Chronic Kidney Disease (CKD) is a risk factor for both periodontal disease and changes in the oral cavity. Several proposed mechanisms contribute to this increased risk in the CKD population, including the disrupted oral homeostasis created by uremia, the immunosuppressed state of this population, and vitamin D deficiency and calcium imbalance that leads to calcium loss from bones and eventual bone loss.
Good dental health is not just about preventing cavities and promoting good oral hygiene in CKD patients. In fact, poor dentition can lead to systemic consequences such as infections, inflammation, protein-energy wasting, and atherosclerotic and cardiovascular complications. In a recent study published in AJKD, Palmer et al performed a multinational, prospective study examining the association of dental health and behaviors on survival. 4205 adults on long term hemodialysis were included in the study with mean follow up of 22.1 months. Results showed that being edentulous and having more extensive dental disease was associated with increased mortality. Certain dental care behaviors such as dental flossing, using mouthwash, brushing teeth daily, spending 2 minutes or more on oral hygiene, changing a toothbrush at least every 3 months, and visiting a dentist within the past 6 months were all associated with longer survival. The results were similar for cardiovascular mortality, with the exception of brushing teeth daily. The extent of decayed, missing, or filled teeth showed a dose response relationship with early mortality.
Although much is known regarding poor dentition and reduced survival in the general population, not much knowledge exists about poor dentition in the dialysis population. Thus far, this is the most comprehensive study identifying novel associations between dental care, certain behavioral practices, and survival in the hemodialysis population. Larger and longer term studies are still needed to form definitive conclusions. Another study had shown that dialysis vintage was associated with a less diverse periodontal microbial community in ESRD.
This study, however, raises awareness of the importance of dental health in the ESKD population. Promoting good dental health is often overlooked by the nephrology team. It is not very common that we are referring our dialysis patients for routine dental visits. More commonly, we communicate with the dentist regarding endocarditis prophylaxis when our patient informs us of a planned dental procedure, when coordinating dental appointments with their dialysis schedule, or when we adjust dialysis heparin prior to a procedure. Still, we are not addressing the more long term possible benefit of good oral hygiene in this population. Perhaps a referral to a dentist should become part of the health maintenance initiative in our ESRD population.
– Post written by Mala Sachdeva, MD, Assistant Professor of Medicine, Hofstra-North Shore- LIJ School of Medicine, and Radha Sachdeva-Munk, DDS