Gingival health among individuals on hemodialysis in a

Saudi population

Farhad Atassi, DDS, MSc, FICOI
Abdullah R. Al-Shammery‡, BDS, MSc
Saeed  Al-Ghamdi†, BDS
College of Dentistry, King Saud University, Riyadh, KSA

The purpose of the study was to evaluate the gingival health status among patients on hemodialysis. Ninety Saudi patients on hemodialysis participated in the study, and were divided into three subgroups of those who have been on dialysis for 1) less than one year; 2) 1 to 3 years; and 3) for more than 3 years. Four indices: the debris index (DI); the calculus index (CI); the plaque index (PlI) and the gingival index (GI) were used. Data were analyzed using one way analysis of variance (ANOVA). The means of debris index were 1.65, 2.07, and 2.15, with SD± 0.67, 0.47 and 0.48 respectively for the subgroups.The means of plaque index were 1.72, 2.16 and 2.26, with SD±0.64, 0.36 and 0.42 respectively for the revealed groups. The means of calculus index were 1.58, 2.02 and 2.09, with SD± 0.58, 0.28 and 0.39 respectively for the subgroups. The means of gingival index were 1.43, 2.97 and 2.06 with SD± 0.67, 0.38 and 0.35 for the subgroups respectively. Results showed a 100% prevalence of mild to moderate gingivitis. Tukey`s post hoc test showed significant difference in all indices between the 1st and 2nd subgroups, and between the 1st and 3rd subgroups, while no significant difference was found between 2nd and 3rd subgroups. It was concluded that  periodontal disease is prevalent in renal dialysis patients who showed unacceptable level of oral hygiene and which may increase with the chronicity of the illness.

Dialysis is an artificial means of removing nitrogenous and other toxic products of metabolism from the blood.  For many patients, dialysis is a life-saving intervention that has significantly reduced the mortality of this once fatal disease.            Published reports estimated that up to 90% of patients receiving renal dialysis will show oral symptoms1 which might be due to an elevated blood urea nitrogen (BUN) and creatinine, and diet restriction.2 The most prominent oral sign found in dialysis patients is pallor of the oral mucosa, which reflects anemia, while other signs may include xerostomia, breath with urea odor and an accelerated rate of calculus formation as a result of altered serum calcium-phosphate product.3   Patients receiving dialysis are more susceptible to infections because of general debilitation, depression of the immunologic response and masking of signs and symptoms of infection by drug therapy.4

Ninety patients undergoing renal dialysis were included in this study.  The purpose of the study was explained to the patients. The patients were divided into 3 subgroups of those on renal dialysis for 1) less than one year; 2) 1 to 3 years; and 3) longer than 3 years. Two renal dialysis centers were selected namely Ibn Ibrahim Al Shaikh Dialysis Center in King Fahad hospital, Al Baha and the dialysis department in King Khalid University Hospital, Riyadh.           

The clinical parameters studied were oral debris index,8 calculus index,8 plaque index,9 and gingival index.10 (Table 1)

Only one examiner performed the assessment on all the renal dialysis patients.

Intra-examiner reliability                

A pilot study was conducted to establish intra-examiner reliability.  Ten subjects who volunteered to participate were selected and examined by one examiner who used the four dental indices and recorded them on two occasions to establish intra-examiner reliability.  The scores from the indices were analyzed for differences using  Kappa test for correlated samples. Intra-examiner reliability indices were k=100% for DI, k=90.3% for PI, k=100% for CI and k=100% for GI respectively. 

The ninety participants were 53 females (58.9%) and 37 males (41.1%). The mean ages were 42.9, 46.7 and 47.2 years for  the 1st, 2nd and 3rd subgroups respectively. The means of DI were 1.65, 2.07 and 2.15 respectively for the 1st, 2nd, and 3rd subgroups respectively. (Table 2) The means of PI were 1.72, 2.16 and 2.26 for the same subgroups respectively. (Table 3). The means of calculus index CI were 1.58, 2.02 and 2.09 for the same subgroups respectively. (Table 4) Finally, the means of GI were 1.42, 2.97 and 2.06 for the same subgroups respectively. (Table 5).One-way analysis of variance (ANOVA) was used to determine significant differences in the 4 indices among the 3 subgroups at 5% level. Tukey`s post hoc test  was used to compare between subgroups (Table 6 & Fig. 1).

The ninety participants were 53 females (58.9%) and 37 males (41.1%). The mean ages were 42.9, 46.7 and 47.2 years for  the 1st, 2nd and 3rd subgroups respectively. The means of DI were 1.65, 2.07 and 2.15 respectively for the 1st, 2nd, and 3rd subgroups respectively. (Table 2) The means of PI were 1.72, 2.16 and 2.26 for the same subgroups respectively. (Table 3). The means of calculus index CI were 1.58, 2.02 and 2.09 for the same subgroups respectively. (Table 4) Finally, the means of GI were 1.42, 2.97 and 2.06 for the same subgroups respectively. (Table 5).One-way analysis of variance (ANOVA) was used to determine significant differences in the 4 indices among the 3 subgroups at 5% level. Tukey`s post hoc test  was used to compare between subgroups (Table 6 & Fig. 1).

1. Results of the study showed a 100% prevalence of mild to moderate gingivitis among the studied population.
2. Individuals on hemodialysis showed a low level of oral hygiene as demonstrated by plaque and debris indices.
3. Tukey`s Post Hoc test showed significant effect of the duration of patients on dialysis.

1. Subjects on hemodialysis should receive initial comprehensive oral examination with oralhygiene instructions.
2. All patients should receive periodic supportive periodontal care.
3. The oral health maintenance should be reinforced by by the dialysis team. Members of the team may require some further training toperform this role adequately.

The authors wish to acknowledge Dr. Nazeer Khan for his assistance with the statistical analysis.  In addition, the authors also wish to thank the Head Division and members of the Renal Dialysis Department in King Fahad Hospital, Al Baha, and King Khalid University Hospital, Riyadh, for their help and support.

1. Levy HM. Dental consideration for the patient receiving dialysis for renal failure. Spec Care Dent 1988;8:34-36.
2. Epstein SR, Mandle I and Scopp IW. Salivary composition and calculus formation in patientsundrgoing hemodialysis. J Periodontol 1980;51:336- 339.
3. Isselbacher KJ, Braunwald E and Wilson JD. Disorders of the kidney and urinary tract. In:, Harrison's principles of internal medicine. 12th ed, New York: McGraw-Hill 1991; 1251-336.
4. Deykin D. Uremic bleeding. Kidney Int 1884;24:698- 705.
5. Naylor GD, Hall EH and Terezhalmy GT. The patient with chronic renal failure who is undergoing dialysisor renal transplantation: Another consideration for antimicrobial prophylaxix. J Oral Surg 1988;65:116-121.
6. Oshrain HI, Mendre S and Mandel ID. Periodontal status of patients with reduced immunocapacity. J Periodontol 1979;50:185-188.
7. Naugle-K, Darby-ML, Bauman-DB, Lineberger-LT and Powers R. The oral health status of individuals on renal dialysis. Ann-Periodontal 1998; 3(1): 197- 205.
8. Green JC and Vermillion JR. The simplified oral hygiene index. J Am Dent Asoc 1964;68:7-13.
9. Silness P and Löe H. Periodontal disease inpregnancy. Acta Odontol Scand 1964;2:121-135.
10. Lee H and Silness J. Periodontal disease in pregnancy.Acta Odontol Scand 1963;21:533-551
11. Westbrook SD. Dental management of patients receiving hemodialysis and kidney transplant. JADA 1978; 96(3): 464-468.
12. Remuzzi G and Pusineri F. Coagulation defects in uremia. Kidney Int 1988;33:513-517.
13. Brown LJ, Oliver RC and Löe H. Periodontal diseases in the U.S. in 1981: Prevalence, severity, extent, androle in tooth mortality. J Periodontol 1989; 60:363- 370.
14. Bottomley WK, Cloffi RF and Martin AJ. Dental management of the patient treated by renaltransplantation: Preoperative and postoperativeconsiderations. JADA 1972;85(12):1330-1335.
15. Eigner TL, Jastak TJ and Bennett WM. Achieving oral health in patients with renal failure and renal transplants. J Am Dent Assoc 1986; 113:612-616.
16. Schroder HF. Crestal morphology and gross structures of miniralized plaque and calculus. Helv Odontol Acta 1965;9:73-79.
17. Listgarten MA. The role of dental plaque in gingivitis and periodontitis. J Clin Periodontol 1988; 15:485-487.
18. Epstein SR, Mandel I and Scopp IW. Salivarycomposition and calculus formation in patientsundergoing hemodialysis. J Periodontol 1980; 51(6): 336-338.
19. Stewart RS and Stweart RM. Neuropsychiatric aspects of chronic renal disease. Psychosommatic1979;20:524-531.
20. Kaplan De-Nour A and Czackes W. The influence of patient`s personality on adjustment to chronic dialysis. J Nerv Ment Dis 1976;162:323-333.

Address reprint requests to:

Dr. Farhad Atassi
PO Box 60169
Riyadh 11545, KSA