title: Oral disease in adults treated with hemodialysis: prevalence, predictors, and association with mortality and adverse cardiovascular events: the rationale and design of the ORAL Diseases in hemodialysis (ORAL-D) study, a prospective, multinational, longitudinal, observational, cohort study.
abstract: BACKGROUND
  People with end-stage kidney disease treated with dialysis experience high rates of premature death that are at least 30-fold that of the general population, and have markedly impaired quality of life. Despite this, interventions that lower risk factors for mortality (including antiplatelet agents, epoetins, lipid lowering, vitamin D compounds, or dialysis dose) have not been shown to improve clinical outcomes for this population. Although mortality outcomes may be improving overall, additional modifiable determinants of health in people treated with dialysis need to be identified and evaluated. Oral disease is highly prevalent in the general population and represents a potential and preventable cause of poor health in dialysis patients. Oral disease may be increased in patients treated with dialysis due to their lower uptake of public dental services, as well as increased malnutrition and inflammation, although available exploratory data are limited by small sample sizes and few studies evaluating links between oral health and clinical outcomes for this group, including mortality and cardiovascular disease. Recent data suggest periodontitis may be associated with mortality in dialysis patients and well-designed, larger studies are now required.
  
  
  METHODS
  The ORAL Diseases in hemodialysis (ORAL-D) study is a multinational, prospective (minimum follow-up 12 months) study. Participants comprise consecutive adults treated with long-term in-center hemodialysis. Between July 2010 and February 2012, we recruited 4500 dialysis patients from randomly selected outpatient dialysis clinics in Europe within a collaborative network of dialysis clinics administered by a dialysis provider, Diaverum, in Europe (France, Hungary, Italy, Poland, Portugal, and Spain) and South America (Argentina). At baseline, dental surgeons with training in periodontology systematically assessed the prevalence and characteristics of oral disease (dental, periodontal, mucosal, and salivary) in all participants. Oral hygiene habits and thirst were evaluated using self-administered questionnaires. Data for hospitalizations and mortality (total and cause-specific) according to baseline oral health status will be collected once a year until 2022.
  
  
  CONCLUSIONS
  This large study will estimate the prevalence, characteristics and correlations of oral disease and clinical outcomes (mortality and hospitalization) in adults treated with dialysis. We will further evaluate any association between periodontitis and risk of premature death in dialysis patients that has been suggested by existing research. The results from this study should provide powerful new data to guide strategies for future interventional studies for preventative and curative oral disease strategies in adults who have end-stage kidney disease.
authors.affiliation: Department of Clinical Pharmacology and Epidemiology, Consorzio Mario Negri Sud, Italy. strippoli@negrisud.it
authors.forename: Giovanni F M
authors.initials: GF
authors.lastname: Strippoli
authors.forename: Suetonia C
authors.initials: SC
authors.lastname: Palmer
authors.forename: Marinella
authors.initials: M
authors.lastname: Ruospo
authors.forename: Patrizia
authors.initials: P
authors.lastname: Natale
authors.forename: Valeria
authors.initials: V
authors.lastname: Saglimbene
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Craig
authors.forename: Fabio
authors.initials: F
authors.lastname: Pellegrini
authors.forename: Massimo
authors.initials: M
authors.lastname: Petruzzi
authors.forename: Michele
authors.initials: M
authors.lastname: De Benedittis
authors.forename: Pauline
authors.initials: P
authors.lastname: Ford
authors.forename: David W
authors.initials: DW
authors.lastname: Johnson
authors.forename: Eduardo
authors.initials: E
authors.lastname: Celia
authors.forename: Ruben
authors.initials: R
authors.lastname: Gelfman
authors.forename: Miguel R
authors.initials: MR
authors.lastname: Leal
authors.forename: Marietta
authors.initials: M
authors.lastname: Torok
authors.forename: Paul
authors.initials: P
authors.lastname: Stroumza
authors.forename: Anna
authors.initials: A
authors.lastname: Bednarek-Skublewska
authors.forename: Jan
authors.initials: J
authors.lastname: Dulawa
authors.forename: Luc
authors.initials: L
authors.lastname: Frantzen
authors.forename: Juan Nin
authors.initials: JN
authors.lastname: Ferrari
authors.forename: Domingo
authors.initials: D
authors.lastname: del Castillo
authors.forename: Jorgen
authors.initials: J
authors.lastname: Hegbrant
authors.forename: Charlotta
authors.initials: C
authors.lastname: Wollheim
authors.forename: Letitzia
authors.initials: L
authors.lastname: Gargano
mesh_terms: D000328:Adult; D002318:Cardiovascular Diseases / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D015331:Cohort Studies; D005060:Europe / Q000453:epidemiology; D005500:Follow-Up Studies; D006801:Humans; D038622:Internationality; D007676:Kidney Failure, Chronic / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D008137:Longitudinal Studies; D009059:Mouth Diseases / Q000175:diagnosis / Q000401:mortality* / Q000628:therapy; D009909:Oral Health / Q000639:trends; D011237:Predictive Value of Tests; D015995:Prevalence; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality* / Q000639:trends; D012307:Risk Factors; D013020:South America / Q000453:epidemiology; D011795:Surveys and Questionnaires; D016896:Treatment Outcome