CINCINNATI, US: Oral health remains largely absent from chronic kidney disease (CKD) care, despite evidence that patients with CKD often have a high burden of oral disease and may experience oral complications of treatment. A recent narrative review has synthesised evidence on the bidirectional relationship between CKD and oral disease, outlining underlying pathophysiological mechanisms, clinical implications and opportunities for interdisciplinary care. The authors also present a framework for integrating oral health into CKD care.
According to Dr Priyanka Gudsoorkar of the University of Cincinnati College of Medicine, patients with kidney disease are often managed in isolation by nephrologists and dentists, pointing to the need for more interdisciplinary care. (Image: Dr Priyanka Gudsoorkar)
Lead author Dr Priyanka Gudsoorkar, assistant professor in the Department of Environmental and Public Health Sciences at the University of Cincinnati College of Medicine, explained that the motivation for the review arose from observing a persistent divide between medicine and dentistry. “Nephrology and dentistry have operated as if they were caring for different patients. They are not,” she told Dental Tribune International.
“My husband is a nephrologist, and over the years, we kept noticing that we were often describing the same patient from two completely different angles,” she said. “He would talk about a dialysis patient whose inflammatory markers would not come down. I would think about how often those same patients have untreated periodontitis that no one on the renal team has thought to ask about,” she continued.
Based on evidence from 150 published articles, including observational studies, meta-analyses and interventional trials, the authors found that CKD and periodontal disease appear to be linked through shared inflammatory, vascular and microbial pathways. They also found that periodontal inflammation may contribute to systemic inflammation, endothelial dysfunction and microbial spread, potentially accelerating decline in kidney function. CKD, in turn, can impair oral immune defences and tissue repair, potentially worsening periodontal disease.
The findings indicated that the burden and severity of oral disease tend to increase as CKD progresses. Standard dental and periodontal indices have been associated with declining kidney filtration function and higher levels of inflammatory markers. This suggests that oral health findings may provide clinically relevant information about systemic inflammatory burden in patients with CKD.
“Oral findings track measurably with kidney disease severity,” Dr Gudsoorkar said. “That means a routine dental exam can, in principle, surface an inflammatory burden before standard renal biomarkers shift,” she added.
The review also highlighted the potential clinical relevance of periodontal treatment. Non-surgical periodontal therapy was found to modestly reduce systemic inflammatory markers, and some studies reported improvements in measures of kidney filtration function. However, the authors emphasised that evidence of benefit to kidney function is inconsistent and that more prospective interventional studies with sufficiently large patient groups are needed.
Early oral assessment may support transplant readiness
The implications are especially important for patients receiving dialysis or awaiting a kidney transplant. According to the review, patients undergoing kidney replacement therapy carry a high oral disease burden owing to immunosuppression, polypharmacy, limited access to dental care and the systemic effects of CKD.
Dr Gudsoorkar said that dental assessment should be treated as part of transplant readiness rather than being left until the final stages of transplant preparation. “Pre-transplant dental clearance should be the standard, not the exception, and chronic infection foci should be eliminated before surgery,” she commented.
She noted that dental assessment is often left until late in the transplant evaluation process. As a result, untreated oral infections may only be identified when they may delay transplantation. “If oral assessment were built into CKD care much earlier, ideally at the point of nephrology referral, certainly well before transplant evaluation, these delays would be largely preventable,” she explained.
“Dentists are not auxiliary to chronic disease management.”
For dentistry, the review reframes periodontal care as part of chronic disease management. It places routine periodontal assessment, maintenance and infection control within a wider medical context, particularly for patients who may be receiving dialysis or preparing for transplantation. Dentists may be in a position to identify oral signs associated with systemic disease, including xerostomia, mucosal lesions, mucosal pallor and radiographic evidence of altered jawbone mineralisation.
“The implication is that dentists are not auxiliary to chronic disease management. They are part of it,” Dr Gudsoorkar said. “When a patient with periodontitis sits in a dental chair, that periodontitis is not only a local problem. It is a measurable contributor to their systemic inflammatory burden and possibly to the trajectory of their kidney function.”
A call for integrated care pathways for CKD patients
Despite the growing evidence base, the authors noted that clinical systems have not kept pace. Dental and renal services rarely share electronic health records, nephrology curricula often include little oral health training and many dental programmes do not sufficiently prepare clinicians to manage medically complex patients. The review sets out a framework for oral–renal care, including proposed stage-specific dental management recommendations for patients with CKD, improved pre-transplant screening pathways, closer oral health monitoring for patients on dialysis and better data sharing between specialties.
The review also places strong emphasis on equity. CKD affects hundreds of millions of people globally, and its burden is greatest in low- and middle-income countries, where oral and renal care are often fragmented or unavailable. According to Dr Gudsoorkar, this overlap in prevalence with periodontal disease and caries makes integration not only a clinical issue but also a public health priority.
“The populations most affected by both diseases are people in low- and middle-income countries and in lower-income communities in high-income countries,” she noted. “Any serious medical–dental integration agenda must put those populations at the centre, not the margin,” she explained. To advance this agenda, the authors have formed the Oral–Kidney Collaborative for Advancing Research and Evidence, an initiative intended to support research, clinical collaboration and policy development at the intersection of oral and kidney health.
Dr Gudsoorkar said that the evidence linking oral health and systemic disease has moved beyond speculation, but that clinical pathways still need to be redesigned. “We have the science. We have the indices. We have feasible interventions,” she said. “What we lack is the willingness to redesign care pathways so that a person with CKD is not asked to navigate dental and renal systems as if they were separate problems,” she added.
“Periodontal disease is a modifiable risk marker for kidney outcomes. Treating it that way, rather than as a cosmetic afterthought, is something the profession can choose to do,” she concluded.
