Oral health in children with renal disease

Evaluation of UK paediatric nephrology teams' understanding, experience and perceptions of oral health outcomes and accessibility to dental care: a mixed-methods study

BACKGROUND

Oral health conditions are common in children and young people (CYP) with kidney disorders. There is currently limited literature on how confident paediatric nephrology teams feel to identify and manage oral health concerns for their patients.

METHOD

An exploratory mixed-method survey was distributed across all 13 UK specialist paediatric nephrology centres with responses received from consultants, registrars, specialist nurses and special interest (SPIN) paediatricians.

RESULTS

Responses received from 109 multidisciplinary team members of 13/13 (100%) UK tertiary units. Ninety-two percent (n = 100) of respondents reported they had never received any training in oral health and 87% (n = 95) felt that further training would be beneficial to optimise care for patients and improve communication between medical and dental teams. Most respondents reported that they did not regularly examine, or enquire about, their patients' oral health. Only 16% (n = 17) reported that all their paediatric kidney transplant recipients underwent routine dental assessment prior to transplant listing. Severe adverse oral health outcomes were rarely reported and only 11% (n = 12) of respondents recalled having a patient who had a kidney transplant delayed or refused due to concerns about oral infection. Seventy-eight percent (n = 85) felt that joint working with a dental team would benefit patients at their unit; however, 17% (n = 18) felt that current infrastructure does not currently support effective joint working.

CONCLUSIONS

Across the UK, paediatric kidney health professionals report lack of confidence and training in oral health. Upskilling subspecialty teams and creating dental referral pathways are recommended to maximise oral health outcomes for CYP with kidney diseases.

Oral findings in paediatric patients with severe heart, liver, and kidney failure prior to organ transplantation

PURPOSE

Organ transplantation is an effective treatment for children with severe heart, liver, and kidney diseases. These patient groups may have more oral and dental diseases than healthy controls. It is important to eliminate oral infection foci before transplantation and to maintain good oral health to avoid potential post-transplant complications. The aim of this study was to describe and compare oral health in Finnish paediatric heart, liver, and kidney transplant recipients prior to organ transplantation.

METHODS

Eighty-six children who received a heart (n = 21), liver (n = 19), or kidney (n = 46) transplant in Finland during the years 2014-2018 were included in this study. The inclusion criterion was a pre-transplantation oral examination. Oral hygiene, enamel anomalies, and the number of decayed, missing, and filled teeth (dmft/DMFT) were analyzed retrospectively from medical and dental records and compared between the three patient groups.

RESULTS

Children with liver (p = 0.043) or heart (p = 0.047) disease had higher combined primary and permanent dentition dmft/DMFT scores compared to children with kidney disease. A higher combined dmft/DMFT score was associated with poor oral hygiene (p = 0.005). No significant differences in oral hygiene between the patient groups were found. Furthermore, all patient groups had a high prevalence of developmental dental defects.

CONCLUSION

Children with liver or heart disease seem to have a higher combined dmft/DMFT score, indicating a higher prevalence of caries compared to children with kidney disease. Prevention of dental caries, along with promoting a good oral hygiene routine and regular check-ups, is suggested in these patient groups.

Assessment of the oral health status of children with chronic kidney disease

BACKGROUND

There are various oral symptoms related to the disease and its management in individuals with chronic kidney disease (CKD). The aim of the study was to investigate the oral health status of children with different stages of CKD, kidney transplant recipients (KTR), and healthy children.

METHODS

A total of seventy-one children diagnosed with CKD and fifty-two healthy children were included in the study. Each patient was examined for dental caries by the decayed-missing-filled-teeth (DMFT/dmft) index and the International Caries Detection and Assessment System (ICDAS-II), developmental defects of enamel (DDE) by the DDE index, and oral hygiene by the debris (DI), calculus (CI), and simplified oral hygiene (OHI-S) indices.

RESULTS

The median number of DMFT/dmft was 1.00 (interquartile range (IQR):1.00-4.00) in children with stage 1-3 CKD, 0.00 (IQR: 0.00-2.50) in stage 4-5 children, 0.00 (IQR: 1.00-3.00) in KTR, and 8.00 (IQR: 1.00-13.00) in healthy children. According to ICDAS-II categories, the percentage of children with severe caries was 53.8% in healthy children, while it was 44.4% in KTR, 25.9% in stage 1-3, and 11.4% in stage 4-5 children. While the percentage of children with DDE was 88.8% in KTR, 80% in stage 4-5, and 66.7% in stage 1-3 children, this rate was 44.2% in healthy children. The highest mean OHI-S score was observed in stage 4-5 children (2.10 ± 1.08), followed by KTR (1.46 ± 1.19), stage 1-3 (1.27 ± 0.61), and healthy children (0.45 ± 0.44), respectively.

CONCLUSIONS

Compared to healthy children, children with CKD had more debris accumulation, calculus formation, and more DDE but a lower severity of dental caries. A higher resolution version of the Graphical abstract is available as Supplementary information.

Developmental Abnormalities of Teeth in Children With Nephrotic Syndrome

Introduction

Treatment with glucocorticoids in children with nephrotic syndrome can be the cause of developmental disorders of the masticatory organ and bone or teeth abnormalities. The aim was to assess the frequency and type of dental abnormalities and the correlation of their occurrence with a dosage of glucocorticoids and treatment time in children with idiopathic nephrotic syndrome.

Methods

The study group consisted of 31 patients aged 5 to 17 diagnosed with idiopathic steroid-sensitive nephrotic syndrome and 33 overall healthy children. The studies included clinical evaluation of dentition, radiologic diagnostics, and statistical analysis.

Results

In the study group, 77.4% of patients were diagnosed with abnormalities in dental development. Tooth number disorders, presence of persistent deciduous teeth and impacted teeth, abnormal crown or root shape, developmental defects of enamel, pulp stones, and bone structure disorders were identified. Statistical analysis showed significant differences in the average treatment time of glucocorticoids in patients without and with tooth developmental abnormalities.

Conclusions

Long-term use of glucocorticoids in children with nephrotic syndrome promotes the occurrence of developmental abnormalities of the teeth, calcification of the pulp, and disorders of bone tissue metabolism. For this reason, patients with steroid-sensitive nephrotic syndrome should be under the constant care of a dentist.

Oral health in children with chronic kidney disease

The review summarizes the current understanding of dental health in children with chronic kidney disease (CKD). Oral conditions associated with CKD and its medical and surgical management have been described in cohort studies. Children with CKD may present with severe developmental defects of enamel (DDE) including discoloration, pitting, and reduced hardness leading to extensive tooth wear with normal function. The alkaline oral pH resulting from the uremia of CKD inhibits cariogenic bacteria, reduces dental caries risk, and increases accumulation of dental calculus. The malnutrition, acidosis, growth hormone resistance, anemia, and renal osteodystrophy in CKD provide multiple mechanisms for abnormal craniofacial growth and delayed tooth eruption. Following successful kidney transplant, caries risk increases due to normalization of oral pH in the presence of DDE; optimized diet and oral hygiene become critical in caries control. Post-transplant medications including cyclosporine A and calcium channel blockers may cause gingival overgrowth which in severe cases requires gingival surgery to allow tooth eruption, improve appearance, or permit orthodontic treatment. Immune suppression with sirolimus or everolimus may cause severe debilitating oral ulcerations. Long-term immune suppression increases the risk for development of oral candidiasis and oral cancers. Dental examinations and treatment are recommended for children with all stages of CKD to mitigate adverse oral outcomes of the disease and its management.

Oro-Dental Health and Primary Nephrotic Syndrome among Vietnamese Children

Primary nephrotic syndrome (PNS) is common in children, affecting the soft and hard tissues of the oral cavity. This study aimed to investigate the percentage of dental caries, gingivitis, hypertrophic gingivitis, and developmental defects of enamel (DDE) in children with PNS. The association of PNS with these diseases and oral care behavior was also assessed. A total of 407 children with PNS and 407 age- and gender-matched controls were recruited. PNS was diagnosed based on blood and urinary tests. The Simplified Oral Hygiene Index (OHI-S), the Gingival Index (GI), the Gingival Overgrowth Index (GOI), the Decayed, Missing, and Filled Teeth Index (dmft/DMFT), and DDE were collected. The PNS patients showed significantly higher scores of OHI-S, GI, and dmft, and higher proportions of dental caries and DDE than those of the controls (p < 0.001). It is necessary to establish a periodic dental protocol for PNS patients to improve their oral health status.

Integrality of care for hemodialysis patient in Brazil: an analysis of access to dental care

The present study aimed to analyze factors associated with access of dental care services by Brazilian hemodialysis patients. A cross-sectional study was carried out with 467 hemodialysis patients aging from 19 to 90 years in two renal therapy centers located in the cities of Contagem and Belo Horizonte, Southeastern Brazil. Data were collected through an oral clinical examination of the patients and the application of a structured questionnaire. The dependent variable was the access to dental care, measured by the question "Have you consulted with a dentist in last six months?". The mean age of participants was 49.9 years. The average number of teeth present in the mouth was 19.3. An average of 1.5 teeth with dental caries cavities lesion was diagnosed among hemodialysis patients. One-third of the sample had gone to the dentist in the last six months (27.8%). The access to dental care was associated with formal education (OR = 1.5 [1.1-2.4]), professional advising to consult with a dentist (OR = 2.1 [1.2-3.8]) and prevalence of dental caries (OR = 2.1 [1.3-3.2]). Hemodialysis patients with eight or more years of formal education, who received professional advising to consult with a dentist and without dental caries cavities had higher chances obtaining access to dental care.

Oral alterations in patients with cystinosis

Cystinosis is a rare autosomal recessive lysosomal storage disorder, which leads to abnormal accumulation of cysteine in various organs, including progressive dysfunction of kidneys. The most severe and frequent form, affecting ∼95% of patients, is termed infantile nephropathic cystinosis (NC) (OMIM 219800). We have reported oral findings in two patients with NC and described esthetic and functional rehabilitation in one of them. The first case describes a 16-year-old male patient, who was diagnosed with NC when he was 1-year-old. The patient exhibited generalized enamel hypoplasia, grade 1 drug-induced gingival overgrowth, caries lesion in molar tooth and supernumerary tooth (ie, distomolar). The second case describes a 14-year-old male patient diagnosed with NC at 3 years old. Clinical examination revealed generalized enamel hypoplasia and grade 1 drug-induced gingival overgrowth. Radiographic examination showed supernumerary tooth (mesiodens). The treatment included gingivoplasty and restoration with direct composite resin. The severity of hypoplasia highlights the importance of a dental rehabilitation treatment, as proposed here. Direct restoration with composite resin allowed harmony, function, and esthetics to be restored, in addition to being a rapid and low-cost technique.

Health and oral health-related quality of life of children and adolescents with chronic kidney disease: a cross-sectional study

PURPOSE

The aim of this study was to evaluate if health and oral health status of children and adolescents with different stages of CKD are associated with their health-related quality of life (HRQoL), oral health-related quality of life (OHRQoL) and socioeconomic and demographic conditions.

METHODS

One hundred children and adolescents with CKD were age and gender matched to 100 individuals without CKD (mean age ± SD = 13.04 ± 2.57). Oral health was characterised by means of gingival bleeding index (GBI), plaque index (PI), the decayed, missing, and filled teeth (DMFT) index and the developmental enamel defect (DED) index. All children and adolescents answered two Peds QL^® instruments (general and oral health scales).

RESULTS

Comparing the mean scores of HRQoL and OHRQoL between groups, we observed that CKD group demonstrated worse perceptions when compared to non-CKD group. Multiple linear regression analysis with bootstrap estimation of variance (1000 replications) showed association between dental caries experience (p < 0.001), gingival inflammation (p < 0.001) and diagnosis of CKD (p = 0.027) with the OHRQoL and between physical and the emotional domain of HRQoL, when moderate/severe gingival inflammation and hypoplasia were present.

CONCLUSION

The implementation of public policies that contemplate the early dental preventive intervention in CKD children and adolescents should occur aiming to improve their oral health, once oral manifestations can directly affect the aspects of the HRQoL and OHRQoL of these individuals.

Dental caries and developmental defects of enamel in individuals with chronic kidney disease: Systematic review and meta-analysis

OBJECTIVE

To evaluate studies assessing the prevalence of dental caries and developmental defects of enamel (DDE) in individuals with chronic kidney disease (CKD) in comparison with individuals without CKD.

MATERIALS AND METHODS

Electronic searches were performed in PubMed, Web of Science, Scopus, Medline via Ovid, and ProQuest databases from their inception date until February 2018. Two review authors independently selected the studies, extracted data, and assessed the methodological quality. Meta-analysis was performed.

RESULTS

Twenty-seven studies were included in this study. For permanent teeth, 14 studies found that individuals without CKD had higher dental caries scores than those with CKD. However, only five studies presented results with a statistically significant difference between groups. Among the studies evaluating primary teeth, five showed that individuals without CKD had higher dental caries scores than those with CKD. Five studies showed that individuals with CKD had a significantly higher prevalence of DDE than individuals without CKD. The meta-analyses showed that individuals without CKD had significantly higher scores of dental caries teeth and surfaces than individuals with CKD. For DDE, no statistical difference between groups was observed.

CONCLUSIONS

Individuals with CKD present lower dental caries scores and a higher prevalence of DDE in comparison with individuals without CKD.

Association between oral findings and laboratory tests in children and adolescents undergoing dialysis: A cross- sectional study

Background

Diagnosis of oral complications in the dialysis patients is important to prevent potential infections. The aim of this cross-sectional study was to compare oral findings in dialysis patients with healthy individuals and determination of the correlation of these findings and laboratory tests.

Material and Methods

In this cross-sectional study, DMFT, dmft, DI , CI , OHIS , PI, GI and enamel defects were evaluated in 25 hemodialysis patients, 30 peritoneal dialysis patients and 26 healthy individuals. Then the correlation of laboratory tests (including Hemoglobin, Urea, Creatinine, Ca, Na, Ph, K and ALP) and oral findings was determined in each groups using SPSS (Version 16). Data analyzed with One-way ANOVA test, Chi-Square , Kruskal-Wallis , Tukey’s test and Fisher’s-Exact test.

Results

Findings revealed significant differences in dmft, DI, CI, OHIs, PI and GI between study groups. A positive correlation between Ca and DI was found in hemodialysis group. In peritoneal dialysis group positive significant correlations between DMFT index and Urea, Cr , ALP and K , between OHIs and K , between PI and Cr and negative correlations between Na and CI and OHIs were found.

Conclusions

Presence of oral problems in dialysis patients, especially hemodialysis, indicate the necessity of appropriate therapeutic considerations in these patients. The correlation of blood biochemical compounds and oral status in dialysis patients may warn clinicians to control the level of the biochemical blood compounds for oral health improvement.

Key words:Hemodialysis, laboratory tests, oral findings, peritoneal dialysis.

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.

Oral conditions in renal disorders and treatment considerations - A review for pediatric dentist

This article reviews the current understanding of the oral and dental aspects of chronic renal disease (CRD). A PubMed literature search was performed and all relevant studies were assessed. As the number of people suffering from CRD increases worldwide, dentists are expected to encounter more patients with CRD who need oral care. In children, CRD can elicit a wide spectrum of oral manifestations in the hard and soft tissues. Bleeding, altered drug metabolism, impaired immune function, and an increased risk of dentally induced bacterial endocarditis are some important features that require attention. Dental management of patients with CRD requires that clinicians appreciate that multiple systems can be affected by the disease. Dentists should consult with nephrologists regarding the specific precautions required for each patient. Medical treatments in these patients may need to be postponed due to an unfavorable oral health status or potential risk of life-threatening infection after surgery. Improving oral hygiene and performing necessary dental and oral treatment before hemodialysis or transplantation may prevent endocarditis and septicemia in these patients. Hence, treatment plans should be formulated to restore the patient's dentition and protect them from potentially severe infections of dental origin.

Clinical evaluation of dental treatment needs in chronic renal insufficiency patients

OBJECTIVE

To evaluate the need for dental treatment in chronic renal insufficiency (CRI) patients undergoing hemodialysis.

DESIGN

Transversal study and case control.

SETTING

CRI patients were examined at the Pequeno Príncipe Hospital in Curitiba, Brazil. The control group was examined at Nossa Senhora da Conceição Health Clinic in Campo Magro, Brazil.

SUBJECTS (MATERIALS) AND METHODS

Thirty-four CRI patients were undergoing hemodialysis. The control group consisted of 34 normoreactive individuals paired by gender and age.

INTERVENTIONS

The clinical examination was performed under an artificial light, using an oral mirror, an exploratory probe, a periodontal probe, and a tongue depressor.

MAIN OUTCOME MEASURES

This study adopted the methodology proposed by the World Health Organization (WHO).

RESULTS

The CRI patient group needs periodontal and orthodontic treatment. The control group needs restorative treatments, prostheses, as well as surgical and endodontic treatment.

CONCLUSION

The profile of dental treatment needs proved to be distinct among the studied groups.

The periodontal health component of the Renal Impairment In Secondary Care (RIISC) cohort study: a description of the rationale, methodology and initial baseline results

INTRODUCTION

Chronic kidney disease (CKD) is associated with significant morbidity and mortality. There is a need to identify novel and modifiable risk factors in such patients. The periodontal component of the Renal Impairment In Secondary Care (RIISC) study aims to evaluate the association between chronic periodontitis and CKD progression.

METHODS

The RIISC study is a prospective, observational cohort study of patients with CKD from a renal clinic at a hospital in the West Midlands region of the UK. Patients undergo a periodontal examination and plaque and saliva sampling. To benchmark the oral health status of the RIISC cohort, we compared it to the Adult Dental Health Survey 2009 (ADHS), a representative survey of the oral health of community dwelling adults in the UK.

RESULTS

Of the first 500 patients recruited into the RIISC study, 469 patients underwent a dental examination and 80 (17%) were edentulous. Among dentate subjects, patients within RIISC were significantly more likely to have any (OR 4.0 95% CI 2.7-5.9) or severe (OR 3.8 95% CI 2.5-5.6) periodontitis compared to the ADHS sample.

CONCLUSION

The prevalence and severity of chronic periodontitis in this cohort of CKD patients is markedly higher than a geographically matched control population.

Lower dental caries prevalence associated to chronic kidney disease: a systematic review

BACKGROUND

The aim of this systematic review was to determine whether there is any evidence in the literature referring to a lower prevalence of dental caries in children and adolescents with chronic kidney disease (CKD) compared to healthy individuals.

METHODS

A search of the PubMed Medline, Ovid Medline and Cochrane Library databases was performed using the MeSH terms "dental caries" and "chronic renal failure". To be eligible for entry in our study, controlled observational studies had to present a decayed, missing and filled index for primary teeth (dmft) and/or for permanent teeth (DMFT) in children and adolescents with CKD.

RESULTS

After evaluation of title, keywords and abstracts of the articles selected, six articles met the inclusion criteria. Three of these six articles included studies which showed susceptibility to bias and possible confounding factors. A subsequent assessment of the six studies revealed that the mean caries indices in both primary (dmf) and permanent (DMF) teeth were lower in the children and adolescents with CKD compared with healthy individuals.

CONCLUSION

Data in the literature weakly support a lower prevalence of caries in children and adolescents with CKD than in their healthy counterparts. There is still a lack of well-designed studies that provide better scientific evidence in support of this conclusion.

Oral manifestations associated with systemic complications of prune belly syndrome

Prune belly syndrome (PBS) is a rare congenital malformation of unknown etiology characterized by congenital abnormalities including abdominal wall flaccidity, urinary tract alterations, and bilateral cryptorchidism. The incidence of the syndrome is between 1/35000 and 1/50000 live births and there is little information about the oral findings. The present case describes the oral manifestations of a 15-year-old boy diagnosed with PBS. The findings include enamel hypoplasia associated with generalized hypocalcemic dental lines. In the radiographic exam, pronounced demineralization of the trabecular bone of the jaws, loss of lamina dura in all the teeth, and discontinuity of the mandibular cortical bone were observed. Prune belly syndrome is a rare disease, whose clinical dental aspects are not pathognomonic of the syndrome. The comprehension of the systemic mechanism of PBS and its comorbidities enable an understanding of the systemic etiologic factors associated with oral manifestations.

Incisor enamel formation is impaired in transgenic rats overexpressing the type III NaPi transporter Slc20a1

Inorganic phosphate (Pi) is required in many biological processes, including signaling cascades, skeletal development, tooth mineralization, and nucleic acid synthesis. Recently, we showed that Pi transport in osteoblasts, mediated by Slc20a1, a member of the type III sodium-dependent phosphate transporter family, is indispensable for osteoid mineralization in rapidly growing rat bone. In addition, we found that bone mineral density decreased slightly with dysfunction of Pi homeostasis in aged transgenic rats overexpressing mouse Slc20a1 (Slc20a1-Tg). Bone and tooth share certain common molecular features, and thus, we focused on tooth development in Slc20a1-Tg mandibular incisors in order to determine the role of Slc20a1 in tooth mineralization. Around the time of weaning, there were no significant differences in serologic parameters between wild-type and Slc20a1-Tg rats. However, histological analysis showed that Slc20a1-Tg ameloblasts formed clusters in the papillary layer during the maturation stage as early as 4 weeks of age. These pathologies became more severe with age and included the formation of cyst-like or multilayer ameloblast structures, accompanied by a chalky white appearance with abnormal attrition and fracture. Hyperphosphatemia was also observed in aging Slc20a1-Tg rats. Micro-computed tomography and electron probe microanalysis revealed impairments in enamel, such as delayed mineralization and hypomineralization. Our results suggest that enamel formation is sensitive to imbalances in Pit1-mediated cellular function as seen in bone, although these processes are under the control of systemic Pi homeostasis.

Effect of high phosphorus diet on tooth microstructure of rodent incisors

Enamel hypoplasia and disruption of dentinogenesis are the most common abnormalities of development and mineralization of human teeth. Several reports are available in the literature on the influence of dietary calcium on the formation of human and rodent tooth; however, the information about the influence of dietary phosphorus on the tooth formation is scarce. The aim of the present investigation was to examine the chronic effect of high phosphorus diet and improper dietary calcium to phosphorus ratio on the mandibular incisor microstructure in a hystricomorph rodent--Octodon degu--using macroscopic observation, histopathological examination, transmission and scanning electron microscopy. The present study shows that enamel and dentin development is disturbed under high phosphorus diet and improper calcium to phosphorus ratio. Disturbed mineral metabolism resulted in enamel depigmentation, enamel hypoplasia, enamel pitting and altered dentin morphology. The results suggest that more attention should be focused on dietary phosphorus content when facing altered tooth structure in young patients with deciduous or permanent dentition. Furthermore, we showed that degus can be used as an experimental animal model for the study of the developmental teeth disturbances.

Craniofacial and dental findings in cystinosis

OBJECTIVES

Cystinosis is a rare autosomal recessive lysosomal storage disorder with developmental and mineralization anomalies as part of its clinical presentation. The objective of this study was to provide the first systematic assessment of the craniofacial and dental characteristics associated with cystinosis.

STUDY DESIGN

Oral and radiographic evaluations were performed on 73 patients with cystinosis. Analyses of cephalometry (n = 20), taurodontism (n = 47), caries (n = 47), enamel defects (n = 48), soft tissue anomalies (n = 48), and dental age (n = 41) were performed on the cystinosis group, and compared with age- and sex-comparable controls or standards.

RESULTS

Cystinosis patients manifested relative mandibular deficiency, an increased facial height, and a reduced airway space. Taurodontism and enamel defects were significantly more prevalent in cystinosis patients compared with controls (P < 0.0001 and P = 0.027, respectively). Children (aged <15 years) with cystinosis also demonstrated a significant delay, of almost 9 months, of their dental development (P < 0.001).

CONCLUSION

Novel craniofacial and dental features are associated with cystinosis. Craniofacial deficiencies may influence the swallowing and respiratory complications seen in cystinosis. Renal pathology and associated mineral imbalance may explain the dental root and enamel anomalies found in cystinosis patients; the developmental delays in cystinosis include delayed dental formation.

Oral disease burden and utilization of dental care patterns among pediatric solid organ transplant recipients

OBJECTIVES

We conducted a study among pediatric renal (RTRs) and liver transplant recipients (LTRs) to determine: a) the overall burden of oral disease; and b) the frequency with which this population utilizes dental care services in relation to sociodemographic factors and oral disease burden.

METHODS

In this cross-sectional survey, study procedures included the completion of a standardized questionnaire (by parents/guardians), oral mucosal examination, assessment of caries, gingival enlargement, and plaque index.

RESULTS

The 142 children (82 RTRs and 60 LTRs) enrolled from April 2002 to November 2005 were predominantly Latino (41 percent) and Caucasian (34 percent). Forty-three percent had at least one carious surface (in either a deciduous or permanent tooth), 19 percent had five or more carious surfaces, and 25 percent had gingival enlargement. We found only one case of oral candidiasis. Even though 72 percent of parents/guardians reported their child had a regular source of dental care, only 49 percent had a dental cleaning and 44 percent had dental radiographs in the past year, reflecting a low prevalence of preventive dental care. Among children with no regular source of dental care, there were statistically significantly higher proportions of Latinos, younger children, and families with an annual household income <$35,000.

CONCLUSION

While the prevalence of oral mucosal disease and gingival enlargement was low, the prevalence of children with caries was high, and there was low use of preventive dental care. Strategies to improve this population's utilization of preventive dental care are needed.

Aetiology of molar-incisor hypomineralization: a critical review

OBJECTIVE

The objective of this study was to assess the strength of evidence for the aetiology of molar-incisor hypomineralization (MIH), often as approximated by demarcated defects.

METHOD

A systematic search of online medical databases was conducted with assessment of titles, abstracts, and finally full articles for selection purposes. The level and quality of evidence were then assessed for each article according to Australian national guidelines.

RESULTS

Of 1123 articles identified by the database search, 53 were selected for review. These covered a variety of potential aetiological factors, some of which were grouped together for convenience. The level of evidence provided by the majority of papers was low and most did not specifically investigate MIH. There was moderate evidence that polychlorinated biphenyl/dioxin exposure is involved in the aetiology of MIH; weak evidence for the role of nutrition, birth and neonatal factors, and acute or chronic childhood illness/treatment; and very weak evidence to implicate fluoride or breastfeeding.

CONCLUSION

There is currently insufficient evidence in the literature to establish aetiological factor/s relevant for MIH. Improvements in study design, as well as standardization of diagnostic and examination protocols, would improve the level and strength of evidence.

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.

Interactions between chronic renal disease and periodontal disease

The incidence of end-stage renal disease (ESRD) is increasing and patients receiving renal replacement therapy including hemodialysis, peritoneal dialysis or renal transplantation will comprise an enlarging segment of the dental patient population. Renal replacement therapy can affect periodontal tissues including gingival hyperplasia in immune suppressed renal transplantation patients and increased levels of plaque, calculus and gingival inflammation and possible increased prevalence and severity of destructive periodontal diseases in ESRD patients on dialysis maintenance therapy. Also, the presence of undiagnosed periodontitis may have significant effects on the medical management of the ESRD patient. Periodontitis has been found to contribute to systemic inflammatory burden including the elevation of C-reactive protein (CRP) in the general population. Atherosclerotic complications including myocardial infarction and stroke are the primary causes of mortality in the ESRD population and, in contrast to that of the general population, the best predictor of all cause and cardiac death in this population is CRP. Consequently, periodontitis may be a covert but treatable source of systemic inflammation in the ESRD population. The objective of this review was to explore the interaction between chronic renal disease, renal replacement therapy and periodontal diseases based upon the results of studies published within the last decade.

The effect of fluoride on enamel and dentin formation in the uremic rat incisor

Renal impairment in children is associated with tooth defects that include enamel pitting and hypoplasia. However, the specific effects of uremia on tooth formation are not known. In this study, we used rat mandibular incisors, which continuously erupt and contain all stages of tooth formation, to characterize the effects of uremia on tooth formation. We also tested the hypothesis that uremia aggravates the fluoride (F)-induced changes in developing teeth. Rats were subjected to a two-stage 5/6 nephrectomy or sham operation and then exposed to 0 (control) or 50 ppm NaF in drinking water for 14 days. The effects of these treatments on food intake, body growth rate, and biochemical serum parameters for renal function and calcium metabolism were monitored. Nephrectomy reduced food intake and weight gain. Intake of F by nephrectomized rats increased plasma F levels twofold and further decreased food intake and body weight gain. Uremia affected formation of dentin and enamel and was more extensive than the effect of F alone. Uremia also significantly increased predentin width and induced deposition of large amounts of osteodentin-like matrix-containing cells in the pulp chamber. In enamel formation, the cells most sensitive to uremia were the transitional-stage ameloblasts. These data demonstrate that intake of F by rats with reduced renal function impairs F clearance from the plasma and aggravates the already negative effects of uremia on incisor tooth development.

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.

Four-year follow-up of oral health surveillance in renal transplant children

To outline the specific oral surveillance needs of renal transplant children, we report the 4-year follow-up data of 106 children examined routinely on a 6-month basis and upon request from the medical team or the parents in the interval. Data were recorded for hard and soft dental tissues, including enamel defects carious lesions, gingival status, orthodontic treatment needs, and wisdom teeth eruption. Hard-tissue lesions were noted in 34.9% of the children, caries lesions on the permanent teeth were seen in 15.0% of cases, 18.86% of the patients had orthodontic treatment. Spontaneous examination, upon request for medical reasons, was given for 26 children. Twenty-one demands originated from the parents. Over a 4-year period the attendance of a dental specialist resulted in a significant improvement in the oral health of the renal transplant children.

Oral findings and periodontal status in children, adolescents and young adults suffering from renal failure

AIM

Describe the oral condition of chronic renal failure and healthy subjects, and the relationship between oral variables, chronic renal failure (CRF) conditions, and their treatment.

MATERIALS AND METHODS

Four renal failure groups: chronic renal disease (n=22); undergoing dialysis (n=22); after dialysis and transplant (n=21); and after transplant (n=32), and a healthy control (n=38) were examined. Caries, enamel hypoplasia, pulp obliteration, plaque index, gingival bleeding, recession, overgrowth and index, probing depths, attachment loss, renal treatments and their relations with the oral variables were analysed.

RESULTS

The renal failure groups had higher gingival index (GI) and bleeding, probing depths, attachment loss, hypoplasia and obliteration and less caries, than the control. Plaque was higher in the dialysis and pre-dialysis (PD) groups. Overgrowth was evident after transplant. The PD group showed lower GI than other renal groups. Dialysis duration and end-stage renal failure significantly correlated with gingivitis, probing depth, attachment loss and enamel hypoplasia. Immuran correlated positively with probing depth, gingival recession and attachment loss. Normiten and Nifedipine had positive correlations with gingival overgrowth.

CONCLUSIONS

CRF patients are characterized by pulp obliteration, gingival and periodontal diseases. Duration of end stage renal failure and type of systemic treatment have a significant influence on the oral condition.

Oro-dental health in children with chronic renal failure and after renal transplantation: a clinical review

As a consequence of chronic renal failure (CRF) and its treatment, a number of oro-dental changes occur that persist after the end-stage is reached. An early effect is enamel hypoplasia due to a defect of enamel development and mineralisation. This is usually reparable to a high aesthetic standard using dental composite filling material. Children with CRF have significantly less dental caries than healthy children due to the inhibitory effect of increased salivary urea levels. Grafted patients frequently develop gingival enlargement as a result of immunosuppression with cyclosporine A, which is further exacerbated by the additional use of antihypertensive calcium-blocking agents. Surgical reduction of gingival hyperplasia is effective and is required in approximately one third of adolescents. A very high standard of home care should be encouraged for all children with CRF in the form of thorough mechanical tooth cleaning and plaque inhibition through the use of an antibacterial mouthwash. In transplanted children presenting an increased risk of infection, antibiotic prophylaxis may be indicated for dental treatment procedures. The drug dosage should be adapted to the reduced renal function. Pediatric nephrologists should be aware that dental surgeons can make a considerable contribution to the general health and well-being of children with CRF. Thus, only oro-dental problems that are mainly encountered and treated by dental surgeons are reviewed.

Oral health and caries related microflora in children during the first three months following renal transplantation

There is little information on the oral health of children undergoing renal transplantation during the early transplant period.

METHODS

Twenty-four children undergoing renal transplantation aged 4-13.2 years and their matched controls were recruited. The dmfs, dmft, DMFS and DMFT, plaque, gingivitis and gingival enlargement scores were recorded. The oral microflora was sampled and cultured for S. mutans, Lactobacllus species and Candida species.

RESULTS

There was a significantly lower mean dmfs (0.3 +/- 0.9; P = 0.03), dmft (0.3 +/- 0.9; P = 0.03), DMFS (2.3 +/- 5.3; P = 0.01) and DMFT (1.5 +/- 2.6; P = 0.02), respectively, in the transplant group. There was a significantly greater mean plaque score (14.7 +/- 11) for the permanent dentition, at baseline only, compared with 90 days post-transplantation (9.4 +/- 10.4; P = 0.02). There was a significantly greater gingival enlargement score (1.8 +/- 1.4; P = 0.04) 90 days post-transplantation compared with baseline. The S. mutans and Lactobacillus counts were significantly lower both at baseline (P = 0.0001 and P = 0.004) and 90 days post-transplantation (P = 0.02; and P = 0.05), respectively, compared with the controls.

CONCLUSIONS

The transplant children had less active dental disease than the controls although gingival enlargement needs careful monitoring.