Uremic stomatitis

Abstract

Uremic stomatitis is a rare mucosal disorder associated with renal disorders. Here, we report a case of a 42-year-old male patient suffering from diabetes, angina pectoris, with white curdly pseudomembrane over the dorsal surface of the tongue, which was diffuse. The etiology, clinical features, and treatment are discussed.

Introduction

Uremic stomatitis is a rarely reported oral mucosal disorder, possibly associated with long standing uremia in chronic renal failure patients. Since it was first mentioned by Lancereaux in 1887 and described by Barie in 1889,[1] there have been only a small number of relevant reports in the literature. Four of 300 patients with uremia were observed to have probable uremic stomatitis in the 1930s,[2] while in 1964 another four affected patients were reported from a group of 262 patients with renal disease.[3] The clinical features of uremic stomatitis are poorly defined and are rarely detailed in relevant textbooks.

Case Report

A male patient, 42 years of age, reported to our department with a complaint of pain in the left lower posterior teeth region for the past 3 days, with history of altered taste sensation for 3 days. He was diabetic since the past 4 years and had a history of chest pain since the past 2 months. Reports suggested angina pectoris, and he was on medication (atorvastatin, clopidogrel, sorbitrate). He was a cigarette smoker for the past 15 years, 15 per day. His vital signs: temperature was afebrile, pulse rate was 75 beats per min, respiratory rate was 20 per min, and blood pressure was 120/80 mmHg. He had generalized periodontal pockets. On examination of the oral mucosa, there was white curdly pseudomembrane over the dorsal surface of tongue, which was diffuse [Figure 1]. This pseudomembrane was scrapable, nontender, and leaving erythematous area below. Based on these findings, a provisional diagnosis of uremic stomatitis was given. A diffuse white keratotic area was seen on the palate, with inflamed minor salivary gland [Figure 2]. A solitary swelling was present in the floor of the mouth on the left side, size 4 mm × 1 mm, extending from 34 to 43 region, which was nontender and was soft in consistency [Figure 3].

Figure 1.

White curdly patches over the dorsal surface of the tongue

Figure 2.

Smoker's palate

Figure 3.

Swelling in the floor of the mouth

On investigation, fasting blood sugar was 168 mg/dL (110 mg/dL) and glycated hemoglobin was 10.7% (4–5.9%). HIV and hepatitis B tests were negative.

The patient was treated with analgesics with seratopeptidase, antibiotic (doxycycline), chlorhexidine mouthwash, and 1% clotrimazole, and was followed up a week later and was counseled to quit the habit [Figure 4].

Figure 4.

After treatment

Discussion

Uremic stomatitis is an uncommon complication of uremia that may occur as a result of advanced renal failure.[4–6] Since it was first reported, few affected patients have been detailed in the literature.

The etiology of uremic stomatitis remains unknown, although it has been suggested that it may be the consequence of raised levels of ammonia compounds.[7] Uremic stomatitis may also be considered a chemical burning.[6] Ammonia is formed through the action of bacterial ureases modifying salivary urea, which can be elevated in affected patients.[7]

Other possible causes of mucosal changes associated with uremia include hemorrhagic diathesis, which is common in uremia, causing decrease of viability of the affected tissues and allowing bacterial infection, which can result in ulceration and pseudomembrane formation.[4]

Four forms of uremic stomatitis are recognized:[8] (a) Ulcerative form, (b) Hemorrhagic form, (c) Nonulcerative, pseudomembranous form, and (d) Hyperkeratotic form. The last two forms appear as white lesions. The nonulcerative, pseudomembranous form presents as painful diffuse erythema covered by a thick whitish-gray pseudomembrane. The hyperkeratotic form presents as multiple, painful, white hyperkeratotic lesions with thin projections. The tongue and the floor of the mouth are more frequently affected. Xerostomia, uriniferous breath odor, unpleasant taste, and a burning sensation are common symptoms. Candidiasis and viral and bacterial infections are common oral complications. The diagnosis is based on the history, the clinical features, urinalysis, and blood urea level determination.[8]

In some instances, uremic stomatitis may clear within a few days after renal dialysis, although such resolution may take place over 2–3 weeks. In other instances, treatment with a mildly acidic mouth rinse, such as diluted hydrogen peroxide, seems to clear the oral lesions. For control of pain while the lesions heal, patients may be given palliative therapy with ice chips or a topical anesthetic such as viscous lidocaine or dycionine hydrochloride. Although renal failure itself is life threatening, at least one example of a uremic plaque that presumably caused a patient's death has been recorded. This event was thought to have been caused by dislodging of the plaque with subsequent obstruction of the patient's airway.[9]

With the growing change in lifestyle and trends, chronic renal diseases have become common in the present day scenario. Hence, a thorough understanding of their oral manifestations would enable the oral physicians to help the patients in need, as in a few cases, oral physicians may be the first persons to diagnose such patients.