探討第五期慢性腎臟病病人之唾液流速、口乾症狀及口腔健康

Abstract

研究背景與目的：慢性腎臟病病人最常出現症狀之一，也是最困擾的主訴為口腔乾燥，且普遍有口腔健康低下問題，尤其在第五期慢性腎臟病病人中更加顯著。而口乾症定義為需同時存在唾液流速低下及口乾感受，過去文獻顯示慢性腎臟病病人的唾液流速未達低下標準 (傳統唾液收集法<0.2mm/min)，然而卻高達5 成有主觀口乾感受 (口乾量表>11分或主訴感到口乾)，口腔健康則缺少統一制式的評估方式。故本研究欲探討第五期慢性腎臟病病人的唾液流速、口乾感受及兩者間是否一致，並以涵括8個面向的口腔評估指引了解口腔健康現況。 研究方法：本研究為橫斷研究設計 (cross-sectional studies) ，自2020年3月1日至 10月31日，以台北市某醫學中心及其附屬院所腎臟科門診為收案場所，20歲以上診斷為第五期慢性腎臟病但尚未接受透析治療的病人為對象；患有自體免疫乾燥症、曾接受頭頸放射線治療、意識不清或無法溝通者予以排除。禁食及避免清潔口腔60 分鐘後，先測量未受刺激唾液三分鐘，接著使用口腔評估指引檢查口腔，填寫口乾量表即完成單次收案評估。 研究結果：68 位第五期慢性腎臟病病人中，未受刺激唾液流速平均36.3±11.7mm，僅26.5%達唾液流速低下標準 (改良式試驗試紙3分鐘<30mm)，但依訪問口乾感受及口乾量表>11 分兩個不同方式調查，仍64.7-92.7%有口乾感受，客觀唾液流速低下與有口乾感受的比例落差大，唾液流速正常與低下兩組在回答是否感到口乾的結果分歧，以Cohen’s Kappa檢定客觀未受刺激唾液流速與口乾量表調查的主觀口乾感受，結果也不具一致性 (Kappa值為0.04)，顯示客觀未受刺激唾液流速與主觀口乾感受不相符。另外95.6%有輕至重度口腔異常，顯示使用口腔評估指引可發現普遍存在口腔健康有異常情形。 結論：本研究結果顯示第五期腎臟病病人唾液流速低下僅佔26.5%，但卻有高達64.7- 92.7%有主觀口乾感受，主客觀資料不相符，而這也說明了改善策略會有所不同，然而監測自身唾液流速及口乾感受改變與否也相當重要，因儘管未達低下標準，或許已發生唾液流速減少幅度超過一半引起的口乾，若加上配合使用口腔評估指引發現口腔異常問題，便能及時介入改善措施，避免後續因口腔乾燥、口腔健康低下引發的合併症。

Background Objectives: One of the most common symptoms and bothering complaint among chronic kidney disease (CKD) patients is dry mouth, especially in stage 5 patients. The definition of xerostomia includes both hyposalivation and dry mouth, but previous studies showed that CKD patients generally don’t meet the criteria of hyposalivation (spitting method<0.2mm/min), however over 50% have objective dry mouth (xerostomia inventory score>11 or mouth feels dry), and there’s lack of unified method to assess oral health. Hence the main purpose of this study is to investigate objective salivary flow rate, subjective dry mouth, and to see if there’s consistency between objective and subjective data, also, to understand oral health status by using Oral Assessment Guide (comprises 8 categories) in CKD stage 5 patients. Methods: This cross-sectional study was conducted in the Nephrology outpatient department of National Taiwan University Hospital, from March 1 to October 31, 2020. We recruited patients who were diagnosed with stage 5 chronic kidney disease and over 20years old, those who had Sjogren's syndrome, taken head and neck radiotherapy, was unconscious or cannot communicate were excluded. Participants were asked to stop eating and brushing teeth 60 minutes before the test, we first measured unstimulated salivary flow rate for 3 minutes, then checked oral cavity by using Oral Assessment Guide, last asked them to fill out Xerostomia Inventory. Results: In 68 CKD stage 5 participants, the mean of unstimulated salivary flow rate was 36.3±11.7mm, only 26.5% hyposalivation was found (3minutes Modified Schirmer’s Test<30mm), while 64.7-92.7% had dry mouth (mouth feels dry or Xerostomia Inventory score>11). The proportion of hyposalivation and dry mouth is profoundly different, and the answer to “mouth feels dry” differed in both hyposalivation and normal salivary flow rate groups, also, the inconsistency was confirmed by using Cohen’s Kappa test (Kappa value: 0.04). All showed objective unstimulated salivary flow rate didn’t coincide with subjective dry mouth, and only 22.1-26.5% xerotomia was found. 95.6% had mild to severe oral problem, which indicated oral health problem would be detected by using Oral Assessment Guide. Conclusion: In CKD stage 5 patients, only 26.5% had hyposalivation while 64.7-92.7% had dry mouth, so objective and subjective data didn’t match, which indicated improving strategy would be different for each group, however, it’s also important to investigate if there’s any change within individuals, since 50% reduction of saliva would cause dry mouth even though it doesn’t reach the criteria of hyposalivation. Together using Oral Assessment Guide, the earlier we found the problem, the sooner we could take action to improve their dry mouth, oral health and to prevent the complications. Keywords: stage 5 chronic kidney disease, saliva secretion, Modified Schirmer’s Test, xerostomia, Xerostomia Inventory, plaque index, Oral Assessment Guide