Article No. 437
24 May 2021
Oral health is very important for everyone, which stays true even when life gets busy with other things. People whose lives are affected by poor kidney function, dialysis, or a renal transplant certainly have plenty of challenges – but neglect of proper dental care can add a surprising number of additional issues that may impact them for years to come. What’s common for most people, and how might dental issues be a bit different for those with kidney disease such as atypical HUS?
Knowing some basics about teeth and oral care is a good place to start, so here are some interesting general facts: dental records are unique (even with identical twins), teeth reveal clues to your age and overall health, tongues have a distinct pattern (like fingerprints), babies are born with 20 teeth formed in their gums to await their 32 permanent teeth, the average person makes a quart of saliva a day, and that sticky coating (plaque) on your unbrushed teeth contains millions of bacteria, made up of 200 to 300 different species (sources: Healthline and ADA MouthHealthy).
Teeth, like your bones and like the gums that surround your teeth, are living tissue with their own blood supply and nerves. Tooth enamel is a non-living outer layer, one of nature’s hardest materials but one which can experience wear over time. Like the rest of your body, teeth also undergo an aging process. Tooth darkening naturally occurs as people age, an effect where teeth may appear increasingly gray or yellow as the enamel surface wears away to expose the darker dentin layer underneath it.
The phrase ‘long in the tooth’ implies that someone is not aging very well, but that unkind description has a bit of dental truth at its root (pardon our pun) Teeth shift over time, and as one dental practice succinctly noted, “As you age, you lose bone and your gums naturally start to recede, making your teeth appear longer. Although teeth are strong, as gum tissue, ligaments and bone start to weaken, teeth can shift more easily. Bottom teeth tend to shift, sometimes as early as your 20s, and as lower teeth shift, they can push against your upper front teeth when you’re chewing, which can wear away enamel and cause top teeth to push forward.” Gum recession and disease are key considerations in general oral health, but dry mouth (xerostomia) caused by certain medications and illnesses can also increase risk of developing tooth decay.
Let’s delve a bit more into how some of these aspects have special importance for people with kidney disease.
Bacteria & Your Oral Health
The continuous war against bacteria doesn’t stop, which holds true for general oral health and in regard to tooth decay and gum disease. Bacteria in your mouth mixes with sugary or starchy foods, and these bacteria release acids to break down those carbohydrates in food and drink. Brushing your teeth will remove this combination of bacteria, acids and carbohydrates, but a few hours of neglect will cause formation of a furry-feeling, colorless film called plaque. A regular daily routine with toothbrush and dental floss can help prevent plaque from hardening into tartar (which requires removal by a hygienist or other dental professional).
According to an article from the Harvard Health Publishing division of Harvard Medical School, in the general population the occurrence of tooth decay in people over age 65 is now higher than the rate for school aged children. They note, “While sturdy teeth are the stars of a healthy mouth, they can’t perform without a strong supporting cast — the gums and soft, wet tissue that line the oral cavity. Periodontal disease, characterized by receding gums, wobbly teeth, and deterioration of the jawbone, is the primary culprit in tooth loss among older adults. It gets started when plaque builds up in the shallow trough between the tooth and the gum.” As teeth shift position with age, tight spacing or overlaps can make trap bacteria to increase risk for tooth decay and inflammation of oral soft tissues.
Bacteria in the mouth varies with each individual, but people with kidney disease seem to experience higher rates of periodontitis than the general population. According to one nephrology publication (Duan et al, 2020), kidney disease is a risk factor for gum disease as “Chronic kidney disease (CKD) patients, especially those with end stage renal disease (ESRD) undergoing hemodialysis (HD), exhibit high prevalence of periodontitis.” The type and severity of oral health issues may differ for kidney disease patients as opposed to the general public notes Costantinides et al (2018), “Adults with ESRD have more severe oral diseases than the general population, and dental conditions such as caries, periodontitis, and poor oral hygiene are associated with increased mortality.” It’s a serious enough issue to delay kidney transplantation, according to dialysis company Davita, “During workup for a kidney transplant a person will undergo a thorough oral exam. Infections from gum disease or advanced tooth decay can prevent someone from being eligible or delay the transplant until dental work is completed.”
When bacteria forms and causes infection, the body fights back with an immune response to inflammation, notes the National Kidney Foundation, “In short, for battles with infection, inflammation is good because it helps the body kick into defense mode and gear up to kill germs. However, chronic or stubborn infections create continuous inflammation, which is harmful. Dental cavities and gum diseases are chronic bacterial infections. In addition to causing pain, difficulty eating, and mouth odors, dental cavities and gum infections can contribute to other problems by fueling harmful chronic inflammation. Also, germs that cause cavities and gum disease don’t stay put and may spread throughout the body, especially if your immune system is weak.” If you have kidney disease or take a prophylactic antibiotic as part of your medical treatment plan, ask about infection risks and specifically about premedication for dental procedures. For atypical HUS patients, ramping up the immune system to fight infection may trigger disease activity. Since all patients are different, be certain to communicate with your dental provider and discuss concerns or questions during review of your medications and treatment plan.
The Kidney Connection: Gum Disease & Bad Breath
When the bacteria which form sticky plaque builds up, on and around teeth, the soft tissue surrounding teeth (gums) can become inflamed as the bacteria multiply. Brushing, flossing, and cleansing swishes with mouthwash can reduce plaque-forming bacteria and thus help to prevent gum disease (also called periodontal disease). Almost half of all adults 30 years or older have gum disease (ClevandClinic.org), which distinguishes stages as: “Early-stage gum disease (gingivitis) includes swollen, bleeding gums. Some people experience no symptoms. It is reversible with timely treatment.” and “Advanced gum disease (periodontitis) occurs when the gums’ inner layer pulls away from the teeth and forms pockets. Periodontitis is defined by the loss of bone supporting the teeth.”
According to Kidney.org Australia, as kidney function declines, wastes build up in the blood (uremia) which can lead to bad breath, a metal-like taste in your mouth, and loss of appetite as foods change in taste. In addition to dysgeusia (impaired taste) and halitosis (bad breath) issues, people with kidney disease may experience: Dry Mouth (xerostomia, with increased potential for dental decay and gum disease) , Viral infections (secondary to immunosuppression), and Candidal (fungal) infections (secondary to immunosuppression) (source: UK National Kidney Federation). The NKF stated, ““Kidney disease is associated with many dental health complications, including increased risk of periodontal disease, tooth loss, and inflammation of the salivary glands.” For people with an autoimmune disease or those who have had a kidney transplant, it appears to be especially important to practice daily oral hygiene at home and to maintain regular visits to your dental office for expert care and advice.
People on dialysis often have strict fluid intake limits, and may make less saliva, leading to increased risk for gum disease, bad breath, and tooth loss. Saliva does more than keep your mouth moist, it changes the pH balance. By making your mouth more alkaline, teeth are less likely to decay from the acids that form when food breaks down. Saliva has enzymes to break down starchy foods, and also contains minerals which help repair tooth enamel. Saliva is important for these reasons and more, making it vital for healthy teeth and gums – which explains why ‘dry mouth’ isn’t to be considered merely a discomfort. (source, Dialysis & Dental Health: Home Dialysis.org) Talk with your doctor and dialysis provider about risks for tooth loss, gum disease, renal diet, and other issues which might impact your oral health.
It’s all about a Holistic view toward Your Health
According to the 2000 US Surgeon General’s report, Oral Health in America, oral examinations have potential to reveal symptoms and health issues for more than 90% of systemic diseases.
If you have kidney disease, make sure that your dentist is informed about your health status and treatment plans on topics which include: medications, dialysis, central lines or stents, and dry mouth. Sometimes clues such as loose teeth may be a result of calcium imbalance, so providing your dentist with medical information can help determine the cause of dental issues.
Dentists treating kidney patients who have anemia and low platelet counts note these medical concerns may present ‘oral findings’ within the mouth during dental visits. Coagulopathies (impairment of blood clotting ability) and different blood disorders can cause mouth tissue changes, pallor (coloration), or gingival (gum) bleeding. Dental professionals may observe oral manifestations of many systemic diseases and as Gaddey in 2017 noted “Numerous systemic conditions, including some autoimmune, hematologic, endocrine, and neoplastic diseases as well as chronic illnesses, cause pathognomonic changes in the oral cavity”. Atypical HUS is characterized by destruction of red blood cells (causing anemia) and low platelet counts due to tiny clots which impair blood flow in small blood vessels throughout the body’s systems. Whether aHUS is grouped in terminology as an autoimmune, hematologic, or kidney disease it’s clear that patients must be vigilant about oral health as a key part of their wellness practices.
Some kidney diseases involve complement dysregulation, where part of the patient’s immune system doesn’t respond as it normally would to infection and inflammation. On the topic of genetic syndromes and complement deficiencies in diseases, such as atypical HUS, “An immunocompromised host is a patient who does not have the ability to respond normally to an infection because of an impaired or weakened immune system. This inability to fight infection can be caused by a number of conditions, including diseases”. Speaking of the 200 to 300 different species of bacteria, which occur by the millions in the sticky plaque on your unbrushed teeth, people with kidney disease need to be aware of ‘encapsulated’ bacteria which is surrounded by a protective capsule. Sadarangani noted in a 2018 article on invasive infections, “The encapsulated bacteria Streptococcus pneumoniae, Neisseria meningitis, Haemophilus influenzae, and Streptococcus agalactiae (Group B Streptococcus) have been responsible for the majority of severe infections in children for decades, specifically bacteremia and meningitis. Isolates which cause invasive disease are usually surrounded by a polysaccharide capsule, which is a major virulence factor and the key antigen in protective protein-polysaccharide conjugate vaccines. Protection against these bacteria is largely mediated via polysaccharide-specific antibody and complement…” Patients with kidney disease need to be aware of issues regarding infection and inflammation, and to speak with their healthcare team about risk factors and concerns.
In a case study specific to atypical HUS about a Candida bloodstream infection (candidemia) jointly with a fungal infection (mucormycosis) following eculizumab treatment, “There is a known risk of infection by encapsulated organisms with eculizumab, but there is scant data regarding infection by other organisms including invasive fungi.” (Sunseri et al, 2019) An infection may occur in one location of the body, but may have far-ranging effects throughout the body when immune response is triggered. Articles such as this underscore the importance of good oral health and the patients’ role in keeping both medical and dental professionals well informed. Arguably the first steps of the communication process are knowledge and awareness, so at the end of this article we’ve offered a short list of articles to provide additional context and information.
Tell your dental professional if you’re already taking a prophylactic antibiotic prescribed by your medical team, as it is possible that your dentist may prescribe an antibiotic prior to a dental procedure to reduce potential infection risk. If you’re on dialysis or taking a complement inhibitor, ask about whether it’s advisable to schedule dental procedures on an off-treatment day or if there’s a timing element for optimal treatment. Since there is no singly-defined ‘renal diet’, people with kidney disease may wish to consult a nutritionist or their dialysis provider to discuss possible concerns regarding whether (or how) their own dietary needs, diet restrictions, or dialysis treatment may affect dental health. Your body’s systems function together as a unit, rather than in isolation. According to a Reuters news article, medication taken to control high blood pressure (hypertension) may increase your risk for gum disease, and gum disease may cause blood pressure medicines to be less effective.
A holistic view and multidisciplinary approach to patient care is vital, ensuring a proactive approach for optimal medical and dental care. Conversations with physicians and dentists need to include broad topics of health, since health of one body system may affect others and unexpected complications may arise. Include oral health within the balance of overall health goals. At the end of the day, it’s up to you to make time each day to regularly brush and floss – and to maintain a schedule with your dental professional to ensure not simply a beautiful smile but also a healthy mouth that will serve you well throughout all stages of your life.
FMI on these Topics
Gum Disease (Gingivitis, Periodontitis) Keeping an eye on your Gums (Am Dental Assoc., Patient Materials)
Is your mouth always dry? American Dental Assn. A Mark, Oct 2020
Your Aging Teeth – Healthy Women.org
Key Facts about Oral Health – World Dental Federation
Dental Health in Kidney Disease Patients – UK: St George’s Kidney Patients’ Assn
The Dental/Kidney Connection – National Kidney Foundation
For Dental Professionals
Gaddey. Oral manifestations of systemic disease. Academy of General Dentistry & AAFP, pdf 2017.
Ismail et al. Periodontal Disease: A Covert Source of Inflammation in Chronic Kidney Disease Patients Intl Journal of Nephrology. 2013, doi: 10.1155/2013/515796
Riordain et al. Developing a standard set of patient‐centred outcomes for adult oral health – an international, cross‐disciplinary consensus. International Dental Journal. 05 July 2020. doi 10.1111/idj.12604
Did we mention keeping lines of communications open
& engaging in regular discussions with your medical and dental health professionals?