular mosaic (Offenbacher, 1996).

turnover, renal function and periodontal disease.

**3. Principal findings from the Niigata Study** 

**3.2 Osteoporosis and periodontal disease** 

the screened population that met all the inclusion criteria.

**3.1 Outline of the Niigata Study** 

Niigata Study.

(Ando et al., 2000).

e. Mucosal lesions

A wide range of oral mucosal lesions, particularly white patches and/or ulceration, have been described in individuals receiving dialysis and allografts (Proctor et al., 2004).

f. Oral malignancy

Kaposi's sarcoma (KS) can occur in the mouths of immunosuppresed renal transplant recipients (Farge, 1993). Any increased risk of oral malignancy in CRF probably reflects the effects of iatrogenic immunosupression, which increases the risk of virallyassociated tumors, such as KS or non-Hodgkin's lymphoma (Proctor et al., 2004).

g. Oral infections

*Candidosis*, angular cheilitis has been described in up to 4% of hemodialysis and renal allograft recipients (King et al*.*, 1994; Klassen and Krasko, 2002). Other oral candidal lesions—such as pseudomembranous (1.9%), erythematous (3.8%), and chronic atrophic candidosis (3.8%)—have been reported in allograft recipients (King et al*.*, 1994).

*Viral infection*, prior to the availability of appropriate anti-viral drugs (*e.g.*, acyclovir, gancyclovir, and valacyclovir), about 50% of renal allograft recipients, who were seropositive for herpes simplex, experienced recurrent, severe, and prolonged HSV infections (Armstrong et al*.*, 1976). However, in recent years, the use of effective antiherpetic regimes has significantly reduced the frequency of such infection (Kletzmayr et al*.*, 2000; Squifflet and Legendre 2002).

h. Dental anomalies

Delayed eruption of permanent teeth has been reported in children with CRF (Wolff et al*.*, 1985; Jaffe et al*.*, 1990). Enamel hypoplasia of the primary and permanent teeth (Kho et al*.*, 1999; Koch et al*.*, 1999; Al Nowaiser et al*.*, 2003) with or without brown discoloration can also occur (Wolff et al*.*, 1985).

i. Bone lesions

A wide range of bone anomalies can arise in CRF. These reflect a variety of defects of calcium metabolism including, loss of hydroxylation of 1-hydroxycholecalciferol to active vitamin D (1,25-dihydroxycholecalciferol), decreased hydrogen ion excretion (and resultant acidosis); hyperphosphatemia, hypocalcemia and resultant secondary hyperparathyroidism and interference with phosphate metabolism by dialysis (Nadimi et al*.*, 1993).

Orofacial features of renal osteodystrophy due to hyperparathyroidism include bone demineralization, decreased trabeculation, decreased thickness of cortical bone, ground-glass appearance of bone, metastatic soft-tissue calcifications, radiolucent fibrocystic lesions, radiolucent giant cell lesions, lytic areas of bone, jaw fracture (due to trauma or during surgery) and abnormal bone healing after extraction. Orofacial features of renal osteodystrophy related to tooth and periodontium include delayed eruption, enamel hypoplasia, loss of the lamina dura, widening of the periodontal ligament, severe periodontal destruction, tooth mobility, drifting, pulp calcification and pulp narrowing (Damm et al*.*, 1997; Okada et al*.*, 2000; Klassen and Krasko, 2002).
