Dental management of chronic haemodialysis patients

Maximizing Oral Health Outcomes of Aboriginal and Torres Strait Islander People With End-stage Kidney Disease Through Culturally Secure Partnerships: Protocol for a Mixed Methods Study

BACKGROUND

Dialysis for end-stage kidney disease (ESKD) is the leading cause of hospitalization among Aboriginal and Torres Strait Islander individuals in Australia. Poor oral health is commonly the only obstacle preventing Aboriginal and Torres Strait Islander people with ESKD in Australia from receiving kidney transplant.

OBJECTIVE

This study aims to improve access, provision, and delivery of culturally secure dental care for Aboriginal and Torres Strait Islander individuals with ESKD in South Australia through the following objectives: investigate the facilitators of and barriers to providing oral health care to Aboriginal and Torres Strait Islander patients with ESKD in South Australia; investigate the facilitators of and barriers to maintaining oral health among Aboriginal and Torres Strait Islander people with ESKD in South Australia; facilitate access to and completion of culturally secure dental care for Aboriginal and Torres Strait Islander individuals with ESKD and their families; provide oral health promotion training for Aboriginal health workers (AHWs) at each of the participating Aboriginal Community Controlled Health Services, with a specific emphasis on oral health needs of patients with ESKD; generate co-designed strategies to better facilitate access to and provision of culturally secure dental services for Aboriginal and Torres Strait Islander people living with ESKD; and evaluate participant progress and AHW oral health training program.

METHODS

This collaborative study is divided into 3 phases: exploratory phase (baseline), intervention phase (baseline), and evaluation phase (after 6 months). The exploratory phase will involve collaboration with stakeholders in different sectors to identify barriers to providing oral health care; the intervention phase will involve patient yarns, patient oral health journey mapping, clinical examinations, culturally secure dental care provision, and strategy implementation workshops; and the evaluation phase will involve 6-month follow-up clinical examinations, participant evaluations of dental care provision, and AHW evaluation of oral health training.

RESULTS

Stakeholder interviews were initiated in November 2021, and participant recruitment commenced in February 2022. The first results are expected to be submitted for publication in December 2022.

CONCLUSIONS

Expected outcomes will identify the burden of oral disease experienced by Aboriginal and Torres Strait Islander people with ESKD in South Australia. Qualitative outcomes are expected to develop a deeper appreciation of the unique challenges regarding oral health for individuals with ESKD. Through stakeholder engagement, responsive strategies and policies will be co-designed to address participant-identified and stakeholder-identified challenges to ensure accessibility to culturally secure dental services for Aboriginal and Torres Strait Islander individuals with ESKD.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/39685.

Evaluation of salivary parameters and dental status in adult hemodialysis patients in an indian population

Background

Renal failure is a process that expresses a loss of functional capacity of the nephrons, independently of its etiology. The most widely used technique to combat renal failure is hemodialysis. Renal failure causes various systemic alterations including oral complications such as variations in the flow and composition of the saliva. Caries is a multifactorial disease and impaired stimulated salivary flow rate and buffering capacity are the best-known risk factors. The present study aims to evaluate the salivary pH, buffering capacity and the flow rate of saliva to the DMFT status in adult hemodialysis patients among the Indian population.

Material and Methods

Twenty healthy individuals and sixty patients undergoing hemodialysis were divided into four groups based on the following criteria: Group 1: Control group; healthy individuals,Group 2: Patients before undergoing dialysis or undergoing dialysis<3 months, Group 3: Patients undergoing dialysis since 6 months-2 years, Group 4: Patients undergoing dialysis>2 years. Dental examinations were performed according to the modified WHO oral health survey 2013 criteria and DMFT index. Saliva was collected after pre-stimulation to measuring the flow rate, buffering capacity and pH.

Results

The results exhibited a decrease in the salivary flow rate and buffering capacity with the increase in the time interval of hemodialysis, but salivary pH was found to be increasing with time. A direct relationship was seen between the DMFT scores with the increasing time interval. There was a significant correlation between DMFT index, stimulated salivary flow rate, and buffering capacity in the patients.

Conclusions

Oral health impairment can beacon to grave problems in infection-prone hemodialysis patients. Hence, the patients on hemodialysis should have regular dental examinations and treatment. Regular dental examination and instruction in patients awaiting a renal transplantation is of vital importance to ensure optimal oral health.

Key words:Saliva, pH, Buffering Capacity, Flow Rate, Hemodialysis, DMFT.

Dental implant treatment for renal failure patients on dialysis: a clinical guideline

Chronic kidney disease (CKD) is a worldwide public health problem that is growing in prevalence and is associated with severe complications. During the progression of the disease, a majority of CKD patients suffer oral complications. Dental implants are currently the most reliable and successful treatment for missing teeth. However, due to complications of CKD such as infections, bone lesions, bleeding risks, and altered drug metabolism, dental implant treatment for renal failure patients on dialysis is more challenging. In this review, we have summarized the characteristics of CKD and previous publications regarding dental treatments for renal failure patients. In addition, we discuss our recent research results and clinical experience in order to provide dental implant practitioners with a clinical guideline for dental implant treatment for renal failure patients undergoing hemodialysis.

Early tooth loss in end-stage renal disease patients on haemodialysis

OBJECTIVE

This article sets out to evaluate the prevalence and aetiopathogenesis of edentulism in patients on haemodialysis.

SUBJECTS AND METHODS

The study group comprised 44 adult patients with end-stage renal disease (ESRD) on haemodialysis. A control group was formed of 44 individuals matched for age and sex and with a glomerular filtration rate >90 ml min(-1) . All participants underwent intra-oral examination, gathering information on dental and periodontal status, and a saliva sample was taken to determine saliva debit and its biochemical composition.

RESULTS

The average number of missing teeth was higher in ESRD patients than in controls (P = 0.018). Six (13.6%) fully edentulous individuals were detected in the study group and 1 (2.2%) in the control group. Some of the clinical and biochemical variables with statistically significant differences between the study group and the control group showed a significant relationship with the number of missing teeth, but the depth of the periodontal pockets presented the highest coefficient of determination (OR = 3511.1; 95%CI = 82.2-6834.3; P < 0.001; R(2)  = 0.827).

CONCLUSIONS

Premature tooth loss is common in haemodialysis patients. Although the aetiology and pathogenesis of this finding has still not been fully clarified, it appears that severe periodontal disease may play a relevant role.

Uremia Induces Dental Pulp Ossification but Reciprocally Inhibits Adjacent Alveolar Bone Osteogenesis

Uremic patients are predisposed to atrophy of the alveolar bone and narrowing of the dental pulp chamber. Such pulp chamber changes have only been diagnosed radiologically; however, this has not been supported by any pathological evidence. We used a uremic rat model with secondary hyperparathyroidism induced by 5/6 nephrectomy surgery and high-phosphate diet to examine the dental pulp and adjacent alveolar bone pathology. In addition, we collected pulp tissues for real-time PCR. We found an opposite histopathological presentation of the ossified dental pulp and the osteomalacic adjacent alveolar bone. Furthermore, pulp cells with positive staining for Thy-1, a surrogate stem cell marker, were significantly reduced in the pulp of uremic rats compared to the controls, indicating a paucity of stem cells. This was further evidenced by the reduced pulp expression of dickkopf-1 (Dkk-1), a Wnt/β-catenin signaling inhibitor produced by mesenchymal stem cells. In contrast, expressions of receptor activator of nuclear factor κB ligand (RANKL) and RANK in uremic pulp were up-regulated, probably to counteract the ossifying process of uremic pulp. In conclusion, uremic pulp ossifications were associated with a paucity of stem cells and dysregulated Dkk-1 and RANKL signaling systems, further shifting the imbalance toward osteogenesis. Strategies to counteract such an imbalance may offer a potential therapeutic target to improve dental health in uremic patients, which warrants further interventional studies.

Establishing an Association between Renal Failure and Periodontal Health: A Cross Sectional Study

Periodontal infections can act as focus of infection, aggravating the immunocompromised state of End Stage Renal Disease patients (ESRD).

AIM

Evaluation of the periodontal health status of ESRD patients undergoing haemodialysis and establishing the underlying association between renal failure and periodontal disease.

MATERIAL AND METHODS

Eighty control and test subjects were included in the study, after matching age and sex. Creatinine and GFR were measured in each patient. Oral hygiene index- Simplified (OHI-S), Gingival Index (GI), Pocket Depth (PD) and Clinical Attachment Level (CAL) were recorded as periodontal parameters to assess the correlation between the subjects of the two groups. Further, the test group was divided into three sub-groups, on basis of duration, as less than 6 months, from 6 months to one year and more than one year.

STATISTICAL ANALYSIS

Student's t - test and ANOVA were used to analyze the inter-group and intragroup comparisons.

RESULTS

Statistical significant difference was observed for all periodontal parameters between the test and control group. However, difference amongst periodontal parameters on basis of duration of haemodialysis was seen between the subgroups of test subjects, it was not found to be statistically significant.

CONCLUSION

Severity of periodontal diseases in ESRD patients undergoing haemodialysis majorly affected due to debilitating condition of the subjects. Dialysis vintage has only a small role to play in worsening of the condition. Further research is needed to potentiate the establishment of two-way relationship between renal disease and periodontal condition.

Prevalence and severity of oral disease in adults with chronic kidney disease: a systematic review of observational studies

BACKGROUND

Oral disease may be increased in people with chronic kidney disease (CKD) and, due to associations with inflammation and malnutrition, represents a potential modifiable risk factor for cardiovascular disease and mortality. We summarized the prevalence of oral disease in adults with CKD and explored any association between oral disease and mortality.

METHODS

We used systematic review of observational studies evaluating oral health in adults with CKD identified in MEDLINE (through September 2012) without language restriction. We summarized prevalence and associations with all-cause and cardiovascular mortality using random-effects meta-analysis. We explored for sources of heterogeneity between studies using meta-regression.

RESULTS

Eighty-eight studies in 125 populations comprising 11 340 adults were eligible. Edentulism affected one in five adults with CKD Stage 5D (dialysis) {20.6% [95% confidence interval (CI), 16.4-25.6]}. Periodontitis was more common in CKD Stage 5D [56.8% (CI, 39.3-72.8)] than less severe CKD [31.6% (CI, 19.0-47.6)], although data linking periodontitis with premature death were scant. One-quarter of patients with CKD Stage 5D reported never brushing their teeth [25.6% (CI, 10.2-51.1)] and a minority used dental floss [11.4% (CI, 6.2-19.8)]; oral pain was reported by one-sixth [18.7% (CI, 8.8-35.4)], while half of patients experienced a dry mouth [48.4% (CI, 37.5-59.5)]. Data for kidney transplant recipients and CKD Stages 1-5 were limited.

CONCLUSIONS

Oral disease is common in adults with CKD, potentially reflects low use of preventative dental services, and may be an important determinant of health in this clinical setting.

Oral and salivary changes among renal patients undergoing hemodialysis: A cross-sectional study

We wanted to assess oral and salivary changes in end stage renal disease (ESRD) patients undergoing hemodialysis (HD) and to understand the correlation of such changes with renal insufficiency. The cross-sectional study was performed among 100 ESRD patients undergoing HD. Among these, 25 patients were randomly selected to assess the salivary changes and compared with 25 apparently healthy individuals who formed the control group. Total duration of the study was 15 months. Oral malodor, dry mouth, taste change, increased caries incidence, calculus formation, and gingival bleeding were the common oral manifestations. The flow rates of both unstimulated as well as stimulated whole saliva were decreased in the study group. The pH and buffer capacity of unstimulated whole saliva was increased in the study group, but stimulated whole saliva did not show any difference. ESRD patients undergoing HD require special considerations during dental treatment because of the various conditions inherent to the disease, their multiple oral manifestations and the treatment side-effects.

Oral health of hemodialysis patients: a cross-sectional study at two German dialysis centers

The aim of the study was to investigate the oral hygiene behavior and state of oral health of hemodialysis (HD) patients in Germany. HD patients attending two dialysis centers were asked to participate in the study. Anamneses and oral hygiene behavior were recorded in a questionnaire. Dental examination included the dental status (DMF-T) and the degree of gingival inflammation (PDI: Periodontol Disease Index). Of 129 patients contacted, 54 (42%), aged 63.9 ± 13.0 years (23 women and 31 men), took part in the study. At an average, dialysis was required for 4.1 years. The cause of terminal renal failure was glomerulonephritis in 30% of patients and diabetic nephropathy in 22% of patients. Since dialysis therapy, 63% of the patients (n = 34) only visited a dentist when they had complaints. In 46 cases (85%), the dentist had been informed about the patient's requirement for dialysis, and in most cases (70%), the dental treatment took place on the day after dialysis. The mean DMF-T of the HD patients was 22.1 ± 6.5. The proportion of carious teeth was low (D-T: 0.7 ± 1.2), of missing teeth (M-T) high (16.2 ± 9.3). The median degree of gingival inflammation (PDI) was 1. Availing themselves of dental treatment after patients needed to have dialysis was mostly "complaint oriented." In addition to a high proportion of missing teeth, a good level of restoration of caries was found. The gingiva showed only a low level of inflammatory changes.

Systemic consequences of poor oral health in chronic kidney disease patients

Changes in the oral cavity, such as periodontitis and other manifestations of poor oral health, are common in patients with chronic kidney disease (CKD) and may contribute to increased morbidity and mortality because of systemic consequences such as inflammation, infections, protein-energy wasting, and atherosclerotic complications. Poor oral health in CKD patients may thus represent an important, but often overlooked, problem. Several studies show that uremic patients have higher rates of decayed, missing, and filled teeth, loss of attachment, and periapical and mucosal lesions than the general population. The consequences of poor oral health may be more severe in CKD patients because of advanced age, common comorbidities such as diabetes, concurrent medications, and a state of immune dysfunction that may increase the risk for systemic consequences of periodontitis and other oral and dental pathologic conditions. Poor dentition and other signs of poor oral health should be an alarm clock also at early stages of CKD. However, it remains to be determined whether more successful management of poor oral health and periodontitis will reduce the risk of inflammation, infection, protein-energy wasting, and atherosclerotic complications in CKD patients. This review explores etiological factors and potential systemic consequences of poor oral health in CKD patients as well as possible preventive and therapeutic strategies.

Oral Health and Inflammation in Patients with End-Stage Renal Failure

Background/Aims

End-stage renal disease (ESRD) patients have an increased risk of atherosclerotic complications. In both hemodialysis (HD) patients and the general population, it has become evident that inflammation plays an important role in the pathogenesis of atherosclerotic complications. Oral and dental problems in ESRD patients could be an important source of inflammation, thus treatment of these problems is important to protect these patients from potential infections. The decayed, missing, and filled teeth (DMFT) index is an indicator of oral and dental health status. Our aim was to analyze and compare salivary flow rate (SFR), salivary pH (SpH), salivary buffering capacity (SBC), and DMFT index and plaque index (PI) values in PD patients to HD patients and healthy controls (C) and establish the relationship between these parameters and C-reactive protein (CRP).

Methods

76 PD patients, 100 HD patients, and 111 Cs were included in the study. SFR (milliliters/minute) was measured in stimulated whole saliva, SpH was measured using the Merck indicator, and SBC was measured according to the method of Ericsson: 1 mL whole saliva was added to 3 mL 0.005 N HCl and a stream of air was passed through this mixture for 20 minutes. Finally, DMFT index and PI values were calculated.

Results

No statistically significant differences were found in age or gender distribution among PD, HD, and C groups. There was also no significant difference in time on dialysis between PD and HD groups. SFR was significantly lower in the PD and HD groups than in the C group (1.30 ± 0.83 and 0.70 ± 0.32 vs 1.64 ± 0.45 mL/min) and lower in the HD than in the PD group ( p < 0.001). SpH (8.35 ± 0.43 and 8.12 ± 0.74 vs 7.16 ± 0.76) and SBC (7.39 ± 0.47 and 6.82 ± 0.70 vs 5.08 ± 0.73) were significantly higher in the PD and HD groups than in the C group and higher in the PD than in the HD group ( p < 0.05 and p < 0.001 respectively). The numbers of filled teeth were significantly higher in the PD than in the HD and C groups ( p < 0.001). DMFT index was significantly higher in the PD than in the HD group ( p < 0.001). Finally, PI values were significantly higher in the PD and HD groups than in the C group ( p < 0.001) and higher in the HD than in the PD group, although this was not statistically significant. In the present study, we also found higher CRP values in HD than in PD patients and a positive correlation between CRP and PI values in PD patients.

Conclusions

PD patients have higher SFR, SpH, and SBC values than HD patients; however, higher DMFT index and higher numbers of filled teeth were observed in PD patients. Compared to healthy controls, patients on dialysis had worse dental and periodontal findings, which might have a role in microinflammation in this group of patients.

Evaluation of periodontal parameters in patients undergoing peritoneal dialysis or hemodialysis

OBJECTIVE

To analyze and compare periodontal parameters in chronic renal failure (CRF) patients undergoing peritoneal dialysis (PD) therapy with a group of patients on hemodialysis (HD) treatment and healthy controls (C).

PARTICIPANTS

Seventy-five PD patients (mean age: 44 +/- 12 years) were matched with 41 HD patients (mean age: 46 +/- 15 years) and 61 C (mean age: 46 +/- 18 years).

METHODS

Plaque (PI) and calculus (CSI) accumulation and gingival bleeding (GI) were recorded with the appropriate indices. Periodontal condition was assessed using the probing pocket depth (PPD). One-way anova test, Pearson chi-squared test, Mann-Whitney U-test and Kruskal-Wallis test were performed to compare PD patients with HD patients and healthy C.

RESULTS

Plaque Index values were significantly higher (P < 0.001) in the PD and HD groups than the C group. GI values were significantly higher (P < 0.01) in the HD group than the PD group. Finally, CSI values in the PD and HD groups were also significantly higher (P < 0.001) than the C group.

CONCLUSIONS

Chronic renal failure patients on PD treatment are more susceptible to periodontal diseases like HD patients. Thus, it is very important to maintain an optimal oral hygiene level. Further studies on periodontal parameters of only PD patients are needed to get more information on the oral health status of this patient group.

Fluid dynamics of gingiva and gingival health in children with end stage renal failure

OBJECTIVES

Impaired homeostasis and fluid balance are important physiopathological alterations in patients with chronic renal failure which may adversely affect the fluid dynamics and health status of tissues and organs. There are insufficient data about this phenomenon in periodontal tissues. The aim of this study was to evaluate the fluid dynamics of gingiva in children with end stage renal failure (ESRF), correlating this entity with gingival health in the same patient group.

DESIGN

Fifteen paediatric ESRF patients undergoing peritoneal dialysis (test group) and 15 systemically healthy children (control group) who were without periodontitis participated in the study. Fluid dynamics of gingiva were assessed via the gingival crevicular fluid (GCF) volume and tissue osmotic pressure (GOP) levels in the groups. GCF volume was measured using a Periotron 8000, whereas GOP was measured using a digital osmometer. Silness and Löe Plaque index (PI) and, Löe and Silness gingival index (GI) scores were utilized to determine the gingival health status in the study population.

RESULTS

There were increases in the GCF volume and GOP of the test group compared to those of the control group (p<0.01). The PI and GI scores were higher in the test group than in the control group (p<0.01). Strong and positive correlations were found between GI and GCF volume, GI and GOP and, GCF volume and GOP in both groups (p<0.01).

CONCLUSIONS

Our findings suggest that the fluid dynamics of gingiva may alter in children with ESRF, and this phenomenon may consequently affect the gingival health of these patients.

Renal disease and the mouth

Oral manifestations of renal disease are common. They may present as unique signs of multi-system disease affecting the kidneys (such as vasculitis), or as common oral pathologies found at an increased prevalence in patients with end-stage renal disease. Despite more oral and dental disease in patients on renal replacement therapy, attendance at dental clinics is infrequent, and physician awareness of the problem is low. In our short review, aimed at renal, transplant, and general physicians, we discuss the link between clinical changes in the mouth and multi-systemic disease involving the kidney. We suggest a standardized approach to oral examination to increase diagnostic yield and discuss common oral complications in patients on dialysis or successfully transplanted. Finally, we suggest potential treatments for oral disease that nephrologists might safely institute.

Periodontal and oral microbiological status of an adult population undergoing haemodialysis: a cross-sectional study

OBJECTIVES

The aim of this cross-sectional study was to evaluate the periodontal status and oral microbiological patterns of a population with end-stage renal disease (ESRD), undergoing haemodialysis (HD).

DESIGN

This was a cross-sectional study, involving 52 patients from the Nephrology Department and 52 matched control subjects.

MATERIALS AND METHODS

The subjects had a periodontal clinical examination; subgingival plaque samples were taken and analysed using a semiquantitative polymerase chain reaction (PCR) test to detect Porphyromas gingivalis, Tannerella forsythia, Prevotella intermedia, Prevotella nigrescens and Actinobacillus actinomycetemcomitans. Subgingival plaque and saliva samples were studied for Candida and Enterobacteriaceae.

MAIN OUTCOME MEASURES

Most of the 104 subjects had some degree of loss of periodontal attachment (LPA) > or =3 mm [11 (10.5%) had severe LPA; 16 (15.4%) moderate LPA; and 64 (61.5%) mild LPA]. Only 13 subjects (12.5%) presented good periodontal health.

RESULTS

No statistically significant differences were found between the HD patients and the control group regarding bleeding index, number of teeth, or percentage of LPA > or =3 mm. However, a statistically significant difference was seen in the degree of oral hygiene.

CONCLUSIONS

On the basis of the findings presented here, we cannot associate ESRD with more severe periodontal destruction. Although HD patients presented a higher number of periodontopathic microorganisms than the matched controls, a prolonged duration of HD did not bear a statistically significant relationship with the percentage of sites with LPA > or =3 mm, specific microbiota or composition of biofilm.

Pathologie buccodentaire et sa prise en charge chez les insuffisants rénaux chroniques

Bad dental status is very often observed in hemodialyzed patients due to the fact of a frequent poor oral hygiene and, in addition of the traditional risk factors, the consequences of uraemic state and its treatment. However , among such immunodepressed patients, oral and dental lesions represent a risk of septic complications. Moreover some works point out the prevalence of inflammation and denutrition due to dental lesions in the uraemic population, with potential atherosclerosis. Therefore, in order to anticipate all these adverse effects and to restore their mouth to health, patients have to be encouraged to have regularly a full dental evaluation and correction if not elimination of all potential sources of infection and other complications. To ensure the best treatment, a close collaboration has to be established with dental practitioners who must be aware and convinced of the complexity of such patients: immunodepression due to uraemic state and sometimes to drug therapy; importance of prophylactic antibiotic therapy surrounding dental cares; cautions to hemostasis circumstances; adjusted use of some medications. To illustrate this matter, we report here a study involving 96 hemodialyzed patients who were investigated by panoramic radiography and clinical cross- examination about their dental complaints and habits. We then expose our practices and detail our collaboration with their dentists in establishing a plan of dental treatment.

Ulcerative uremic stomatitis associated with untreated chronic renal failure: Report of a case and review of the literature

Uremic stomatitis represents a relatively uncommon intraoral complication seen, mostly, in cases of end-stage renal disease or undiagnosed/untreated chronic renal failure. Its incidence has decreased due to the advent of renal dialysis. Clinically uremic stomatitis is characterized by the presence of painful plaques and crusts that are usually distributed on the buccal mucosa, dorsal or ventral surface of the tongue, gingiva, lips, and floor of the mouth. Treatment consists of improvement of urea blood concentration and the underlying renal failure, supported by increased oral hygiene with antiseptic mouthwashes and antimicrobial/antifungal agents if necessary. Although uremic stomatitis occurs in patients with end-stage renal disease, we report a case of a patient who exhibited an ulcerative form of uremic stomatitis related to the sudden relapse of uremia, although not in an advanced stage of her renal disease. A description of the clinical and microscopic appearance is given along with our hypothesis for the pathogenesis of the disease.

Oral and dental aspects of chronic renal failure

The present article reviews, in detail, the current knowledge of the oral and dental aspects of chronic renal failure (CRF). Worldwide, increasing numbers of persons have CRF; thus, oral health care staffs are increasingly likely to provide care for patients with such disease. Chronic renal failure can give rise to a wide spectrum of oral manifestations, affecting the hard or soft tissues of the mouth. The majority of affected individuals have disease that does not complicate oral health care; nevertheless, the dental management of such individuals does require that the clinician understand the multiple systems that can be affected. The clinician should also consider the adverse side-effects of drug therapy and appropriate prescribing, in view of compromised renal clearance.