Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study

Oral Health-Related Quality of Life, A Proxy of Poor Outcomes in Patients on Peritoneal Dialysis

Introduction

We sought to evaluate the associations of poor oral health hygiene with clinical outcomes in patients receiving peritoneal dialysis (PD).

Methods

As part of the multinational Peritoneal Dialysis Outcomes and Practice Patterns Study (PDOPPS), PD patients from 22 participating PD centers throughout Thailand were enrolled from May 2016 to December 2019. The data were obtained from questionnaires that formed part of the PDOPPS. Oral health-related quality of life (HRQoL) used in this study was the short form of the oral health impact profile (oral health impact profile [OHIP]-14, including 7 facets and 14 items). Patient outcomes were assessed by Kaplan-Meier analysis. Cox proportional hazards model regression was used to estimate associations between oral HRQoL and clinical outcomes.

Results

Of 5090 PD participants, 675 were randomly selected, provided informed consent, and completely responded to the OHIP-14 questionnaire. The median follow-up time of the study was 3.5 (interquartile range = 2.7–5.1 months) years. Poor oral health was associated with lower educational levels, diabetes, older age, marriage, and worse nutritional indicators (including lower time-averaged serum albumin and phosphate concentrations). After adjusting for age, sex, comorbidities, serum albumin, shared frailty by study sites, and PD vintage, poor oral health was associated with increased risks of peritonitis (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI]: 1.06–2.00) and all-cause mortality (adjusted HR = 1.55, 95% CI: 1.04–2.32) but not hemodialysis (HD) transfer (adjusted HR = 1.89, 95% CI: 0.87–4.10) compared to participants with good oral health.

Conclusion

Poor oral health status was present in one-fourth of PD patients and was independently associated with a higher risk of peritonitis and death.

Higher dental care is positively associated with key prognosis factors in peritoneal dialysis patients: findings from a retrospective study

Background

Oral disease may be increased in people with end-stage renal disease and associated with inflammation, cardiovascular disease, and mortality. Moreover, oral disease may be essential to decide the prognosis of peritoneal dialysis (PD) patients. However, only a few reports have explored the effects of dental care (DC) on cardiovascular diseases and mortality in PD patients. Thus, we aimed to investigate the association of DC with the prognosis of PD patients.

Methods

In this single-center, retrospective study, we enrolled 165 incident PD patients aged ≥ 20 years. We classified patients based on their dental care score, assessed using a self-reported questionnaire into the better dental care group (Group A, score ≥ 7) or the worse dental care group (Group B, score < 7). Demographic, clinical, hospitalization, hospital admission, comorbidities (including congestive heart failure, acute coronary syndrome, stroke, peripheral artery disease, and pneumonia), and mortality (including specific causes) data were extracted from the patient’s medical records. Data were analyzed using one-way ANOVA, Wilcoxon t-test, Kruskal–Wallis, Mann–Whitney U-test, chi-square test, Fisher’s exact test and multiple regression when appropriate. We compared the survival distributions among groups using the long-rank test.

Results

Of the 165 patients, 75 were allocated to group A and 90 to group B. PD patients with better dental care (group A) had significantly lower levels of C-reactive protein (CRP) and higher levels of serum albumin compared to PD patients with worse dental care (group B). Hospital admissions due to congestive heart failure, acute coronary syndrome, pneumonia, and peritonitis were also lower in group A than group B. Mortality rates due to congestive heart failure, acute coronary syndrome, pneumonia, and sepsis were lower in group A than in group B.

Conclusions

The study highlights the importance of good dental care, particularly for PD patients. Nephrologists and dental professions should design and implement oral health education strategies to improve PD patients’ dental care.

Electric and Manual Oral Hygiene Routines Affect Plaque Index Score Differently

This cross-sectional study aimed to examine the oral hygiene behaviors in the general population and identify factors affecting oral hygiene behaviors and plaque removal efficacy. A survey was distributed to patients through 11 dental practices in Japan, and each patient’s plaque index score (PIS) was recorded. In total, 1184 patients participated (521 women and 660 men), with 84.04% using manual toothbrushes (MTBs) and 15.96% using electric toothbrushes (ETBs). ETB users had a significantly lower PIS compared to MTB users (p = 0.0017). In addition, a statistically significant difference in the PIS was detected in relation to the frequency of brushing per day (≥2 times) and time spent on brushing (≥1 min). Some MTB users spent less than 1 min brushing, while all ETB users spent at least 1 min brushing, and extended brushing periods significantly improved the PIS for the MTB users. MTB users tend to replace brush heads more frequently than ETB users, and the frequency of replacement affected the PIS significantly (p < 0.01) for the MTB users. The status of dental treatment (first visit, in treatment versus recall) also significantly affected the PIS (p < 0.01). The ETB was more effective than the MTB in terms of better plaque removal and reduced frequency of brush head replacement.

Complications related to dental extractions in patients with chronic kidney failure undergoing hemodialysis: a pilot study

OBJECTIVE

To clinically assess socket healing after tooth extraction and the occurrence of intra- and postoperative complications in patients with chronic kidney failure (CKF) receiving hemodialysis (HD) by comparing them with a control group.

STUDY DESIGN

This prospective study involved 48 patients with CKF receiving HD (study group [SG]) and 29 participants without CKF (control group [CG]) undergoing tooth extractions. No prophylactic antibiotic was administered to the participants. One calibrated dentist evaluated all individuals at 3, 7, 21, and 60 days after the tooth extractions and assessed hemostasis time, occurrence of local or distant infection, epithelialization, and deposition of alveolar bone.

RESULTS

In the SG, 87 teeth were extracted through 65 interventions, and in the CG, 76 teeth were extracted through 36 interventions. Bleeding beyond 30 minutes was observed in 12 interventions (18.5%) in SG participants and was controlled with local hemostatic agents. Neither group had individuals presenting with postoperative infectious complications at the surgical site or at a distance. After 21 days, we observed delayed epithelialization in 29.9% (26 of 87) of the individuals in the SG compared with 3.9% (3 of 37) of those in the CG (P < .001). After 60 days, all the sockets were epithelialized and showing radiographic signs of alveolar bone neoformation.

CONCLUSIONS

Individuals with CKF receiving hemodialysis tend to heal well after dental extractions. They did not have an increased risk of infectious complications after simple tooth extractions, but they showed prolonged bleeding events more often than control subjects. Additional research studies using larger sample sizes of patients with CKF receiving hemodialysis are needed to confirm our findings.

Oral symptoms and pathologies in Danish patients with chronic kidney disease- a pilot study

The aim was to investigate oral health in randomly selected patients with chronic kidney disease (CKD). Data obtained by structured interview (self-reported lifestyle, oral symptoms and regularity of dental visits) and oral examination of patients with CKD from the Copenhagen University Hospital. Fourteen patients with CKD were screened. Only half of the patients reported regular dental visits and poor dental status was registered in half of the patients. Oral mucosal changes were registered in thirteen patients (93%). Eleven patients (79%) had gingival inflammatory disease. Twelve patients (86%) were carriers of Candida, and three (21%) had oral candidosis. Six patients (43%) had low whole saliva flow rate. Twelve patients (86%) reported at least one oral symptom. Overall, there was no differences in oral symptoms or findings related to kidney transplanted or not transplanted patients. The small sample size most likely influences the results. However, the vast majority of patients with CKD reported oral symptoms and only half consulted a dentist regularly. Poor dental status, oral mucosal changes and gingival disease were prevalent findings. Patients with CKD need focus on daily oral healthcare and regular dental visits. Interdisciplinary cooperation could encourage patients with CKD to focus on oral health.

Oral health in patients with chronic kidney disease

Objective: In the available literature data, there is not much information about problems of patients with end stage kidney disease in relation to oral health. Our objective was to show the importance of oral diseases for patients on hemodialysis. Data sources: In this review article, the sources of data are review articles and scientific articles in the English language published in MEDLINE database. The choice of studies was based on keywords: Chronic kidney disease, Hemodialysis, Oral health, Periodontal diseases. Results: It is assumed that almost 90% patients with chronic kidney disease manifest some symptoms of oral disease. Therefore, it is important to determine the impact of periodontal disease on the progression of kidney failure in these individuals, to evaluate inflammatory parameters in this patient population, to assess the degree of bone loss and periodontal disease index, to determine the presence of bacterial strains, paradontopathy of gingival fluid and antibody titers, to examine correlations of proinflammatory cytokines in the gingival sulcus and serum, as well as to determine the relationship between periodontal tissue and inflammatory mediators. Periodontal diseases can increase the possibility of developing chronic kidney disease by 1.5 to 2 times. These oral diseases include gingival hyperplasia, periodontitis, xerostomia, unpleasant breath, changes in the oral mucosa, malignancies, oral infections, dental abnormalities and bone lesions. Conclusion: This requires serious cooperation between nephrologists and dentists to make proper communication possible, in order to provide quality dental care for this growing patient population in accordance with new treatment strategies.

Impact of Periodontal Inflammation on Nutrition and Inflammation Markers in Hemodialysis Patients

Background: Malnutrition-inflammation complex syndrome (MICS) is a common and usually concurrent condition occurring in patients undergoing hemodialysis (HD), with a pathogenesis linked to biological and in situ environmental traditional risk factors. Periodontitis, one of the major types of infection-driven inflammation, often co-occurs in the in the hemodialysis population and correlates with markers of malnutrition and inflammation, such as albumin, creatinine, and C-reactive protein. Aim: The present study aimed to determine whether the periodontal inflammatory status parameters correlate with the albumin, creatinine, and C-reactive protein serum concentrations in HD patients, and investigate whether periodontal treatment improves these markers of nutritional and systemic inflammation. Materials and Methods: The serum creatinine, albumin, and C-reactive Protein (CRP) levels were measured at baseline and after non-surgical periodontal treatment, at 3 months and 6 months. Results: At 3 months, a significant correlation between plaque index and C-reactive protein (p = 0.012), bleeding on probing and C-reactive protein (p < 0.0019), and clinical attachment level and C-reactive protein (p = 0.022) was found. No significant correlation was found between clinical periodontal parameters and nutrition markers at each time. Conclusions: Our results confirmed the association between C-reactive protein serum concentration and periodontal inflammatory status, but further research is necessary to identify the contributing role of periodontitis on the onset and progression of MICS.

Oral mucosal lesions and risk of all-cause and cardiovascular mortality in people treated with long-term haemodialysis: The ORAL-D multinational cohort study

Background

Chronic kidney disease is a risk factor for oral diseases, which may be associated with premature death. We evaluated the risk of all-cause and cardiovascular mortality associated with oral mucosal lesions in adults with kidney failure treated with long-term haemodialysis.

Methods

Oral mucosal lesions (herpes, ulceration, neoformation, white lesion, red lesion, oral candidiasis, geographical tongue, petechial lesions, and fissured tongue) were evaluated within the Oral Diseases in Haemodialysis (ORAL-D) study, a multinational cohort study of 4726 haemodialysis adults. We conducted cox regression analyses adjusted for demographic and clinical variables to evaluate the association with all-cause and cardiovascular mortality.

Results

Overall, 4205 adults (mean age 61.6 ± 15.6 years) underwent oral mucosal examination with 40% affected by at least one lesion. The prevalence of oral lesions was (in order of frequency): oral herpes 0.5%, mucosal ulceration 1.7%, neoformation 2.0%, white lesion 3.5%, red lesion 4.0%, oral candidiasis 4.6%, geographical tongue 4.9%, petechial lesions 7.9%, and fissured tongue 10.7%. During median follow-up of 3.5 years, 2114 patients died (1013 due to cardiovascular disease). No association was observed between any individual oral lesion and all-cause or cardiovascular mortality when adjusted for comorbidities, except for oral candidiasis, which was associated with all-cause mortality (adjusted hazard ratio 1.37, 95% CI 1.00 to 1.86) and cardiovascular mortality (adjusted hazard ratio 1.64, 95% CI 1.09 to 2.46).

Conclusion

Oral mucosal lesions are prevalent in haemodialysis patients. Oral candidiasis appears to be a risk factor for death due to cardiovascular diseases.

The association between periodontal conditions, inflammation, nutritional status and calcium-phosphate metabolism disorders in hemodialysis patients

Objectives

To analyze the association between periodontal conditions and inflammation, nutritional status and calcium-phosphate metabolism disorders in hemodialysis (HD) patients.

Material and Methods

We analyzed 128 HD patients divided into two groups: dentate (n = 103) and edentulous (n=25). The following items were assessed: baseline characteristics, age at the start and duration of HD, biochemical data: C-reactive protein (CRP), serum albumin, calcium, phosphorus, alkaline phosphatase, parathormone. A single dentist performed a complete dental/periodontal examination, including parameters of oral hygiene and gingival bleeding.

Results

One person had healthy periodontium, 62.14% of the patients had gingivitis, and 36.9% had moderate or severe periodontitis. The age at HD onset had a positive impact on periodontal status and negatively correlated with the number of teeth. A positive correlation between age and CRP level and negative correlations between age and serum albumin and phosphorus were found. Pocket depth (PD) was negatively correlated with serum albumin. The number of teeth was negatively correlated with serum CRP.

Conclusions

High prevalence and severity of periodontal disease are observed in hemodialysis patients. There is a high probability that periodontal disease may be present at the early stages of chronic kidney disease (CKD) before the hemodialysis onset.

Periodontitis and early mortality among adults treated with hemodialysis: a multinational propensity-matched cohort study

BACKGROUND

Periodontitis is associated with cardiovascular mortality in the general population and adults with chronic diseases. However, it is unclear whether periodontitis predicts survival in the setting of kidney failure.

METHODS

ORAL-D was a propensity matched analysis in 3338 dentate adults with end-stage kidney disease treated in a hemodialysis network in Europe and South America designed to examine the association between periodontitis and all-cause and cardiovascular-related mortality in people on long-term hemodialysis. Participants were matched 1:1 on their propensity score for moderate to severe periodontitis assessed using the World Health Organization Community Periodontal Index. A random-effects Cox proportional hazards model was fitted with shared frailty to account for clustering of mortality risk within countries.

RESULTS

Among the 3338 dentate participants, 1355 (40.6%) had moderate to severe periodontitis at baseline. After using propensity score methods to generate a matched cohort of participants with periodontitis similar to those with none or mild periodontal disease, moderate to severe periodontitis was associated with a lower risk of all-cause (9.1 versus 13.0 per 100 person years, hazard ratio 0.74, 95% confidence interval 0.61 to 0.90) and cardiovascular (4.3 versus 6.9 per 100 person years, hazard ratio 0.67, 0.51 to 0.88) mortality. These associations were not changed substantially when participants were limited to those with 12 or more natural teeth and when accounting for competing causes of cardiovascular death.

CONCLUSION

In contrast to the general population, periodontitis does not appear to be associated with an increased risk of early death in adults treated with hemodialysis.

Patterns of oral disease in adults with chronic kidney disease treated with hemodialysis

BACKGROUND

Oral disease is a potentially treatable determinant of mortality and quality of life. No comprehensive multinational study to quantify oral disease burden and to identify candidate preventative strategies has been performed in the dialysis setting.

METHODS

The ORAL disease in hemoDialysis (ORALD) study was a prospective study in adults treated with hemodialysis in Europe (France, Hungary, Italy, Poland, Portugal and Spain) and Argentina. Oral disease was assessed using standardized WHO methods. Participants self-reported oral health practices and symptoms. Sociodemographic and clinical factors associated with oral diseases were determined and assessed within nation states.

RESULTS

Of 4726 eligible adults, 4205 (88.9%) participated. Overall, 20.6% were edentulous [95% confidence interval (CI), 19.4-21.8]. Participants had on average 22 (95% CI 21.7-22.2) decayed, missing or filled teeth, while moderate to severe periodontitis affected 40.6% (95% CI 38.9-42.3). Oral disease patterns varied markedly across countries, independent of participant demographics, comorbidity and health practices. Participants in Spain, Poland, Italy and Hungary had the highest mean adjusted odds of edentulousness (2.31, 1.90, 1.90 and 1.54, respectively), while those in Poland, Hungary, Spain and Argentina had the highest odds of ≥14 decayed, missing or filled teeth (23.2, 12.5, 8.14 and 5.23, respectively). Compared with Argentina, adjusted odds ratios for periodontitis were 58.8, 58.3, 27.7, 12.1 and 6.30 for Portugal, Italy, Hungary, France and Poland, respectively. National levels of tobacco consumption, diabetes and child poverty were associated with edentulousness within countries.

CONCLUSIONS

Oral disease in adults on hemodialysis is very common, frequently severe and highly variable among countries, with much of the variability unexplained by participant characteristics or healthcare. Given the national variation and high burden of disease, strategies to improve oral health in hemodialysis patients will require implementation at a country level rather than at the level of individuals.

Does Treatment of Periodontal Disease Influence Systemic Disease?

Periodontal diseases are the most common human diseases globally, with gingivitis affecting up to 90% and periodontitis affecting 50% of adults. Tooth enamel is the only nonshedding tissue in the human body. In the absence of proper oral hygiene measures, microbial biofilm (dental plaque) develops on the teeth to include more than 700 different bacterial species, along with viruses, fungi, archea, and parasites. With time, ecological imbalances promote the growth of selected commensal species that induce host inflammatory pathways resulting in tissue destruction, including ulceration of the periodontal epithelium.

Current status of collaborative relationships between dialysis facilities and dental facilities in Japan: results of a nationwide survey

BACKGROUND

Recent studies have reported an association between periodontal disease and mortality among dialysis patients. Therefore, preventive dental care should be considered very important for this population. In Japan, no systematic education has been undertaken regarding the importance of preventive dental care for hemodialysis patients--even though these individuals tend to have oral and dental problems. The aim of this study was to investigate the current state of collaborative relationships between hemodialysis facilities and dental services in Japan and also to identify strategies to encourage preventive dental visits among hemodialysis outpatients.

METHODS

A nationwide questionnaire on the collaborative relationship between dialysis facilities and dental facilities was sent by mail to all medical facilities in Japan offering outpatient hemodialysis treatment.

RESULTS

Responses were obtained from 1414 of 4014 facilities (35.2%). Among the 1414 facilities, 272 (19.2%) had a dental service department. Approximately 100,000 dialysis outpatients were receiving treatment at these participating facilities, which amounts to one-third of all dialysis patients in Japan. Of those patients, 82.9% received hemodialysis at medical facilities without dental departments. Only 87 of 454 small clinics without in-house dental departments (19.2%) had collaborative registered dental clinics. Medical facilities with registered dental clinics demonstrated a significantly more proactive attitude to routine collaboration on dental matters than facilities lacking such clinics.

CONCLUSIONS

Our nationwide survey revealed that most dialysis facilities in Japan have neither an in-house dental department nor a collaborative relationship with a registered dental clinic. Registration of dental clinics appears to promote collaboration with dental facilities on a routine basis, which would be beneficial for oral health management in hemodialysis patients.

Periodontitis: Tip of the iceberg in chronic kidney disease

The prevalence of chronic kidney disease (CKD) is constantly escalating not only in industrialized countries but throughout the world. It is of major significance because of to its high morbidity and mortality. Strategies to tackle this worldwide health problem include identification of its associated risk factors, comorbidities, and complications as well as proper management to handle all the pertinent issues. Periodontal disease, a treatable infectious state of the dental supporting tissues, is common in CKD patients. Its association with CKD is believed to be in a reciprocal or bidirectional fashion and has been massively studied. This paper, therefore, aims to review the recent evidence pertaining to the association between periodontal disease and a variety of renal illnesses. Most of the current evidence was collected from cross-sectional studies and clinical trials. There is substantial evidence indicating that periodontal disease contributes markedly to the chronic systemic inflammatory burden, leading to cardiovascular and cerebrovascular complications, the principal causes of death among chronic renal disease patients. Furthermore, several studies demonstrated that proper periodontal intervention could help improve systemic inflammation and even nutritional status among CKD patients, resulting in a better quality of life. Suggestions have been made that periodontal disease should be diagnosed early, and managed and controlled to, at least, eradicate a source of inflammation in this population. Awareness of such an important issue should be increased in the relevant medical personnel.