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Oral Tori in Chronic Peritoneal Dialysis Patients

Identifieur interne : 000760 ( Pmc/Corpus ); précédent : 000759; suivant : 000761

Oral Tori in Chronic Peritoneal Dialysis Patients

Auteurs : Chia-Lin Hsu ; Ching-Wei Hsu ; Pei-Ching Chang ; Wen-Hung Huang ; Cheng-Hao Weng ; Huang-Yu Yang ; Shou-Hsuan Liu ; Kuan-Hsing Chen ; Shu-Man Weng ; Chih-Chun Chang ; I-Kuan Wang ; Aileen I. Tsai ; Tzung-Hai Yen

Source :

RBID : PMC:4898723

Abstract

Background

The pathogenesis of oral tori has long been debated and is thought to be the product of both genetic and environmental factors, including occlusal forces. Another proposed mechanism for oral tori is the combination of biomechanical forces, particularly in the oral cavity, combined with cortical bone loss and trabecular expansion, as one might see in the early stages of primary hyperparathyroidism. This study investigated the epidemiology of torus palatinus (TP) and torus mandibularis (TM) in peritoneal dialysis patients, and analyzed the influences of hyperparathyroidism on the formation of oral tori.

Method

In total, 134 peritoneal dialysis patients were recruited between July 1 and December 31, 2015 for dental examinations for this study. Patients were categorized into two subgroups based on the presence or absence of oral tori. Demographic, hematological, biochemical, and dialysis-related data were obtained for analysis.

Results

The prevalence of oral tori in our sample group was high at 42.5% (57 of 134), and most patients with oral tori were female (61.4%). The most common location of tori was TP (80.7%), followed by TP and TM (14.0%), then TM (5.3%). All 54 TP cases were at the midline, and most were <2 cm (59.3%), flat (53.7%), and located in the premolar region (40.7%). Of the 11 TM cases, all were bilateral and symmetric, mostly <2 cm (81.9%), lobular (45.4%), and located at premolar region (63.6%). Interestingly, patients with oral tori had slightly lower serum levels of intact parathyroid hormones than those without oral tori, but the difference was not statistically significant (317.3±292.0 versus 430.1±492.6 pg/mL, P = 0.126). In addition, patients with oral tori did not differ from patients without tori in inflammatory variables such as serum high sensitivity C-reactive protein levels (6.6±8.2 versus 10.3±20.2 mg/L, P = 0.147) or nutritional variables such as serum albumin levels (3.79±0.38 versus 3.77±0.45 g/dL, P = 0.790). Furthermore, there were no differences between patients with and without oral tori in dialysis adequacy (weekly Kt/Vurea, 2.14±0.39 versus 2.11±0.33, P = 0.533; weekly creatinine clearance rate, 59.31±17.58 versus 58.57±13.20 L/1.73 m2, P = 0.781), or peritoneal membrane transporter characteristics (P = 0.098).

Conclusion

Secondary hyperparathyroidism does not contribute to the formation of tori in peritoneal dialysis patients. Further studies are warranted.


Url:
DOI: 10.1371/journal.pone.0156988
PubMed: 27275607
PubMed Central: 4898723

Links to Exploration step

PMC:4898723

Le document en format XML

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<name sortKey="Yen, Tzung Hai" sort="Yen, Tzung Hai" uniqKey="Yen T" first="Tzung-Hai" last="Yen">Tzung-Hai Yen</name>
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<nlm:aff id="aff002">
<addr-line>Department of Nephrology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Linkou, Taiwan</addr-line>
</nlm:aff>
</affiliation>
<affiliation>
<nlm:aff id="aff003">
<addr-line>Kidney Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan</addr-line>
</nlm:aff>
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<addr-line>Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan</addr-line>
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<title level="j">PLoS ONE</title>
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<div type="abstract" xml:lang="en">
<sec id="sec001">
<title>Background</title>
<p>The pathogenesis of oral tori has long been debated and is thought to be the product of both genetic and environmental factors, including occlusal forces. Another proposed mechanism for oral tori is the combination of biomechanical forces, particularly in the oral cavity, combined with cortical bone loss and trabecular expansion, as one might see in the early stages of primary hyperparathyroidism. This study investigated the epidemiology of torus palatinus (TP) and torus mandibularis (TM) in peritoneal dialysis patients, and analyzed the influences of hyperparathyroidism on the formation of oral tori.</p>
</sec>
<sec id="sec002">
<title>Method</title>
<p>In total, 134 peritoneal dialysis patients were recruited between July 1 and December 31, 2015 for dental examinations for this study. Patients were categorized into two subgroups based on the presence or absence of oral tori. Demographic, hematological, biochemical, and dialysis-related data were obtained for analysis.</p>
</sec>
<sec id="sec003">
<title>Results</title>
<p>The prevalence of oral tori in our sample group was high at 42.5% (57 of 134), and most patients with oral tori were female (61.4%). The most common location of tori was TP (80.7%), followed by TP and TM (14.0%), then TM (5.3%). All 54 TP cases were at the midline, and most were <2 cm (59.3%), flat (53.7%), and located in the premolar region (40.7%). Of the 11 TM cases, all were bilateral and symmetric, mostly <2 cm (81.9%), lobular (45.4%), and located at premolar region (63.6%). Interestingly, patients with oral tori had slightly lower serum levels of intact parathyroid hormones than those without oral tori, but the difference was not statistically significant (317.3±292.0 versus 430.1±492.6 pg/mL, P = 0.126). In addition, patients with oral tori did not differ from patients without tori in inflammatory variables such as serum high sensitivity C-reactive protein levels (6.6±8.2 versus 10.3±20.2 mg/L, P = 0.147) or nutritional variables such as serum albumin levels (3.79±0.38 versus 3.77±0.45 g/dL, P = 0.790). Furthermore, there were no differences between patients with and without oral tori in dialysis adequacy (weekly Kt/V
<sub>urea</sub>
, 2.14±0.39 versus 2.11±0.33, P = 0.533; weekly creatinine clearance rate, 59.31±17.58 versus 58.57±13.20 L/1.73 m
<sup>2</sup>
, P = 0.781), or peritoneal membrane transporter characteristics (P = 0.098).</p>
</sec>
<sec id="sec004">
<title>Conclusion</title>
<p>Secondary hyperparathyroidism does not contribute to the formation of tori in peritoneal dialysis patients. Further studies are warranted.</p>
</sec>
</div>
</front>
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<journal-id journal-id-type="nlm-ta">PLoS One</journal-id>
<journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id>
<journal-id journal-id-type="publisher-id">plos</journal-id>
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<journal-title>PLoS ONE</journal-title>
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<issn pub-type="epub">1932-6203</issn>
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<publisher-name>Public Library of Science</publisher-name>
<publisher-loc>San Francisco, CA USA</publisher-loc>
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</journal-meta>
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<article-id pub-id-type="pmid">27275607</article-id>
<article-id pub-id-type="pmc">4898723</article-id>
<article-id pub-id-type="doi">10.1371/journal.pone.0156988</article-id>
<article-id pub-id-type="publisher-id">PONE-D-16-08436</article-id>
<article-categories>
<subj-group subj-group-type="heading">
<subject>Research Article</subject>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Medicine and Health Sciences</subject>
<subj-group>
<subject>Nephrology</subject>
<subj-group>
<subject>Medical Dialysis</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Physical Sciences</subject>
<subj-group>
<subject>Mathematics</subject>
<subj-group>
<subject>Topology</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Biology and Life Sciences</subject>
<subj-group>
<subject>Biochemistry</subject>
<subj-group>
<subject>Hormones</subject>
<subj-group>
<subject>Parathyroid Hormone</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Biology and Life Sciences</subject>
<subj-group>
<subject>Biochemistry</subject>
<subj-group>
<subject>Biomarkers</subject>
<subj-group>
<subject>Creatinine</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Medicine and Health Sciences</subject>
<subj-group>
<subject>Oral Medicine</subject>
<subj-group>
<subject>Oral Diseases</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>People and Places</subject>
<subj-group>
<subject>Geographical Locations</subject>
<subj-group>
<subject>Asia</subject>
<subj-group>
<subject>Taiwan</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Medicine and Health Sciences</subject>
<subj-group>
<subject>Nephrology</subject>
<subj-group>
<subject>Chronic Kidney Disease</subject>
</subj-group>
</subj-group>
</subj-group>
<subj-group subj-group-type="Discipline-v3">
<subject>Biology and Life Sciences</subject>
<subj-group>
<subject>Biochemistry</subject>
<subj-group>
<subject>Proteins</subject>
<subj-group>
<subject>C-Reactive Proteins</subject>
</subj-group>
</subj-group>
</subj-group>
</subj-group>
</article-categories>
<title-group>
<article-title>Oral Tori in Chronic Peritoneal Dialysis Patients</article-title>
<alt-title alt-title-type="running-head">Oral Tori in Peritoneal Dialysis</alt-title>
</title-group>
<contrib-group>
<contrib contrib-type="author">
<name>
<surname>Hsu</surname>
<given-names>Chia-Lin</given-names>
</name>
<xref ref-type="aff" rid="aff001">
<sup>1</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Hsu</surname>
<given-names>Ching-Wei</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Chang</surname>
<given-names>Pei-Ching</given-names>
</name>
<xref ref-type="aff" rid="aff001">
<sup>1</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Huang</surname>
<given-names>Wen-Hung</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Weng</surname>
<given-names>Cheng-Hao</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Yang</surname>
<given-names>Huang-Yu</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Liu</surname>
<given-names>Shou-Hsuan</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Chen</surname>
<given-names>Kuan-Hsing</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Weng</surname>
<given-names>Shu-Man</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Chang</surname>
<given-names>Chih-Chun</given-names>
</name>
<xref ref-type="aff" rid="aff004">
<sup>4</sup>
</xref>
</contrib>
<contrib contrib-type="author">
<name>
<surname>Wang</surname>
<given-names>I-Kuan</given-names>
</name>
<xref ref-type="aff" rid="aff005">
<sup>5</sup>
</xref>
</contrib>
<contrib contrib-type="author" equal-contrib="yes">
<name>
<surname>Tsai</surname>
<given-names>Aileen I.</given-names>
</name>
<xref ref-type="aff" rid="aff001">
<sup>1</sup>
</xref>
<xref ref-type="corresp" rid="cor001">*</xref>
</contrib>
<contrib contrib-type="author" equal-contrib="yes">
<name>
<surname>Yen</surname>
<given-names>Tzung-Hai</given-names>
</name>
<xref ref-type="aff" rid="aff002">
<sup>2</sup>
</xref>
<xref ref-type="aff" rid="aff003">
<sup>3</sup>
</xref>
<xref ref-type="aff" rid="aff006">
<sup>6</sup>
</xref>
<xref ref-type="corresp" rid="cor001">*</xref>
</contrib>
</contrib-group>
<aff id="aff001">
<label>1</label>
<addr-line>Department of Pediatric Dentistry, Chang Gung Memorial Hospital, Linkou, Taiwan</addr-line>
</aff>
<aff id="aff002">
<label>2</label>
<addr-line>Department of Nephrology, Chang Gung Memorial Hospital and College of Medicine, Chang Gung University, Linkou, Taiwan</addr-line>
</aff>
<aff id="aff003">
<label>3</label>
<addr-line>Kidney Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan</addr-line>
</aff>
<aff id="aff004">
<label>4</label>
<addr-line>Department of Clinical Pathology, Far Eastern Memorial Hospital, New Taipei, Taiwan</addr-line>
</aff>
<aff id="aff005">
<label>5</label>
<addr-line>Department of Nephrology, China Medical University Hospital and College of Medicine, China Medical University, Taichung, Taiwan</addr-line>
</aff>
<aff id="aff006">
<label>6</label>
<addr-line>Center for Tissue Engineering, Chang Gung Memorial Hospital, Linkou, Taiwan</addr-line>
</aff>
<contrib-group>
<contrib contrib-type="editor">
<name>
<surname>Aguilera</surname>
<given-names>Abelardo I</given-names>
</name>
<role>Editor</role>
<xref ref-type="aff" rid="edit1"></xref>
</contrib>
</contrib-group>
<aff id="edit1">
<addr-line>Hospital Universitario de La Princesa, SPAIN</addr-line>
</aff>
<author-notes>
<fn fn-type="conflict" id="coi001">
<p>
<bold>Competing Interests: </bold>
The authors have declared that no competing interests exist.</p>
</fn>
<fn fn-type="con" id="contrib001">
<p>Conceived and designed the experiments: AIT THY. Performed the experiments: CLH. Analyzed the data: CWH PCC WHH CHW HYY SHL KHC SMW CCC IKW. Wrote the paper: CLH THY.</p>
</fn>
<corresp id="cor001">* E-mail:
<email>ait001@adm.cgmh.org.tw</email>
(AIT);
<email>m19570@adm.cgmh.org.tw</email>
(THY)</corresp>
</author-notes>
<pub-date pub-type="epub">
<day>8</day>
<month>6</month>
<year>2016</year>
</pub-date>
<pub-date pub-type="collection">
<year>2016</year>
</pub-date>
<volume>11</volume>
<issue>6</issue>
<elocation-id>e0156988</elocation-id>
<history>
<date date-type="received">
<day>27</day>
<month>2</month>
<year>2016</year>
</date>
<date date-type="accepted">
<day>23</day>
<month>5</month>
<year>2016</year>
</date>
</history>
<permissions>
<copyright-statement>© 2016 Hsu et al</copyright-statement>
<copyright-year>2016</copyright-year>
<copyright-holder>Hsu et al</copyright-holder>
<license xlink:href="http://creativecommons.org/licenses/by/4.0/">
<license-p>This is an open access article distributed under the terms of the
<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>
, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.</license-p>
</license>
</permissions>
<self-uri content-type="pdf" xlink:href="pone.0156988.pdf"></self-uri>
<abstract>
<sec id="sec001">
<title>Background</title>
<p>The pathogenesis of oral tori has long been debated and is thought to be the product of both genetic and environmental factors, including occlusal forces. Another proposed mechanism for oral tori is the combination of biomechanical forces, particularly in the oral cavity, combined with cortical bone loss and trabecular expansion, as one might see in the early stages of primary hyperparathyroidism. This study investigated the epidemiology of torus palatinus (TP) and torus mandibularis (TM) in peritoneal dialysis patients, and analyzed the influences of hyperparathyroidism on the formation of oral tori.</p>
</sec>
<sec id="sec002">
<title>Method</title>
<p>In total, 134 peritoneal dialysis patients were recruited between July 1 and December 31, 2015 for dental examinations for this study. Patients were categorized into two subgroups based on the presence or absence of oral tori. Demographic, hematological, biochemical, and dialysis-related data were obtained for analysis.</p>
</sec>
<sec id="sec003">
<title>Results</title>
<p>The prevalence of oral tori in our sample group was high at 42.5% (57 of 134), and most patients with oral tori were female (61.4%). The most common location of tori was TP (80.7%), followed by TP and TM (14.0%), then TM (5.3%). All 54 TP cases were at the midline, and most were <2 cm (59.3%), flat (53.7%), and located in the premolar region (40.7%). Of the 11 TM cases, all were bilateral and symmetric, mostly <2 cm (81.9%), lobular (45.4%), and located at premolar region (63.6%). Interestingly, patients with oral tori had slightly lower serum levels of intact parathyroid hormones than those without oral tori, but the difference was not statistically significant (317.3±292.0 versus 430.1±492.6 pg/mL, P = 0.126). In addition, patients with oral tori did not differ from patients without tori in inflammatory variables such as serum high sensitivity C-reactive protein levels (6.6±8.2 versus 10.3±20.2 mg/L, P = 0.147) or nutritional variables such as serum albumin levels (3.79±0.38 versus 3.77±0.45 g/dL, P = 0.790). Furthermore, there were no differences between patients with and without oral tori in dialysis adequacy (weekly Kt/V
<sub>urea</sub>
, 2.14±0.39 versus 2.11±0.33, P = 0.533; weekly creatinine clearance rate, 59.31±17.58 versus 58.57±13.20 L/1.73 m
<sup>2</sup>
, P = 0.781), or peritoneal membrane transporter characteristics (P = 0.098).</p>
</sec>
<sec id="sec004">
<title>Conclusion</title>
<p>Secondary hyperparathyroidism does not contribute to the formation of tori in peritoneal dialysis patients. Further studies are warranted.</p>
</sec>
</abstract>
<funding-group>
<award-group id="award001">
<funding-source>
<institution-wrap>
<institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/501100004663</institution-id>
<institution>Ministry of Science and Technology, Taiwan</institution>
</institution-wrap>
</funding-source>
<award-id>MST 104-2221-E-182A-003</award-id>
<principal-award-recipient>
<name>
<surname>Yen</surname>
<given-names>Tzung-Hai</given-names>
</name>
</principal-award-recipient>
</award-group>
<award-group id="award002">
<funding-source>
<institution-wrap>
<institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/501100005795</institution-id>
<institution>Chang Gung Memorial Hospital, Linkou</institution>
</institution-wrap>
</funding-source>
<award-id>G3D0012, G3E0361, G3D0072, G3F0601</award-id>
<principal-award-recipient>
<name>
<surname>Yen</surname>
<given-names>Tzung-Hai</given-names>
</name>
</principal-award-recipient>
</award-group>
<award-group id="award003">
<funding-source>
<institution-wrap>
<institution-id institution-id-type="funder-id">http://dx.doi.org/10.13039/501100005795</institution-id>
<institution>Chang Gung Memorial Hospital, Linkou</institution>
</institution-wrap>
</funding-source>
<award-id>G3F0371</award-id>
<principal-award-recipient>
<name>
<surname>Chang</surname>
<given-names>Pei-Ching</given-names>
</name>
</principal-award-recipient>
</award-group>
<funding-statement>Support was provided by the Ministry of Science and Technology, Taiwan (MST 104-2221-E-182A-003) and Chang Gung Memorial Hospital, Linkou, Taiwan (CMRP G3D0012, G3E0361, G3D0072, G3F0601, C3F1161, G3F0371). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement>
</funding-group>
<counts>
<fig-count count="1"></fig-count>
<table-count count="5"></table-count>
<page-count count="11"></page-count>
</counts>
<custom-meta-group>
<custom-meta id="data-availability">
<meta-name>Data Availability</meta-name>
<meta-value>All relevant data are within the paper. Detailed data about the study cohort is improper to provide online according to the privacy policy of Linkou Chang Gung Memorial Hospital Ethics Committee. Readers who are interested in the study or who want to understand the data can contact corresponding authors via e-mail (Dr Aileen I Tsai: E-mail:
<email>ait001@adm.cgmh.org.tw</email>
or Tzung-Hai Yen, E-mail:
<email>m19570@adm.cgmh.org.tw</email>
).</meta-value>
</custom-meta>
</custom-meta-group>
</article-meta>
<notes>
<title>Data Availability</title>
<p>All relevant data are within the paper. Detailed data about the study cohort is improper to provide online according to the privacy policy of Linkou Chang Gung Memorial Hospital Ethics Committee. Readers who are interested in the study or who want to understand the data can contact corresponding authors via e-mail (Dr Aileen I Tsai: E-mail:
<email>ait001@adm.cgmh.org.tw</email>
or Tzung-Hai Yen, E-mail:
<email>m19570@adm.cgmh.org.tw</email>
).</p>
</notes>
</front>
<body>
<sec sec-type="intro" id="sec005">
<title>Introduction</title>
<p>A torus is a common exostosis found in the oral cavity. TP develops in the midline of the hard palate’s vault, while TM occurs along the lingual aspect of the mandible. [
<xref rid="pone.0156988.ref001" ref-type="bibr">1</xref>
] Tori are classified into four morphological types: flat, spindle, nodular, and lobular. [
<xref rid="pone.0156988.ref001" ref-type="bibr">1</xref>
] Because tori are non-symptomatic and painless, they are usually found by accident during oral examinations. The pathogenesis is multifactorial, including genetic factor (autosomal dominant trait) and environmental influence (masticatory stress), age, sex, regional factor, ethic factor, but no single cause is definitive. [
<xref rid="pone.0156988.ref002" ref-type="bibr">2</xref>
] Removal of the tori is not always necessary but is an alternative to oral function rehabilitation with removable prostheses or implants. Since tori are a non-pathological change, no surgical intervention was required in these patients. [
<xref rid="pone.0156988.ref003" ref-type="bibr">3</xref>
]</p>
<p>Taiwan has been recognized as an endemic area for kidney disease, with the highest incidence and prevalence rates of end-stage renal disease (ESRD) in the world. According to 2015 Annual Data Report of United States Renal Data System [
<xref rid="pone.0156988.ref004" ref-type="bibr">4</xref>
], Taiwan, the Jalisco region of Mexico, and the United States continue to report the highest incidence of treated ESRD (458, 421 and 363 per million population, respectively. Furthermore, the highest prevalence of treated ESRD was reported for Taiwan, Japan, and the United States (3138, 2411, and 2043 per million population, respectively). [
<xref rid="pone.0156988.ref004" ref-type="bibr">4</xref>
]</p>
<p>Renal osteodystrophy, which is most evident in dialysis patients, usually begins when kidney functions deteriorate. The spectrum of skeletal abnormalities seen in renal osteodystrophy is classified according to the state of bone turnover. Classic descriptions of the histologic abnormalities include high-turnover (osteitis fibrosa cystica), low-turnover (osteomalacia, adynamic bone disease), and low-to-high bone disease (mixed uremic osteodystrophy). [
<xref rid="pone.0156988.ref005" ref-type="bibr">5</xref>
] Osteitis fibrosa cystica is the result of the development of secondary hyperparathyroidism. [
<xref rid="pone.0156988.ref006" ref-type="bibr">6</xref>
] It is characterized by increased bone turnover, an increase in the number and activity of osteoblasts and osteoclasts, and variable amounts of peritrabecular fibrosis, which are increased osteoids with a woven pattern. Osteomalacia is characterized by increased osteoid seam width, increased in the trabecular surface area covered by osteoids, and decreased bone mineralization. Adynamic bone disease is characterized by normal or decreased osteoid volume and reduced bone formation rate, and reduced numbers of osteoblasts and osteoclasts. The gold standard for the diagnosis and specific classification of renal osteodystrophy is a bone biopsy with bone histomorphometry. [
<xref rid="pone.0156988.ref007" ref-type="bibr">7</xref>
] Nevertheless, most nephrologists do not perform bone biopsies on a routine basis.</p>
<p>In a study, Sisman et al [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
] investigated the prevalence, size, location and shape of TP in 91 chronic peritoneal dialysis patients. The prevalence of TP was 41.7%. Most cases of TP were < 2 cm in size (81.6%) and spindle-shaped (78.9%). The duration of PD was statistically higher in patients with TP size > 2 cm (6.8±3.6 years) than patients with TP size of < 2 cm (3.5±2.6 years). Thus, the development of TP in peritoneal dialysis patients was attributed to an underlying disorder, such as secondary hyperparathyrodism [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
]. On the other hand, Chao et al found that the prevalence of oral tori in 119 chronic hemodialysis patients was 33.6%. [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
] The most common location of tori was TP (70.0%), followed by TM (20.0%), and then both TP and TM (10.0%). Of the 40 tori cases, most (67.5%) were <2 cm in size; moreover, the majority (52.5%) were flat in shape. Notably, the levels of intact parathyroid hormones in these hemodialysis patients did not differ in patients with or without tori (P = 0.611). Furthermore, patients with tori did not differ from patients without tori in inflammatory variables such as log high-sensitivity C-reactive protein (P = 1.000) or nutritional variables such as albumin (P = 0.247). Finally, there were no differences between patients with and without tori in adequacy of dialysis (P = 0.577). Therefore, neither hyperparathyroidism nor inflammation malnutrition syndrome was found to contribute to the formation of oral tori in chronic hemodialysis patients. [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
]</p>
<p>The objective of this study was to undertake a broader assessment of potential environmental influences and, in doing so, address whether medical conditions, or chronic kidney disease—mineral and bone disease, or inflammation malnutrition syndrome were associated with chronic peritoneal dialysis patients with oral tori.</p>
</sec>
<sec id="sec006">
<title>Material and Methods</title>
<sec id="sec007">
<title>Ethical statement</title>
<p>This clinical study was carried out in accordance with Declaration of Helsinki for Human Experimentation and was approved by the Medical Ethics Committee of Chang Gung Memorial Hospital. The Institutional Review Board numbers were 104-6913C and 102-2761B, and all patients provided written informed consent.</p>
</sec>
<sec id="sec008">
<title>Patients</title>
<p>All study patients were recruited between July 1 and December 31, 2015 from the Chang Gung Memorial Hospital, Linkou, Taiwan. Only patients undergoing chronic peritoneal dialysis for more than 6 months were enrolled, after excluding those with malignancies [
<xref rid="pone.0156988.ref010" ref-type="bibr">10</xref>
], active infectious diseases, hospitalizations, or surgery in the past 3 months, or lead [
<xref rid="pone.0156988.ref011" ref-type="bibr">11</xref>
] or cadmium [
<xref rid="pone.0156988.ref012" ref-type="bibr">12</xref>
] intoxication. The peritoneal dialysis prescription for each patient was based on the peritoneal membrane characteristics as determined by the peritoneal equilibration tests, with intermittent therapies used primarily for patients with high transport characteristics and continuous therapies for those with average or low transport characteristics. Low-calcium (1.5 or 1.25 mmol/L), icodextrin-based (7.5 g/dL) or standard dialysates containing glucose (sodium, 135 mmol/L; lactate, 35 mmol/L; calcium, 1.75 mmol/L) were used according to the patients' peritoneal transport characteristics and serum calcium levels to maintain adequate ultrafiltration and normal calcium levels. Dialysis prescription aimed at obtaining a total Kt/V of at least 1.8 per week.</p>
</sec>
<sec id="sec009">
<title>Groups</title>
<p>Patients who met the inclusion criteria were classified into 2 groups according to the presence or absence of oral tori.</p>
</sec>
<sec id="sec010">
<title>Laboratories</title>
<p>All laboratory values, including blood cell counts, biochemical data, dialysate/plasma creatinine ratio, peritoneal transport characteristics, weekly creatinine clearance, weekly Kt/V
<sub>urea</sub>
, were measured by automated and standardized methods. All blood samples were collected in the morning after at least 12 hours of fasting. Serum levels of albumin, blood urea nitrogen, creatinine and transferring saturation were measured and used as nutritional markers. Serum levels of calcium, phosphate, and intact parathyroid hormone were also measured and the corrected serum calcium level was calculated as: calcium (mg/dL) = [0.8 (4.0—albumin [g/dL])]. All other markers were measured via standard laboratory methods using an automatic analyzer.</p>
</sec>
<sec id="sec011">
<title>Diagnosis of oral tori</title>
<p>The same dentist examined all patients and used mouth mirrors or tongue blades to check the oral condition of these patients. The examination for oral tori consisted of inspection and palpation. TP (
<xref ref-type="fig" rid="pone.0156988.g001">Fig 1a and 1b</xref>
) was defined as a raised bony exostosis along the midline of the hard palate whereas TM (
<xref ref-type="fig" rid="pone.0156988.g001">Fig 1c and 1d</xref>
) was defined as exostosis that develops along the lingual aspect of the mandible. The maximum elevation of the outgrowth of tori was used to measure the size of tori. Tori were graded as>2 cm or <2 cm using a periodontal probe, as described by Gorsky et al [
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
]. The shape of tori was classified as flat, spindle, nodular, or lobular according to the criteria described by Jainkittivong et al [
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
].</p>
<fig id="pone.0156988.g001" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.g001</object-id>
<label>Fig 1</label>
<caption>
<p>a, b. Torus palatinus. Intraoral view of two peritoneal dialysis patients with a flat torus palatinus (asterisk), which is an exophytic bony mass that arises along the midline of the hard palate. c, d. Torus mandibularis. Intraoral view of two peritoneal dialysis patients with a symmetrical lobular torus mandibularis (asterisk), which is an exophytic bony mass that arises along the lingual aspect of the mandible. Heavy dental calculus accumulating at cervical portion of teeth was also found in most patients.</p>
</caption>
<graphic xlink:href="pone.0156988.g001"></graphic>
</fig>
</sec>
<sec id="sec012">
<title>Statistical analysis</title>
<p>Continuous variables were expressed as a mean with a standard deviation, while categorical variables were expressed as numbers and percentages in brackets. All data were tested for normality of distribution and equality of standard deviation before analysis. Comparisons between the 2 groups of patients were performed using Student’s t test for quantitative variables and Chi-square or Fisher’s exact tests for categorical variables. The criterion for significance was a 95% confidence interval to reject the null hypothesis. All analyses were performed using IBM SPSS Statistics Version 20.0.</p>
</sec>
</sec>
<sec sec-type="results" id="sec013">
<title>Results</title>
<p>A total of 134 ESRD patients were recruited into this study (
<xref ref-type="table" rid="pone.0156988.t001">Table 1</xref>
). The prevalence of oral tori in our sample group was high at 42.5% (57 of 134). Most patients with oral tori were female (61.4%). Furthermore, there were no significant differences in baseline variables between patients with and without tori formations (P > 0.05).</p>
<table-wrap id="pone.0156988.t001" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.t001</object-id>
<label>Table 1</label>
<caption>
<title>Baseline characteristics of peritoneal dialysis patients with or without oral tori (n = 134).</title>
</caption>
<alternatives>
<graphic id="pone.0156988.t001g" xlink:href="pone.0156988.t001"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
</colgroup>
<thead>
<tr>
<th align="left" rowspan="1" colspan="1">Variable</th>
<th align="left" rowspan="1" colspan="1">All patients (n = 134)</th>
<th align="left" rowspan="1" colspan="1">Patients with oral tori (n = 57)</th>
<th align="left" rowspan="1" colspan="1">Patients without oral tori (n = 77)</th>
<th align="left" rowspan="1" colspan="1">P value</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">Age, year</td>
<td align="left" rowspan="1" colspan="1">47.2±14.9</td>
<td align="left" rowspan="1" colspan="1">46.2±14.9</td>
<td align="left" rowspan="1" colspan="1">47.9±15.0</td>
<td align="char" char="." rowspan="1" colspan="1">0.521</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Female sex, n (%)</td>
<td align="left" rowspan="1" colspan="1">69 (51.5)</td>
<td align="left" rowspan="1" colspan="1">35 (61.4)</td>
<td align="left" rowspan="1" colspan="1">34 (44.2)</td>
<td align="char" char="." rowspan="1" colspan="1">0.048
<xref ref-type="table-fn" rid="t001fn002">*</xref>
</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Body mass index, kg/m2</td>
<td align="left" rowspan="1" colspan="1">23.0±4.4</td>
<td align="left" rowspan="1" colspan="1">23.5±5.2</td>
<td align="left" rowspan="1" colspan="1">22.6±3.7</td>
<td align="char" char="." rowspan="1" colspan="1">0.264</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Hypertension, n (%)</td>
<td align="left" rowspan="1" colspan="1">81 (60.4)</td>
<td align="left" rowspan="1" colspan="1">36 (63.2)</td>
<td align="left" rowspan="1" colspan="1">45 (58.4)</td>
<td align="char" char="." rowspan="1" colspan="1">0.581</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Diabetes mellitus, n (%)</td>
<td align="left" rowspan="1" colspan="1">24 (17.9)</td>
<td align="left" rowspan="1" colspan="1">8 (14.0)</td>
<td align="left" rowspan="1" colspan="1">16 (20.8)</td>
<td align="char" char="." rowspan="1" colspan="1">0.314</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Coronary artery disease, n (%)</td>
<td align="left" rowspan="1" colspan="1">11 (8.2)</td>
<td align="left" rowspan="1" colspan="1">6 (10.5)</td>
<td align="left" rowspan="1" colspan="1">5 (6.5)</td>
<td align="char" char="." rowspan="1" colspan="1">0.400</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Dialysis duration, months</td>
<td align="left" rowspan="1" colspan="1">60.5±43.3</td>
<td align="left" rowspan="1" colspan="1">62.9±43.1</td>
<td align="left" rowspan="1" colspan="1">57.3±43.7</td>
<td align="char" char="." rowspan="1" colspan="1">0.455</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Smoking habit, n (%)</td>
<td align="left" rowspan="1" colspan="1">14 (10.4)</td>
<td align="left" rowspan="1" colspan="1">4 (7.0)</td>
<td align="left" rowspan="1" colspan="1">10 (13.0)</td>
<td align="char" char="." rowspan="1" colspan="1">0.264</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Alcohol consumption, n (%)</td>
<td align="left" rowspan="1" colspan="1">1 (0.7)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
<td align="left" rowspan="1" colspan="1">1 (1.3)</td>
<td align="char" char="." rowspan="1" colspan="1">0.388</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Betel nut habit, n (%)</td>
<td align="left" rowspan="1" colspan="1">1 (0.7)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
<td align="left" rowspan="1" colspan="1">1 (1.3)</td>
<td align="char" char="." rowspan="1" colspan="1">0.388</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="t001fn001">
<p>Note:</p>
</fn>
<fn id="t001fn002">
<p>*P<0.05</p>
</fn>
</table-wrap-foot>
</table-wrap>
<p>
<xref ref-type="table" rid="pone.0156988.t002">Table 2</xref>
shows that patients with oral tori had slightly lower serum levels of intact parathyroid hormones than those without oral tori, but the difference did not reach statistical significance (317.3±292.0 versus 430.1±492.6 pg/mL, P = 0.126). Nevertheless, there were no significant differences in the serum levels of alkaline phosphatase (83.5±53.8 versus 91.3±61.8 U/L, P = 0.447), calcium (9.7±1.1 versus 9.6±1.0 mg/dL, P = 0.858), or phosphorus (5.7±1.4 versus 5.6±1.4, P = 0.463) between groups. In addition, patients with oral tori did not differ from patients without tori in inflammatory variables such as high sensitivity C-reactive protein (6.6±8.2 versus 10.3±20.2 mg/L, P = 0.147) or nutritional variables such as albumin (3.79±0.38 versus 3.77±0.45 g/dL, P = 0.790).
<xref ref-type="table" rid="pone.0156988.t003">Table 3</xref>
shows that there were no differences between patients with and without oral tori in term of dialysis adequacy (weekly Kt/V
<sub>urea</sub>
, 2.14±0.39 versus 2.11±0.33, P = 0.533; weekly creatinine clearance rate, 59.31±17.58 versus 58.57±13.20 L/1.73 m
<sup>2</sup>
, P = 0.781). Finally, there was no difference in the peritoneal transporter characteristics between patients with and without tori (P = 0.098).</p>
<table-wrap id="pone.0156988.t002" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.t002</object-id>
<label>Table 2</label>
<caption>
<title>Laboratory findings of peritoneal dialysis patients with or without oral tori (n = 134).</title>
</caption>
<alternatives>
<graphic id="pone.0156988.t002g" xlink:href="pone.0156988.t002"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
</colgroup>
<thead>
<tr>
<th align="left" rowspan="1" colspan="1">Variable</th>
<th align="left" rowspan="1" colspan="1">All patients (n = 134)</th>
<th align="left" rowspan="1" colspan="1">Patients with oral tori (n = 57)</th>
<th align="left" rowspan="1" colspan="1">Patients without oral tori (n = 77)</th>
<th align="left" rowspan="1" colspan="1">P value</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">Blood urea nitrogen, mg/dL</td>
<td align="left" rowspan="1" colspan="1">64.8±18.8</td>
<td align="left" rowspan="1" colspan="1">65.1±21.9</td>
<td align="left" rowspan="1" colspan="1">64.6±16.3</td>
<td align="char" char="." rowspan="1" colspan="1">0.883</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Creatinine, mg/dL</td>
<td align="left" rowspan="1" colspan="1">13.1±3.5</td>
<td align="left" rowspan="1" colspan="1">13.4±3.6</td>
<td align="left" rowspan="1" colspan="1">12.8±3.3</td>
<td align="char" char="." rowspan="1" colspan="1">0.398</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Uric acid, mg/dL</td>
<td align="left" rowspan="1" colspan="1">7.0±1.4</td>
<td align="left" rowspan="1" colspan="1">7.2±1.5</td>
<td align="left" rowspan="1" colspan="1">6.8±1.3</td>
<td align="char" char="." rowspan="1" colspan="1">0.112</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Estimated glomerular filtration rate, mL/min/1.73 m
<sup>2</sup>
</td>
<td align="left" rowspan="1" colspan="1">3.9±1.5</td>
<td align="left" rowspan="1" colspan="1">3.7±1.1</td>
<td align="left" rowspan="1" colspan="1">4.1±1.7</td>
<td align="char" char="." rowspan="1" colspan="1">0.112</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Sodium, mEq/L</td>
<td align="left" rowspan="1" colspan="1">136.4±4.0</td>
<td align="left" rowspan="1" colspan="1">136.7±4.1</td>
<td align="left" rowspan="1" colspan="1">136.2±4.0</td>
<td align="char" char="." rowspan="1" colspan="1">0.513</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Potassium, mEq/L</td>
<td align="left" rowspan="1" colspan="1">4.0±0.7</td>
<td align="left" rowspan="1" colspan="1">4.0±0.6</td>
<td align="left" rowspan="1" colspan="1">4.0±0.8</td>
<td align="char" char="." rowspan="1" colspan="1">0.612</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Calcium, mg/dL</td>
<td align="left" rowspan="1" colspan="1">9.6±1.0</td>
<td align="left" rowspan="1" colspan="1">9.7±1.1</td>
<td align="left" rowspan="1" colspan="1">9.6±1.0</td>
<td align="char" char="." rowspan="1" colspan="1">0.858</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Inorganic phosphorus, mg/dL</td>
<td align="left" rowspan="1" colspan="1">5.6±1.4</td>
<td align="left" rowspan="1" colspan="1">5.7±1.4</td>
<td align="left" rowspan="1" colspan="1">5.6±1.4</td>
<td align="char" char="." rowspan="1" colspan="1">0.463</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Fasting glucose, mg/dL</td>
<td align="left" rowspan="1" colspan="1">107.0±41.7</td>
<td align="left" rowspan="1" colspan="1">109.8±47.1</td>
<td align="left" rowspan="1" colspan="1">104.9±37.3</td>
<td align="char" char="." rowspan="1" colspan="1">0.504</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Glycated hemoglobin, %</td>
<td align="left" rowspan="1" colspan="1">5.63±0.87</td>
<td align="left" rowspan="1" colspan="1">5.61±0.99</td>
<td align="left" rowspan="1" colspan="1">5.64±0.77</td>
<td align="char" char="." rowspan="1" colspan="1">0.815</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Albumin, g/dL</td>
<td align="left" rowspan="1" colspan="1">3.78±0.42</td>
<td align="left" rowspan="1" colspan="1">3.79±0.38</td>
<td align="left" rowspan="1" colspan="1">3.77±0.45</td>
<td align="char" char="." rowspan="1" colspan="1">0.790</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Alkaline phosphatase, U/L</td>
<td align="left" rowspan="1" colspan="1">88.0±58.5</td>
<td align="left" rowspan="1" colspan="1">83.5±53.8</td>
<td align="left" rowspan="1" colspan="1">91.3±61.8</td>
<td align="char" char="." rowspan="1" colspan="1">0.447</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Total cholesterol, mg/dL</td>
<td align="left" rowspan="1" colspan="1">187.4±45.2</td>
<td align="left" rowspan="1" colspan="1">188.8±48.3</td>
<td align="left" rowspan="1" colspan="1">186.3±43.1</td>
<td align="char" char="." rowspan="1" colspan="1">0.744</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">High-density lipoprotein, mg/dL</td>
<td align="left" rowspan="1" colspan="1">42.9±13.6</td>
<td align="left" rowspan="1" colspan="1">43.9±12.1</td>
<td align="left" rowspan="1" colspan="1">42.1±14.6</td>
<td align="char" char="." rowspan="1" colspan="1">0.454</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Low-density lipoprotein, mg/dL</td>
<td align="left" rowspan="1" colspan="1">139.0±84.4</td>
<td align="left" rowspan="1" colspan="1">136.9±75.8</td>
<td align="left" rowspan="1" colspan="1">140.5±90.8</td>
<td align="char" char="." rowspan="1" colspan="1">0.808</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Triglyceride, mg/dL</td>
<td align="left" rowspan="1" colspan="1">184.9±180.6</td>
<td align="left" rowspan="1" colspan="1">200.7±196.1</td>
<td align="left" rowspan="1" colspan="1">173.2±168.5</td>
<td align="char" char="." rowspan="1" colspan="1">0.385</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Aspartate aminotransferase, U/L</td>
<td align="left" rowspan="1" colspan="1">21.8±9.4</td>
<td align="left" rowspan="1" colspan="1">20.6±7.5</td>
<td align="left" rowspan="1" colspan="1">22.7±10.6</td>
<td align="char" char="." rowspan="1" colspan="1">0.180</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Alanine aminotransferase, U/L</td>
<td align="left" rowspan="1" colspan="1">17.3±7.8</td>
<td align="left" rowspan="1" colspan="1">16.1±5.8</td>
<td align="left" rowspan="1" colspan="1">18.1±8.9</td>
<td align="char" char="." rowspan="1" colspan="1">0.115</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Intact parathyroid hormone, pg/mL</td>
<td align="left" rowspan="1" colspan="1">382.1±421.5</td>
<td align="left" rowspan="1" colspan="1">317.3±292.0</td>
<td align="left" rowspan="1" colspan="1">430.1±492.6</td>
<td align="char" char="." rowspan="1" colspan="1">0.126</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Iron, ug/dL</td>
<td align="left" rowspan="1" colspan="1">81.9±36.8</td>
<td align="left" rowspan="1" colspan="1">82.3±32.6</td>
<td align="left" rowspan="1" colspan="1">81.7±39.9</td>
<td align="char" char="." rowspan="1" colspan="1">0.923</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Total iron binding capacity, ug/dL</td>
<td align="left" rowspan="1" colspan="1">280.5±61.3</td>
<td align="left" rowspan="1" colspan="1">270.3±62.2</td>
<td align="left" rowspan="1" colspan="1">288.0±59.9</td>
<td align="char" char="." rowspan="1" colspan="1">0.098</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Ferritin, ng/mL</td>
<td align="left" rowspan="1" colspan="1">391.6±595.6</td>
<td align="left" rowspan="1" colspan="1">369.6±289.7</td>
<td align="left" rowspan="1" colspan="1">407.9±747.2</td>
<td align="char" char="." rowspan="1" colspan="1">0.714</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">White blood cell count, 103/uL</td>
<td align="left" rowspan="1" colspan="1">7.7±2.6</td>
<td align="left" rowspan="1" colspan="1">7.7±2.5</td>
<td align="left" rowspan="1" colspan="1">7.8±2.8</td>
<td align="char" char="." rowspan="1" colspan="1">0.792</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Red blood cell count, 106/uL</td>
<td align="left" rowspan="1" colspan="1">3.5±0.6</td>
<td align="left" rowspan="1" colspan="1">3.4±0.5</td>
<td align="left" rowspan="1" colspan="1">3.6±0.6</td>
<td align="char" char="." rowspan="1" colspan="1">0.118</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Hemoglobin, g/dL</td>
<td align="left" rowspan="1" colspan="1">10.2±1.4</td>
<td align="left" rowspan="1" colspan="1">10.1±1.3</td>
<td align="left" rowspan="1" colspan="1">10.3±1.5</td>
<td align="char" char="." rowspan="1" colspan="1">0.391</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Hematocrit, %</td>
<td align="left" rowspan="1" colspan="1">30.4±4.3</td>
<td align="left" rowspan="1" colspan="1">29.9±4.2</td>
<td align="left" rowspan="1" colspan="1">30.8±4.3</td>
<td align="char" char="." rowspan="1" colspan="1">0.229</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Mean corpuscular volume, fL</td>
<td align="left" rowspan="1" colspan="1">86.6±7.1</td>
<td align="left" rowspan="1" colspan="1">87.1±5.8</td>
<td align="left" rowspan="1" colspan="1">86.3±7.9</td>
<td align="char" char="." rowspan="1" colspan="1">0.462</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Mean corpuscular hemoglobin, pg/Cell</td>
<td align="left" rowspan="1" colspan="1">29.1±2.7</td>
<td align="left" rowspan="1" colspan="1">29.4±2.2</td>
<td align="left" rowspan="1" colspan="1">28.9±3.0</td>
<td align="char" char="." rowspan="1" colspan="1">0.213</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Mean corpuscular hemoglobin concentration, gHb/dL</td>
<td align="left" rowspan="1" colspan="1">33.6±1.1</td>
<td align="left" rowspan="1" colspan="1">33.8±1.0</td>
<td align="left" rowspan="1" colspan="1">33.4±1.1</td>
<td align="char" char="." rowspan="1" colspan="1">0.082</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Red blood cell distribution width, %</td>
<td align="left" rowspan="1" colspan="1">14.5±1.5</td>
<td align="left" rowspan="1" colspan="1">14.3±1.1</td>
<td align="left" rowspan="1" colspan="1">14.7±1.7</td>
<td align="char" char="." rowspan="1" colspan="1">0.147</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Platelet count, 10
<sup>3</sup>
/uL</td>
<td align="left" rowspan="1" colspan="1">228.0±81.2</td>
<td align="left" rowspan="1" colspan="1">231.8±84.3</td>
<td align="left" rowspan="1" colspan="1">225.2±79.4</td>
<td align="char" char="." rowspan="1" colspan="1">0.645</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">High sensitivity C-reactive protein, mg/L</td>
<td align="left" rowspan="1" colspan="1">8.7±16.3</td>
<td align="left" rowspan="1" colspan="1">6.6±8.2</td>
<td align="left" rowspan="1" colspan="1">10.3±20.2</td>
<td align="char" char="." rowspan="1" colspan="1">0.147</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="t002fn001">
<p>Note: P<0.05</p>
</fn>
</table-wrap-foot>
</table-wrap>
<table-wrap id="pone.0156988.t003" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.t003</object-id>
<label>Table 3</label>
<caption>
<title>Dialysis-related data of peritoneal dialysis patients with or without oral tori (n = 134).</title>
</caption>
<alternatives>
<graphic id="pone.0156988.t003g" xlink:href="pone.0156988.t003"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
</colgroup>
<thead>
<tr>
<th align="left" rowspan="1" colspan="1">Variable</th>
<th align="left" rowspan="1" colspan="1">All patients (n = 134)</th>
<th align="left" rowspan="1" colspan="1">Patients with oral tori (n = 57)</th>
<th align="left" rowspan="1" colspan="1">Patients without oral tori (n = 77)</th>
<th align="left" rowspan="1" colspan="1">P value</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">Dialysate/plasma creatinine</td>
<td align="left" rowspan="1" colspan="1">0.66 ± 0.11</td>
<td align="left" rowspan="1" colspan="1">0.65± 0.11</td>
<td align="left" rowspan="1" colspan="1">0.67± 0.11</td>
<td align="char" char="." rowspan="1" colspan="1">0.224</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Peritoneal equilibration test</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="char" char="." rowspan="1" colspan="1">0.098</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">High, n (%)</td>
<td align="left" rowspan="1" colspan="1">13 (9.7%)</td>
<td align="left" rowspan="1" colspan="1">3 (5.3%)</td>
<td align="left" rowspan="1" colspan="1">10 (13.0%)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">High average, n (%)</td>
<td align="left" rowspan="1" colspan="1">58 (43.3%)</td>
<td align="left" rowspan="1" colspan="1">21 (36.8%)</td>
<td align="left" rowspan="1" colspan="1">37 (48.0%)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Low average, n (%)</td>
<td align="left" rowspan="1" colspan="1">55 (41.0%)</td>
<td align="left" rowspan="1" colspan="1">30 (52.6%)</td>
<td align="left" rowspan="1" colspan="1">25 (32.5%)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Low, n (%)</td>
<td align="left" rowspan="1" colspan="1">8 (6.0%)</td>
<td align="left" rowspan="1" colspan="1">3 (5.3%)</td>
<td align="left" rowspan="1" colspan="1">5 (6.5%)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Weekly Kt/V
<sub>urea</sub>
</td>
<td align="left" rowspan="1" colspan="1">2.12± 0.35</td>
<td align="left" rowspan="1" colspan="1">2.14 ± 0.39</td>
<td align="left" rowspan="1" colspan="1">2.11 ± 0.33</td>
<td align="char" char="." rowspan="1" colspan="1">0.533</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Weekly creatinine clearance rate, L/1.73 m
<sup>2</sup>
</td>
<td align="left" rowspan="1" colspan="1">58.88± 15.16</td>
<td align="left" rowspan="1" colspan="1">59.31 ± 17.58</td>
<td align="left" rowspan="1" colspan="1">58.57 ± 13.20</td>
<td align="char" char="." rowspan="1" colspan="1">0.781</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="t003fn001">
<p>Note: Kt/V
<sub>urea</sub>
is a number used to quantify peritoneal dialysis treatment adequacy. K dialyzer clearance of urea. t dialysis time. V volume of distribution of urea.</p>
</fn>
</table-wrap-foot>
</table-wrap>
<p>
<xref ref-type="table" rid="pone.0156988.t004">Table 4</xref>
shows that 57 patients were found to have oral tori; 46 patients had TP (80.7%); 3 patients had TM (5.3%), and 8 patients had both TP and TM (14%). Of the 54 TP cases, all were midline and most were <2 cm in size (59.3%), flat in shape (53.7%), and located at premolar region (40.7%). Of the 11 TM cases, all were bilateral and symmetric, and most were <2 cm in size (81.9%), lobular in shape (45.4%), and located at premolar region (63.6%).</p>
<table-wrap id="pone.0156988.t004" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.t004</object-id>
<label>Table 4</label>
<caption>
<title>Clinical findings of oral tori (n = 57).</title>
</caption>
<alternatives>
<graphic id="pone.0156988.t004g" xlink:href="pone.0156988.t004"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
</colgroup>
<thead>
<tr>
<th align="left" rowspan="1" colspan="1">Variable</th>
<th align="left" colspan="2" rowspan="1"></th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">Type</td>
<td align="left" colspan="2" rowspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">TP, n (%)</td>
<td align="left" colspan="2" rowspan="1">46 (80.7)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">TM, n (%)</td>
<td align="left" colspan="2" rowspan="1">3 (5.3)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">TP+TM, n (%)</td>
<td align="left" colspan="2" rowspan="1">8 (14.0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Symmetric occurrence</td>
<td align="left" rowspan="1" colspan="1">TP (n = 54)</td>
<td align="left" rowspan="1" colspan="1">TM (n = 11)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Symmetric, n (%)</td>
<td align="left" rowspan="1" colspan="1">54 (100.0)</td>
<td align="left" rowspan="1" colspan="1">11 (100.0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Size</td>
<td align="left" rowspan="1" colspan="1">TP (n = 54)</td>
<td align="left" rowspan="1" colspan="1">TM (n = 11)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1"><2cm, n (%)</td>
<td align="left" rowspan="1" colspan="1">32 (59.3)</td>
<td align="left" rowspan="1" colspan="1">9 (81.9)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">>2cm, n (%)</td>
<td align="left" rowspan="1" colspan="1">22 (40.7)</td>
<td align="left" rowspan="1" colspan="1">2 (18.1)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Shape</td>
<td align="left" rowspan="1" colspan="1">TP (n = 54)</td>
<td align="left" rowspan="1" colspan="1">TM (n = 11)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Flat, n (%)</td>
<td align="left" rowspan="1" colspan="1">29 (53.7)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Spindle, n (%)</td>
<td align="left" rowspan="1" colspan="1">9 (16.7)</td>
<td align="left" rowspan="1" colspan="1">2 (18.2)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Nodular, n (%)</td>
<td align="left" rowspan="1" colspan="1">11 (20.3)</td>
<td align="left" rowspan="1" colspan="1">4 (36.4)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Lobular, n (%)</td>
<td align="left" rowspan="1" colspan="1">5 (9.3)</td>
<td align="left" rowspan="1" colspan="1">5 (45.4)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Location</td>
<td align="left" rowspan="1" colspan="1">TP (n = 54)</td>
<td align="left" rowspan="1" colspan="1">TM (n = 11)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Incisor, n (%)</td>
<td align="left" rowspan="1" colspan="1">1 (1.9)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Premolar, n (%)</td>
<td align="left" rowspan="1" colspan="1">22 (40.7)</td>
<td align="left" rowspan="1" colspan="1">7 (63.6)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Molar, n (%)</td>
<td align="left" rowspan="1" colspan="1">5 (9.3)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Incisor + premolar, n (%)</td>
<td align="left" rowspan="1" colspan="1">3 (5.5)</td>
<td align="left" rowspan="1" colspan="1">4 (36.4)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Premolar + molar, n (%)</td>
<td align="left" rowspan="1" colspan="1">18 (33.3)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Incisor + premolar +molar, n (%)</td>
<td align="left" rowspan="1" colspan="1">5 (9.3)</td>
<td align="left" rowspan="1" colspan="1">0 (0)</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="t004fn001">
<p>Note: TP torus palatinus, TM torus mandibularis</p>
</fn>
</table-wrap-foot>
</table-wrap>
</sec>
<sec sec-type="conclusions" id="sec014">
<title>Discussion</title>
<p>Few data are available regarding the prevalence rate of oral tori in dialysis patients; this is the first study examining the prevalence of oral tori in ESRD patients treated with peritoneal dialysis in Taiwan. Our data revealed that 57 out of 134 (42.5%) peritoneal dialysis patients had oral tori. TP generally occurs in 4.1–60.5% of the population, and TM from 1.4–38.2%; different studies have reported marked differences between various ethnic groups (
<xref ref-type="table" rid="pone.0156988.t005">Table 5</xref>
). In chronic hemodialysis patients, our previous data [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
] indicated that the prevalence rates of TP and TM were 23.5% and 6.7%, respectively. In chronic peritoneal dialysis patients, Sisman et al [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
] reported that the prevalence rate of TP was 41.6%, but the rate of TM was not assessed.</p>
<table-wrap id="pone.0156988.t005" orientation="portrait" position="float">
<object-id pub-id-type="doi">10.1371/journal.pone.0156988.t005</object-id>
<label>Table 5</label>
<caption>
<title>Comparison of prevalence rate of oral tori from different studies.</title>
</caption>
<alternatives>
<graphic id="pone.0156988.t005g" xlink:href="pone.0156988.t005"></graphic>
<table frame="hsides" rules="groups">
<colgroup span="1">
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
<col align="left" valign="middle" span="1"></col>
</colgroup>
<thead>
<tr>
<th align="left" rowspan="1" colspan="1">Study</th>
<th align="left" rowspan="1" colspan="1">Year</th>
<th align="left" rowspan="1" colspan="1">Geographic area</th>
<th align="left" rowspan="1" colspan="1">Sample size,</th>
<th align="left" rowspan="1" colspan="1">Population</th>
<th align="left" rowspan="1" colspan="1">TP, % (female)</th>
<th align="left" rowspan="1" colspan="1">TM, % (female)</th>
<th align="left" rowspan="1" colspan="1">Age, year</th>
</tr>
</thead>
<tbody>
<tr>
<td align="left" rowspan="1" colspan="1">Eggen et al. [
<xref rid="pone.0156988.ref036" ref-type="bibr">36</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1986</td>
<td align="left" rowspan="1" colspan="1">Norwegian</td>
<td align="left" rowspan="1" colspan="1">829</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">32.8 (68.3)</td>
<td align="left" rowspan="1" colspan="1">27.5 (54.5)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Reichart et al. [
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1988</td>
<td align="left" rowspan="1" colspan="1">German</td>
<td align="left" rowspan="1" colspan="1">1317</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">13.5 (60.1)</td>
<td align="left" rowspan="1" colspan="1">5.2 (24.6)</td>
<td align="left" rowspan="1" colspan="1">1->80</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Reichart et al. [
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1988</td>
<td align="left" rowspan="1" colspan="1">Thailand</td>
<td align="left" rowspan="1" colspan="1">947</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">23.1 (70.8)</td>
<td align="left" rowspan="1" colspan="1">9.2 (56.3)</td>
<td align="left" rowspan="1" colspan="1">1->80</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Haugen et al. [
<xref rid="pone.0156988.ref026" ref-type="bibr">26</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1992</td>
<td align="left" rowspan="1" colspan="1">Norway</td>
<td align="left" rowspan="1" colspan="1">5000</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">9.2 (67.6)</td>
<td align="left" rowspan="1" colspan="1">7.2 (49.0)</td>
<td align="left" rowspan="1" colspan="1">16–89</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Eggen et al [
<xref rid="pone.0156988.ref030" ref-type="bibr">30</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1994</td>
<td align="left" rowspan="1" colspan="1">Norwegian</td>
<td align="left" rowspan="1" colspan="1">1181</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">38.4 (60.1)</td>
<td align="left" rowspan="1" colspan="1">12.7 (43.1)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Gorsky et al. [
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
]</td>
<td align="left" rowspan="1" colspan="1">1996</td>
<td align="left" rowspan="1" colspan="1">Israel</td>
<td align="left" rowspan="1" colspan="1">1002</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">21.0 (63.9)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">4–40
<xref ref-type="table-fn" rid="t005fn002">*</xref>
</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Al-Bayaty [
<xref rid="pone.0156988.ref003" ref-type="bibr">3</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2001</td>
<td align="left" rowspan="1" colspan="1">India</td>
<td align="left" rowspan="1" colspan="1">667</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">9.4 (73.0)</td>
<td align="left" rowspan="1" colspan="1">5.7 (55.2)</td>
<td align="left" rowspan="1" colspan="1">11–50</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Bruce et al. [
<xref rid="pone.0156988.ref028" ref-type="bibr">28</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2004</td>
<td align="left" rowspan="1" colspan="1">Ghana</td>
<td align="left" rowspan="1" colspan="1">926</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">3.9 (74.2)</td>
<td align="left" rowspan="1" colspan="1">12.1 (55.2)</td>
<td align="left" rowspan="1" colspan="1"></td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Yildiz et al. [
<xref rid="pone.0156988.ref020" ref-type="bibr">20</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2005</td>
<td align="left" rowspan="1" colspan="1">Turkey</td>
<td align="left" rowspan="1" colspan="1">1943</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">30.9 (50.7)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">5–15</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Jainkittivong et al. [
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2007</td>
<td align="left" rowspan="1" colspan="1">Thailand</td>
<td align="left" rowspan="1" colspan="1">1520</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">60.5 (62.8)</td>
<td align="left" rowspan="1" colspan="1">32.2 (48.1)</td>
<td align="left" rowspan="1" colspan="1">10–60</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Sisman et al. [
<xref rid="pone.0156988.ref021" ref-type="bibr">21</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2008</td>
<td align="left" rowspan="1" colspan="1">Turkey</td>
<td align="left" rowspan="1" colspan="1">2660</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">4.1 (81.8)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">13–85</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Yoshinaka et al. [
<xref rid="pone.0156988.ref019" ref-type="bibr">19</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2010</td>
<td align="left" rowspan="1" colspan="1">Japan</td>
<td align="left" rowspan="1" colspan="1">664</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">17.0 (80.5)</td>
<td align="left" rowspan="1" colspan="1">29.7 (46.7)</td>
<td align="left" rowspan="1" colspan="1">60–82</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Simunkovic et al [
<xref rid="pone.0156988.ref031" ref-type="bibr">31</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2011</td>
<td align="left" rowspan="1" colspan="1">Croatia</td>
<td align="left" rowspan="1" colspan="1">1679</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">42.9 (54.8)</td>
<td align="left" rowspan="1" colspan="1">12.6 (52.6)</td>
<td align="left" rowspan="1" colspan="1">9–99</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Hiremath et al. [
<xref rid="pone.0156988.ref025" ref-type="bibr">25</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2011</td>
<td align="left" rowspan="1" colspan="1">Malaysia</td>
<td align="left" rowspan="1" colspan="1">65</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">50.8 (90.9)</td>
<td align="left" rowspan="1" colspan="1">4.6 (66.7)</td>
<td align="left" rowspan="1" colspan="1">13–59</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Sisman et al. [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2012</td>
<td align="left" rowspan="1" colspan="1">Turkey</td>
<td align="left" rowspan="1" colspan="1">91</td>
<td align="left" rowspan="1" colspan="1">Uremic</td>
<td align="left" rowspan="1" colspan="1">41.7 (55.3)</td>
<td align="left" rowspan="1" colspan="1"></td>
<td align="left" rowspan="1" colspan="1">19–81</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Sathya et al. [
<xref rid="pone.0156988.ref023" ref-type="bibr">23</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2012</td>
<td align="left" rowspan="1" colspan="1">Malaysia</td>
<td align="left" rowspan="1" colspan="1">1532</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">12.0 (64.7)</td>
<td align="left" rowspan="1" colspan="1">2.8 (65.1)</td>
<td align="left" rowspan="1" colspan="1">10->40</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Chiang et al. [
<xref rid="pone.0156988.ref029" ref-type="bibr">29</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2014</td>
<td align="left" rowspan="1" colspan="1">Taiwan</td>
<td align="left" rowspan="1" colspan="1">2050</td>
<td align="left" rowspan="1" colspan="1">Nonuremic</td>
<td align="left" rowspan="1" colspan="1">21.1 (76.2)</td>
<td align="left" rowspan="1" colspan="1">24.2 (52.1)</td>
<td align="left" rowspan="1" colspan="1"><18->65</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Chao et al. [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
]</td>
<td align="left" rowspan="1" colspan="1">2014</td>
<td align="left" rowspan="1" colspan="1">Taiwan</td>
<td align="left" rowspan="1" colspan="1">119</td>
<td align="left" rowspan="1" colspan="1">Uremic</td>
<td align="left" rowspan="1" colspan="1">23.5(56.2)</td>
<td align="left" rowspan="1" colspan="1">6.7 (41.7)</td>
<td align="left" rowspan="1" colspan="1">9–90</td>
</tr>
<tr>
<td align="left" rowspan="1" colspan="1">Present study</td>
<td align="left" rowspan="1" colspan="1">2015</td>
<td align="left" rowspan="1" colspan="1">Taiwan</td>
<td align="left" rowspan="1" colspan="1">135</td>
<td align="left" rowspan="1" colspan="1">Uremic</td>
<td align="left" rowspan="1" colspan="1">40.3(63.0)</td>
<td align="left" rowspan="1" colspan="1">8.2 (54.5)</td>
<td align="left" rowspan="1" colspan="1">9–81.7.9</td>
</tr>
</tbody>
</table>
</alternatives>
<table-wrap-foot>
<fn id="t005fn001">
<p>Note: Note: TP torus palatinus, TM torus mandibularis</p>
</fn>
<fn id="t005fn002">
<p>* radiographic study</p>
</fn>
</table-wrap-foot>
</table-wrap>
<p>Our finding, which shows that patients with oral tori had slightly (but statistically insignificant) lower serum levels of intact parathyroid hormones than those without oral tori (P = 0.126), opposes Sisman’s hypothesis [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
], which attributes the high prevalence of TP in peritoneal dialysis to secondary hyperparathyroidism. However, blood levels of intact parathyroid hormone were not measured during the study. In our previous study [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
], the blood levels of intact parathyroid hormone also did not differ between hemodialysis patients with or without oral tori (P = 0.611). In addition, since renal osteodystrophy presents a broad spectrum of histologic abnormalities (osteitis fibrosa cystica, osteomalacia, adynamic bone disease, or mixed uremic osteodystrophy, etc), it is difficult to determine whether uremic milieu can predict oral tori risk. Furthermore, without bone biopsy, the gold standard of diagnosis, the utility of blood intact parathyroid hormone concentration in the assessment of renal osteodystrophy remains controversial.</p>
<p>The pathogenesis of oral tori has long been debated and is generally thought to be multifactorial with genetic and environmental factors, including occlusal (biting) forces, contributing to their formation. Another proposed mechanism [
<xref rid="pone.0156988.ref015" ref-type="bibr">15</xref>
] for oral tori is the combination of biomechanical forces, particularly in the oral cavity, combined with cortical bone loss and trabecular expansion that result in an increased incidence of TM. This preferential loss of cortical bone and increased formation of trabecular bone usually occurs in the early stages of primary hyperparathyroidism. In a study, Padbury et al [
<xref rid="pone.0156988.ref015" ref-type="bibr">15</xref>
] demonstrated that patients with primary hyperparathyroidism were more likely to have oral tori and reductions in radicular lamina dura on dental radiographs. Subsequently, Rai et al [
<xref rid="pone.0156988.ref016" ref-type="bibr">16</xref>
] also reported that loss of lamina dura, a ground-glass appearance, and mandibular cortical width reduction were common in patients with primary hyperparathyroidism, and these findings were significantly correlated with elevated parathyroid hormone and alkaline phosphatase. Notably, none of the patients had TP [
<xref rid="pone.0156988.ref016" ref-type="bibr">16</xref>
]. Since renal osteodystrophy presents a broad spectrum of histologic abnormalities (osteitis fibrosa cystica, osteomalacia, adynamic bone disease, or mixed uremic osteodystrophy), it is difficult to determine if uremic milieu could predict oral tori risk. Furthermore, the utility of blood intact parathyroid hormone concentration in the assessment of renal osteodystrophy remains controversial without bone biopsy, the gold standard of diagnosis. [
<xref rid="pone.0156988.ref007" ref-type="bibr">7</xref>
]</p>
<p>Most of our peritoneal dialysis patients with oral tori were females (61.4%). The idiopathic TP is transmitted as an autosomal dominant trait, and it is believed that there may be a dominant type linked to the X chromosome. [
<xref rid="pone.0156988.ref017" ref-type="bibr">17</xref>
] In a study of 162 Lithuanian twins [
<xref rid="pone.0156988.ref018" ref-type="bibr">18</xref>
], TM were found in 56.8% and TP in 1.8% of the subjects and a calculation of heritability estimate also verifies dominant influence of genetic factor on the etiology of oral bony outgrowths. No significant difference was found between men and women in the prevalence of oral tori [
<xref rid="pone.0156988.ref018" ref-type="bibr">18</xref>
]. Females were more likely to have TP, from 5.7% to 70.5% [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
,
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
,
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
,
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
,
<xref rid="pone.0156988.ref019" ref-type="bibr">19</xref>
–
<xref rid="pone.0156988.ref030" ref-type="bibr">30</xref>
]. Only one study showed a higher TP prevalence in males than in females. [
<xref rid="pone.0156988.ref031" ref-type="bibr">31</xref>
] In our study, a higher TP prevalence rate was found in females. The prevalence of TM is higher in males [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
,
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
,
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
,
<xref rid="pone.0156988.ref023" ref-type="bibr">23</xref>
–
<xref rid="pone.0156988.ref026" ref-type="bibr">26</xref>
,
<xref rid="pone.0156988.ref028" ref-type="bibr">28</xref>
,
<xref rid="pone.0156988.ref029" ref-type="bibr">29</xref>
,
<xref rid="pone.0156988.ref031" ref-type="bibr">31</xref>
–
<xref rid="pone.0156988.ref033" ref-type="bibr">33</xref>
]; however, in Sathya [
<xref rid="pone.0156988.ref023" ref-type="bibr">23</xref>
] and our studies, higher TM prevalence rates were found in females.</p>
<p>Most studies found that the most common onset-age ranged from the third to the fourth decades of life. [
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
,
<xref rid="pone.0156988.ref026" ref-type="bibr">26</xref>
,
<xref rid="pone.0156988.ref028" ref-type="bibr">28</xref>
,
<xref rid="pone.0156988.ref033" ref-type="bibr">33</xref>
] The increased production of tori was associated with age [
<xref rid="pone.0156988.ref029" ref-type="bibr">29</xref>
]. The present study investigated ESRD patients with an average age of 47.2 years old, older than subjects in previous research which usually recruited patients from school examinations [
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
,
<xref rid="pone.0156988.ref020" ref-type="bibr">20</xref>
,
<xref rid="pone.0156988.ref025" ref-type="bibr">25</xref>
], dental outpatient care [
<xref rid="pone.0156988.ref003" ref-type="bibr">3</xref>
,
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
,
<xref rid="pone.0156988.ref022" ref-type="bibr">22</xref>
–
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
,
<xref rid="pone.0156988.ref029" ref-type="bibr">29</xref>
,
<xref rid="pone.0156988.ref033" ref-type="bibr">33</xref>
], or residents in certain areas [
<xref rid="pone.0156988.ref021" ref-type="bibr">21</xref>
,
<xref rid="pone.0156988.ref031" ref-type="bibr">31</xref>
,
<xref rid="pone.0156988.ref034" ref-type="bibr">34</xref>
] with a more average distribution of different ages. However, the prevalence rates of TP and TM in this study did not differ from other studies. [
<xref rid="pone.0156988.ref019" ref-type="bibr">19</xref>
,
<xref rid="pone.0156988.ref032" ref-type="bibr">32</xref>
,
<xref rid="pone.0156988.ref035" ref-type="bibr">35</xref>
]</p>
<p>TP can be classified as flat, nodular, lobular or spindle-shaped [
<xref rid="pone.0156988.ref003" ref-type="bibr">3</xref>
,
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
,
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
,
<xref rid="pone.0156988.ref026" ref-type="bibr">26</xref>
], and TM is usually nodular, unilateral or bilateral, and single or multiple. [
<xref rid="pone.0156988.ref003" ref-type="bibr">3</xref>
,
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
,
<xref rid="pone.0156988.ref026" ref-type="bibr">26</xref>
]. In previous studies, the most common shape of TP and TM was the flat and nodular type. [
<xref rid="pone.0156988.ref013" ref-type="bibr">13</xref>
,
<xref rid="pone.0156988.ref035" ref-type="bibr">35</xref>
] In our study, the most common TP shape was flat (53.7%), while the most common TM shape was lobular type (45.4%). Other studies show that the most common shape is spindle. [
<xref rid="pone.0156988.ref008" ref-type="bibr">8</xref>
,
<xref rid="pone.0156988.ref014" ref-type="bibr">14</xref>
,
<xref rid="pone.0156988.ref024" ref-type="bibr">24</xref>
,
<xref rid="pone.0156988.ref031" ref-type="bibr">31</xref>
]. The current data were similar to our previous findings in hemodialysis population [
<xref rid="pone.0156988.ref009" ref-type="bibr">9</xref>
], which may be due to the similar ethnic background and environment.</p>
</sec>
<sec id="sec015">
<title>Conclusion and Limitations</title>
<p>The prevalence of oral tori in our sample group was high at 42.5% (57 of 134), and most patients with oral tori were female (61.4%). Analytical results revealed that secondary hyperparathyroidism did not contribute to the formation of tori in peritoneal dialysis patients. Nevertheless, the current study is limited by a small sample size, short follow-up duration, lack of healthy controls, lack of protocol dental radiograph analysis, lack of histopathology analysis between spontaneous and peritoneal dialysis induced tori, and lack of histochemical or genetic analysis of TP samples for marker of renal osteodistrophy. Further studies are warranted.</p>
</sec>
</body>
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