ORAL FINDINGS IN PATIENTS WITH REPLACED RENAL FUNCTION-a pilot study

INTRODUCTION In scientific literature the question of oral lesions in patients with end-stage of chronic renal failure is widespread and considered. Most authors agree on the great diversity in clinical oral findings in these patients (1, 3, 6, 8, 9, 14, 15, 22, 25, 27, 29, 31, 38). The fact is that non-specific diversity largely might mislead dentists in making accurate diagnosis, if they rely only on oral manifestations. In Bulgarian literature there are no reports analyzing the frequency of various oral lesions in these patients, which prompted us to realize this study. It is a great interest for us to find the oral changes in people with replaced renal function before the start of project won by our team “Optimisation of complex focal dental sanation of patients with hemodialysis and renal transplantation”, which would be oriented us about expected findings in the oral cavity.


INTRODUCTION
In scientific literature the question of oral lesions in patients with end-stage of chronic renal failure is widespread and considered.Most authors agree on the great diversity in clinical oral findings in these patients (1,3,6,8,9,14,15,22,25,27,29,31,38).The fact is that non-specific diversity largely might mislead dentists in making accurate diagnosis, if they rely only on oral manifestations.
In Bulgarian literature there are no reports analyzing the frequency of various oral lesions in these patients, which prompted us to realize this study.It is a great interest for us to find the oral changes in people with replaced renal function before the start of project won by our team "Optimisation of complex focal dental sanation of patients with hemodialysis and renal transplantation", which would be oriented us about expected findings in the oral cavity.

METHODS OF STUDY
We identified the oral status (dental status, oralhygiene level, bleeding from gum papillae, but we don't reflect these indicators in this study) 30 patients with replaced renal function (13 men ; 17 women , with middle age of 43 ± 1,17 -62% of them on hemodialysis and 38% with renal transplantation).
The first step in clinical examination was the determining the degree of fur, using scale Kojima et al. (table 1), followed by determining the frequency and degree of gingival hyperplasia and registration of existing oral manifestations .
We choose the index of Kojima for two reasons : -the evaluation of the fur is performed on color photographs, which allow us to take in consideration the view of a second researcher if we suspected a particular case; -this index system give an account not only of the presence of coating on the tongue, but also its thickness , question that is often neglected in other lingual measurement systems; In assessing the degree of gingival hyperplasia we used the index of Angelopoulos and Goaz, described by Prof. T. Djemileva (11) .0-No hyperplasia 1-Hyperplastic gingiva covering the cervical area to one third of the anatomic crown of front teeth ; 2-Hyperplastic gingiva covering the cervical area to two third of the anatomic crown of front teeth ; 3-Hyperplastic gingiva covering the cervical area above two third of the anatomic crown of front teeth ;

Lingual index of Kojima et al. :
50% of investigated persons had a value 2 of lingual index of fur (displaying the presence of a thin coating occupying less than two thirds of the dorsal surface of the tongue or reflecting tongue coated with a thick coating of less than 1 / 3; fig. 2  Our data are consistent with data from literature showing that furred tongue is viewed not only in febrile illness, dehydration, diet soft foods but also as an expression of various systemic diseases (Chronic renal failure, diabetes, gastric ulcer and duodenal ulcer, enterocolitis, chronic nephritis, leukemia, glossitis in infectious, febrile conditions, etc.).A great interest is a comparison of our data with the pattern of Chinese researchers (37) , who found correlation between furred lingual areas and the presence of systemic disease .
According to them, in renal diseases furred zones of the tongue should be extended to the rear (oesophageal) part (fig.6).Our results, although pilot show that in over 60% of the examined persons this area was always furred and only four individuals were not .Fig. 6.
gingival expansion occurred more frequently in the early post-transplant period (4 months) and in combination with low oral hygiene (11,28,35) .
Of the studied patients gingival hyperplasia was recorded only in two with renal transplantation, which immunosuppressive therapy was accompanied with the intake of antihypertensive drugs-Corinfar retard, Cordaflex (fig.12) and transplantation made more than three years .
This fact quite surprised us because we expected a higher incidence of people with medicated hyperplastic gingivitis.In both patients the index of Angelopoulos and Goaz was with value 1.

Gingival hyperplasia
One of the most typical findings in patients with end-stage renal failure is gingival hyperplasia (drugi indused overgrowth), which mechanism of occurrence is multifactorial and still unknown .Taking antihypertensive drugs and immunosuppressive drugs give its impact in the oral cavity (5,10,12,16,17,32,33,36) .Such fig.12.

IN CONCLUSION
Our pilot results confirm that oral manifestations observed in patients with replaced renal function, although non-specific cause subjective complaints of patients and this character determines the need for additional dental intervention although we didn't found a wide variety of oral manifestations .
It is undeniable that these patients burdened by his primary renal disease have subjective complaints of the oral cavity, which further suppresses them.This necessitates their periodic meeting with dentists, although the data in the scientific literature about caries-resistance of the dentition of children and adults on dialysis (3,13,26) .
We hope in the course of our work with patients with transplantation and those on dialysis (the project is for the whole country) to expand the spectrum of the data and to compare the incidence of oral lesions in different countries.