Assessment of the oral health status of children with chronic kidney disease

Oral health status in children with chronic kidney disease, kidney transplantation, and nephrotic syndrome: a cross-sectional study

INTRODUCTION

Chronic kidney disease (CKD) has been previously associated with a decline in oral health. This study aimed to examine the oral health of children with CKD, nephrotic syndrome (NS), and children that received kidney transplantation (KTR).

METHODS

A case-control study was conducted involving children with CKD stages 1-3, children with CKD stages 4-5, pediatric kidney transplant recipients, and children with NS. Developmental Defects of Enamel (DDE) were evaluated using the DDE Index, while dental caries was assessed with the Decayed Missing Filled Teeth Index (DMFT). Plaque and debris were measured utilizing the Simplified Oral Hygiene Index (OHI-S), which includes the two subindices Simplified Calculus Index (CI-S) and Simplified Debris Index (DI-S).

RESULTS

Children with CKD 1-3, CKD 4-5, and KTR presented with significantly higher DI-S and CI-S scores and significantly more DDE. There was no difference in the DMFT score in children with CKD 4-5 and KTR. For children with CKD 1-3, a significantly lower DMFT score was observed compared to the control group. Children with NS did not show any differences for DI-S, CI-S, DMFT, and DDE compared to healthy peers.

CONCLUSION

Oral health status is not affected in children with NS. Children with CKD 1-3, CKD 4-5, and KTR have more plaque, debris, and DDE and should be surveyed regularly by their dentists.

A Causal Association Study Between Chronic Kidney Disease and Oral Health: A Mendelian Randomization Study

Background and Aims

Previous studies have shown that chronic kidney disease (CKD) can lead to changes in oral health, but the conclusions remain controversial. Thus, we conducted a Mendelian randomization (MR) study from the perspective of genetic analysis to assess the causal association between CKD and oral health conditions, including dental caries, pulp diseases, periapical tissues, and diseases of the gum and periodontal tissues.

Methods

We performed inverse variance weighted (IVW) random effects MR analyses and several sensitivity MR analyses using summary statistics from genome-wide association studies (GWAS). The data were derived from the European population in 2021, which included 3902 cases of CKD, 4170 cases of dental caries, 5354 cases of diseases of the pulp and periapical tissues, and 4120 cases of gingivitis and periodontal diseases.

Results

We found a positive causal relationship between CKD and dental caries, and the effect odds ratio (OR) of CKD on dental caries was 1.368 (95% CI, 1.124-1.664; p = 0.002). There was no direct causal relationship between CKD and diseases of the pulp and periapical tissues and diseases of the gum and periodontal tissues, with the effect OR of 1.176 (95% CI, 0.973-1.420; p = 0.094) and 1.201 (95% CI, 0.977-1.477; p = 0.08).

Conclusions

Our findings suggest that CKD could affect oral health and only with a direct causal link to dental caries. However, pulp diseases, periapical tissues, and diseases of the gum and periodontal tissues have no direct causal relationship.

Perspectives on Matrix Metalloproteinase-8 and Salivary Osteoprotegerin in Orthodontic Strategy in Children with Chronic Kidney Disease

Background/Objectives: This study aimed to establish the regularities of changes in the content of matrix metalloproteinase 8 (MMP-8) and osteoprotegerin (OPG), the most well-known indicators of bone metabolism disorders, in the saliva of children with different severities of chronic kidney disease (CKD) who need orthodontic treatment. Methods: The study of MMP-8 and OPG content in saliva was carried out in 76 children in need of orthodontic treatment, who were divided into equal groups (G) of 19 people: G1-children with congenital malformations of the urinary tract, acquired renal pathology, and CKD stage 1 and 2, receiving medical therapy, as well as more having a deep distal bite formed by mandibular micrognathia; G2-children with a terminal stage of CKD, receiving renal replacement therapy in the volume of hemodialysis, with a characteristic distal bite of different etiology; G3-children one year after kidney transplantation, with a tendency to form an open distal bite, associated to a greater extent with maxillary macrognathia. G4-practically healthy children without renal pathology stratified by sex and age. Results: It was found that the content of MMP-8 and OPG in the saliva of children with different CKD stages who needed orthodontic treatment was significantly higher than the G4. The maximum values of MMP-8 were registered in G2. An increase in OPG content in saliva was observed in the G1 and G3. Conclusions: The identified changes in markers of mineral and bone disorders in the saliva of children with different stages of CKD show the possibility of their use as non-invasive predictive and prognostic markers for the diagnosis of preclinical stages of bone metabolic disorders.

Interplay between periodontitis and chronic kidney disease

Periodontitis is a ubiquitous chronic inflammatory disease affecting the supporting tissues of the teeth and is a major cause of multiple tooth loss. Despite being preventable, periodontitis and dental caries are responsible for more years lost to disability than any other human condition. The most severe form of periodontitis affects 1 billion individuals, and its prevalence is increasing globally. Periodontitis arises from a dysregulated and hyperactive inflammatory response to dysbiosis in the periodontal microbiome. This response has systemic effects associated with premature mortality and elevated risk of several systemic non-communicable diseases (NCDs), including atheromatous cardiovascular disease, type 2 diabetes and chronic kidney disease (CKD). This risk association between periodontitis and NCDs is independent of their shared common risk factors, suggesting that periodontitis is a non-traditional risk factor for NCDs such as CKD. As periodontitis progresses, the immune cells and mediators underpinning its pathophysiology leak into the systemic circulation through the ulcerated oral mucosal lining, inducing in a systemic inflammatory profile that closely mirrors that observed in patients with CKD. The relationship between periodontitis and CKD seems to be bi-directional, but large-scale intervention studies are required to clarify causality and could lead to new care pathways for managing each condition as an exposure for the other.

Dental caries, oral hygiene and salivary characteristics in children with chronic kidney disease: a case-control study

BACKGROUND

The aim of this study was to compare the oral health findings and salivary parameters of children with different stages of chronic kidney disease (CKD) with those of healthy peers.

METHODS

Intraoral examinations were performed on 43 children aged 8-17 years with CKD and 40 healthy controls from the same pediatric nephrology clinic. Oral health was assessed using the DMFT/dft indices (decayed-missing-filled-teeth), debris index (DI), calculus index (CI), and simplified oral hygiene index (OHI-S). Saliva samples from the children were analyzed for salivary flow rate (SFR), pH, buffering capacity (BC), total oxidant status (TOS), total antioxidant capacity (TAOC), urea, creatinine (Cr), calcium (Ca), potassium (K), phosphorus (P), and salivary α-amylase (SAA). Spearman's rho coefficient was used to examine the relationship between salivary and serum biomarkers levels and oral health findings.

RESULTS

While the DMFT/dft scores were lower in children with CKD (p = 0.001), DI, CI, and OHI-S scores were higher in healthy peers (p < 0.001). Children with CKD had lower SFR, Ca, and TAOC levels, and higher BC, pH, urea, Cr, K, P, TOS, and SAA levels (p < 0.001) compared to healthy controls. Later stages of CKD was associated with the lower dft ( r s = - 0.35; p = 0.022).

CONCLUSIONS

Children with CKD exhibit fewer caries and poorer oral hygiene compared to their healthy peers, and their saliva characteristics differ significantly from those of the healthy group. Disease-related changes in serum and salivary characteristics affect the oral health of children with CKD, necessitating collaboration between pediatric nephrologists and dentists.

TRIAL REGISTRATION

ClinicalTrials.gov (NCT06578832).

Oral Health in Children with Chronic Kidney Disease, Hemodialysis, and Renal Transplantation: A Comprehensive Narrative Review of the Oral Manifestations and Dental Implications

Chronic kidney disease (CKD) in children presents multifaceted challenges, impacting various aspects of health, including oral health. This narrative review provides a comprehensive synthesis of literature focusing on the oral health status of pediatric CKD patients, encompassing oral manifestations, dental considerations, and management challenges associated with hemodialysis and kidney transplantation. A comprehensive search strategy was employed, utilizing databases such as PubMed, Scopus, Web of Science, and Google Scholar, to identify relevant literature on oral manifestations in children with CKD, including those undergoing hemodialysis or renal transplantation. Search terms were carefully selected to capture studies examining enamel hypoplasia, dental caries, delayed tooth eruption, gingival diseases, periodontal diseases, radiographic alterations, craniofacial development, dry mouth, and changes in the oral mucosa. Our narrative review meticulously selected articles through a systematic process. Ultimately, 12 studies meeting the inclusion criteria were included in the review. Relevant data from each included study were independently extracted and synthesized, focusing on oral manifestations and their implications in pediatric CKD patients. The synthesized findings were organized and presented in a structured manner within the review article, considering their clinical implications and informing recommendations for dental management of children with CKD. This article highlights the importance of a coordinated effort between nephrologists, dentists, and other healthcare professionals in providing holistic care for pediatric CKD patients. A comprehensive understanding of the oral health status of these children, along with proactive dental management strategies, contributes to improved overall health outcomes and a better quality of life. This review aims to serve as a valuable resource for the oral healthcare providers involved in the care of pediatric CKD patients.

Evaluation of UK paediatric nephrology teams' understanding, experience and perceptions of oral health outcomes and accessibility to dental care: a mixed-methods study

BACKGROUND

Oral health conditions are common in children and young people (CYP) with kidney disorders. There is currently limited literature on how confident paediatric nephrology teams feel to identify and manage oral health concerns for their patients.

METHOD

An exploratory mixed-method survey was distributed across all 13 UK specialist paediatric nephrology centres with responses received from consultants, registrars, specialist nurses and special interest (SPIN) paediatricians.

RESULTS

Responses received from 109 multidisciplinary team members of 13/13 (100%) UK tertiary units. Ninety-two percent (n = 100) of respondents reported they had never received any training in oral health and 87% (n = 95) felt that further training would be beneficial to optimise care for patients and improve communication between medical and dental teams. Most respondents reported that they did not regularly examine, or enquire about, their patients' oral health. Only 16% (n = 17) reported that all their paediatric kidney transplant recipients underwent routine dental assessment prior to transplant listing. Severe adverse oral health outcomes were rarely reported and only 11% (n = 12) of respondents recalled having a patient who had a kidney transplant delayed or refused due to concerns about oral infection. Seventy-eight percent (n = 85) felt that joint working with a dental team would benefit patients at their unit; however, 17% (n = 18) felt that current infrastructure does not currently support effective joint working.

CONCLUSIONS

Across the UK, paediatric kidney health professionals report lack of confidence and training in oral health. Upskilling subspecialty teams and creating dental referral pathways are recommended to maximise oral health outcomes for CYP with kidney diseases.

The association between dental caries and steroid-sensitive nephrotic syndrome in children

BACKGROUND

Pathogenesis and relapse of steroid-sensitive nephrotic syndrome (SSNS) are primarily associated with infection. Dental caries is the most common chronic progressive oral infection in children. However, clinical studies of SSNS combined with dental caries in children are rare.

METHODS

In our retrospective cohort study from January 2021 to June 2022, 145 children with SSNS were included in the baseline analysis and 105 in the follow-up analysis. The follow-up period was 1 year. The primary study endpoints were the relapse-free period and frequently relapsing nephrotic syndrome (FRNS). Secondary endpoints included the number and triggers of relapses and concomitant medications.

RESULTS

The median age was 5.5 years, with a caries rate of 60.7%, the mean DMFT/dmft was 3.86, and the caries filling rate was 1.6%. Except for the lower proportion of high household income and high parental education observed in the caries group, no statistical differences were found when comparing the other baseline data with the non-caries group. The caries group had a shorter relapse-free period and a lower 1-year cumulative relapse-free survival rate (HR = 1.90, 95% CI 1.17-3.09, P = 0.009). Univariate regression analysis showed caries associated with FRNS (OR = 2.714, 95% CI 1.021-7.219, P = 0.045), but the correlation no longer remained in the multivariate analysis. Additionally, seven cases of caries-derived pulpal periapical inflammation triggered SSNS relapses. The caries group had more infection triggers and concomitant medication use.

CONCLUSION

Dental caries and relapse of SSNS are potentially associated, but careful evaluation is needed.

Dentoalveolar Alterations in an Adenine-Induced Chronic Kidney Disease Mouse Model

Chronic kidney disease (CKD) is characterized by kidney damage and loss of renal function. CKD mineral and bone disorder (CKD-MBD) describes the dysregulation of mineral homeostasis, including hyperphosphatemia and elevated parathyroid hormone (PTH) secretion, skeletal abnormalities, and vascular calcification. CKD-MBD impacts the oral cavity, with effects including salivary gland dysfunction, enamel hypoplasia and damage, increased dentin formation, decreased pulp volume, pulp calcifications, and altered jaw bones, contributing to clinical manifestations of periodontal disease and tooth loss. Underlying mechanisms are not fully understood, and CKD mouse models commonly require invasive procedures with high rates of infection and mortality. We aimed to characterize the dentoalveolar effects of an adenine diet (AD)-induced CKD (AD-CKD) mouse model. Eight-week-old C57BL/6J mice were provided either a normal phosphorus diet control (CTR) or adenine and high-phosphorus diet CKD to induce kidney failure. Mice were euthanized at 15 weeks old, and mandibles were collected for micro-computed tomography and histology. CKD mice exhibited kidney failure, hyperphosphatemia, and hyperparathyroidism in association with porous cortical bone in femurs. CKD mice showed a 30% decrease in molar enamel volume compared to CTR mice. Enamel wear was associated with reduced ductal components, ectopic calcifications, and altered osteopontin (OPN) deposition in submandibular salivary glands of CKD mice. Molar cusps in CKD mice were flattened, exposing dentin. Molar dentin/cementum volume increased 7% in CKD mice and pulp volume decreased. Histology revealed excessive reactionary dentin and altered pulp-dentin extracellular matrix proteins, including increased OPN. Mandibular bone volume fraction decreased 12% and bone mineral density decreased 9% in CKD versus CTR mice. Alveolar bone in CKD mice exhibited increased tissue-nonspecific alkaline phosphatase localization, OPN deposition, and greater osteoclast numbers. AD-CKD recapitulated key aspects reported in CKD patients and revealed new insights into CKD-associated oral defects. This model has potential for studying mechanisms of dentoalveolar defects or therapeutic interventions. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).

Association between serum biomarkers and oral health status in children with chronic kidney disease: A cross-sectional study

OBJECTIVES

The aim of this study was to investigate the association between serum biomarkers and oral health parameters in children with chronic kidney disease (CKD).

MATERIALS AND METHODS

Serum hemoglobin, blood urea nitrogen, serum creatinine, calcium, parathormone, magnesium, and phosphorus levels were measured in 62 children with CKD aged between 4 and 17 years. Intraoral examinations of the patients were performed by two different pediatric dentists. Dental caries was assessed using the decayed-missing-filled-teeth (DMFT/dmft) indexes, and oral hygiene was assessed using the debris (DI), calculus (CI), and simplified oral hygiene (OHI-S) indexes. Spearman's rho coefficient and generalized linear modeling were used to examine the association between serum biomarkers and oral health parameters.

RESULTS

The results of the study showed that there were negative and statistically significant correlations between serum hemoglobin and creatinine levels and dmft scores in pediatric patients with CKD (p = 0.021 and p = 0.019, respectively). Furthermore, blood urea nitrogen levels and DI and OHI-S scores (p = 0.047 and p = 0.050, respectively); serum creatinine levels and DI, CI, and OHI-S scores (p = 0.005, p = 0.047, p = 0.043, respectively); and parathormone levels and CI and OHI-S scores (p = 0.001 and p = 0.017, respectively) were found to be positively and statistically significantly related.

CONCLUSIONS

There are associations between various serum biomarker levels and dental caries and oral hygiene parameters in pediatric patients with CKD.

CLINICAL RELEVANCE

The impact of changes in serum biomarkers on oral and dental health is important for dentists' and medical professionals' approaches to patients' oral and systemic health.