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在宅歯科医療と口腔ケア(在宅医療)

著者: 花形哲夫1) 花形歯科医院

著者: 田村文誉2) 日本歯科大学附属病院

監修: 和田忠志 いらはら診療所 在宅医療部

著者校正済:2019/03/04
現在監修レビュー中

概要・推奨   

  1. 在宅歯科診療は、地域におけるかかりつけ歯科医が、基礎疾患を有する要介護高齢者や障害者など在宅や施設等で療養する状態になり、通院不可能になった患者に対して継続して、適切、安全かつ良質な診療室とほぼ同じ歯科医療を訪問して提供できるものである。
  1. 誤嚥性肺炎の予防において口腔ケアは有効である。
  1. 歯科医師・歯科衛生士等が行う専門的口腔ケアとしての口腔健康管理には、一連の口腔清掃を中心とした口腔衛生管理と、口腔の働き(摂食嚥下・咀嚼・発音・呼吸等)の維持・向上を目的とした口腔機能管理がある。
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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。
※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、実際の保険適用の査定において保険適用及び保険適用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用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:
花形哲夫 : 特に申告事項無し[2021年]
田村文誉 : 特に申告事項無し[2021年]
監修:和田忠志 : 特に申告事項無し[2021年]

まとめ

まとめ  
  1. 在宅歯科診療は、地域におけるかかりつけ歯科医が、基礎疾患を有する要介護高齢者や障害者など在宅や施設等で療養する状態になり、通院不可能になった患者に対して継続して、適切、安全かつ良質な診療室とほぼ同じ歯科医療を訪問して提供できるものである。
  1. 対象となる患者は、口腔内の疾患に加え脳梗塞・認知症などの基礎疾患等を有している。
  1. 小児期においての在宅歯科診療の充実が認められた。
  1. 医師、病院、高次医療機関と連携して医療情報を収集・活用しての全身管理(基礎疾患・服薬等)、また緊急時の対応施策の指針を立てることが不可欠である。
  1. 患者は、摂食嚥下機能の低下、全身の抵抗力の低下がみられることから、誤嚥性肺炎の発症リスクは高い。
  1. 日本人の死亡原因において従来死亡原因の第3位が肺炎であると報告されていたが市中肺炎とは別に口腔内細菌の誤嚥が主な原因と考えられる誤嚥性肺炎のみで7位であると報告された。ホームケアとしての口腔ケアと専門的口腔ケアは誤嚥性肺炎の予防に不可欠である。
  1. 専門的口腔ケアには、口腔健康管理として口腔衛生の維持・向上を主眼におく一連の口腔清掃を中心とした口腔衛生管理と、口腔の働き(摂食嚥下・咀嚼・発音・呼吸等)の維持・向上を目的とした口腔機能管理がある。
  1. ホームケアとしての口腔ケアと専門的口腔ケアを実施するためには、患者・介護者・介護職・医療職との連携・協働、情報の共有が不可欠である。
  1. 地域(医療機関と在宅チーム)が一体となったネットワーク(地域連携クリティカルパス)を構築する。
  1. 専門職種が揃っていない地域や在宅において、限られた資源のもとで適切な在宅歯科医療・口腔ケアを実施するためには、Trans-disciplinary型と呼ばれるチーム形態をとる。
  1. 保険医療機関においては、医療保険・介護保険での在宅歯科診療の実施・療養管理が認められる。平成30年度の医療保険および介護保険の同時改訂への対応が必要である。
  1. 医療保険改訂に伴い、より小児在宅医療についての対応が必要である。

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文献 

著者: B Vellas, Y Guigoz, P J Garry, F Nourhashemi, D Bennahum, S Lauque, J L Albarede
雑誌名: Nutrition. 1999 Feb;15(2):116-22.
Abstract/Text The Mini Nutritional Assessment (MNA) has recently been designed and validated to provide a single, rapid assessment of nutritional status in elderly patients in outpatient clinics, hospitals, and nursing homes. It has been translated into several languages and validated in many clinics around the world. The MNA test is composed of simple measurements and brief questions that can be completed in about 10 min. Discriminant analysis was used to compare the findings of the MNA with the nutritional status determined by physicians, using the standard extensive nutritional assessment including complete anthropometric, clinical biochemistry, and dietary parameters. The sum of the MNA score distinguishes between elderly patients with: 1) adequate nutritional status, MNA > or = 24; 2) protein-calorie malnutrition, MNA < 17; 3) at risk of malnutrition, MNA between 17 and 23.5. With this scoring, sensitivity was found to be 96%, specificity 98%, and predictive value 97%. The MNA scale was also found to be predictive of mortality and hospital cost. Most important it is possible to identify people at risk for malnutrition, scores between 17 and 23.5, before severe changes in weight or albumin levels occur. These individuals are more likely to have a decrease in caloric intake that can be easily corrected by nutritional intervention.

PMID 9990575  Nutrition. 1999 Feb;15(2):116-22.
著者: M Lamy, P Mojon, G Kalykakis, R Legrand, E Butz-Jorgensen
雑誌名: J Dent. 1999 Aug;27(6):443-8.
Abstract/Text OBJECTIVES: To evaluate, in an elderly population, whether poor oral status might be a contributing factor to the development of undernutrition and might be associated with less eating pleasure, more subjective eating difficulty and increased mashed food consumption.
METHODS: An oral examination and an evaluation of masticatory capacity were performed on 120 institutionalized elderly subjects. The nutritional assessment included serum albumin concentration, the Mini Nutritional Assessment and a questionnaire on eating habits.
RESULTS: Edentulous subjects without dentures or with only one complete denture had significantly lower MNA scores than edentulous subjects with two complete dentures (p < 0.05). Edentulous subjects with two complete dentures more frequently reported taking pleasure from eating (p = 0.05), and had less frequent difficulties with hard foods (p = 0.01) than edentulous subjects without dentures or with only one complete denture. Mashed food consumption (p < 0.01) was also reported more frequently in edentulous subjects without dentures or with only one complete denture. Subjects with two complete dentures had similar or better MNA scores as dentate subjects with relatively few remaining teeth (10.4 +/- 7.8 teeth). About half of the subjects (53%) could not perform the masticatory test. These subjects had lower MNA scores (p = 0.001) and a larger proportion ate mashed food (p < 0.001) compared to those who were able to perform the test.
CONCLUSIONS: Poor oral status (edentulous without dentures or with only one complete denture) increased difficulty in eating hard foods, increased mashed food consumption and decreased eating pleasure. It seemed also to put institutionalized subjects at higher risk of undernutrition.

PMID 10399411  J Dent. 1999 Aug;27(6):443-8.
著者: Fumiyo Tamura, Takeshi Kikutani, Takashi Tohara, Mitsuyoshi Yoshida, Ken Yaegaki
雑誌名: Dysphagia. 2012 Dec;27(4):556-61. doi: 10.1007/s00455-012-9407-z. Epub 2012 Apr 27.
Abstract/Text Many elderly people under long-term care suffer from malnutrition caused by dysphagia, frequently leading to sarcopenia. Our hypothesis is that sarcopenia may compromise oral function, resulting in dysphagia. The objectives of this study were to evaluate sarcopenia of the lingual muscles by measuring the tongue thickness, and elucidate its relationship with nutritional status. We examined 104 elderly subjects (mean age = 80.3 ± 7.9 years). Anthropometric data, such as triceps skinfold thickness and midarm muscle area (AMA), were obtained. The tongue thickness of the central part was determined using ultrasonography. Measurement was performed twice and the mean value was obtained. The relationship between tongue thickness and nutritional status was analyzed by Pearson's correlation coefficient and Spearman's rank correlation coefficient. AMA and age were identified by multiple-regression analysis as factors influencing tongue thickness. The results of this study suggest that malnutrition may induce sarcopenia not only in the skeletal muscles but also in the tongue.

PMID 22538556  Dysphagia. 2012 Dec;27(4):556-61. doi: 10.1007/s00455-0・・・
著者: A Ishikawa, T Yoneyama, K Hirota, Y Miyake, K Miyatake
雑誌名: J Dent Res. 2008 Jun;87(6):594-8.
Abstract/Text Silent aspiration of oropharyngeal pathogenic organisms is a significant risk factor causing pneumonia in the elderly. We hypothesized that regular oral hygiene care will affect the presence of oropharyngeal bacteria. Professional cleaning of the oral cavity and/or the gargling of a disinfectant liquid solution was performed over a five-month period in three facilities for the dependent elderly. Total oropharyngeal bacteria, streptococci, staphylococci, Candida, Pseudomonas, and black-pigmented Bacteroides species were monitored. The levels of these oropharyngeal bacteria decreased or disappeared after weekly professional oral health care, i.e., cleaning of teeth, dentures, tongue, and oral mucous membrane by dental hygienists. After lunch, gargling with povidone iodine was shown to be less effective than professional oral care. These findings indicate that weekly professional mechanical cleaning of the oral cavity, rather than a daily chemical disinfection of the mouth, can be an important strategy to prevent aspiration pneumonia in the dependent elderly.

PMID 18502972  J Dent Res. 2008 Jun;87(6):594-8.
著者: Takeyoshi Yoneyama, Mitsuyoshi Yoshida, Takashi Ohrui, Hideki Mukaiyama, Hiroshi Okamoto, Kanji Hoshiba, Shinichi Ihara, Shozo Yanagisawa, Shiro Ariumi, Tomonori Morita, Yasuro Mizuno, Takayuki Ohsawa, Yasumasa Akagawa, Kenji Hashimoto, Hidetada Sasaki, Oral Care Working Group
雑誌名: J Am Geriatr Soc. 2002 Mar;50(3):430-3.
Abstract/Text OBJECTIVES: Aspiration of oral secretions and their bacteria is increasingly being recognized as an important factor in pneumonia. We investigated whether oral care lowers the frequency of pneumonia in institutionalized older people.
DESIGN: Survey.
SETTING: Eleven nursing homes in Japan.
PARTICIPANTS: Four hundred seventeen patients randomly assigned to an oral care group or a no oral care group.
INTERVENTION: Nurses or caregivers cleaned the patients' teeth by toothbrush after each meal. Swabbing with povidone iodine was additionally used in some cases. Dentists or dental hygienists provided professional care once a week.
MEASUREMENTS: Pneumonia, febrile days, death from pneumonia, activities of daily living, and cognitive functions.
RESULTS: During follow-up, pneumonia, febrile days, and death from pneumonia decreased significantly in patients with oral care. Oral care was beneficial in edentate and dentate patients. Activities of daily living and cognitive functions showed a tendency to improve with oral care.
CONCLUSION: We suggest that oral care may be useful in preventing pneumonia in older patients in nursing homes.

PMID 11943036  J Am Geriatr Soc. 2002 Mar;50(3):430-3.
著者: T Yoneyama, M Yoshida, T Matsui, H Sasaki
雑誌名: Lancet. 1999 Aug 7;354(9177):515.
Abstract/Text
PMID 10465203  Lancet. 1999 Aug 7;354(9177):515.
著者: A Yoshino, T Ebihara, S Ebihara, H Fuji, H Sasaki
雑誌名: JAMA. 2001 Nov 14;286(18):2235-6.
Abstract/Text
PMID 11710887  JAMA. 2001 Nov 14;286(18):2235-6.
著者: Aya Watando, Satoru Ebihara, Takae Ebihara, Tatsuma Okazaki, Hidenori Takahashi, Masanori Asada, Hidetada Sasaki
雑誌名: Chest. 2004 Oct;126(4):1066-70. doi: 10.1378/chest.126.4.1066.
Abstract/Text BACKGROUND: Intensive oral care can reduce the incidence of pneumonia in elderly nursing home patients, but the mechanism is unknown.
OBJECTIVE: To explore the effects of intensive oral care on impaired cough reflex sensitivity, which is a known risk factor of aspiration pneumonia.
METHODS: Cough reflex sensitivity to citric acid was measured in elderly nursing home patients, who were randomly assigned to the intervention group (n = 30) and the control group (n = 29). The patients in the intervention group had their teeth and gingiva cleaned by caregivers after every meal for 1 month. The patients in the control group performed their own oral care during the same period. Serum substance P (SP) concentration, cognitive function, and activities of daily living (ADL) were also assessed.
RESULTS: In the intervention group, cough reflex sensitivity at 30 days showed significantly higher sensitivity than baseline (p < 0.01). At 30 days, the cough reflex sensitivities in the intervention group were significantly higher than that of the control group (p < 0.05). Compared with the control group, the odds ratio of improvement of cough reflex sensitivity was 5.3 (95% confidence interval, 1.7 to 16.0; p < 0.005) for the intervention group. One month of intensive oral care did not have a significant effect on serum SP concentration, cognitive function, and ADL.
CONCLUSION: Intensive oral care may reduce the incidence of pneumonia by improving cough reflex sensitivity in elderly nursing home patients.

PMID 15486365  Chest. 2004 Oct;126(4):1066-70. doi: 10.1378/chest.126.・・・
著者: R Hamada, J Suehiro, M Nakano, T Kikutani, K Konishi
雑誌名: IET Nanobiotechnol. 2011 Jun;5(2):25-31. doi: 10.1049/iet-nbt.2010.0011.
Abstract/Text In this study, a bacteria detection apparatus based on dielectrophoretic impedance measurement (DEPIM) method was demonstrated for rapid evaluation of oral hygiene. The authors integrated a micro electrode chip on which bacteria were captured by dielectrophoresis (DEP), an AC voltage source to induce DEP force, and an impedance measurement circuit to a portable instrument that enables rapid and automated oral bacterial inspection in hospitals and clinics. Special considerations have been made on effects of high electrical conductivity of oral samples on DEP force and DEPIM results. It was shown experimentally and theoretically that using a higher electric field frequency for the DEP bacteria trap and the impedance measurement could realise DEPIM application to bacteria inspection from oral samples with higher conductivity. Based on these investigations, the authors optimised the frequency condition of the DEPIM suitable for inspecting an oral sample along with the design and development of a portable DEPIM apparatus for on-site inspection of oral bacteria. Under the optimised frequency condition, DEPIM results were in good agreement with the conventional culture method showing significant applicability of the DEPIM apparatus for practical rapid oral bacteria inspection.

PMID 21495776  IET Nanobiotechnol. 2011 Jun;5(2):25-31. doi: 10.1049/i・・・
著者: Takeshi Kikutani, Fumiyo Tamura, Yukihiro Takahashi, Kiyoshi Konishi, Ryo Hamada
雑誌名: Gerodontology. 2012 Jun;29(2):e560-5. doi: 10.1111/j.1741-2358.2011.00517.x. Epub 2011 Aug 3.
Abstract/Text OBJECTIVE: To clarify the oral environment, we evaluated the usefulness and clinical applicability of a new apparatus developed for the simple and rapid quantification of oral bacteria.
BACKGROUND: Professional oral health care can reduce the number of oral bacteria and days of fever and inhibit the development of pneumonia. A novel detection apparatus was developed by applying the dielectrophoretic impedance measurement method.
METHODS: First, to determine the accuracy of this apparatus, employing standard samples of Escherichia coli. Next, to evaluate the oral environment, samples were taken from the tongue in elderly (mean age: 86.6 years) in nursing home.
RESULTS: In the first study, a good correlation was observed between the two methods (R = 0.999). In the second study, there were significant correlations between measurement values obtained using this apparatus and those obtained by the culture method (R = 0.852), as well as those obtained by the FM method (R = 0.885).
CONCLUSION: Our data showed that this rapid oral bacterial detection apparatus is effective in evaluating the oral hygiene to prevent pneumonia in the elderly.

© 2011 The Gerodontology Society and John Wiley & Sons A/S.
PMID 21812809  Gerodontology. 2012 Jun;29(2):e560-5. doi: 10.1111/j.17・・・

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