Oral health in patients with chronic kidney disease : emphasis on periodontitis

ORAL HEALTH IN PATIENTS WITH CHRONIC KIDNEY DISEASE - EMPHASIS ON PERIODONTITIS Background: Periodontitis is a common bacteria-induced chronic inflammatory disease with mild symptoms. It leads to destruction of the periodontium and finally to tooth loss in a susceptible patient. Periodontitis is associated with many systemic diseases such as diabetes, atherosclerosis, cardiovascular diseases, and chronic kidney disease (CKD) through low-grade systemic inflammation. However, no causality can be drawn. CKD is defined as a deficiency in kidney structure or function lasting over three months. Its prevalence is over 10% globally. The main risk factors of CKD are diabetes mellitus, hypertension, and obesity although periodontitis has been proposed to be a non-traditional risk factor. When CKD is progressed to end-stage renal disease (ESRD), renal replacement therapy (dialysis or kidney transplantation) is needed. Prior to entering kidney transplantation, the candidate must be screened for infections, including oral infections, before immunosuppressive medication can be administered. Patients with ESRD have higher mortality rates compared with general population. Aim and hypotheses: The general aim of this thesis was to examine the oral health of 144 CKD patients with emphasis on periodontal disease; first at predialysis and secondly at post-transplantation stage. Other purposes were to investigate the association between periodontal inflammatory burden and salivary matrix metalloproteinase -8 (MMP-8) concentration, and further, to determine whether oral inflammatory burden associates with mortality. Oral health of diabetic nephropathy patients were compared with other CKD patients. The main hypotheses were that oral health, periodontal disease in particular, is more severe among diabetic nephropathy patients than among other CKD patients. Furthermore, we expected oral health being worse at predialysis compared with post-transplantation stage. Methods: CKD patients were followed up for 157 months (over 13 years). They underwent a full clinical and radiographic oral examination. Salivary samples were collected both at predialysis and post-transplantation stages for detection of MMP-8 by immunofluorometric assay (IFMA). Results: Patients with diabetic nephropathy indeed had worse oral health. Higher salivary MMP-8 concentrations associated with worse oral health at prediaysis stage. The follow-up study showed that the 10-year survival rate of diabetic nephropathy patients was 28% compared to 62% of the other CKD patients. The overall 10-year survival rate was 50%. The most common cause of death was a major cardiovascular event, followed by infection and malignant disease. In the multivariable Cox regression model, older age, diabetic nephropathy diagnosis and having fewer teeth were significant independent risk factors for death. Oral health was better at the follow-up than at the predialysis stage when oral infection treatment had been given. Conclusion: The present results support the existing protocol of the Helsinki University Hospital, where oral examination, accurate diagnosis and proper treatment of oral infection foci are mandatory at the predialysis stage for reducing systemic inflammation among CKD patients. Salivary MMP-8 assessment could help clinical decision making in the future. The association of missing teeth and mortality could be explained by long lasting low grade systemic oral inflammation. Since diabetic nephropathy is associated with poorer oral health, this patient group needs particular attention.KROONINEN MUNUAISSAIRAUS JA SUUN TERVEYS Tausta: Hampaiden kiinnityskudossairaus, parodontiitti on yleinen krooninen tulehdussairaus joka etenee usein vähäoireisena. Se tuhoaa hammasta ympäröivää ienkudosta ja leukaluuta taudille alttiilla yksilöllä. Parodontiitti on yhdistetty useisiin yleissairauksiin kuten diabetekseen, ateroskleroosiin, sydän- ja verisuonitauteihin sekä krooniseen munuaistautiin (KMT) yleisen matala-asteisen tulehduksen kautta, vaikkakaan syy-seuraussuhdetta ei ole voitu osoittaa. KMT määritellään munuaisten rakenteen tai toiminnan puutteeksi, joka kestää yli kolme kuukautta. Taudin esiintyvyys on yli 10 % monissa maissa. KMT:n tärkeimpiä riskitekijöitä ovat diabetes, kohonnut verenpaine ja ylipaino. Parodontiittia on ehdotettu yhdeksi KMT:n riskitekijäksi. Munuaissairauden edettyä loppuvaiheeseen, tarvitaan munuaisten aktiivista korvaushoitoa, dialyysihoitoa tai munuaisen siirtoa. Ennen munuaisen siirtoa ja immunosuppressiivisen lääkityksen aloittamista, infektiot, kuten suuinfektiot on hoidettava. KMT potilaiden kuolleisuus verrattuna yleiseen väestöön on korkeampi. Tavoite ja hypoteesi: Tämän väitöskirjatyön päätavoitteena oli tutkia 144 CKD-potilaan suun terveyttä, erityisesti parodontiittia ensin predialyysi vaiheessa ja seuraavaksi munuaisen siirron jälkeen. Tutkimme parodontiitin aikaansaaman tulehduskuorman ja syljen matriksimetalloproteinaasi – 8 (MMP-8) entsyymipitoisuuksien yhteyttä. Tavoitteena oli selvittää liittyykö suun tulehduskuorma korkeampaan KMT kuolleisuuteen sekä eroavatko diabeteettista nefropatiaa sairastavat muista KMT potilaista. Hypoteesimme oli, että suun terveys, erityisesti parodontiitti on vaikeampi diabeteettista nefropatiaa sairastavilla kuin muilla KMT potilailla ja huonompi predialyysivaiheessa verrattuna siirteen jälkeiseen vaiheeseen. Metodit: Potilaita seurattiin 157 kuukautta, eli yli 13 vuotta. KMT potilaille tehtiin täydellinen kliininen ja radiologinen suun perustutkimus sekä kerättiin sylkinäytteet MMP-8 määritystä varten (immunofluoresenssi-menetelmä, IFMA) predialyysi sekä seurantavaiheessa. Kuolinsyyt selvitettiin Tilastokeskuksen kuolinsyyrekisteristä. Tulokset: Diabeettista nefropatiaa sairastavilla oli huonompi suuterveys varsinkin parodontiitin suhteen verrattuna muuta munuaissairautta sairastaviin. Syljen korkeampi MMP-8-pitoisuus liittyi huonompaan suuterveyteen, erityisesti parodontiittiin predialyysivaiheessa. Seurantatutkimuksemme osoitti, että 10-vuotis eloonjäämisaste oli diabeettista nefropatiaa potilailla 28 % verrattuna 62 % muuta munuaissairautta sairastaviin. Yleinen eloonjäämisaste oli 50 %. Tavallisimmat kuolinsyyt olivat sydän- ja verisuonitaudit, infektiot ja maligniteetit. Coxin regressioanalyysissa korkea ikä, diabeettinen nefropatia ja vähähampaisuus olivat itsenäisiä kuoleman riskitekijöitä. Suuterveys oli kaiken kaikkiaan parempi seurantavaiheessa kuin predialyysivaiheessa, jolloin suun infektiofokussaneeraus oli suoritettu. Yhteenveto: Tutkimuksen tulokset tukevat Helsingin yliopistollisen sairaalan käytäntöä, jonka mukaan suun perustutkimus, diagnosointi ja huolellinen fokussaneeraus on tehtävä predialyysivaiheessa. Syljen MMP-8 pitoisuuden määrittäminen saattaa tukea kliinistä diagnostiikkaa tulevaisuudessa. Vähähampaisuuden yhteys kuolemaan voi selittyä pitkään jatkuneella systeemisellä matala-asteisella tulehduskuormalla. Diabeteettista nefropatiaa sairastavien potilaiden suun terveyteen tulee kiinnittää erityistä huomiota sillä heidän parodontaaliterveys oli huonompi niin predialyysi- kuin seurantavaiheessakin

Oral symptoms and oral health-related quality of life in patients with chronic kidney disease from predialysis to posttransplantation

ObjectiveThis prospective follow-up cohort study analyzed chronic kidney disease (CKD) patients' oral symptoms, health habits, and oral health-related quality of life (OHRQoL), from predialysis to posttransplantation. A simplified questionnaire method (Oral Health Quality Score, OHQS), based on these and clinical findings, was constructed and tested for identifying patients in need for referral to a dentist.Material and methodsFifty-three CKD patients were followed up for a mean of 10.3years. Clinical oral, radiological, and salivary examination was performed at baseline and posttransplantation. Total Dental Index (TDI) indicating inflammation was calculated. The patients filled out a questionnaire on symptoms, oral hygiene and health care habits, smoking, alcohol use, and medication. General health-related quality of life was assessed with the 15-dimensional (15D) instrument at posttransplantation. Descriptive and analytical methods were used in statistics.ResultsOHQS significantly correlated with high TDI (p=0.017), number of teeth (p=0.031), and unstimulated salivary flow rate (p=0.001) in transplanted patients. Number of daily medications showed a negative correlation with the OHQS (r=-0.30; p=0.028). The prevalence of oral symptoms was slightly, but not significantly, more common posttransplantation compared with predialysis stage.ConclusionOHQS identified patients with high oral inflammatory score thus confirming our study hypothesis.Clinical relevanceUse of OHQS and measuring salivary flow indicate patients at risk for oral diseases. These markers might be easy to use chair-side also by auxiliary personnel.Peer reviewe

The relationship between oral diseases and infectious complications in patients under dialysis

Objectives Association was investigated between oral health before dialysis and the incidence of systemic infections during dialysis. We hypothesized that low-grade systemic inflammation caused by poor oral health associates with infectious episodes in patients on dialysis, despite earlier eradication of oral infection foci. Subjects and methods A total of 117 patients (46 with peritoneal and 71 with hemodialysis) were examined and treated at predialysis stage and followed up during dialysis. Number of infection episodes and microorganisms cultured from blood and peritoneal fluid were analyzed. Number of teeth, periodontal inflammatory burden, and total dental index scores were assessed, and salivary matrix metalloproteinase 8, triggering receptor on myeloid cells 1, peptidoglycan recognition protein 1 (PGLYRP1), and interleukin-1 beta were measured. Results In hemodialysis, 134 infection episodes were recorded, while peritoneal dialysis group had 77 peritonitis episodes. Culture-negative samples were 69% in hemodialysis and 23% in peritoneal dialysis group. Staphylococci were the most frequently associated microorganisms. Infections during dialysis did neither associate with oral health parameters nor associate with salivary inflammatory biomarkers, except for PGLYRP1, which associated with number of infection episodes during hemodialysis (p = .046). Conclusions A number of infection episodes during hemodialysis were associated with salivary PGLYRP1 but not the other salivary markers or oral infection markers.Peer reviewe

Triage and urgent dental care for COVID-19 patients in the Hospital District of Helsinki and Uusimaa

Objective This paper describes and reports the patient-specific characteristics of an urgent dental care clinic for COVID-19 infected, suspected, exposed or quarantined patients from March to December 2020 in the Hospital District of Helsinki and Uusimaa, Finland. Material and methods The triage and the treatment protocol were established based on the scientific data. Patient files were evaluated from the hospital district's electronic medical record system. IBM SPSS software was used for statistical analysis. Results There were 1114 consultations and 257 visits at the clinic. Most of the patients were generally healthy with mean age of 35, had toothache and were suspected to be SARS-CoV-2 positive. Seventeen of the patients received positive tests for COVID-19 infection. The main treatment was tooth extraction, mostly due to caries. Statistically significant differences between COVID-19 infected and other patients occurred in age (45 vs 34 years-of-age, p = .009) and number of teeth (25 vs 28, p = .031). No SARS-CoV-2 infection transmission chains were traced to the clinic. Conclusion During the challenging pandemic time, patients were carefully screened by specialists in clinical dentistry and treated safely and effectively. Patient-specific characteristics revealed no differences between COVID-19 infected and other patients in terms of symptoms or treatment needs.Peer reviewe

Oral findings and treatment of patients with face transplants in Helsinki

Objectives. Oral health and balanced occlusion are important aspects of a well-functioning face transplant. This study describes the oral and dental status, dental management, and sialoendoscopy of the first 2 patients in Helsinki who underwent face transplantations. Study Design. Two patients received near-full face transplantations in 2016 and 2018, respectively. The transplanted tissues included a Le Fort type II maxilla, angle-to-angle mandible, all oral mucosa, ventral tongue tissue, and the muscles of the floor of the mouth. Comprehensive oral examinations and all required dental treatment, including follow-up examinations, were performed for both patients after the transplantations. Results. Both patients rehabilitated well, and their quality of life improved. Stable, functioning dentition and occlusion were achieved for both patients. Hyposalivation and dental caries were issues for both patients. Patient 1 also experienced infections in the jaws. Implants were placed in the transplanted jaws of patient 2 with successful osseointegration. Conclusions. We report successful tooth-bearing face transplantations in 2 patients. Patient selection, particularly regarding oral health, is crucial in avoiding posttransplantation complications. Moreover, the oral and dental status of the donor should be examined by a dentist before transplantation, and regular follow-up dental examinations should be performed after transplantation.Peer reviewe

Persistent oral mucosal lesions preceding diagnosis of Crohn's disease and primary sclerosing cholangitis

Oral mucosal lesions may persist years before symptoms or diagnosis of inflammatory bowel disease (IBD) and subsequent primary sclerosing cholangitis (PSC). Since a dental practitioner may be the first clinician to suspect IBD with extraintestinal manifestations (EIMs), early referral, and close collaboration with a gastroenterologist are recommended.Peer reviewe