氟錠投予對身心障礙兒童口腔健康之影響：口腔健康影響因子、尿液氟濃度追蹤與齲齒預防成效評估

Impact of Fluoride Tablet Ingestion on Children with Disabilities: Risk Factors of Oral Health, Tracing of Urinary Fluoride Concentration, and Evaluation of Fluoride Tablet Ingestion effectiveness

劉秀月(Hsiu-Yueh Liu)

指導教授 ： 黃純德

高雄醫學大學/口腔醫學院/牙醫學研究所/博士(2012年)

https://doi.org/10.6832/KMU.2012.00027

摘要

由於口腔疾病不會對生命造成立即性威脅，而經常被大眾所忽略。身心障礙兒童的口腔健康，牽繫著其每天的口腔活動。身心障礙兒童相較於一般同年齡者，有著較多未治療的齲齒與較差的口腔健康狀況。許多研究證實，氟化物可有效提升齲齒預防效果。在公共衛生與流行病學方面，尿液是最常被用來作為氟化物代謝的測量指標。兒童攝入的氟化物大約有30 - 50%會透過尿液，代謝出體外。尿中氟濃度，反映不同來源所攝入的氟化物總量。因此，在氟化物使用的同時，觀察與監測尿中氟濃度的變化情形，相當重要。然而，及早建立身心障礙兒童口腔健康預防計畫，刻不容緩。眾多研究證實，以學校為基礎的氟化物計畫能有效地預防齲齒。其中，氟錠是較適合身心障礙兒童使用的齲齒防治措施。因此，本研究藉由氟錠的使用，來探討氟錠投予對身心障礙兒童齲齒之預防效果。
在探討齲齒預防成效前，必須先建立身心障礙兒童的口腔狀況，以及觀察氟錠使用後尿中氟濃度的變化情形。因此，本論文之研究目的先後依序為：1.探討潔牙與飲食習慣，對特殊教育學校身心障礙兒童齲齒的影響；2.探討短期與長期氟錠投予前後，尿中氟濃度之變化與差異；3.評估長期氟錠投予，對身心障礙兒童的齲齒預防成效。
第一部分研究，為橫斷性研究，共有535位受訪者，來自10所特殊教育學校，年齡6-12歲的身心障礙兒童參與本研究。其中，60.93%為男生，39.07%為女生。口腔檢查由6位受過訓練的牙醫師來負責，牙醫師彼此間的內部一致性達0.8以上。由父母親/照護者來填寫結構式問卷，內容包含身心障礙兒童的基本資料、飲食和潔牙習慣等情形。結果顯示，超過三分之一的參加者，具有重度或極重度的身心障礙。相較於多數輕/中度的身心障礙兒童潔牙是由自己完成(81.60%)，極重度身心障礙兒童有較高的比率潔牙是倚賴父母親/照護者來完成(67.37%)。潔牙完全倚賴父母親/照護者的身心障礙兒童，相對地有較好的口腔健康和較低的齲齒盛行率。分析影響身心障礙兒童齲齒數的主要危險因子包含：食用甜食的頻率、潔牙能力，以及牙菌斑的存在與否。
第二部分研究，有535位、年齡6-12歲的身心障礙兒童，來自氟錠投予組A、氟錠投予組B與氟錠未投予組三組，分別投予1.0毫克氟錠、0.5毫克氟錠與不含氟之安慰劑。從三組分別隨機選取25人，共75人為尿液追蹤對象。短期尿液收集時機為氟錠投予前一天(基礎值)、第1天、第3天、第5天與第8天，而長期尿液收集時機則自氟錠投予前一天(基礎值)，氟錠投予滿6個月、滿12個月與滿18個月時，全程為期18個月。分別收集早上起床後的晨尿與氟錠投予後2小時的尿液。研究結果顯示，氟錠投予後2小時的尿中氟濃度顯著地高於晨尿的尿中氟濃度。但三組彼此間的晨尿氟濃度，沒有呈現顯著性差異。氟錠投予後2小時的尿中氟濃度則以氟錠投予組A顯著高於氟錠投予組B與氟錠未投予組。從追蹤18個月的尿中氟濃度結果，本研究證實不論短期或長期氟錠投予，尿中氟濃度都在氟錠投予後2小時上升，在隔天的早晨回到基礎值。其中，造成氟錠投予後2小時尿中氟濃度高低差異的主因，乃氟錠投予劑量的高低不同所致。
第三部分研究，共有217位身心障礙兒童，分成二組。介入組投予1.0毫克氟錠，控制組投予不含氟之安慰劑。在氟錠投予前一天(起始值)與之後每隔6個月，分別進行口腔檢查，以追蹤氟錠投予成效。研究結果顯示，相較於控制組，介入組在接受氟錠投予24個月後，DMFT指數增加量較減少控制組減少0.63顆，DMFS指數增加量較減少控制組減少1.25面。氟錠投予的抗齲齒效益，可顯著減少DMFT指數增加量30.42%與DMFS指數增加量36.84%。其中，在鄰接面、咬合面與唇舌面的齲齒增加量，分別可減少53.27%、31.72%與52.57%。透過本研究這24個月的追蹤，清楚的看到氟錠投予，有效地減少身心障礙兒童的齲齒。
綜合來說，要改善身心障礙兒童的口腔健康，除了應該促進身心障礙兒童父母親/照護者在潔牙技巧、飲食行為和預防計畫方面的口腔健康衛生教育，也應該根據不同的身心障礙種類、障礙程度和障礙特性，來教導身心障礙兒童潔牙技巧，讓身心障礙兒童能及早將潔牙行為生活化，以期能自我維護口腔健康。對於具有高齲齒風險或身處氟化物缺乏地區的身心障礙兒童，建議以學校為基礎，來實施氟錠投予齲齒防治計畫。

關鍵字

身心障礙兒童 ； 口腔健康 ； 潔牙 ； 飲食習慣 ； 氟錠 ； 尿 ； 氟濃度 ； 齲齒預防 ； 學校基礎 ； 成效

並列摘要

Oral disease is often neglected as it is not life threatening. Daily oral activities may severely influence the oral health of children with disabilities. The dental health of children with disabilities is worse than that of ordinary children the same age. As a result, the disadvantages lead to poor oral health and more untreated decayed teeth. Numerous studies have proven that fluoride is effective in preventing dental caries. Urine is the most commonly utilized biomarker for fluoride excretion in public health and epidemiological studies. Approximately 30 - 50% of fluoride is excreted from urine in children. Moreover, urinary fluoride excretion reflects the total fluoride intake from multiple sources. After administering fluoride tablets to children with disabilities, investigating urinary fluctuation patterns is important. Establishing an oral health prevention program for children in special schools at an early stage is crucial. School-based fluoride programs have been proven in many studies to be effective in preventing dental caries. Fluoride tablet is regarded as a suitable means to control dental caries in children with disabilities. Therefore, we evaluated the effect of caries prevention by the application of fluoride tablets.
Before evaluating the effectiveness of fluoride, we must realize the oral health status of children with disabilities and monitor fluctuating patterns of urinary fluoride concentration after fluoride tablets are ingested. The three purposes of this thesis were: First, to analyze the impact of dietary and tooth-brushing habits to dental caries in special school children with disabilities. The second aim was to monitor the short and long term fluctuating patterns of urinary fluoride concentration after fluoride tablets were ingested by children with disabilities. The third aim was to evaluate the anti-caries effect of long term application of fluoride tablets on children with disabilities.
Study 1 was a cross-sectional survey which investigated 535 special school children , 60.93% male and 39.07% female, with disabilities aged 6-12 years from 10 special schools in Taiwan. Oral examinations were carried out by dentists with a Kappa score of their inter-examiner agreement exceeding 0.8. Data on demographics, diet, and tooth-brushing habits of children with disabilities were collected using a standardized questionnaire completed by the parents/caregivers. The study results showed that more than three quarters of the participants had severe or profound disability. The children with profound disability were more likely to have their teeth brushed by a parent/caregiver (67.37%). The children with mild/moderate disability brushed their teeth by themselves (81.60%). Children whose teeth were brushed by parents/caregivers had better dental health, and lower caries prevalence than those who brushed themselves. The main risk factors related to decayed teeth of children with disabilities are frequency of sweets intake, ability to brush teeth and with/without plaque.
In Study 2, 535 children with disabilities aged 6 - 12 years old were selected randomly and divided into three groups: Group A, 1.0 mg fluoride tablet, Group B, 0.5 mg fluoride tablet, and Group C, control group. Seventy-five children with disabilities were randomly selected from three special education primary schools to participate in this survey. Urine was collected on the day prior to fluoride intake (baseline), the first, third, fifth and the eighth day of fluoride ingestion for short term observation, and once every six months for a total of 18 months for long-term observation. The urine samples were collected in the morning (MU) and 2 hrs after fluoride tablets were ingested (AU). The AU sample showed statistically significantly higher concentrations of urine fluoride than those of the MU samples, and no statistically significant difference was noted in the MU samples among the three groups. Group A showed the highest urinary fluoride concentration (UFC) among the three groups. UFC increased as ingested fluoride tablet dosage increased, and it returned to the baseline level on the following day and persisted throughout the study period.
In Study 3, 217 school children with disabilities were divided into two groups: the intervention group ingested 1.0 mg fluoride tablet while the control group ingested a placebo. The oral examinations were conducted in the daytime prior to fluoride intake (baseline) and once every six months to trace the effectiveness of fluoride tablet ingestion. The results of this study indicated significant reductions of 0.63 DMFT index inceratment as well as 1.25 DMFS index inceratment than in the control group. Observations of dental caries found that the anti-cariogenic benefit of fluoride tablet ingestion was statistically significantly effective with 30.42% of new DMFT index and 36.84% of new DMFS index examined after 24 months follow-up. Reductions of inceratmental DMFS index on the surface types occurred in mesio-distal, occlusal, and bucco-linqual surfaces with 53.27%, 31.72% and 52.57%, respectively. Through a 24-month period of tracing the effectiveness of fluoride tablet ingestion, there is clear evidence of a caries-inhibiting effect of fluoride tablets.
In conclusion, the dental health education, prevention program and periodical oral check-up of children with disabilities and their parents/caregivers should be reinforced. Brushing skills should be taught to children according to their type, severity and individual characteristics of disability. Fluoride tablets should be regarded as a caries preventive means in school-based caries prevention programs for children with disabilities in fluoride deficient countries and for individuals with high caries risk.

並列關鍵字

children with disabilities ； oral health ； tooth-brushing ； dietary habits ； fluoride tablet ； urine ； fluoride concentration ； caries prevention ； school-based ； effectiveness

參考文獻

Aasenden, R., & Peebles, T. C. (1974). Effects of fluoride supplementation from birth on human deciduous and permanent teeth. Archives of Oral Biology, 19(4), 321-326.

Adair, S. M. (1999). Overview of the history and current status of fluoride supplementation schedules. J Public Health Dent, 59(4), 252-258.

Aithal, K. S., Udupa, D. N., & Tandon, S. (1996). Clinical evaluation of sodium fluoride chewable tablets in dental caries. Indian Journal of Dental Research, 7(4), 136-139.

Arnold, M., & Spies, R. (1989). [Influence of preventive measures on caries increase in preschool children]. Stomatol DDR, 39(8), 536-539.

Arruda AO, Senthamarai Kannan R, Inglehart MR, Rezende CT, Sohn W. Effect of 5% fluoride varnish application on caries among school children in rural Brazil: a randomized controlled trial. Community Dent Oral Epidemiol. 2011 Dec 8. doi: 10.1111/j.1600-0528.2011.00656.x. [Epub ahead of print]