Hemodialysis patients need extra TLC

Good periodontal care is important for everyone, but it can be especially critical to the health of hemodialysis patients. Recent research shows that periodontitis is prevalent and severe in these patients, possibly increasing their risk of heart attacks and strokes.

At the same time, the condition of their kidneys poses challenges when it comes to maintaining their oral health.

So when should an oral health professional consult with the patient's nephrologist? "As soon as the patient walks in and says, 'I'm on renal dialysis'," said Ronald Craig, DMD, PhD, of the New York University Department of Periodontology, and co-author of a paper in the October Compendium of Continuing Education in Dentistry (Vol. 30:8, pp. 546-552). "I'd immediately contact the patient's physician of record and their nephrologist. These folks are very medically complex."

And they're showing up with increasing frequency in the offices of oral health providers. There has been a dramatic increase in patients with end-stage renal disease (ESRD) compared to a decade ago, particularly among elderly patients. According to the 2009 U.S. Renal Data System Annual Data Report, there has been a 24% to 28% increase in ESRD patients among Americans older than age 65 in the last decade, with an increased prevalence in those older than 75.

Taking precautions

ESRD patients have less than 15% kidney function, requiring either dialysis or a kidney transplant to survive. In 2006, 328,000 Americans were receiving hemodialysis. Dialysis removes waste products and water from the bloodstream that would usually be removed by filtration through the kidneys.

Hemodialysis poses several potential challenges for dental care. Hemodialysis patients have a surgically created access site, often a surgically created fistula between an artery and a vein (A-V fistula or A-V graft or "shunt") that is accessed at the time of dialysis, traditionally performed three times a week for four hours at a time. Heparin, an anticoagulant, is used during this process to keep the blood from clotting.

Dr. Craig warns that the access site should be identified before any procedures, even before taking a blood pressure or leaning on a patient's arm during a procedure, to make sure that these fragile sites are not impinged upon.

These sites also get infected easily, so Dr. Craig recommends antibiotic prophylaxis for any procedures that could introduce bacteria into the bloodstream, such as periodontal probing, root planing, and periodontal surgery.

"Sometimes patients don't tell you where their access site is, and once you lose a shunt, it's very difficult to create another one," he said.

In addition to removing wastes and water from the bloodstream in the form of urine, the kidneys also produce hormones that regulate blood pressure, red blood cell production, and bone mineralization. As a result, clinicians need to be aware that patients with ESRD can have anemia, very high or very low blood pressure, and decreased bone density.

And because of the heparin used in hemodialysis, the clinician also needs to be aware of bleeding times and when the patient last had dialysis. Dental procedures, particularly extractions or other invasive procedures, should generally not be done on the day of dialysis.

The Renal Research Institute advises withholding heparin if there is an invasive procedure scheduled within 24 hours of the end of the dialysis session, said Peter Kotanko, MD, research laboratory director for the institute and co-author of the Compendium article. He notes that there is variability in the practice, however, and that some nephrologists put the limit at 12 hours, depending upon the procedure and the coagulation status of the patient.

Medication and hygiene help

Pain medication poses another set of challenges.

"Some pain medications are more likely to cause side effects in dialysis patients than in patients with normal kidney function," said Stephen Gluck, MD, a nephrologist at the University of California, San Francisco.

Demerol should not be used at all, he said, and even acetaminophen with codeine and Vicodin can sometimes cause delirium in hemodialysis patients. Codeine is more likely to do that than hydrocodone (which is in Vicodin), said Dr. Gluck, "because metabolites usually excreted by the kidney are retained in dialysis patients."

Both Dr. Gluck and Dr. Craig note an increased prevalence and severity of periodontal disease in the hemodialysis population, a population already at higher risk of infection. In fact, chronic renal failure can lead to gingival enlargement, xerostomia, alterations in salivary composition and flow rate, adverse effects related to drug therapy, mucosal lesions, oral malignancies, oral infections, dental anomalies, and bone lesions, according to Esra Guzeldemir, DDS, PhD, et al, in the October Journal of the American Dental Association (Vol. 140:10, pp. 1283-1293)

Dr. Guzeldemir and his co-authors also found that oral care was not a high priority for the hemodialysis patients in their study, even though the patients reported a high incidence of functional, psychological, and behavioral impacts related to their periodontal disease.

The authors recommend using subjective oral health assessment tools to determine patients' priorities and involve them in their own treatment. "Oral hygiene is unsatisfactory and the oral hygiene motivation is very weak," Dr. Guzeldemir noted in an e-mail to Dr. Bicuspid.com. "Studies showed increased plaque and calculus levels. These patients do not spend much time taking care of themselves."

Improving appetite

It is also common for hemodialysis patients to have mouth discomfort or mouth pain. In the Guzeldemir study, 90.8% of the participants reported having bad appetites, and 72.1% of these stated the reason as having pain in their mouths.

Because of the dietary restrictions on hemodialysis patients, 93% of participants reported their diet as unsatisfying. Many patients are on fluid restrictions, exacerbating discomfort in the mouth. Periodontal treatment may improve some of this discomfort, according to Dr. Gluck.

"Periodontal disease can cause a bitter taste more in dialysis patients because the bacteria that grow in periodontal disease break down urea in the mouth, which is in high concentrations in dialysis patients," he said. "Also, some of the bacteria can actually cause ulcerations in the mouth." If patients are having problems with food not tasting good, or a bitter taste in the mouth, they may need a teeth cleaning or have periodontal disease, he added.

Fungal infections can also be a problem. Not only do generalized fungal infections contribute to the morbidity and mortality of hemodialysis patients, but oral fungal infections are more prevalent in this population (Scandinavian Journal of Urology and Nephrology, April 2009, Vol. 43:4, pp. 325-330).

Oral/systemic link

The link between periodontal disease and cardiovascular disease is also critical in hemodialysis patients. "Half of the folks who die each year on hemodialysis die from heart attacks and strokes, complications of atherosclerosis," Dr. Craig said. "And you can predict the people who are going to die because certain laboratory markers start to increase. Things like C-reactive protein, albumin, those kinds of markers start to change, and one of the things associated with serum inflammation is periodontal disease."

Dr. Craig would like to see more research about the reversibility of these inflammatory markers with good periodontal care, particularly in hemodialysis patients.

But in order to decrease the implications of poor oral health upon these patients' physical health and quality of life, they need to be motivated.

"The clinician has to spare enough time not only to treat them but also educate them and their families for consequences of oral diseases on their general health," Dr. Guzeldemir said.