Poor oral hygiene and dental caries predict high mortality rate in hemodialysis: a 3-year cohort study

Preventive dental care reduces risk of cardiovascular disease and pneumonia in hemodialysis population: a nationwide claims database analysis

This study aims to investigate the impact of dental care utilization status on the occurrence of fatal complications such as cerebral/cardiovascular disease (CVD) and infectious diseases in patients with end-stage renal disease (ESRD) undergoing hemodialysis. This retrospective cohort study was performed using the Japanese claims database and included patients who first underwent hemodialysis between April 2014 and September 2020. The exposure variable of interest was the pattern of dental utilization, which was categorized into three groups, "dental treatment group", "preventive dental care group", and "no-dental visit group". The primary outcomes were the time interval until a composite end point of first major cardiovascular event (acute myocardial infarction, heart failure, or cerebral infarction) of infectious disease (pneumonia and sepsis). The secondary outcomes were the time interval until the incidence of each component of primary outcomes. Survival analyses, including log-rank tests and Cox proportional hazards regression analyses, were performed. Among the 10,873 patients who underwent the first dialysis treatment, 6152 were assigned to the no-dental visit group, 2221 to the dental treatment group, and 2500 to the preventive dental care group. The preventive dental care group had significantly lower hazard ratios (HRs) of the incidence of CVD (adjusted hazard ratio [aHR]: 0.86, 95% confidence interval [CI]: 0.77-0.96) and infectious diseases (aHR: 0.86, 95% CI: 0.76-0.97). As for pneumonia, preventive dental care and dental treatment groups had significantly lower HRs (aHR: 0.74 and 0.80, 95% CI: 0.61-0.88, 0.66-0.96) than the no-dental visit group. This study demonstrated that dental visits for preventive dental care were associated with a significant risk reduction in CVD and infectious complications in patients with ESRD undergoing hemodialysis.

Periodontitis and risk of mortality in patients with chronic kidney disease: A systematic review with meta-analysis

Studies examining the link between periodontitis and survival outcomes have yielded conflicting results in patients with chronic kidney disease (CKD). This systematic review with meta-analysis aims to assess the association between periodontitis and cardiovascular or all-cause mortality in CKD patients. A thorough search was conducted on the PubMed, Web of Science, and Embase databases for studies investigating the association between periodontitis and survival outcomes in CKD patients. Two authors independently scanned the titles or abstracts and then identified the eligible full-text article based on the PECOS criteria: Participants (CKD patients), Exposure (periodontitis), Comparison (mild/no periodontitis), Outcomes (cardiovascular or all-cause mortality), and Study design (retrospective or prospective cohort). Six cohort studies, including 7731 patients, were identified. The included studies had low-to-moderate risk of bias. The mean/median follow-up duration ranged from 18.1 months to 8.67 years. The all-cause mortality rate was 44.8% for patients with periodontitis and 28.0% for controls. Meta-analysis showed that periodontitis, defined through clinical attachment loss (CAL), was significantly associated with an increased risk of all-cause (adjusted hazard ratio [HR] 1.24; 95% confidence intervals [CI] 0.89-1.72; I2  = 80.9%) and cardiovascular mortality (HR 1.57; 95% CI 1.08-2.27; I2  = 34.0%). Additionally, a significant association between periodontitis and the risk of cardiovascular or all-cause mortality was observed in studies with a predominance of females, follow-up duration ≥5 years, all stages of CKD, and low risk of bias subgroups. Periodontitis is significantly associated with an increased risk of all-cause and cardiovascular mortality in CKD patients within low risk of bias subgroup or based on defining periodontitis through CAL. Registration number: PROSPERO CRD42018512391.

Investigating the causal relationship between human blood/urine metabolites and periodontal disease using two-sample Mendelian randomization

Background and Aims

The aim is to investigate the cause-and-effect connection between metabolites found in blood/urine and the likelihood of developing periodontal disease (PD) through the utilization of a two-sample Mendelian randomization (MR) method.

Methods

Using an inverse variance weighted (IVW) method and two additional two-sample MR models, we examined the relationship between blood/urine metabolites and PD by analyzing data from a comprehensive metabolome-based genome-wide association study and the Genome-Wide Association Studies (GWAS) of PD. To assess the consistency and dependability of the findings, diversity, cross-effects, and sensitivity analyses were conducted.

Results

Out of the 35 metabolites found in blood and urine, a total of eight metabolites (C-reactive protein, Potassium in urine, Urea, Cystatin C, Non-albumin protein, Creatinine, estimated Glomerular Filtration Rate, and Phosphate) displayed a possible causal connection with the risk of dental caries/PD using the inverse variance weighted (IVW) method (p < 0.05). This includes five metabolites in the blood and three in the urine. No metabolites were statistically significant in IVW MR models (p < 3.68 × 10- 4). Even after conducting sensitivity analysis with the leave-one-out method and removing the confounding instrumental variables, the impact of these factors on dental caries/PD remained significant.

Conclusion

Based on the available evidence, it is not possible to establish a significant causal link between the 35 blood metabolites and the likelihood of developing dental caries and PD.

Association between periodontitis and its treatment on mortality rates of end-stage renal disease: A systematic review and meta-analysis

BACKGROUND

The association between periodontitis and systemic diseases is widely researched. Conflicting literature exists on the relationship between periodontitis and the outcomes of end-stage renal disease (ESRD) patients. We hereby reviewed evidence to examine if periodontitis and its management impact the mortality rates of ESRD patients.

MATERIAL AND METHODS

Literature was searched on the databases of PubMed, Embase, CENTRAL, Web of Science, and Scopus till 27th April 2023. All cohort studies reporting adjusted effect size of the relationship between periodontitis or its management and mortality rates of ESRD patients were included.

RESULTS

Eight studies were eligible of which six reported the association between periodontitis and mortality while two reported between periodontal treatment and mortality. Pooled analysis showed no association between the presence of periodontitis and all-cause mortality amongst ESRD patients (HR: 1.13 95% CI: 0.77, 1.65 I2=72%). Results were unchanged on sensitivity analysis. Pooled analysis of three studies showed no difference in the risk of cardiovascular mortality amongst ESRD patients with and without periodontitis (HR: 1.44 95% CI: 0.57, 3.60 I2=86%). A descriptive analysis of two studies showed that periodontal treatment could reduce the risk of mortality in ESRD patients with periodontitis.

CONCLUSIONS

Limited evidence indicates that periodontitis does not impact all-cause and cardiovascular mortality in ESRD patients. Data on the role of periodontal therapy in improving outcomes is scarce. Further research is needed to generate high-quality evidence on this subject.

Dental cleaning behavior and related factors among hemodialysis patients in the West of Iran: A cross-sectional study

OBJECTIVES

Oral health-related behaviors in hemodialysis patients are reduced, potentially leading to adverse consequences. The aim of the present study was to evaluate dental cleaning behavior (DCB) and related factors among hemodialysis patients.

METHODS

This cross-sectional study was carried out in Sanandaj city, in the west of Iran in 2022. Using the census method, 115 hemodialysis patients from the dialysis center of Tohid Hospital were recruited. Data were gathered by a three-section questionnaire. The first section included demographic characteristics, the second section involved variables related to the health belief model (HBM), and the third section assessed stages of DCB change based on the trans-theoretical model. Analysis of data was done by assessing frequency, descriptive and inferential statistics such as t test, correlation coefficient, and regression.

RESULTS

Only 26.1% of participants reported DCB, defined as tooth brushing at least twice daily; 30.4% were in the precontemplation stage, 26.1% in contemplation, and 17.4% in the preparation stage. Perceived self-efficacy was lower among patients who did not perform DCB. The odds of DCB increased with perceived self-efficacy (odds ratio [OR] = 1.51, 95% confidence interval [CI] = 1.19-1.92, p < .05), cues to action (OR = 1.63, 95% CI = 1.03-2.55, p < .05), and decreased with perceived barriers (OR = 0.68, 95% CI = 0.47-0.97, p < .01).

CONCLUSIONS

DCB of patients on hemodialysis requires improvement. Perceived self-efficacy, cues to action, and perceived barriers constructs of the HBM should be considered in interventional programs targeting to increase oral health as well as in future research in the field.

Malnutrition- inflammation- atherosclerosis (MIA) syndrome associates with periodontitis in end-stage renal disease patients undergoing hemodialysis: a cross-sectional study

Malnutrition-inflammation-atherosclerosis (MIA) syndrome is a significant risk factor for mortality in patients undergoing hemodialysis. This study aimed to investigate the association between MIA syndrome and oral health status in hemodialysis patients. A cross-sectional study was conducted on 254 hemodialysis patients. Comprehensive medical and dental examinations were performed. Three components were included to define MIA syndrome: Geriatric Nutritional Risk Index, serum high-sensitivity C-reactive protein, and history of cardiovascular events as indicators of malnutrition, inflammation, and atherosclerosis, respectively. The association of MIA syndrome components with periodontitis and occlusal support was examined by multiple-ordered logistic regression analysis. Of 254 participants, 188 (74.0%) had at least one component of MIA syndrome. After adjusting for possible confounding factors, severe periodontitis was significantly associated with presence of more components of MIA syndrome (odds ratio [OR]: 2.64, 95% confidence interval [CI], 1.44-4.84, p = 0.002) and inflammation and malnutrition components (OR: 2.47 and 3.46, 95% CI 1.16-5.28 and 1.70-7.05, p = 0.020 and 0.001). On the other hand, occlusal support, evaluated by Eichner index, was not significantly associated with MIA syndrome or any of its components. In conclusion, periodontitis is associated with MIA syndrome, particularly with inflammation and malnutrition in hemodialysis patients, independent of occlusal support.

Development and validation of a nursing home mortality index to identify nursing home residents nearing the end of life in dental clinics

BACKGROUND

Nursing home (NH) residents seek care at dental offices, yet many of them are at the end of life. The uncertain life expectancy further complicates the care of NH residents. This study aimed to develop and validate a Nursing Home Mortality Index (NHMI) to identify NH residents in the last year of life.

METHODS

Logistic modeling was used to develop predictive models for death within 1 year after initial appointment by utilizing the new patient examination data and mortality data of 903 Minnesota NH residents. The final model was selected based on areas under the curve (AUC) and then validated using data from 586 Iowa NH residents. Based on the final model, the NHMI was developed with the estimated 1-year mortality for the low, medium and high risk group.

RESULTS

One-year mortalities were 21% and 26% in the development and validation cohorts, respectively. Predictors included age, gender, communication capacity, physical mobility, congestive heart failure, peripheral vascular disease, cancer, cerebrovascular disease, chronic renal disease and liver disease. AUCs for the development and validation models were 0.73 and 0.68, respectively. For the validation cohort, the sensitivity and specificity were 0.79 and 0.53, respectively. The estimated 1-year mortality risks for three risk groups were 0%-10%, 11%-19%, and ≥20%, respectively CONCLUSION: The high mortality rate of NH residents following a dental exam highlighted a need to incorporate patients' prognoses in treatment planning along with normative needs and patients' preferences. The NHMI provides a practical way to guide treatment decisions for end-of-life NH residents.

Prevalence of Dental Caries in Patients on Renal Replacement Therapy-A Systematic Review

Patients under renal replacement therapy (RRT) often show oral problems, including dry mouth, periodontal and dental diseases. This systematic review aimed to evaluate the caries burden in patients on RRT. Therefore, a systematic literature search based on the databases PubMed, Web of Science and Scopus was performed by two independent individuals in August 2022. Search terms were: "caries" AND "dialysis", "caries" AND "renal replacement therapy", "caries" AND "kidney". The systematic process was complemented by manual search. Studies on adult patients (age ≥ 18 years), treated by any form of RRT and explicitly reporting caries prevalence or incidence were checked for their eligibility and subsequently analyzed qualitatively. For all included studies, a quality appraisal was applied. From the systematic search, 653 studies were identified, of which 33 clinical investigations were included in the qualitative analysis. The majority (31 studies) of all included patients underwent hemodialysis (HD), with a sample size between 28 and 512 participants. Eleven studies investigated a healthy control group. Oral examinations were heterogeneous across studies; the caries burden was primarily assessed by decayed-(D-T), missing- and filled-teeth index (DMF-T). The number of decayed teeth ranged between 0.7 and 3.87 across studies. Only six out of these 11 studies found significant differences in caries prevalence/incidence between RRT and controls, whereby only four studies confirmed worse caries burden in RRT individuals. No information was provided on caries stadium (initial caries, advanced caries, invasive treatment need), caries activity or location (e.g., root caries) across studies. Most of the included studies were assessed to be of moderate quality. In conclusion, patients on RRT suffer from a high prevalence of dental caries. Alongside a need for further research in the field, improved, multidisciplinary, patient-centered dental care concepts are required to support dental and overall oral health in individuals on RRT.

The Impact of Chronic Kidney Disease on Nutritional Status and Its Possible Relation with Oral Diseases

Several studies have demonstrated a strong relation between periodontal diseases and chronic kidney disease (CKD). The main mechanisms at the base of this link are malnutrition, vitamin dysregulation, especially of B-group vitamins and of C and D vitamins, oxidative stress, metabolic acidosis and low-grade inflammation. In particular, in hemodialysis (HD) adult patients, an impairment of nutritional status has been observed, induced not only by the HD procedures themselves, but also due to numerous CKD-related comorbidities. The alteration of nutritional assessment induces systemic manifestations that have repercussions on oral health, like oral microbiota dysbiosis, slow healing of wounds related to hypovitaminosis C, and an alteration of the supporting bone structures of the oral cavity related to metabolic acidosis and vitamin D deficiency. Low-grade inflammation has been observed to characterize periodontal diseases locally and, in a systemic manner, CKD contributes to the amplification of the pathological process, bidirectionally. Therefore, CKD and oral disease patients should be managed by a multidisciplinary professional team that can evaluate the possible co-presence of these two pathological conditions, that negatively influence each other, and set up therapeutic strategies to treat them. Once these patients have been identified, they should be included in a follow-up program, characterized by periodic checks in order to manage these pathological conditions.

Association of type 2 diabetes with periodontitis and tooth loss in patients undergoing hemodialysis

BACKGROUND

Limited evidence are available regarding the influence of diabetes on periodontitis in hemodialysis patients, although the association between diabetes and periodontal disease is well-known.

OBJECTIVE

This study aimed to investigate the influence of type 2 diabetes mellitus (T2D) and its control level on periodontal disease and the number of missing teeth in patients undergoing hemodialysis.

SUBJECTS AND METHODS

A single-center cross-sectional study was conducted on 246 Japanese patients with end-stage renal disease undergoing hemodialysis. Comprehensive medical and dental examinations were performed. The association between severity of periodontitis and T2D was examined by multiple ordered logistic regression analysis. A multiple linear regression model was fitted to assess the association of periodontal probing depth (PPD) ≥4 mm and the number of missing teeth with T2D (n = 125). A subgroup analysis involving only the patients with T2D was performed to investigate the factors associated with missing teeth among them.

RESULTS

After adjusting for confounders, the classification of periodontitis severity was significantly advanced in patients with T2D (odds ratio: 1.64, 95% confidence interval [CI]: 1.02-2.65, p = 0.04). The proportion of PPD≥4 mm sites and the number of missing teeth was significantly associated with T2D (coefficient: 4.1 and 5.7, 95% CI: 0.2-8.0 and 3.4-8.0, p = 0.04 and <0.001, respectively). Subgroup analysis of T2D patients revealed that glycoalbumin levels (coefficient: 0.4, 95% CI: 0.03-0.80, p = 0.03), but not hemoglobin A1c levels (coefficient: 0.8, 95% CI: -1.0-2.7, p = 0.37), were significantly associated with the number of missing teeth.

CONCLUSION

T2D was significantly associated with periodontitis and the number of missing teeth in hemodialysis patients. Moreover, it is first documented that poor glycemic control, as determined by glycoalbumin levels, was significantly associated with the number of missing teeth in hemodialysis patients with T2D.

Association between periodontitis and chronic kidney disease

Periodontitis and chronic kidney disease are chronic conditions with high community prevalence across the world. Patients with chronic kidney disease have been noted to have a high burden of periodontitis, and several shared risk factors have been associated with the prevalence and severity of both conditions. However, the precise relationship between the two conditions, and the extent to which each may contribute to the development of the other, remains a matter of debate. The goals of the present work were to: (a) provide the most current and relevant literature overview of the association between periodontitis and chronic kidney disease; (b) explore mechanisms underlying this association; and (c) determine if evidence exists for an independent association between these conditions. We also assessed whether improved oral hygiene and periodontal treatment could reduce the risk of developing chronic kidney disease and, if so, what protocols these strategies involve. Finally, we aimed to reveal gaps in our current knowledge to delineate the directions of future research. Although the exact relationship between these two conditions has not yet been defined, we highlight the importance of the interprofessional interaction between dental practitioners and the nephrology team and the importance of oral health assessment in the management of chronic kidney disease.

Association between oral health and cardiovascular outcomes in patients with hypertension: a nationwide cohort study

OBJECTIVE

Studies on the association of oral hygiene indicators with cardiovascular disease in hypertensive patients have been lacking. Oral hygiene is directly or indirectly associated with systemic inflammation, one of the essential mechanisms of cardiovascular disease. Therefore, we hypothesized that oral hygiene would be related to the risk of cardiovascular diseases in hypertensive patients.

METHODS

We included 52 677 hypertensive participants who completed oral health checkups from the Korean National Health Insurance Service-National Health Screening Cohort between 2003 and 2004. We collected data on periodontitis diagnosis and treatment history, number of teeth loss, number of dental caries, and frequency of tooth brushing from medical records of health claims and oral health examination. The primary outcome was defined as composite outcomes of stroke and myocardial infarction. Follow-up was done until the date of primary outcome, or 31 December 2015.

RESULTS

During the 11.26 ± 2.39 years (mean ± standard deviation) of the study follow-up, 3292 participants developed primary outcomes [stroke (n = 2430), myocardial infarction (n = 862)]. In multivariable Cox regression analyses, participants with dental caries (≥ 5) were independently associated with occurrence of a primary outcome [adjusted hazard ratio: 1.37; 95% confidence interval (CI):1.10-1.72; P = 0.006]. Frequent tooth brushing (≥ 2 times/day) was significantly related to lower risk of primary outcomes (adjusted hazard ratio: 0.88; 95% CI: 0.81-0.96; P = 0.002).

CONCLUSION

Our study demonstrated that multiple dental caries were related to the risk of cardiovascular diseases in hypertensive patients. Better oral hygiene may attenuate the risk of cardiovascular events in hypertensive patients.

Torus Mandibularis in Patients Receiving Hemodialysis

Reports on the prevalence of torus mandibularis among dialysis patients have been limited and inconclusive. A wide variety of oral manifestations has been found in patients with hyperparathyroidism. Furthermore, uremia-related changes in facial bone structures have been described in the literature. This prospective observational study examined 322 hemodialysis patients treated at the Chang Gung Memorial Hospital from 1 August to 31 December 2016. Two subgroups were identified: patients with torus mandibularis (n = 25) and those without (n = 297). Clinical oral examinations including inspection and palpation were employed. Our study found that most mandibular tori were symmetric (84.0%), nodular (96.0%), less than 2 cm in size (96.0%), and located in the premolar area (92.0%). Poor oral hygiene was observed among these patients, with 49.7% and 24.5% scoring 3 and 4, respectively, on the Quigley-Hein plaque index. More than half (55.0%) of patients lost their first molars. Multivariate logistic regression analysis revealed that blood phosphate level (odds ratio = 1.494, p = 0.029) and younger age (odds ratio = 0.954, p = 0.009) correlated significantly with torus mandibularis. The prevalence of torus mandibularis in patients receiving hemodialysis in this study was 7.8%. Younger age and a higher blood phosphate level were predictors for torus mandibularis in these patients.

Effects of Antioxidant in Adjunct with Periodontal Therapy in Patients with Type 2 Diabetes: A Systematic Review and Meta-Analysis

This review investigated whether the adjunctive use of antioxidants with periodontal therapy improves periodontal parameters in patients with type 2 diabetes. A systematic and extensive literature search for randomized controlled trials (RCTs) conducted before April 2021 was performed on the PubMed, Cochrane Library, and Web of Science databases. The risk of bias was assessed using the Cochrane risk-of-bias tool. A meta-analysis was performed to quantitatively evaluate the clinical outcomes following periodontal therapy. After independent screening of 137 initial records, nine records from eight RCTs were included. The risk-of-bias assessment revealed that all RCTs had methodological weaknesses regarding selective bias, although other risk factors for bias were not evident. This meta-analysis of two RCTs showed that periodontal pocket depths were significantly reduced in the groups treated with combined non-surgical periodontal therapy and melatonin than in those treated with non-surgical periodontal therapy alone. The present systematic review and meta-analysis suggest that the adjunctive use of melatonin, resveratrol, omega-3 fatty acids with cranberry juice, propolis, and aloe vera gel with periodontal therapy significantly improves periodontal disease parameters in patients with type 2 diabetes, and melatonin application combined with non-surgical periodontal therapy might significantly reduce periodontal pocket depth. However, there are still limited studies of melatonin in combination with non-surgical periodontal therapy in Type 2 diabetic patients, and more well-designed RCTs are required to be further investigated.

Association between periodontal inflammation and serum lipid profile in a healthy population: A cross-sectional study

AIMS

The impact of periodontal inflammation on lipid metabolism is controversial. This study aimed to investigate the association between full-mouth periodontal inflammation and serum lipid levels.

MATERIALS AND METHODS

In this cross-sectional study, we performed periodontal and bacteriological examinations during medical checkup on 131 subjects. The association between the periodontal inflamed surface area (PISA) and the lipid markers was analyzed by multiple linear regression, adjusting for age, sex, smoking, and body mass index.

RESULTS

Overall, 118 medically healthy participants were analyzed. The proportions of none, mild, moderate, and severe periodontitis were 37.3%, 32.2%, 25.4%, and 5.1%, respectively. Multivariate analysis showed that high-density lipoprotein cholesterol was significantly higher in participants with the lowest tertile of PISA values (PISA low, coefficient: 7.94; 95% confidence interval [CI]: 1.63, 14.26, p = .01) compared to those in other tertiles (PISA high). Low-density/high-density lipoprotein cholesterol and total/high-density lipoprotein cholesterol ratios were significantly lower in the PISA-low group than the PISA-high group (coefficient: -0.26 and -0.30; 95% CI: -0.50, -0.02, and -0.59, -0.0002; p = .04 and .0498). Serum high-sensitivity C-reactive protein level, but not serum Porphyromonas gingivalis antibody titer, partly explained the association between PISA and high-density lipoprotein cholesterol. A significant interaction between female sex and PISA values toward high-density lipoprotein cholesterol level was detected.

CONCLUSION

Periodontal inflammation was inversely associated with higher high-density lipoprotein cholesterol, especially in females. Elevated serum C-reactive protein partly explained this association.