Oral Health and the Renal Patient

Patients suffering from chronic kidney disease and those undergoing dialysis are more prone to periodontal disease and other oral
health problems for multiple reasons. One of the main reasons is often the secondary importance that dental care takes when
individuals have kidney problems. These patients often have a multitude of doctor appointments to go to and changes in medical
insurance, which does not promote preventive dental care or treatment of dental problems.

Dialysis and dry mouth (xerostomia)

Patients on dialysis usually have to adhere to a fluid restriction. By lowering the intake of fluids, the production of saliva is
diminished.

Saliva has enzymes that help digest starch, and it also makes the mouth more alkaline. Therefore, the teeth are less prone to decay
from acid that forms when the food breaks down. Saliva makes the food easier to swallow and less irritable to the throat, and the
minerals in saliva help with repairing of the enamel.

Oral dryness is managed with synthetic saliva substitutes, by sipping water, or by sucking small ice cubes. Saliva production also is
stimulated by chewing sugar-free gum; dentate patients and individuals with good dentures may benefit from chewing sugar-free gum.
The enhanced buffering properties of stimulated saliva also protect the patient against increased risk of tooth demineralization and
cavities.

Many medications are known to cause dry mouth. If dry mouth becomes a problem, it is important to discuss this with a physician.
Often it is possible to substitute a medication with another that does not cause this problem.

Below is a list of medications known to cause dry mouth, listed by brand name:

Antihypertensive: Capoten®, Catapres®, Coreg®, Ismelin®, Minipress®, Serpasil®, Wytensin®

Anticonvulsant: Felbatol®, Lamictal®, Neurontin®, Tegretol®

Antidiarrheal: Imodium® AD, Lomotil®, Motofen®

Sedative: Dalmane®, Halcion®, Restoril™

Diuretic: Diuril®, Dyazide®, Maxzide®, HydroDIURIL®, Esidrix®, Hygroton®, Lasix®, Midamor®

Decongestant: Sudafed®

Anti-Parkinsonian: Akineton®, Artane®, Cogentin®, Larodopa®, Sinemet®

Antianxiety: Atarax®, Vistaril®, Ativan®, Centrax®, Equanil®, Miltown®, Librium®, Paxipam®, Serax®, Valium®, Xanax®

Antidepressant: Anafranil®, Asendin®, Luvox®, Norpramin®, Prozac®, Sinequan®, Tofranil®, Wellbutrin®

Antihistamine: Actifed®, Benadryl®, Chlor-Trimeton®, Claritin® Dimetane®, Dimetapp®, Hismanal®, Phenergan®, Pyribenzamine®
(PBZ)

Bronchodilator: Atrovent®, Isuprel®, Proventil®, Ventolin®

Muscle relaxant: Flexeril®, Lioresal®, Norflex™, Disipal®

Antinauseant: Antivert®, Dramamine®, Marezine®

Anti-inflammatory analgesic: Dolobid®, Feldene®, Motrin®, Nalfon®, Naprosyn®

Malnutrition
For multiple reasons, malnutrition is a significant problem for dialysis patients. This condition is exacerbated by poorly fitting oral
prosthetic devices and decayed or missing teeth.

If dental care is neglected, malnutrition becomes a worsening problem. The blood albumin level will decrease, because of protein
and/or calorie malnutrition, and because of worsening inflammation. The ferritin level will show an increase, and it is not possible to
administer iron to treat anemia. The overall health of the patient will worsen.

It is very important to investigate any dental problems All members of the health care team should question patients about their dental
and oral health.

Dental disease, inflammation, and heart disease

Dialysis patients have a high mortality rate associated to cardiovascular disease. An established correlation exists between C-reactive
protein (CRP) and atherosclerotic problems. Studies have shown that oral infections are related to elevated CRP and an increased
incidence of heart disease. It is important to control any inflammation caused by dental disease in an effort to decrease the risk of
cardiovascular events.

Diabetes and dental disease

A majority of dialysis patients also have diabetes. Elevated blood glucose levels cause an increased bacterial production, therefore a
higher rate of periodontal disease and oral infection. Diabetes also is associated with other oral complications, such as bleeding gums,
hard-to-heal mouth sores, inflammation, and bad breath. It is very important to maintain a blood glucose level within the normal range
and to have good dental hygiene habits.

Renal osteodystrophy dental disease

Renal osteodystrophy is a bone disease commonly seen in patients with renal failure. It results from secondary hyperparathyroidism
and causes structural bone changes in the tooth as well. Elevated parathyroid hormone synthesis causes accelerated bone loss, less
mineralized teeth, and more fragile teeth.
The alteration in calcium and phosphorus metabolism also is known to cause enamel hypoplasia. The severity usually is related to the
patient’s age when the kidney problems start and the duration of renal failure.

Dialysis patients may form calculus more rapidly than healthy individuals, because of the elevated salivary urea and phosphate levels.
Frequent dentist visits sometimes are required for calculus removal and to reduce the risk for oral infections or transient bacteremia.

Transplant and oral care

Patients who are candidates for kidney transplantation should receive meticulous pretransplant dental care. The lack of care may put
these patients at higher risk for local or disseminated infection related to dentition once they are taking immunosuppressive
medication. Any untreated dental infection can potentially compromise a transplanted organ.

Planning dental interventions

People with chronic kidney disease, especially those on dialysis, need to pay special attention to preparing for dental interventions.
They always should inform their nephrologists or health care team of upcoming dental checkups or procedures.

To prevent infections, nephrologists may prescribe an antibiotic prior to a procedure. If a patient is on an oral anticoagulant,
sometimes it is necessary to stop taking it for a few days to prevent abnormal bleeding. Patients on dialysis usually are given heparin
(blood thinner) throughout the treatment; therefore, patients should schedule any dental procedures on nondialysis days. Patients also
need to tell their dentist if they are on dialysis. It may influence the type of medication prescribed or the procedure performed.

Preventive steps
The following tips may help:

Eat a balanced diet

Avoid refined carbohydrates

Drink fluoridated water and use fluoride mouthwash—avoid mouthwash containing alcohol, because it makes the mouth drier

Avoid alcohol and tobacco products, which can cause oral and throat disease

Choose a soft-bristle toothbrush and dental floss that have the American Dental Association (ADA) Seal of Acceptance

Never share your toothbrush and replace it every 3 months

Brush teeth twice a day with fluoridated toothpaste

Floss between teeth daily

Always wash hands before and after brushing and flossing

Review Date 4/09

R-0580