Oral Care Guideline for Adult Patients with CKD · CKD is associated with age-related decline of renal function and is highly prevalent, estimated to affectbetween 11% to 13% of the

Oral Care Guideline for Adult Patients with CKD

EditorsTai Mooi HoNavdeep Kumar

All rights are reserved by the author and publisher, including the rights of reprinting, reproduction in any form and translation. No part of this book may be reproduced, stored in a retrieval system or transmitted, in any form or by means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the publisher.

First edition: July 2018

European Dialysis and Transplant Nurses Association/ European Renal Care Association (EDTNA/ERCA)Seestrasse 91, CH 6052 Hergiswil, Switzerlandwww.edtnaerca.org

ISBN: 978-84-09-03339-3

D.L.: M-22828-2018

AcknowledgementThe authors would like to thank Sergi Diez for providing the illustrations.

Layout, Binding and Printing: Imprenta Tomás Hermanos Río Manzanares, 42-44 · E28970 Humanes de MadridMadrid - Spainwww.tomashermanos.com

Oral Care Guideline for Adult Patients with CKDA Guide to Clinical Practice

AuthorsTai Mooi Ho, RN, RM - Spain.

EDTNA/ERCA Project Coordinator.

Dr. Navdeep Kumar, BDS, FDSRCS (Eng), PhD, Cert RDP, Cert Surg & Pros Implantology - UK.

Consultant in Special Care Dentistry / Clinical Lead Dental Medicine.

European Dialysis and Transplant Nurses Association/ European Renal Care AssociationTai Mooi Ho | Navdeep Kumar

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Contents1. Aim ......................................................................................... 62. Objectives ............................................................................... 63. Importance of oral care in CKD .............................................. 64. Main functions of the mouth ................................................... 75. Indicators of a healthy mouth ................................................. 86. Oral manifestations in adult patients with CKD ...................... 87. Impact of poor oral hygiene on the general health

of adult patients with CKD .................................................... 108. Oral assessment: tools and what to look for ........................ 119. Recommendations ............................................................... 1210. Conclusions .......................................................................... 1511. Key points ............................................................................. 1512. References ........................................................................... 16

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1. Aim

The key principle of this Oral Care Guideline is to ensure that oral health assessment forms an integral part of the care plan for each patient with chronic kidney disease (CKD).

2. ObjectivesThe main objectives are to:• Support renal nurses who are involved in caring for adult patients

with CKD• Highlight the importance of oral care• Outline the oral manifestations which may be seen in patients

with CKD• Provide guidance with regards to the assessment of the oral

cavity• Provide guidance on the management of observed changes in

the oral cavity

This Guideline is based on results of scientific research andsubsequent expert recommendations.

3. Importance of Oral Care in CKDCKD is associated with age-related decline of renal function and is highly prevalent, estimated to affect between 11% to 13% ofthe global population1. Approximately 90% of patients with CKDwill have oral signs or symptoms, including bleeding gums, a dry mouth, candidiasis, burning mouth, abnormal taste and abnormal lip pigmentation2. Ruospo and colleagues performed a systemic review of 88 studies in 125 populations (11,340 dialysis adult patients) and reported3:

• 57%hadgumdisease• 50%haddrymouth• 20%wereedentulous• 19%hadoralpain• 25%neverbrushedtheirteeth

Thesefactorscansignificantlyimpactonthewell-beingofpatientswith renal disease and their quality of life. For example, a tooth with


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dental decay and/or gum disease may be associated with pain, infection and swelling, particularly when the decay involves the nerve of the tooth and there is a dental abscess. This can cause problems with eating, drinking and swallowing. In addition, a dry mouth lacks adequate saliva to mix with food particles during the process of mastication. The dry mouth is often accompanied by an abnormal taste as well as a burning sensation. All these factors can have a significanteffectonnutrition.

Furthermore,manystudieshavedescribedasignificant interactionbetween oral health and CKD2, 4-7. Indeed, a bidirectional link between CKD and gum (periodontal) disease has been demonstrated by Fisher et al5. Thiseffectispostulatedtobeinpartduetoendovascularinflammation,which is a feature of both conditions, andmediatedby diabetes duration and hypertension. Periodontal disease has subsequentlybeenidentifiedasariskfactorforthedeclineofrenalfunction and increased mortality rate8,9.

In this context, mouth care and prevention strategies are essential not only to maintain good oral health but also to reduce general complications10. In addition, effective screening for potential oralmanifestations will enable early detection and management. These measures can have a positive outcome on the quality of life for patients with CKD.

Nurses have a key role in ensuring that patients under their care are supported to maintain good oral hygiene10. However, it has been demonstrated that, in general, mouth care is given a low priority in clinical practice11,12. This may be linked to a lack of adequate knowledge about the importance of oral health and minimal clinical experience in the assessment of the oral cavity13.

4. Main functions of the mouthRawlins and Trueman described the main functions of the mouth being mastication of food and communication, both of which involve the lips, tongue and teeth/dentures as well as adequate salivation14. Saliva is an important component of a healthy mouth and has several functions. It lubricates the mouth thus facilitating speech anddietaryintake,cleanstheoralcavitybyflushingfoodanddebris,neutralises acids and helps to strengthen tooth surfaces. It contains a digestive enzyme (amylase), which acts on carbohydrate starches

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to help break them down into simple sugars. It also possesses antimicrobial properties15.

5. Indicators of a healthy mouthMost adults have a maximum of 32 teeth. A healthy mouth should have the features listed and annotated in the illustration below:• Lips: pink, smooth & moist, no pigmentation or lesions• Tongue: clean, pink, moist, normal papillae, no lesions• Teeth/dentures: clean (free of plaque & debris/food particles)• Gums: pink and moist• Mucous membrane (cheeks, palate & under the tongue):

smooth, moist and pink, no lesions• Saliva: thin and watery, covering all surfaces

Teeth/well-fittingdentures: Clean & without debris

Oral mucosa

Tongue

Gums

Pinkish, moist,clean &

without lesions

Lips: Pinkish, moist

& without lesions

Including nodifficultieswitheatingand/orswallowingfood

Figure 1: Indicators of a healthy mouth

6. Oral manifestations in adult patients with CKDPatients with CKD may experience a wide range of oral manifestations as summarised in Table 1. The underlying cause for these is variable. Renalnursesneedtobeawareofthesesothattheycanofferadviceand support.


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Table 1: Common oral manifestations in adult patients with CKD4

Manifestations Underlying cause in CKDXerostomia (dry mouth)

• Restriction in fluid intake/dehydration,• Side eff ects of drug therapy, • Uremic involvement of salivary glands, • Mouth breathing.

Metallic taste • Increased concentration of urea in the saliva transformed into ammonia & carbon dioxide by bacterial urease,

• Metabolic disturbance,• Change in salivary flow/composition,• Low levels of zinc.

Halitosis (bad breath)

• Uraemia – ammonia release causing a ‘fishy/urine odour’,

• Poor oral health/gum disease,• Contributed by underlying diabetic

ketoacidosis,• Dietary factors.

Gingival changes• Gingival hyperplasia

(enlargement)• Gingival bleeding• Pale gingivae

• Drug therapy such as cyclosporin (transplantation) and/or calcium channel blockers (hypertension).

• Platelet dysfunction and the effects of anticoagulants used (HD).

• Anaemia.Mucosal lesionse.g. white patches and/or ulcerations

• Drug therapy and/or uraemia.

Periodontal disease • Infectious inflammatory

condition characterised by the damage of tooth support tissues due to the accumulation of bacterial dental plaque.

• Poor oral hygiene in the elderly,• Burden of common co-morbidities such as

diabetes mellitus, multiple drugs regimen and immune dysfunction.

Oral infections• Candidiasis (thrush) • Viral

• Suppressed immune system among dialysis and transplant patients.

Dental anomalies• Narrowing or

calcification of the pulp chamber

• Loss of non-carious tooth tissue

• Alterations in calcium and phosphorus metabolism.

• Frequent nausea/vomiting or regurgitation induced by uraemia and medication.

Orofacial features• Bones, teeth and

periodontium

• Alterations in calcium and phosphorus metabolism.

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7. Impact of poor oral hygiene on the general health of adult patients with CKD

Poor oral hygiene can impinge on a patient’s wellbeing and may compromise nutritional intake due to related dental pain, mobile teeth due to gum (periodontal) disease, and loss of teeth16.

Periodontal disease is highly prevalent among patients with CKD4. It has been associated with many systemic consequences such as low serum albumin17, inflammation, infections, protein-energy wasting(PEW), atherosclerotic complications18 and increased levels of markersofinflammation(e.g.C-reactiveprotein),andmaypotentiallycontribute to higher cardiovascular risk19. As stated previously, recent studies have established that periodontal disease increases the risk for mortality6-8. Its association with cardiovascular morbidity and mortality has been observed not only in patients on haemodialysis (HD)20 but also in those with stages 3-5 CKD7.

Epidemiologicalstudieshaveidentifiedthatinadditiontountreatedoral infection being associated with systemic disease, it may be also be the trigger for the spread of potentially pathogenic microorganisms such as candida, to other parts of the body, particularly in the immunocompromised transplant patients21.

Furthermore, it is also important for renal nurses to be aware that patients receiving dialysis often suffer from a dry mouth. Salivais an essential component of the oral cavity and a diminished flow can result in a host of other oral health problems such as discomfort/loss of oral tissue integrity due to xerostomia, difficultywith chewing, swallowing foods, and speech, and an increased risk of dental decay and oral infections15. Renal nurses need to be able to identify when xerostomia is present so that they can implement support and encourage preventative strategies.

Conditions arising from poor oral health can also result in profound psychosocial effects for the individual, affecting negatively theirquality of life. For example:

• Halitosis can cause embarrassment and consequently can interfere with social relationships22.

• Tastedisordercanaffectappetiteandhencetheenjoymentoffood23.


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• Missing teeth can negatively impact on self-image and self-esteem, as well as resulting in problems with speech and eating24,25.

• Xerostomia, caries and mucosa lesions can cause discomfort/pain,resultingindistressandaffectingappetite/speech26.

8. Oral assessment: tools and what to look for27

A. Tools• Light source (preferably a pen torch) for better visibility.• A clean wooden spatula.

B. Patient’s condition• Isthepatientphysicallyandmentallyfittoperformoralcareon

his/her own?• Does the patient complain of:

- Pain? - Difficultywithspeaking? - Difficultywithchewing/swallowingfoods? - Unpleasant taste?

C. Oral cavity Condition• Lips

- Are they pink, smooth & moist? - Aretheydried/cracked,withdifficultyopeningthemouth? - Are they swollen/ulcerated?

• Tongue - Is it clean, pink, smooth & moist? - Isitdry,coated,fissuredandshiny? - Does it look abnormal (white patches, very sore/ulcerated)?

• Teeth/dentures - Are they clean (free of plaque & debris/food particles)? - Any missing/broken/loose teeth? If dentures, are they well-fitted&comfortable?

- Any dental caries?• Gums

- Are they pink and moist? - Aretheyswollenandred(inflamed)? - Do they bleed during tooth brushing?

• Mucous membrane (cheeks, palate & under the tongue) - Is it smooth, moist and pink? - Are there any lesions (ulceration & bleeding or white patches)? - Is it reddened and coated?

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• Saliva - Is it thin and watery? - Is the mouth very dry with cracked tongue and lips? - Does the mouth have an unpleasant smell?

9. RecommendationsExamples of evidence-based recommendations that may be used for patients with CKD (hospitalised non-critical renal patients, those who are receiving dialysis treatment and transplant patients) are outlined below:

Assessment• Prior to assessment, explain the procedure to the patient and

obtain verbal consent.• Use an oral assessment guide to carry out a thorough screening

of the patient’s oral cavity and develop a care plan tailored to patient’s individual needs.

• Assessment findings and all subsequent oral care providedshould be recorded accordingly in the patient’s clinical notes10, 27.

• Nurses should provide oral hygiene care to admitted patients who are unable to carry out the procedure for themselves28.

• Any patient with unusually swollen and/or ulcerated lips/palate/tongue, as well as any with decayed tooth/teeth with pain and swollenfaceshouldbereferredtomedicalstaff.

Toothbrushing• Ensure that all patients have his/her own toothbrush.

Toothbrushing is the best method for removing dental plaque29. • Dental plaque is a thin coat of sticky colourless bacteria that

forms on teeth through eating and drinking, particularly sugary foods and beverages. These bacteria absorb the sugar and convert it into acid, which destroys tooth enamel, thus resulting in caries27.

• Advocate for regular oral cleansing with a toothbrush (small headwithsoftbristles)andapea-sizedamountoffluoridatedtoothpastecontainingatleast1350ppmfluoride.Higherfluoride(2800 or 5000ppm) toothpaste can be prescribed for patients with dry mouth and/or sensitive teeth to erosion30,31.

• Tooth brushing should be done at least twice a day - morning and night29-31. Do not drink/eat for 30 minutes after brushing and not at all after brushing at night.


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• Advise patients to spit, do not rinse the mouth during/after toothbrushing (this ensures that the beneficial effects of thefluoride in thetoothpasteareoptimized)30. Patients should not brush their teeth immediately after an acidic meal/vomiting. Instead they can be encouraged to rinse their mouth with water.

• Inform patient to replace his/her toothbrush regularly (about every 3 months) before the bristles become excessively frayed, as this iswhenthetoothbrushislessefficienttoremovedentalplaque32.

• Chlorhexidine 0.2%, without alcohol mouthwash (used 30 minutes after tooth brushing) is the agent of choice to reduce dental plaque by inhibiting bacterial growth but frequent use tends to stain teeth33,34. It may be advised for gum disease.

Denture Care• Dentures should be cleaned thoroughly after each meal, using a

small toothbrush/denture brush and a denture cleaning paste or fragrance free-soap to remove debris and plaque.

• They should be removed every night, cleaned and left overnight in water. Denture cleansing tablets have been proven to reduce the total bacterial count,35 but some can damage metal framed dentures and should not be used.

• For a hospitalised patient, dentures should be placed in a container with lid and marked clearly with the corresponding patient’s full name.

Sore/dry mouth care• It is important to determine the cause of a painful mouth. It could beduetoill-fittingdenturesand/orinfection(e.g.thrush).

• Incaseofasoreand/ordrymouth,useamildflavouredsodiumlauryl sulphate (SLS) free toothpaste as it causes less irritation27.

• Remind patients to keep their mouths clean and have frequent sipsofwater. Ifonfluidrestriction,hydratethemucosawithasponge stick/moist soft toothbrush27.

• Although foam swabs/cleansers can be useful if the mouth is dry and sore, they should not be used as a routine substitute for a toothbrushastheydonoteffectivelyremovedentalplaque27,36.

• To relieve a dry mouth, recommend sugar-free chewing to stimulatesalivaryflow27.

• Sweets/lemon drinks used by some patients to stimulate saliva should be avoided as they greatly increase the risk of dental decay and dental erosion27.

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• Do not recommend the use of lemon and glycerine swabs for mouth care as they are harmful, causing acidity/dental decay and dryness, respectively37.

• Apply a lubricant to dry lips to keep them intact, thus preventing soreness from cracked lips and also providing a natural barrier to infections. Olive oil, aloe vera gel and rapeseed oil spray may alsobeeffectivealternatives38.

• Bear in mind that medications can cause xerostomia4. Most patients receiving dialysis have other common chronic conditions such as hypertension, diabetes, cardiovascular disease, and mineral and bone disorder, all of which require long-term polypharmacy management.

Mouth ulcer care27

• Advise the patient to rinse the mouth after meals besides maintaining standard oral care.

• Ask the doctor about the use of topical analgesic and/or anti-inflammatorymouthsprays/mouthwasheswithanumbingeffect(e.g.benzydamineHCL0.15%).

• If the ulcer is present for longer than 2 weeks, refer urgently to themedicalstaff.

Oral thrush (candidiasis) care27

• Pay particular attention to patients who are immunocompromised (e.g. dialysis and transplant), those having dry mouth, taking antibiotics and/or steroids and those not cleaning their dentures properly as oral thrush is common in these patients.

• Thrush usually appears as white patches on the palate, above the tongue or elsewhere in the mouth (sometimes as red patches). The white patches can sometimes be scraped off,turning into painful raw areas that can bleed.

• Advise the patient to maintain good oral hygiene and refrain from smoking.

• Patients who use dentures should be advised on how to clean their dentures (see “Denture Care”).

• Chlorhexidine0.2%canbeusedtocleanandsoakdenturesinmouthwash for 15 minutes twice a day.

• Manage/treat dry mouth, if present.• Encourage patients who use a corticosteroid inhaler to rinse

their mouth with water after use.


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• Refertomedicalstafffortheprescriptionofantifungaltreatmentand to identify any underlying causes which need to be treated.

Dental check-up• Educate patients and/or carers on the importance of proper

oral hygiene and advise regular dental check-up at least every 6 months, although some people may avoid going to the dentist because of the cost of dental care/treatment.

10. ConclusionsTheprovisionofeffectivemouthcaretopatientswithCKD(regardlessof the disease stage and type of treatment option) is possible if nephrology nurses are fully aware that poor oral hygiene can lead to oral disease that may predispose these patients to systemic complications, increasing the risk for mortality. In the renal setting, it has been demonstrated that educational intervention can increase nurses’ knowledge of oral health in CKD and the use of an oral and nutritional assessment tool can help to improve oral care provision and patient’s health outcomes, thus, enhancing quality of life16,39. Educational intervention to increase renal nurses’ knowledge about oral health in CKD and skills related to mouth care can be addressed, for instance, through face-face training in the work environment, use ofonlinelearningtools,guidelinesandinformationleaflets.

11. Key points

• CKD can give rise to a wide range of oral manifestations.• Poor oral health can result in periodontal disease which may

contribute to many systemic consequences, increasing the risk for mortality. It can also lead to malnutrition.

• Good oral care can prevent complications and improve patients’ quality of life.

• Nurses should raise awareness on the importance of oral care among patients and ensure that this is integrated into their care plans.

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