Dental screening pathway for paediatric nephrology patients: A service development and evaluation

Abstract

Some children and young people with kidney disease are at increased risk of opportunistic and severe oral infections due to their immunocompromised status arising from their renal disease, medical comorbidities and use of immunosuppressant medications. Untreated oral disease can also adversely affect renal patients' oral health-related quality of life.¹ Furthermore, poor oral health may also lead to patients being refused or delayed a kidney transplant due to concerns about post-transplant opportunistic infection. Caries has been shown to be prevalent amongst children and young people with kidney diseases (although less prevalent than the general population).^{2, 3} Developmental defects of enamel are also more common in young people with kidney diseases³ and drug-induced gingival overgrowth can arise from antihypertensive and antirejection medications.

Regular dental surveillance is especially important for those on immunosuppressants who are at increased risk of systemic cancers including lip and oral cancer and lymphoma.⁴ An estimated 1%–2% of paediatric kidney transplant recipients will develop post-transplant lymphoproliferative disease within 5 years,⁵ presenting signs of which could be oral soft tissue changes, neck or parotid lumps.

Invasive dental treatment in this group can also prove challenging due to complex medical histories which may necessitate specialist involvement. Early prevention, diagnosis and management of dental disease may therefore allow patients to avoid more invasive dental procedures and receive simpler treatment in a more convenient primary care setting. Due to the added complexity of dental care and potential effects of renal disease on the developing dentition, specialist paediatric dentistry input is recommended for all paediatric renal patients to optimise their oral health.

As such, a screening pathway was developed at Newcastle Dental Hospital for paediatric nephrology patients attending the Great North Children's Hospital. An initial pilot was completed in August 2020 of nine patients to assess project feasibility and troubleshoot the practicalities of inpatient-based ward screening. Pilot numbers were restricted due to the impact of the COVID-19 pandemic. The paediatric nephrology dental screening service then formally restarted in November 2021. A Microsoft Excel® (Microsoft Corporation, Redmond, USA) database was developed alongside the paediatric nephrology team to allow systematic screening, starting with those with the most impaired renal function. Efforts were made to co-ordinate screening appointments with existing medical appointments to minimise patient burden. Where possible, staff would complete screening on nephrotic and post-transplant outpatient clinics and peritoneal dialysis and haemodialysis wards. If dental concerns were identified, a subsequent appointment for more comprehensive assessment with radiographs at the dental hospital was arranged. Clinical findings were documented and relayed back to the patients' medical teams via letters and electronic patient records.

Data were collected on the database from November 2021 to August 2023 by screening clinicians. Information recorded included patients' names, hospital number, renal diagnosis, medical co-morbidities, name of allocated specialist nurse, date of last dental assessment, dental diagnoses, dental outcome and date of next dental review.

As of August 2023, 93 of 158 patients (59%) within the target groups were screened. Eighty per cent of appointments made since November 2021 (n = 51/64) were co-ordinated alongside existing medical appointments. All haemodialysis (n = 9), peritoneal dialysis (n = 7), post-transplant (n = 29) and CKD stage 5 (n = 5) patients received screening. A breakdown of the categories of renal patient screened are summarised by Table 1. Patients may have changed categories over the time period encompassed by the evaluation if their kidney function deteriorated, they received a transplant or if their transplant failed and they had to resume dialysis.

The most common renal diagnoses encountered were nephrotic syndrome (n = 28), renal dysplasia (n = 19), acute kidney injury (n = 10) and vesicoureteric reflux (n = 6). Other medical comorbidities were common. These included cardiac (n = 12), hepatic (n = 8) and neurological (n = 8) diagnoses. Six patients had previous cancer treatment, eight patients had another organ transplant (heart/lung/liver), and 20 had additional special care needs (such as learning disability, autism or severe visual impairment).

Dental diagnoses are summarised by Table 2. To summarise, one in three patients (n = 32) were dentally fit and were discharged back to their general dental practitioner. One in three patients, however, had developmental defects of enamel (n = 33), and one in five had caries (n = 20). One in five (n = 19) received treatment on a staff list at the dental hospital under local anaesthetic or inhalation sedation, with treatment including extractions, fillings, preformed metal crowns and biopsies. Twelve patients were treated by specialty training registrars (STRs), two by consultants and five by staff therapists. In addition, four patients were seen on undergraduate clinics. One in five patients (n = 20) required onward referral to other dental specialties or community-based dental services. One in six required dental treatment under general anaesthetic (n = 15).

Following the successful implementation of this screening service, screening will be continued on the remaining nephrology groups (CKD stages 3A-4 and nephrotic syndrome). Patient and staff feedback will also be obtained to allow further refinement of the pathway. Work is also planned alongside renal specialist dieticians to incorporate oral health advice within dietary patient information leaflets. Two oral health training sessions have been delivered to the paediatric nephrology team during their multidisciplinary meetings covering oral health manifestations of renal disease and prevention. Interdisciplinary learning will continue to be supported in the future, incorporating ‘Mini Mouth Care Matters’ to ensure every contact counts and the mouth is put back into the body.⁶

This project has improved access to specialist dental care for children and young people with kidney diseases, which has been especially important during the current UK primary dental care access crisis. On a practical level, the project was successful at identifying and prioritising those with the most severe renal impairment, maximising the efficiency of available resources for the project.

One in three of the patients screened would have had to travel over 30 miles to reach the dental hospital, and one in 10 would have had to travel over 60 miles. Therefore, by co-ordinating 80% (n = 51/64) of dental appointments with existing medical appointments, this has saved patients and their families time, cost and inconvenience. There is also the additional environmental benefit of avoiding unnecessary patient travel.

This project has improved lines of communication between both the dental and paediatric nephrology teams and allowed them to learn from one another to achieve best practice. Not only have patients received dental examinations, but they have also received preventative advice, with this being further supported by the delivery of oral health packs (toothbrushes, timers, stickers and disclosing tablets) to the dialysis units.

One of the biggest challenges faced was the mismatch between Newcastle Dental Hospital's paper notes and the Great North Children's Hospital's electronic patient record. Co-ordination and streamlining of records are therefore recommended to reduce inefficiency and enhance communication between dental and medical services. Furthermore, the rate of inattendance on the renal outpatient clinics was high, leading to some wasted time and effort. Having alternative duties available for staff members who are completing screening duties is therefore advised to minimise the risk of wasted resources should patients not be brought for these appointments.

In conclusion, it is hoped that this project inspires others to set up similar pathways at their own units and encourages further interdisciplinary collaboration with paediatric nephrology teams.

There are no conflicts of interest to declare.