抗菌光動力治療於慢性牙周炎非手術性治療上之輔助成效

The Adjunctive Effect of Multiple Antimicrobial Photodynamic Therapy in The Non-surgical Treatment of Chronic Periodontitis: A Randomized Controlled Clinical Trial

陳雅雯(Ya-Wen Chen)

指導教授 ： 杜裕康

國立臺灣大學/公共衛生學院/公共衛生碩士學位學程/碩士(2015年)

https://doi.org/10.6342/NTU.2015.00359

摘要

牙周病是口腔中最常見的慢性疾病，牙周病所影響的牙周組織包含牙齦、齒槽骨及牙周韌帶。臨床常見以牙齦炎及慢性牙周炎為多數，牙齦炎的主要症狀侷限牙齦組織，常見牙齦發紅、腫脹、疼痛和刷牙流血等症狀。牙周炎除了有上述牙齦炎的症狀外，還有侵犯牙齦下方的齒槽骨和牙周韌帶。
口腔內有多達500-600種細菌，分別存在於牙齒、黏膜、唾液中，牙菌斑內的細菌組成，會因為不同的生態環境而有所改變，不同細菌彼此相互架構成嚴密的生物薄膜(biofilm)。從牙周囊袋中所分離的細菌，以革蘭氏陰性厭氧菌為主。依目前研究所瞭解牙周病致病菌的機轉是由於牙周致病菌所分泌的毒素，激發了牙齦組織，使宿主產生免疫反應，在此過程中有許多的胞激素(cytokines)或分解組織的酵素釋放出來，造成齒槽骨及組織的破壞。破壞程度因宿主的防衛功能、白血球功能、個人基因差異或環境因素有所不同，如：不良口腔衛生、抽菸、患有系統性疾病等因素有關。在一毫克的牙菌斑中，大約含有一億個細菌，當口腔衛生不良，堆積在牙齒或牙齦溝內的細菌數目將會增加二至十倍，因此，牙周病治療主要是控制發炎現象及抑制致病菌量，從牙齦上牙菌斑清除到牙齦下牙菌斑的移除都是治療的重點。本實驗針對慢性牙周炎患者採非手術性治療及非手術性治療合併使用抗菌光動力治療測試其輔助效果。在治療期間除了醫師利用適當的牙周器械移除牙齦下的牙結石及發炎組織，並同時給予指導正確而有效率的潔牙方法，減少牙齦上的牙菌斑。

臨床實驗（Clinical Trial）的受試納入標準，36位35-70歲罹患慢性牙周炎的受試者，全口總齒數至少16齒，針對同顎前牙、犬齒或小臼齒的至少一對對稱牙配對及至少兩個牙面牙周囊袋深度≧ 5mm且牙周附連高度≧ 4mm，作為實驗組或對照組齒位。篩選門診時，受試者同意並接受臨床檢查紀錄。篩選出不具有全身性系統性疾病，過去六個月內未曾服用抗生素且未曾接受過洗牙或牙周病治療，沒有對lidocaine過敏而女性受試者未受孕的受試者。試驗期間分兩階段，第一階段納入的受試者皆以 scaling and root planing（Sc/RP）的方式進行全口牙周病非手術性治療，之後採用split-mouth的模式進行試驗，經電腦軟體產生亂數序列將受試者隨機分配為兩組，實驗組使用甲基藍光感物劑合併使用抗菌光動力療法來輔助傳統的慢性牙周炎非手術性治療，對照組則給予注射用水作為安慰劑。藉此，評估改善口內包含牙周囊袋的深度、牙齒搖動的程度、牙齦角質化程度等臨床指標，抑制牙周致病菌量的增生及抑制口內硫化合物硫當量濃度為參考指標。

關鍵字

抗菌光動力治療 ； 慢性牙周炎 ； 牙根整平術

並列摘要

Periodontitis is the most common chronic oral disease. Periodontitis involves the periodontal tissue including gingiva, alveolar bone and periodontal ligament. Gingivitis and chronic periodontitis are frequently in clinical examination. The symptom and sign of gingivitis mostly confined to gingival tissue, gingival redness, swelling, pain, and gingival bleeding while brushing. Periodontitis the symptoms and signs of gingivitis, but the alveolar bone beneath the gingiva and periodontal ligament.
There are 500-600 species of bacteria in the oral environment, existing on the tooth surface, mucosa and saliva. The bacteria species alter in different oral ecological environments. Different bacteria together a biofilm. The bacteria extracted from the periodontal pockets were mainly Gram's negative anaerobic bacteria. Based on current literture, the periodontal disease pathogenic mechanism is caused by toxins released by the pathogenic bacteria. The toxins would evoke the gingival tissue and the host would the immune response to react. Cytokines and histodialysis enzymes are released during the process, causing alveolar bone and tissue destruction. The degree and extent of destruction depends on the defensive system function, leukocyte ability, genetic variances or environment differences, for example, inadequate oral hygiene, smoking habits, and systemic condition factors. There are 1 hundred million bacteria in 1 milligram of plaque. Inadequate oral hygiene environment increases the amount of bacteria accumulated on the tooth surface or gingival sulcus by 2 to 10 folds. Periodontal disease treatment focuses on supragingival and subgingival plaque and calculus removal. This experiment examined the adjunctive effect of photodynamic therapy on nonsurgically-treated chronic periodontitis patients. During the course of treatment, periodontal curette was applied to remove the subgingival calculus and inflammation tissue. Correct and effective oral hygiene care instructions and tooth-brushing techniques were given to the patients to reduce the amount of plaque.
Clinical trial 36 patients aged between 35 to 70 years old with chronic periodontitis. At least 16 teeth in the oral cavity. Incisor, canine, or premolar teeth in the same arch on different sides were selected in pairs, and there were at least two sites with periodontal probing depth than 5mm, periodontal attachment level than 4mm as the experimental group and control group. Patients not under antibiotic medication or periodontal treatment in six month. The course of this clinical trial was arranged into two steps. In the first step, participants were all treated with scaling and root planing as full mouth periodontal nonsurgical treatment. Split mouth, the participants were into two groups experimental group then photodynamic therapy as adjunctive treatment for the nonsurgically-treated chronic periodontitis patients. And the control group injection saline as placebo for adjunctive treatment. After the photodynamic therapy and nonsurgical periodontal treatment, periodontal pocket depth, tooth mobility, and keratinized degree of gingiva were. Also, the amount of periodontal pathogenic bacteria and the amount of sulfide compound in the oral cavity were .

並列關鍵字

antimicrobial photodynamic therapy ； chronic periodontitis ； scaling and root planing

參考文獻

1. Burt, B., S. Research, and P. Therapy Committee of the American Academy of, Position paper: epidemiology of periodontal diseases. J Periodontol, 2005. 76(8): 1406-19.

2. Socransky, S.S. and A.D. Haffajee, Dental biofilms: difficult therapeutic targets. Periodontol 2000, 2002. 28: 12-55.

3. Mattila KJ, N.M., Valtonen VV, et al., Association between dental health and acute myocardial infarction. BMJ., Mar 251989: 298(6676).

4. Hernichel-Gorbach, E., K.S. Kornman, S.C. Holt, F. Nichols, H. Meador, J.T. Kung, and C.A. Thomas, Host responses in patients with generalized refractory periodontitis. J Periodontol, 1994. 65(1): 8-16.

5. Manuel V Mendez, T.S., Wayne LaMorte, Pantel Vokonas, James O Menzoian, Raul Garcia, An association between periodontal disease and peripheral vascular disease. Am J Surg, 1998: 176:153-7.