Pam Harrison

June 19, 2014

AMSTERDAM — Poor dental health is independently associated with a higher risk for all-cause and cardiovascular mortality in hemodialysis patients with end-stage renal disease (ESRD), new research shows. And good oral hygiene is independently associated with better overall survival.

"Dialysis patients die at an excessive rate, compared with the general population," said Giovanni Strippoli, MD, PhD, senior vice president of scientific affairs and chair of the Diaverum Academy in Sweden.

"Basically, no drug seems to work that well for them, so we have to look at other potentially treatable factors," he told Medscape Medical News.

"Our general finding was that dialysis patients who had either no teeth or bad teeth had a higher risk of all-cause mortality than those who did not, and the adjusted risk of cardiovascular mortality followed a similar pattern," he explained.

Dr. Strippoli presented findings from the Oral Diseases in Hemodialysis (ORAL-D) study here at the European Renal Association-European Dialysis and Transplant Association 51st Congress.

ORAL-D Study

The prospective cohort study involved 4320 adults with ESRD randomly selected from European outpatient dialysis clinics administered by Diaverum, a kidney services provider.

At baseline, dental surgeons with training in periodontology and oral diseases assessed the oral health of all participants. Oral hygiene habits were evaluated using self-administered questionnaires.

Total and cause-specific data for hospitalizations and mortality were analyzed.

At a median follow-up of 22.1 months, 650 participants had died from any cause and 325 had died from a cardiovascular event.

For the 23% of the subjects with no teeth, the hazard ratio for all-cause mortality, after adjustment for multiple potential confounders, was 1.27.

For the subjects with more than 14 decayed, missing, or filled teeth, the hazard ratio for all-cause mortality was 1.46.

Patients with good dental hygiene had better overall survival.

Table. Survival Advantage in Patients With Teeth

Dental Hygiene Behavior Hazard Ratio
Brushing teeth 0.74
Flossing 0.49
Changing toothbrush at least every 3 months 0.79
Spending ≥2 min/day on oral hygiene 0.81


"When you go into dialysis clinics, you see that patients have terrible teeth, among other conditions," said Dr. Strippoli. "One day, I thought, why don't we look into this, because the association between dental health in ESRD patients and mortality was unknown," he explained.

In a recent meta-analysis of ESRD patients, Dr. Strippoli's team found that one-quarter of patients never brushed their teeth, and only a minority ever flossed (Nephrol Dial Transplant. 2014;29:364-375). This might explain why oral disease is more severe in dialysis patients than in the population overall.

The association between poor dental health and increased mortality risk suggests that improved oral hygiene would improve survival in ESRD patients, Dr. Strippoli said, and it certainly couldn't do any harm.

This is a "simple but important observation," said Lynda Anne Szczech, MD, from Durham Nephrology Associates in North Carolina.

ORAL-D confirms findings from a previous study of ESRD patients (Kidney Int. 2009;75:746-751). Those researchers found a significant association between moderate to severe periodontal disease and cardiovascular mortality, she reported.

"Inflammation is a powerful force that we are just beginning to recognize," Dr. Szczech told Medscape Medical News.

"The key is knowledge and action," she said. "And the role of good dental health in people with normal or abnormal kidney function is such an 'actionable' area."

Proper randomized trials are still needed, said Massimo Petruzzi, DDS, PhD, assistant professor of dentistry at the University of Bari in Italy. Nevertheless, this study "certainly strongly suggests that dental care should be provided for hemodialysis patients," he added.

The study was funded by Diaverum. Dr. Strippoli, Dr. Szczech, and Dr. Petruzzi have disclosed no relevant financial relationships.

European Renal Association-European Dialysis and Transplant Association (ERA-EDTA) 51st Congress: Abstract 4054. Presented June 1, 2014.


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