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Relationship Between Periodontal Disease and Kidney Disease

Relationship Between Periodontal Disease and Kidney Disease

Jing Zhang and Beatriz G. Acosta

Lamar Institute of Technology Dental Hygiene Program

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Relationship Between Periodontal Disease and Kidney Disease

Table of Contents
Overview of Periodontitis and Kidney Disease ………………………..………………3

Periodontitis and Kidney Disease……………………………………………………….3

How PD Plays a Role in CKD…………………………….…………………………….4

Studies Overlooking the Correlation of PD & CKD…….………………………………5

Clinical Trials………………………………………………….…………………………6

Summary…………………………………………………………………………………8

References……………………………………………………………………………….10
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Overview of Periodontitis and Kidney Disease

Chronic periodontitis, the most common periodontal disease, destroys periodontal

support tissues, such as pocket formation, attachment loss, and alveolar bone resorption,

resulting in tooth loss. A bacterial infection can cause periodontitis and is a worldwide problem

in adults. Periodontitis is associated with many chronic diseases; we often learn about

cardiovascular disease and diabetes, so is there any association between periodontitis and kidney

disease. Relevant information shows that periodontitis-causing bacteria cause local

inflammation and are deposited in the kidneys, triggering and amplifying the body’s immune and

inflammatory response, which can induce kidney disease and aggravate kidney damage. This

research projects will focus on the research progress of the interaction between periodontitis and

CKD (chronic kidney disease) and its pathogenesis.

Periodontitis & Chronic Kidney Disease

Periodontal disease is an immunoinflammatory disease of the periodontal tissues caused

by periodontopathogen bacteria. Chronic periodontitis is categorized as mild, moderate, severe

according to its severity. “PD affects the soft and hard tissues of the oral cavity…can lead to

tooth loss of not treated or controlled,” (Olson, 2022, p. 6). The incidence of periodontal disease

increases with age. The disease develops slowly and has multiple risks factors including age,

socioeconomic conditions, education level, smoking, stress, and diabetes. Periodontal

pathogenic bacteria can cause local periodontal tissue inflammation, such as gingival redness,

swelling, bleeding, etc., and at the same time can be directly into the bloodstream or stimulate

the production of inflammatory mediators, stimulate the body to activate the immune system,

and play the role of inflammatory stimulation of the systemic systems. Studies have shown that
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periodontitis is an independent risk factor for systemic disease such as hypertension and diabetes

mellitus, and as the severity of PD increases, the correlation with hypertension also increases.

Chronic kidney disease (CKD) is defined as a low estimated glomerular filtration rate

(eGFR) (eGFR <60mL-min-1-1.73m-2) lasting for more than three months due to renal organ

damage or unknown causes. CKD can be categorized into stages 1-5 according to its severity,

and its prevalence is high. When CKD develops into end-stage renal disease (ESRD), most

patients can only extend their lives through maintenance hemodialysis (MHD) treatment, and its

mortality and complications are significantly higher than those of the average population. “Most

commonly reported symptoms were weakness, decreased urine output, poor appetite…

breathlessness,” (Khan, 2022, p.5). Studied have shown that CKD and chronic PD have some

common risk factors, such as diabetes, hypertension, age, smoking, etc., and both are also one of

the risk factors for cardiovascular disease such as hypertension. In recent years, many studies

have shown that there may also be an interaction between CKD and chronic PD.

How Periodontitis Plays a Role in CKD

“Mechanisms connecting PD with CKD may involve systemic inflammation,” (Kapellas, 2019,

p. 202). Periodontal pathogens and their products enter the blood circulation directly through the

soft tissues of ulcerated periodontal pockets, causing systemic bacteremia, promoting

inflammatory reactions in renal tissues, and causing direct or indirect damage to renal endothelial

cells, glomerular capillaries, interstitial cells of the renal stroma, and glomeruli.

Periodontitis can promote the release of various inflammatory factors IL-1β, IL-6, IL-8, tumor

necrosis factor α (TNF-α), so that the body is in an inflammatory state, causing endothelial

function damage, inflammatory cytokines can also increase the permeability of glomerular

proteins, promote the proliferation of fibroblasts and fibrogenesis. At the same time,
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inflammatory mediators caused by periodontitis will promote renal inflammation through hepatic

activation and production of acute phase proteins leading to endothelial cell injury and increase

the permeability of endothelial cell membranes, altering the filtration ability of glomeruli, and

ultimately causing renal insufficiency.

Periodontal inflammation can cause an increase in advanced glycation end-products and insulin

resistance, which in turn leads to poor glycemic control. Meanwhile, periodontal inflammation

can further alter the glomerular filtration rate by promoting the development of atherosclerosis,

inducing glomerular inflammation, and destroying the integrity of the endothelial cells of the

vasculature, which leads to renal function impairment.

Studies Overlooking the Correlation of PD and CKD

Seven cross sectional studies conducted in Brazil, Canada, Turkey, USA and Taiwan

reported that chronic severe periodontitis was significantly more frequent among HD patients as

compared to normal persons and periodontal disease was comparatively more severe and

prevalent in CKD patients (Souza, 2005). These studies enrolled above 1000 study subjects for a

better comparison among patients and healthy controls. Based on Community periodontal Index

of Treatment needs (CPITN), Borawski et al. (2007) also presented high severity of periodontitis

as compared to healthy population. Using attachment loss as an indicator of periodontitis,

Thorman et al. (2009) reported that HD patients had significantly more attachment loss as

compared to healthy individuals. Studies focusing on the periodontal health of End Stage Renal

disease (ESRD) patients on HD maintenance therapy have reported the presence of poor oral

hygiene and gingival inflammation in study subjects (Chen LP, 2006). However cross-sectional

studies from Spain and Netherland reported that they did not find any significant association

between periodontal disease and CKD in HD patients (Castillo, 2007). They enrolled 105
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patients on HD therapy and compared them with healthy population. Results were not

statistically significant about association of CKD with periodontal disease. These studies are

from developed countries and these results may be due to dental treatment being part of their

routine therapy. It is important to mention that studies reporting higher prevalence examined a

larger number of patients as compared to other studies.

Clinical Trials

Clinical trials of this topic also showed different results. In a clinical trial performed on 352

patients, researcher found an increased severity of periodontitis in HD patients as compared to

normal healthy persons (Souza CR, 2005). On the other hand, Bots CP et al (2006) in a study

from Netherlands of End Stage Renal Disease (ESRD) patients, some of whom were receiving

HD, did not find an increased loss of attachment when compared with some healthy case-

matched controls. Periodontal status of ESRD patients receiving HD showed no increase in

periodontal indices when compared with case-matched controls (Bots CP, 2006). The authors

noticed that the HD group had greater numbers of periodontopathic bacterial species than the

control group (Bots CP, 2006). After adjusting other risk factors, periodontitis was highlighted

as an independent risk factor for CKD in most of the trials..

Effect of CKD on Periodontitis: Studies revealed that CKD affects teeth, oral mucosa,

periodontium, salivary glands, and tongue resulting in a negative effect on the oral health status

of the patient. Many cross-sectional studies as well as clinical trials have been carried out on this

aspect. Increased levels of plaque have been reported for hemodialysis (HD) populations from

several countries including Brazil. The poor oral hygiene and increased level of plaque and

gingival inflammation have been attributed to neglected oral care due to presence of ESRD (Bots

CP, 2006). The ultimate progressive outcome of CKD is end-stage renal disease, characterized
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by uremia. It has been found that dysregulation of the immune system caused by uremia will

increase opportunistic infections and thus chronic infections are prevalent. About 90% of

patients with chronic renal failure have oral abnormalities, and the inflammatory response caused

by CKD also has a serious impact on the oral periodontal tissues. It has been suggested that

CKD is also a risk factor for periodontal disease, aggravating the process.

Studies have found that young CKD patients and untreated children often have significant

periodontal tissue destruction, and that the extent of periodontal lesions is worsened during

continuous dialysis treatment, increasing the susceptibility to periodontal inflammation. 2011

Ioannidou’s group studied 12,081 subjects using the US Healthy Nutrition Examination Survey

database. The results showed that 14.6% of CKD patients developed moderate periodontitis,

significantly higher than the 8.7% in the non-CKD group, and after adjusting for confounders

such as smoking, diabetes, and socio-economic status, the CKD group was also shown to be

more susceptible to periodontitis. Secondly, a dose-response relationship between the

prevalence of periodontitis and the severity of CKD disease stage was found, which has been

confirmed in other studies, Ruospo’s group conducted a systematic retrospective observational

study of CKD patients with different stages of CKD and found that periodontitis had a higher

prevalence and was more likely to occur in patients with end-stage CKD. Ausavarungnirum and

Tadakamadla’s group compared the oral conditions of CKD patients at various stages of the

disease and found that the gingival condition and cavity hygiene affected by renal disease

showed a worsening progression with the progression of severity, and that periodontal lesions

become more severe in the advanced stages of CKD. Garcez’s group found that there was no

significant difference in oral health between patients with preliminary stages of CKD and healthy

controls, which indirectly proves that the periodontal disease is affected by CKD. This also
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indirectly proves that the effect of CKD on periodontal disease is related to the degree of renal

impairment. In 2014 Sharma’s group designed a 10-year cohort study to analyze the relationship

between periodontitis and CKD. The first baseline results found that the prevalence and severity

of chronic periodontitis was significantly higher in CKD patients than in healthy controls. In the

future, possible changes in chronic periodontitis with the progression of CKD will be seen, thus

more accurately exploring the relationship between CKD and periodontitis.

Summary

In summary, there is a correlation between chronic periodontitis and CKD, and the correlation

increases with the severity of periodontitis, chronic periodontitis is one of the potential risk

factors for CKD, and moderate evidence suggests that periodontitis is a risk factor for CKD.

When lesions exist in the periodontal tissues, bacteria, inflammatory factors, and metabolites in

the periodontal pockets may act directly or indirectly to diffuse to the kidneys to play a role or

aggravate renal disease by worsening the systemic micro inflammatory state. However, most of

the available studies have not compared the effects of periodontal therapy on renal function in

CKD patients, and therefore there is not yet sufficient evidence to prove that periodontal therapy

is beneficial to CKD patients, nor can it be decided for which severity of CKD patients'

periodontal therapy is most beneficial. Many well-designed randomized trials are still needed to

further investigate this issue. Although more is known about CKD and better early diagnosis and

treatment is possible, treatment of CKD patients is still difficult and expensive, and CKD stays

one of the leading causes of death worldwide, making it particularly important to treat and

control its risk factors. Chronic periodontitis, as a new and easy-to-control risk factor for CKD, is

simple and inexpensive to treat, and its rational diagnosis and treatment will be of great benefit

to CKD patients and society. If there is conclusive evidence of a relationship between the two,
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periodontal treatment may be considered for inclusion in the standard management program for

CKD patients in the future.

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Kapellas, K., Singh, A., Bertotti, M., Nascimento, G. G., & Jamieson, L. M. (2019). Periodontal

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