臺灣博碩士論文加值系統

研究背景 近來文獻指出，牙周病使身體暴露於慢性發炎狀態，可導致動脈粥狀硬化症的發生。當末期腎病變患者暴露於動脈粥狀硬化症之危險時，會致使此類患者的心臟血管併發症比例高於常人。而營養不良及發炎反應複合症候群(Malnutrition inflammation complex syndrome，簡稱MICS) 常見於血液透析患者，且同時合併發生較高的心臟血管動脈粥狀硬化疾病、較差的生活品質及較高的住院率和死亡率。因此，吾人希望能建立以牙周狀態做為評估營養不良及發炎反應複合症候群的工具，以及早改善此症候群所帶來的副作用。
研究設計與方法 本研究以亞東紀念醫院接受長期穩定血液透析患者為研究對象，總共收案253位。屬於橫斷性及相關性研究，口腔檢查期間自民國九十三年二月一日至民國九十三年二月二十八日。牙周狀態指標包括三項：牙菌斑指數，牙齦炎指數及牙周病指數。資料收集及建檔，包括：個案社會人口學、血液學、生化學及透析相關資料。營養及發炎反應相關指標，如：血清白蛋白、血液尿素氮、肌酸酐、攜鐵蛋白、絕對淋巴球數、normalized protein catabolic rate，簡稱nPCR 、高敏感性C反應性蛋白及ferririn。分析牙周病狀態指標與上述因子之相關性，並進一步探討以牙周病嚴重度作為營養不良及發炎反應複合症候群診斷依據之可行性。
結果 口腔健康檢查顯示： 91.7%的血液透析患者的牙周狀態屬於中至嚴重程度。分析個案社會人口學及疾病相關證據指出：老化、低教育程度、抽煙、糖尿病、高合併症及接受較久的血液透析治療患者，其牙周病較為嚴重。分析營養不良與發炎反應相關指標時，發現較差的營養狀態及較高發炎狀態的患者，其牙周病也較為嚴重。進一步以回歸分析發現，年齡、高合併症指數、血清白蛋白及血液尿素氮值為血液透析患者牙周病嚴重度的獨立預測指標。再來，以牙周病嚴重度指標分級，將研究個案分為三組，證實牙周病嚴重度可為營養不良及發炎反應複合症候群的有用臨床指標。
結論 本研究指出血液透析患者的牙周健康狀態極為不良，需要進一步給予關注。牙周病可作為評估營養不良及發炎反應複合症候群嚴重程度之一項有用臨床指標。

Background. Recent studies implicate exposure to systemic conditions involving chronic inflammation, including chronic periodontitis, in the etiology of atherosclerosis. Patients with end-stage renal disease (ESRD) are at a markedly increased risk for cardiovascular complications compared with the general population. Malnutrition inflammation complex syndrome (MICS) occurs commonly in maintenance hemodialysis (MHD) patients and may be correlated with high rate of cardiovascular atherosclerotic disease, decreased quality of life, and increased mortality and hospitalization in dialysis patients. We therefore attempted to develop and validate periodontal status as a tool of clinical evaluation of MICS in hemodialysis patients
Methods. A total of 253 MHD patients were included to evaluate the periodontal status by using plaque index (PlI), gingival index (GI) and periodontal disease index (PDI) in Far Eastern Memorial Hospital since Feb. 1 to 28, 2004. The geographic, hematological, biochemical and hemodialysis-related data were also collected. Nutritional and inflammatory markers, such as albumin, blood urea nitrogen, creatinine, transferring, absolute lymphocyte count, normalized protein catabolic rate, high sensitivity C-reactive protein and ferririn, were included to analyze with periodontal markers.
Results. Poor oral health status was demonstrated by 91.7% of MHD patients having moderate to severe periodontal disease. Analyzing geographic and disease-related parameters, we found that aging, lower education status, smoker, patients with diabetes and higher comorbidity and longer dialysis duration were associated with severe periodontal disease. Furthermore, malnutrition and inflammation were also associated with poor periodontal status. We further conducted multiple regression analysis and found that age, comorbidity status, albumin and blood urea nitrogen were showed as independent predictors of periodontal disease. According to the severity of periodontal disease, we stratified the whole study subjects into three catoglories. The findings suggest that periodontal disease severity can be a useful marker of malnutrition and inflammation.
Conclusions. We conclude that the periodontal health of MHD patients is poor and requires greater attention. Severity of periodontitis can be a useful marker of MICS of MHD patients.

指導教授推薦書…………………………………………………………ii
口試委員會審定書………………………………………………………iii
授權書……………………………………………………………………iv
簽署人須知………………………………………………………………v
誌謝………………………………………………………………………vi
中文摘要…………………………………………………………………viii
英文摘要…………………………………………………………………x
第一章 緒論………………………………………………………………1
第一節 研究背景及研究動機……………………………………………1
第二節 研究目的…………………………………………………………3
第二章 文獻回顧…………………………………………………………6
第一節 牙周病的定義與致病機轉………………………………………6
第二節 牙周病與系統性疾病的關係……………………………………8
第三節 末期腎病變的定義、治療、發生機轉及相關文獻……………14
第四節 血液透析患者的營養及發炎反應之評估方式…………………21
第五節 營養不良及發炎反應與牙周病之關係…………………………23
第六節 營養不良及發炎反應與末期腎病變之關係……………………24
第七節 血液透析患者者之口腔健康及牙周病現況……………………26
第三章 研究方法及材料…………………………………………………28
第一節 研究對象…………………………………………………………28
第二節 研究工具…………………………………………………………28
第三節 研究指標…………………………………………………………29
第四節 統計方法…………………………………………………………32
第四章 結果………………………………………………………………35
第一節 受試者基本屬性及醫療相關資料………………………………35 第二節 受試者口腔狀態之相關資料……………………………………36 第三節 受試者營養及發炎狀態之相關資料……………………………37 第四節 受試者口腔狀態之相關因素……………………………………37 第五節 營養及發炎狀態與口腔健康指標之關係………………………45 第六節 牙周病嚴重度之獨立預測因子…………………………………47 第七節 以牙周病嚴重度分級探討是否可代表營養不良及發炎狀態…48
第五章 討論………………………………………………………………50
第一節 血液透析患者的口腔健康狀態…………………………………50
第二節 影響口腔健康狀態的因子及獨立預測血液透析患者牙周病嚴重程度的因子……………………………………………………………………52
第三節 牙周病是否可成為代表血液透析患者的營養不良-發炎反應複合症候群之指標及其應用……………………………………………………58
第六章 本研究之限制……………………………………………………60
第七章 結論與展望………………………………………………………61
參考文獻……………………………………………………………………62
圖表…………………………………………………………………………81
附錄…………………………………………………………………………93

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