# Effect of Educational Level on Oral Health in Peritoneal and Hemodialysis Patients

Authors: Gulsen Bayraktar; Idil Kurtulus; Rumeyza Kazancioglu; Isil Bayramgurler; Serdar Cintan; Canan Bural; Mine Besler; Sinan Trablus; Halim Issever; Nilgun Aysuna; Oktay Ozkan; Alaattin Yildiz
Journal: International Journal of Dentistry
 (2009)

---

## Abstract

Background. In previous studies, the oral and dental health statuses were compared in hemodialysis (HD) and peritoneal dialysis (PD) patients without taking into account the effect of educational levels on oral health. Hence we aimed to make a comparison of these parameters based upon the subjects educational levels.
Patients and Methods. 76 PD (33 males, 43 females-mean age: 44±12 years) and 100 HD (56 males, 44 females-mean age: 46±14 years)  patients were included. The number of decayed, missing and filled teeth were detected, DMFT index was calculated and plaque index (PI) values were assessed.
Results. Significantly higher numbers of filled teeth (P<.001)  and lower PI values (P<.01) in the PD group were detected with higher educational levels, whereas no significance was detected in the HD group. Higher DMFT index values were assessed in the lower educated and high school levels in PD than HD patients (P<.05). Higher numbers of filled teeth (P<.05) were detected in the secondary school level in PD patients. This difference was even more significant in the high school level (P<.001).
Conclusion. We assume that PD patients, who were found to be in a higher educational level, are more caring for their oral health as compared to HD patients.


---

## Body

## 1. Introduction

Dialysis treatment aims to clear  blood from
toxins by using a semipermeable membrane  in patients diagnosed with chronic
renal failure (CRF). Either the patient own peritoneal membrane (peritoneal
dialysis (PD)), or a semipermeable synthetic  membrane (hemodialysis (HD)) is
used for this purpose [1].To date, there have been studies
evaluating the oral hygiene and dental health status of mostly HD patients in
comparison to healthy controls (Cs). The mostly observed oral findings are xerostomia and parotitis,
which are believed to result from a combination of direct gland involvement,
chemical inflammation, dehydration, and mouth breathing [2–4].
Epstein et al. [5] reported that salivary sodium and
chloride concentrations were not lower in dialysis patients, but potassium
tended to be higher in these patient groups. These authors  also detected
significantly higher phosphate values, but no decrease in salivary calcium
levels indicating that in the salivary gland there was any compensatory decrease in calcium when
phosphate was elevated. An accelerated rate of calculus formation has also been
reported in these patients, which was attributed to elevated salivary urea
levels [3, 5, 6]. But on the contrary, this was reported
to contribute to remineralization of decayed dental enamel, which leads to
lower caries levels in this patient group [7]. However, conflicting data exists on the
prevalence of caries in chronic renal failure (CRF) patients. Levy [8] reported a lower prevalence of caries in
these patient groups, but there are also studies which claim to detect higher  [6, 9] decayed (D), missing (M), and filled (F)
teeth index (DMFT) scores which were developed to determine the oral and dental health statuses [10], as well as studies
reporting comparable results [11, 12]. Furthermore, several studies [13–16] evaluating
plaque accumulation in CRF patients attributed higher plaque indices (PIs) in
the oral neglect of these patients.Detecting oral problems in dialysis
patients is of utmost importance for preventing potential infections [4, 17] because recent
studies of the healthy population have shown that oral infections are associated with an increased risk
of systemic complications like atherosclerosis [18], chronic obstructive pulmonary
disease [19], and adverse pregnancy outcomes [20]. Due to the usage of the patient own
peritoneal membrane during PD therapy, they are demanded to complete a hygiene
training program at the onset of therapy in order to prevent an infection of
the membrane. In this training program, the patients are instructed in the
rules of PD therapy and in maintaining general hygiene. In patients elected for
the PD instruction program, educational level is usually not a selection criterion.  In spite of
this fact, people with higher educational level are obviously more capable of completing this
program.In our literature
search, one study was found evaluating the effect of educational level on
dialysis choice amongst other factors like age, gender, and clinical parameters
[21]. But none of
these studies aimed at
determining the relationship between the educational level and dental
parameters or oral hygiene status of these patients.Hence, it was the
aim of this study to analyze
and compare the effect of educational level on the number of decayed, missing
and filled teeth, and DMFT index and PI values in a group of PD and HD
patients.


## 2. Subjects and Methods

In this cross-sectional study, 76 PD patients (PD group-test group: 33
males, 43 females-mean age: 44 ± 12 years) and 100 HD patients (HD
group-test group: 56 males, 44 females-mean age: 46 ± 14 years), who were followed up in Istanbul School of Medicine and Faculty of
Dentistry out-patient clinics in 2000–2005, were
included. All participants gave informed consent to take part in this study.Patients on dialysis for
more than 6 months were included in the study. The duration of dialysis was 4 hours per session with
300–350 mL/min blood
flow rate and with a dialysate flow of 500 mL/min. All HD patients were
dialyzed with standard bicarbonate containing dialysate bath. All PD patients
were dialyzed using conventional lactate-buffered glucose-based PD solutions. Fifty
five of PD patients were on CAPD (4 to 5 times exchanges per day with 2000 mL)
and remaining 21 patients were on APD. Twenty
eight patients had diabetes mellitus, and it was the reason for ESRD in 23
patients.In
2 of HD patients (2%) and 1 of PD patients (1%), hepatitis B surface antigen
was positive. Anti- HCV  was found positive in 19 (19%) of HD patients and 12
(16%) of PD patients. Vascular access was AVF in 90 (90%) of HD patients and the
remaining 10 (10%) had AVG. There was not any evidence for clinical findings of
a vascular access infection.


## 2.1. Clinical Examination and Indices

Prior to clinical examination, a
detailed medical history including the information about age, gender, and
education level was recorded for all the participants. Intraoral evaluation of
all patients was performed
according to WHO standard methods and criteria [22]. Decayed, missing, and filled teeth
were detected, and DMFT index was calculated using a mirror and a probe in all
participants.The
thickness of microbial dental plaque on the tooth surface near the marginal
gingiva was assessed using Silness and Löe Plaque Index (PI). After the
teeth were dried, the microbial dental plaque was scraped by the Williams
periodontal probe and evaluated by unaided eye [23].


## 2.2. Statistical Analyses

Statistical analyses were performed using a software
(SPSS for Windows Software Package, Version 11.5.0; SPSS Inc., Chicago, Ill,
USA).Student’st-test was used to calculate the means
and to assess the differences between the ages and biochemical parameters of PD
and HD groups. The difference between the distribution of the gender of the PD
and HD patients was analyzed
with Pearson’s chi-square
test. Differences between time on dialysis of PD and HD groups were analyzed
using Mann-Whitney U test.The median (min-max) values and statistical difference of
the number of decayed, missing, and filled teeth and DMFT index and PI values
were assessed using Kruskal-Wallis test.The differences of the number of decayed, missing, and
filled teeth, and DMFT index and PI values between PD and HD groups based upon
their educational levels was assessed using the one way Anova analysis. The
level of significance was set atP<.05.


## 3. Results

No statistically significant differences
were found between the distribution of age and gender as well as the means of
time on dialysis among PD and HD groups. BUN (P<.001) and blood phosphor (P<.01) levels were statistically significantly higher in HD
than PD patients, while creatinine and blood calcium levels were comparable in
both groups (Table 1).Table 1
Distribution of age, gender, and time on dialysis and laboratory findings among PD and HD
groups.
PD groupHD groupP-valuen76100Age (year ± SD)44 ± 1246 ± 14Gender (male/female)33/4356/44Time on dialysis (months)25 ± 2927 ± 21BUN (mg/dL)55 (30–91)142 (32–282)Creatinin (mg/dL)8.95 (2.30–16.50)9.05 (3.90–147)Kt/V2.25
(0.30–4.05)1.11
(0.41–2.54)Ca (mg/dL)9.18 ± 0.99.04 ± 0.7P (mg/dL)5.06 ± 1.25.95 ± 1.6n: Number of
patients in the groups;    PD group: Group
of patients receiving peritoneal dialysis treatment;  HD group: Group
of patients receiving hemodialysis treatment;  BUN: Blood urea nitrogen;  Kt/V: Marker
of dialysis adequacy (k
(clearance) × t (dialysis time)/V (patient’s body water));  NS: Statistically not significant (P>0.05).Distribution of educational level in the PD and HD groups is given in
Table2. The PD group was found to be composed of 37% of patients in the
uneducated and primary school levels, whereas 34% of patients were in the high school level.
In the HD group, these proportions were 72% and 7%, respectively. The secondary
school level in both the PD and HD groups was found to be comparable (23% and 21%, resp.).Table 2
Distribution of educational level in the PD ve HD groups . (χ2 test, P<.001).
Educational levelPD
group (n; %)HD
group (n; %)TotalUneducated and primary school28 (%37)72 (%72)100Secondary school22 (%29)21 (%21)43High school26 (%34)7 (%7)33Total76100176n: Number of
patients in the groups; PD group: Group of patients receiving peritoneal
dialysis treatment; HD group: Group of patients receiving hemodialysis
treatment.Median (min-max) values and statistical comparisons according to the
educational levels of the PD patients for decayed, missing, and filled teeth; DMFT
index; PI values are shown in Table3. With higher educational levels,
significantly higher numbers of filled teeth (P<.001), but lower PI values (P<.01), were detected.Table 3
Median (min-max) values and statistical comparisons for decayed,
missing, and filled teeth, DMFT index, and PI values in the PD group.
PD groupUneducated and primary school
median (min-max)Secondary school
median (min-max)High school
median (min-max)PMissing11 (0–30)7 (0–32)9 (0–23)NSDecayed2 (0–7)1 (0–7)0 (0–7)NSFilled0 (0–22)3 (0–15)6 (0–24)P<.001DMFT index14 (0–37)13 (1–32)16 (3–39)NSPI2 (0.38–3)0.95 (0.08–3)1.23 (0.25–3)P<.01PD group: Group
of patients receiving peritoneal dialysis treatment; DMFT index: Decayed,
missing and filled teeth index; PI:
Plaque index; NS: Statistically not significant (P>.05).Median (min-max) values and statistical comparisons according to the
educational levels of the HD patients for decayed, missing, and filled teeth;
DMFT index; PI values are shown in Table4. No statistical differences were
found between the educational levels and dental parameters or oral hygiene
status.Table 4
Median (min-max) values and statistical
comparisons for decayed, missing, and filled teeth, DMFT index, and PI in the
HD group.
HD groupUneducated and primary school
median (min-max)Secondary school
median (min-max)High school
median (min-max)PMissing7 (0–26)7 (0–16)5 (1–21)NSDecayed1 (0–9)1 (0–5)1 (0–6)NSFilled0 (0–7)0 (0–10)0 (0–4)NSDMFT index10 (0–30)10 (0–25)9 (1–22)NSPI1.93 (0–3)2.17 (0.43–3)0.59 (0–3)NSHD group: Group
of patients receiving hemodialysis treatment; DMFT index: Decayed, missing
and, filled teeth index;
PI: Plaque index; NS: Statistically
not significant (P>.05).Mean (±SD) values and statistical comparisons according to the educational
levels of HD and PD patients for decayed, missing, and filled teeth; DMFT index;
PI values are shown in Table5. In the uneducated and primary school levels, DMFT index values
were statistically significantly higher in PD than HD patients (P<.05). In the secondary school
level, higher numbers of filled teeth, but lower PI index values, were detected
in the PD than HD group (P<.05).
In the high school level statistically significantly higher DMFT index scores (P<.05) and remarkably higher numbers
of filled teeth (P<.001) were
detected in the PD than HD group.Table 5
Mean (±SD)
values and statistical comparisons for missing, decayed, and filled teeth, DMFT
index, and PI in the PD and HD groups based upon their educational levels.
PD
group
mean (  ±SD)HD
group
mean (  ±SD)PUneducated
and primary schoolMissing12.4 ± 99.72±7.8NSDecayed2.32±2.31.71±2.1NSFilled2.07±5.10.92±1.8NSDMFT index16.79±10.512.35±8.2P<.05PI2.06±0.91.87±0.9NSSecondary
schoolMissing8.14±7.67.62±4.5NSDecayed1.55±2.31.38±1.3NSFilled4.05±4.11.76±2.7P<.05DMFT index13.73±8.110.76±5.4NSPI1.29±0.92.09±0.9P<.05High schoolMissing8.85±5.36.57±6.9NSDecayed1.31±1.91.71±2.2NSFilled7.42±6.80.86±1.6P<.001DMFT index17.58±8.99.14±6.5P<.05PI1.42 ± 0.71.33±1.5NSPD group: Group
of patients receiving peritoneal dialysis treatment; HD group: Group of
patients receiving hemodialysis treatment; DMFT index:
Decayed, missing and filled teeth index; PI:
Plaque index; NS: Statistically not significant (P>.05).


## 4. Discussion

It was shown in this study, conducted based upon the educational level
of the patients, that with higher educational level the number of filled teeth was higher and oral
hygiene status was  improved
statistically in only PD patients (Tables3 and 5). Although not statistically
significant, the oral hygiene status tended to improve also in the HD group
with higher educational level (Table 4). Comparisons of dental parameters and
oral health status according to educational levels between PD and HD groups
revealed clearly that in all educational levels the number of filled teeth,
DMFT index, and PI values was
better in PD than HD patients. In the high school level, these differences were
even remarkable (Table 5).There were 5 times more patients in the higher educational level in the
PD than HD group. Due to the instruction in hygienic rules PD patients get at
the beginning of therapy, the authors believe that these people are expectedly
more caring for their oral hygiene. The higher numbers of filled teeth as well
as the lower PI values in the PD group are supporting this opinion.In the present
study, the comparison of the dental parameters and PI values in the HD group
based upon their educational levels revealed no statistical significant
differences. In spite of this, it was found that PI values were the lowest in
the patient group with higher educational level (Table4). It has also to be
taken into account that patients in the uneducated and primary school levels are 2 times more
in the HD than PD group. As a result of this, the authors believe that this patient
group is neglecting their dental health and oral hygiene. Several studies [13–16] also confirm
that oral hygiene negligence would cause higher plaque accumulation in this
patient group. They explain this fact in that HD patients would be more
dependent on a dialysis center than PD patients. HD patients are usually bound
to a dialysis machine for approximately 4 hours several times a week. Galili et
al. [15] claimed that HD patients would be in
a depressive state because of their life threatening disease and thus would
rather be uncooperative during dental  treatment and would further neglect their oral hygiene. PD patients in contrast are usually capable of continuing their
treatment outside a dialysis center. Because of the fact that this patient
group has a more free life, they are supposed to care more for their oral
hygiene. In our literature search, we were unable to find any study comparing
dental parameters and oral hygiene statuses according to the educational level of these patient
groups. Hence, we are unable to compare our results with previous studies.In conclusion, regular dental visits
and remotivation in plaque control is of vital importance to ensure optimal
oral health in dialysis patients in order to prevent rejection of the allograft
after transplantation as a result of oral infection [24].The authors suggest that further
studies on this topic should be conducted as multicenter approaches when
necessary to get data from large patient groups.



---

*Source: 159767-2009-03-10.xml*