**4. Influence of hemodialysis on oral health according to various studies**

Hemodialysis has emerged as an optimum treatment modality for the patients with compromised renal function significantly reducing the mortality rate of these diseases. Researchers have provided with substantial evidence that chronic systemic diseases like renal failure and its treatment modalities have a significant effect on the oral environment resulting in an increased burden of oral diseases among these


#### **Table 1.**

*Oral health and hemodialysis: summary of literature review.*

patients [2, 10, 11]. An insight into the various studies conducted worldwide would help us understand the topic (**Table 1**).


**29**

*Hemodialysis and Oral Health*

*DOI: http://dx.doi.org/10.5772/intechopen.87085*

order to improve their overall oral health.

small sample size evaluated.

the controls.

frequency and periodic dental checkup frequency. Oral examination findings indicated severe enamel hypoplasia in the study group with significant difference for DMFT and gingival and plaque indices when compared with the control group. It was further observed that study group showed high salivary buffer capacity in 89.5% of patients. Salivary levels of cariogenic streptococcus mutans and lactobacilli in the study group were significantly lower than in the control group. It was concluded that high salivary buffer capacity was observed due to increased concentrations of antibacterial chemicals such as urea in the saliva of children with ESRD. Also decreased levels of cariogenic microorganisms were detected. Thus, the authors suggested that all hemodialysis patients should receive dental health education, including oral hygiene instruction, in

3.**Marakogolu et al.** [15] **carried out a study** to assess the microbial dental plaque load among the patients undergoing hemodialysis. For clinical parameters, gingival Index (GI), plaque index (PI) scores, and probing depths (PD) were recorded for hemodialysis patients and controls matched with the patient group. However, the results showed no statistically significant difference regarding clinical parameters between the two groups attributed mostly to the

4.**Bayraktar et al.** [16] compared the periodontal and oral health status of

5.**Torkzaban et al.** [10] conducted a survey to assess the prevalence of periodontal disease and its related characteristics in 31 hemodialysis patients from the dialysis department of educational Ekbatan Hospital in Hamadan. Clinical parameters that were assessed were periodontal disease index (PDI), papillary bleeding index (PBI), and plaque control record index (PCRI), and medical history was recorded. Then, the recorded data were analyzed. It was observed that all hemodialysis patients had periodontal disease. Plaque control record index was higher than 50% in nearly all patients. Despite the high accumulation of plaque in the patients, the rate of gingival bleeding was low. Also, it was observed that more than half of the patients did not brush their teeth. Renal transplantation patients had a lower plaque accumulation than the others, and consequently periodontal disease was less observed. Periodontal condition

6.**Joseph** [13] carried out a study with an aim to assess the prevalence of periodontal disease among a group of patients with renal disease and healthy controls. A total of 77 renal disease patients and 77 healthy controls were examined for clinical parameters like oral hygiene status, gingival inflammation, probing pocket depth, and clinical attachment loss. Periodontal findings

debilitated with the duration of hemodialysis.

hemodialysis patients and healthy controls. Seventy-six hemodialysis patients and 61 controls were examined for plaque deposits, gingivitis, periodontitis, calculus accumulation, and oral health status. The results showed no statistical difference in the probing pocket depths (PPD) but a highly significant difference for plaque index (P < 0.001), gingival index (GI) (P = 0.007), and calculus surface index (P < 0.001). There was a highly significant difference for GI (P = 0.001) and PPD scores (P < 0.001) between subgroups receiving hemodialysis 3 years or more. A positive correlation between time on dialysis and parameter of missing teeth, GI scores, and measurement of PPD was found in the patient group. The hemodialysis group showed less DMFT than

*Renal Diseases*

**Table 1.**

patients [2, 10, 11]. An insight into the various studies conducted worldwide would

**S. No. Oral findings in hemodialysis patients Previous studies** 1. Debilitated periodontal status 1. Klassen and Krasko [7]

2. Poor dental caries status 1. Dumitrescu et al. [18]

3. Poor oral hygiene behavior 1. Klassen and Krasko [7]

5. Increased salivary buffer capacity 1. Ertugrul [14]

4. Neglected oral health care seeking behavior among

hemodialysis patients

*Oral health and hemodialysis: summary of literature review.*

2. Bayraktar et al. [16] 3. Torkzaban et al. [10] 4. Joseph [13] 5. Dencheva [17] 6. Malekmakan [12] 7. Parkar et al. [11] 8. Bhatsange et al. [19] 9. Ziebolz et al. [20] 10. Jenabian et al. [8] 11. Kaushik et al. [21] 12. Jain et al. [23]

2. Ziebolz et al. [20]

2. Dumitrescu et al. [18] 3. Xie et al. [22]

1. Klassen and Krasko [7] 2. Dumitrescu et al. [18] 3. Xie et al. [22] 4. Jain et al. [23]

2. Kaushik et al. [21]

1.**Klassen and Krasko** [7] conducted a study to assess the dental health of dialysis patients. A questionnaire and a noninvasive oral examination were obtained from hemodialysis and peritoneal dialysis patients registered in the dialysis program at St. Paul's Hospital in Saskatoon, Saskatchewan. A detailed medical history was obtained and recorded of a total of 373 dialysis patients in Central and Northern Saskatchewan. The clinical examination revealed that 64% of the patients who were dentate had been on dialysis for a mean of more than 2 years. Majority of the patients were diabetic, and almost all were hypertensive. Sixty (64%) of the dentate patients were candidates for kidney transplantation. The oral findings revealed an increased prevalence of tooth mobility, fractures, erosion, attrition, recession, gingivitis, and a high plaque index. Majority of the patients reported brushing once or more daily, but they flossed infrequently or never. Dental visits were infrequent, less than every 5 years in 59 (63%) of the dentate patients. Almost 81% of the treating dentists were aware about the medical condition of their patients. The author has concluded that the oral health of hemodialysis patients was compromised and

2.**Ertugrul** [14] assessed the oral health status of children suffering from

end-stage renal disease identifying the causes of low caries prevalence in this population in comparison with the control group. The study group consisted of 38 children, aged 4–17 years being treated in pediatric nephrology units at three different hospitals in Izmir, Turkey. The study and control groups had similar baseline oral hygiene habits with respect to daily tooth brushing

help us understand the topic (**Table 1**).

required urgent attention and intervention.

**28**

frequency and periodic dental checkup frequency. Oral examination findings indicated severe enamel hypoplasia in the study group with significant difference for DMFT and gingival and plaque indices when compared with the control group. It was further observed that study group showed high salivary buffer capacity in 89.5% of patients. Salivary levels of cariogenic streptococcus mutans and lactobacilli in the study group were significantly lower than in the control group. It was concluded that high salivary buffer capacity was observed due to increased concentrations of antibacterial chemicals such as urea in the saliva of children with ESRD. Also decreased levels of cariogenic microorganisms were detected. Thus, the authors suggested that all hemodialysis patients should receive dental health education, including oral hygiene instruction, in order to improve their overall oral health.


were grouped into three as no/mild, moderate, and severe periodontitis. All periodontal parameters were significantly high in patients as compared to controls (p < 0.001). The prevalence and severity of periodontal disease was also significantly higher in the case group (p < 0.001). This study provides evidence for a greater prevalence and severity of periodontal disease among patients with renal disease. The periodontal health of all patients with renal disease needs to be carefully monitored.


**31**

especially in males.

*Hemodialysis and Oral Health*

these patients.

*DOI: http://dx.doi.org/10.5772/intechopen.87085*

10.**Parkar et al.** [11] assessed the periodontal status of patients in hemodialysis patients in two super specialty renal institutes in Gujarat, India, through a cross-sectional study in 152 hemodialysis patients and 152 controls. Clinical parameters were evaluated through simplified oral hygiene index, community periodontal index (CPI), and loss of attachment (LOA) as per WHO methodology 1997. The findings of the study highlighted that the dialysis group had compromised oral hygiene than controls (**P** < 0.001). There was a high severity of periodontitis in the dialysis group as compared with the control group (**P** < 0.001). None of the subjects had healthy periodontium. There was a high severity of periodontitis (for both in terms of CPI and LOA) in the dialysis group as compared with control group that was found to be statistically highly significant (**P** < 0.001). For the intergroup comparison for CPI and LOA, there was no statistical significant difference regarding the periodontal findings. It was thus concluded that periodontal diseases are prevalent in chronic renal failure patients emphasizing the need for concurrent dental treatment among

11. **Bhatsange et al.** [19] conducted a study to gain an insight into whether duration of dialysis therapy influences the oral and periodontal health of hemodialysis patients. A total of 75 hemodialysis patients and 25 controls was assessed.

significant difference between the groups rather than within the groups.

12.**Ziebolz et al.** [20] evaluated oral hygiene behavior and oral health status of hemodialysis patients in Germany. Dental examination findings consisted of DMFT and the degree of gingival inflammation (PDI: periodontal disease index) among 129 patients. The findings revealed the average dialysis duration was 4.1 years. The underlying kidney diseases were glomerulonephritis in 30% of patients and diabetic nephropathy in 22% of patients. Only 63% of the patients (n = 34) visited a dentist when they had complaints. In 46 cases (85%), the dentist had been informed about the patient's requirement for dialysis, and in most cases (70%), the dental treatment took place on the day after dialysis. The clinical parameters showed that the mean DMFT of the patients was 22.1 ± 6.5. The median degree of gingival inflammation (PDI) was 1. In addition to a high proportion of missing teeth, a good level of restoration of caries was found. The gingiva showed only a low level of inflammatory changes.

13.**Jenabian et al.** [8] assessed the periodontal status of hemodialysis patients in Babol, Northern Iran. A total of 115 patients were studied (63 males, 52 females). The clinical parameters which were assessed were plaque index (PI), gingival index (GI), clinical attachment level (CAL), and probing pocket depth (PPD). The data were collected and analyzed. The results showed that PI, GI, CAL, and PPD scores were 2.37 ± 0.55, 2.36 ± 0.63, 3.98 ± 1.61, and 4.41 ± 1.4, respectively. It was observed that the PI scores deteriorated with increasing age (p < 0.024). Also, CAL was significantly higher in males than in females (4.39 ± 1.57 vs. 3.53 ± 1.56, p < 0.02). The results showed that longer duration of hemodialysis is associated with severe periodontal diseases,

Depending upon the duration of dialysis, the study groups were divided into three subgroups. Simplified oral hygiene index and periodontal disease index by Ramfjord were recorded. The results showed that the prevalence of periodontal disease was evident in the dialysis group. Oral hygiene status was poor in comparison with the control group. Clinical and biochemical parameters showed a statistically

## *Hemodialysis and Oral Health DOI: http://dx.doi.org/10.5772/intechopen.87085*

*Renal Diseases*

were grouped into three as no/mild, moderate, and severe periodontitis. All periodontal parameters were significantly high in patients as compared to controls (p < 0.001). The prevalence and severity of periodontal disease was also significantly higher in the case group (p < 0.001). This study provides evidence for a greater prevalence and severity of periodontal disease among patients with renal disease. The periodontal health of all patients with renal

7.**Dencheva** [17] conducted a study to estimate the periodontal conditions and treatment needs by CPITN of 150 patients out of which 45 (30%) were on hemodialysis, 45 (30%) were renal transplanted patients, and 60 (40%) were healthy controls, aged between 18 and 84 years. All patients were asked not to brush their teeth before the examination. Periodontal examination was done after dialysis. The results showed that CPI score 3 and CPI score 2 in the control group were more significant than those in hemodialysis groups and transplanted group. Sixty percent from transplanted group have gingival pockets of up to 3.5 mm and sub- and/or supragingival calculus. The percentage of patients with code CPI 3 is also high and shallow. Most patients in control group (71%) were with CPI 2. None of the three groups of patients with

8.**Dumitrescu et al.** [18] assessed oral health status and behaviors among

Romanian adult individuals on renal dialysis along with self-reported anxiety, stress, and depression level. A cross-sectional study was conducted on a total sample size of 61 adults (mean age 53.9 years; 44% women; 66% married). The questionnaire included information about sociodemographic factors, behavioral factors, self-reported oral health status, anxiety, stress, and depression. The clinical parameters revealed that 99.4% of the participants reported to have current non-treated caries, 94.4% were not satisfied by appearance of own teeth, 97.5% presented extracted teeth, and 64.6% of them reported to have gum bleeding. 34.5% of the individuals brushed once a day or less, 92.5% of them never used dental floss, and 78.3% never used mouth rinse. Regarding oral hygiene practices, only 13% of participants availed dental treatment services, and 89.4% had consulted the dentist only when treatment is needed or when in pain. The main reasons for non-consultation from a dentist were anxiety and financial roadblock. A high percentage of dialysis patients presented anxiety (85.1%), stress (60.9%), and depression in everyday life (61.5%). Duration of hemodialysis did not affect the clinical oral parameters examined. The results supported the view that there was an increased risk for anxiety, stress, depression, and impaired dental/gingival health and behaviors among individuals on renal dialysis. Early dental treatment and psychological

9.**Malekmakan** [12] aimed to assess the oral health status and related risk factors in Iranian hemodialysis patients. Sociodemographic information, medical history, and dental health findings were recorded for 72 patients (mean age and HD time of 53.4 ± 15.3 years and 36.9 ± 33.8 months, respectively). The results showed that 48.6% of the patients complained of dry mouth, 49.3% of taste change, and 31% of bad breath. A high 46.9% of the hemodialysis patients had dental calculus. The mean DMFT score was 18.6 ± 9.9. The authors observed that DMFT score was significantly lower in patients with dental

disease needs to be carefully monitored.

healthy periodontium in all sextants existed.

interventions were recommended.

calculus than in patients without it (P = 0.001).

**30**

