Better Oral Health May Reduce Mortality Risk for Patients with End Stage Renal Disease

Better dental hygiene and oral health can lead to better overall outcomes for patients with end stage renal disease (ESRD). Researchers saw the effect regardless of the age at which patients initiated oral hygiene practices.

Poor oral health is a risk factor for cardiovascular and all-cause death among patients with chronic kidney disease (CKD). Compared to the general population, dialysis patients have more severe oral disease, and their uptake of dental health services is very low. But questions remain whether improving oral health would result in better outcomes.

No drug or other intervention appears to work very well to lower the elevated mortality risk of hemodialysis patients, so other interventions need to be examined, according to Giovanni Strippoli, MD, PhD, MPH, of the University of Bari, Italy, and Senior Vice President and Scientific Director of Diaverum, a global provider of renal services.

Therefore, Strippoli and colleagues undertook the prospective multinational ORAL Diseases in hemodialysis (ORAL-D) study involving 4320 consecutive adult hemodialysis patients recruited from randomly selected clinics in the Diaverum dialysis network in Europe and South America between July 2010 and February 2012. Patients had a mean age of 61.7 years, 58 percent were men, and 23 percent lacked teeth.

The study assessed the relationship between periodontal, dental, salivary, and mucosal health and mortality. At baseline, patients underwent a standardized oral examination and were surveyed about their dental health practices, other behavioral health risks, thirst, co-morbidities, and demographic factors.

Presenting the ORAL-D results at the the ERA-EDTA conference in Amsterdam, Strippoli reported that at a median follow-up of 22.1 months (12 months minimum), 650 participants died from any cause, and of those, 325 died from a cardiovascular event.

After adjusting for age, sex, income, smoking, cardiovascular disease, blood pressure, time on dialysis, and serum phosphorus level, the researchers saw a 27 percent increased risk of death (hazard ratio, HR = 1.27) among participants without teeth. Even worse, the risk of death in people with teeth (dentate) was elevated by 46 percent (HR = 1.46) for individuals with more than 12 decayed, missing, or filled teeth.

In the dentate population, oral hygiene practices were associated with a reduced risk of death by a statistically significant amount. Brushing teeth was associated with a 26 percent reduced risk of all-cause death, flossing 51 percent, changing a toothbrush at least every 3 months 21 percent, and spending 2 minutes or more on oral hygiene daily 19 percent. However, the age of starting dental care did not matter. The risk of death from cardiovascular causes followed a similar pattern. For people older than 60 years, the association between decayed, missing, and filled teeth and the risk of death was not as strong as for younger participants but was still statistically significant (31 percent greater; HR = 1.31).

The authors concluded that these results show an independent association between poor dental health and mortality for adult hemodialysis patients. Oral hygiene practices were associated with lower mortality.

A previously published meta-analysis by Strippoli and co-workers (Nephrol Dial Transplant 2014; 29: 364–375) comprising 11,340 adults with CKD in 88 studies supports the present findings. In that paper, they found that one in five people with stage 5D disease (therefore on dialysis) lacked any teeth, and 57 percent had periodontitis compared to 32 percent with less severe CKD. Among the stage 5D patients, 26 percent reported never brushing their teeth, only 11 percent flossed, 19 percent reported oral pain, and about half reported dry mouth.

Although a causal link between poor oral hygiene and all-cause or cardiovascular mortality cannot be drawn from observational data, and common pathways may be at play leading to oral problems and cardiovascular events, the authors did cite research showing that intensive periodontal treatment was associated with improved endothelial function. Furthermore, poor, painful, or absent dentition may be a factor in malnourishment.

Strippoli said the study findings strongly suggest that good dental care and dental hygiene should be urged for anyone with ESRD.