CKD and oral health

Kidney can be described as the "filter" of the human body. The latter produces energy through food, which comes from a series of reactions producing useful but harmful toxic substances for the organism. 

  • The role of the kidney as a filter is responsible for maintaining or removing these substances from the body. Chronic renal insufficiency is characterized by a progressive and irreversible reduction in kidney function, resulting in the inability to remove toxic substances.
  • CKD and Periodontal disease
  • Periodontal disease is a chronic inflammatory disease of the dental supporting tissues, known as gingivitis and periodontitis, which are caused by a pathogenic microbiota in the subgingival. Studies suggest that periodontal disease may increase the risk of a stroke, myocardial infarction, premature birth and reduced birth weight, respiratory diseases, Alzheimer's disease and other systemic conditions.
  • The correlation of periodontal disease with renal function has been a field of study of great interest. Regarding the condition of periodontal tissues, several studies have shown that a large proportion of patients undergoing dialysis indicate increased levels of microbial and dental plaque compared to healthy patients, whereas the severity of the periodontal disease is related to age, diabetes, smoking, and the period the patient undergoes dialysis. Recent evidence has indicated that patients with periodontal disease have raised blood levels of inflammation markers.
  • More specifically, patients undergoing dialysis have high serum CRP levels, which also demonstrates the presence of periodontal disease. Research has also shown that periodontal disease is associated to a significant extent with low glomerular filtration rate as well as elevated creatinine levels. The greater the severity of the periodontal disease, the lower the glomerular filtration rate, which indicates the flow rate of the infusions through kidneys per unit time. In addition, it was observed that patients with advanced periodontitis undergoing hemodialysis have greater chances of frequent nutrition and inflammation disorders.
  • Last but not least, studies investigating the possible correlation of periodontal disease with the complications of CKD and the mortality of dialysis patients, have ascertained that mortality from cardiovascular disease in people with moderate or severe periodontal disease is much greater (up to five times) than those who are not suffering from periodontal disease or experience early periodontitis.
  • CKD and oral mucosa
  • The paleness of the oral mucosa is the most common finding in dialysis patients due to uremic anemia. Nephropathy patients tend to bleed due to qualitative and quantitative changes in platelets and clotting factors. A large proportion of patients experience hairy tongue, fissured tongueand candidiasis. Also, patients feel dry, smelly, and have a metallic taste in the mouth. These are effects of reduced fluid intake and side effects of drugs. Saliva exhibits high concentrations of urea which breaks down into ammonia and gives the characteristic odor and flavor.
  • CKD and bones
  • Metabolic renal osteodystrophy that occurs in people with CKD is a result of the disorders in calcium, phosphorus and vitamin D metabolism. Blood calcium levels are reduced resulting in an increased calcium release from the bones. Thus, osteoporotic lesions are often observed in the jawbone. The panoramic radiograph of the jaws is considered a reliable tool in revealing such lesions. Osteoporotic lesions are also found in soft tissues, often in the salivary glands, as well as in the calcification of the pulp. Bone loss can cause jaw fractures.
  • CKD patients and oral hygiene
  • The dentist must:
  • •ensure a good level of oral hygiene, tailored to the needs of each patient with detailed instructions on toothbrushing, the use of mouthwashes and the frequency of visits to the dentist.
  • •be careful when taking the patient's history. Also, it is important that the dentist clarifies the causes leading to CKD, so that the underlying disease is also taken under consideration.
  • •consult with the patient's nephrologist before surgery or tooth extraction or periodontal treatment. Usually, the use of antibiotics is required to protect the patient from infections, and inflammations, since CKD patients have an increased risk of developing them.
  • •control blood pressure before and during a session.
  • •check blood coagulation before any surgery, because several patients suffer from cardiovascular problems and anticoagulant medications are administered during dialysis.
  • •avoid possible dental surgery on the day of the dialysis session.
  • General conclusions:
  • -CKD patients have increased chances of oral diseases, mainly periodontal problems, some of which can adversely affect general health.
  • -The dentist should be aware of these interactions and ensure a good level of oral health in nephropathy patients, especially in patients with CKD who are at increased risk of developing infections and inflammation.
  • -The collaboration of a specialized dentist and periodontist with the nephrologist is considered necessary for the treatment of these patients.
  • At this point, it should be noted that the results of the studies that associate periodontal disease with CKD are not always comparable due to the different design of the studies, the variety of factors affecting the general condition of the patient, e.g. smoking, different methods of examining and assessing the periodontal condition of the patient as well as systemic inflammation. It is certain that patients suffering from CKD should include the maintenance of good oral health and hygiene in their medical care to minimize and eliminate potential complications of the disease.
  • Alice Chatzogianni, Dental surgeon, Specialist in Periodontics, Implantology & Oral Pathology 
  • Bibliography
  • 1.Agrogiannis B, Koutsikos DK: Chronic Renal Insufficiency. Raptis SA: Internal Pathology, Athens. Scientific Publications «Gr. Κ. Parisianos» 1996
  • 2.Glinou ΤΜ, Dimitriou Α, Agrafiotis Α, Koromantzos PΑ, Ζervou - Valvi FS, Vrotsos Ι. Effect of periodontal treatment at the levels of systemic inflammation of dialysis patients with artificial kidney. 30th Panhellenic Dental Conference, Athens
    3. Zervou - Valvi F, Perdikidis P., Peliatos P., Drouzas A., Papadakis G. Events from the oral mucosa in diseases undergoing chronic periodic hemodialysis. 5th Panhellenic Congress of General Medicine, Corfu
  • 4.Laskaris G Stomatology. Color Atlas. 2nd edition, Athens. Medical publications "Litsas" 1998
    5.Aikaterini Dimitriou, Zervou -Valeni F. "Chronic kidney disease and oral health"
  • 6.Kadiroglou AK, Kadiroglou ET, Sit D, Dag A, Yilmaz ME: Periodontotis is an important and occult source of inflammation in hemidiaysis patients. Blood Purif 2006
  • 7.Ioannidou E., Fares G.: The periodontal patient and chronic kidney disease. Analecta Periodontologica 2009
  • 8.De Rossi S., Glick M: Dental consideration for the patient with renal disease receiving hemodialysis. JADA 1996
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