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1 J Dent Hyg Sci Vol.12, No.5, 2012, pp RESEARCH ARTICLE 제 2 형당뇨병환자에서혈당조절에따른구강건강인식도 강희은ㆍ김선주 1 ㆍ최준선 2 가천대학교보건대학원치위생학과, 1 청주대학교치위생학과, 2 가천대학교보건과학대학치위생학과 Self-Perceived Oral Health Status according to Regulation of Blood Glucose in the Type 2 Diabetic Patients Hui-Eun Kang, Sun-Ju Kim 1 and Jun-Seon Choi 2 Department of Dental Hygiene, Graduate School of Public Health, Gachon University, Incheon , 1 Department of Dental Hygiene, Cheongju University, Cheongju , 2 Department of Dental Hygiene, College of Health Science, Gachon University, Incheon , Korea The aim of this study was to investigate the oral health problems among type 2 diabetes patients and suggest basic data for the promotion of their body and oral health by emphasizing the correlation between hemoglobin A1c and subjective oral health status. For 174 patients with type 2 diabetes and who were older than 40 years old, the questionnaire and measurement of hemoglobin A1c were conducted from January 9, 2012 to March 9, The results of the study were as follows. 1. They tended to be most aware of the following; inflammation on the oral mucosa and pain on the oral mucosa among the symptoms of oral mucosa, gum bleeding when brushing teeth among the symptoms of periodontal disease, and feels dry in general among the symptoms of xerostomia. 2. The patients with longer duration of diabetes showed greater recognition with regards to the symptoms of oral mucosa disease, periodontal disease, and xerostomia (p<0.05). 3. The group with regular meal showed lower level of hemoglobin A1c (p<0.001). 4. The level of hemoglobin A1c was higher in the group that recognized burning sensation, gum bleeding, gum recession and bad breath (p<0.05) as well as in the group that responded get up at night to drink among the symptoms of xerostomia (p<0.05). Especially the symptoms of periodontal disease were revealed to be a factor that showed the 3rd strongest correlation with hemoglobin A1c. Key Words: Hemoglobin A1c, Periodontal disease, Type 2 diabetes mellitus 서론 당뇨병은당대사장애로인해혈액내포도당농도가증가할뿐아니라, 탄수화물과단백질및지질의대사이상을동반하며, 다뇨나다음, 다식과같은특징적인증상을보인다 1). 당뇨병은제1형당뇨병과제2형당뇨병으로분류되는데, 제1 형당뇨병은췌장의베타세포파괴로인슐린이분비되지않아나타나고, 제2형당뇨병은인슐린이상대적으로부족하거나, 인슐린은분비되지만세포가포도당을효과적으로연 소하지못하는인슐린저항성으로인해나타난다 2). 당뇨병의진단에있어혈당치의기준은식후 2시간혈당치 200 mg/dl 이상, 공복혈당치 126 mg/dl 이상이다 3). 2010년기준만 30세이상성인에서당뇨병유병률은 9.7% 이고 4), 당뇨병은우리나라에서 5대사망원인중하나이다 5). 고혈당이오랫동안지속됨에따라나타날수있는만성합병증으로는동맥경화증, 뇌혈관경색증, 망막증및신장질환등이있으며 3), 구강내경ㆍ연조직뿐아니라구강환경에도많은변화를일으킨다 6). 특히 Lamster 등 7) 은당뇨병합병증의첫임 Received: August 20, 2012, Revised: October 16, 2012, Accepted: October 16, 2012 ISSN (Print) / ISSN (Online) Correspondence to: Jun-Seon Choi Department of Dental Hygiene, College of Health Science, Gachon University, 191, Hambakmoe-ro, Yeonsu-gu, Incheon , Korea Tel: , Fax: , junseon@gachon.ac.kr Copyright 2012 by the Korean Society of Dental Hygiene Science This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

2 J Dent Hyg Sci Vol. 12, No. 5, 2012 상적지표가치주변화라고보고하면서당뇨병과치주건강과의연관성을강조하였고, Löe 8) 또한당뇨병합병증의 6번째질환으로치주질환을언급하였다. 선행연구를살펴보면당뇨병환자는정상인에비해치면세균막이더많이축적되며 9), 부착소실이나치은출혈, 치아동요가더많았고 10), 치주낭깊이가 5 mm 이상인병적치주염을가진사람이더많다 11). Shlossman 등 12) 도당뇨병환자에서치주부착소실과골흡수량이건강인에비해심각한수준이라하였고, Hintao 등 13) 은치은퇴축으로인해치근우식증이높게발생한다고보고하였다. 이외에타액에도변화가나타나는데, 타액분비량이감소하고타액내포도당이증가함에따라구강건조증을인식하거나구강캔디다증이발생하기도한다 6). 당뇨병환자에서혈당조절이안될수록이러한합병증이증가하지만, 반대로혈당조절의향상성에있어구강건강상태는매우중요하다. 특히구강내존재하는염증은인슐린의기능을감소시켜세포가포도당을효과적으로연소하지못하게만드는인슐린저항성을유발하여혈당의정상화를방해한다 14). Karikoski 등 15) 은비외과적치주치료후당화혈색소수준이감소하였다고하였고, Grossi 등 16) 은정기적으로치석제거를시행한집단에서당화혈색소가감소하였다고하였다. 이와같이당뇨병은치주질환등의합병증을야기할뿐아니라, 반대로구강내발생한치주질환은혈당조절에부정적인영향을미치기때문에의료보건인력은당뇨병환자의혈당관리와구강건강상태에더많은관심이필요하다. 지금까지당뇨병과구강내합병증에관한국내연구를살펴보면대부분임상적지표를활용하여구강건강상태를보고하였고, 혈당조절정도를평가하는데공복시혈당측정법을이용한연구가대부분이었다. 그러나, 세계보건기구 (World Health Organization, WHO) 에의한 적극적건강 (positive health) 의개념을고려해볼때환자가스스로인식하는구강건강상태는중요한의미를가질수있다. 또한자신에의해평가된구강건강상태나치아만족도에따라구강건강행동에대한인식이달라지며 17), 삶의질을저하시키는통증이나불편함과같은증상은임상적지표로측정하기곤란하므로 18), 주관적구강건강상태에관한연구는구강건강행동실천율을높이고삶의질을향상시키는데의미있는연구로생각한다. 또한공복혈당검사는단기간의혈당수준을나타내지만, 당화혈색소검사법은장기간의혈당조절정도를파악할수있을뿐만아니라식사시간에영향을받지않는다는장점이있다. 따라서, 본연구는제2형당뇨병환자가인식하고구강건강문제를파악하고, 당화혈색소와주관적구강건강상태와의연관성을제시함으로써당뇨병환자들의전신및구강건강증진과삶의만족도향상을위한 기초자료를제시하고자한다. 연구대상및방법 1. 연구대상본연구는 2012년 1월 9일부터 2012년 3월 9일까지편의표본추출법을적용하여경기도에소재한의원 1곳에내원한만 40세이상제2형당뇨병을가진환자를연구대상으로선정하였다. 연구목적을설명하고설문지작성과당화혈색소측정에동의한총 178명을대상으로연구를진행하였다. 자료수집후결측치가많거나신뢰성이의심되는 4명의설문지를제외한 174명 (97.7%) 의자료를최종분석에사용하였다. 2. 연구도구본연구의목적을달성하기위하여사용된설문요인으로는연구대상자의일반적특성 7문항과주관적구강건강상태를파악하기위하여구강점막상태 5문항, 치주건강상태 8 문항, 구강건조증증상 7문항, 혈당조절을위한건강행동 6 문항을이용하였다. 이외에최근 2 3개월동안혈당조절상태를평가하기위하여당화혈색소수준을이용하였다. 설문문항중구강점막상태를파악하기위한문항은 Bergdahl 19) 의연구결과를참고하였다. 치주건강상태는 Ng와 Leung 20) 의연구에서, 구강건조증증상은 Thomson과 Williams 21) 의연구에서사용한문항을우리말로번안후사용하였다. 구강점막상태는각문항에대해 아니오 (0), 예 (1) 로측정하여 0 5점사이의점수를보이며총점수가높을수록구강점막질환증상이많음을의미한다. 구강점막상태를평가하기위한문항의 Cronbach's α값은 0.733이었다. 치주건강상태는각문항에대해 아니오 (0), 예 (1) 로측정하여 0 8점사이의점수를보이고, 총점수가높을수록치주질환증상이많음을의미하며, Cronbach's α값은 이었다. 구강건조증증상은각문항에대해 3 점 Likert 척도를이용하여 그렇지않다 (0), 가끔그렇다 (1), 자주그렇다 (2) 로조사하였고 0점에서 14점사이의점수를보인다. 총점수가높을수록구강건조증증상이많음을의미하며, Cronbach's α값은 0.877이었다. 혈당조절을위한건강행동은이 22) 의연구에서사용된문항을수정 보안하였으며, 각문항을 3점 Likert 척도를사용하여 그렇지않다 (0), 가끔그렇다 (1), 자주그렇다 (2) 로측정하였고, 총점수가높을수록혈당조절을위한건강행동실천율이높다고해석하였다. 마지막으로당화혈색소는전문의가연구대상자의손가락모세혈관으로부터약 0.2 ml 혈액을채취한후 In2it TM 494

3 강희은외 : 제 2 형당뇨병환자에서혈당조절에따른구강건강인식도 Table 1. Self-Reported Oral Health Status of the Subjects Self-reported oral health status Classification N % Oral mucosa disease symptoms I have inflammation on the oral mucosa Yes No I have a pain on the oral mucosa Yes No I don't feel well food taste than in the past Yes No I have burning sensation on the tongue Yes No I have a pain in my tongue Yes No Periodontal disease symptoms I am gum bleeding when brushing my teeth Yes No My gum are often swelling Yes No I have food impaction by gum recession Yes No My teeth are crowding by aging Yes No I have a bad breath Yes No I have mobile tooth Yes No I have a pain in my gum Yes No I have gum recession toward the tooth root Yes No Xerostomia symptoms My mouth feels dry in general Never Occasionally Very often I get up at night to drink Never Occasionally Very often I sip liquids to aid in swallowing food Never Occasionally Very often My mouth feels dry when eating a meal Never Occasionally Very often I take gums or candies to relieve dry mouth Never Occasionally Very often I have difficulty in eating dry foods Never Occasionally Very often I have difficulties swallowing certain foods Never Occasionally Very often Total

4 J Dent Hyg Sci Vol. 12, No. 5, 2012 (Bio-Rad Laboratories Inc., Richmond, CA, USA) 을이용하여당화혈색소를측정하고기록하였다. 3. 자료분석수집된모든자료는 SPSS Windows ver (SPSS Inc., Chicago, IL, USA) 프로그램을이용하여분석하였다. 연구대상자의주관적구강건강상태를파악하기위해빈도분석을실시하였다. 일반적특성에따른주관적구강건강상태, 혈당조절을위한건강행동에따른당화혈색소수준, 당화혈색소에따른주관적구강건강상태를분석하기위해 t-test와 one-way ANOVA 분석을시행하였고, 유의미한변수에대하여 Scheffe 사후검정법을이용하였다. 마지막으로당화혈색소와의관련요인들의연관강도를분석하기위하여다중선형회귀분석을실시하였다. 다중선형회귀분석시종속변수는당화혈색소수준이었으며, 독립변수중성별 ( 남자 =0, 여자 =1), 직업 ( 없음 =0, 있음 =1), 교육수준 (0= 고졸이하, 1= 대졸이상 ) 및결혼여부 (0= 미혼 / 사별등, 1= 기혼 ) 를더미변수화하였다. 통계학적유의성검정을위한유의수준 (α) 은 0.05를기준으로하였다. 결과 1. 연구대상자의주관적구강건강상태구강점막증상중 입안점막에염증이있다 와 입안점막이아프다 라고응답한자가 14명 (8.0%) 으로가장많았고 예전과는달리음식맛을잘느낄수없다 13명 (7.5%), 혀에타는듯한느낌이있다 10명 (5.7%), 혀가아프다 4 명 (2.3%) 순으로나타났다. 치주질환증상중 칫솔질시잇몸에서피가난다 고응답한자가 50명 (28.7%), 잇몸이자주붓는다 39명 (22.4%), 잇몸이내려가음식물이낀다 34 명 (19.5%), 나이가들면서치아가점점틀어진다 33명 (19.0%), 입에서나쁜냄새가난다 27명 (15.5%), 흔들리는치아가있다 22명 (12.6%), 잇몸이아프다 20명 (11.5%), 잇몸이치아뿌리쪽으로내려갔다 16명 (9.2%) 순으로나타났다. 구강건조증증상에서양의반응 ( 가끔그렇다, 자주그렇다 ) 이가장높았던문항으로는 평상시내입안은마른다고느낀다 가 30명 (17.2%) 이었고, 다음으로는 나는목이말라자다가일어나물을마신다 28명 (16.1%), 나는음식을삼킬때음료 ( 물 ) 를한모금씩마신다 24명 (13.8%), 나는음식을먹을때내입이마른다고느낀다 19명 (10.9%), 나는입안이마르는것때문에사탕이나껌을먹는다 16명 (9.2%), 나는마른음식을삼키는것 Table 2. Self-Reported Oral Health Status according to General Characters Self-reported oral health status (no. of symptoms) Variable Oral mucosa Periodontal Xerostomia N M±SD t p M±SD t p M±SD t p Gender Male ± ± * 1.2± Female ± ± ±2.1 Age (year) ± ± ± ± ± ±2.3 Occupation Yes ± ± ± No ± ± ±2.3 Education High school ± ± * 2.8± College or above ± ± ±5.3 Marital status Widowed, single ± ± ± Married ± ± ±1.9 Income/per month a ± ± ** 0.5± (million won) ± ± ±2.2 Duration of type 2 < ± * 1.1± * 0.6± * Diabetes (year) ± ± ±2.6 a Divided by subjects' medium score M: mean, SD: standard deviation p-value determined from t-test *p<0.05, **p<

5 강희은외 : 제 2 형당뇨병환자에서혈당조절에따른구강건강인식도 Table 3. Hemoglobin A1c according to Health Behaviors for Blood Glucose Control Variable N Hemoglobin A1c (%), M±SD F p Periodic medical checkup Never 6 6.9± Occasionally 7 7.8±1.8 Very often ±1.1 Periodic blood glucose checkup Never ± Occasionally ±1.2 Very often ±0.9 Regular meal Never 7 8.0±1.5 a * Occasionally ±1.3 a Very often ±1.0 b Periodic take medicine Never 2 7.3± Occasionally 6 7.7±1.9 Very often ±1.1 Periodic my weight checkup Never ± Occasionally ±0.9 Very often ±1.2 Exercise at least 30 minutes Never ± Occasionally ±1.2 Very often ±0.7 a,b The same characters are not significant by Scheffe's multiple comparison at α=0.05. M: mean, SD: standard deviation p-value determined from one-way ANOVA *p<0.01 이어렵다 12명 (6.9%) 이었고, 나는약간의음식도삼키기가어렵다 는 8명 (4.6%) 으로가장낮게조사되었다 (Table 1). 2. 연구대상자의일반적특성과주관적구강건강상태일반적특성에따라주관적구강건강상태를분석한결과, 구강점막증상은당뇨병유병기간과연관성을보였다 (p <0.05). 또한치주질환증상은성별, 교육수준, 월평균수입및당뇨병유병기간과 (p<0.05), 구강건조증증상은당뇨병유병기간과연관성을보였다 (p<0.05). 즉, 당뇨병유병기간이 10년이상인집단에서구강점막질환증상이더많았고, 남성이고대졸이상이며, 월평균수입이 151만원이상이고당뇨병유병기간이 10년이상인집단에서치주질환증상이더많았다. 또한당뇨병유병기간이 10년이상인집단에서구강건조증증상을더많이인지하는것으로나타났다 (Table 2). 3. 혈당조절을위한건강행동과당화혈색소수준혈당조절을위한건강행동에따라당화혈색소수준을분석한결과, 당화혈색소는규칙적식사여부와연관성이있 어, 규칙적인식사를잘실천하는집단에서당화혈색소수준이더낮은것으로나타났다 (p<0.01, Table 3). 4. 주관적구강건강상태와당화혈색소주관적구강건강상태에따른당화혈색소수준을분석한결과, 구강점막질환증상중 혀에타는듯한느낌이있다 고응답한집단에서당화혈색소수준이높은것으로나타났다 (p<0.05). 치주질환증상에서 칫솔질시잇몸에서피가난다 와, 잇몸이치아뿌리쪽으로내려갔다, 입에서나쁜냄새가난다 를인식한집단에서당화혈색소수준이높았다 (p<0.05). 구강건조증증상중 나는목이말라자다가일어나물을자주마신다 라고응답한집단에서당화혈색소수준이높았다 (p<0.05, Table 4). 5. 당화혈색소와의관련요인당화혈색소와의관련성의강도를분석하기위해다중선형회귀분석을실시한결과당화혈색소는교육수준, 직업, 당뇨병유병기간, 치주질환증상및혈당조절을위한건강행동과연관성이있는것으로나타났다 (p<0.05). 즉, 교육수준이높고직업이없으며당뇨병유병기간이길고, 치주 497

6 J Dent Hyg Sci Vol. 12, No. 5, 2012 Table 4. Hemoglobin A1c according to Self-Reported Oral Health Status Self-reported oral health status N Hemoglobin A1c (%), M±SD Oral mucosa disease symptoms I have inflammation on the oral mucosa Yes ±1.2 No ±1.9 I have a pain on the oral mucosa Yes ±1.0 No ±1.2 I have burning sensation on the tongue Yes ±1.6 No ±1.1 I have a pain in my tongue Yes 4 6.6±0.5 No ±1.2 I don't feel well food taste than in the past Yes ±1.1 No ±1.2 Periodontal disease symptoms I am gum bleeding when brushing my teeth Yes ±1.2 No ±1.1 My gum are often swelling Yes ±1.2 No ±1.1 I have gum recession toward the tooth root Yes ±1.5 No ±1.2 I have food impaction by gum recession Yes ±1.1 No ±1.1 I have mobile tooth Yes ±1.6 No ±1.1 I have a pain in my gum Yes ±1.2 No ±1.2 I have a bad breath Yes ±1.3 No ±1.1 My teeth are crowding by aging Yes ±1.2 No ±1.1 Xerostomia symptoms I sip liquids to aid in swallowing food Never ±1.2 Occasionally ±0.6 Very often 5 7.3±1.0 My mouth feels dry when eating a meal Never ±1.2 Occasionally ±0.8 Very often 7 6.6±0.7 t or F p * ** * * Occasionally ±0.7 a * I get up at night to drink Never ±1.2 a,b Very often 7 8.0±1.7 b My mouth feels dry in general Never ±1.1 Occasionally ±0.9 Very often ±1.7 a,b The same characters are not significant by Scheffe's multiple comparison at α=0.05. M: mean, SD: standard deviation p-value determined from t-test or one-way ANOVA *p<0.05, **p<

7 강희은외 : 제 2 형당뇨병환자에서혈당조절에따른구강건강인식도 Table 4. Continued Self-reported oral health status N Hemoglobin A1c (%) M±SD I take gums or candies to relieve dry mouth Never ±1.2 Occasionally ±0.8 Very often 3 7.6±1.4 I have difficulty in eating dry foods Never ±1.2 Occasionally ±0.8 Very often 1 6.7±6.7 I have difficulties swallowing certain foods Never ±1.2 Occasionally 7 6.7±0.4 Very often 1 6.7±7.9 a,b The same characters are not significant by Scheffe's multiple comparison at α=0.05. M: mean, SD: standard deviation p-value determined from t-test or one-way ANOVA *p<0.05, **p<0.01 t or F p Table 5. Related Factors of the Hemoglobin A1c Unstandardized coefficient Standardized coefficient t p Independent variable B SE β Gender Age (year) Education ** Occupation * Marital status Income per a month Duration of type 2 diabetes * No. of oral mucosa disease symptoms No. of periodontal disease symptoms ** No. of xerostomia symptoms Health behaviors for blood glucose control *** R 2 =0.252, Adj.R 2 =0.196, F=4.528*** p-value determined from multiple linear regression analysis SE: standard error, Adj.R: adjusted R *p<0.05, **p<0.01, ***p<0.001 질환증상이많으며혈당조절을위한건강행동실천율이낮을수록당화혈색소수준이높은것으로나타났다. 당화혈색소와가장연관성이높은요인은혈당조절을위한건강행동 (β=-0.279) 이었고, 다음은교육수준 (β=0.275), 치주질환증상 (β=0.268), 직업 (β=-0.216), 당뇨병유병기간 (β= 0.189) 이었다. 본회귀모형의설명력은 19.6% 로나타났다 (Table 5). 고찰 구강내당뇨합병증으로는치주질환이나치아우식증, 구강건조증, 타액분비량감소및구강캔디다증등이있다 6). 특히치주질환은 6번째당뇨합병증으로 8) 구강내합병증을감소시키기위해계속구강건강관리프로그램등을통하여철저한환자관리가이루어져야한다. 세계보건기구 (WHO) 는과거에비해건강의개념을포괄적으로접근하고있으며, 최근삶의질을더욱중요하게인식하는사회적분위기에서당뇨병환자를대상으로환자가스스로인식하는주관적구 499

8 J Dent Hyg Sci Vol. 12, No. 5, 2012 강건강상태에관한연구는의미가있을것이다. 또한당뇨병합병증과관련된연구에서는혈당조절상태를정확히평가하기위하여식사나간식등에영향을받지않는혈당측정법의적용이필요하다고생각한다. 따라서, 본연구는제2 형당뇨병환자가인식하고있는구강건강문제를파악하고, 당화혈색소와주관적구강건강상태와의연관성을제시함으로써당뇨병환자들의전신및구강건강증진과삶의만족도향상을위한기초자료를제시하고자한다. 첫째, 혈당조절을위한건강행동에따라당화혈색소수준을분석한결과, 규칙적으로식사를하는집단에서당화혈색소수준이더낮은것으로나타났다 (p<0.001). 이외에혈당조절을위해다양한건강행동을실천하는집단에서당화혈색소수준이낮은경향을보였으나, 통계적으로유의한차이를보이지않았다. 당뇨병은만성적인고혈당으로인한합병증이문제가되는데, 구강내합병증또한혈당조절에실패할수록더욱심각하게나타나고치과치료후감염이나치료지연등의문제가나타날수있기때문에식이나운동및약물요법등의자가관리를통해정상범위로혈당이조절되어야한다 6). 비록본연구에서는유의한차이를보이지않았지만, 특히운동요법은혈당을감소시키며인슐린감수성을증가시켜혈당조절에긍정적영향을미치고 23), 식이요법또한인슐린요구량을낮추고인슐린예민도를개선시키며체중감량에효과적이므로 24) 반드시실천되어야할행동이다. 이러한자가관리정도는 개인이바람직한결과를얻는데필요한행동을성공적으로수행할수있다 는신념인자기효능감 (self-efficacy) 의수준에따라다르게나타난다 25). 따라서, 구강보건인력은혈당조절에있어환자자신이책임감을가지고능동적으로참여할수있도록동기를부여하고, 자기효능감을향상시키기위해다양한중재방법에대한연구가계속되어야할것이다. 둘째, 주관적구강건강상태에따른당화혈색소수준을분석한결과, 구강점막증상과구강건조증증상각각 1가지 ( 각혀작열감, 자는도중물섭취 ), 치주질환증상 3가지 ( 잇몸출혈, 치은퇴축, 구취 ) 는당화혈색소수준과연관성이있었는데, 특히치주질환의다양한증상은당화혈색소수준과연관되어있었다. 또한다중선형회귀분석결과에서도치주질환증상 (β=0.268) 은혈당조절을위한건강행동 (β=-0.279) 과교육수준 (β=0.275) 다음으로당화혈색소와강한연관성을보였다. 또한치주질환증상중 칫솔질시잇몸출혈 을경험한집단에서당화혈색소수준이높게나타났는데, Ostberg 등 26) 은자가인지한치은출혈이임상적방법으로측정한치주질환과강한연관성이있음을보고하였으므로위의결과는혈당조절상태가치주건강에부정적영향을미 친다는선행연구를지지하는결과라생각한다. 당뇨병과구강건강상태와의관련성을제시한선행연구를살펴보면특히당뇨병은치주질환과매우밀접한연관성을보인다. Persson 등 11) 은당뇨병환자는건강한집단에비해치주낭깊이가 5 mm인분악수가더많은것으로나타나당뇨병환자에서고도의치주병유병률이더욱우세함을보고하였다. 나와정 27) 은당뇨병환자가대조군에비해지역사회치주지수가더높다고하였으며, Lagervall 등 28) 은잔존치아수와의연관성을제시하였고, Hintao 등 13) 은치은퇴축으로인한치근우식증의증가를보고하였다. 특히김 29) 은혈당조절에실패한당뇨병환자에서치주질환이더욱심각하게나타남을보고하면서구강내합병증예방을위해혈당조절의중요성을강조하였다. 본연구결과는선행연구와같이임상적인지표를이용한결과는아니지만자가인지한구강건강상태는임상적평가방법에의한구강건강상태를잘반영할수있다는연구결과 30) 를고려해볼때의료보건인력은당뇨병환자의구강건강상태에많은관심과주의를기울여야한다. 특히정등 31) 의결과에서도알수있듯이당뇨병환자는상대적으로구강건강을위한건강행동의실천율이낮게나타나므로치과위생사는치료지원에서벗어나예방중심의업무를더욱강화하여야할것이다. 또한치주질환증상이외에도 목이말라자는도중물을섭취하는집단 에서당화혈색소수준이높게나타났다. 당뇨병환자는정상인에비해타액분비가감소되고타액내포도당농도가증가한다 9). 특히구강건조증은개인의삶의만족도와연관성이매우높으므로 18) 의료보건인력은당뇨병환자를대상으로구강건조증의발생여부를주기적으로평가하여야하고, 구강건조증의예방을위한보건교육프로그램의도입및활성화를위해노력하여야할것이다. 또한본연구결과당뇨병유병기간이길수록구강건강문제를많이인식하는것으로나타났다. 따라서, 당뇨병환자를대상으로치과의료기관내에서행하는구강관리프로그램과구강건강에대한교육ㆍ홍보를더욱강화하여구강관리의중요성을더욱부각시켜야한다. 또한구강뿐아니라내과적병력을정확히파악하고내과적질병관리에대한주기적인모니터링을실시하여야하며, 전신질환자관리를위한능력개발에더욱힘써야할것이다. 이외에도당뇨병환자에게이루어지는교육이나매체를살펴보면전신합병증에대한내용은여전히강조하고있으나구강내합병증에대한내용은아직까지부족한실정이다. 김과한 32) 은구강건강지식수준이높은집단에서도당뇨병과구강질환의연관성을인지하지못한다고하였으므로보건소나의료기관에서진행하는당뇨병환자교육프로그램의구성에있어 500

9 강희은외 : 제 2 형당뇨병환자에서혈당조절에따른구강건강인식도 구강내합병증에대한내용을추가하고, 의료인력과구강보건인력의협진을통해구강내당뇨합병증을최대한감소시켜야할것이다. 본연구는제2형당뇨병환자를대상으로장기간의혈당조절상태를평가할수있는당화혈색소검사법을이용하였고, 이러한당화혈색소수준과다양한구강건강문제의연관성을보고한연구이지만, 다음과같은제한점을가지고있다. 첫째, 구강건강상태를파악하는데객관적인임상지표를함께사용하지않고선행연구에서개발된자가평가문항만을이용하였다는것이다. 그러나주관적인구강건강평가방법은임상적인구강검사결과와높은연관성을보이기도하고 30), 객관적평가보다안녕 (well-being) 을더잘반영하기도하며, 건강증진행위에있어자가인식한건강상태가더큰영향을미친다고하였다 33). 또한주관적으로인지하는구강건강문제에관한연구는최근대두되고있는적극적건강 (positive health) 의개념을고려하거나당뇨병환자의삶의질개선에있어의미가있을것으로생각한다. 둘째, 연구대상자를선정함에있어서편의표본추출법을적용하여의원 1곳에내원한당뇨병환자를대상으로하였고, 연구대상자의특성중성별과연령의분포가고르지못하기때문에본연구결과를모든당뇨병환자로일반화하는데제한이있을수있다. 마지막으로본연구의주목적을달성하기위하여독립변수를제한적으로설정하였으며, 단면조사연구로진행하였기때문에당화혈색소와다양한구강건강문제들과의시간적선후관계를밝히지못했다는것이다. 추후연구에서는체계적인표본추출법의적용과함께임상적인구강검사결과의활용및포괄적인연구모형이설정된다면이러한한계점은해결할수있을것으로생각한다. 요약 본연구는제2형당뇨병환자가인식하고있는구강건강문제를파악하고, 당화혈색소와주관적구강건강상태와의연관성을제시함으로써당뇨병환자의전신및구강건강증진을위한기초자료를제시하고자시행하였다. 2012년 1월 9일부터 2012년 3월 9일까지만 40세이상제2형당뇨병을가진환자 174명에게설문지조사와 In2it TM 을이용하여당화혈색소를측정한결과다음과같은결론을얻었다. 1. 연구대상자의구강건강문제를파악한결과구강점막질환증상중 입안점막에염증이있다 와 입안점막이아프다, 치주질환증상중 칫솔질시잇몸에서피가난다, 구강건조증증상중 평상시내입안은마른다고느낀다 를가장많이인식하는것으로나타났다. 2. 일반적특성에따라주관적구강건강상태를분석한결과, 특히당뇨병유병기간이길수록입안점막질환과치주질환의증상및구강건조증증상을더많이인식하는것으로나타났다 (p<0.05). 3. 혈당조절을위한건강행동에따라당화혈색소수준을분석한결과, 규칙적인식사를잘실천하는집단에서당화혈색소수준이더낮은것으로나타났다 (p<0.01). 4. 주관적구강건강상태에따라당화혈색소수준을분석한결과, 혀에타는듯한느낌이있다, 칫솔질시잇몸에서피가난다, 잇몸이치아뿌리쪽으로내려갔다 및 입에서나쁜냄새가난다 를인식한집단에서당화혈색소수준이더높았다 (p<0.05). 또한구강건조증증상중 나는목이말라자다가일어나물을마신다 에응답한집단에서당화혈색소수준이더높았다 (p<0.05). 특히다중선형회귀분석결과치주질환증상은당화혈색소와 3번째로강한연관성을보인요인으로나타났다. 이상의결과로볼때혈당조절정도는다양한구강건강문제와관련성이있으므로당뇨병환자를대상으로구강관리프로그램의적용을더욱강화하고, 의료인력의협진을통해구강내당뇨합병증을최대한감소시켜야할것이다. 감사의글 이논문은 2012년도가천대학교교내연구비지원에의한결과임 (GCU-2012-M047). 참고문헌 1. Harvard Medical School: Harvard medical school - family health guide. 1st ed. Dong-A Ilbo, Seoul, pp , Mealey BL, Ocampo GL: Diabetes mellitus and periodontal disease. Periodontol : , Korean Diabetes Association: What is diabetes. Korean Diabetes Association, Seoul, Ministry of Health & Welfare, Centers for Disease Control& Prevention: Korea Health Statictics 2010: Korean national health and nutrition examination survey (knhanes V-1). Ministry of Health & Welfare, Seoul, Statistics Korea: 2010 Causes of death statistics. Statistics Korea, Seoul, Wilkins EM: Clinical practice of the dental hygienist. 9th ed. Lippincott Williams & Wilkins, Philadelphia, pp ,

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서론 34 2

서론 34 2 34 2 Journal of the Korean Society of Health Information and Health Statistics Volume 34, Number 2, 2009, pp. 165 176 165 진은희 A Study on Health related Action Rates of Dietary Guidelines and Pattern of