專業口腔照護對安寧病房癌症末期病人口腔衛生、黏膜健康及功能改善之影響

Professional Oral Care in Terminal Cancer Patients in Hospice Wards: Effectiveness on Oral Hygiene, Mucosal Health and Oral Function

吳亭瑩(Ting-Ying Wu)

指導教授 ： 陳丙何

高雄醫學大學/口腔醫學院/牙醫學系碩士班/碩士(2020年)

摘要

背景：
在癌症末期病人中，口腔檢查、口腔照護和口腔複檢非常重要。儘管口腔症狀是許多末期病人的主訴之一，但很少有研究關注這些病人的口腔照護。本研究檢查癌症末期病人的口腔症狀與口腔乾燥之間的關聯，並量化由專業牙醫師進行口腔照護介入後口腔健康狀況的改善情況。
方法：
本前瞻性介入研究分別在兩間醫院的安寧病房中，針對癌症末期病人進行收案，共納入實驗組28名和對照組15名癌症末期病人。實驗組每天早晨進行專業的口腔照護，對照組則維持原有口腔照護方式；口腔複檢每三天進行一次，通過比較介入前後的口腔狀況來評估口腔狀況的改善。病人口腔健康狀況評估使用口腔健康評估工具（Oral Health Assessment Tool (OHAT)）和口腔評估指南(Oral Assessment Guide) 進行口腔評估；並以口腔乾燥的臨床診斷分類和口腔水分測試機評估口腔乾燥狀況。病人口腔清潔度使用口腔細菌定量儀評估，並以舌部抹片進行白色念珠菌檢查，並記錄口腔功能。
結果：實驗組經專業口腔照護介入前後相較之下，OHAT總分（中位數：7 比 2）和其他組（嘴唇，舌頭，牙齦和組織，唾液和口腔清潔度）的總得分顯著下降，此外，介入前後相較之下，病人發生黏膜炎（35.7% 比 0%），。念珠菌感染率（75.0%比42.1%），口腔自我感覺乾燥感（89.5%比61.5%）和嚴重口內痂皮沉積（46.4%比10.0%）的比率顯著性降低。接受一般口腔照護的對照組僅在OHAT總分（中位數：7 比 0）和嘴唇項目（中位數：1 比 0）得分出現顯著降低，其他口腔情形均無顯著改善。實驗組和對照組於照護後第四天發現在黏膜炎、臨床口腔乾燥診斷分級(Clinical Diagnosis Classification of Oral Dryness (CDCOD))，口腔髒污沉積量、舌苔指數和口腔健康評估量表(OHAT)的總分，舌頭和唾液的子項目得分中均出現顯著差異性；口腔水分測試機讀數在頰黏膜部分則出現邊際差異傾向（p = 0.052）。上述出現差異的項目，實驗組均出現顯著較佳的表現。可知經過專業口腔照護後第四天，病人在黏膜健康、口腔清潔度和口腔濕潤度上，均優於接受一般口腔照護的對照組。口腔黏膜炎何嚴重口腔乾燥密切關聯，（調整後的危險對比值adjusted odds ratio [AOR] = 8.97；95%信賴區間95% confidence interval [CI]: 1.37-58.89），意味著發生黏膜炎的病人其口腔乾燥的發生率也較高。
結論：
適當的口腔照護可改善末期病人的口腔健康和衛生狀況，降低黏膜炎比率，減輕口腔乾燥感，增加口腔濕潤度，並減少口腔感染的機會。因此，日常性專業口腔照護是必要的，可以減輕口腔不適，增加食物攝取能力並增加癌症末期病人與其家人之間的交流機會。

關鍵字

末期癌症 ； 前瞻性介入研究 ； 專業口腔照護 ； 口腔健康評估工具 ； 黏膜炎 ； 口腔乾燥 ； 口腔髒污 （口痂）沉積

並列摘要

Background:
In patients with terminal cancers, oral examination, oral care, and oral reexamination are crucial. Although oral symptoms are among the major complaints of end-of-life patients, few studies have focused on oral care in these patients. In this study, the association between oral symptoms and oral dryness among end-of-life patients was examined, and improvement of oral conditions after oral care interventions by a professional dentist was quantified.

Methods:
This prospective intervention study included 28 patients as experimental group and 15 patients as control group, all were patients with terminal cancers in hospice ward. In the experimental group, professional oral care was administered every morning. In the control group, the original oral care protocol was maintained. The improvement of oral conditions was assessed every 3 days to compare oral conditions before and after the intervention. Oral assessment was performed using the Oral Health Assessment Tool (OHAT) and Oral Assessment Guide. Oral dryness was evaluated through Clinical Diagnosis Classification of oral dryness and an oral moisture device. Oral cleanliness was evaluated using a bacterial counter, and tongue smears were collected for Candida examination; furthermore, oral function was recorded.

Results:
In the experimental group, total OHAT scores (median: 7 vs 2) and those of other subgroups (lip, tongue, gums and tissues, saliva, and oral cleanliness showed a significant decrease after the professional oral care. Furthermore, the occurrence of mucositis (35.7% vs 0%), candidiasis rate (75.0% vs 42.1%), oral dryness self-sensation (89.5% vs 61.5%) and severe oral debris (46.4% vs 10.0%) decreased significantly. In the control group, OHAT total scores (Median: 7 vs 0) and subgroup of lip (Median: 1 vs 0) shows significant improvement after general oral care. Other oral condition scores didn’t show significant improvement in the control group. Compare the oral findings in day 4, the mucositis rate, Clinical Diagnosis Classification of Oral Dryness, oral debris retention rate, tongue coating index and OHAT total score and scores of subgroups of tongue, saliva all show significant difference. And the reading of oral moisture device shows border significant tendency (p=0.052). Experimental group have better presence in the oral findings mentioned above, which means professional oral care provides better mucosal healthiness, oral cleanliness and oral moisture than the general oral care on Day 4. The presence of oral mucositis was closely associated with severe oral dryness (adjusted odds ratio [AOR] = 8.97; 95% confidence interval [CI]: 1.37-58.89). Which represent the presence of mucositis, showed severe oral dryness.

Conclusions:
Proper oral care can improve oral health and hygiene, reduce the rate of mucositis, reduce the sensation of oral dryness, increase oral moisture, and reduce the chances of oral infections among advanced cancer patients. Daily oral care is necessary and can alleviate oral discomfort, increase food intake, and increase the chances of communication between end-of-life patients and their families.

並列關鍵字

terminal cancers ； prospective intervention study ； professional oral care ； Oral Health Assessment Tool ； mucositis ； oral dryness ； oral debris

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