臺灣博碩士論文加值系統

90%接受放射線治療之頭頸部癌症病人會發生口腔黏膜炎，易造成續發性口腔感染及影響生活品質，系統性的口腔護理措施有助於降低口腔黏膜炎發生的可能性。臨床上最常用的漱口液為寶馬生(Chlorhexidine)，但蜂膠也常被使用(Propolis)；但目前少有研究比較蜂膠及寶馬生對口腔黏膜炎成效之差異情形，因此，本研究目的為比較蜂膠與寶馬生兩種不同漱口液，對於接受放射線治療之頭頸部癌症病人的口腔黏膜變化、口腔續發性感染及口腔舒適感受之差異。
本研究採類實驗設計，研究對象為南部某醫學中心之頭頸部腫瘤病人初次接受放射線治療者，共收案44位，其中實驗組24人使用0.4%蜂膠漱口，對照組20人使用0.1%寶馬生漱口，所有參與者皆由研究者教導PRO-SELFC Mouth Aware口腔清潔方案(Larson et al., 1998)，並搭配不同漱口水。以『WHO口腔黏膜炎等級』與『口腔黏膜評估表』(OMAS)兩種量表來評估病人的口腔黏膜狀態；以口腔致病菌培養及臨床診判斷來評估口腔續發性感染情形、以口腔疼痛評估視覺量表和對漱口水耐受度量表來評估口腔舒適感受，初次評估時機為開始接受放射線治療的五次之內，之後每隔治療三次收集一次資料，而口腔致病菌培養為每兩週採檢一次，整個方案直到放射線治療結束為止。本研究所得的資料結果，以SPSS/Window 14.0版套裝軟體進行資料建檔與分析，描述性資料主要採用chi-square test以及Independent t-test，兩組時間序列的比較性資料主要採用Mixed model以及Survival curve來分析。
研究結果顯示蜂膠與寶馬生不同漱口液在口腔黏膜炎、發生嚴重三級口腔黏膜炎個案數、經放射線治療至發生口腔黏膜炎的時間、經放射線治療至診斷發生口腔白色念珠菌時間、口腔內菌落數包括白色念珠菌、格蘭氏陰性菌及金黃色葡萄球菌菌落數均無差異。在舒適感受方面，兩組在口腔疼痛上亦無顯著差異，但對漱口水耐受度上，蜂膠組比寶馬生組在整體的漱口水耐受度低，其耐受度較佳(F=14.730，p< .001)。整體而言，蜂膠用於口腔漱口與寶馬生之安全性相當，且使用者有較佳的耐受度，故建議臨床上可考慮使用蜂膠漱口來代替臨床常規之寶馬生漱口水之可行性，惟在蜂膠漱口水的濃度調配需專業人員指導。

Background: Oral mucositis is the most symptomatic problem of patients in head and neck cancer patients with radiotherapy. The impaired oral function, secondary infections, and pain may cause distress and altered the patient’s quality of life. Chlorhexidine is a commonly prescribed mouthwash for oral complications. Currently bee propolis has been used as an alternative mouthwash. However, little study has documented whether propolis has a similar effects to Chlorhexidine. Therefore, this study aimed to compare effects of propolis and Chlorhexidine on oral mucositis, flora of candidiasis, streptococcus, and Gram-negative bacterium, and preference in head and neck cancer patients with radiotherapy.
Methods:A quasi-experimental study was used in 44 subjects. Each subject followed the same protocol of oral care. However, 24 of them used 0.4% propolis and 20 used 0.1%Chlorhexidine to rinse their mouths. The WHO Grade System and Oral Mucositis Assessment Scale were used to measure severity of oral mucositis with an interval of three-time radiotherapy. Floras of bacteria and candidiasis were cultivated in a two-week interval. The patient’s preference was measured with a Pain Visual Analogue Scale and l-5 Likert scale for tolerance. Mixed model, independent t-test, Mann-Whitney U test, and survival curve were used for statistical testing.
Results: No significant difference in onset and severity of oral mucositis, floras of candidiasis, streptococci, Gram-negative bacterium, and pain sensation between subjects used propolis and Chlorhexidine mouthwashes. However, the tolerance of propolis is better than Chlorhexidine (F=14.730，p< .001).
Conclusion: The propolis mouthwash has a similar effect to Chlorhexidine and produce less discomfort in head and neck cancer patients with radiotherapy. Concerning the patient’s preference, it can be used as alternative selection for oral hygiene.

目錄
中文摘要………………………………………………………… I
英文摘要 …………………………………………………………III
致謝 ………………………………………………………………IV
論文目錄 ………………………………………………………VIII
表目錄 ……………………………………………………………XI
圖目錄……………………………………………………………XII
附件目錄…………………………………………………………XIII
論文目錄
第一章 緒論
第一節 研究動機與重要性………………………………1
第二節 研究問題與研究目的……………………………3
第二章 文獻查證
第一節 口腔黏膜的基本解剖構造……………………4
第二節 放射線治療或化學治療引發口腔黏膜炎的生理病理機
轉……………4
第三節 口腔黏膜炎臨床表徵與分級…………………8
第四節 影響放射線治療或化學治療病人口腔黏膜炎之相關因
素 …………10
第五節 不同漱口水對於口腔護理之成效探討 ……15
第六節 研究架構與研究假設 ………………………21
第七節 名詞解釋及操作性定義 …………………22


第三章 研究方法
第一節 研究設計…………………………………23
第二節 研究場所與研究對象……………………24
第三節 介入措施…………………………………25
第四節 研究工具…………………………………28
第五節 信效度檢定………………………………31
第六節 資料收集過程……………………………31
第七節 倫理考量…………………………………33
第八節 資料分析…………………………………33
第四章 研究結果
第一節 研究對象之基本人口學與疾病、治療屬性分析
……………………35
第二節 不同漱口水對口腔黏膜炎之影響………39
第三節 不同漱口水對口腔續發性感染之影響…44
第四節 不同漱口水對口腔舒適感受之影響……49
第五章 討論
第一節 不同漱口水對口腔黏膜炎影響之探討…58
第二節 不同漱口水對口腔續發性感染影響之探討61
第三節 不同漱口水對口腔舒適感受影響之探討…66
第四節 臨床運用……………………………………67
第六章 結論、限制與未來研究方向
第一節 結論…………………………………………71
第二節 研究限制……………………………………71
第三節 未來研究方向與建議………………………72

參考文獻
中文部份………………………………………………73
英文部份………………………………………………74
表目錄
表2-1 不同漱口水用於口腔護理成效之比較……………19
表3-1 評價設計表…………………………………………23
表3-2 研究問題所使用之統計分析方法…………………34
表4-1.1 兩組基本人口學特質之比較……………………36
表4-1.2 兩組疾病與治療屬性之比較……………………38
表4-2.1 兩組在不同時間之口腔黏膜炎比較……………40
表4-2.2兩組經過放射線治療至發生口腔黏膜炎時間之比 較……………42
表4-2.3兩組發生嚴重口腔黏膜炎之比較…………………43
表4-3.1兩組經過放射線治療至發生口腔白色念珠菌感染時間之比較……………44
表4-3.2兩組不同時間點口腔白色念珠菌菌落數之比較…46
表4-3.3兩組不同時間點口腔格蘭氏陰性菌菌落數之比較……47
表4-3.4兩組不同時間點口腔金黃色葡萄球菌菌落數之比較…48
表4-4.1兩組不同時間之口腔疼痛比較…………………………50
表4-4.2a兩組使用止痛藥總數之比較 …………………………52
表4-4.2b兩組使用止痛藥類型之比較 …………………………53
表4-4.3兩組在不同時間對漱口水耐受度的平均分數之比較…55
表5-3.1不同菌種與肉眼診斷口腔念珠菌感染的區辨診斷……64
表5-3.2口腔念珠菌的敏感度與特異度…………………………64

圖目錄
圖2-1研究架構圖…………………………………………………21
圖2-2介入措施執行流程圖………………………………………27
圖3-6.1資料收集流程圖…………………………………………32
圖4-2.1兩組在不同時間平均口腔黏膜炎的變化………………41
圖4-2.2兩組經過放射線治療至發生口腔黏膜炎時間之比較…42
圖4-3.1兩組經過放射線治療至發生口腔白色念珠菌感染時間之比較…………………44
圖4-3.1a兩組服用Nystatin之比較………………………………45
圖4-3.2兩組不同時間口腔白色念珠菌菌落數之比較…………46
圖4-3.3兩組不同時間點口腔格蘭氏陰性菌菌落數之比較……47
圖4-3.4兩組不同時間點口腔金黃色葡萄球菌菌落數之比較……48
圖4-4.1兩組不同時間口腔疼痛平均分數之比較………………51
圖4-4.2兩組在不同時間平均對漱口水耐受度之比較…………56
圖5-2.1不同菌落數之ROC Curve………………………………65
圖5-5.1口腔護理方式……………………………………………70


附件目錄
附錄一 受試者同意書 ………………………………………79
附錄二 研究對象基本資料表 ………………………………85
附錄三 口腔護理持續評估記錄表 …………………………87
附錄四 口腔清潔頻率登記表 ………………………………89
附錄五Oral Mucositis Assessment Scale(OMAS)口腔黏膜評估表………………………90
附錄六 國際健康組織(WHO)口腔黏膜炎等級 ……………91
附錄七 口腔舒適感受評量表 ……………………………91
附錄八 口腔護理衛教單 …………………………………92
附錄九 口腔清潔自我登記表 ……………………………94

吳碧雲、田聖芬（2002）•不同口腔護理方案對接受化學治療之血液腫瘤患者口腔黏膜成效之評估•馬偕學報，2，11-28。
辛隆士、邱泰源、胡文郁、程邵儀、陳慶餘（1996）•癌末病人之另類療法•家庭醫學雜誌，6(3)，127-136。
行政院衛生署國民健康局(2007)•中華民國九十四年癌症登記報告•台北。
岡田真（1999）•蜂膠治療癌症，林芸譯，台北：智慧。
林佳靜（2001）•以實證為基礎的腫瘤護理•護理雜誌，48(6)， 21-26。
林靜琪（1998）•化學治療引起口腔黏膜潰瘍之文獻探討•護理雜誌，45(2)， 79-84。
莊慧君、陳雅珍、董醒任（2001）．與防治牙周病有關的牙膏與漱口水的調查與評估．中華牙周醫誌，6(3)， 183-195。
詹日全、黃穰基、潘超群、王仲祺、王景平、劉時安（2007）•口腔癌治療後影響局部復發之相關因素分析•台灣耳鼻喉頭頸外科雜誌，42(4)， 115-125。
解玉�氶]1999）•不同種類蜂膠之組成份分析及抗生特性研究•未發表碩士論文，台北：私立大葉大學。
劉玉雅（2001）•頭頸部癌化學治療患者口腔衛教效果之評價•健康促進暨衛生教育雜誌，21，81-89。
楊翠雲（1996）•頭頸部放射線療法之癌症病人施行口腔謢理方案成效之探討•未發表碩士論文，台北：私立長庚醫學暨工程學院。
鄭鴻鈞（2001）．癌症之放射線治療．台灣醫學，2(3)， 316-320。
謝瑞坤（1993）•化學治療的併發症-口腔炎•臨床醫學，31(1)， 23-27。
賴裕和（2000）•病人對癌痛及麻醉性止痛藥之信念探討-量表發展與現況•護理雜誌，8(5)， 557-567。
Adamietz, I. A., Rahn, R., Bottcher, H. D., Schafer, V., Reimer, K., & Fleisher, W. (1998). Prophylaxis with povidone-iodine against induction of oral mucositis by radiochemotherapy. Support Care Cancer, 6, 373-377.
Andersson, P., Persson, L., Hallberg, I. R., & Renvert, S. (1999). Testing oral assessment guide during chemotherapy treatment in a Swedish care setting: a polit study. Journal of Clinical Nursing, 8, 150-158.
Beck, S. (1979). Impact of a systematic oral care protocol on stomatitis after chemotherapy. Cancer Nursing, 2(3), 185-199.
Cawley, M. M., & Benson, L. M. (2005). Current trends in managing oral mucositis. Clinical Journal of Oncology Nursing, 9(5), 584-592.
Cole, A., & Shanley, E. (1998). Complementary therapies as a means of developing the scope of professional nursing practice. Journal of Advanced Nursing, 27, 1171-1176.
Cheng, K. Kin-fong., Yuen, J. K. T. (2006). A pilot study of Chlorhexidine and Benzydamine oral rinses for the prevention and treatment of irradiation mucositis in patients with head and neck cancer. Cancer Nursing, 29(5), 423-430.
Elting, L., Cooksley, C., Chambers, M., Cantor, S., Manzullo, E.,& Rubenstein, E. (2003). The burdens of cancer therapy: Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer, 98, 1531-1539.
Eldridge, K. R., Finnie, S. F., Stephens, J. A., Mauad, A. M, Munoz, C. A., & Kettering, J. D. (1998). Efficacy of an alcohol-free chlorhexidine mouth rinse as an antimicrobial agent. The Journal of prosthetic Dentisity, 80 (6), 685-690.
Eilers, J., Berger, A. M., & Peterson, M. C. (1988). Development, testing, and application of the oral assessment guide. Oncology Nursing Forum, 15, 325-330.
Elting, L. S., Cooksley, C., Chamber, M., Cantor, S. B., Manzullo, E., & Rubenstein, E. B. (2003). The burdens of cancer therapy. Clinical and economic outcomes of chemotherapy-induced mucositis. Cancer, 98, 1531-1539.
Epstein, J. B., Silverman, S., & Paggiarino, D. A. (2001). Benzydamine HCL for prophylaxis of radiation-induced oral mucositis: result from a multi-cencer, randomised, double-blind, placebo-controlled clinical trial. Cancer, 92,875-885.
Epstein, J. B., & Schubert, M. M. (2003). Oropharyngeal mucositis in cancer therapy. Review of pathogenesis, diagnosis, and management. Oncology, 17, 1761-1782.
Feber, T. (1995). Mouth care for patients receiving oral irradiation. Cancer Nursing, 10(10), 666-670.
Ferretti, G. A., Raybould, T. P., Brown, A. T., Macdonald, J. S., Greenwood, M., Maruyama, Y., et al. (1990). Chlorhexidine prophylaxis for chemotherapy-and radiotherapy-induced stomatitis: A randomized double-blind trial. Oral Surgery, Oral Medicine, and Oral Pathology, 69, 331-338.
Foote, R. L., Loprinzi, C. L., & Frank, A. R., et al.(1994). Randomized trial of a chlorhexidine mouthwash for alleviation of radiation-induced mucositis. Journal Clinic Oncology, 12(12), 2630-2633.
Gibson, F., Cargill, J., Jenny, A., Joanna, B., Cole, S., Stone, J., et al. (2006). Establishing content validity of the oral assessment guide in childern and young people. European Journal of Cancer, 42, 1817-1825.
Holmes, S., & Mountain, E. (1993). Assessment of oral status: evaluation of three oral assessment guides. Journal of Clinical Nursing, 2, 35-40.
Larson, P. J., Miaskowski, C., MacPhail, L., Dodd, M. J., Greenspan, D., & Dibble, S et al. (1998). The PRO-SELF mouth aware program: An effective approach for reducing chemotherapy mucositis. Cancer Nurse, 21, 263-268.
Madeya, M. (1996). Oral complication from cancer therapy: Part 1. pathophysiology and secondary complications. Oncology Nursing Forum, 23, 801-807.
McGuire, D. B., Peterson, D. E., Muller, S., Owen, D. O., Slemmons, M. F., & Schubert, M. M. (2002). The 20 item oral mucositis index: reliability and validity in bone marrow and stem cel l transplant patients. Cancer investigation, 20(7), 893-903.
Miller, M., & Kearney, N. (2001). Oral care for patients with cancer: A review of the literature. Cancer Nursing, 24(4), 241-254.
Murray, M. C., Worthington, H. V., & Blinkhorn, A. S. (1997). A study to investigate the
effect of a propolis-containing mouth rinse on the inhibition of de novo plaque
formation. Journal of Clinical Periodontology, 24, 796-798.
O’Leary, T. J., Drake, R. B., & Naylor, J. E. (1972). The plaque control record. Journal of Periodontol, 43, 38.
Parulekar, W., Mackenzie, R., Bjarnason, G., & Jordan, R. C. (1998). Scoring oral mucositis. Oral Oncol, 34(1), 63-71.
Ramirez-Amador, V., Silverman, S., Mayer, P., Tyler, M., & Quivey, J. (1997). Candidal colonization and oral candidiasis in patients undergoing oral and pharyngeal radiation therapy. Oral Surgery Oral Medicine Oral Pathology, 84(2), 149-153.
Roth, B. J., Sledge, GW. J., Williams, S. D., Meyer, S. C., Ansari, R.,& Fisher, W. B. (1991). Methotrexate, vinblastine, doxorubicin, and cisplatin in metastatic. A phase II trial of the Hoosier Oncology Group. Cancer, 68, 248-252.
Robien, K., Schubert, M. M., Bruemmer, B., Lloid, M. E., Potter, J. D., & Ulrich, C. M. (2004). Predictors of oral mucositis in patients receiving hematopoietic cell transplants for chronic myelogenous leukemia. Journal of Clinical Oncology, 22(7), 1268-1275.
Santos, V. R., Pimenta, F. J. G. S., Aguiar, M. C. F., do Carmo, M. A. V., Naves, M. D., & Mesquita, R. A. (2005). Oral candidiasis treatment with Brazilian ethanol propolis extract. Phytotherapy Research, 19, 652-654.
Schubert, M. M., William, B. E., Lloid, M. E., Donaldson, G., & Chapko, M. K. (1992). Clinical assessment scale for the rating of oral mucosal changes associated with bone marrow transplantation: Development of an oral mucositis index. Cancer, 69(10), 2469-2477.
Scully, C., Sonis, C., & Diz, P.D. (2006). Oral mucositis. Oral Disease, 12, 229-241.
Scully, C., Epstein, J., & Sonis, S. (2004). Oral mucositis: A challenging complication of radiotherapy, chemotherapy, and radiochemotherapy. Part 2: Diagnosis and management of mucositits. Head & Neck, 26, 77-84.
Sonis, S. T., Elting, L. S., Keefe, D., Peterson, D. E., Schubert, M., Hauer-Jensen, M., et al. (2004). Perspectives on cancer therapy-induced mucosal injury: Pathogenesis, measurement, epidemiology, and consequences for patients. Cancer, 100(9, Suppl.), 1995-2025.
Sonis, S. T. (2004a). A biological approach to mucositis. Journal of Supportive Oncology, 2(Suppl. 1), 21-36.
Sonis, S. T. (2004b). Oral mucositits in cancer therapy. Journal of Supportive Oncology, 2(Suppl. 3), 3-8.
Sonis, S. T. (2004c). Pathobiology of mucositis. Seminars in Oncology Nursing, 20, 11-15.
Snmez, S., Kirilmaz, L., Yucesoy, M., Yucel, B., & Yilmaz, B. (2005). The effect of bee propolis on oral pathogens and human gingival fibroblasts. Journal of Ethnopharmacology, 102, 371-376.
Spijkervet, F. K. L., van Saene, H. K. F., van Saene, J. J. M., Panders, A. K., Vermey, A., & Mehta, D. M. (1990). Mucositis prevention by selective elimination of oral flora in irradiated head and neck cancer patients. Journal Oral Pathol Medicine, 19, 486-489.
Trotti, A. (2000). Toxicity in head and neck cancer: a review of trends and issues. Int Journal Radiation Oncol Biol Phys, 47,1-12.
Trotti, A., Bellm, L. A., Epstein, J. B., Frame, D., Fuchs, H. J., & Gwede, C. K. (2003). Mucositis incidence, severity and associated outcomes in patients with head and neck receiving radiotherapy with or without chemotherapy: a systematic literature review. Radiation and Oncology,(66),253-262.
Vissink, A., Jansma, J., Spijkervent, F. K., Burlage, F. R., & Coppes, R. P. (2003). Oral sequelae of head and neck radiotherapy. Critical Review Oral Biol Medicine, 14(3), 199-212.
Vokurka, S., Scudlova, J., Pavlicova, V., Valentova, D., Bockova, J., & Misaniova, L. (2005). The comparative effects of povidone-iodine and normal saline mouthwashes on oral mucositis in patients after high-dose chemotherapy and APBSCT-results of a randomized multicentre study. Support Care Cancer, 13, 554-558.
Vokurka, S., Bystricka, S., Koza, V., Scudlova, J., Pavlicova, V., & Valentova, D. (2006). Higher incidence of chemotherapy induced oral mucositis in females: a supplement of multivariate analysis to a randomized multicentre study. Support Care Cancer, 14, 974-976.
Wijers, O. B., Levendage, P. C., Harms, E. R., Gan-Teng, A. M., Schmitz, P. I., & Hendriks, W. D., et al. (2001). Mucositis reduction by selective elimination of oral flora in irradiated cancers of the head and neck: a placebo-controlled double-blind randomized study. Int Journal Radiation Oncol Biol Phys, 50,343-352.