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Established renal failure can give rise to a variety of oral problems (Table 1), most commonly gum overgrowth (gingival enlargement secondary to drugs such as ciclosporin and calcium channel blockers) and sometimes a dry mouth (xerostomia).

Good mouth care is essential for patients with established renal failure, helping to keep the mouth free of dental decay (caries) and gum disease (gingivitis) and lessening the discomfort associated with mouth dryness (xerostomia).

The present advice document provides an outline of the mouth care that individuals with established renal failure can themselves undertake.

GUM ENLARGEMENT

Enlargement of the gums can be a side-effect of therapy with ciclosporin, calcium channel blockers (e.g. nifedipine) and perhaps tacrolimus. The enlargement is typically painless, although there can be mild bleeding from the gums — especially during tooth-cleaning. Regular tooth-cleaning, at least twice a day, will help reduce the risk of gum enlargement developing. Regular oral hygiene care by a dentist and/or hygienist is also important.

PREVENTION OF DENTAL DECAY (CARIES)

Dental decay (caries) is due to destruction of the tooth substance by acids produced by dental plaque. Individuals with renal disease may be at increased risk of tooth decay as a consequence of a lack of saliva (as saliva helps neutralise the acids of dental plaque).

Dental Decay – prevention

Dental decay can be minimised by:

• Control of dietary sugars (e.g. avoid sweet snacks between main meals, avoid sticky sweet food)
• Effective tooth-cleaning
• Use of fluorides

Tooth-cleaning

Tooth-brushing removes much of the plaque from the teeth but does not provide effective cleaning of the areas between the teeth. Effective cleaning between the teeth is only possible using a suitable interdental cleaning aid such as dental floss. Teeth should be brushed at least twice daily.

The ideal toothbrush

The ideal toothbrush should have nylon bristles of an even length and should be of medium hardness. The toothbrush should be small enough to be easily placed in the mouth and yet suitably designed to effectively remove all the dental plaque – a toothbrush head of approximately 1cm in length is usually sufficient. Soft brushes will not effectively remove plaque and debris and are only recommended when there is extreme dentine hypersensitivity. Hard brushes are not advisable as they can cause wearing of the teeth (toothbrush abrasion) and may lead to dentine hypersensitivity. There are an increasingly wide variety of manual brushes available, these including:

• Angled brushes – to facilitate access to areas of the mouth that are difficult to reach. These often have small heads and flexible handles.

Altered filament length brushes

• – these brushes clean above and below the tooth without causing over-brushing. These are excellent for patients with generally healthy mouths.

Easy-grip brushes

• – these are particularly useful for patients who do not have the strength to grip closely or firmly. The toothbrush handle can be altered by fixing a ball of sponge rubber, nail brush or bicycle handle bar grip to the brush handle.

In addition, Electric toothbrushes are increasingly popular and are often more effective than some manual brushes in removing plaque. They are ideal for patients who have limited manual dexterity. Electric toothbrushes are generally light and easy to hold.

Tooth-brushing techniques

The ideal tooth-brushing technique should remove the plaque, but not cause any damage to the teeth or gums. The two methods that are best suited to patients with established renal failure using a manual toothbrush are:

The roll technique

This is particularly useful for patients with healthy gums. The brush is placed with bristles on the gum tissue, the bristles are then pressed onto the gums making them blanche; maintaining the same pressure the bristles are moved across the gums onto the tooth surface. Behind the front teeth, the brush is held vertically and gently moved upwards and downwards.

The Bass technique

This is useful for patients with pre-existing gum disease. The bristles of the toothbrush are placed on the gum margins such that they point away from the crown of the tooth at an angle of 45 degrees. The brush is vibrated backwards and forwards with a horizontal movement to gently dislodge the plaque. This can be a time-consuming method, is difficult to master and may cause mild trauma to the gums if not carried out appropriately with the correct brush.

Toothpastes

Toothpaste aids the removal of any subsequent build up of plaque and calculus (tartar). In addition it provides a pleasant tasting mouth and fresh breath and can include fluoride, antimicrobials and desensitising agents. Most commercially available toothpastes contain fluoride that gradually causes a microscopic hardening of the outer surface of the teeth. As fluoride has no notable oral or other side-effects, patients with established renal failure are advised to use a fluoride-containing toothpaste.

Individuals with a high risk of dental decay (e.g. those with a dry mouth) may benefit from regular use of toothpaste with very high fluoride content such as Colgate Duraphat® 2800ppm, which can be prescribed by a dentist or a doctor.

Fluoride mouthrinses

Fluoride mouthwashes (e.g. Fluorigard®) are particularly recommended for patients who have a dry mouth (xerostomia) to lessen the risk of dental decay. Fluoride mouthrinses can be used on a daily or weekly basis and may be used in addition to fluoride-containing toothpastes. Fluoride mouthrinses should not be swallowed.

Other aids to tooth-cleaning

Disclosing agents

These stain dental plaque, thus indicating areas of plaque left behind after tooth-cleaning. These are useful in assessing how effective is tooth-cleaning.

Interdental cleaning devices

These are designed to remove plaque not cleaned from between the teeth during tooth-brushing. Dental floss and dental tape are the most frequently used interdental cleaning aids. The floss or tape requires to be threaded between the teeth and gently curled around the side of the tooth, slid down to the gums and gently brought back up to the top of the tooth. These agents can sometimes be difficult to use, thus it may be best to use dental floss with a suitable floss holder.

PREVENTION OF GUM DISEASE

Gum disease (gingivitis) can be prevented by effective tooth-cleaning. In addition anti-microbial mouthrinses such as Corsodyl® reduce levels of plaque and the severity of gingivitis. Advice about a suitable mouthrinse should be from your dentist, therapist or dental hygienist. However mouthrinses are not a substitute for effective tooth-cleaning. It remains unclear if alcohol-containing dental mouthwash increase the risk of mouth cancer, thus if you have any concerns it could seem sensible to use an alcohol-free mouthwash.

DENTINE HYPERSENSITIVITY

Dentine hypersensitivity manifests as diffuse dental pain in response to cold air, cold water or fruit drinks. The pain is short lasting and dull in nature. Use of a good toothbrush, an effective method of tooth-cleaning together with a fluoride-containing toothpaste minimises the risk of dentine hypersensitivity.

Treatment of dentine hypersensitivity

The treatment of dentine hypersensitivity comprises:

• Modification of tooth-brushing technique to ensure the teeth and gums are not damaged by overzealous or inappropriate tooth-brushing
• Application of desensitising agents
• Regular use of a desensitising toothpaste (e.g. MacLeans Sensitive®, Sensodyne F® or Colgate Sensitive®)
• Daily use of a fluoride mouthrinse — (please remember — the mouthrinse should not be swallowed).

Treatment of dry mouth

The management of long-standing dry mouth in established renal failure comprises principally:

• Salivary substitutes
• Moisturising gels
• Non-specific stimulation of salivary secretion

Salivary substitutes

These comprise two main approaches — water and drinks that the patient sips on a regular basis, and artificial salivary substitutes — often provided by doctors and dentists.

Many individuals find that sipping water or a non-sugary drink on a regular basis provides them with some degree of relief of symptoms, however, this can be impractical or impossible for some persons and may be contraindicated as a consequence of the renal disease. Certainly drinking or sipping sucrose-containing drinks must be avoided.

A range of synthetic salivary substitutes are available, these are either based upon carboxymethylcellulose (e.g. Glandosane®, Luborant®, Salivace® and Saliveze®) or porcine gastric mucin based products (e.g. Saliva Orthana®). No one product is better than another, and individuals often vary greatly in their preference of agents. Alcohol-free mouthrinses are also being suggested to be of benefit (e.g. BioXtra® and Biotène®).

If dryness at night is a particular problem, then using a teaspoonful of olive oil as a mouthwash last thing at night may be helpful and making sure that your bedroom’s atmosphere is not too hot and is moist may be helpful. A saucer of water on the radiator is a simple way of doing this.

Moisturising gels

A number of moisturising gels that can be rubbed on the dry surfaces of the mouth are now available (e.g. Oralbalance® and BioXtra®).

Non-specific stimulation of saliva secretion

The non-specific stimulation of saliva production is best achieved with chewing gums. However patients, particularly those with dentures, often find chewing gums difficult or unacceptable. At least two chewing gums have been developed specifically for the management of dry mouth; these are Biotène® dry mouth gum and BioXtra® chewing gum. A non-sucrose based pastille (Salivex®) is also available.

Stimulation of saliva production

Pilocarpine (Salagen®) stimulates saliva production. Pilocarpine has a number of side effects (e.g. some gastrointestinal upset and excess sweating) and is not suitable for all patients. Your doctor or specialist may be able to prescribe this.

DENTURE PROBLEMS

Poor retention of the upper denture due to a dry mouth – the upper denture can become easily dislodged causing rubbing and ulceration of the adjacent mouth lining (oral mucosa). This can be minimised by applying salivary substitutes to the fitting surface of the denture and having the denture regularly checked and/or modified.

Denture associated candidal infection – poor denture cleaning, in particular infrequent cleaning of the denture or wearing the denture during sleep, may lead to the development of a candidal infection that manifests as a painless red patch beneath the upper denture. To minimise this, dentures should be regularly cleaned using soap and water and a denture brush. It is best to clean dentures after each meal or at least once daily. Toothpastes should not be used to clean dentures as these are too abrasive. In addition, dentures should not be worn whilst asleep. Antifungal cream (e.g. miconazole) can be applied to the fitting surface of the denture.

Angular stomatitis – poorly fitting dentures and dry mouth may cause the development of red patches or ulcers at the corners of the mouth (angular stomatitis). This can be avoided by the dentures being regularly checked by your dentist.

Advice regarding other oral complications of established renal failure

Mouth ulcers

These are usually due to mild trauma of the lining due to dentures. Rarely they may be a complication of anaemia or drug therapy.

White patches

White patches on the lining of the mouth (oral mucosa) can arise as a result of some drugs. The white patches are usually painless but should always be investigated by a dentist or a specialist.

The investigation and treatment of these and other rare oral complications of established renal failure can be undertaken by a Specialist in Oral Medicine or a Specialist in Special Care Dentistry. Details of possible specialists can be obtained from:

• The British Society for Oral Medicine – www.bsom.org.uk

  or

• The British Society of Disability and Oral Health – www.bsdh.org

  or

• The General Dental Council List of Specialists – www.gdc-uk.org

Written by Professor Stephen Porter, Miss Fatimah Alsayer, and Dr Andrew Stein

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The National Kidney Federation cannot accept responsibility for information provided. The above is for guidance only. Patients are advised to seek further information from their own doctor.