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«COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY ADVISORY TITLE Use of the dental hygiene interventions of scaling of teeth and root planing ...»

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CDHO Advisory | Kidney Disease and Kidney Failure



Use of the dental hygiene interventions of scaling of teeth and root planing including

curetting surrounding tissue, orthodontic and restorative practices, and other invasive

interventions for persons1 with kidney disease or kidney failure.


Cite as College of Dental Hygienists of Ontario, CDHO Advisory Kidney Disease and Kidney Failure, 2010-07-15


Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE DISEASE/CONDITION(S)/PROCEDURE(S) Kidney disease and kidney failure


Advanced practice nurses Nurses Dental assistants Patients/clients Dental hygienists Pharmacists Dentists Physicians Denturists Public health departments Dieticians Regulatory bodies Health professional students


To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have kidney disease or kidney failure, chiefly as follows.

1. Understanding the medical condition.

2. Sourcing medications information.

3. Taking the medical and medications history.

4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.

1 Persons includes young persons and children P a g e |1 CDHO Advisory | Kidney Disease and Kidney Failure

5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.

6. Deciding when and when not to proceed with the Procedures proposed.

7. Dealing with adverse events arising during the Procedures.

8. Record keeping.

9. Advising the patient/client.


Child (2 to 12 years) Adolescent (13 to 18 years) Adult (19 to 44 years) Middle Age (45 to 64 years) Aged (65 to 79 years) Aged, 80 and over Male Female Parents, guardians, and family caregivers of children, young persons and adults with kidney disease or kidney failure.


For persons who have kidney disease or kidney failure: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

–  –  –

3. Childhood nephrotic syndrome, also called nephrosis, in which the kidneys leak large quantities of protein into the urine, leading to edema often of the eyelids, feet and ankles and, eventually, the abdomen.

4. Chronic kidney disease, chronic renal insufficiency a. is the commonest pattern in kidney disease b. develops slowly c. may be silent for many years, but presents various symptoms as the kidney function deteriorates, including i. frequent headaches ii. fatigue iii. itching over the entire body d. as it deteriorates, uremia develops because excretion of waste products and excess water is impaired; additional symptoms become evident, including i. frequent urination or reduction in urinary output ii. swelling of legs, ankles, feet, face and/or hands iii. metallic taste in the mouth iv. nausea and vomiting v. loss of appetite vi. shortness of breath vii. feelings of cold viii. difficulty with mental concentration ix. dizziness x. leg pain or muscle cramps.

e. may progress to permanent kidney failure, with high risk of i. death from stroke ii. heart attack.

5. End-stage renal disease a. is near-total or total and permanent kidney failure b. requires dialysis or kidney transplant to sustain life.

6. Glomerular filtration rate, the rate at which the kidneys clear creatinine, a waste product of muscle activity, from the body.

7. Glomerulonephritis, also called nephritis, a disease of the kidneys in which the glomeruli become inflamed or damaged, allowing blood protein and red blood cells to pass into the urine.

8. Hemodialysis, a process for cleaning the blood, in which blood is withdrawn from the body by a machine and passed through an artificial kidney called a dialyzer.

9. Lesion, a term variously and loosely used in medicine to refer to such things as a. any abnormality of tissue in the body, including the mouth and skin b. any localized abnormal structural change in a bodily part c. a mass especially before a definite diagnosis is established d. cancer e. an injury to living tissue, such as a cut or break in the skin.

10. Nephron, of which each kidney possesses more than a million, comprises a. the glomerulus, which filters water-soluble waste products from the blood b. the attached tubule, which reabsorbs much of the water.

11. Oral ulcer, an open lesion, often painful, inside the mouth or upper throat, an alternative name for a. a mouth ulcer

–  –  –

Overview of kidney disease and kidney failure Resources consulted  The Kidney Foundation of Canada: Chronic Kidney Disease  The National Institute of Diabetes and Digestive and Kidney Diseases: Kidney Disease and Kidney Failure  National Kidney Foundation Classification of Chronic Kidney Disease: Definition and Classification Of Stages Of Chronic Kidney Disease

–  –  –

Table 2: Kidney failure Kidney failure in adults Amyloidosis and Kidney Disease Anemia in Kidney Disease and Dialysis Eat Right to Feel Right on Hemodialysis Hemodialysis Hemodialysis Dose and Adequacy Kidney Failure Glossary Kidney Failure: Choosing a Treatment That’s Right for You Kidney Failure in Adults Kidney Transplantation Peritoneal Dialysis Peritoneal Dialysis Dose and Adequacy Vascular Access for Hemodialysis

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with kidney disease and kidney failure but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

Resources consulted  American Family Physician Clinical Practice Guideline: Clinical Practice Guidelines for Chronic Kidney Disease in Adults

–  –  –

 Australian Institute of Health and Welfare: Comorbidity of cardiovascular disease, diabetes and chronic kidney disease in Australia  WellCare Summary: Clinical Practice Guidelines for the Management for the Evaluation, Classification and Stratification of Chronic Kidney Disease

–  –  –

Oral health considerations Resources consulted  CMAJ: Guidelines for the management of chronic kidney disease  JCDA: The Dental Health Status of Dialysis Patients  National Kidney and Urologic Diseases Information Clearinghouse: Treatment Methods for Kidney Failure: Peritoneal Dialysis  National Kidney and Urologic Diseases Information Clearinghouse: Treatment Methods for Kidney Failure: Hemodialysis

–  –  –


Sourcing medications information

1. Adverse effect database  Health Canada’s Marketed Health Products Directorate toll-free 1-866-234-2345  Health Canada’s Drug Product Database

–  –  –

3. Medications considerations All medications have potential side effects whether taken alone or in combination with other prescription medications, or over-the-counter (OTC) or herbal medications.

4. Information on herbals and supplements  US National Library of Medicine and the National Institutes of Health Medline Plus Drug Information All Herbs and Supplements

–  –  –

5. Complementary and alternative medicine  National Center for Complementary and Alternative Medicine Types of medications Warnings Individual medications may be subject to important warnings, which

1. change from time to time

2. may affect the appropriateness, efficacy or safety of the Procedures

3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above

4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

–  –  –

3. Medications are used for prevention of rejection of a transplanted kidney, using medications such as cyclosporine (Neoral®, Sandimmune®, Gengraf®) Side effects of medications Resources consulted  National Kidney and Urologic Diseases Information Clearinghouse: Analgesic Nephropathy Painkillers and the Kidneys

–  –  –


Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.

2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.

3. Use a consent/medical consultation form, and be prepared to fax the form to the provider.

4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.


Infection control Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

1. The Recommendations published by the Centers for Disease Control and Prevention.

2. Relevant occupational health and safety legislative requirements.

3. Relevant public health legislative requirements.

4. Best practices or other protocols specific to the medical condition of the patient/client.


–  –  –


Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.

First-aid provisions and responses as required for current certification in first aid.


Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2) For a patient/client with a history of kidney disease or kidney failure, the dental hygienist should specifically record

1. A summary of the medical and medications history.

2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.

3. The decision made by the dental hygienist, with reasons.

4. Compliance with the precautions required.

5. All Procedure(s) used.

6. Any advice given to the patient/client.


The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of kidney disease or kidney failure.

As appropriate, discuss

1. The importance of the patient/client’s a. self-checking the mouth regularly for suspicious signs or symptoms b. reporting to the appropriate healthcare provider any changes in the mouth indicative of suspicious lesions.

2. The need for regular oral health examinations and preventive oral healthcare.

3. Oral self-care including information about a. choice of toothpaste b. tooth-brushing techniques and related devices P a g e | 13 CDHO Advisory | Kidney Disease and Kidney Failure c. dental flossing d. mouth rinses e. management of a xerostomia.

4. The importance of an appropriate diet in the maintenance of oral health.

5. For persons at an advanced stage of a disease or debilitation a. regimens for oral hygiene as a component of supportive care and palliative care b. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves c. scheduling and duration of appointments to minimize stress and fatigue.

6. Comfort level while reclining, and stress and anxiety related to the Procedures.

7. Medication side effects such as xerostomia, and recommend treatment.

8. Mouth ulcers and other conditions of the mouth relating to kidney disease and kidney failure, comorbidities, complications or associated conditions, medications or diet.

9. Pain management, emphasizing warnings about certain over-the-counter pain-relief medications.

–  –  –


1. Promoting health through oral hygiene for persons who have kidney disease or kidney failure.

2. Reducing the adverse effects, such as inappropriate use of pain medication or stress in a person who is debilitated by kidney disease or kidney failure, by a. detailed inquiry about medications and, in particular, pain medications b. generally increasing the comfort level of persons in the course of dental hygiene interventions c. using appropriate techniques of communication d. providing advice on scheduling and duration of appointments.

3. Reducing the risk that oral healthcare needs are unmet.

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