How to help your patients overcome dental phobia

Every dentist experiences this on an almost daily basis – the terrified patient who cannot relax, no matter how well you explain that you’re not in the torture business. It’s a problem that knows no borders. Researchers in Jaipur, India, studied the fear and annoyance that the sound of dental drills causes in patients. A study of Brazilian women tied their anxiety level to socioeconomic factors. Dentists in Turkey, Singapore, and the U.K. have all tried to determine what clothing will be most comforting to their pediatric patients.

So how can we best soothe nervous patients? Let’s take a closer look at the problem and some possible solutions.



Understanding dental phobias

At the most basic level, letting a stranger put his or her fingers in one’s mouth does not come naturally. It goes against our survival mechanisms to allow access to sensitive gums and vulnerable airways. But people also suffer from more specific types of dentist-related fears, called dentophobia or odontophobia. Some patients are afraid of needles, while the drill freaks out others. They might also fear gagging and choking, or pain.

If patients confide in you about their anxiety – which will probably be all too apparent to you anyway – take a moment to try to understand what they’re afraid of. This will help you figure out the best way to help your patients cope. Many will feel more relaxed simply because you care enough to ask. This will make you seem more human, and less like somebody who graduated from dental school just to get some sadistic jollies.

Appearance

What to wear can be tricky, especially if you see patients of all ages. Studies of what attire puts children at ease have had mixed and surprising results. In a study in Singapore published in a 2014 issue of the European Archives of Pediatric Dentistry, both children and parents preferred that dentist wear personal protective equipment. The Singaporean children and those in a U.K. study favored informally dressed dentists, while children in a Turkish study chose formal.

Gender and ethnicity also play a part in patient comfort. The children in the Singapore study preferred dentists of their own gender and ethnicity. Parents chose young female dentists of the same ethnicity. The U.K. study also found that children were more comfortable with a dentist of their own gender.

While you can’t do much about your ethnicity and gender, you can tailor your clothing to your clientele. These studies also suggest that having both male and female dentists on staff could be good for business.

Encourage parents to be good dental role models

With all the things going against us in our efforts to calm patients – pain, noisy drills, needles – the last thing we need is for parents to pass their dental fears on to their children. But this fear was probably passed down to them from their parents, and down the line, back to when their forefathers had one relative designated as the “family tooth puller.” Now that was painful!

So how do we raise fearless – or at least less fearful – little patients? Inform new parents about the importance of starting dental care early. Encourage them to try hard not to share their dental fears with their children. A Spanish study published in a 2014 issue of the International Journal of Paediatric Dentistry found that fathers’ fears of dentistry had an especially strong impact on children.

Promote self care

Practice helping your patients help themselves. Reassure them that all they need to do is give you a signal if they need more Novocain. Encourage your patients to close their eyes, put on headphones, and listen to whatever music calms them. Tell them to go ahead and zone out; you’ll squeeze their hand if you need to get their attention.

If new patients call to schedule appointments but seem to have severe dental phobia, have your staff invite them in for a scaled back getting-to-know-you appointment. Develop rapport, and they may become regular patients. Either way, by helping patients overcome their fears, you’ll have done your part for the greater good of humanity – or at least for humanity’s dental health.



Source: http://www.dentistryiq.com/articles/2014/07/how-to-help-your-patients-overcome-dental-phobia.html



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Blood, Guilt, and the Roots of Dental Dread

In his foundational 1728 text Le Chirurgien Dentiste (roughly, “The surgical dentist”), Pierre Fauchard laid out a lot of the basis for modern dentistry, including dispelling the persistent belief that cavities were caused by worms (he rightly fingered sugar as a significant factor) and demonstrating that you could affect the growth and alignment of teeth with wire braces (it wasn’t widely accepted at the time that teeth had roots, much less malleable ones).



More than just a technician, though, he also had a host of recommendations for dealing with patients, who tended to be somewhat nervous in the clutches of relatively primitive dentists, who were often as not either barbers (which at the time was essentially a surgeon with a specialization in removing problem areas from people) or charlatans. Probably his biggest piece of advice was that patients should be laid on a raised platform, with an overhead light and the dentist standing or sitting behind them to work. It was a fairly serious improvement over the accepted practice of lying on the floor with the dentist sitting on your chest, your head between his knees, useful as that was for the relatively common practice of tooth removal.



Like most of his recommendations, though, easing the nerves of patients was also considerably ahead of its time. Among professionals, even professionals whose job it is to repair and align our endlessly decaying bodies, no one engenders fear quite like dentists. By some estimates, as much as 75 percent of the population has at least a mild discomfort about dentists; somewhere between 20 and 25 percent have severe enough anxiety that they need to be lightly drugged to make it through a session; anywhere between five and ten have such a paralyzing fear they avoid dental care at all costs, which pretty much means neglecting to go in until and unless their teeth hurt so much they can’t even get through their day. I, for instance, fall into the category of people who will occasionally show up if they’re promised drugs, but I suffered through more than a year of wisdom tooth eruption with some help from Anbesol, a baby’s teething ring, and a fastidious recycling of reminder postcards, in the belief that they wouldn’t try to remove them once they had grown in.



We tend to think of our teeth as mostly a cosmetic concern, and that’s a not inconsequential aspect of dentistry: on forums devoted to dental phobia, you will occasionally encounter people who dismiss dentists as arms of the personal-hygiene-industrial complex, i.e. just another person trying to shame you into buying something to cover up your hideous, smelly, unattractive body. But inadequate dental care can actually have some semi-serious consequences, from your more obvious risks like oral cancer and jaw problems, to links to inflammatory diseases of the body (most notably arthritis), and a still-under-debate correlation with heart disease: dentists will point out studies have shown that people with gum disease are almost twice as likely to have problems with their coronary arteries, whereas heart associations suggest that the connection might just be a coincidence and tell you to exercise.



Not that any further complications are particularly convincing to people who see tooth scrapers as medieval instruments of torture. Of course, most dental tools are Enlightenment-era instruments of torture at absolute worst (Fauchard all but bragged about borrowing tools from jewellers and watch-makers), although the official history pushed by most dental professional organizations almost inevitably includes some reference to Hammurabi’s Code, the ancient Babylonian system of law, which included tooth extraction as a form of punishment. They also frequently mention Saint Apollonia, the patron saint of dentistry, a Christian martyr whose punishment supposedly involved having every last one of her teeth violently removed, although some of them might have just been shattered while they were still in her mouth. So that lesson about assuaging patients’ nerves may not have entirely sunk in.



Most people’s fears have less to do with the cultural history of dentistry, though, than their own personal history. Sometimes that just means they’ve seen Marathon Man (I’m told the dental torture scene is quite gruesome, but I’m pretty much incapable of watching past the shot of the dental instruments), but usually it has to do with a bad experience in their past. Occasionally that means a botched procedure of some kind—true to the fascination of fear, people supposedly terrified of dentists can and do recount these experiences at some length while explaining their current discomfort, though you’re on your own if want more specifics—but shame tends to be just as powerful a progenitor of dread. Phobics are not the most fabulously reliable self-reporters, but studies have suggested that up to half of even serious phobics, and more among the merely uncomfortable, have experienced nothing more traumatic than a dentist being a weapons-grade dick about how often they floss.



This is actually kind of a double-edged sword for dentists, insomuch as the longer you go without professional care, generally, the worse things get, and attempts to correct the behaviour can often just inflame the insecurity and fear. There are ways of getting you into the chair—most dentists are happy to provide either laughing gas or anti-anxiety medication, and some even specialize in just knocking you right out even for routine cleanings—but there isn’t really a way to make you floss regularly or show up ever again (at least if you’re only a dentist: cognitive behavioural therapy has been shown to be fairly effective, but even getting started on that tends to require a first visit, so you can see how this is something of a whirlpool).



About the only saving grace to any of this is that, on the whole, people’s fear of dentists tends to decrease while they age. Although, going back to that shame thing, children are as a group less afraid of the dentist than middle-aged adults; it’s only once you start to reach retirement age that your fears begin to lessen. This is generally attributed to successful outside intervention, and the fact that repeated exposure reveals that dentists (especially ones who know you’re nervous) aren’t really the inhuman monsters of phobics’ nightmares, but it behooves the phobic in me to also point out that no one really judges seniors for having entirely false teeth.



Source: http://www.randomhouse.ca/hazlitt/blog/blood-guilt-and-roots-dental-dread



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California Removes Outdated Mental Health Terms From Laws

SACRAMENTO (AP) Governor Jerry Brown has signed a bill that deletes from most California laws outdated terms once used to describe mental health conditions.



AB1847 by Democratic Assemblyman Wesley Chesbro of Arcata replaces references to insane, mentally disordered or defective persons with references to mental health disorders, intellectual disability or developmental disability.



Chesbro says using such outdated terms increases the stigma against people who suffer from mental health issues and puts the focus on the disability rather than the person. Previous legislation already replaced references to imbeciles and lunatics in state laws.



The legislation that Brown announced signing Friday does not apply to penal codes used in legal proceedings. Terms such as insane have specific meanings in criminal law and are used in determining sentences.



Source: http://blogs.kqed.org/newsfix/2014/07/18/california-law-mental-health-terms



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Eating habits of the nation worrying oral health charity

A new look into the nation’s dietary habits has left an oral health charity calling for people to think about the impact their diet can have on their oral health.



The call comes as the findings showed almost three in four ignore the impact diet could have on their oral health when consuming food and drink, with men ranked as the worst offenders.



The results also appeared to suggest nearly a third are unaware of the relationship between diet and oral health, and are oblivious as to the potential damage sugary foods and drinks can cause.



Chief Executive of the British Dental Health Foundation, Dr Nigel Carter OBE, is concerned about the lack of education surrounding diet and oral health and says it is important that people take more responsible with the food and drink they consume while encouraging healthy eating habits, especially in children of a younger age.



Dr Carter says: “Most of us know and understand how various foods and drinks affect our body and overall health but many remain unaware that diet also plays a vital role in oral health. Poor diet contributes to a variety of problems in the mouth including dental decay, erosion and bad breath.



“Every time we eat or drink anything sugary, teeth are under attack for up to one hour. Saliva plays a major role in neutralising acid in the mouth, and it takes up to an hour for that to happen. If sweetened foods and drinks are constantly being eaten, the mouth is constantly under attack and does not get the chance to recover. That is why one of our key messages is to cut down on how often you have sugary foods and drinks.



“Frequent consumption of sugary foods and drinks naturally weakens the enamel on the teeth, and as a result we recommend eating three square meals a day instead of having seven to ten ‘snack attacks'.”



The UK in general has developed a very unhealthy food environment, with more than 60 per cent of adults classed as overweight or obese. This is contributing to a growing social and economic burden of chronic disease including cardiovascular disease and type II diabetes. Both of these killers have also been linked to poor oral health , and Dr Carter offered some simple advice on how people can help their waistbands and oral health.



“If you do snack between meals, choose foods and drinks that do not contain sugar, such as cheese, breadsticks, raw vegetables or nuts. It is better, particularly for children, to eat sugary foods all together at mealtimes rather than to spread eating them out over a few hours. More than one in four five-year-olds suffer from tooth decay, so there is a very real need for parents to moderate their child's snacking on sweet foods and drinks. Try and keep to three meals a day and no more than two snacks.



“It is also worth bearing in mind the Foundation's messages. Brushing your teeth for two minutes twice a day using a fluoride toothpaste and visiting the dentist regularly, as often as they recommend will help to reduce and identify oral health problems . By following this advice we can create a swift improvement in oral health while decreasing the amount of totally preventable dental treatment that is carried out every year.”



Source: http://www.femalefirst.co.uk/health/eating-habits-worrying-oral-health-charity-505039.html



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NYU College of Dentistry and University of California San Francisco researchers develop a framework

Each year, approximately 22,000 Americans are diagnosed with oral cancer. The five-year survival rate of 40% in the U.S. is one of the lowest of the major cancers, and it has not improved in the past 40 years. More people die each year in the U.S. from oral cancer than from melanoma, cervical, or ovarian cancer. Worldwide, the incidence of oral cancer is increasing, particularly among young people and women, with an estimated 350,000 – 400,000 new cases diagnosed each year.

“The major risk factors, tobacco and alcohol use, alone cannot explain the changes in incidence because oral cancer also commonly occurs in patients without a history of tobacco or alcohol exposure,” said Dr. Brian Schmidt, professor of oral and maxillofacial surgery and director of the Bluestone Center for Clinical Research at the NYU College of Dentistry (NYUCD).

Changes in the microbial community are commonly associated with dental diseases, such as periodontal disease, which is most likely a poly-microbial disease characterized by outgrowth of certain pathologic organisms, as well as chronic periodontitis, which has been reported to be a risk factor for oral premalignant lesions and cancers.

“We know that other cancers, including gallbladder, colon, lung, and prostate, have been associated with particular bacterial infections, so we hypothesized that shifts in the composition of the normal oral cavity microbiome could be promoters or causes of oral cancer,” said Dr. Albertson.

Drs. Schmidt and Albertson and their team profiled cancers and anatomically matched contralateral normal tissue from the same patient by sequencing 16S rDNA hypervariable region amplicons. The team’s findings begin to develop a framework for exploiting the oral microbiome for the monitoring of oral cancer development, progression, and recurrence.

[Note: The team's findings, "Changes in abundance of oral microbiota associated with oral cancer," were published in the June 2, 2014 issue of the online journal, PLOS ONE.]

In cancer samples from both a discovery (n=5) and a subsequent confirmation cohort (n=10), abundance of Firmicutes (especially Streptococcus) and Actinobacteria (especially Rothia) were significantly decreased relative to contralateral normal samples from the same patient. Significant decreases in abundance of these phyla were observed for pre-cancers but not when comparing samples from contralateral sites, such as the tongue and the floor of the mouth, from healthy individuals. Using differences in abundance of the genera Actinomyces, Rothia, Streptococcus, and Fusobacterium, the team was able to separate most cancer samples from pre-cancer and normal samples.

“The oral cavity offers a relatively unique opportunity to screen at-risk individuals for [oral] cancer because the lesions can be seen, and as we found, the shift in the microbiome of the cancer and pre‑cancer lesions, compared to anatomically matched clinically normal tissue from the same individual, can be detected in non‑invasively collected swab samples.” said Dr. Schmidt.

Non-invasively sampling the microbiome of oral lesions and corresponding normal tissue opens the possibility not only to detect cancer‑associated changes at one time point, but the relative stability of the adult oral microbiome also offers the opportunity to monitor shifts in bacterial communities over time.

“Here we observed changes in the microbiome, which, in future larger studies, may be confirmed as a potential biomarker of oral cancers or pre‑cancers and may even have utility for discriminating patients with lymph node metastases,” notes Dr. Albertson. “In addition, there are other challenges in clinical management of oral cancers that would benefit from better diagnostic tools.”

Oral cancer patients are also at risk of second primary cancers and recurrences. The microbiome may provide signatures that can be used as biomarkers for monitoring field changes associated with the high rate of second primary oral cancers and recurrences. The team also notes the possibility of medically modulating the oral microbiome for treatment of oral pre-cancers and damaged fields (field cancerization).

About the Bluestone Center for Clinical Research

The Bluestone Center for Clinical Research, in conjunction with the NYU Oral Cancer Center, is an academic research organization located at the NYU College of Dentistry. Bluestone’s mission is to take a creative scientific approach to transform world health. Bluestone is dedicated to conducting research in oral cancer, cancer symptomology, pharmaceuticals, medical devices, emerging biotechnology, periodontics, implants, and oral health products.

About UC San Francisco

UC San Francisco (UCSF), now celebrating the 150th anniversary of its founding, is a leading university dedicated to promoting health worldwide through advanced biomedical research, graduate-level education in the life sciences and health professions, and excellence in patient care. It includes top-ranked graduate schools of dentistry, medicine, nursing, and pharmacy, a graduate division with nationally-renowned programs in basic, biomedical, translational and population sciences, as well as a preeminent biomedical research enterprise and two top-ranked hospitals, UCSF Medical Center and UCSF Benioff Children’s Hospital San Francisco. Please visit ucsf.edu for more information.

About New York University College of Dentistry

New York University College of Dentistry (NYUCD) is the third oldest and the largest dental school in the U.S., educating more than 8 percent of all dentists. NYUCD has a significant global reach and provides a level of national and international diversity among its students that is unmatched by any other dental school. For more information, please visit nyu.edu/dental.



Source: http://www.dentistryiq.com/articles/2014/06/nyu-college-of-dentistry-and-university-of-california-san-francisco-researchers-develop-a-framework-for-monitoring-oral-cancer-development-progression-and-recurrence.html



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New series aims to inform dialogue on dental health

Oregon is in an oral health crisis



That's what a source of mine told me about a month ago. The story she helped me tell in May was a sobering one.



An estimated 77 people per day go to an Oregon emergency room to receive dental care, many because they lack access to routine and preventive care, according to a study commissioned by the Oral Health Funders Collaborative. The hospital emergency room is the highest cost place of care, but it doesn't always provide the best care.



For $8 million annually, hospitals generally will give oral health patients antibiotics and painkillers then advise them to follow up with a dentist. But considering they ended up in the ER due to hurdles barring patients from accessing dentists in the first place, a quarter of the time, they will return to the ER for the same problem.



Meanwhile, oral pain inhibits people's ability to eat, work, care for their children and learn in school. It invades every aspect of life.



Private stakeholders and the state government have both decided it's time for change. And as a reporter, it was important for me to bear witness to these efforts on your behalf. This is why, on Monday, we launched a new occasional series called Oregon's Oral Exam.



This isn't going to be an easy task. There needs to be a solution on what to do about the shortage of dentists and how to make treating under served populations financially rewarding. There are questions of new training paths and how to instill good oral hygiene habits to young children.



As the Oral Health Funders Collaborative works on its strategic plan on oral health and the Oregon Health Authority starts overseeing pilot projects targeting this issue, we'll be there to help inform the public dialogue.



Here are some aspects I'm hoping to get a closer look at:



Lives impacted



Like most other social and health issues, low-income Oregonians are disproportionately affected by this systemic problem.



Uninsured people are eight times more likely to to visit the ER for dental problems, and Medicaid patients were four times more likely compared to commercially insured people.



Because it's so difficult finding dentists willing to see Medicaid patients and paying out of pocket is unaffordable for the uninsured, the ER becomes the default care setting that guarantees treatment.



In addition, tooth decay is the most common chronic condition in children with many of them going untreated.



The financial burden



Until recently, dental health benefits in the Oregon Health Plan was in flux. If the state budget needed some relief, it was the benefit that was compromised.



It wasn't until 2014 that dental health benefits were restored beyond emergency care, so it will be interesting what coordinated care organizations do to address the new demand.



If we don't figure out a way to take care of people's teeth in low-cost, preventive and routine settings, evidence shows we will be paying through higher cost, less effective care, not to mention the cost to quality of life.



The professional shortage



It has been a while since the medical field began acknowledging that we need mid-level providers like nurse practitioners to perform at the top of their training to help expand access to care. It was a cultural shift, as we began distributing the workload off the overburdened shoulders of medical doctors.



The same question has emerged in dentistry, with dental therapists being authorized to practice in Minnesota, Maine and tribal communities in Alaska. Dental therapists provide a range of routine services like drilling and extracting teeth.



However, this too, will take a shift in mindset. The American Dental Association contends that only dentists should be able to perform irreversible surgical procedures.



As I cover this topic over the next few months, please help us by pointing me to story ideas and sources.



Source: http://www.statesmanjournal.com/story/news/health/2014/06/30/new-series-aims-inform-dialogue-dental-health/11810499/





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Oil pulling for oral health: Fad or fabulous?

I like to stay ahead of the curve. So when I hear about a procedure or a product that is new, I'm not likely to put it down. I get curious, knowing that some new things can be good. Most every doctor has some level of interest in something new. But we all look to see if the risks are worth the rewards and then make our recommendations accordingly.



But when we doctors are not sure what to say to a patient who has read an article or seen a news story that is the "latest thing," we all do the same thing. We go to the dental or medical literature.



The website that we go to is a National Library of Medicine website called Pubmed.gov. There we find abstracts of every article published in medical journals. We can see what's been written about the procedure or product. It's where we get some objectivity, as we can see how monitored trials using that procedure or product came out. Often, these trials are done using controls, so we can see data that compares the experimental group and the control group. You can go there, too.



So when, Bob, who has been a loyal patient and friend for many years, sent me an article on the Internet on "oil pulling," I was intrigued. I had heard about oil pulling from another patient a couple of years ago. She had tried it for her periodontal disease and it hadn't worked, so she decided to see me. Oil pulling has been part of Ayurvedic medicine for years. That's likely a good thing.



Now, all I hear about is "oil pulling." It was on TV this weekend. It's all over the Internet. It was in this section a few weeks ago. It is the latest thing, even though it was proposed thousands of years ago in India. I hear a doctor talking about how swishing coconut oil in the mouth will not only improve oral health, it will help general health. He says that it will remove dental abscesses, and I'm sitting there stunned, because it makes no sense to me.



I look on Pubmed.gov. I see nearly nothing about oil pulling and dental disease, but a couple of articles at least show that oil will emulsify if left in the mouth for 20 minutes and that there is at least a mild antibacterial effect as good as chlorhexidine when studied in the laboratory. So, at least there is some literature, but chlorhexidine won't treat abscesses.



So what's my next step? I bought some coconut oil and swished it around my mouth for 20 minutes. I didn't feel that I had to swallow. It tasted pretty good, too. So, I'm buying the book, will read it on vacation, just to see what the author says. And I'll likely tell my most periodontally resistant patients about oil pulling, that it's likely harmless, and see what happens. I'll get back to you.



Dr. Lee Sheldon has a dental implant and periodontal practice in Melbourne. He is a featured guest on "Focus on Seniors" on WMEL radio. He also serves as vice president of the advocacy group, Helping Seniors of Brevard County. He is the author of the book, "The Ultimate Mouth Manual," available at all bookstores.



Source: http://www.floridatoday.com/story/life/wellness/2014/07/03/oil-pulling-oral-health-fad-fabulous/12013131/



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from Affinity Dental Fresno http://affinitydental.livejournal.com/19338.html

Does Running Lead to Worse Oral Health?

New research shows that carbs, altered saliva flow can harm teeth.

Aside from overuse injuries and skin cancer, runners score well on most measures of good health. But another red flag has been raised by new research: Runners may suffer higher risks of tooth erosion and cavities.



In the Scandinavian Journal of Medicine & Science in Sports, a team of German dental researchers report significantly higher tooth erosion in triathletes than in non-athletes. In addition, the researchers found that athletes who engaged in more weekly training had more cavities than those who trained less.



“The triathletes’ high carbohydrate consumption, including sports drinks, gels, and bars during training, can lower the mouth’s pH below the critical mark of 5.5,” Cornelia Frese told Runner’s World Newswire. “That can lead to dental erosion and caries. Also, the athletes breathe through the mouth during hard exercise. The mouth gets dry, and produces less saliva, which normally protects the teeth.”



Frese, a marathoner, is a researcher in the Department of Conservative Dentistry at the University Hospital in Heidelberg, Germany. She and her husband, triathlete Falko Friese, were part of a team that investigated the dental health of 35 triathletes who trained almost 10 hours a week with a mix of cycling, running, and swimming. The athletes were examined for cavities and tooth erosion. They also took a saliva test both at rest and while exercising. All results were compared to the control group.



Both groups had an average age of 36, but the athletes were significantly lighter, with lower BMIs. This leanness is known to correlate with many positive health outcomes.



From a questionnaire, the researchers learned that 46 percent of the athletes consumed sports drinks while training, and 51 percent water. Seventy-four percent used gels or bars.



Results from the various dental tests revealed no statistically significant difference in cavities between the two groups, although the athletes who trained the most had the most cavities. Type of sports beverage consumed was also not linked to cavities. However, there was a highly significant difference in tooth erosion, with the athletes having more.



At rest, members of the two groups had similar saliva profiles. However, when they began exercising, the athletes produced less saliva and it was acidic (i.e., pH lower than 7). Also, the degree of acidity increased with the length of time exercising. The exercise test given to the athletes lasted just 36 minutes on average. Saliva is considered important to good tooth health.



“Based on these findings, it can be suggested that endurance training has detrimental effects on oral health,” the researchers write. “Additionally, there is a need for exercise-adjusted oral hygiene regimes and nutritional modifications in the field of sports dentistry.”



Cornelia Friese told Newswire that her team is looking into possible modifications. “We are conducting a randomized, controlled clinical trial with 55 endurance athletes to test special toothpastes and mouth rinses," she said. "If we could find a superior product that athletes can apply before training, that would be the ideal prevention.”



Until then, it would seem prudent to brush your teeth following a run, particularly if you have consumed various carbs during the run or after it.



Source: http://www.runnersworld.com/health/does-running-lead-to-worse-oral-health



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from Affinity Dental Fresno http://affinitydental.livejournal.com/18714.html

Poor Dental Health Increases Mortality Risk in ESRD Patients

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.



"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. 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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