Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study

Abstract

BackgroundPeople with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated.Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required.Methods/designThe ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022.DiscussionThis large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.

Better Oral Hygiene Habits Are Associated With a Lower Incidence of Peritoneal Dialysis‐Related Peritonitis

“…If it is difficult to verify the effectiveness of interventional studies, prospective observational studies can be preferred as a suboptimal solution to strengthen the causal relationship. Accordingly, prospective observational studies, such as ORAL‐D study , that examine the relationship between PD‐related peritonitis and oral disease in addition to oral hygiene habits should be carried out in the future.…”

Dental Health and Mortality in People With End-Stage Kidney Disease Treated With Hemodialysis: A Multinational Cohort Study

“…14 We enrolled participants from July 2010 to February 2012. Patients were not enrolled if they had cognitive impairment sufficient to preclude consent or they preferred not to participate.…”

“…11 Oral disease is associated with inflammation and malnutrition, which may accelerate cardiovascular disease in the setting of dialysis treatment, and therefore represents a putative etiology for cardiovascular events in the context of kidney failure. 12,13 To our knowledge, the Oral Diseases in Hemodialysis (ORAL-D) Study 14 is the first cohort study to investigate whether oral disease using standardized assessments of dental disease and preventative dental health practices are associated with early death independent of existing cardiovascular disease and other sociodemographic factors.…”

Oral manifestations in chronic uremia patients

“…Uratemic stomatitis is basically diagnosed clinically, but it mimics other common pathologies of the oral cavity, and there are few clinical aspects that are useful for its differential diagnosis. 11 To avoid the development of potentially fatal uratemia, uratemic patients soon become dependent on renal function replacement therapy (i.e., dialysis or transplantation). 12 Several studies have proven that the injuries that develop after months or years of uratemic conditions are resistant to local treatments (e.g., antiseptic and antifungal mouthwashes) if the plasma levels of the nitrogenous catabolites are continually elevated; symptom regression is only possible with a reduction in the serum level of urea.…”