근거에기반한예방치과진료가이드라인 Evidence Based Clinical Guideline in Preventive Dentistry 2017.6.24 부산대학교예방과사회치의학교실 정승화
EBM EBD What is evidence-based medicine? Evidence-Based Medicine Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values. Dave Sackett Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Sackett, et al. BMJ 1996;312:71-72 개별환자의치료 ( 관리 ) 계획수립시, 현재의최고의증거를양심적이고, 명백하고신중한판단하에사용하자는의학의한분야 ( 흐름 ). 체계적연구로부터증명된임상적으로타당한증거들을통합한술식을활용함으로써환자에게가장최선의치료법을제공할수있다. Patient Concerns EBM Best research Clinical evidence Expertise
Evidence-Based Dentistry DEFINITION OF EBD Evidence-based dentistry (EBD) is based on three important domains: 1. the best available scientific evidence, 2. dentist's clinical skill and judgment, 3. each individual patient's needs and preferences 근거기반치의학은 환자의구강및전신상태와관련하여, 임상적으로타당한과학적증거들에대한체계적평가결과를기반으로, 치과의료진의임상적전문기술을 환자의치과치료필요및선호분야에적용함으로써 환자중심의최고의치과진료및구강건강관리를가능하게하는치의학한분야 Systematic Review ( 체계적문헌고찰 _ A review that identifies and evaluates all of the evidence with which to answer a specific, narrowly focused clinical question. Critical Summary ( 비판적요약 ) A critical summary is a short (1-2 page) summary and discussion of a systematic review. Clinical Recommendation ( 임상권고 ) a recommendation for patient treatment made by an expert panel based on the best evidence available
코크런 ( 단체 ) 코크런 (Cochrane, 이전명칭 : 코크런공동계획 /Cochrane Collaboration) 은 130개이상국가의 37,000명이상의자원봉사자들의그룹으로이루어져있는독립적인비영리, 비정부단체이다. [1] 이단체는의료전문가, 환자, 정책결정자등이근거중심의학의원칙에따라마주치는선택을용이케하는체계적인방법에대한의학연구정보를구성하기위해설립되었다. [2][3] 코크런라이브러리에게시될때의료개입, 진단테스트의무작위대조시험에대한체계적검토를수행한다. [4][5] 위키백과, 우리모두의백과사전.
소개내용 Guideline 1. 전문가불소도포가이드라인 2. 유소아의불소치약사용가이드라인 3. 올바른칫솔질, 치간관리가이드라인 4. 항균, 항염증제재 ( 구강양치액등 ) 가이드라인
진료법적근거 For people at risk of developing dental caries 국민건강보험요양급여의기준에관한규칙 제9조 ( 비급여대상 ) 1법제41조제4항에따라요양급여의대상에서제외되는사항 ( 이하 " 비급여대상 " 이라한다 ) 은별표 2와같다. 비급여대상 ( 제9조제1항관련 ) 3. 다음각목의예방진료로서질병 부상의진료를직접목적으로하지아니하는경우에실시또는사용되는행위 약제및치료재료 라. 불소국소도포, 치면열구전색 ( 치아홈메우기 ) 등치아우식증예방을위한진료. 치아우식이발생할위험이있는환자에대한권고 나이구분 전문가불소도포제재 진료실처방, 가정에서활용 6 세이하 3-6 개월간격불소바니시 6-18 세 18 세이상 성인치근우식 3-6개월간격불소바니시 3-6개월간격4분동안불소겔도포 3-6개월간격불소바니시 3-6개월간격4분동안불소겔도포 3-6개월간격불소바니시 3-6개월간격4분동안불소겔도포 일주일간격불소용액양치하루두번 5000ppm 고농도불소치약사용일주일간격불소용액양치하루두번 5000ppm 고농도불소치약사용일주일간격불소용액양치하루두번 5000ppm 고농도불소치약사용 6 세이하의어린이에게는오직 5% NaF 불소바니시만을사용한다. 불소겔은 4 분동안도포한다.
APF 불소겔도포전치면세마가우식예방에효과적인가? 전문가불소도포요약 우식발생위험이낮은환자에게불소개입 (Fluoride intervention) 은필요하지않다. 불소개입을고려할때는, 술자와환자모두이로부터얻을수있는이익과부작용을고려해야한다. 잘못삼킴으로인한매스꺼움과구토 6세이전에불소치약, 불소처방, 가정용불소겔도포중지속적섭취로인한치아불소증 6세이하에서는 5% NaF 불소바니시를추천한다. 근거에기반한가이드라인은임상가의전문적판단, 환자의요구와선호도와통합하여적용되어야한다. 불소바니시의효과 불소바니시의효과 Study characteristics This review of existing studies was carried out by the Cochrane Oral Health Group and the evidence is current up to 13 May 2013. In this updated review there are now 22 trials published between 1975 and 2012 in which a total of 12,455 children were randomised to treatment with either fluoride varnish or placebo/no treatment. Study duration ranged from one to five years among included trials (12 of these lasted two years).
불소바니시의효과 Determination of Caries Risk Key results The evidence produced has been found to be of moderate quality due to issues with trial designs. However in the 13 trials that looked at children and adolescents with permanent teeth, the review found that the young people treated with fluoride varnish experienced on average a 43% reduction in decayed, missing and filled tooth surfaces. In the 10 trials looking at the effect of fluoride varnish on first or baby teeth the evidence suggests a 37% reduction in decayed, missing and filled tooth surfaces. There was little information concerning possible adverse effects or acceptability of treatment. Caries risk assessment 질병의임상적발생이전에미래의우식발생여부를예측하기위한과정 개개인의질병 ( 치아우식증 ) 에대한미래의위험에대해획득가능한최선의정보에근거하여전문가적판단을내리는행위 이를통해구강질병의발생의위험을파악하고, 위험을제거하기위한비용 - 효과적인예방진료계획을수립할수있다 Caries activity assessment 질병 ( 우식 ) 의발생이후에질병의진행또는회복에대한질병활성의실제수준을측정하기위한과정 획득가능한최선의정보에근거하여치아우식증진행여부에대한전문가적판단을내리는행위 이를통해환자에게적절하고효과적인진료계획을수립하고지속적인모니터링을수행할수있다. Caries Risk / Caries Activity Determination of Caries Risk Primary Preventive Dentistry 6 th edition
Individual risk factors increasing risk for developing caries may also include, but are not limited to: 치아우식활성검사법의종류 High titers of cariogenic bacteria Eating disorders I. 세균인자 Mutans Streptococci 검사 Lactobacilli 검사 Poor oral hygiene Drug/alcohol abuse 구강내산생성도검사 Prolonged nursing (bottle or breast) Poor family dental health Developmental or acquired enamel defects Genetic abnormality of teeth Irregular dental care Cariogenic diet Active orthodontic treatment Presence of exposed root surfaces II. 숙주인자 치아타액 과거치아우식경험치아의해부학적형태타액분비율검사타액점조도검사타액완충능검사 Many multisurface restorations Chemo/radiation therapy Restoration overhangs and open margins Physical or mental disability with inability or III. 식이인자 식생활일지분석 unavailability of performing proper oral health care IV. 시간인자 구강내포도당잔류시간검사 Cariogram 임상가들의우식예측과정을돕기위해서 Cariogram 과같은상호작용형소프트웨어를사용할수있음 (Bratthal, 1996)
치아우식활성검사키트 허가받지않은의료기기를이용해우식활성검사를하면임의비급여행위가됩니다. 주의가필요합니다. 유소아의불소치약 사용가이드라인
불소치약 2014 년이전권고사항 The results of the review demonstrated that for children younger than 6 years, Fluoride toothpaste use is effective in reducing caries. Ingesting pea-sized amounts or more can lead to mild fluorosis. for children younger than 2 years Brush with water, Consult with a dentist or physician before using fluoride toothpaste. for children from 2 to 6 years of age Use of a pea-sized amount (0.25g) of fluoride toothpaste. The optimal dose of fluoride is 0.05 mg per kilogram per day. 최근권고사항 Council recommends from eruption of the first tooth to age 3 years use of a smear of toothpaste for children aged 3 to 6 years. followed by use of a pea-sized amount This regimen is intended to maximize the caries-preventive benefits of fluoride while further reducing the risk of developing fluorosis ADA NHS
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Dental Fluorosis 반점치 (Dental fluorosis) Hypomineralization: Increase in enamel porosity along the striae of Retzius The normal structure of the enamel remains but the tissue is less well mineralized. Hypomineralization is very different from hypoplasia. The extent and degree of hypomineralization increases with increasing F exposure during tooth development. 치아형성기동안에불소의과도한노출로인해법랑질이덜광화되어치아의색또는외형이변하는현상
Hypomineralized enamel is very fragile Clinical apperance of fluorosed enamel Such severely hypomineralized enamel will be very fragile; hence, when the tooth erupts, surface damage may occur due to mastication, attrition, and abrasion F has not been documented to cause true hypoplastic changes; the characteristic pits, bands, and loss of extensive areas of enamel occur posteruptively and are not true hypoplasias. 덜광화되어약해진법랑질이외부의물리적자극에의해손상되어법랑질의손실이나타남. the porosity of the fluorosed enamel reflects itself as opacity of the enamel from thin, white, opaque lines corresponding to the perikymata running across the tooth surface, to an entirely chalky white surface this chalky white enamel may then change posteruptively, due to mechanical damage, resulting in the more severe forms of fluorosis. Normal Questionable Very mild 올바른칫솔질, 치간관리가이드라인 Mild Moderate Severe Source from CDC
Medical benefits of dental floss unproven 1. http://jdr.sagepub.com/cgi/content/abstract/85/4/298 1 2. http://www.ncbi.nlm.nih.gov/pubmed/19138178 3. http://www.ncbi.nlm.nih.gov/pubmed/22161438 4. http://www.ncbi.nlm.nih.gov/pubmed/25581718 5. http://onlinelibrary.wiley.com/doi/10.1111/jcpe.12366/pdf
The effect of dental flossing 143 2 인접면우식에대한효과를측정한연구이긴하지만전문가치실질이아닌자가치실질의인접면우식예방효과는통계적으로유의하지못했음을보여주고있다.
3 4 Authors' conclusions There is some evidence from twelve studies that flossing in addition to toothbrushing reduces gingivitis compared to toothbrushing alone. There is weak, very unreliable evidence from 10 studies that flossing plus toothbrushing may be associated with a small reduction in plaque at 1 and 3 months. No studies reported the effectiveness of flossing plus toothbrushing for preventing dental caries. 5 Consensus views of Working Group 2 of the 11th European Workshop in Periodontology on the primary prevention of periodontitis.
Managing Gingivitis The aims of this working group were to systematically review the evidence for primary prevention of periodontitis by preventing gingivitis via four approaches: 1. the efficacy of mechanical self-administered plaque control regimes; 2. the efficacy of self-administered inter-dental mechanical plaque control; 3. the efficacy of adjunctive chemical plaque control; and 4. anti-inflammatory (sole or adjunctive) approaches. 1. There is moderate evidence to suggest that the adjunctive use of IDB s provides higher levels of plaque removal than manual tooth brushing alone. 2. Other interproximal cleaning devices show very inconsistent/weak evidence for an adjunctive effect, either due to a lack of efficacy (flossing) or a lack of evidence from appropriate clinical investigations (oral irrigators and wood sticks). 3. There is, however, limited evidence that gingival inflammation is reduced by interproximal cleaning, even when IDB s are employed. General recommendation of one interdental cleaning method? 1. Evidence suggests that inter-dental cleaning with IDB s is the most effective method for interproximal plaque removal. 2. IDB s were consistently associated with higher levels of plaque removal when compared to flossing and the use of wood sticks. 3. Despite being widely advocated, it is noteworthy that the majority of available studies fail to demonstrate that flossing is generally effective in plaque removal and in reducing gingival inflammation. Should all individuals perform inter-dental plaque removal at least once daily to prevent the onset of gingival inflammation or manage its resolution? 모든사람이하루한번치간치면세균막제거를해야하는가? 1. 잇몸이건강한사람을대상으로한무작위임상시험연구는없다. 2. 치간부치은염증이존재하는경우주기적인치간부관리는효과적이다. 3. While there is currently no optimal method for interproximal cleaning, IDB s should be the first choice. 4. Importantly, interproximal cleaning advice requires professional training irrespective of the devices utilized 5
The effect of dental flossing 올바른치실질 Only when flossing is performed professionally on a daily basis by trained personnel may a caries reduction be obtained. Self-performed flossing does not lead to the expected effect. Flossing is difficult to perform. 치실손잡이 Dental Caries The Disease and its clinical management 2 nd edi. 항균, 항염증제재 ( 구강양치액등 ) 가이드라인
Structured Abstract Clinical Questions: Do adults who use antimicrobial mouthrinses have less plaque and gingivitis than those who do not? 항균양치액을사용하는성인은그렇지않은사람보다치면세균막이나치은염이덜생기는가? Structured Abstract Structured Abstract Review Methods: 저자는 2개의전자데이터베이스에서 1983년부터 2009년 9월까지보고된논문을검색했다. 첫째, 저자는장기간 (6개월) 수행된무작위위약대조군임상연구에서평가된항치면세균막, 항치은염양치액의효과를평가하는체계적문헌고찰문헌 (SRs) 을검색하였다. 둘째, 저자는구강양치액의치면세균막과치은염의감소퍼센트를위약군 ( 구강위생교육과전문가세균막제거만을시행 ) 과비교함으로써임상적타당성을결정했다. Main Results: 3개의 SRs가포함되었고, 그중 2개는임상연구의질을평가하였다. 하나의리뷰는 CHX와 essential oil가치면세균막, 치은염억제제로써의강한증거가있음를보고하였다. CPC의증거는일관적이지않았고, 양치액의조성에따라달랐다. 치은염감소는 CHX가 28.7%, Essential oil이 18.2%, CPC가 13.4% 였다. 치면세균막감소는 CHX가 40.4%, Essential oil이 27%, CPC가 15.4% 였다. 저자는다른 SRs에는자료가불충분한이유로오직하나의 SRs에포함된결과에나타난결과만을감소비율산출에사용하였다. 하지만, 두개의 SRs는일관된결과를보였고, 정도의차이는있지만양치액사용이치면세균막과치은염억제의효능을지지하였다.
Structured Abstract Plain Language Summary Conclusion: 3개의 SRs에대한이체계적인문헌고찰은가정에서치면세균막과치은염을조절을위한항균양치액의정기적인사용의효과를검토하였다. 양치액사용은구강위생교육과전문가치면세균막관리 (adult prophylaxis) 의효과를능가한다. Source of Funding: Johnson & Johnson Author s Findings: 저자는관련된리뷰연구 3개를검토하였다. 모든연구에서 CHX와 Essential oil 함유양치액이치면세균막과치은염을감소시키는것으로확인하였고, 일부연구에서 CPC는도움을줄수있다고제안하였다. Conclusion: 이러한결과를바탕으로저자는칫솔질과치실을사용하는사람에게있어 CHX, essential oils, or CPC 함유양치액을함께사용하는사람이사용하지않는사람보다치면세균막과치은염을감소시키는데도움을줄수있다. 주목할것은이연구가특정회사 (Johnson & Johnson) 의재정적지원을받았고, 회사로부터자문료를받은것이다.
Plain Language Summary Agents for Chemical Plaque Control Authors findings 분석에의하면, 저자들은비록 CHX 양치가치면세균막조절에더낫지만, 두양치액은전체적으로치은염조절에는동등하였다. 또한착색정도는둘간에어느하나가크다고볼수없었다. 다른요인들에대해서는분석할수없었다. Conclusion 올바른구강위생 ( 하루 2번칫솔질과하루에한번치아청결 ) 은치은병예방에필수적이다. 하지만, 양치액은종종치은염증상을조절하는데도움을주곤한다. 이리뷰는 CHX 양치가치면세균막조절에더낫지만, Essential oil과 CHX 양치는유사한정도로치은염을감소시킨다. 양이온성물질 Biguanides (CHX) Quaternary ammonium compounds (cetylpyridinium chloride, CPC) Heavy metal salts (silver, zinc, copper) Pyrimidines (hexetidine) Herbal extracts (sanguinaria extract) 음이온성물질 Sodium lauryl sulfate 비이온성물질 Phenolic compounds(thymol, Listerine, triclosan) 기타 Amino alcohos(decapinol) Antiplaque enzymes (dextranase, mutanase) Bispyridines Halogens (iodine and fluorides) Oxyganating agents Antiplaque modifying agents (ascorbic acid, urea peroxide) Combinations of different agents Chlorhexidine(CHX) Chlorhexidine(CHX) Loe and Schiott, 1970 Bis-biguanides 계열의양이온성의광범위항균제 그람음성보다그람양성균 (MS) 에효과적 1984년에미국에서구강용항균제로사용됨. 기전 : 음이온성의세포표면에작용, 세포부착 (Glucosyl transferase) 억제 지속유리효과. 중성, 약알칼리성에서최고효과 Dose-dependent effect 치약속성분인음이온성의 SLS, SMFP와반응함. 음이온이없는치약이나시간간격 (1-2시간후추천 ) 두고사용 CHX 분자크기가커서치면세균막침투효과가약함 물리적제거후사용하면가장좋음.. 주로 0.2%, 0.12% 사용됨. 12-14시간동안지속됨. 하루 2 번사용
CHX 의이상적인항균효과를위해서는칫솔질후최소 30 분이후에사용해야하며, 2 시간이후가가장효과적이다. Chlorhexidine(CHX) 부작용 : 전신부작용없음 대웅제약 착색 치아, 수복물, 의치, 혀 구강점막탈락, 작열감. 미각변화 쓴맛 부광약품 장기간 (2 주 ) 사용금지 삼일제약 92
Quaternary ammonium compounds Listerine Cetylpyridinium choride (CPC), benzethonium chloride; CHX와실험실비교연구에서는 CHX만큼뛰어난항균력을나타냄. 하지만, 구강내적용한임상연구에서는효과가떨어짐. 초기효과는크지만, 구강내타액에의해빠르게제거됨. 지속효과없음. 19세기후반미국에서개발. Phenol related essential oils Thymol, eucalytol, menthol, methyl salicylate 기전 : 고농도에서세포벽, 세포단백질파괴, 저농도에서필수효소불활성화 중성과약산성에서효과적 단기, 장기사용모두효과적. 많은연구와경험을통해검증된 OTC 제품. 미국치과의사협회최초공인 Listerine 항염증효과, 6 주무작위임상시험비교에서 CHX 과유사. 20ml 30 초간하루 2 회양치
CHX vs Listerine CHX Listerine 사용횟수 1일 2회 1일 2회 항균효능 Good Good 지속효과 Good Moderate 장기사용 No Good 맛 Poor Moderate 점막자극유발 Moderate Moderate 구강건조유발 No Yes 구강착색유발 Yes No 전문가상담필요 Yes Yes 근거기반예방치과진료 최선의진료는개개인에맞는최고의옵션을찾기위해환자와소통하면서과학적증거와임상가의판단이조화를이루는것이다. Best care for each patient rests neither in clinician judgment nor scientific evidence but rather in the art of combining the two through interaction with the patient to find the best option for each individual. Jean E. Suvan Francesco DAiuto [ 우리가꿈꾸는미래지금, 여기, 나부터시작됩니다 ] jsh0917@pusan.ac.kr 경청해주셔서감사합니다.