The study sample consisted of 60 users of the Tertiary Care of the Brazilian Unified Health System (kidney patients) aged 38 to 74 years old, of both sexes, and undergoing treatment in a CKD-specialized service in a municipality in the South of Brazil. Kidney patients on dialysis who agreed to participate in the interviews and clinical examinations and who showed communication skills were included in the survey. The exclusion criteria were: having any cognitive impairment that would make it difficult for them to participate in the focus group, and/or being a kidney transplant patient, since, to undergo kidney transplantation, the patient must present an oral condition without foci of dental infections, and dental treatments during the first six months after the transplant are not recommended (Gudapati, Ahmed, & Rada, 2002).

Data were collected in 2018 in two moments. First, six to ten patients per focus group were selected, and three groups were created for interviews that lasted 40 to 60 minutes, with the participation of a researcher/moderator, an observer, and the kidney patients distributed in teams (Trad, 2009), so that the interview, through the focus group technique, would not be influenced by clinical examinations.

At the beginning of the meeting with each group of kidney patients, some instructions were adopted for the use and standardization of the focus group technique: presentation of the moderator and observer; explanation of the objectives and importance of the research; request for permission to record the speeches; clarification on the importance of the participation of all members of the group, and in an organized manner; delimitation of the minimum and maximum meeting length; distribution of a sequential number to the participants to preserve their identities and guarantee their anonymity (Moimaz, Amaral, Miotto, Costa, & Garbin, 2016).

To use the technique, the first researcher of the study conducted the interview guided by a script with topics, in order to allow free speech, to provide a structure for the conversation, and to reveal the meanings and perceptions of the CKPs about their oral health. Throughout the meeting, the moderator sought to keep the interview guided by the objectives of the research. The speeches were recorded on an audio recorder and, to end the interviews, the theoretical saturation criterion was used, that is, when the speeches with new participants were collected, and the interviews started to present frequent repetitions as to content (Turato, 2003).

Five guiding questions and several complements were applied to the focus group: 1) Do you have, or have you had dental pain? 1.1) How long ago? 1.2) Where have you get treatment? 1.3) For how long have you had/have you been with this pain? 1.4) Has dental pain interfered with your life? 2) Do you currently undergo any dental treatment? 2.1) If not, why? 2.2) If yes, how was it? 3) Do you think your oral health is important? 3.1) What about that of your family members? 3.2) How do you think your oral condition is? 4) Do you think kidney disease is related to oral health? 4.1) Does dialysis treatment interfere with your oral condition? 4.2) And the medications you take, do they cause any problems or discomfort? 5) Does your current condition interfere with your access to dental services? 5.1) What would a good treatment be? 5.2) Where would this service be provided? 5.3) Have you ever received this type of treatment in any public or private place? After the end of the meeting of each group, the speeches were transcribed in full, on the day right after the interviews.

At a later date, all 60 patients underwent clinical oral examinations in a spacious environment, in a service room specifically designed for chronic kidney disease, with good natural lighting, complemented, when necessary, with a portable flashlight, and with the examinees seated and the examiner standing. The latter wore a mask and gloves and used a WHO millimeter probe (WHO, 2013) and a flat mouth mirror, previously sterilized, following all biosafety standards.

The examination team was composed of an examiner (the first author) and a note taker (a graduate Dentistry student), in accordance with the classification criteria recommended by the World Health Organization (WHO, 2013) in its fifth version of the Oral Health Surveys, Basics Methods. In this study, data related to severity of caries (DMFT) and need for dental prosthesis were considered.

The DMFT index indicates one’s previo

For qualitative analysis, the textual corpus of the focus groups was processed in the IRAMUTEQ software, version 0.7, and analyzed using the similarity analysis and word cloud techniques.

The Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires (IRAMUTEQ), free software that is anchored in the R programming language, was used in the research because it allows processing and statistically analyzing several textual corpuses (Ratinaud, 2009).

This software runs different types of analysis in textual sets, from the simplest (frequency, means and word cloud), known as lexical analyses, to the most complex ones, called multivariate analyses (descending hierarchical classification and similarity analysis) (Lebart & Salem, 1994).

To perform classic textual statistics, IRAMUTEQ scales and reformats a set of texts or Initial Context Units (ICUs) into text segments or Elementary Context Units (ECUs).

Word cloud is a type of lexical analysis that uses a graphic representation based on the frequency of words and allows its immediate visual identification through a figure generated by IRAMUTEQ (Camargo & Justo, 2013).

After the textual content of the focus groups was processed, the frequencies of words in the corpus of the text were calculated (quantitative approach), and the set of characteristics in a given fragment of the content was considered (qualitative approach) (Bardin, 2011). The interpretive analysis of said corpus used content analysis, as the latter is quanti-qualitative.

This study was approved by the Research Ethics Committee of Paraná’s Cesumar University [Universidade Cesumar] (UniCesumar), Paraná, Brazil, in accordance with legal opinion No 1.672.905/2016, and is in compliance with Resolution 466/2012 of the National Health Council.

The similarity analysis anchored in the theory of co-occurrences allowed identifying the connection between the words in the graphic representation, and its result shows, through their frequency, a greater prominence and respective contribution to form trees of similarities among the words (Marchand & Ratinaud, 2012).

Figure 1 displays a semantic range among the most frequent words: ‘tooth’ and ‘treatment’.

Analyzing the similarity tree, it is possible to observe the relationship among these words and the relevance of oral health for kidney patients through statements such as:

[...] the health of the mouth is very important, and our teeth should come first, so if you can’t have your teeth, you have to change them or become toothless (CKP 8).

[...] the teeth are important to all of us, regardless of our health condition, and have many functions in our lives (CKP 6).

[...] teeth are essential for social interaction and the relationships with the people we live with (CKP 11).

[...] teeth are necessary for talking, chewing and smiling, and they need treatment for our life, and even when we have other worse diseases (CKP 3).

Figure 1. Similarity analysis – “Chronic kidney patients’ view on oral health”. South region (Brazil, 2018).

Chronic kidney disease remains a prevalent public health problem that disproportionately affects minorities and individuals with worse socioeconomic conditions, despite intense efforts to control traditional risk factors (Grubbs et al., 2017). And from the previous speeches presented, the importance of access to dental care to meet the social needs referred to in this research is considered, which go beyond the biological factor of the dental element.

The relevance of oral health care in the management of patients with systemic diseases, including chronic kidney disease, has been reported in the literature. Many CKD patients have different oral infections, but there has been a lack of attention to oral care, especially in developing countries and those with a large increase in CKD incidence (Oyetola et al., 2015).

The similarity analysis still shows many doubts and uncertainties about public health services, which can be proven by the words ‘no’ and ‘treatment’, which emerged 277 and 73 times, respectively, in the research corpus.

Lack of access to dental treatment affects the principles of integrality, universality and equity of the Brazilian health system (Mattos, 2006), which coincides with the report “I don’t seek dental treatment because of money. This is the biggest problem, a little because I’m afraid of the dentist, and another problem that makes me put it off it’s because there is no service for kidney patients” (CKP 4), which reveals an image of inequity in the Brazilian Unified Health System. Similarly, still according to Mattos (2006), a remedial health system must offer answers to the different population groups affected by different chronic diseases.

According to Ordinance No. 1.675 of the Brazilian Ministry of Health (Brasil, 2018), the minimum team for care in a unit specialized in chronic kidney disease is composed of: nephrologist, nurse, nutritionist, psychologist and social worker. It would be important to include a dental surgeon in this multidisciplinary team, as clinical dental examinations, treatments for oral infections, and preventive procedures for many affections could be performed. It should be emphasized that, according to the results of the present study, such addition is essential for the oral health of kidney patients to be valued.

The patients reported that the large amount of time they spend having their kidney disease treated, in many cases, for three or more days a week, is an impediment to them seeking dental treatment, which can be seen in the following reports: “I spend more than eight hours between going to and being in dialysis sessions every day, so how am I supposed to get my teeth treated? I can’t get treatment anywhere” (CKP 14), “Over the week, I don’t have any time left to treat my teeth and can’t get this treatment in my city either” (CKP 16).

In accordance with the word cloud method, and through a visual representation generated by the software, based on the occurrence of words (Moura et al., 2014), those words that obtained relative frequency were: ‘pain’, ‘health’, ‘mouth’, ‘denture’ and ‘prosthesis’, which appeared 54, 38, 27, 25 and 21 times in the transcript of the research corpus (Figure 2).

Figure 2. Word cloud – “Chronic kidney patients’ view on oral health”. South region (Brazil, 2018).

Ferreira, Piuvezam, Werner, & Alves (2006) argue in their study conducted with a low-income population in northeast Brazil that there is a negative perception of oral condition, which is strongly linked to their experience of pain and dental losses. In this context, elderly people aged 80 years or more reported self-perception of dry mouth, difficulties to eat, and seeking less routine dental appointments over the years (Pauli, Figueiredo, Barbosa, Castro, & Mello, 2018). However, this research found a positive representation of oral health, which can be observed in several of the kidney patients’ speeches, such as:

[...] I think that, in the first place, comes the health of the mouth, because what’s the use of having a healthy body, if you don’t have oral health, so you’ll have your teeth all rotten or no teeth at all, and you’ll continue to be sick (CKP 5).

[...] look, I’m going to tell you the truth, what I really value in life is a person who has many teeth, and I want to have my teeth treated and have access to a place to take care of my mouth and smile (CKP 10).

[...] I’d really like to improve my oral health, and I’ve already had a lower denture, but it didn’t work, it didn’t adapt very well, so I’m waiting for another one. I really wish I could afford a treatment with everything I need (CKP 11).

Also according to Ferreira et al. (2006), the social representations of oral health care highlight the negative consequences of dental practice experienced by these individuals and point to the need to restructure the oral health services offered.

Chronic kidney disease is associated with the significant morbidity and mortality of population groups worldwide, and there is a need to identify new risk factors for this disease, be they clinical and/or subjective factors of these patients’ self-perception (Sharma et al., 2014). In this context, this study also sought to discuss subjective aspects related to self-perception of CKD concerning oral health.

Thus, it should be recognized that biomedical care actions and those meant for repairing inequalities for chronic kidney patients are as important as their family structure and the individual profile of those who go through this disease. Finally, it is worth stressing that, despite being marked by so many ambiguities and challenges, life with CKD is perceived by patients as being full of possibilities (Santos, Borges, Lima, & Reis, 2018).

marcelo.amaral@unicesumar.edu.br