今日の臨床サポート

口腔感染症と他臓器への影響

著者: 米原啓之 日本大学 歯学部口腔外科学第Ⅱ講座

著者: 生木俊輔 日本大学 歯学部口腔外科学第Ⅱ講座

監修: 近津大地 東京医科大学

著者校正/監修レビュー済:2022/03/30
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、 著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※同効薬・小児・妊娠および授乳中の注意事項等は、海外の情報も掲載しており、日本の医療事情に適応しない場合があります。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適応の査定において保険適応及び保険適応外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適応の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
米原啓之 : 特に申告事項無し[2022年]
生木俊輔 : 特に申告事項無し[2022年]
監修:近津大地 : 特に申告事項無し[2022年]

改訂のポイント:
  1. 改訂された『感染性心内膜炎の予防と治療に関するガイドラインが改訂された』にもとづき見直しを行った。
  1. 薬剤投与と顎骨壊死について追記した。

まとめ

口腔感染症のまとめ  
  1. 口腔感染症とは病原性微生物によって引き起こされる感染症で、主に口腔内で一番多くみられる歯性感染症について述べる。
  1. 口腔感染症の多くは、歯垢、粘膜表面、歯肉溝内などに存在する口腔内常在菌によって引き起こされる[1]
  1. これらの細菌は、好気性グラム陽性球菌、嫌気性グラム陽性球菌、嫌気性グラム陰性桿菌であり、う蝕、歯肉炎、歯周炎など一般歯科疾患の原因菌である。
  1. 原因菌として好気性菌の主体はStreptococcus milleriグループ、嫌気性グラム陽性球菌が約65%の症例にみられ、嫌気性レンサ球菌とPeptostreptococcusである。口腔においてはグラム陰性嫌気性桿菌が3/4の症例で検出される。PrevotellaPorphyromonas spp.がそれらの約75%を占め、Fusobacteriumが50%以上に検出される[2]
  1. 口腔感染症は他臓器に影響を与えるが、歯の支持組織である顎骨や歯肉、またさらにその周囲にある筋組織、筋組織と筋組織の間に存在する隙や上顎洞等の口腔周囲局所に影響を与える場合と、感染性心内膜炎に代表される血流を介した遠隔臓器に影響を与える場合がある。
  1. 歯周囲の局所に存在する組織に影響を与える場合、一般的に2つの経路によって感染が拡がっていく。すなわち、感染根管から根尖周囲への細菌の侵入して行く経路と歯周ポケットからの細菌の侵入する経路(いわゆる歯周病)である[1]
  1. 遠隔臓器に影響を与える場合、抜歯など観血的処置を行った場合や、ブラッシングなどによる擦過創などから細菌が侵入して菌血症が起こり、血管内膜に定着し感染性心内膜炎を引き起こす。一般的に 感染性心内膜炎 で口腔内常在菌が検出されることが多い[1]
  1. 糖尿病と歯周病の関連が指摘されており[3]、歯周病が糖尿病を悪化させることもある。また、 糖尿病 患者においては智歯周囲炎や抜歯後の創部感染が重症化する場合もある。
  1. 内臓疾患など全身疾患と関連する口腔粘膜疾患があり、口腔粘膜に特徴的な症状を引き起こす場合がある。これらの疾患による病変と口腔感染症との鑑別が必要になることが多い。
  1. ビスホスホネート系製剤(BP系製剤)服用により、 顎骨壊死 (MRONJ)を生じることがある。BP製剤を投与する場合、事前に必要な歯科処置を終わらせておくことや、BP製剤服用中に歯科処置を行う場合には安易な外科処置を行わないようにすることなどが必要である。
 
歯性感染に関連する組織隙

組織学的隙と連絡路を示す。

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文献 

H Sakamoto, H Kato, T Sato, J Sasaki
Semiquantitative bacteriology of closed odontogenic abscesses.
Bull Tokyo Dent Coll. 1998 May;39(2):103-7.
Abstract/Text Pus samples from twenty-three dentoalveolar abscesses were collected by needle aspiration and examined by direct inoculation technique using 6 different aerobic and anaerobic agar plates. For aerobic culture, sheep blood agar and chocolate agar (Kyokuto Pharmaceutical Co., Tokyo, Japan) were used. For anaerobic culture, four different media, 1) brucella HK agar with hemolyzed rabbit blood and defibrillated sheep blood, 2) paramomycin-vancomycin brucella HK agar with hemolyzed rabbit blood, 3) phenylethyl alcohol brucella HK agar with hemolyzed rabbit blood, 4) bacteroides bile esculin agar (Kyokuto Pharmaceutical Co., Tokyo, Japan) were prepared in an anaerobic jar prior to inoculation. The aerobic agar plates were incubated for 24 h at 37 degrees C, and the anaerobic plates at least 48 h at 37 degrees C in anaerobic jars. From 23 closed odontogenic abscess samples, a total of 112 bacterial strains were isolated; 81 strains (72.3%) were strict anaerobes, and 31 strains (27.7%) were aerobes. The mean number of bacterial strains per positive sample was 4.86. Oral Streptococci, Prevotella, Fusobacterium, Peptostreptococcus and Veillonella were common isolates. The combination of Oral Streptococci and Prevotella was found in 11 patients (47.8%), and that of Prevotella and Peptostreptococcus in 12 patients (52.2%). The present study demonstrated that closed odontogenic abscesses are polymicrobial infections by aerobes and anaerobes. Application of a direct inoculation technique for bacterial culture made it possible to isolate more anaerobes than our commonly used technique using transport medium and to delineate the semiquantitative bacteriology of closed odontogenic abscess.

PMID 9667143
R G Nelson, M Shlossman, L M Budding, D J Pettitt, M F Saad, R J Genco, W C Knowler
Periodontal disease and NIDDM in Pima Indians.
Diabetes Care. 1990 Aug;13(8):836-40.
Abstract/Text The goal of this study was to determine the prevalence and incidence of periodontal disease and its relationship with non-insulin-dependent diabetes mellitus (NIDDM). Two thousand two hundred seventy-three Pima Indians (949 men, 1324 women) aged greater than or equal to 15 yr from the Gila River Indian Community in Arizona were examined between 1983 and 1989. Periodontal disease was diagnosed by tooth loss and by percentage of interproximal crestal alveolar bone loss ascertained from panoramic radiography. Subjects with little or no evidence of periodontal disease were classified as nondiseased. Thus, the incidence of advanced periodontal disease was determined. The age- and sex-adjusted prevalence of periodontal disease at first dental examination was 60% in subjects with NIDDM and 36% in those without. Twenty-two new cases developed in a subset of 701 subjects (272 men, 429 women) aged 15-54 yr who initially had little or no evidence of periodontal disease and had at least one additional dental examination. The incidence of periodontal disease in this group was similar in men and women (incidence-rate ratio 1.0, 95% confidence interval [Cl] 0.5-1.9, controlled for age and diabetes). Higher age predicted a greater incidence of periodontal disease (chi 2 = 30.6, df = 3, P less than 0.001, controlled for sex and diabetes). The rate of periodontal disease in subjects with diabetes was 2.6 times (95% Cl 1.0-6.6, controlled for age and sex) that observed in those without. Although periodontal disease was common in nondiabetic Pima Indians, in whom most of the incident cases occurred, diabetes clearly conferred a substantially increased risk. Thus, periodontal disease should be considered a nonspecific complication of NIDDM.

PMID 2209317
Ana Belén Navarro-Sanchez, Ricardo Faria-Almeida, Antonio Bascones-Martinez
Effect of non-surgical periodontal therapy on clinical and immunological response and glycaemic control in type 2 diabetic patients with moderate periodontitis.
J Clin Periodontol. 2007 Oct;34(10):835-43. doi: 10.1111/j.1600-051X.2007.01127.x.
Abstract/Text OBJECTIVES: The purpose of this study was to compare the local efficacy of nonsurgical periodontal therapy between type 2 diabetic and non-diabetic patients and the effect of periodontal therapy on glycaemic control.
BACKGROUND: A complex two-way relationship exists between diabetes mellitus and periodontitis.
MATERIALS AND METHODS: After selection, 20 subjects (10 diabetic and 10 non-diabetic) underwent baseline examination, periodontal clinical study and biochemical analysis of gingival crevicular fluid (GCF). After the pre-treatment phase, subgingival scaling and root planing were performed. Subsequently, all subjects continued the maintenance programme and were re-examined at 3 and 6 months.
RESULTS: Diabetic and non-diabetic subjects responded well after therapy, showing a very similar progression during the follow-up period. Both groups showed clinically and immunologically significant improvements. Significant reductions were also found in the total volume of GCF and levels of interleukin-1beta and tumour necrosis factor-alpha. Diabetic subjects showed an improvement in their metabolic control. The change in glycosylated haemoglobin (HbA(1C)) was statistically significant at 3 and 6 months.
CONCLUSIONS: The clinical and immunological improvements obtained were accompanied by a significant reduction in HbA(1C) values in type 2 diabetic subjects. Larger studies are needed to confirm this finding and establish whether periodontal therapy has a significant effect on glycaemic control.

PMID 17850602
Walter Wilson, Kathryn A Taubert, Michael Gewitz, Peter B Lockhart, Larry M Baddour, Matthew Levison, Ann Bolger, Christopher H Cabell, Masato Takahashi, Robert S Baltimore, Jane W Newburger, Brian L Strom, Lloyd Y Tani, Michael Gerber, Robert O Bonow, Thomas Pallasch, Stanford T Shulman, Anne H Rowley, Jane C Burns, Patricia Ferrieri, Timothy Gardner, David Goff, David T Durack, American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, Quality of Care and Outcomes Research Interdisciplinary Working Group, American Dental Association
Prevention of infective endocarditis: guidelines from the American Heart Association: a guideline from the American Heart Association Rheumatic Fever, Endocarditis and Kawasaki Disease Committee, Council on Cardiovascular Disease in the Young, and the Council on Clinical Cardiology, Council on Cardiovascular Surgery and Anesthesia, and the Quality of Care and Outcomes Research Interdisciplinary Working Group.
J Am Dent Assoc. 2007 Jun;138(6):739-45, 747-60.
Abstract/Text BACKGROUND: The purpose of this statement is to update the recommendations by the American Heart Association (AHA) for the prevention of infective endocarditis, which were last published in 1997.
METHODS AND RESULTS: A writing group appointed by the AHA for their expertise in prevention and treatment of infective endocarditis (IE) with liaison members representing the American Dental Association, the Infectious Diseases Society of America and the American Academy of Pediatrics. The writing group reviewed input from national and international experts on IE. The recommendations in this document reflect analyses of relevant literature regarding procedure-related bacteremia and IE; in vitro susceptibility data of the most common microorganisms, which cause IE; results of prophylactic studies in animal models of experimental endocarditis; and retrospective and prospective studies of prevention of IE. MEDLINE database searches from 1950 through 2006 were done for English language articles using the following search terms: endocarditis, infective endocarditis, prophylaxis, prevention, antibiotic, antimicrobial, pathogens, organisms, dental, gastrointestinal, genitourinary, streptococcus, enterococcus, staphylococcus, respiratory, dental surgery, pathogenesis, vaccine, immunization and bacteremia. The reference lists of the identified articles were also searched. The writing group also searched the AHA online library. The American College of Cardiology/AHA classification of recommendations and levels of evidence for practice guidelines were used. The article subsequently was reviewed by outside experts not affiliated with the writing group and by the AHA Science Advisory and Coordinating Committee.
CONCLUSIONS: The major changes in the updated recommendations include the following. (1) The committee concluded that only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100 percent effective. (2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE. (3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa. (4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE. (5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure. These changes are intended to define more clearly when IE prophylaxis is or is not recommended and to provide more uniform and consistent global recommendations.

PMID 17545263
Toyoko Morita, Yoji Yamazaki, Ayae Mita, Koji Takada, Misae Seto, Norihide Nishinoue, Yoshiyuki Sasaki, Masafumi Motohashi, Masao Maeno
A cohort study on the association between periodontal disease and the development of metabolic syndrome.
J Periodontol. 2010 Apr;81(4):512-9. doi: 10.1902/jop.2010.090594.
Abstract/Text BACKGROUND: An association between periodontal disease and metabolic syndrome based on cross-sectional and case-control studies was recently reported, but their causal relationship has not been fully clarified. The objective of this cohort study is to investigate the association between periodontal disease and changes in metabolic-syndrome components to accumulate evidence of the causal relationship between the two conditions.
METHODS: The study subjects consisted of 1,023 adult employees (727 males and 296 females; mean age: 37.3 years) who underwent medical and dental checkups between 2002 and 2006 and in whom all metabolic-syndrome components were within the standard values in 2002. The association between the presence of periodontal pockets and the positive conversion of metabolic-syndrome components was investigated using multiple logistic-regression analysis, odds ratios (ORs), and 95% confidence intervals (CIs).
RESULTS: The presence of periodontal pockets was associated with a positive conversion of one or more metabolic components during the 4-year observation period (OR: 1.6; 95% CI: 1.1 to 2.2). The ORs for a positive conversion of one component and two or more components were 1.4 (95% CI: 1.0 to 2.1) and 2.2 (95% CI: 1.1 to 4.1), respectively, and the difference was significant for two or more positive components. Of the metabolic-syndrome components, positive conversions of blood pressure and the blood-lipid index were significantly associated with the presence of periodontal pockets.
CONCLUSION: The presence of periodontal pockets was associated with a positive conversion of metabolic-syndrome components, suggesting that preventing periodontal disease may prevent metabolic syndrome.

PMID 20367094
Advisory Task Force on Bisphosphonate-Related Ostenonecrosis of the Jaws, American Association of Oral and Maxillofacial Surgeons
American Association of Oral and Maxillofacial Surgeons position paper on bisphosphonate-related osteonecrosis of the jaws.
J Oral Maxillofac Surg. 2007 Mar;65(3):369-76. doi: 10.1016/j.joms.2006.11.003.
Abstract/Text
PMID 17307580

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