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Chronic Kidney Disease and the Oral Systemic Link

Metabolic Health

Unraveling the Connection Between Oral Health and Chronic Kidney Disease

Introduction

Chronic kidney disease, or CKD, causes more deaths than breast cancer or prostate cancer. It is an under-recognized public health crisis. CKD affects an estimated 37 million people in the U.S. (15% of the adult population; more than 1 in 7 adults) (CDC, 2022). Alarmingly, the vast majority of individuals afflicted with CKD, approximately nine out of ten, remain unaware of their condition. Early diagnosis is paramount, particularly for individuals with predisposing factors such as diabetes or hypertension. 

Oral systemic practitioners constantly seek a deeper understanding of the intricate connections between various aspects of our patient's health. One emerging area of interest lies in the bidirectional relationship between oral health and chronic kidney disease. Recent research suggests that the health of the oral cavity may influence the progression and development of CKD, shedding light on the importance of comprehensive patient care. 

"Understanding the intricate interplay between kidney dysfunction and dental diseases is essential for dental providers,” according to Anne O. Rice, AAOSH Fellow and Advisory Board Member. “When disease compromises kidney health, it can exacerbate harmful systemic inflammation, leading to a cascade of adverse effects on overall health. From weakened immunity to complications of infections, bone-related disorders, and xerostomia, the impact on patient wellness is profound. As dental professionals, we have a unique opportunity to actively engage in our patients' well-being by addressing these interconnected issues" (Rice, 2023).

The Bidirectional Link: Evidence from Academic Research

Compelling evidence from academic research illuminates the significant association between oral health and the risk and progression of chronic kidney disease. Notably, studies, such as those published in the American Journal of Kidney Diseases (Fisher et al., 2008), reveal a pronounced link between periodontal disease and an elevated risk of CKD. Individuals afflicted with severe periodontitis (gum disease) exhibit a heightened likelihood of developing CKD compared to those with optimal gum health.

This correlation is fortuitous and deeply rooted in shared risk factors and common pathophysiological mechanisms. Chronic inflammation, a hallmark of periodontal (gum) disease and CKD, is a unifying factor. The inflammatory response triggered by oral pathogens exacerbates systemic inflammation, thereby contributing to endothelial dysfunction and vascular damage within the kidneys.

Furthermore, the oral cavity serves as a potential reservoir for pathogenic bacteria. These microorganisms and their byproducts can infiltrate the bloodstream through compromised oral mucosa, seeding infections in distant organs, particularly the kidneys. In individuals predisposed to kidney disease, this systemic dissemination of oral pathogens may contribute significantly to the progression of renal damage (Grubbs et al., 2015; Kshirsagar et al., 2005).

Saliva as a Keystone Player

Beyond the direct impact of periodontal disease, alterations in saliva composition and reduced salivary flow in CKD patients play a pivotal role in oral health. Saliva, far beyond being a mere lubricant, is a critical component of the oral defense system. It aids in maintaining a balanced pH, remineralizing tooth enamel, and washing away bacteria. However, xerostomia is prevalent in CKD patients, increasing susceptibility to dental caries and oral infections.

A study in the Journal of Dental Research underscores the prevalence of xerostomia in CKD patients and its correlation with poor oral health outcomes, emphasizing the need for targeted interventions to address salivary dysfunction and mitigate associated oral health risks in this population.

Implications for Clinical Practice

Recognizing the intricate interplay between oral health and chronic kidney disease is important for comprehensive patient care. Physicians must integrate oral health assessments into routine clinical evaluations. A thorough examination of the oral cavity, consideration of periodontal status, and awareness of the patient's oral hygiene practices can yield valuable insights into potential risk factors for CKD.

Ellie Campbell, DO, the Secretary of the AAOSH Board, emphasizes the critical need for dentists and primary care physicians to collaborate in identifying risk factors and addressing co-morbid conditions like type 2 diabetes and hypertension, which can escalate to early-stage CKD. She illustrates hypertension as a prime example, stating, "Uncontrolled hypertension serves as a significant catalyst for CKD." Campbell highlights academic literature emphasizing the connection between poor oral health, oral bacterial pathogens, mouth breathing, and elevated blood pressure levels. Individuals with hypertension are at higher risk of developing chronic kidney disease. Thus, it's essential for individuals to discuss the underlying causes of high blood pressure with both their primary care physician and dentist to mitigate the risk of CKD onset.

Interdisciplinary collaboration between nephrologists and dental professionals is also imperative. Integrating oral health education and preventive measures into CKD management protocols represents a proactive approach to mitigating the impact of oral health on renal outcomes.

Conclusion

The evolving understanding of the oral-renal axis underscores the significance of adopting a holistic approach to patient care. By recognizing and addressing oral health as an integral component of overall health, physicians contribute to more comprehensive and effective management of chronic kidney disease. Dental providers can play a pivotal role in supporting CKD patients by offering education, guidance, and appropriate management of oral microbiome health. As our comprehension of these connections deepens, avenues for interdisciplinary collaboration and innovative strategies to enhance patient outcomes continue to emerge. 

AAOSH Resources

Within our library of resources, AAOSH offers a robust Core Curriculum with many courses on systemic inflammation, diabetes, and chronic kidney disease. We hope you will enjoy this free resource from our course library for March.

Kidneys and Teeth: A Review of Rare Diseases by Craig B. Langman, MD 

Course Overview:

This course provides an in-depth examination of rare skeletal diseases that impact the skeleton and other organs and teeth, including hypophosphatasia, X-linked dominant hypophosphatemic rickets, osteogenesis imperfecta, and FAM20A mutations. The lecture will focus primarily on hypophosphatasia, exploring its pathophysiology, clinical phenotypes, and the potential of enzyme replacement therapy. 

Learning Objectives:

  • Understand the differential diagnosis of early tooth loss in the context of genetic bone diseases, including hypophosphatasia, X-linked dominant hypophosphatemic rickets, and osteogenesis imperfect.
  • Explore the role of alkaline phosphatase deficiency in systemic calcium homeostasis, particularly its impact on dental health.
  • Analyze the potential benefits and limitations of enzyme replacement therapy in managing hypophosphatasia, considering varying ages of onset, severity, and systemic manifestations.
  • Develop a comprehensive framework for evaluating and managing patients with hypophosphatasia, integrating knowledge of its pathophysiology, clinical manifestations, and therapeutic options to optimize patient outcomes.

 

AAOSH offers over 270 hours of continuing education within 14 core competency areas, monthly webinars, Mastermind Study Groups, and New Member Meetups. To learn more about joining AAOSH, visit https://www.aaosh.org/about-membership.

 

References:

1. Chronic Kidney Disease in the United States, 2021.Centers for Disease Control and Prevention. 2022. https://www.cdc.gov/kidneydisease/publications-resources/ckd-national-facts.html

2. Rice, AO. The Oral Health Connection to Chronic Kidney Disease. Today's RDH. 2023. https://www.todaysrdh.com/the-oral-health-connection-to-chronic-kidney-disease/

3. Fisher MA, Taylor GW, Shelton BJ, et al. Periodontal disease and other nontraditional risk factors for CKD. Am J Kidney Dis. 2008;51(1):45-52. https://doi.org/10.1053/j.ajkd.2007.09.018

4. Grubbs V, Vittinghoff E, Beck JD, et al. Association Between Periodontal Disease and Kidney Function Decline in African Americans: The Jackson Heart Study. J Periodontol. 2015;86(10):1126-1132. https://doi.org/10.1902/jop.2015.150195

5. Kshirsagar AV, Moss KL, Elter JR, Beck JD, Offenbacher S, Falk RJ. Periodontal disease is associated with renal insufficiency in the Atherosclerosis Risk In Communities (ARIC) study. Am J Kidney Dis. 2005;45(4):650-657. https://doi.org/10.1053/j.ajkd.2004.12.009

6. Ruospo M, Palmer SC, Craig JC, et al. Prevalence and severity of oral disease in adults with chronic kidney disease: a systematic review of observational studies. Nephrol Dial Transplant. 2014;29(2):364-375. https://doi.org/10.1093/ndt/gft401