J Dent Hyg Sci Vol.13, No.4, 2013, pp.434-439 RESEARCH ARTICLE Quantitative Light Induced Fluorescence Digital 을이용한수종의구강양치액의치면세균막감소효과에대한비교연구 이새롬 ㆍ김재홍 1 ㆍ허성윤 2 경희대학교대학원치의학과영상치의학교실, 1 고려대학교일반대학원보건과학과치의기공전공, 2 신구대학교치위생과 Comparative Study of Dental Plaque Reduction according to Various Mouthwashes Using Quantitative Light Induced Fluorescence-Digital Sae-Rom Lee, Jae-Hong Kim 1 and Sungyoon Huh 2 Department of Oral and Maxillofacial Radiology, School of Dentistry, Kyung Hee University, Seoul 130-701, 1 Department of Health Science Specialized in Dental Laboratory Science and Engineering, Graduate School, Korea University, Seoul 136-703, 2 Department of Dental Hygiene, Shingu College, Seongnam 462-743, Korea This study was conducted to compare the dental plaque reduction using various mouthwashes with Quantitative Light induced Fluorescence-Digital (QLF-D). A survey on 20 students was carried out. The students who were at Shingu College. Experimental group was gargled 20 ml of Listerine during 30 seconds and 15 ml of Hexamedine during 60 seconds. Control group was gargled distilled water during 30 second. The data were analyzed with t-test using SPSS 20.0 program. The ratios of control group and experimental group were reduced. Degree of R30 and R70 Listerine group was a significant difference (p>0.05). Degree of Simple Plaque Score and R30 Hexamedine group was a significant difference (p>0.05). There was no significant difference in the distilled water gargle group (p<0.05). The result of this study has the effect of two mouthwashes reduced dental plaque. The evaluation data of this study will be used in clinical application and research about QLF-D. Key Words: Delta R, Dental plaque, Mouthwash, Simple Plaque Score, Quantitative Light induced Fluorescence-Digital 서론 국민의생활수준이높아짐에따라구강건강에대한관심이증대되고이러한변화에따라구강양치액등의구강위생관리용품의소비량또한증가되고있다. 이러한추세에서구강양치액이나치약과같은구강관련용품들은많이발전되어왔고, 치아우식예방, 치주질환예방은물론구취의효과적인제거등의목적을두고많은연구와제품들이출시되고있다 1). 대표적으로구강양치액에배합되는물질로는불화나트륨이있다. 이불화나트륨은효과가입증된물질로서 0.05% 의 농도로배합하여사용하고있으며 2) 이는대개 0.05% 농도로배합되어사용되며치면세균막 (dental plaque) 형성의억제나재부착억제에효과를보고하고있다. 또한임상에서가장일반적으로사용되는구강양치액성분으로서 chlorhexidine gluconate는 1970년 Löe와 Schiott의연구결과 3) 가장강력하고안정된치태억제및향균효과를나타내는화학요법제로인정받고있으나, 장기간사용하였을때치아및혀의이상, 점막자극과민증유발등을야기하므로 4), 최근에는식물에서추출한천연물질인 essential-oil을구강양치액에활용하려는움직임이활발하다. Essential-oil이함유된구강양치액은치석형성이나치아착색과같은부작용이없 Received: October 5, 2013, Revised: November 28, 2013, Accepted: November 28, 2013 ISSN 1598-4478 (Print) / ISSN 2233-7679 (Online) Correspondence to: Sae-Rom Lee Department of Oral and Maxillofacial Radiology, School of Dentistry, Kyung Hee University, 26-6, Kyungheedae-ro, Dongdaemun-gu, Seoul 130-701, Korea Tel: +82-2-958-9401, Fax: +82-2-958-9406, E-mail: saerom0928@naver.com Copyright 2013 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 (http://creativecommons.org/licenses/ by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
이새롬외 :QLF-D 를이용한수종의구강양치액의치면세균막감소효과에대한비교연구 어안전하며상당한항균작용, 항치은염효과, 치태감소효과를나타내는것으로알려져있다 5). 치면세균막이란섭취한음식물의당단백질 (glycoprotein) 성분이치아표면에부착된얇은막, 즉치구 (acquired pellicle) 에구강내각종세균들이부착하여형성되는점착성세균덩어리의막을말한다 6). 이치면세균막내의산생성균에의해생성된산은치질내의무기질을탈회시켜치아우식증을발생시키고, 치면세균막내의일부혐기성세균을포함한치주질환관련세균들이치주조직에유해한독소를생성하여치주질환발생에직접적인원인이된다. 이치면세균막의세균들은구강내에서혀와뺨의상피나치아의표면등에다양하게존재한다 7). 하지만식사후치면양치를위한잇솔질이나구강위생용품의사용이용이하지않은상황에서는구강양치액을이용하여구강에존재하는미생물의생육을억제하거나사멸시켜구강청결과구취제거및치아우식증이나치주질환을예방할수있을것이다. 임상적으로널리사용되고있는구강양치액이실제로치면세균막에효과가있는지확인하기위해서는일반적으로치면착색제를이용하여부착된치면세균막을염색하여관찰한다. 최근개발된 Quantitative Light Induced Fluorescence (QLF) 는착색제사용의단점을보완하기위한초기우식진단장비로써인체에무해한푸른색가시광선을이용하여광학적방법으로디지털카메라와접목시켜구강촬영하는장비이다. 이장비의원리는구강내에존재하는세균이포피린이라는대사산물에서발생하는붉은색의형광을탐지하는것이다 8). 미생물활성이높은치면세균막이발현하는이포피린의붉은색형광을 Quantitative Light induced Fluorescence-Digital (QLF-D) 을이용하여촬영하여, 착색제를사용하지않고치면세균막의정량적평가를할수있다. 또한 Quantitative Light Induced Fluorescence system (Inspektor Research Systems BV, Amsterdam, The Netherlands) 은전통적인치아우식증의진단방법의한계를넘어서, 초기우식증시치아를구성하는무기질의미세한변화를민감하게정량적으로탐지할수있기때문에, 초기우식증발생여부및진행상태를평가하는데매우유용한장비로인정받고있다 9). 이에본연구의목적은이종의구강양치액에따른구강내치면세균막의감소효과를비교함으로써, 치면세균막을효율적으로관리하는데필요한구강양치액의효과차이를규명하고최근주목받고있는 QLF-D의치면세균막평가수치를분석하여임상적용가능성을재평가하며, QLF-D의임상효용성연구를위한기초자료를마련하고자한다. 연구대상및방법 1. 연구대상본실험의취지에맞는임상실험의개요및구강양치액효과의내용을비롯한모든관련사항을설명받고적극적으로참여의사를밝히고동의한후실험을시행하였다. 피험자 20명 ( 남학생 10명, 여학생 10명 ) 의대학생을대상으로실시하였다. 실험에참여한대상은상ㆍ하악 6전치부위에치아우식증과치주병이이환되어있지않고비교적치열이고르며실험에영향을주는항생제복용및전신질환이없는자로결정하였다. 2. 연구설계본연구는구강양치액을사용하기전, 사용한후를비교한연구로서모집된 20명의실험참가자전원을대상으로주 1회반복적으로총 3주에걸쳐서적용하는교차연구모형 (cross over design) 실험설계이다. 실험자는식이및잇솔질에대한제한없이통상적으로생활하였고점심식사를하고난 3 4시간뒤치면세균막이어느정도형성된오후시간에 QLF-D 촬영을하여각피검자들이가지는초기값을측정하였다. 구강양치액을각피검자에게배분하여사용하도록한후실험결과를조사를실시하였다. 3. 실험재료본실험은 essential-oil 계열용액 (Listerine; Johnson & Johnson K.K. Consumer Company, Morris Plains, NJ, USA) 과 0.12% chlorhexidine gluconate 용액 (Hexamedin; Bukwang Pharm Co., Ltd., Seoul, Korea) 의이종의구강양치액을선정하여양치전후치면세균막감소효과를비교하기위함이다. 실험전실험자에대해어떠한환경적인제약없이연구대상자는제조사에서지시하는규정에맞추어 Listerine은 20 ml의구강양치액을 30초동안양치하게하였으며, Hexamedin은 15 ml의구강양치액을 1분동안양치하도록지시하였다. 대조군은 distilled water를 30초동안양치하는것으로설정하였다. 치면세균막감소효과를측정하기위해동일한연구대상자 20명모두를대조군및실험군에노출시켜동질성을유지하게하였다 (Table 1). 4. 측정도구본연구에서는연구도구의동일화를위하여실험자는 1 인으로설계하며매번동일한장비와기준값, 동일한환경에서측정하였다. QLF-D 영상은일정한조명하에서디지털카메라 (EOS550D; Canon, Tokyo, Japan), 마크로렌즈 435
J Dent Hyg Sci Vol. 13, No. 4, 2013 Table 1. Brand, Composition and Manufacturers of Materials Selected for This Study Brand Ingredient Direction Manufacturer Hexamedin 0.12% chlorhexidine gluconate Rinse full strength for 30 seconds with 20 ml Bukwang Pharm Co., Ltd., Seoul, Korea Listerine 0.09% 1.8-cineol 0.06% thymol 0.05% methyl salicylate 0.04% l-menthol 27% ethanol Rinse full strength for 1 minute with 15 ml Johnson & Johnson K.K. Consumer Company, Morris Plains, NJ, USA Fig. 1. Analysis result for Simple Plaque Score superimposed on Quantitative Light Induced Fluorescence image. The white number represents the value of the Simple Plaque Score, the blue areas indicate where the software found pixels with significantly raised amounts of red fluorescence. Table 2. Quantitative Parameters Obtained with Quantitative Light induced Fluorescence-Digital Name Symbol Unit Description Simple Plaque Score SPS - A value from 0 (no mature plaque) to 5 (high amount of mature plaque). Delta R R % Percentage of increase of the ratio of the red and the green component with respect to that ratio of sound tissue. Related to the presence of porphyrins and indirectly related to bacterial activity (EF-S 60 mm Ultrasonic; Canon), 520 nm 황색필터를사용하여셔터스피드, 조리개, ISO 감도그리고화이트밸런스수동으로설정하여촬영하였다. 촬영한영상은영상분석프로그램 (Able image analysis, Able, Dallas; TX, USA) 을이용하였다. 측정된 QLF-D 영상에서추출된 Simple Plaque Score (SPS) 는 0에서 5까지나타나며점수가낮을수록치면세균막이적음을뜻한다 (Fig. 1). 또한 SPS와함께나오는수치로치면세균막의두께, 강도, 성숙도를나타낸다. QLF-D 촬영에서건전치질은녹색, 치면세균막부위는붉은색형광을띠게되는데, 이때붉은색과녹색의비율을말한다. SPS의하위점수로 R30, R70, 120의단계로나타나며, % 로표현되고, R값이클수록치면세균막의성숙정도가크다 10) (Table 2). 5. 통계분석측정된결과는통계적유의성을검증하기위하여 IBM SPSS Statistics 20.0 program (IBM Co., Armonk, NY, USA) 을이용하였다. 구강양치액사용전과후의 QLF-D 측정값은평균과표준편차로보고되었고, 두실험군에측정된값들이정규성검정을위해실시된 Shapiro-Wilk 검정결과두실험군모두 p>0.05로정규성이검증되었기에, 모수검정법인대응표본 t검정을실시하였으며, 제1종오류의수준은 0.05로설정하였다. 결과 각실험군과대조군을피험자에게시행한후 QLF-D로측정하여평균과표준편차로나타내었고, 구강양치액에따른치면세균막제거효과를확인하기위하여대응표본 t검정을시행하였다 (Table 3). 대조군과실험군모두양치전에비해양치후의각결과값은감소하였다 (Fig. 2). 실험군 Listerine의 R30값은 3.81±6.26% 에서 2.79±4.81% 로, R70값은 1.49±2.87% 에서 1.18±2.66% 로크게감소하는결과를보였으며, 통계적으로유의한차이를보였다 (p 436
이새롬외 :QLF-D 를이용한수종의구강양치액의치면세균막감소효과에대한비교연구 Fig. 2. Comparison of dental plaque reduction according to two types mouthwash. (A) Listerine gargle before and after. (B) Hexamedin gargle before and after. Table 3. Effect of Inhibition and Removal of Dental Plaque in Before and After Gargle Distilled water (control group) Variables Before After p-value SPS 1.25±1.51 1.20±1.43 0.833 R30 (%) 2.12±2.91 2.04±1.96 0.162 R70 (%) 0.22±0.48 0.19±0.48 0.537 R120 (%) 0.13±0.48 0.11±0.44 0.274 Listerine SPS 1.80±1.96 1.25±1.58 0.017* R30 (%) 3.81±6.26 2.79±4.81 0.041* R70 (%) 1.49±2.87 1.18±2.66 0.025* R120 (%) 0.38±0.88 0.32±0.79 0.402 Hexamedin SPS 1.15±1.56 0.90±1.44 0.034* R30 (%) 1.96±2.90 1.08±0.70 0.028* R70 (%) 0.45±0.81 0.39±0.97 0.355 R120 (%) 0.31±0.62 0.21±0.77 0.114 Values are presented as mean±sd. SPS: Simple Plaque Score. p-value by paired t-test *p<0.05. <0.05). Hexamedin의경우에서 SPS는 1.15±1.56에서 0.90± 1.44로, R30값은 1.96±2.90에서 1.08±0.70으로더크게나타났으며, 통계적으로유의한차이를보였다 (p<0.05). 대조군인 distilled water는전체적으로극히작은감소효과를보였으나, 모든결과값에서통계적인유의성은없었다 (p>0.05). 고찰 건강증진의개념이사회전반적으로확산되면서, 구강건강에대한수요가증가하고있어, 구강병의예방과치료및상실기능재활뿐만아니라사회생활에장애가되는구취의예방과제거에관심이증대됨에따라구강양치액에대한관 심역시증가하고있다 11). 이런관점에서구강질환예방을목적으로구강질환의직접적인원인인치면세균막의생성의관리가필요하다. 치면세균막관리를위해기본적으로다양한물리적인잇솔질방법이활용되고있으나, 전문적인방법으로관리된구강내상태를오랫동안쉽게관리하고유지하기가어렵다. 그러나구강양치액은쉽고간편하게사용할수있는이점이있다 12). 이미 essential-oil, chlorhexidine gluconate, glutaraldehyde 등의성분을가진다양한구강양치액이시판되고있으며치면세균막에대한항균효과가입증되었다 5). 이에본연구는 QLF-D를활용하여구강양치액종류에따라양치전과후에치면세균막이제거되는효과가어떠한지를비교하고자하였다. 이전의연구들에서는일반적으로치면세균막의미생물측정방법인 Oʼ Leary plaque control index를사용하였으나본연구에서는일반적인검사법이아닌 QLF-D 측정을통해치면세균막의감소효과를측정하였다. QLF는 1995년사람의치아에서나타나는형광빛이나는것에착안하여고안되었고그후 2003년상용화되어개발된장치이다. Inspektor Research System사가보유하고있는 transverse microradiography (TMR) 의핵심기술인초기법랑질우식증의영상분석프로그램을 QLF 영상과접목시켜임상과접목시켜임상과실험실에서 TMR을대체하여무기질함량의변화와병소깊이의변화를모니터링할수있도록하였다 13). 또한 QLF는구내카메라를사용하여치아의국소부위를쉽게촬영할수있고, 특정부위를정확하게재촬영할수있는기술이포함되어있으며, 촬영된영상의무기질함량과병소깊이를정량화할수있도록영상분석프로그램이포함되어있다 14). 본연구에서 QLF-D를활용하여 20명의대학생을이종의 437
J Dent Hyg Sci Vol. 13, No. 4, 2013 구강양치액으로양치한후치면세균막의감소효과를비교한결과 Listerine의 R30값과 R70값은크게감소하는결과를보였으며, Hexamedin는 SPS, R30값에서통계적으로유의한차이를알수있었다. 이는실험대상자들의치면세균막지수가전체적으로모두높지않아 R120값은별다른차이가없는것을알수있었다. Listerine의양치실험후일주일간격으로 Hexamedin 양치실험을진행하였으므로실험대상자들의인지에따른심리적요인이작용했을것으로추측된다 15). 또한 Hexamedin과 Listerine은미생물감소에효과가있어치면세균막의결합을방해하지만각각의주성분은차이가있으므로치면세균막의반응에따라결과값의차이가나타날수있다. 이러한제한점에도불구하고이종의구강양치액으로인해치면세균막의제거효과가있는것으로판단할수있었다. 따라서구강양치액의사용이치과진료시감염관리와기계적인양치의제약이있는환경에서구강위생상태의증진을위한대안이될수있을것이다. 실험대상자가적고 1회의측정값만으로비교하였다는점, 그리고구강양치액양치후바로실험결과를측정하였기때문에구강양치액의효과를발현할수있는시간이없었다는한계점이있었다. 또한실험자의식이및잇솔질에대한환경제약에는어려움이있어정확한세균감소의표준값을성정하는것에어려움이있었다. 하지만시중에판매되는구강양치액의치면세균막감소효과를 QLF-D 장비를통해비교했다는점에서의미있는연구라고생각된다. 이후에는다양한구강양치액의효과에관한반복적인측정을통하여더신뢰도있는연구가기대된다. 현재국내에 QLF-D 장비가도입단계이며여러가지연구가활발히진행되고있으므로이시스템을적극적으로활용한다면구강위생상태를직접확인할수있고, 시간과인력낭비를줄일수있을것이다. 또한임상에서효과적으로작용할수있도록지속적인연구가필요한것으로생각된다. 요약 본연구는시중에서널리사용되고있는구강양치액 (Listerine, Hexamedin) 을선정하여치면세균막의제거효과를평가하기위하여 20명의실험참가자를대상으로반복적으로동일한대상자에게적용하는교차연구모형으로구성하여실험을진행하였다. 치면세균막측정은최근에주목받고있는 QLF-D를이용하여치면세균막제거효과를정량적으로평가하여다음과같은결론을도출하였다. 1. 이종의구강양치액모두치면세균막이감소하는경향을보였다. Listerine의 R30값과 R70값은통계적으로 유의한차이를보였으며 (p<0.05), Hexamedin는경우에서는 SPS와 R30값은통계적으로유의한차이를보였다 (p< 0.05). 2. 측정결과를종합한결과 Hexamedin이 Listerine보다치면세균막제거효과는더큰폭으로나타났다. 이상의결과에서구강양치액은효과적인치면세균막조절제재로효과적임을확인하였으며, QLF-D를이용하여치면세균막의제거효과를평가하는새로운방법이시도되었다. 추후에임상적용시유용한치면세균막의평가도구로활용할수있을것으로기대된다. 감사의글 본연구는신구대학교교수연구비지원에의하여수행되었음. References 1. Giertson E, Emberland H, Schieic AA: Effects of mouthrinses with xylitol and fluoride on dental plaque and saliva. Caries Res 33: 23-31, 1999. 2. Kim JB, Paik DI, Moon HS, et al.: Clinical preventive dentistry. 5th ed. KMS, Seoul, p.127, 2005. 3. Löe H, Schiott CR: The effect of mouth rinses and topical application of chlorhexidine on the development of dental plaque and gingivitis in man. J Periodont Res 5: 79-83, 1970. 4. Gjermo P: Chlorohexidine and related substances. J Dent Res 68: 1602-1608, 1989. 5. Sharma N, Charles CH, Lynch MC, et al.: Adjunctive benefit of an essential oil-containing mouthrinse in reducing plaque and gingivitis in patients who brush and floss regularly: a six-month study. J Am Dent Assoc 135: 496-504, 2004. 6. Kim JB, Choi YJ, Paik DI, et al. : Preventive dentistry. 4th ed. KMS, Seoul, pp.282-287, 2004. 7. Haffajee AD, Arguello EI, Ximenez-Fyvie LA, Socransky SS: Controlling the plaque biofilm. J Int Dent 53: 191-199, 2003. 8. Kim BI: QLF Concept and clinical implementation. J Korea Dent Assoc 49: 443-450, 2011. 9. Kim HE: Quantitative Light-Induced Fluorescence: a potential tool for dental hygiene process. J Dent Hyg Sci 13: 115-124, 2013. 10. Waller E, Daelen CJ, Veen MH: Application of QLF for 438
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