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A dental survey of renal dialysis patients
PubL Htth, Lond. (1979) 93, 153-156
A Dental Survey of Renal Dialysis Patients Janet L. Potter 8.D.S.
University Dental Hospital of Manchester and N. H. F. Wilson B.D.S.. F.D.S.
DepartmenZ of Conservative Dentistry, University Dental l-/ospita/ of Manchester. Bridgeford Street, Manchester M I5 6FN A survey o f the dental needs o f a random sample of 100 renal dialysis patients and of the treatment facilities made available by haemodialysis units is reported. The results o f this st udy indicate that many ( > 60 ~ ) renal dialysis patients may be in need o f dental treatment; that the majority of these patients are not aware of the possible complications of dental neglect while on haemodialysis and that most renal dialysis units refer patients to general dental practitioners for most forms of treatment. Policies for a possible dental care programme for haemodialysis patients have been proposed. Introduction The dental care o f renal dialysis patients is complicated by the iatrogenic effects o f therapy and by the medical condition o f the patient. ~ Complications influencing the dental management o f h a e m o d i a l y s i s patients m a y include a n increased susceptibility to infection, 4 hypertension, increased blood loss following surgery, predisposition t o w a r d s osteo-dystrophy and its sequellae in the jaws, 7 an impaired stress response and hazards posed by a high rate o f subclinical viral hepatitis? While appropriate operative techniques, treatment priorities, precautions 3.s and the need to provide special dental services for renal dialysis patients have been investigated 1.s.6 little information is available on the dental health a n d treatment facilities m a d e available to this expanding minority group. This study was undertaken to determine the dental needs o f a sample o f haemodialysis patients and to investigate the treatment facilities m a d e available in renal dialysis units in the United Kingdom. Materials and Methods A r a n d o m sample o f 100 dialysis patients was surveyed in two Manchester hospitals. A specially designed precoded questionnaire was completed during a dental examination o f each o f these patients. The results were transferred to p u n c h cards for computer analysis. All reasonable measures were taken to minimize errors in this surveyJ ~ In an attempt to obtain information on the dental treatment facilities available to renal dialysis patients, a short questionnaire was sent to each o f the 32 renal dialysis units in the United Kingdom. Results Sixty-nine males a n d 31 females with an age range o f I0-60 years (mean 35-6 years), were examined. Eighty-six per cent o f this sample had been on dialysis for m o r e than 6 m o n t h s (mean 40 months), none o f the samples were long-term in-patients. Eighty-right per cent o f 0038-3506/79/030153+04 $01.00/0
© 1979 The Society of Commun/ty Medicine
154
J. L. Potter and N. H. F. Wilson
the patients had natural teeth present in either one or both dental arches; 3 7 ~ were found to possess at least one prosthesis and all of the edentulous patients (12 og of the ~mple) had replacement dentures. The results indicate that 55 O//oof this sample received regular dental care ever3' 6 months, tbat 24 patients (24°~) only sought dental treatment when they were in pain or discomfort and that the remaining 21 patients (21%) made no use of dental care facilities. Of the 79 patients who ever sought dental care, 43 (54~o) ~v.ere treated in the hospital in which they were dialysed: 34 (433.~} were treated by general dental practitioners and 2 (3°/~) were patients of the Manchester Dental Hospital. Dental treatment was seen to be required by 660/0 o f the samples. 42 (64%) of these 66 patients required minimal care; 12 (I8°/0) were in need o f treatment which would have o/ required extensive taken between 1 and 2 hours ofaclinician'stime to complete and 12 (18/o) therapy. The amount of treatment seen to be required by the three types of dental attenders is detailed in Table I. Restorative care (especially periodontal therapy and conservative dentistry) was required by 63 % of the 66 patients considered to require treatment. A small number (< 10) of patients were considered to 'require extractions or other forms of minor oral surgery. TAULE |. Details of the extent of treatment seen to be required by the three types of attenders
Extent of treatment required Frequency of seeking Dental care
Regularly Only when in pain or discomfort Make no use of dental care facilities Tote!s and percentages of sample
Intermediate Minimal (Between i and 2 Totals and (Less than I hour of hours of a clinician's .percentages None a clinician's time) time) Extensive of sample 24
26
5
0
55 (55 ~ )
2
12
5
5
24 (24~)
8 34 (34~)
4 42 (42 ~ )
2 12 (12 ~ )
7 12 (l 2 %)
21 (21 ~ ) 100 (100~)
Sixty-eight (68 ~ ) of the patients in the sample indicated that the importance of maintaining a high standard o f oral health and cleanliness when on dialysis had not been impressed on them. All of the 24 patients considered to have a poor standard of oral hygiene and 54 (82 ~ ) of the 66 patients seen to require dental treatment were found to be included in these 68 patients. N o significant difference in the treatment requirements, dental health awareness or oral hygiene standards were found to be present between males and females or between the patients of the hospitals in which this survey was carried out. Replies were received from 20 (62-5 ~o) of the 32 renal dialysis units which were asked to provide information on the dental treatment facilities made available to patients. The results of this part of the investigation are summarized in Table 2. Di~ussion The results of this survey indicate that dental treatment may be required by many renal dialysis patients most of whom may be unaware of the importance of maintaining a high standard of oral health. To ensure that all haemodialysis patients are made aware o f the
Dental surrey of renal dialysis paNents
155
TABLE2. Details of ~he arrangements made for the dental care of patients in 20 renal dialysis units in the U.K. lid
.
.
.
.
.
.
.
i
IIIIII
Arrangements for dental care Left to individual patient All care provided by parent hospital Referred to GDP for non-surgical procedure Referred to dental hospital for all care GDP for all care if possible Totals
III
i
iiii I
Ell
II
It
I
IIIII
IIIIlll
Illimll
~
pll
I
Number of units
Percentage of units
4 4 3 l 8 2O
(20%) (20%) 05%) (5%) (40%) 100%
importance o f establishing and maintaining dental health and that all patients receive effective regular dental care it is proposed that: (1) All new and established haemodialysis patients should be made aware of the possible complications o f failing to maintain a high s ~ n d a r d o f dental health. (2) All renal dialysis patients should have a comprehensive oral examination after stabilization on haemodialysis and subsequently at six monthly intervals. Patients who require extractions or other forms of oral surgery should be referred to specialized units in hospitals. Patients requiring restorative care should be referred to dentists providing such care within hospitals or to general dental practitioners who are prepared and equipped to undertake the treatment o f these patients in their practices. (3) Dentists and ancilla D' dental staffwho specialize in preventive care should formulate preventive programmes appropriate to haemodialysis patients and visit renal dialysis units to instruct patients on h o w they could best achieve a n d maintain a high standard of oral care. (4) The maintenance of preventive pr0grammes should be encouraged by hospital nursing staff, who may require further training to perform this role adequately, l~ Further studies are indicated to determine the' effectiveness and benefits of implementing the above recommendations and to assess the time required by various types of dental staff to run such a dental care programme. The data collected from the 20 renal dialysis units which provided information indicates that general dental practitioners may treat more than 50~o o f the renal dialysis patients referred for dental care. It is suggested that this finding and those of earlier studies on the dental care of other expanding minority groups o f hospital patients ~.1° indicate that both undergraduates and practising dental surgeons should receive instruction in the operative procedures and patient management techniques appropriate to specific groups o f patients whose conditions or therapy m a y eomplicate dental treatment. Aelmowledgements The authors wish to acknowledge the kind help o f Dr N. P. Mallick, Consultant Renal Physician, Manchester Royal Infirmary, Drs P. Ackrill and A. J. Ralston, Consultant Nephrologists, Withington Hospital, Manchester and Dr V. F. Hillier, Computation Advisory Group, Faculty of Medicine, Manchester University. Referen~ 1. Bottomley, W. K., Joffe, R. F. & Martin, A. 3. (1972). Dental management of the patient |reared by renal transplantation; preoperative and post-operative considerations. Journal o f American Dental Association 8.5, 1330--35.
156
J. L. Potter and N. H. F. Wilson
2. Dental Survey (1973). Dental hazards in haemodialysi~ patients reviewed. Dental Sur)~'3: 49, 34. 3. Donaldson, D. (1972). Homologous serum hepatitis and the dental treatment o f renal dialysis and kidney transplant pali,ents. British Dental Journal 132, 391-3. 4. Herman. L. T. & Friedman, J. M. (1975). Management of orofacial infection in patients with chronic renal disease. Journal o f Oral Surgery 33, 9~2- 5. 5. Hooley, J. R. & Petersen, W. M. (1969). Dental management of patients with renal failure treated by renal dialysis. Or~-ISurgery 28, 660-6.5. 6. Kirkpalrick, T. J. & Morton, J. B. (1971). Factors influencing the dental management of renal transplant and dialysis patients. British Journal o f Oral Surgery 9,57-64. 7. S~_,derholm, G., Lysell, L. & Svensson, A. 0974). Changes in the jaws in chronic renal insufficiency and haemodialysis. Journal of Clinical t'eriodontotogy | , 36-42. 8. Uthrnan, A. A. (I975). Viral hegatitis and the derital treatment o f renal dialysis and kidney transplant patients. Journal of Oral ~.h,dicine 30, 70-72. 9. Wilson, N. I4. F. (1975). An investigation of urgent dental treatment needs o f short ~erm in-patients and of the dental care required by both long-stay and dental priolity in-patients in a selected group o f Edinburgh hospitals. A Report from the Department of Restorative Dentistry, University of Ed~.aburgh. 10. Wilson, N. H- F. (1977). The dental care o f geriatric patients in hospitals, Public ltealth 91, 97-102. 11. '~Vood, G. D. & Bellamy, E. M. 0973). A survey o f the dental knowledge of nursing staff. Nursing Mirror 137, 12-16. 12. World Health Organisation (1971). Oral Health Surveys. Basic Methods. World Health Organisation: Geneva.
A Dental Survey of Renal Dialysis Patients Janet L. Potter 8.D.S.
University Dental Hospital of Manchester and N. H. F. Wilson B.D.S.. F.D.S.
DepartmenZ of Conservative Dentistry, University Dental l-/ospita/ of Manchester. Bridgeford Street, Manchester M I5 6FN A survey o f the dental needs o f a random sample of 100 renal dialysis patients and of the treatment facilities made available by haemodialysis units is reported. The results o f this st udy indicate that many ( > 60 ~ ) renal dialysis patients may be in need o f dental treatment; that the majority of these patients are not aware of the possible complications of dental neglect while on haemodialysis and that most renal dialysis units refer patients to general dental practitioners for most forms of treatment. Policies for a possible dental care programme for haemodialysis patients have been proposed. Introduction The dental care o f renal dialysis patients is complicated by the iatrogenic effects o f therapy and by the medical condition o f the patient. ~ Complications influencing the dental management o f h a e m o d i a l y s i s patients m a y include a n increased susceptibility to infection, 4 hypertension, increased blood loss following surgery, predisposition t o w a r d s osteo-dystrophy and its sequellae in the jaws, 7 an impaired stress response and hazards posed by a high rate o f subclinical viral hepatitis? While appropriate operative techniques, treatment priorities, precautions 3.s and the need to provide special dental services for renal dialysis patients have been investigated 1.s.6 little information is available on the dental health a n d treatment facilities m a d e available to this expanding minority group. This study was undertaken to determine the dental needs o f a sample o f haemodialysis patients and to investigate the treatment facilities m a d e available in renal dialysis units in the United Kingdom. Materials and Methods A r a n d o m sample o f 100 dialysis patients was surveyed in two Manchester hospitals. A specially designed precoded questionnaire was completed during a dental examination o f each o f these patients. The results were transferred to p u n c h cards for computer analysis. All reasonable measures were taken to minimize errors in this surveyJ ~ In an attempt to obtain information on the dental treatment facilities available to renal dialysis patients, a short questionnaire was sent to each o f the 32 renal dialysis units in the United Kingdom. Results Sixty-nine males a n d 31 females with an age range o f I0-60 years (mean 35-6 years), were examined. Eighty-six per cent o f this sample had been on dialysis for m o r e than 6 m o n t h s (mean 40 months), none o f the samples were long-term in-patients. Eighty-right per cent o f 0038-3506/79/030153+04 $01.00/0
© 1979 The Society of Commun/ty Medicine
154
J. L. Potter and N. H. F. Wilson
the patients had natural teeth present in either one or both dental arches; 3 7 ~ were found to possess at least one prosthesis and all of the edentulous patients (12 og of the ~mple) had replacement dentures. The results indicate that 55 O//oof this sample received regular dental care ever3' 6 months, tbat 24 patients (24°~) only sought dental treatment when they were in pain or discomfort and that the remaining 21 patients (21%) made no use of dental care facilities. Of the 79 patients who ever sought dental care, 43 (54~o) ~v.ere treated in the hospital in which they were dialysed: 34 (433.~} were treated by general dental practitioners and 2 (3°/~) were patients of the Manchester Dental Hospital. Dental treatment was seen to be required by 660/0 o f the samples. 42 (64%) of these 66 patients required minimal care; 12 (I8°/0) were in need o f treatment which would have o/ required extensive taken between 1 and 2 hours ofaclinician'stime to complete and 12 (18/o) therapy. The amount of treatment seen to be required by the three types of dental attenders is detailed in Table I. Restorative care (especially periodontal therapy and conservative dentistry) was required by 63 % of the 66 patients considered to require treatment. A small number (< 10) of patients were considered to 'require extractions or other forms of minor oral surgery. TAULE |. Details of the extent of treatment seen to be required by the three types of attenders
Extent of treatment required Frequency of seeking Dental care
Regularly Only when in pain or discomfort Make no use of dental care facilities Tote!s and percentages of sample
Intermediate Minimal (Between i and 2 Totals and (Less than I hour of hours of a clinician's .percentages None a clinician's time) time) Extensive of sample 24
26
5
0
55 (55 ~ )
2
12
5
5
24 (24~)
8 34 (34~)
4 42 (42 ~ )
2 12 (12 ~ )
7 12 (l 2 %)
21 (21 ~ ) 100 (100~)
Sixty-eight (68 ~ ) of the patients in the sample indicated that the importance of maintaining a high standard o f oral health and cleanliness when on dialysis had not been impressed on them. All of the 24 patients considered to have a poor standard of oral hygiene and 54 (82 ~ ) of the 66 patients seen to require dental treatment were found to be included in these 68 patients. N o significant difference in the treatment requirements, dental health awareness or oral hygiene standards were found to be present between males and females or between the patients of the hospitals in which this survey was carried out. Replies were received from 20 (62-5 ~o) of the 32 renal dialysis units which were asked to provide information on the dental treatment facilities made available to patients. The results of this part of the investigation are summarized in Table 2. Di~ussion The results of this survey indicate that dental treatment may be required by many renal dialysis patients most of whom may be unaware of the importance of maintaining a high standard of oral health. To ensure that all haemodialysis patients are made aware o f the
Dental surrey of renal dialysis paNents
155
TABLE2. Details of ~he arrangements made for the dental care of patients in 20 renal dialysis units in the U.K. lid
.
.
.
.
.
.
.
i
IIIIII
Arrangements for dental care Left to individual patient All care provided by parent hospital Referred to GDP for non-surgical procedure Referred to dental hospital for all care GDP for all care if possible Totals
III
i
iiii I
Ell
II
It
I
IIIII
IIIIlll
Illimll
~
pll
I
Number of units
Percentage of units
4 4 3 l 8 2O
(20%) (20%) 05%) (5%) (40%) 100%
importance o f establishing and maintaining dental health and that all patients receive effective regular dental care it is proposed that: (1) All new and established haemodialysis patients should be made aware of the possible complications o f failing to maintain a high s ~ n d a r d o f dental health. (2) All renal dialysis patients should have a comprehensive oral examination after stabilization on haemodialysis and subsequently at six monthly intervals. Patients who require extractions or other forms of oral surgery should be referred to specialized units in hospitals. Patients requiring restorative care should be referred to dentists providing such care within hospitals or to general dental practitioners who are prepared and equipped to undertake the treatment o f these patients in their practices. (3) Dentists and ancilla D' dental staffwho specialize in preventive care should formulate preventive programmes appropriate to haemodialysis patients and visit renal dialysis units to instruct patients on h o w they could best achieve a n d maintain a high standard of oral care. (4) The maintenance of preventive pr0grammes should be encouraged by hospital nursing staff, who may require further training to perform this role adequately, l~ Further studies are indicated to determine the' effectiveness and benefits of implementing the above recommendations and to assess the time required by various types of dental staff to run such a dental care programme. The data collected from the 20 renal dialysis units which provided information indicates that general dental practitioners may treat more than 50~o o f the renal dialysis patients referred for dental care. It is suggested that this finding and those of earlier studies on the dental care of other expanding minority groups o f hospital patients ~.1° indicate that both undergraduates and practising dental surgeons should receive instruction in the operative procedures and patient management techniques appropriate to specific groups o f patients whose conditions or therapy m a y eomplicate dental treatment. Aelmowledgements The authors wish to acknowledge the kind help o f Dr N. P. Mallick, Consultant Renal Physician, Manchester Royal Infirmary, Drs P. Ackrill and A. J. Ralston, Consultant Nephrologists, Withington Hospital, Manchester and Dr V. F. Hillier, Computation Advisory Group, Faculty of Medicine, Manchester University. Referen~ 1. Bottomley, W. K., Joffe, R. F. & Martin, A. 3. (1972). Dental management of the patient |reared by renal transplantation; preoperative and post-operative considerations. Journal o f American Dental Association 8.5, 1330--35.
156
J. L. Potter and N. H. F. Wilson
2. Dental Survey (1973). Dental hazards in haemodialysi~ patients reviewed. Dental Sur)~'3: 49, 34. 3. Donaldson, D. (1972). Homologous serum hepatitis and the dental treatment o f renal dialysis and kidney transplant pali,ents. British Dental Journal 132, 391-3. 4. Herman. L. T. & Friedman, J. M. (1975). Management of orofacial infection in patients with chronic renal disease. Journal o f Oral Surgery 33, 9~2- 5. 5. Hooley, J. R. & Petersen, W. M. (1969). Dental management of patients with renal failure treated by renal dialysis. Or~-ISurgery 28, 660-6.5. 6. Kirkpalrick, T. J. & Morton, J. B. (1971). Factors influencing the dental management of renal transplant and dialysis patients. British Journal o f Oral Surgery 9,57-64. 7. S~_,derholm, G., Lysell, L. & Svensson, A. 0974). Changes in the jaws in chronic renal insufficiency and haemodialysis. Journal of Clinical t'eriodontotogy | , 36-42. 8. Uthrnan, A. A. (I975). Viral hegatitis and the derital treatment o f renal dialysis and kidney transplant patients. Journal of Oral ~.h,dicine 30, 70-72. 9. Wilson, N. I4. F. (1975). An investigation of urgent dental treatment needs o f short ~erm in-patients and of the dental care required by both long-stay and dental priolity in-patients in a selected group o f Edinburgh hospitals. A Report from the Department of Restorative Dentistry, University of Ed~.aburgh. 10. Wilson, N. H- F. (1977). The dental care o f geriatric patients in hospitals, Public ltealth 91, 97-102. 11. '~Vood, G. D. & Bellamy, E. M. 0973). A survey o f the dental knowledge of nursing staff. Nursing Mirror 137, 12-16. 12. World Health Organisation (1971). Oral Health Surveys. Basic Methods. World Health Organisation: Geneva.