第20章P480-500

INTRODUCTION




The numbers and types of bacteria which enter the host via the oral cavity is greater than that which enters through all the other body orifices combined. While most of these organisms cannot survive on the mucous membranes, some not only could survive, but could cause infections. The host responds to these exogenous organisms with several antibacterial proteins which are always present in the saliva and which react without an obvious specificity against a heterogeneous array of bacterial types. At another level the host mounts a specific antibody response to various bacterial types which is mediated by not only the classic serum immunoglobulins but by a unique class of immunoglobulins known as secretory IgA. Collectively these defense mechanisms account for the virtual absence of serious bacterial infections emanating from the oral cavity.



The nonspecific mechanisms are for the most part poorly understood, but in recent years under the impetus created by the desirability of an anticaries vaccine, much has been learned concerning the role of specific antibodies in the regulation of S. mutans infections. Often the specific and the nonspecific mechanisms have a common final step, namely the clumping of bacteria so that they are cleared from the oral cavity. While bactericidal mechanisms occur, they do not seem to have the same importance as the clearance mechanisms. This will become apparent from the studies to be described in this chapter.



前言

從口腔進入宿主的細菌種類和數量遠遠大於從其他身體開口進入細菌的總和。所幸除了少數一些特定的菌種外，大部份的細菌並沒有辦法存活於人體黏膜上。然而這些少數的菌種不但得以存活還會造成感染。一般宿主的抗菌機制是啟動唾液裡的非特異性的抗菌蛋白對抗這些外來菌，而這樣的機制並沒有菌種特定性。另外宿主也有對抗特定細菌的抗體反應，是由典型的血漿球蛋白或是特定的免疫球蛋白(例如secretory IgA)啟動。這兩種抗菌機制相輔相成使得宿主免於產生嚴重的細菌感染。



NON-IMMUNE ANTIBACTERIAL MECHANISMS



There are several salivary proteins or glycoproteins, such as lysozyme, lactoperoxidase, lactoferrin and high molecular weight agglutinins (Table 20-1), which possess antibacterial activities. These proteins are chemically distinct from immunoglobulins, are present at relatively constant levels, exhibit broad spectrum activity and lack any aspects of immunological memory. Those organisms which colonize the oral surfaces seem to be resistant to these proteins, and this characteristic could have contributed to their selection as members of the indigenous oral flora. These proteins do not appear to be of importance in caries protection, as their levels are similar in caries-free and caries-susceptible individuals. However, in vitro, these proteins can inhibit or aggregate S. mutans to varying degrees, and accordingly they might play some role in vivo in regard to S. mutans colonization.



非免疫性抗菌機制 (NON-IMMUNE ANTIBACTERIAL MECHANISMS)

有許多唾液蛋白或球蛋白(例如: lysozyme, lactoperoxidase, lactoferrin以及高分子量的agglutinins)都有抗菌的能力(見表20-1)。這些蛋白在化學結構上和免疫球蛋不同，在人體裡常態性的保持一定濃度，可以對抗細菌的範圍很廣並且沒有免疫記憶專一性。能夠在口腔黏膜中存活的外來菌種多對這些蛋白有抵抗力，只有這樣的菌種能夠在口腔環境中被選擇留下來而自成菌落。這些非特異性蛋白對於防止蛀牙似乎沒有太大影響，因為在無蛀牙和容易蛀牙的個體裡，這些蛋白的濃度並沒有差異。然而，在實驗室裡，這些蛋白可以在某些程度上抑制或是聚集S. mutans，所以在人體裡的S. mutans聚集菌落，這些蛋白可能仍扮演某種重要的角色。



Lysozyme



Lysozyme is a low molecular weight basic protein that is present in high concentrations in the saliva. The actual concentrations vary inversely with the salivary flow rate and range from four to six mg/l00 ml. At high flow rates there will be about 20 micro-grams of lysozyme secreted per minute, whereas about nine micro-grams per minute is secreted at low flow rates.



The highly cationic nature of lysozyme suggests that it will act as an adhesive molecule for the bacterial surfaces. Purified lysozyme has six active sites which bind to carbohydrate receptors on the cell surface in a lectin-like manner (carbohydrate-protein interaction). If the bound lysozyme gains access to the cell wall peptidoglycan, the lysozyme acts as a muramidase, causing cell lysis. Most oral species are resistant to this lysis, and it is doubtful whether such lysis occurs in vivo in the oral cavity. Lysozyme can kill bacteria by inhibiting the respiratory system located in the cell membrane or by activating an endogenous autolytic enzyme system. However, the most likely antibacterial role of lysozyme in the saliva may be the aggregation of bacteria so that they can no longer attach to oral surfaces.



Studies by Pollack and his colleagues indicate that lysozyme binds to the various S. mutans serotypes, but at significantly different rates (Table 20-2). Serotypes a and b strains become saturated with lysozyme within 12 to 15 minutes, whereas three hours are required for the other serotypes to become saturated. The growth of serotype a and b strains in vitro was inhibited by 50 mg of lysozyme, whereas 20 to 100 fold higher levels were necessary to inhibit the other serotypes (Table 20-2). These findings predict that serotype a and b strains could be influenced in vivo by lysozyme, a fact which could account for the low frequency with which these serotypes are encountered in human plaque samples.



Lysozyme

Lysozyme是種在唾液裡濃度很高的低分子量基本蛋白。他的實際濃度與唾液流量正好成反比，大約4~6 mg/100 ml。在高流量時一分鐘約有20 微克的lysozyme被分泌而低流量時一分鐘約有9微克。 (?這裡我不懂為何成反比 vary inversely 但後來的例子卻是成正比!!??)



Lysozyme分子表面帶高正電陽離子，使得它很容易和細菌表面黏附。純化的lysozyme表面有6個活潑的位子可以和細胞表面的碳水化合物接受器產生lectin-like方式結合 (carbohydrate-protein interaction)。理論上lysozyme黏上細菌的會形成細胞壁上的胜糖通道使得lysozyme像是muramidase而造成細胞溶解。而大部分的口腔細菌可以對抗溶解所以目前對溶解反應是否真會在人體內產生仍然存疑。Lysozyme可經由抑制細菌細胞壁上的呼吸系統或是活化細菌內生性的自溶酵素來殺死細菌。然而，lysozyme在唾液裡扮演最重要的抗菌角色應是聚集細菌使得他們無法黏附在口腔黏膜上。Pollack等人的研究指出lysozyme可與很多類型的S. mutans 黏附，唯不同類型的黏附速率不同 (見表20-2)。血漿類型a和b型可在12到15分鐘內被lysozyme完全黏附到飽和，而其他的種類可能需要三小時。在實驗室裡只需要50mg的lysozyme即可抑制血漿類型a和b型的生長，而其他種類需要20~100倍的濃度才能抑制(見表20-2)。這個發現可知在人體中血漿類型a和b型可被lysozyme抵抗消除，這呼應了人類牙菌斑裡這兩種類型的細菌濃度很低的事實。



對lysozyme有反應的S.mutans中，BHT種(serotype b)是最敏感的一種。BHT和其他種類不同的地方在於它有大量的lipoteichoic acid(LTA)。Iacona研究指出LTA是提供lysozyme黏結的重要因子，因此在牙菌斑裡鮮少看到血漿類型b種應是lysozyme的功勞。這種類型的細胞通常零星散落在唾液裡並且會很快的經由LTA接受器和lysoyme黏結，造成細胞聚集或是被吞下或是因為細胞膜上的呼吸酵素被抑制而死亡。以上的情況顯示出宿主有防止外來的mutans streptococci在牙齒表面聚集的抗菌能力。血漿類型a和b也因此被歸類為另一種類(S.cricetus 和 S.rattus)，分別是倉鼠和老鼠體內的主要細菌。



Lactoperoxidase (LPO)



Lactoperoxidase (LPO) is an enzyme found in the saliva which converts hydrogen peroxide formed by plaque bacteria to water and an oxidized product(s) (oxidants). These oxidants in turn react with sulfhydryl groups present in proteins, thereby forming disulfide bonds. If these sulfhydryl groups are at the active sites of bacterial enzymes, then enzyme functions, such as those involved in glycolysis, are inhibited. LPO can bind to hydroxyapatite and to various streptococci so that it is likely to be a component of plaque. Saliva contains thiocyanite ions (SCN), which can be oxidized by LPO, in the presence of hydrogen peroxide, to form the highly toxic hypothiocyanite radical (OSCN ). The amount of SCN- and LPO present in vivo is adequate to give rise to levels of OSCN-, which should be inhibitory for S. mutans and other acidogenic organisms. However, some plaques cannot generate sufficient amounts of hydrogen peroxide to drive the reaction towards OSCN- production. S. sanguis is known to produce hydrogen peroxide, leading to the surmise that plaques that are unable to form hydrogen peroxide are also low in S. sanguis. Plaques low in S. sanguis could be high in S. mutans and therefore, cariogenic in nature. This argument suggests that cariogenic plaques escape the inhibitory action of LPO by virtue of their inability to generate hydrogen peroxide.



Lactoperoxidase

Lactoperoxidase (LPO) 是種在唾液裡的酵素，它可以轉換牙菌斑裡細菌產生的氫和氧成為水或其他氧化產物 (氧化劑)。這些氧化劑可以和蛋白裡面的氫硫物質反應形成二硫化物。如果細菌酵素上的活性位子是氫硫基，那麼這個酵素的功能像是糖解(glycolysis)作用就會被抑制。LPO可以黏附在hydroxyapatite以及多種streptococci上而一起組成牙菌斑。唾液裡有thiocyamite離子(SCN)會被LPO氧化，在有二氧化氫的狀態下可以形成高毒性的hypothiocyanite自由基(OSCN-)。SCN-和LPO在人體中的數量可以使OSCN-濃度提高，抑制S.mutans和其他的耐酸性細菌。然而有些菌斑沒有足夠的二氧化氫來形成OSCN-。我們知道S.sanguis可以形成二氧化氫所以可以推測無法二氧化氫的菌斑裡S.sanguis占的比例不高。當菌斑裡的S.sanguis占的比例不高，S. mutans就會較高，也就比較容易蛀牙。這個結論指出易蛀牙的菌斑裡二氧化氫產量少，即不易被LPO抑制。



Lactoferrin



Lactoferrin is a salivary glycoprotein which exerts an antibacterial action through its ability to bind iron so avidly that it essentially depletes the environment of this mineral. Iron is an essential nutrient for most bacteria and accordingly, these organisms fail to multiply and are either cleared from the mouth via swallowing or are neutralized by other host defense mechanisms. There is no evidence that lactoferrin is important in caries prevention. Mandel has observed that lactoferrin levels in saliva and plaque do not differ between caries resistant and susceptible subjects. In vitro lactoferrin is bactericidal for S. mutans by virtue of its ability to chelate cell-associated iron. S. salivarius and S. mitior are not as susceptible, presumably because the lactoferrin does not bind as efficiently to these organisms. This raises the possibility that schemes for optimizing the anti-S. mutans action of lactoferrin can be devised similar to what has been done for the LPO system.



Lactoferrin

Lactoferrin是種唾液裡的糖蛋白，他的抗菌作用來自於和鐵離子的黏結能力很強使得鐵離子減少。鐵是多數細菌的必需營養來源，所以當鐵缺乏時，細菌就不能增生，容易被吞下或是被宿主抵抗機制中和。Lactoferrin並沒有直接證據顯示可以抗蛀牙。Mandel觀察到在不易蛀牙與易蛀牙的個體裡，lactoferrin在唾液和菌斑裡的濃度都沒有差別。在實驗室，lactoffrin可以藉由與鐵結合的能力來抑制S. mutans。而對S.salivarius和S. mitior就沒有這麼好的抑制能力可能是因為lactoferrin對它們的黏結能力較差所致。以上可推論lactofettin的抗S. mutans機制可如同LPO系統般運作。



Salivary Adhesins



The high-molecular-weight glycoproteins (mucins), which adsorb to the tooth surface to form the acquired enamel pellicle (AEP), promote the colonization of S. sanguis but not S. mutans (See "The First Colonizers" in Chap. 6). The relative paucity of sites specific for S. mutans on the AEP comprises a host defense mechanism against S. mutans colonization. There now is evidence that these or other glycoproteins do bind S. mutans, but that when this binding occurs in solution, S. mutans becomes aggregated in such a manner that its chances of colonizing a tooth surface are greatly reduced. This would constitute another mechanism by which the host could clear organisms rapidly from the mouth. This phenomenon has been studied in regard to S. mutans' ability to bind to solid surfaces in the presence of saliva. Magnusson and Ericksson investigated the in vitro attachment of a serotype c strain of S. mutans to powdered hydroxyapatite (HAP) in a system involving S. mutans, HAP and saliva. Incubation of the saliva with S. mutans prior to the addition of HAP consistently gave lower adsorption of S. mutans, compared to the situation where the three components were mixed simultaneously. This suggested that some component in the saliva interacted with S. mutans, so as to reduce its ability to bind to HAP.



Clark and Gibbons, studied the adsorption of tritium-labeled cells of S. sobrinus (strain 6715, serotype g) to HAP disks. The disks were suspended in either saline or saliva containing about one hundred million S. mutans CFU per ml. The amount of radioactivity retained on the disks after washing reflected the amount of bacterial adsorption. In this model system the adsorption of S. mutans was logarithmically related to cell concentration, with equilibrium reached after 45 minutes of incubation. Only a small percentage of the streptococci became attached, and the adsorped cells occupied about three percent of the available surface area on the disks. This behavior would seem to mimic the weak adsorption of S. mutans to the teeth that is observed in vivo.



Maximum adsorption of S. mutans occurred when cells and disks were suspended in saline (Table 20-3). If the disks were pretreated with saliva, fewer cells adsorped. But if the disks were pretreated with saliva and then both the disks and the bacteria were suspended in saliva, there was a 30-fold reduction in adsorption (Table 20-3). The addition of sucrose to the suspension fluid, so as to permit synthesis of glucan during the attachment period, did not improve adsorption. Even when the cells were pretreated with sucrose, so as to have glucan already on their surfaces, there was no improvement in adsorption. The attached cells were weakly bound to the HAP, as most could be desorped either by saline or saliva (Table 20-3). As the saliva was obtained from a single individual who presumably had no unique caries background, the inference is that saliva contains a factor(s) which seriously compromises the ability of in-vitro-grown strains of S. mutans to attach to HAP. This is in agreement with clinical studies which demonstrated the great difficulty related to the implantation in humans of in vitro-grown S. mutans (See "S. mutans Colonization" in Chap. 6).



唾液黏結

唾液黏著劑



高分子量的醣蛋白(mucins) 會被牙齒表面吸收成為acquired enamel pellicle (AEP)，AEP可以促進S. sanguis而不是S. mutans的菌落聚集(見第6章 “The First Colonizers”)。這樣相對少量可以讓S. mutans黏結在AEP上的位子，可看做是一種宿主對抗S. mutans的機制。現在有證據指出這些或其他的醣蛋白的確會和S. mutansr黏結，而當這種黏結在溶液裡產生時，S. mutans會彼此聚集因此就降低了S. mutans黏附在牙齒上的機會。這形成了另一個機制使宿主得以快速的清除這些外來菌。此現象如同在唾液裡S. mutans黏附在堅硬表面上，因此許多研究著重於S. mutans黏附在表面的能力。Magnusson和Ericksson發現在體外實驗裡，血漿類型c的S. mutans 和粉末狀的hydroxyapatite (HAP)黏結是一個系統，這系統包括了S. mutans，HAP和唾液。S. mutans在唾液裡培養之後再加入HAP產生的S. mutans, HAP系統黏結會比一開始就讓三者混合來得低。這說明了唾液裡有某些物質會降低S. mutans黏附到HAP上的能力。



Clark和Gibbons研究用氚標出S. sobrinus內細胞 (strain 6715, serotype g)黏附在HAP圓盤碎片上被吸收的情形。HAP圓盤碎片懸浮在含有十億個S. sobrinus CFU每毫升的生理食鹽水或是唾液裡面。圓盤碎片上有X光不透性物質，清洗過後可以清楚見到上面黏附的細菌，借以觀察吸收黏附的情形。在這個實驗的狀況下，經過45分鐘的培養，S. mutans的吸收和細胞含量成正比。只有少量的鏈球菌會聚集在一起，而黏附被吸收的細菌大約佔據了圓盤碎片表面積的3%。S. mutans只有少量被黏附吸收情形和在口內黏附吸收到牙齒上的狀況很像。



當細胞和圓盤碎片是懸浮在生理食鹽水裡的時候，細菌會達到最多的黏附吸收(表20-3)，如果園盤碎片被唾液浸潤，細菌黏附吸收率就降低。但如果圓盤碎片被唾液浸潤而細菌和圓盤碎片同時懸浮在唾液裡，吸收率會降低約三十倍(表20-3)。另外添加蔗糖到懸浮液裡，讓肝醣得以同時形成，並不會增加對吸收率。即使先用蔗糖處理過細菌使表面帶有肝醣，也不會增加吸收率。這些細胞和HAP的黏結力很低，不論在生理食鹽水或唾液裡都不太會黏附吸收(表20-3)。這唾液樣本來自於一個沒有特殊蛀牙情況的個體，表示唾液裡含有某些因子可有效的阻斷S. mutans和HAP的黏結，以上的結論以及臨床實驗都證實S. mutans植入人體內生長是非常困難的。(見”S. mutans 菌落”於第6章)



Other studies have shown that lectin-like interactions mediate the attachment of certain oral bacteria to oral epithelial cells. A characteristic of lectin-like reactions is that they can be inhibited by one or more low molecular weight sugars which attach firmly to the binding site on the protein (lectin). These sugar-lectin interactions are highly specific, as each lectin receptor site will recognize only a single sugar or closely related structures.



Various low-molecular-weight compounds were evaluated for their ability to inhibit the adsorption of the S. mutans serotypes to salivary-coated HAP disks. Adsorption of all serotypes was inhibited by galactose and melibiose but not by 16 other related compounds (Table 20-4). Both galactose and melibiose contain an alpha galactoside residue, whereas, lactose which has a beta galactoside residue was without any effect. This indicates that the lectin capable of binding all serotypes of S. mutans recognized an alpha galactoside residue on the surface of S. mutans. Certain amine configurations also inhibited the adsorption of S. mutans. Thus, spermine (a polyamine) inhibited the adsorption of all serotypes, whereas mannosamine inhibited serotypes a,d and b, and galactosamine inhibited serotypes a,c and e. Iodoacetate was effective against all serotypes (Table 20-4). The ability of galactose, spermine and iodoacetate to inhibit the adsorption of S. mutans to HAP raises the possibility that these compounds could be used in vivo to prevent the colonization of teeth by S. mutans.





其他的研究發現lectin-like的反應是某些口腔細菌和口腔上皮黏膜細胞黏附的媒介，lectin-like反應主要是藉由蛋白質(lectin)上的位子使一個或多個低分子量的糖分子和它們緊密鍵結來達到抑制細菌和口腔上皮黏附。這種糖-lectin反應是具有高度獨特性的，每個lectin的接收點只會辨認出一個單一糖分子或是結構類似的分子。



許多低分子量的化合物被用來評估他們對於抑制S. mutans血漿類型到有唾液包覆的HAP圓盤碎片，galactose和melibiose可以抑制所有血漿類型的黏附吸收而其他16種結構類似的化合物就不行(表20-4)。Galactose和melibiose都有一個alpha galactoside反應存留物，然而，lactose的bata galactoside反應存留物就沒有太大的作用，這指出lectin可以和所有表面有alpha galactoside反應存留物的S. mutans鍵結，不論是哪種血漿類型。有些氨基化合物也會抑制S. mutans的吸收。因此spermine(一種polyamine)抑制所有類型的吸收而mannosamine抑制血漿類型a,d和b而galactosamine抑制血漿類型a, c 和 e，Iodoacetate則對任何類型都有效(表20-4)。Galactose, spermine 和iodoacetate對S. mutans黏附HAP的抑制能力可用來防止S. mutans在人體裡黏附牙齒組成菌落。



Salivary Proteins



The host has several salivary proteins which exhibit an anti-S. mutans effect. If these proteins encounter S. mutans that is free in solution, they can cause aggregation of this organism which results presumably, in the exit of S. mutans from the mouth via swallowing. This is probably the major mechanism which the host has for removal of S. mutans. This system can be enhanced by adding to the oral environment those sugar molecules that bind to either lectin-like receptors on the surfaces of the bacteria or on the acquired enamel pellicle. In either case, they would reduce the adsorption of S. mutans by blocking those attachment sites necessary for adsorption. If these proteins attach to already adherent cells of S. mutans, then their protective effects are less. However, if they have bactericidal action, such as possessed by lysozyme, lactoperoxidase or lactoferrin, then some degree of microbial killing could occur. Of these mechanisms, the lactoperoxidase system is open to manipulation by the usage of exogenous enzyme systems which generate hydrogen peroxide.



唾液蛋白

宿主有很多唾液蛋白可以抗S. mutans，在S. mutans自由懸浮在液體裡的情況下這些蛋白可以造成細菌聚集使得細菌被吞下然後離開口腔，這大概是宿主移除S. mutans細菌最主要的機制。這機制可藉由在環境中加入蔗糖分子使它們與細菌表面上的lectin-like接收器鍵結或是後天的enamel薄膜來提升。無論哪種情況，它們都可以藉由占據鍵結位子來降低S. mutans的黏結吸收，但如果這些蛋白質黏附在已經鍵結的S. mutans上，那抑制的效果就會降低。然而，如果蛋白質有殺菌的作用像是lysozyme, lactoperoxidase或lactoferrin，仍然可以達到某種程度的殺菌。在這些機制裡面，lactoperoxidase系統是由外來酵素系統使用後產生了二氧化氫來完成。



SPECIFIC MECHANISMS. THE IMMUNE SYSTEM.



The SPH invites speculation about the role which the immune system might play in dental diseases. If a limited number of bacterial species initiate caries, then it may be possible to identify mechanisms of immunity against these organisms in disease-free people, and thereby develop means of actively immunizing other individuals who are at risk to dental disease. Both are formidable tasks. The obvious association of S. mutans with human decay has caused the recent interest in vaccination as a means of caries control. In this chapter we will describe the results obtained with vaccination experiments involving S. mutans and discuss the findings in the context of plaque microbial ecology.



專一機制 免疫反應

SPH引起免疫反應在牙科疾病裡扮演何種角色的推論，如果很少種類的細菌可導致蛀牙，那麼在沒有蛀牙的人身上就很容易找出哪種免疫機制阻擋了這疾病，進而可以知道用甚麼免疫方法可以用來預防高危險群的人罹病，然而這些現實上都很難達成。S. mutans和蛀牙的明確關係引起近年來用疫苗來控制感染的想法。在這個章節裡我們會討論對抗S. mutans的實驗性疫苗結果以及在牙菌斑裡微生物組成及生態。



Immune Globulins



Hosts have specialized cells and organs, collectively referred to as the immune system, which recognize non-self chemical structures. This recognition causes the immune system to synthesize antibodies of exquisite specificity against the foreign compound or cell which usually results in the destruction or neutralization of the interloper. This acquired information is then stored in a memory-like fashion so that it can be rapidly retrieved and amplified when the foreign body is again encountered. Antibodies can be either cellular or protein in nature. Immunity against dental caries, as it currently is understood, is mediated primarily, if not exclusively, by globular proteins known as immunoglobulins which circulate in the blood stream and to a lesser extent are present in secretions.



Five immunoglobulins have been identified and given the designation IgG, IgA, IgM, IgD and IgE. Only the major immunoglobulins, i.e., IgG, IgA and IgM have been implicated in immunity to caries. Some of the characteristics of these immunoglobulins are given in Table 20-5. IgG comprises about 80 percent of the total immunoglobulins, but is found in low levels in secretions such as saliva. Its concentration in gingival crevice fluid obtained from sites of dental inflammation is high (Table 20-5). However, the gingival crevice fluid flow in the absence of inflammation is low and may amount to only a few ml per day. IgG exerts its antimicrobial activity in conjunction with phagocytic cells, complement and platelets, all of which are in small supply on the dental surfaces. Nevertheless, there is data from both man and monkeys which suggest a role for specific IgG antibody to S. mutans in immunity against dental decay.



免疫球蛋白

宿主有特別的細胞和器官，統稱為免疫系統，它可以辨認出非自身的化學結構。這個辨識可以造成免疫系統合成靈敏的抗體對抗造成破壞的外來化合物或細胞。這些資訊會像記憶般被儲存，當外來物再度進入，它可以很快的辨識並且製造抗體。抗體可以細胞或是蛋白質的形式存在。對於蛀牙的免疫，就目前所知，主要是血液循環中的球蛋白又叫做免疫球蛋白。



目前發現有五種免疫球蛋白，分別取名為IgG, IgA, IgM, IgD和IgE。只有主要的球蛋白例如IgG, IgA, IgM與蛀牙免疫相關。這些免疫球蛋白的特性列在表20-5。有80%的免疫球蛋白是IgG，但IgG在唾液裡的含量很低，只在有牙齒發炎反應發生的時候，IgG在牙齦溝液中含量會增高(表20-5)。而在沒有發炎狀態下，牙齦溝液中的含量就很低，大約一天只有幾個毫升。IgG和巨噬細胞(phagocyte)，補體(complement)還有血小板(platelets)會互相配合達到抗菌效果，這些物質在牙齒表面都很少。然而有研究顯示同時在人和猴子體內都發現有種特殊的IgG抗體會特別針對S. mutans產生免疫效果，避免蛀牙。



IgA antibodies are found in elevated amounts in secretions such as saliva and are not dependent upon serum components for their ability to provide immunity. They need only to coat or agglutinate bacteria in such a way that the microbes cannot adhere to surfaces such as the teeth. IgA antibodies are synthesized by the plasma cells found in the various salivary glands. They are dimerized with a J-chain prior to release from the plasma cell and then acquire an additional protein called secretory component as they pass through the secretory epithelial cell. This configuration renders the secretory or S-IgA molecule resistant to proteolysis so that it is well designed to operate in an environment containing microbial proteases. S-IgA antibody to S. mutans is associated with immunity to caries in man and in rodents.



IgM antibodies, so named because of the macro size of this immunoglobulin, do not appear to be important in caries immunity. However, in cases of selective IgA deficiency, IgM antibodies to S. mutans are found in the saliva and are associated with some degree of protection against dental decay.



IgA抗體在分泌物當中含量高，像是唾液，並且它不需要依靠其他的血漿因子來達到免疫的效果。它們只需要包覆或是凝結細菌使細菌無法和表面(例如牙齒)黏結。IgA抗體是由漿細胞合成，出現在很多分泌性唾腺裡，它們有兩個化合物，在被漿細胞釋出前會有一個J-chain，然後需要結合一個額外的蛋白質叫做分泌因子，之後再一起通過分泌上皮細胞。這樣的結構使得分泌性或是S-IgA分子可以抵抗蛋白質水解可以在有蛋白質溶解酵素內的環境裡作用。S-IgA抗體在人類和嚙齒類對S. mutans有免疫的作用。



IgM抗體得名來自於這種免疫球蛋白很大，對於抗蛀牙並沒有扮演重要角色。然而，在選擇性IgA缺乏的情況下，在唾液裡會發現有IgM康體可對抗S. mutans防止蛀牙。



Presence of Specific Antibody(ies) to S. mutans in Human Sera and Saliva



Human sera contain specific antibodies against many indigenous bacteria. The presence of these antibodies does not mean that any organism(s) under investigation was associated with an infection, or that these antibodies are protective against a new infection by the organism. In order to draw a conclusion concerning the former, the antibody levels would have to be determined before, during and after an infection; whereas the latter would require evidence showing that an elevated titer of specific antibody coincided with the disappearance of symptoms, or was able to prevent a new infection by the specific organism. These types of data are not available for S. mutans. Research is at an early stage, concerned with the documentation of specific antibody to S. mutans in individuals of varying caries experience. This data must be interpreted cautiously because caries experience, as measured by the classic DMF score, is a morbidity index, and is inadequate in describing whether decay is currently active or whether the individual has been, or still is, subjected to the challenge of the disease determinants, i.e., sucrose, S. mutans, low fluoride, etc. This information is necessary in order to assess the significance of the antibody levels. In the succeeding discussion we will define the caries status of the individuals as caries-free, i.e., DMF score = 0; caries inactive, i.e., MF score greater than one; caries active, i.e., D score greater than one; in order to have diagnoses corresponding to no infection, post infection and infection.



在人類唾液和血漿中出現S. mutans特定的抗體

人類血漿有很多對抗原生性細菌的特殊抗體，出現這些抗體並不意味著生物體受到感染或抗體要對抗新的感染。為了要區別受到感染和正常的不同，必須知道感染前中後抗體的濃度，為了要區別是否有新感染，需要檢測症狀消失是否是由於特殊的抗體濃度升高或是有特殊的生物體可以避免感染發生。S. mutans的這些資料都無法取得。研究目前都停留在很早期的階段想證明不同蛀牙經驗的個體內有不同的抗S. mutans抗體。這些資訊必須小心的解讀因為蛀牙經驗像是DMF指數是個發病指數並不足以提供蛀牙目前的活躍性，也無法知道個體曾經或正在有患病因子(例如蔗糖，S. mutans和低氟環境)的環境下。這些資訊對於評估抗體的的濃度很重要。在接下來的討論裡我們會定義個體的蛀牙狀態像是無蛀牙情況下 DMF值等於0; 蛀牙不活躍, MF值大於1 ; 蛀牙活躍, D值大於1，這些都是為了分辨無感染，感染中或感染後。



Cross-sectional Studies



Caries-Free Individuals: In populations which are isolated and/or have low sucrose diets, the absence of caries may be due to the absence of a cariogenic infection, an undefined genetic-based resistance, or the presence of protective antibodies against a cariogenic flora. Animal studies indicate that caries-free animals usually had not been sufficiently challenged by sucrose and S. mutans. When they were properly infected with S. mutans, they developed caries, thereby discounting the role of a genetic factor or an immunological factor in their caries-free state. By analogy, and the obvious susceptibility of isolated peoples, i.e., Eskimos, Polynesians, Indians, etc., to caries when sucrose is added to their diets, one would suspect that the human caries-free state also reflects an insufficient cariogenic challenge rather than an immunologic or genetic component.





Cross-sectional 研究

無蛀牙的個體: 飲食中只有很少或是沒有蔗糖，沒有蛀牙可能是因為沒有蛀牙性感染，未定義的基因抗蛀性，或是有保護性的抗體


Cross-sectional Studies




Caries-Free Individuals: In populations which are isolated and/or have low sucrose diets, the absence of caries may be due to the absence of a cariogenic infection, an undefined genetic-based resistance, or the presence of protective antibodies against a cariogenic flora. Animal studies indicate that caries-free animals usually had not been sufficiently challenged by sucrose and S. mutans. When they were properly infected with S. mutans, they developed caries, thereby discounting the role of a genetic factor or an immunological factor in their caries-free state. By analogy, and the obvious susceptibility of isolated peoples, i.e., Eskimos, Polynesians, Indians, etc., to caries when sucrose is added to their diets, one would suspect that the human caries-free state also reflects an insufficient cariogenic challenge rather than an immunologic or genetic component.





Cross-sectional 研究

無蛀牙的個體: 飲食中只有很少或是沒有蔗糖，沒有蛀牙可能是因為沒有蛀牙性感染，不明確的抗蛀基因，或是有保護性的抗體。動物實驗指出無蛀牙的個體是未受到蔗糖或是S.mutans的足夠的挑戰，如果他們被S.mutans ”適當” 感染後還是會出現蛀牙的情形。因此基因和免疫力這兩個因子可能並不能擔任持續無蛀牙狀態這樣的角色。根據這樣的類比，有些如易蛀牙的人種像是愛斯基摩人,玻里尼西亞人,印度人等等會蛀牙是因為飲食內有了蔗糖這樣的蛀牙因子，因此我們也可以合理懷疑沒有蛀牙的人可能反映出飲食內沒有足夠致齲物的挑戰而不是因為有抗蛀的免疫或基因因子。



Table 20-6

Antibody Titers (Log2) to Streptococcus mutans in Individuals of Varying Caries Activity



Antibody Class

Serum Saliva

Subjects DMF IgG IgA IgM IgA

Naval Recruits (18-19 yrs)a

CF Caries Free (n=26)

HCA High Caries Active (24)

0

>15

4.5}

4.2}

Young Children (2.5-5.5 yrs)b

RCA Rampant Caries (15)

HCA Caries Active (12)

11.5

5.1

1.8

2.7

0.7

0.4

1.3

0.9

1.8

1.9

Young Adults (18-14 yrs)c

LCI Low Caries Inactive (34)

HCI High Caries Inactive (31)

HCA High Caries Active (31)

2.9

17.6

17.2

5.8

3.9

5.3

4.0

4.1

4.2

5.2}

3.7}

4.3

4.5

6.2

4.5



} Significant difference

value in box was significantly different from other values in column.

a) adapted from Kennedy et al., 1968. Archs. Oral Biol. 13:1275. Log2 titers calculated from agglutination titers shown for strain SL1 (serotype d).

b) adapted from Lehner et al., 1978. Archs. Oral Biol. 23:1061. Serum antibodies measured by indirect fluorescent technique. Salivary antibody by agglutination.

c) adapted from Challacombe, 1980. Archs. Oral Biol. 25:495. Antibodies measured as in b.





Nevertheless, there do exist a few individuals who ingest modern-type diets, and reach adult age caries free. These individuals tend to have elevated levels of specific antibody against one or more serotypes of S. mutans when compared to levels present in caries-active subjects. For instance, caries-free naval recruits had higher agglutinin titers to S. mutans that did similar-aged recruits with rampant caries (Table 20-6). The magnitude of this difference was not great and raises the question as to how a certain level of serum antibody could be protective in the caries-free population, but be of no apparent value in a high-caries-active population. One explanation could be that the antibody measured by an agglutination assay is not a protective antibody and merely indicated that the host's immune system had been exposed to S. mutans. This latter possibility is supported by the almost universal occurrence of S. mutans in human mouths.

然而，有些人在攝取現代的飲食下到了成人還是沒有齲齒。這些人和有齲齒的人比起來傾向於對一種或多種S. mutans有特殊的抗體。例如，海軍招募時無齲齒的人比起同年紀有齲齒的人就有比較高的抗體凝集含量(Table20-6)。這差異並不顯著，不過讓人想知道多少含量的血清抗體可以保護無蛀牙個體免於蛀牙。一種解釋是抗體凝集試驗做出來的可能不是保護性的抗體，只是宿主免疫系統對抗S. mutans的反應。後面的可能較被支持的，因為幾乎所有人口中都有S. mutans。



Infants are exposed to S. mutans present in the mouths of their family members, and some teeth become demonstrably colonized shortly after their eruption. An immune response, measured by agglutinating antibodies to cell walls of S. mutans, appears to be age related (Table 20-7). Fourteen percent of the sera obtained from infants under six months of age exhibited a positive reaction with various S. mutans serotypes and three percent had high titer antibodies. This is surprising, given the edentulous nature of these infants and the apparent need of a solid tooth surface for effective colonization of S. mutans. Could these early strong reactors represent that segment of the population which remains caries free or low caries inactive? Studies which identify these children in infancy and then follow them through the caries-prone years are necessary in order to answer this question.

嬰兒在出生幾個月後就會因為家中成員而有S. mutans，出現牙齒後不久S. mutans就會附著在牙齒上。有一種免疫反應似乎和年齡相關，他是檢驗S. mutans細胞壁上的抗體是否會產生凝集(Table 20-7)。14%的六個月嬰兒血漿就對多種S. mutans有反應而其中3%有高濃度的反應。這發現很驚人，因為表示S. mutans可以無牙脊上聚集。有這些早期的抗體反應的人可以因此而無齲齒或是齲齒活性很低嗎?必須要做研究這樣的嬰兒長到容易齲齒的年紀後才能有答案。

Table 20-7

Number and Percentage of Cell Wall Agglutination Reactions to Four S. mutans Strains (BHT serotype b, SL-1 (d), 20, 10557 (c)) by Sera from Children of Five Age Groups



Under 6 mos 6 mos - 3 yrs 3 - 6 years 6 - 12 years 12 - 16 years

No. % No. % No. % No. % No. %

Negative 152 86 165 72 108 59 149 58 96 46

Positive (a) 25 14 65 28 76 41 109 42 111 54

Strong positive (b) 6 3 7 3 7 4 25 10 27 13

(a) titers ≥ 1/20 (b) titers ≥ 1/80

Adapted from Berkenbilt and Bahn 1971, JADA 83:332.



But how would neonates acquire this "immunity"? Some understanding in this regard was provided by experiments which showed that the oral administration of various vaccines led to increased titers of specific IgA antibody in tears, saliva and colostrum. In other experiments gnotobiotic rats were fed formalin-killed S. mutans (serotype g) in their food. These animals demonstrated elevated salivary and colostrum IgA titers to serotypes g and a strains of S. mutans, and were able to resist a subsequent cariogenic challenge with a serotype g strain of S. mutans. The presence of specific antibodies to S. mutans in the colostrum suggested that immunity to S. mutans could be passively transferred by means of mother's milk. This was confirmed by studies in which bovine milk containing antibodies to S. mutans was shown to significantly reduce the numbers of carious lesions in rats fed this lyophilized milk and challenged with the homologous (same serotype) S. mutans strain.

但是新生兒的"免疫"從那裏來?有些實驗顯示由口腔給予多種疫苗可以增加眼淚，唾液和初乳中某些特殊的IgA抗體。其他的實驗，把無菌老鼠用無菌的食物(含福馬林可殺死S. mutans (serotype g))餵養，這些動物在唾液和初乳中的IgA含量增加，因此可以對抗S. mutans (serotype g)。這樣特別的抗體被認為可以由母乳傳遞給嬰兒，也有實驗證明。用含S. mutans抗體的牛奶餵老鼠，顯示這樣的老鼠齲齒率有顯著性的降低。



Some infants may become passively immunized in the neonatal period if their mother's milk contains high levels of secretory IgA and probably IgG antibody to S. mutans. This possibility could account then for the three percent of the infants who exhibited a strong positive reaction to S. mutans, (Table 20-7) and perhaps for that small segment of the population that is caries free. This phenomenon of passive immunity is being investigated as one of the tactics that can be used for the delivery of an anticaries vaccine (See "Human Vaccines" in this chapter).

有些嬰兒會在新生兒時期有母奶中的高含量分泌性IgA和 IgG而有了被動的免疫能力。這可能解釋了3%的新生兒對S. mutans 有很強的反應 ( Table 20-7)也解釋了某些人是無齲齒的狀況。這現象裡被動的免疫反應可用在給新生兒抗齲齒的疫苗概念上(詳見本章中的"Human Vaccines")



Caries-Active Individuals: Decay (D) Greater Than 1



These individuals have open lesions and/or are in the process of developing new lesions. If an immunological response is involved, these individuals would be expected to exhibit elevated antibody levels to S. mutans. The number of decayed surfaces or teeth would appear to be the most reliable indicator of the magnitude of the antigenic challenge. However, 2.5- to 5.5-year-old children with rampant caries (greater than 10 carious surfaces) and those with one or more lesions had comparable levels of serum IgG, IgA and IgM antibody, as well as salivary IgA antibody (Table 20-6). Serum IgM antibody showed a significant positive correlation with the DMFS score and this was thought to reflect the antigenic load experienced by the child. Other than this observation, there was little evidence of a protective immune response to active decay in these children.



齲齒活躍的個體 : 齲齒(D)大於1

這些個體有病灶或是正在產生新的病灶。如果有免疫反應介入，這些個體對S. mutans的抗體反應會提高。齲齒的表面數和顆數是有抗原反應最好的指標。然而，2.5歲到5.5歲的有猛爆性齲齒的孩童(大於十個蛀牙表面)和只有一個或幾個病灶的比較起來，前者的血清中IgG, IgA和IgM抗體還有唾液裡的IgA抗體含量高(Table20-6)。血清IgM抗體和DMFS有顯著的正相關，且被視為可反映出孩童身上抗原性。除此之外，在這些孩子身上有很少的證據顯示有保護性的免疫反應。



Caries-Inactive Individuals: Missing and Filled (MF) Teeth Greater Than l



The overwhelming majority of people ingesting sucrose-containing diets develop caries. If these lesions are treated and the individual develops no new lesions in the succeeding years, he is considered to be caries inactive. Could this absence of caries reflect an immune state in which the individual has developed protective antibodies as a result of his prior infection? This is difficult to ascertain from the available cross-sectional information. The caries-inactive individual may have missing and/or filled teeth (MF score) which range in number from one to over 30. The titers of specific serum antibody against S. mutans antigens is significantly higher in the low MF subjects than in the high MF subjects. This negative correlation suggests that the low MF individuals were able to mount and sustain an effective immune response against S. mutans, whereas the high MF subjects did not. Why this variation in immune response to the same organism? Why did the high MF subjects, who presumably had the highest antigenic exposure, exhibit the lower response of IgG antibody? What role might salivary antibodies play in this protection or lack of protection?



齲齒不活躍性個體: 失去或是填補(MF)牙大於1

大部分的人吃了含蔗糖的飲食都會產生齲齒，如果這些病灶被治療了而這些人之後也沒有新的齲齒，就被認為是齲齒不活躍性的個體。這樣沒有齲齒的狀態是因為免疫系統產生了保護性的抗體嗎?這問題很難就cross-section的資料來加以回答。齲齒不活躍性個體可能有失去或是被填補的牙齒(MF 數可從1~30)。對抗S. mutans的特殊血漿抗體在低MF的人身上比較高。這樣的負相關解釋了低MF的人可以對S. mutans產生有效的免疫反應而高MF的人沒有辦法。為什麼在同樣生物體中會有不同樣的免疫反應呢? 為什麼在高MF個體裡應該有高抗原卻只有引發低抗體反應呢? 唾液性抗體是否扮演保護性角色還是根本不具保護性呢?



Antibodies to S. mutans and S. sanguis were examined in serum and parotid saliva of 96 young adults. The subjects were divided into three groups: 1) a low caries-inactive (LCI) group that had seven or less missing or filled teeth; 2) a high-caries-inactive (HCI) group that had 13 or more filled or missing teeth; and 3) a high-caries-active (HCA) group that had 13 or more DMF teeth and between one and four approximal lesions which extended into the dentin (Table 20-6). The LCI and HCA groups had similar antibody profiles, despite their dissimilar clinical backgrounds. Both differed from the HCI group in having significantly higher titers of serum IgG antibody and significantly lower titers of salivary IgA antibody (Table 20-6).

在96個年輕人的血漿和腮腺唾腺中檢驗對S. mutans和S. sanguis 的抗體反應。將他們分成三組: 1) 小於或等於7顆失去或填補牙的屬於低齲齒活性組(LCI) ; 2) 13顆以上失去或填補牙的屬於高齲齒低活性組(HCI) 還有3) 13顆以上DMF牙和1~4個鄰接面到牙本質的蛀牙屬於高齲齒活性組(HCA)(Table 20-6)，LCI和HCA雖有不同的臨床狀態但有相似的抗體濃度反應。他們都和HCI不同，有高濃度的血漿中IgG抗體和低分泌性IgA (Table 20-6)



These paradoxical findings were explained via an interesting hypothesis. The elevated serum IgG and IgM titers in the LCI subjects are indeed protective. For some reason, possibly genetic in origin, these LCI subjects were able to mount and maintain an effective immune response to S. mutans for long periods of time. The key word here is "maintain", as the HCA patients were also able to mount an antibody response to S. mutans, but when the carious lesions were treated these antibody titers dropped to levels which were no longer protective. Accordingly, the HCA patient became an HCI subject who could continue to develop new carious lesions whenever S. mutans regained ascendancy in the plaque.

這樣似是而非的發現可以用一個很有趣的假說解釋。在LCI組中提升的IgG與IgM的確是有保護性的。因為一些原因，也許是基因，這些LCI個體可以有效並長期維持對S. mutans的免疫反應。這裡的關鍵字是"維持"，HCA組可以有S. mutans抗體反應但當齲齒病灶時抗體反應降低到不再有保護效果。因此，當S. mutans 在牙菌斑中變得有優勢時，HCA就繼續產生新的齲齒病灶然後變成HCI。



No role for salivary IgA in caries protection was proposed in this hypothesis, probably because the low levels of IgA in the LCI subjects could not be correlated with low caries experience. However, the high levels of salivary IgA antibody in the HCI individuals could reflect a mechanism by which S. mutans was cleared from the oral cavity, and this in turn could be responsible for the caries-inactive status of these individuals. Thus, this data permits a role for both serum IgG and salivary IgA in caries protection against S. mutans. No immunological documentation could be found for the involvement of S. sanguis in the carious lesion.

在這個假說裡並沒有唾液性IgA保護抗蛀，可能因為LCI個體中低濃度的IgA無法和低齲齒相關。然而，HCI個體中唾液高濃度的IgA能反應S. mutan從口中清除也可以成為齲齒不活躍的機制。因此，這些資料證實血漿中IgG和唾液中IgA對S. mutans有抗齲作用。但沒有資料可以顯示S. sanguis在齲齒病灶內有影響



Patients with an Immune Deficiency. Considerable information concerning the functions and interactions of the various components of the immune system has been obtained from individuals who possess one or more immune deficiencies. Selective IgA deficiency is the most common form of immune deficiency occurring at a frequency of about one in every 600 to 700 individuals. Arnold and his colleagues compared the caries status of 29 patients with IgA deficiencies with the ability of the patient's saliva to agglutinate the various serotypes of S. mutans (Table 20-8).

有免疫缺失的病人

這些人就的免疫系統裡有一個或多個的缺失，造成免疫系統間的關係或是功能產生異常。選擇性的IgA缺失是最常見的免疫缺失，發生率大約是六、七百分之一。Arnold等人比較了29個有IgA缺失的人唾液抗體對抗多種S. mutans的齲齒狀況，





Table 20-8

Effect of IgA Deficiency With and Without IgM Compensation on Salivary Agglutinin Titers to S. mutans and on Dental Caries Morbidity



Immune Status

IgA Deficient

Normal IgA IgM Compensation No IgM Compensation

No. of Subjects 31 11 18

Parotid Agglutinin Titer (Log2)

S. mutans

serotype a

b

c

d

e

g

5.8

3.4

5.3

5.5

6.5

3.3

6.3

3.5

7.1

6.3

5.8

2.2

<1

<1

<1

<1

<1

<1

Dental Caries Incidence Relative to Normal

DMFT

DMFS 0

0 -1.7

-3.6 + 6.9

+ 21.6

Adapted from Arnold et al., 1977. Clin. Immun. Immunopathol. 8:475; Arnold et al., 1978. Adv. Exp. Med. Biol. 107:401-410; McGhee and Michalek 1981. Ann. Review Microbiology.



In certain instances of IgA deficiency the IgM class of antibodies compensated for the missing IgA. This IgM antibody resembled secretory IgA in that it was synthesized locally at the mucosal surfaces, had both the secretory component and J chain, and was similar to secretory IgA in its secretory dynamics. Eleven of the patients had IgM compensation in that their saliva exhibited significant agglutinin titers to the six S. mutans serotypes. These IgM-compensated patients had DMFT and DMFS scores that were similar to the normal individuals (Table 20-8).

在某些IgA缺失的情況裡會有IgM類抗體來彌補遺失的IgA。IgM抗體很像是分泌性IgA，在黏膜表面合成，都有分泌的成分和J鏈，和分泌性IgA一樣。11個病人在唾液裡有IgM補償，對

六種S. mutans有顯著的凝集反應。這些有IgM補償病人的DMFT和DMFS和正常人差不多(Table 20-8)



The 18 IgA deficient patients with no IgM compensation had no demonstrable agglutinin activity to S. mutans and had about seven more DMF teeth and 22 more DMF surfaces than the normals and the IgM-compensated patients (Table 20-8). These data indicate that in the absence of specific s-IgA antibody to S. mutans in the saliva, there is a high level of dental morbidity.

有18個IgA缺失的病人沒有IgM補償對S. mutans沒有凝集反應，大約比正常人和有IgM補償有多於7個DMF和22個DMF的表面(Table 20-8)。這些資料顯示在唾液裡缺失了對S. mutans特殊的s-IgA抗體，會容易造成牙齒的病態。



Longitudinal Studies. A limitation of the previous investigations was their cross-sectional nature. A single antibody titer does not tell if the immune response is rising, declining or static. A single caries score does not describe the current extent of the carious attack, nor the antigenic load of S. mutans that the host is encountering. Some of these problems can be reduced if multiple measurements of the various parameters are taken over a period of time. Longitudinal investigations have been performed in conjunction with caries development in radiation xerostomia patients and in patients who have received symptomatic dental treatment.

長期縱向的研究 之前的研究有斷面的限制。一個單獨的抗體並不能反應免疫反應升高，降低或是持平。一個單一的齲齒數字不能代表目前的齲齒狀況也不能代表宿主目前有S. mutans抗原性。有些問題會因為一段時間用多樣不同的因子衡量後而減少。用長期的檢驗來檢查經過放射線治療後乾口症和接受牙科治療的病人齲齒狀況。



Radiation-Xerostomic Patients. The patients who were studied for bacteriological changes in plaque after radiation therapy (Table 12-5) were also followed immunologically. Serum IgG agglutination titers to S. mutans or lactobacilli pre and post radiation were unrelated to the microbial counts of these organisms in the plaque or to caries activity. This was not the case with salivary IgA levels and antibody titers to S. mutans. Those patients destined to be caries inactive in the post-radiation period had, prior to radiation therapy, significantly higher levels of s-IgA antibody to S. mutans than did those patients destined to develop caries (Table 20-9).

放線後乾口症的病人 研究接受放射線治療後病人的口中牙菌斑細菌變化和免疫反應(Table 12-5) 接受放射線前後，血漿中S. mutans或是lactobacilli 的IgG抗體凝結和牙菌斑中的微生物或齲齒的活性和並不相關。但唾液中IgA含量與S. mutans 抗體卻不一樣。在接受放線治療後無齲齒活性的病人在接受放射線前，唾腺裡S-IgA抗體含量本來就比容易產生齲齒的人來得高。



These data provide strong evidence that, at least in radiation xerostomia patients, salivary IgA antibody rather than serum or salivary IgG antibodies, were involved in caries protection. However, a preeminent role for IgA antibody in this protection cannot be derived from this study, as most of the caries-inactive patients had received intensive fluoride and dietary therapy (Tables 19-6, 19-7). The levels of salivary IgA and agglutinin titers to S. mutans prior to radiation, however, might act as predictors of which patients will develop caries.

這些資料提供了一個強大的證據顯示，除非是接受放線後乾口症的病人，唾腺中的IgA抗體比IgG抗體(不論在血漿或是唾腺中)有更強的抗齲保護力。然而，這研究並不能保證卓越的IgA抗體保護功能，因為此研究中無齲齒活性的病人都有接受密集大量的氟化物和飲食治療。(Table19-6, 19-7)。然而，接受放線治療前的唾液IgA和S. mutans凝集程度可能可以當作此病人是否會有齲齒的預測因子。







Table 20-9

Relationship Between Subsequent Caries Activity and Changes in Salivary Agglutinin Titers to S. mutans and S. sanguis in Radiation Xerostomia Patients



Salivary Salivary agglutinin titer (log2)

Post Radiation

Caries Status IgA IgG Pre-radiation 6 mos 12 mos

Caries Inactive (13)a 5.4 b 8.9b

S. mutansd

S. sanguis 8.0

9.0 10.0

10.5 9.2

9.0

Caries Activec (23)a 3.4 7.1

S. mutans

S. sanguis 6.7

6.8 7.8

7.0 6.7

6.0

a) number of patients

b) percent of total salivary protein

c) caries active patients developed an average of 17.6 carious lesions (range 1-77)

d) titer to S. mutans strain 10449 (serotype c)

values in box significantly different from corresponding value in caries-active patients

Adapted from Brown et al., 1981. J. Dent. Res. 60:10.



Table 20-9

Relationship Between Subsequent Caries Activity and Changes in Salivary Agglutinin Titers to S. mutans and S. sanguis in Radiation Xerostomia Patients



Salivary Salivary agglutinin titer (log2)

Post Radiation

Caries Status IgA IgG Pre-radiation 6 mos 12 mos

Caries Inactive (13)a 5.4 b 8.9b

S. mutansd

S. sanguis 8.0

9.0 10.0

10.5 9.2

9.0

Caries Activec (23)a 3.4 7.1

S. mutans

S. sanguis 6.7

6.8 7.8

7.0 6.7

6.0

a) number of patients

b) percent of total salivary protein

c) caries active patients developed an average of 17.6 carious lesions (range 1-77)

d) titer to S. mutans strain 10449 (serotype c)

values in box significantly different from corresponding value in caries-active patients

Adapted from Brown et al., 1981. J. Dent. Res. 60:10.



Effect of Dental Treatment on Antibody Levels. If serum and salivary antibody levels to S. mutans are a direct reflection of the antigenic load which the host is experiencing in regard to this organism, then treatment which suppresses or eliminates S. mutans might cause a corresponding decrease in antibody titer(s) to S. mutans. This hypothesis was evaluated by reexamining the young adults who had previously been described in terms of antibody levels and caries diagnosis (Table 20-6). During the approximately nine-month interval between examinations, some patients remained caries inactive, some caries-inactive patients developed new lesions, some caries-active patients remained untreated and some received the necessary dental restorations. Challacombe compared the change in antibody titers at the zero and nine-month time periods as a function of the changing clinical status of the patient (Table 20-10).



牙科治療對抗體濃度的影響

如果血清和唾液中的S.mutans抗體是直接反應宿主接觸到的抗原生物體，那治療後就會抑制或是減少S.mutans會造成的抗體反應。這假說用之前表20-6談到的年輕人體中的抗體濃度和蛀牙情形來檢驗。在將近九個月的時間內檢驗，有些病人仍然是齲齒不活躍，有些齲齒不活躍的病人產生了新的病灶，有些齲齒活躍的病人仍未得到牙科治療，有些獲得了需要的牙科治療。Challacombe比較了從一開始到九個月後，病人體內的抗體濃度和臨床狀態的改變。(Table20-10)

Table 20-10

Sequential Change Over a None-month Period in Antibody Titers (Log2) to S. mutans as a Function of Caries Activity or Treatment



Antibody Class

Serum

Young Adults

18-14 years No. of Subjects IgG IgA IgM Saliva IgA

Mean Change in Titerb

No active caries

New caries (1.7)a

Untreated caries (2.2)a

Treated caries 15

10

9

10 0.05

0.6

0.2

-0.9

0.4

0.55

-0.4

-0.6

0.3

0.5

0.6

-0.7

-1.0

0.2

0.7

+1.5


a) mean number of carious lesions

b) serum antibody titers assayed by indirect fluorescent antibody technique. Salivary antibody titers determined by agglutination of whole cells.

values in box reflect significantly different changes in antibody titer. Paired t test.

Adapted from Challacombe, 1980. Archs. Oral Biol. 25:495.



Caries-inactive patients showed no significant changes in the levels of serum antibodies to S. mutans, but exhibited a significant decrease in salivary IgA antibody. In these patients the maintenance of the serum IgG antibody to S. mutans was associated with the caries-inactive state. But in those patients who developed new carious lesions there was a significant rise in serum IgG antibody, which argues that this antibody was not protective (Table 20-10). No significant changes in antibody titers were observed in the untreated patients. However, those caries-active patients who were treated, demonstrated significant reductions in all classes of serum antibodies and a significant increase in salivary IgA antibody (Table 20-10). This last observation was interpreted as indicating that the antigenic load of S. mutans had been decreased by the placement of dental restorations, which in turn, led to decreased synthesis of IgG antibody. Several studies have shown that dental restorative treatment does not significantly reduce the salivary levels of S. mutans (Table 13-1). Thus, the explanation for the decreased titers of S. mutans in the treated group may not be entirely valid.

齲齒活性不強的人在血清濃度裡的S. mutans抗體並沒有顯著的多，但對分泌性IgE抗體有明顯的減少。在這些病人裡，維持血漿中S. mutans的IgG抗體濃度和齲齒不活躍有相關性。然而在產生新病灶的這些病人中，IgG抗體是顯著增加的，這令人質疑是否抗體具有保護性(Table20-10)。在沒有治療的病人裡，抗體濃度沒有顯著性的改變。然而齲齒活躍而接受治療的病人，在血漿中各種抗體都減少了而分泌性的IgA顯著上升(Table20-10)。最後這個觀察被解釋成S. mutans的抗原性會因為放置了牙科復形物而減少，也就是說會降低IgG抗體的合成。有很多實驗都顯示牙科復形治療並不會降低唾液中的S. mutans(Table13-1)。因此，這解釋了在治療組中降低S. mutans的情形並不完全是有效的。



These findings were interpreted as indicating that protection against caries was correlated with high titers of serum IgG to S. mutans and that salivary IgA antibodies to S. mutans were not related to caries resistance. The results do not appear to support this conclusion. In addition, it was suggested that serum IgG antibodies regulate, in a negative feedback fashion, the secretion of salivary antibodies. This would account for the inverse relationship between serum IgG and salivary IgA antibodies to S. mutans. Thus when serum IgG levels decreased, the salivary IgA levels 這個發現可用來解釋血漿中高含量的IgG與唾液中的IgA和防止齲齒並不相關。因為結果並沒有顯示支持他們相關的結論。另外，此結論也指出血漿中IgG抗體用負向回饋調節唾液中抗體的分泌。這解釋了IgG和IgA的相互關係。因此，當血漿中IgG降低，分泌性IgA就會升高。



Summary - Human Studies. These clinical investigations demonstrate the complexity of the interrelationships between serum and salivary antibody titers to S. mutans and caries immunity. There appears to be an immune component in caries protection which was clearly demonstrated by the importance of salivary IgA antibody in the radiation xerostomia and IgA-deficient patients. However, in healthy subjects no protective role for salivary IgA has been shown. In these "normal" subjects there may be a group who mount and maintain a protective serum IgG response to S. mutans and another group who can mount but not sustain such a response. This dichotomy between the relative importance of s-IgA and serum IgG antibodies to S. mutans is sustained by animal experiments which support a role for both classes of immunoglobulins. Thus, vaccines which elicit either an IgA or an IgG response to S. mutans confer some degree of immunity to caries in animal models.

人體實驗的結論 這些臨床的檢驗了顯示血漿和唾液中S. mutans抗體和齲齒免疫反應之間關係的複雜性。這顯示出免疫因子在齲齒保護上的確有功能，這可由唾腺IgA抗體對放線後乾口症病人和缺乏IgA病人身上得到明確的驗證。然而，在健康的個體中，IgA並沒有表現出有保護抗齲的功能。在"正常"的個體哩，可能有一組抗體可以吸附並維持血漿中IgG對抗S. mutans，另一組可以吸附但無法維持這樣的反應。對於S-IgA和IgG抗體這樣的二種理論都可在動物實驗裡得到支持。因此，在一些動物實驗上可證實，疫苗某種程度地能夠引發IgA和IgG對S. mutans的反應。



Mechanisms of Antibody Protection



IgG Classical Mechanisms. If the high titer serum IgG antibody to S. mutans in the caries-free and low-MF individuals indicates a protective antibody response, then we must provide an explanation as to how these antibodies protect. Serum antibodies are readily delivered to sites in vascularized tissue where they combine with antigens to activate the complement system and/or promote surface phagocytosis. This



reaction may take place in the infected pulp and gingival crevice area, but is not likely to occur on the occlusal surfaces of teeth. Immune elements derived from the serum can only reach the organisms responsible for caries if they are liberated into the saliva or, in the case of cells, if they migrate over the tooth surface. Salivary IgG levels are low relative to serum, i.e., l0 to 20 mg/l00 ml saliva vs. l240 mg/l00 ml serum, and complement, if present in the saliva, is so dilute that it cannot be routinely detected. The titer of salivary IgG antibody specific for S. mutans is usually three to five log dilutions lower than the corresponding serum levels. Hence, specific salivary IgG antibody is so dilute that in the absence of concentrating mechanisms, the probability of this antibody encountering a single S. mutans cell is remote. Polymorphonuclear leukocytes (PMNs) enter the mouth primarily via the gingival crevice fluid (gcf). The PMNs remain functional within the gingival crevice and perhaps within that short distance about the gingival margins and interproximal areas over which the gcf flows. Once the PMNs are in saliva, they may degenerate, due to osmotic lysis in the hypotonic saliva.

抗體保護的機制



IgG古典機制 如果無齲齒和低MF的人身上有高濃度的IgG對抗S. mutans反應是代表保護性抗體反應，那麼我們必須提出這些抗體如何保護的解釋。當抗原引起了補體反應或是表面吞噬反應，血漿抗體會被準備製造好藉由血管系統運送過去。這些反應可能發生在被感染的牙髓中或是牙齦溝區域，但不會在牙齒的咬合面出現。血漿中產生的免疫因子只能到達在唾液裡或是細胞裡(當他們移動到牙齒表面時)來對抗造成齲齒的生物體。唾液IgG濃度和血漿濃度有低相關性，例如: 10到20 mg/100ml唾液 vs. 1240 mg/100 ml 血漿，還有如果唾腺中有補體，都被稀釋的很厲害以致於一般時候無法偵測到。唾液中對抗S. mutans 的特殊IgG抗體常常是血漿中三到五次方的稀釋程度。因此唾腺中IgG抗體被稀釋到幾乎不存在在機制裡，這可能因為抗體很少會遇到S. mutans細胞。多形性白血球(PMNs)主要經由牙齦溝液(gcf)進入口腔。PMNs不只在牙齦溝裡有作用且在距牙齦不遠的區或是牙縫間隙區，只要有gcf在的區域，他都有作用。當PMN進到唾液裡，因為滲透壓的關係，他們便開始在低滲透壓的唾液裡分解。



These considerations tend to minimize the protective role which IgG antibodies could play in surfaces which are bathed by saliva. Structures in the flow bed of the gingival crevice fluid however, might be exposed to the necessary concentrations of antibody, PMNs and even complement. Under normal conditions of gingival health the daily volume of the gcf is probably measured in a few mls per tooth surface per day. Whether this is adequate to provide protection against cervical and approximal caries is a matter of speculation. Even so, this protection would not extend to the occlusal surfaces where most caries initiates in humans.

這些降低了IgG抗體在有唾液的牙齒表面上的保護。然而，在有gcf流過的牙齒表面結構上，應會有足夠濃度的抗體，PMN和補體。在牙齦健康的正常情況下，每天gcf的量大約是幾毫升/牙齒表面。我們會懷疑這樣的量是否足夠保護齒頸和齒間不齲齒?即便如此，這樣的保護仍可能可以延伸到人類最容易引發齲齒的咬合面。



Fig. 20-1

Glucosyltransferase inhibition by antibody



Interference with Glucan Synthesis and Binding. If these classic mechanisms for antibody-mediated protection are unlikely to occur in saliva, how then would vaccines protect against caries? A consideration of S. mutans unique ability to form glucans and to adhere to surfaces provides some plausible hypotheses. S. mutans has on its surface at least one glucosyltransferase (GTF) site and a glucan binding site (Fig. 20-1). Suppose that one or both of these sites acts as an antigenic determinant. Antibodies directed toward these sites might inhibit glucan synthesis and/or glucan binding. Interference with synthesis and binding of this retentive polymer could result in an inability of S. mutans to form plaque or to persist in high numbers in plaque. These possibilities have been tested in vitro.

阻礙生醣作用和鍵結 如果抗體保護的古典機制不能在唾液中產生，那疫苗要如何保護防齲?另一個想法是S. mutans有獨特能力能夠合成肝醣而且可以黏附表面的假說。S. mutans表面上至少有一個glucosyltransferase(GTF)位置和一個肝醣建結位置(Fig.20-1)。假設一個或兩個鍵結位置都當作是抗原，抗體直接黏附在這些位置上會抑制肝醣的合成或是鍵結。阻礙合成或是鍵結可以抑制S. mutans產生牙菌斑或是在菌斑中的含量。這些可能性都在體外實驗中進行測試。





Crude GTF isolated from S. mutans was incubated with sucrose in the presence and absence of human sera. The rate of glucan formation was inversely related to the hemagglutinating titer, i.e., the higher the titer, the greater the inhibition of glucan formation. Modifications of this assay using radioactive sucrose have confirmed that specific IgG antibody to S. mutans will inhibit glucan synthesis by S. mutans. Subsequent experiments performed in rodents have shown that vaccines containing purified GTF elicits antibodies which confer a significant degree of protection against a cariogenic challenge with S. mutans. However, the protective antibody(ies) belonged to the IgA class of immunoglobulins (See "Rodent Models" in this chapter).

把S. mutans放在蔗糖中，沒有人類血清下培養分離出天然的GTF。肝醣的合成速度和血凝集程度成負相關，例如凝集多，肝醣合成被抑制的就多。用有放線性的蔗糖可以確認對S. mutans的特殊抗體會抑制S. mutans的肝醣生成。接下來在老鼠身上做的實驗顯示出含有純化的GTF疫苗會引發抗體反應使個體達到某種程度的防齲保護。然而，這些保護性的抗體屬於IgA免疫球蛋白類(見本章中的"老鼠實驗")

第13章P291-301

CHAPTER THIRTEEN




The Symptomatic Treatment of Dental Decay





I. Introduction

II. Removal of Infection

A. Caries Debridement

B. Indirect Pulp Capping

C. Pulpal Sterilization

III. Evaluation of Symptomatic Dental Treatment

A. Cost of Symptomatic Treatment

B. Dental Health Resulting from

Symptomatic Treatment

C. Symptomatic Treatment vs Preventive Treatment

l. Karlstad studies

2. Ypsilanti, Michigan studies

IV. Summary





INTRODUCTION



The treatment of dental decay has been concerned primarily with the physical removal of the carious tooth material followed by the replacement of the lost tooth substance, either with an inert restorative material or if the tooth was extracted, with an artificial tooth. This is a sound bacteriological approach, regardless of whether one is treating according to the nonspecific plaque hypothesis or the specific plaque hypothesis. In the former case the carious tooth substance is removed because the decay ultimately will progress into the pulp, thereby causing pain and jeopardizing the future of that tooth in the mouth. In the case of the specific plaque hypothesis, there is the added concern that the carious lesion will serve as a focus of infection that can seed other teeth in the mouth with S. mutans and other odontopathogens.



簡介



治療齲齒的方法主要是移除蛀牙的區域，接著將失去的牙齒物質以填補的方法、或是拔牙後以假牙取代。從細菌學的觀點來看，不論操作者是依據非專一性牙菌斑假說(nonspecific plaque hypothesis)或專一性牙菌斑假說(specific plaque hypothesis)，這種去除齲齒的方法都是合乎理論的。若是根據非專一性牙菌斑假說，蛀牙的齒質需被移除的理由，是為了避免進一步產生疼痛，以及避免危害這顆牙齒在口中的未來。而根據專一性牙菌斑假說的理論，齲齒患處則被認為是感染的來源，可能會將S.mutans以及其他口中致病菌傳染到其他顆牙齒上。



Great technological improvements in the physical properties of dental materials and in painless and efficient ways of removing the carious tissue from the tooth have occurred in the 20th century. Yet these improvements have had no effect on the incidence of dental caries. If it were not for the accidental discovery of fluoride's protective role against dental decay, the magnitude of decay in societies eating high proportions of foods sweetened with sucrose would be catastrophic. As it is, dental caries is regarded as being universal in man.



在二十世紀，牙科材料在物理性質方面有很大的進步，而且開始能以無痛且有效的方式將蛀牙移除，可是這些進步卻對蛀牙的發生率沒有幫助。如果不是偶然間發現了氟對於蛀牙的預防效果，在現今高蔗糖飲食的社會裡，蛀牙發生的量將會大到像場災難。因此，蛀牙被視為全人類共通的問題。



Why hasn't dental science been able to curtail the incidence of dental decay? Why haven't there been other advances commensurate with the efficacy of water fluoridation? To begin to answer these questions one has to examine the basic premise regarding caries etiology. The prevailing view since Miller's time has been that bacteria cause dental decay by their accumulation on retentive sites on the tooth surfaces. To control caries, therefore, one must suppress these accumulations. This has proved to be most difficult, considering the ability of the bacteria to attach on the tooth surfaces and to rapidly proliferate. Accordingly, preventive tactics based upon the nonspecific plaque hypothesis have been unsuccessful. But what would be the strategy and tactics for prevention if decay resulted from the dominance in the plaque of certain acidogenic organisms such as S. mutans and lactobacilli. Treatment would be limited to those individuals in whom a diagnosis of infection with these organisms could be made. Until recently there has not been enough information for treatments according to the specific plaque hypothesis to be directed effectively. In this and in Chapters 14-20, various treatment strategies and tactics, based upon both the nonspecific and specific plaque hypotheses, will be discussed. The mechanical debriding of tooth surfaces will be described first, as this represents the dominant modality of treatment in clinical dentistry.



為什麼目前牙科的技術仍無法降低蛀牙的發生率？是否有其他和飲水加氟一樣有效的方法？要回答這些問題前，必須先由齲齒發生的原因來檢視。從Miller時期開始，普遍的觀點認為蛀牙是來自於牙齒齒面上細菌的累積。因此，要控制蛀牙，就必須抑制細菌在牙齒上的累積。但這是很難做到的，因為細菌具有附著在牙齒上的能力，並且可以很快速的繁殖。因此，依據非專一性牙菌斑假說所提出的預防性措施是不成功的。但是，如果蛀牙是因為某些特定的口內細菌，如：S.mutans或是Lactobacilli所造成，那什麼才是有效的預防措施呢？首先必須能正確診斷出哪些病人已感染某些特定菌種，之後才能發展出治療的方法。但直到目前為止，根據專一性牙菌斑假說進行治療的資料仍不足以證明有效。在本章以及14-20章將以非專一性牙菌斑假說和專一性牙菌斑假說為基礎，討論不同的治療方法。首先會討論在牙齒表面進行機械式清創(mechanical debriding of tooth surface)的方法，這也是目前臨床牙醫界最常用的方法。



REMOVAL OF INFECTION (Symptomatic Treatment)



Patients usually appear in the dental office when symptoms are present. This necessitates a symptomatic treatment regimen which invariably includes the physical removal of decay from the tooth, or the tooth from the mouth. This removal of decay is also required by a specific infection hypothesis, as the carious tooth can serve to infect other teeth, as was shown in studies with the artificial fissure in which labelled strains of S. mutans spread from a discrete tooth location to colonize adjacent teeth (See "S. mutans Colonization" in Chap. 6).



去除感染(根據症狀的治療)



病人通常是因為有症狀而求診，所以我們必須依症狀做不同的治療，例如將牙齒上的齲齒移除，或是將牙齒由口內移除。因為蛀牙的牙齒會對其他牙齒造成感染，因此在專一性的感染假說(specific infection hypothesis)中，齲齒的移除也是必須的，像是在實驗中，若在人工製造的溝隙內放入標記過的S. mutans，會發現細菌會散播至鄰近的牙齒上(見第六章的"S. mutans Colonization")。



Caries Debridement



The extraction of a tooth is a quick and efficient means of eliminating an infected reservoir, but ideally should be a last resort because of the functional morbidity that it introduces into the dentition. The usual means of removing decay is by a combination of high speed drills and hand instruments. The tooth, thus debrided, is restored with a suitable dental material so as to achieve a functional and aesthetic clinical result. But how effective is this debridement in removing a S. mutans infection from these teeth or from the dentition? Loesche et al. have examined pooled approximal and fissure plaque as well as saliva in rampant caries patients before and after the delivery of the required dental treatment, i.e., placement of restorations and extraction of teeth. The levels of S. mutans were decreased compared to pretreatment values three to five fold in plaque and ten fold in saliva immediately after the completion of the polishing procedure (Table 13-1). However, one week later the fissure and salivary levels of S. mutans increased. The dental treatment had minimal effect on the proportions of S. mutans in the plaque (Table 13-1). This demonstrated that the standard method of caries treatment leaves the teeth still infected with S. mutans, a fact which might account for recurrent caries on some teeth and continued caries activity in many patients. What seems indicated are additional means of suppressing S. mutans during this mechanical debridement procedure (See "Fluoride-antimicrobial effects" in Chap. 18).



齲齒清創 Caries Debridement



拔牙是一個快又有效去除感染的方法，但是通常是最後一步，因為拔牙會造成齒列功能上的缺失。最常用來移除齲齒的方法是使用高速磨牙機(high speed drills)和手動器械(hand instruments)。清創完成的牙齒，會用合適的牙科材料進行復形，以回復臨床上的功能及美觀。但是，這樣的清創，對於受感染的牙齒或齒列其移除S. mutans的效果又是如何呢？Loesche et al曾研究猛爆型齲齒病人在接受牙科治療（例如：補牙或拔牙）前後，牙齒鄰接面和溝隙面的牙菌斑及唾液中S. mutans的量。結果發現在剛完成治療時，牙菌斑中的S. mutans的量會下降3-5倍，唾液中S. mutans的量會減少十倍(表13-1)。但是在一週後，溝隙和唾液中的細菌量都上升了，牙科治療對於牙菌斑中S. mutans所占比例的影響很小(表13-1)。這證明了標準的齲齒治療使牙齒仍受S. mutans的感染，這可能也說明了為何有些牙齒會有續發性齲齒，而有些人會一直蛀牙。這表示在對齲齒進行機械性的清創過程中，需要在加入某些步驟以減低S. mutans的量 (請見第十八章"氟化物的抗菌作用")。



The heat of friction generated by drilling against the tooth requires an air-water coolant to be used. The resulting aerosol has elevated levels of bacteria, but this appears to pose no threat to the medical health of the patient or the dentist. The bacterial density of the aerosol is highest within the mouth and declines extraorally with distance from the drilling site. The bacterial composition of the aerosol that is sprayed on the other teeth can be high in proportions of S. mutans. In the experiment presented in Table 13-2 a saliva ejector, which was connected to a high-power suction source and which had a bacterial filter positioned in line prior to the suction, was placed on the occlusal surfaces on the side opposite to the tooth to be drilled. Prior to drilling, only a few bacteria were aspirated by the suction device. When the tooth was being excavated, the bacterial count increased 100,000-fold and contained high proportions of S. mutans. The same pattern was observed in regard to the proportions of S. mutans deposited on a filter held in the vicinity of the operator's face.



因為鑽牙時產生的熱需要空氣-水冷卻，所造成的氣霧(aerosol)裡細菌的量會隨著上升，但這似乎對病人或牙醫沒有危害。在口內的氣霧中細菌濃度是最高的，隨著離鑽牙區的距離增加而下降。散佈到其他牙齒上的氣霧中，其細菌組成中可能含有高濃度的S. mutans。表13-2是對吸唾管中細菌的含量進行檢測，將吸唾管放置於鑽牙區另外一邊牙齒的咬合面上，並在和強力抽吸裝置(high power suction)連接之前，裝置一個細菌的濾器。在還沒鑽牙前，吸唾管中細菌的量很少，但當開始清除蛀牙時，吸唾管中細菌的量增加了100,000倍，而且含了高比例的S. mutans。同樣的情況也可在牙醫師面罩上的過濾器周圍被觀察到。



This raises the possibility that the debriding procedure can serve to inoculate other teeth in the patient's mouth as well as the attending dental personnel with S. mutans. This would be of concern only if S. mutans is a specific dental pathogen. The likelihood of the operator becoming infected is low when one considers the great difficulty associated with the implantation of in vitro-grown S. mutans in humans (See "S. mutans Colonization" in Chap. 6). However, the colonization of the patient's teeth by his indigenous S. mutans could be another matter, especially considering that the teeth are pulsed with about 6,000 S. mutans per minute, and that these S. mutans cells have already proved to be capable of living on the teeth of this particular host. This potential seeding can be prevented or minimized by the usage of high speed suction in the immediate vicinity of the drilling site and/or the usage of the rubber dam.



這表示由清創(debriding)這個步驟，而造成S. mutans傳播到口中其他牙齒或到牙科人員身上的可能性增加了，若S. mutans為會引起牙齒疾病的特定細菌時，這項發現才有意義。因為in vitro培養的S. mutans很難在人體存活(見第六章"S. mutans Colonization")，因此操作者受到感染的機會很低。然而，在一個原本就有S. mutans的宿主口中傳播S. mutans又是另當別論，尤其是當這顆牙每分鐘被S. mutans衝擊6000次，而且這隻S. mutans又已被證明可在此宿主生存時。這種潛在的感染，可以藉由在鑽牙處使用強力抽吸裝置，或是橡皮防濕障的使用來避免。



Indirect Pulp Capping



The debriding of the carious lesion continues until all the soft, infected dentin is removed, except in those instances where complete removal might cause pulpal exposure. In this situation the clinician temporizes by placing a dressing, usually of calcium hydroxide, over the residual carious dentin in a procedure known as indirect pulp capping. The alkalinity of the calcium hydroxide causes a hardening of this dentin, but more importantly, stimulates the odontoblasts lining the wall of the pulp to lay down a layer of secondary dentin in the vicinity of the lesion. Months later the clinician can reenter the tooth and remove the residual carious dentin with minimal risk of pulpal exposure. The necessity of this reentry process has been debated, as in most instances the teeth are asymptomatic and there is no x-ray evidence of extension of the decay into the pulp. Some argue that any remaining bacteria can continue to grow, possibly obtaining nutrients by diffusion from the pulp or by leakage about the restoration, and thereby remain a constant threat to the vitality of the tooth.



間接覆髓術 (Indirect Pulp Capping)



一般蛀牙的清除會將所有軟化的、受感染的牙本質移除，除了在某些情況之下，完全的移除會造成牙髓的暴露。在這種情況下，牙醫師會在剩餘的蛀牙區放上一個暫時的敷藥(通常是氫氧化鈣)，這個術式為間接覆髓術(indirect pulp capping)。氫氧化鈣的鹼性會造成牙本質的硬化，但更重要的是，可以刺激牙髓腔周圍的牙本質母細胞產生二級牙本質(secondary dentin)。經過數月後，醫師可以重新將剩餘的蛀牙清除乾淨，而減低牙髓暴露的機率。到底需不需要再重新進入，將剩餘的蛀牙清除仍有爭議，因為大部分牙齒通常是無症狀的，而且X-ray上也沒有顯示蛀牙區有擴大到牙髓的跡象。也有些人質疑殘留的細菌也許可以藉由從牙髓滲透作用獲得養分、或由復形物的裂縫獲取營養，進而持續生長，並對牙齒的活性造成危害。



Several studies have sought to determine the viability of organisms left behind in the carious dentin after calcium hydroxide treatment. The teeth were reentered and the softened dentin was deposited in broth media without any regard for quantitative enumeration or anaerobic procedures. In most instances, the residual dentin was sterile. This is not surprising considering that calcium hydroxide at a pH of 11 to 12 would cause cell death of most bacteria, especially those with a pH optima below 7, as would be characteristic of the aciduric organisms found in the dentinal lesion.



在放置氫氧化鈣後，殘存在蛀牙區的微生物是否仍具有生存能力，有些實驗對此進行了研究。在不考慮定量或無菌的情況下，重新進入牙齒並取出軟化的牙本質加以培養，發現大部分都是無菌的。這並不令人意外，因為大部分牙本質蛀牙內發現到的細菌為耐酸性的，適合生活在pH值小於7的環境，而pH值為11至12的氫氧化鈣會使大部分這類的細菌死亡。



The extent of the killing effect of calcium hydroxide in situ was determined in the following experiment. Carious teeth with extensive dentinal involvement, which did not encroach upon the pulp, were opened and the occlusal portion of the carious dentin was removed (Fig. 13-1A and 1B). The remaining carious dentin on one side was then excavated with hand instruments (Fig. 13-1C) and thereafter weighed, dispersed, serially diluted and cultured anaerobically. The dentin left in situ was covered with a layer of either calcium hydroxide, or zinc oxide eugenol (Fig. 13-1E) or by a wax bandage (Fig. 13-1D) before the cavity preparation was filled with a temporary cement. The wax bandage served as a control, as the wax exerted no antimicrobial activity and acted as a barrier against any antimicrobial activity on the part of the temporary cement filling.



以下的實驗則是研究在放置氫氧化鈣原位(in situ)處其殺細菌的範圍。實驗選取有大量牙本質蛀牙卻尚未侵犯至牙髓的牙齒，將靠近咬合面的蛀牙移除後(圖13-1A和1B)，剩餘的蛀牙以手動器械刮除後(圖13-1C)，將蛀牙秤重、分散、序列性稀釋，然後進行無菌培養。剩下的牙本質則用氫氧化鈣或ZOE(圖13-1E)或蠟條(was bandage)覆蓋後(圖13-1D)，再用暫時性的黏著劑充填。因為蠟不會產生抗菌的能力，而且也可以阻擋暫時性黏著劑產生的抗菌力，因此，此實驗將蠟條視為控制組。



Either one or five months later, the teeth were reentered and the remaining half of the carious dentin was removed (Fig. 13-1F) and cultured as before. The treated teeth exhibited a 95 percent reduction in bacterial counts, whereas in the control teeth, the counts increased by about 100 percent (Table 13-3). No control teeth were sterile, whereas 26 of the 80 treated teeth were sterile (Table 13-3). Thirteen of 20 control teeth showed an increase in bacterial counts, whereas an increase occurred in only five of 86 treated teeth. In 55 treated teeth the bacterial levels decreased.



經過一個月和五個月後，再重新進入牙齒，並移除剩下的蛀牙(圖13-1F)，並照之前的程序進行培養。治療過的牙齒細菌量降低了95％，而控制組則增加了100％(表13-3)。控制組的牙齒全都是有菌的，但治療過的牙齒80顆中有26顆是無菌的(表13-3)。控制組的牙齒中，20顆牙齒裡有13顆細菌是增加的，但治療過的牙齒86顆中只有5顆的細菌增加，而剩下55顆則是減少的。



The surviving bacteria in the treated teeth could have been bacteria that were resistant to calcium hydroxide and zinc oxide eugenol, or more simply, bacteria that did not contact these agents because they were in the core of the residual dentin. In this regard, the amount of dentin left behind in these experiments was considerable compared to that left behind in the actual clinical pulp capping procedure. This difference is illustrated in Figure 13-1C where the black bottom layer represents the thickness of the dentin that would normally be left in the indirect pulp capping procedure and the speckled area, the additional amount left behind in these experiments. Thus if the clinical procedure had been followed, it is reasonable to expect that even more bacteria would have been killed. If this is so, then reentry to remove the residual carious dentin after capping with either calcium hydroxide or zinc oxide-eugenol may not be necessary, if the final restoration maintains its seal and the tooth is asymptomatic.



在治療過的牙齒中，那些存活下來的細菌之所以沒有死亡，可能是對氫氧化鈣或ZOE有抵抗力，也可能是因為它存在於蛀牙的中心，而不與這些物質接觸。如此一來，比較實驗時和臨床上操作間接覆髓術時，到底各留下多少的牙本質，這點差異是必須考慮在內的。兩者間的差異可見圖13-1C：黑色的底層是間接覆髓術會留下的牙本質，而斑點處則是實驗中多留下的牙本質。如果實驗是按照臨床的步驟去操作，可以合理的推測將會有更多的細菌被殺死。如果真是這樣，如果最後的復形物有好的密封性，而且牙齒是沒有症狀的，那麼在放置氫氧化鈣或ZOE後，可能就不需要再重新進入牙齒，移除剩餘的蛀牙了。



Pulpal Sterilization



When decay extends into the pulp, an acute inflammatory response results that inevitably leads to pulpal death, frequently to abscess formation at the tooth apex and rarely to a bacteremia that results in subacute bacterial endocarditis. Treatment is either extraction or root canal therapy with systemic antibiotics such as penicillin given if acute symptoms are present. Root canal therapy is to be preferred, as it retains the tooth in situ and has an extremely high success rate, i.e., greater than 95 percent.



牙髓消毒 Pulpal Sterilization



當蛀牙延伸到牙髓時，急性的發炎反應最後必然會造成牙髓的死亡，接著經常產生根尖膿瘍或是極少見的亞急性細菌性心內膜炎(subacute bacterial endocarditis)。治療的方法為拔牙或是根管治療配合系統性的給予抗生素，例如：在有急性症狀時給予盤尼西林。因為根管治療可以保留牙齒，並且擁有高於95%的成功率，所以傾向選擇根管治療。



Because of the concern over periapical infections and because of the seriousness of subacute bacterial endocarditis, the endodontist seeks to sterilize the root canal before it is filled. He/she mechanically debrides the canal surface, irrigates with potent protein denaturants, such as paraformaldehyde, camphorated monoparachlorophenol and hydrogen peroxide during these debriding procedures, and then between treatment visits, places a tapered paper point saturated with one of the above medicaments into the canal. The sterility of the canal is tested by aseptically placing a sterile paper point into the full length of the canal and then placing this point into a broth medium which is incubated aerobically. Any bacterial growth means that the canal remains contaminated and should not be filled. Two or three successive negative cultures indicate that the canal is sterile and can be filled.



因為要避免根尖的感染以及嚴重的亞急性細菌性心內膜炎的發生，牙髓病科醫師在進行根管充填前，必須先將根管進行消毒。醫師會以機械性的方式進行根管的清創，並在清創過程中使用強效的蛋白質變性劑進行沖洗，例如：多聚甲醛(paraformaldehyde)、CMCP(camphorated monoparachlorophenol)和過氧化氫(H2O2)，在每次治療間，在根管內置放浸滿上述藥劑的紙針。在無菌的環境下將無菌的紙針放到根管全長處，再將紙針拿出、放入培養基中進行無氧培養，以測試根管內是否達到無菌。只要有任何的細菌被培養出來，即表示根管內不是無菌的，就不進行根管的充填。必須培養出二到三次是陰性的結果時，才表示根管內是無菌，這時才可以進行充填的動作。



This culturing procedure is fraught with conceptual and technical problems and has been the subject of disagreement among endodontists. The method is so sensitive that the presence of a single bacterial cell could result in a positive culture. This single cell could arise from the canal itself, from contact with any part of the cavity preparation, from the air, from nonsterile instruments, from a nonsterile paper point or from contact with the operator. Thus it is possible to obtain false-positive cultures. There is also no way to determine whether the positive culture reflects contamination at the apex or at the coronal opening to the canal. Contamination at the latter site is rather inconsequential, given its long distance from the apex and the antimicrobial nature of the filling cement. Also, by this procedure there is no way to quantitate the level of residual bacteria in the canal. A microbial load of less than 1000 may have no biological significance, whereas a load greater than a million might require prompt retreatment. Finally, false negatives can arise if the paper point adsorps within the canal any residual medicaments such as the formaldehyde and/or phenolic compounds used to sterilize between visits. Several investigators have shown that paper points can become contaminated with these chemicals to the extent that they inhibit bacterial growth if they are placed on an agar medium which had been previously inoculated with bacteria. If such a point containing medicaments at its coronal end and bacteria at its apical end is inoculated into broth, it is possible that the medicaments could diffuse into the broth and inhibit bacterial growth giving rise to a false negative. False negatives can also arise if the paper point cannot gain access to an area of the root canal which harbors bacteria, i.e., the apical aspect of the canal, lateral canals, etc.



這樣的培養過程伴隨著許多概念上與技術上的問題，所以無法受到牙髓病科醫師的認同。這個方法靈敏度太高，只要存在一個細菌，結果就會是陽性。而這個細菌可能來自於根管本身、窩洞的修形、空氣、非無菌的器械、非無菌的紙針或是和操作者的接觸，因此獲得的結果可能是偽陽性。此外，我們也無法確定到底陽性結果代表的是來自於根尖、或是來自於根管開口的感染。若是來自於根管開口的感染，則較不重要，因為位置離根尖的距離較遠，且封填的材料具有抗菌力。另外，這個步驟也無法將根管內殘餘的細菌進行定量，當microbial load低於1000可能沒有生物性上的差異，但若細菌量大於1,000,000，可能需要重新治療。再來，如果紙針吸附了根管內殘存用於殺菌的藥物，如：每次治療間放置在根管內的藥物(甲醛或酚化合物)，就可能會出現偽陰性的結果。有些學者研究了這些受到藥物汙染的紙針，若將這些紙針置放在有細菌的培養皿上，結果發現這些紙針受到藥物汙染的程度已足以抑制細菌的生長。若紙針在根管的開口處沾上了藥物，而在根尖處是有細菌的，這些藥物可能會藉由滲透作用達到根尖處，而抑制細菌的生長，導致偽陰性的結果。另外，若紙針無法到達細菌存在的地方，像是根管的最根尖處、側枝根管等地方，也可能發生偽陰性的結果。



These inadequacies of the paper point culturing technique suggest that the information provided by it is of questionable clinical value. This is borne out by numerous investigations which indicate that the bacteriological status of the canal, as determined by the paper point technique, has a minimal effect upon clinical success. In teeth filled after a positive culture, success occurred in 76 to 86 percent of the cases, whereas in teeth filled after a negative culture, success was obtained in 82 to 96 percent of the cases. Thus a presumably sterile canal was associated with about a 10 percent higher success rate. Clearly some factor other than sterility was achieved by therapy, which accounted for the high degree of healing. This could be a reduction in the bacterial load in the canal from those which caused symptoms to those which could be handled by the host's defense mechanisms. This possibility was examined for by Lindemann and Loesche in the following study.



這些利用紙針進行培養的技術並不適當，因此實驗結果所提供的資訊其臨床價值並不高。許多調查也指出，利用紙針技術決定的根管內細菌量，其對於臨床成功率的影響很微小。陽性反應的根管在充填之後，成功率有76%到86%，而陰性反應的根管在充填之後，成功率為82%到96%。因此，假設為無菌的根管，其治療的成功率只約高出10%。很明顯的，這表示治療除了能達到無菌的狀態以外，還能產生其他的因子以提高根管本身的痊癒程度。可能是根管內細菌量的降低，使宿主可用本身的防禦機制來避免症狀產生。這個可能性將由以下Lindemann和Loesche的實驗來驗證。



Forty non-vital teeth in which the pulp chamber had not been exposed to the oral cavity were chosen for study. The teeth were isolated with a rubber dam and disinfected prior to opening into the canal. A 0.1 ml aliquot of a bacterial transport medium was placed into the canal and this was introduced into all areas of the canal by instrumenting for 45 seconds with a sterile endodontic file. The file was withdrawn and the blade end cut off and cultured using a quantitative anaerobic procedure (See "Serial Dilutions" in Chap. 2). Two sterile paper points were then consecutively placed into the canal for one minute and then inoculated into broth which was incubated either aerobically or anaerobically. This procedure was followed at each of three treatment visits prior to the instrumentation of the canal.



總共選取40顆已喪失活性、但牙髓腔未暴露在口腔內的牙齒，利用橡皮防濕障將這些牙齒進行隔離與消毒，之後進行髓腔開擴。接著，將0.1 ml的細菌帶入根管中後，用消毒過的根管銼針(file)將細菌帶入根管內的每個面，45秒後將銼針取出，並將末端切下進行定量的無菌培養(見第二章”序列性稀釋”)。另外，連續在根管內放入兩支消毒過的紙針，經過一分鐘後取出，分別進行無氧及有氧的培養。以上這些步驟會在每次開始根管治療前進行。



The teeth were randomly assigned to one of the following four treatment regimens: in Group I, tap water was used as the irrigating fluid and an unmedicated sterile cotton pellet was placed in the pulp chamber prior to closure; in Group II, tap water was used to irrigate and a dry cotton pellet containing formocresol was placed in the pulp chamber; in Group III, Chlorox® was used to irrigate and an unmedicated pellet was placed in the pulp chamber; in Group IV Chlorox® was used to irrigate and a pellet containing formocresol was placed in the pulp chamber. All teeth were sealed with Cavit® as a temporary restoration.



這些牙齒被隨機分成四組：第一組使用自來水做為沖洗液並在髓腔內放置不含藥劑的棉球；第二組使用自來水做為沖洗液並在髓腔內放置含有甲醛甲酚(formocresol)的棉球；第三組使用Chlorox®做為沖洗液並在髓腔內放置不含藥劑的棉球；第四組使用Chlorox® 做為沖洗液並在髓腔內放置含有甲醛甲酚(formocresol)的棉球。所有的牙齒都以Cavit®做暫時的復形。



The bacteriological findings are presented in Table 13-4. In the initial cultures the median anaerobic bacterial counts outnumbered the median aerobic counts by about 100 to 1, clearly demonstrating that in the majority of the teeth the pulpitis was due to an anaerobic infection. Instrumentation and irrigation with water (Group I) did not reduce the number of organisms in the canals and actually was associated with a significant increase in the aerobic flora at the second visit. Instrumentation and irrigation with Chlorox® (Group III) decreased the anaerobic count, but selected for the aerobic organisms. Instrumentation, irrigation and medication with formocresol (Groups II and IV) caused a significant decrease in the anaerobic counts and a marked 10 to 100-fold decrease in the aerobic counts. As most clinicians medicate between visits with agents as potent as formocresol, the results obtained in Groups II and IV probably reflect the bacteriological status of most treated root canals.

All teeth were filled after three treatment visits, provided the tooth was asymptomatic, dry and prepared to receive the filling material. Thus teeth treated with formocresol and having a cultivable bacterial load of less than 200 organisms, appeared clinically to be no different than the teeth irrigated with water, given no medication and having a cultivable bacterial load of 100,000 organisms. This is a surprising finding and indicates that bacteriological cultures are of little value in determining when to fill a root canal.



表13-4為測試出來細菌的結果，最一開始的培養基中顯示，厭氧菌的數量遠大於好氧菌，約為100：1，表示大多數的牙髓炎是由於厭氧菌感染引起的。使用自來水沖洗(第一組)並不能降低根管內微生物的數量，而且和第二次治療時根管內好氧菌的數量增加有關。使用Chlorox®為沖洗液(第三組)可以使厭氧菌的數量減少，但卻會對好氧菌進行選擇。使用甲醛甲酚(第二、四組)可顯著的降低厭氧菌的數量，好氧菌的數量也可以減少10至100倍。許多醫師會在治療期間放置如同甲醛甲酚有效的藥劑，但事實上根管內的變化為何，我們可由第二和第四組看出。在經過三次治療後，若沒有症狀且根管已為乾燥的，所有的牙齒將會進行根管充填。在此發現，使用甲醛甲酚治療的牙齒其細菌量小於200，而只用清水沖洗的牙齒其細菌量大於100,000，但兩者間在臨床上並沒有顯著差異，這是一個令人驚訝的發現，表示其實細菌量的多少與何時進行根管充填是沒有相關的。



The availability of results from the paper point cultures and the quantitative cultures on the same teeth permitted an evaluation of the paper point procedure. Sixty of 93 paper points incubated aerobically and 74 of 111 incubated anaerobically were positive, whereas all cultures were positive by the quantitative procedure (Table 13-5), with the counts ranging from 200 to l00,000,000 organisms per canal. There was a tendency for the paper point cultures to be negative at counts less than l0,000 and positive at counts greater than l0,000. However, only in those tubes incubated aerobically in which the inocula contained ten million or more organisms did the paper point cultures correctly reflect, in all instances, the positive bacteriological status of the canal (Table 13-5). At all other bacterial levels the paper point cultures exhibited from 14 to 50 percent false negatives.



因為可以獲得利用紙針做細菌培養和細菌數定量的結果，讓我們可以對紙針的使用程序進行評估。當進行定量程序時，每根紙針上都有細菌的，而在有氧環境下的培養結果，93根紙針中有60根是陽性的；而在無氧環境下，111根紙針中有74根是陽性的(表13-5)，每個根管內細菌數量多少由200個到100,000,000個。當細菌量小於10,000時，培養出結果為陰性的可能性較大；而當細菌量大於10,000時，結果為陽性的可能性較大。然而，只有在細菌量大於一千萬時，紙針培養程序才會正確的反映出陽性結果(表13-5)。當細菌量不在這個範圍內時，約14%到50%的結果為偽陰性。



This unreliability of the paper point culturing procedure, plus the lack of correlation between bacterial levels (Table 13-4) and clinical appearance at the time of filling a root canal, argues against routine bacteriological cultures in endodontic therapy. The usage of intra-canal medication with formocresol or similar compounds between visits has a decided antimicrobial effect and should be encouraged. Diagnostic culturing should be performed when a tooth is acutely symptomatic and/or unresponsive to instrumentation.



由於紙針培養程序的結果不夠準確，而且細菌量的多少和決定臨床上是否進行根管充填間並無關係(表13-4)，因此，根管治療是否需要常規細菌的培養是有爭議的。在每次療程中間於根管內放置甲醛甲酚或類似的藥劑的確有抗菌的效果，且是被鼓勵的。而當牙齒是有症狀且/或對清創無反應時，才需進行診斷性的細菌培養(diagnostic culturing)。

第19章P437-467

CHAPTER NINETEEN




Antimicrobial Treatment Based Upon The Specific Plaque Hypothesis (SPH)





I. Introduction

II. Diagnosis of a Cariogenic Infection

A. Clinical

B. Saliva

C. Bacteriological Tests

1. Snyder Test Agar

2. Diagnostic Broths for S. mutans

3. Semi-quantitative Tests for S. mutans

4. Summary of Diagnostic Criteria

III. Chemical Agents Directed Against S. mutans

A. What Topical Antimicrobial Agent to Use

1. Substantivity

2. Taste

3. Stability

4. Safety

B. Delivery of the Agent

1. Dentifrices

2. Mouthwashes

3. Applicator Trays

4. Chewing gums, Tablets, Adherent Pastes and Lozenges

5. Depot Devices

C. Dosages and Treatment Schedules

IV. Clinical Studies

A. Topical Fluorides

1. Anti S. mutans Studies

2. Anti Caries Studies

B. Vancomycin

C. Furadroxyl

D. Iodine

E. Kanamycin

1. The White Spot Hypothesis

2. Testing the While Spot Hypothesis

V. Risk-Benefit and Cost-Benefit Considerations

A. Short Term Fluoride Treatments

B. Combined Treatment Modalities

VI. Antimicrobial Resistant Bacteria

A. Unique Aspects of Microbial Resistance on Mucous Membranes

B. Fluoride Resistance in S. mutans

VII. Summary





第十九章

根據特定性牙菌斑假說(SPH的抗菌治療

I. 前言

II. 蛀牙感染的診斷

III. A. 臨床

B. 唾液

C. 細菌學的測試

1. Snyder Test Agar　

2. Diagnostic Broths for S. mutans

　　　　　　診斷S. mutans的培養液

3. Semi-quantitative Tests for S. mutans

S. mutans的半定量測試

4. 診斷準則的總結

III. 抗S. mutans的化學藥劑

A. 使用什麼局部抗菌藥劑

1. Substantivity

2. 味道

3. 穩定性

4. 安全性

B. 藥劑的給予

1. 牙膏

2. 漱口水

3. 牙托

4. 口香糖, 藥片, 黏膠和錠劑

5. 儲存裝置

C. 劑量與使用時間表

IV. 臨床研究

A. 局部塗氟

1. 抗S. mutans 研究

2. 抗蛀牙研究

B. Vancomycin 萬古黴素

C. Furadroxyl

D. 碘

E. Kanamycin

1. 白斑假說

2. 測試白斑假說

V. 風險與益處和花費與益處的考量

A. 短期氟化物治療

B. 合併治療療法

VI. Antimicrobial Resistant Bacteria抗菌抵抗細菌?

A. 在黏膜表面微生物抵抗力的特殊面

B. S. mutans對的氟化物抵抗力

VII. 總結







INTRODUCTION



The efficacy of antimicrobial treatment increases to the extent that it can be focused upon those patients with an odontopathic infection or at risk to this infection. This is the essential tenet of the specific plaque hypothesis (SPH). The procedures described in previous chapters, whether mechanical or chemical, can be used with greater efficacy and at less cost, if they are properly targeted on individuals with an odontopathic infection. The same criteria used to identify these individuals can be used to monitor the response to the therapeutic regimen employed. The dosages and treatment schedules, after initial empirical trials, can be optimized to give the most favorable benefit to risk ratio. In this manner, the clinician will be better able to control the prognosis for a given individual's odontopathic infection.



Treatment according to the SPH is in its infancy. In this chapter some of the exploratory investigations, which seek to verify this concept, will be described.



前言



抗菌治療的效用增加對牙科病變感染或對這些感染有風險的病患的重視程度，是特定性牙菌斑假說必要的宗旨，這些程序在之前的章節有描述過，不管是機械性或化學性，可以有更好的效率且花費較低，如果他們被適當地把有牙科病變感染的個體選為目標，可使用相同用來辨別這些個體的標準，來監控使用治療療法的反應。在起初經驗法則的試驗之後，劑量與時間表可被有效的給予最佳的風險益處比例?，所以，使臨床醫師更能夠控制有牙科病變感染的個體的癒後。



根據SPH的治療還在未發達的階段，在本章，將會描述一些探究如何證實此想法的研究調查。



DIAGNOSIS OF A CARIOGENIC INFECTION



Clinical



The diagnosis of an odontopathic infection is the indispensable entry criterion for treatment according to the SPH. This diagnosis can be made clinically by the presence of multiple carious lesions and a high DMFS score. A dental history should reveal whether the patient's parents or siblings have had a high caries morbidity, or if they are wearing dentures. If the mother or older siblings have a high DMFS score, then the child being examined most likely has been infected with S. mutans and other odontopathic organisms. Diet histories that indicate frequent between-meal eating of sucrose would identify those children with a high caries risk. Unusual oral sucrose retention or low salivary flow should be suspected when smooth surface decay is observed on anterior teeth.



蛀牙感染的診斷



臨床



根據SPH，牙齒病變感染的診斷對治療的準則是必不可缺的，診斷以臨床上由多種蛀牙損害及高DMFS分數取得，牙科病史會顯示是否此患者的父母或兄弟姐妹有高蛀牙率，或是他們是否有配帶假牙，如果母親或年長的哥哥姐姐有高DMFS分數，則此孩童會有很高機會被檢查出有S. mutans的感染，或其他造成牙齒病變的微生物。飲食紀錄指出正餐間有高頻率的蔗糖攝取，將辨別出這些孩童有高蛀牙率，當發現前牙有平滑面蛀牙，可預知這些孩童有不常見的口腔蔗糖殘留或低唾液分泌。



Saliva



Decreased salivary flow resulting in a dry mouth can usually be elicited from the dental history given by a patient. The clinician can confirm this and quantify the patient's salivary secretion rate by asking the patient to expectorate saliva into a test tube or cup, either with (stimulated) or without (unstimulated) the concurrent chewing of a piece of paraffin wax for a fixed time interval. The salivary flow rate per unit time for a population of Swedish schoolchildren is shown in Table 19-1 About 30 percent of these children had what appeared to be a low salivary flow, i.e., less than 1.0 ml/min. These children could comprise a subpopulation that would be at risk to an odontopathic infection because of inadequate salivary defense mechanisms.



唾液



唾液流量的減少造成口腔乾燥時常可經由患者提供的牙科病史得到，臨床醫師可以確認且測量病患的唾液分泌速率，經由在固定時間內咀嚼蠟片(刺激)或不咀嚼蠟片(非刺激)測得，表19-1顯示瑞典學齡孩童每單位時間的唾液分泌速率，約30%的孩童顯示低唾液流量，例如少於1.9ml/min，這些孩童因為他們不全的唾液防禦機制，組成一個得到牙齒病變感染的subpopulation次級的高危險群組?，



Bacteriological Tests



These clinical and historical data should be supplemented by bacteriological evidence of an odontopathic infection. The Lactobacillus Index (See "Lactobacillus Index" in Chap. 16) was shown to be a reliable indicator of an odontopathic infection when it was applied to rampant caries patients (Tables 16-2 and 16-3). However, its reliability in identifying a high-caries-risk patient prior to the onset of clinical caries has not been demonstrated. The diagnostic value of a saliva culture can be enhanced if S. mutans is also examined for. This was not possible until the advent of the selective MSB medium (See "Selective Media" in Chap. 2), which permits reliable estimates of the salivary levels of S. mutans to be made. The salivary levels of S. mutans are related to the tooth levels of S. mutans and correlate with the number of carious lesions and the DMFS scores. This is understandable as the tooth surface and the carious lesion are the main, if not only, niche for S. mutans in the oral cavity. S. mutans levels above 100,000 per ml of saliva have been associated with active decay and may provide an accurate indication of a S. mutans infection.



細菌學實驗



這些臨床及病史資料應該以牙齒病變感染的細菌學證據來補充，實施在猛爆性蛀牙的患者身上，Lactobacillus Index指標(查閱第十六章"Lactobacillus Index)被認為是一個牙齒病變感染可靠的指標，然而，在辨認臨床蛀牙發生前的高蛀牙率病人的可靠性還未被證明，若S. mutans也被檢察，則唾液培養的診斷價值可被提高，直到selective MSB medium(查閱第二章"Selective Media")出現才有其診斷價值，其提供可靠的唾液中S. mutans預估量，唾液中S. mutans的量與牙齒表面S. mutans的量有關，且與其蛀牙的數目和DMFS有關聯，可了解的是，因為牙齒表面和蛀牙是主體，不只是S. mutans在口腔中活動範圍?，若唾液中每毫升有超過100,000的S. mutans的量，則與蛀牙活躍性有關，且能提供一個切確S. mutans感染的徵兆。



The enumeration of S. mutans and lactobacilli in salivary samples, while capable of being incorporated into a routine culturing procedure in a hospital microbiology laboratory is, as of 1981, not cost efficient in a private practice clinical situation. In an effort to transfer some of the knowledge that could be obtained from these bacteriological procedures to the clinical sector, the selective media have been simplified or modified so as to give information which, though less reliable, is nonetheless useful as a first approximation of risk to caries.



S. mutans和lactobacili在唾液樣本中的細目，將其合併當作醫院微生物實驗室常規培養程序，在1981年代私人臨床現狀成本很高，從這些細菌學過程得到的知識，轉移到臨床部分，簡單化或修改selective media，可給予一些雖然較不可靠，但對評估蛀牙的風險是有效的資料。



Snyder Test Agar. The first successful effort in this regard was the Snyder Test Agar which added a pH indicator to a glucose agar that had been adjusted to a pH of 4.7 to 5.0. Bromocresol green was chosen as the indicator dye because its pK is below pH 5.0, and therefore, it would change from green to yellow only if growth of aciduric organisms occurred. As aciduricity is a characteristic of both lactobacilli and S. mutans, this diagnostic medium was well designed to detect the presence of these organisms. Accuracy was lost because the medium was designed in a yes-no configuration and could not differentiate reliably along a spectrum of microbial levels in the saliva. Thus, one ml of saliva, which contained 1,000,000 CFU of lactobacilli might give the same positive reaction as one ml of saliva which contained only 100 CFU of lactobacilli. The correlation with salivary lactobacilli levels improved with the rapidity of the onset of color change. Thus, a color change after one or two days of incubation was more likely to indicate high levels of lactobacilli than was a change after 7 days of incubation.



Snyder Test Agar

最初成功的例子是加入pH值偵測並調整在pH值4.7-5.0的一個葡萄糖培養基Synder Test Agar，選擇三溴甲酚綠當做偵測的染色工具，因為其pK值是低於pH 5.0，所以，只有當產酸微生物存在時，會從綠色變成黃色，由於產酸能力是lactobacilli與S. mutans的特質，設計這種診斷培養基來偵測是否有這些微生物的出現，因為此培養基是設計成非是及非的型態，且無法在唾液中單憑微生物量的範圍來分辨其可靠性，使得準確性不被重視。因此，一毫升的唾液含1,000,000 CFU的lactobacilli可能與一毫升的唾液只含100 CFU的lactobacilli有相同的正反應，與唾液中lactobacilli量的關係加快了出現顏色變化的速度，所以，一或兩天培養後出現顏色變化，會較七天培養後出現顏色變化，顯示其所含lactobacilli的量更高。



In retrospect, it was unreasonable to expect that such a complex inoculum, as saliva, could yield easily interpretable data on caries susceptibility when placed into a single diagnostic medium. The fact that it seemed to do so in many instances, indicated that the trait selected for, i.e., aciduricity, was a prime requirement of a cariogenic organism.



回朔以往，這無法合理的預期，像唾液如此複雜的接種體，當放在一個單一診斷培養基中，容易產生可解釋的蛀牙敏感性資料，事實上，這似乎在很多情況下都顯示其選擇的特性，例如產酸性，是致蛀牙微生物的主要必須條件。



Diagnostic Broths for S. Mutans . Diagnostic media that give information concerning S. mutans would be of greater value in assigning individuals to high and low caries risk groups. Several broth media, which relied upon pH changes and which contained bromocresol purple as a pH indicator, were designed to give yes-no information concerning S. mutans in plaque samples. The 20 percent sucrose and 0.2 units/ml bacitracin formulation that was responsible for the success of the MSB agar medium, were added to thioglycolate broth. In another medium one percent mannitol was substituted for the sucrose, while retaining the bacitracin. Because of the instability of the bacitracin, these broths had to be used within a week after preparation, which meant that they would be of little value in a clinical setting.



診斷S. Mutans的培養液

診斷培養基提供分配辨認高低蛀牙率的組別，其S. mutans的資料，一些培養液，靠著pH值變化，以三溴甲酚紫當做pH值指示劑，設計來提供使否在牙菌斑樣本中含有S. mutans，含20%的蔗糖和0.2 units/ml的崔西桿菌素bacitracin加入thioglycolate培養液中，可成功的做成MSB培養基，其他的培養基以1%的mannitol代替蔗糖，保留崔西桿菌素，因為崔西桿菌素的不穩定性，這些培養液必須在配置後一星期內使用完，這意味著在臨床上其使用價值不高。



A third medium contained one percent mannitol and one percent arginine HC1 in a dilute trypticase base. The mannitol was added to permit the growth of mannitol fermenters such as S. mutans and L. casei, while the arginine permitted the growth of arginine fermenters and/or arginine hydrolyzers, such as S. sanguis. This medium was designed to exploit the inverse relationship, seen in plaques, between S. mutans and S. sanguis (See "Longitudinal Studies" in Chap. 12). If S. mutans dominated in the plaque, the mannitol-arginine broth would turn yellow, whereas if S. sanguis and other amino-acid-fermenting bacteria dominated, enough ammonia would be released so as to neutralize any acid production from mannitol and the broth would remain purple.



第三種培養基是在稀釋的trypticase基底含1%mannitol和1% arginine蛋白胺酸HC1，當蛋白胺酸容許蛋白胺酸發酵物及/或蛋白胺酸水解物生長，加入mannitol使得mannitol發酵物，例如S. mutans和L. casei生長，這種培養基設計來開發在牙菌斑中，S. mutans和S. sanguis間的反轉關係(查閱第十二章"Longitudinal縱向實驗")。如果在牙菌斑中，S. mutans是主要的，則mannitol-arginine培養液會變成黃色，相反的若S. sanguis或其他胺基酸發酵性細菌是主要的，會釋放出足夠的氨，去中和從mannitol產生出的酸性產物，則培養液會維持紫色。



The color changes in these diagnostic broths were evaluated according to the proportions of S. mutans in the plaque and according to the S. mutans-S. sanguis ratio. The frequency distribution of the positive results obtained with the mannitol-arginine (MA) and the sucrose-bacitracin (SB) broths were highly significant (Table 19-2). However, none of these broths was so specific that it separated out all those plaques with high and low proportions of S. mutans and high and low mutans-sanguis ratios. The MA broth was slightly better statistically primarily because of the lower levels of false positives encountered, i.e., samples in which the color changes, but S. mutans was not detectable or present in low proportions.



根據在牙菌斑中S. mutans的比例和S. mutans-S. sanguis的比率來評估這些診斷培養液的顏色變化，在mannitol-arginine(MA)及sucrose-bacitracin(SB)培養液中，得到正反應結果的分佈頻率有很高的指標意義（表19-2)。然而，沒有一種培養液有足夠特定性來分別牙菌斑中高或低比例的S. mutans，及高或低Nutans-sanguis比率，MA培養液有較高的統計學上意義，因為他的偽陽性比率較低，例如，在顏色變化的樣本中，S. mutans沒有被偵測到或表現出比例較低。



These comparisons were performed on single site occlusal plaque samples taken from individual teeth and were more likely to reflect the caries risk status of the sampled tooth rather than the patient. Accordingly the study was extended to compare the salivary levels of S. mutans with color changes in the MA, SB and a third broth, thallium acetate (TA). The TA broth contained 0.5 percent mannitol, which permits growth of S. mutans and 0.5 percent thallium acetate and 1 ppm crystal violet, which inhibits the growth of the other oral organisms. Unstimulated saliva was collected from 109, twelve to thirteen-year-old children, and inoculated into each of the diagnostic broths and onto MSB agar. One hundred of these salivas had detectable levels of S. mutans on the MSB agar, and the SB broth was positive in 95 percent of these samples; the MA broth in 70 percent, and the TA broth in 25 percent. The SB broth was thus extremely sensitive for detecting S. mutans but was not able to differentiate between the levels of S. mutans (Table 19-2). The TA broth appeared to be insensitive to S. mutans levels, whereas the MA broth was best able to distinguish between high and low proportions of S. mutans in the saliva.



這些對照以從個體取出牙齒咬合面的單一位置牙菌斑樣本完成，且較易反映出樣本牙齒的蛀牙風險狀況而不是病人個體，於是，這些研究延伸以在MA、SB和第三個培養液醋酸鉈thallium acetate(TA)的顏色變化，來比較唾液中的S. mutans的量，TA培養液含有0.5%的mannitol，可使S. mutans生長，還有0.5% thallium acetate與1ppm的紫羅蘭晶，能抑制其他口腔為生物的生長，從109個12-13歲孩童身上取得非刺激分泌的唾液，灌輸進入每個診斷培養液及MSB培養基中，發現在MSB培養基中可探測到100個唾液樣本有S. mutans存在，SB培養液中95%的樣本表現出正反應，在MA培養液中有70%，而在TA培養液中有23%。所以SB培養液對偵測S. mutans是最敏感的，但無法分辨S. mutans量的不同(表19-2)，TA培養液對S. mutans的量是不敏感的，MA培養液則是最能夠分別唾液中不同高低比率的S. mutans。



Semi-quantitative Tests for S. mutans . The diagnostic broths sacrifice diagnostic accuracy for simplicity. Bratthall, Kohler and their associates have sought to overcome these deficiencies by introducing a semiquantative salivary culturing procedure using the MSB agar. The subject chews a piece of paraffin to increase the shedding of bacteria from the teeth into the saliva. A wooden tongue depressor (spatula) is turned around ten times in the mouth in order to wet it with saliva. The tongue depressor is removed from the mouth and pressed directly against the MSB agar, thereby inoculating the agar with the saliva. A comparison of this technique with conventional cultivation of the saliva showed that more than 100 CFUs obtained with the tongue depressor corresponded to more than 1,000,000 S. mutans per ml of saliva (Table 19-3). No colonies indicated fewer than 400 CFUs of S. mutans per ml of saliva.



S. mutans的半定量測試

診斷培養液因為其簡單性犧牲了診斷的正確性，Bratthall、Kohler與其同事引進採用了一個使用MSB培養基的半定量唾液培養程序，來尋找克服這些短處的方法，個體咀嚼一片蠟片來增加細菌從牙齒脫落而進入唾液中，一個木頭製壓舌板在口中翻轉約十次使其被唾液浸濕，壓舌板從口中取出直接壓在MSB培養基上，以唾液灌輸在培養基上，與傳統培養唾液方式比較，顯示以壓舌板會取得大於100 CFUs相當於每毫升的唾液有大於1,000,000 的S. mutans (表19-3)，沒有菌落顯示其每毫升唾液少於400 CFUs的S. mutans。



This methodology was then used to survey select groups of subjects residing in Sweden for their salivary S. mutans levels. About 20 percent of the school children and military recruits sampled had high salivary S. mutans levels and were considered on the basis of a clinical examination to belong to a high caries risk group (Table 19-3). Only three percent of the dental students sampled were considered to be at risk to caries, a finding that is consistent in general with the caries status of dental students. A group of Vietnam refugees was also sampled. The individuals had a low caries experience in the past, but were developing caries in the Swedish environment. About 50 percent of the 14 to 21-year-old individuals were, on bacteriological criteria, placed in the high risk group, a finding which was confirmed by clinical examination.



這種方法論後來被使用在測量選取出居住在瑞典的個體，其唾液中S. mutans的量，約有20%學童和徵募軍人的唾液樣本有高含量的S. mutans，且以臨床實驗為基礎來考慮其屬於高蛀牙危險的組別(表19-3)，一般而言，一個牙科學生連續的蛀牙情況發現，只有3%的牙科學生樣本是有蛀牙危險的，一群越南徵召軍人也被取得樣本，在瑞典社會中，那些以往有低蛀牙率的個體，但漸漸發展出蛀牙的個體，以細菌學準則來說，臨床實驗確認在14-21歲的個體，約有20%屬於高蛀牙率組別。



These investigators are using the same culturing procedure to identify mothers with high salivary levels of S. mutans. They hope that by eliminating or reducing the S. mutans infection in the mothers, that their children will not become infected with S. mutans and accordingly will have a low caries experience. Preliminary results indicate that a comprehensive treatment program for the mothers, which included professional tooth cleaning, excavation of carious lesions, fluoride varnish and discussions about the role of sucrose, have reduced the incidence of a S. mutans infection in their children compared to children in a control group whose mothers had not received similar treatment. This type of protocol, with its apparent positive results, demonstrates the efficiency of treatment when directed according to the SPH.



這些研究者使用相同的培養程序，來辨認唾液中有高含量S. mutans的母親，他們希望藉由限制或減低母親口中S. mutans的感染，使得他們的孩子不會被S. mutans感染，也就會有較低的蛀牙率，初步的結果發現，在母親廣泛的治療計畫，包含專業潔牙，挖掘蛀牙，塗氟漆及討論蔗糖扮演的角色，與對照組中母親的小孩比較，實驗組中母親的小孩，其S. mutans感染的發生會下降，這種療程，有很明顯良好的結果，顯示當根據SPH治療的效果是很好的。



Summary of Diagnostic Criteria. Diagnosis of a cariogenic infection is essential in order to focus treatment upon those individuals either infected or at risk to infection. This selectivity is what distinguishes the SPH from the NSPH and provides for a greater efficiency and intensity of treatment. Clinical symptomatology can serve to identify those patients who should receive preventive treatment. This approach was introduced by Jay and Becks, (See "Diet Therapy" in Chap. 16) who directed their dietary therapy at rampant caries patients. They introduced the Lactobacillus Index as a means of monitoring patient compliance with the dietary regimens, and as the basis for increasing, decreasing or stopping the preventive therapy. Tests for lactobacilli can now be supplemented with tests for S. mutans, such as the semiquantitative salivary MSB cultures and the qualitative mannitol-arginine broth. In the following sections, the efficacy of various antimicrobial agents to combat an S. mutans infection and/or dental caries will be discussed. These studies were conceivable only in the context of a diagnosable cariogenic infection.



診斷準則的總結

為了針對不論是被感染的或是有危險被感染的個體治療，診斷蛀牙感染是必要的，這種選擇方法能辨別SPH與NSPH的不同，且提供了高效率及高強度的治療。臨床樣本學sympomotology可提供辨認須接受預防性治療的患者。此方法由Jay和Becks提出(查閱第十六章"飲食治療")，指引猛爆性蛀牙的患者飲食治療。他們提出以Lactobacillus為指標當作監視病人對飲食療法的合作度，且視為增加、減少或停止預防性治療的基礎。檢查lactobacilli現今可使用檢查S. mutans的方法來補充，像是半定量測試唾液MSB培養，及定性mannitol-arginine培養液。在接下來的段落文章，會討論不同的抗菌藥物對抗S. mutans感染或蛀牙的效率。這些研究只在診斷性蛀牙感染的文章中出現是可理解想見的。



CHEMICAL AGENTS DIRECTED AGAINST S. MUTANS



The ecological niche of S. mutans is the tooth surface. This has important implications for antimicrobial therapy as treatment need only be applied on the teeth, and if successful, may lead to a prolonged period without a S. mutans reinfection, as there are apparently no other oral soft tissue reservoirs of this organism. The therapist can, under these conditions, use topical agents, thereby avoiding certain problems related to the usage of systemic agents. In regard to the topical agents, a series of questions need to be answered before their usage can be considered routine. In this section investigations will be described which address such issues as 1. What topical agents to use? 2. How is this agent delivered to the dento-gingival surfaces? 3. What dosages should be used? 4. When do you stop treatment?



抗S. mutans的化學藥物



S. mutans的致病因所在在牙齒表面，這對抗為生物治療有重大含意，因為治療只需要侷限在牙齒，且如果治療成功，可能導致延長沒有S. mutans重新感染的時間，因為顯然沒有其他口腔軟組織儲存這個微生物。此治療在此狀況下可以，使用局部藥物，避免一些與使用系統性藥物相關的問題，至於局部藥物，在被視為常規使用之前，必須回答一系列的問題，在這個段落會闡述以下論點的研究，1. 使用哪一種局部藥物？2. 此藥物如何被傳遞到牙齒及牙齦表面？3. 須使用多少劑量？4. 何時停止治療？



What Topical Antimicrobial Agent to Use?



Substantivity. Any agent recommended for usage in dentistry must possess antibacterial activity against S. mutans and lactobacilli in vivo. The killing action of an agent is a function of the chemistry of the compound, but perhaps more importantly, of the contact time of the agent with the bacteria. This aspect is well recognized in medicine where the goal of antimicrobial treatment is to maintain a 24-hour level of the agent in the blood that is above the minimal inhibitory concentration (MIC) determined in vitro. This concept has not been appreciated in dentistry, since most antimicrobial agents have been packaged in mouthrinses, gels and dentifrices which by design, are present for only minutes per day in the oral cavity. If the agent is not immediately bactericidal and/or capable of penetrating the depth of the plaque, it will have a minimal and/or transient effect on the oral flora. From this consideration alone, the failures of most oral antimicrobial agents can be explained. Thus when chlorhexidine was shown to prevent plaque (See "Chlorhexidine" in Chap. 18), it meant that there was something unique about chlorhexidine. This appears now to be the substantivity of chlorhexidine in the oral cavity due to its basic charges, which allow it to adsorb to the mainly negatively-charged tooth and mucosal surfaces.



使用哪一種局部藥物？



獨立自力性? Substantivity

任何被建議使用在牙科上的藥物必須在人體，具備抗S. mutans 和lactobacilli的抗菌能力，藥物的殺菌作用是一個複合體的化學功效，但更重要的是，此藥物與細菌接觸的時間，在藥物上此觀點被認可，抗菌治療的目標是在血液中，24小時維持定量藥物，需高過體外實驗的最低抗菌濃度(MIC)。此論點在牙科不被賞識，因為多數抗菌藥物被包裝入漱口水、膠或牙膏中，且被設計使用在口腔中一天只有數分鐘時間，如果藥物沒有立刻殺菌或深入牙菌斑中，其作用在口腔微生物的效果只是侷限且短暫的。單獨考慮到此，可以解釋為什麼大部分抗菌藥物會失敗。所以當chlorhexidine顯示可預防牙菌斑(查閱第十八章"Chlorhexidine")，這表示chlorhexidine有一種獨特性，這顯然是在口腔中，chlorhexidine的substantivity，因為其鹼性帶電荷，能使其附著到主要帶負電的牙齒及黏膜表面。



The experience with chlorhexidine indicates that substantivity on the dentogingival surfaces should be a characteristic of a topical agent. Accordingly, potential oral antimicrobial agents should be evaluated for release in an active form. A demanding in vitro test for the substantivity and prolonged antimicrobial activity has been described by Turesky et al. Extracted teeth are polished and immersed into a one percent solution of the test agent for one minute. The tooth is air dried, immersed again for one minute, and again air dried. The tooth is placed into 250 ml of distilled water for five minutes to remove any loosely-bound agent. At this point the tooth is sequentially placed for various periods of time into a series of broth media inoculated with S. mutans. Chlorhexidine and dodecylamine were the most potent inhibitors in this system, as after four serial passages totaling 25 hours in broth, the teeth treated with these agents were still capable of inhibiting growth.



使用chlorhexidine的經驗顯示，在牙齒牙齦表面的substantivity應該是局部用藥的一種特性，因此，必須評估以活性型態釋放可能的口內抗菌藥物，Turesky及其同事描述，在體外高要求標準的研究substantivity，及延長的抗菌活性的實驗，研磨拔出的牙齒並將其包埋入1%實驗用藥的溶液中一分鐘，將牙齒風乾，再次浸泡在250 ml蒸餾水五分鐘，去除任何零星附著的用藥，此時，依序將牙齒放入且灌輸入S. mutans不同系列的培養液，以不同時間期間點放入，在此系統中，chlorhexidine與dodycylamine是最顯著的抑制劑，在培養液中25小時通過四個系列過程後，以這兩種藥物治療的牙齒還是能夠抑制微生物的生長。



Substantivity may be enhanced by pretreating the enamel so as to make it more receptive for the retention of the agent. Acid treatment of the enamel permits more fluoride to penetrate the enamel layer and as discussed in Chapter 18, this fluoride could act as a reservoir of antimicrobial activity (See "Fluoride-Antimicrobial Effects" in Chap. 18). The enamel could be treated in other ways so as to increase substantivity of other agents. When enamel slabs were treated in vitro with chelating agents, such as oxalate and fumarate and then exposed to hexachloraphene, the enamel levels of hexachloraphene increased by six- to seven-fold. These slabs exhibited marked inhibition of plaque formation compared to controls when incubated with S. mutans. These results warrant clinical testing of the enamel conditioning system in the caries-susceptible patient.



經由穿越牙釉質可加強substantivity，使其藥物的保留更能被容納接受，在第十八章討論到，牙釉質的酸治療容許更多氟化物穿越牙釉質表面，氟可以扮演抗菌能力的儲藏室(查閱第十八章"氟化物的抗菌作用")，牙釉質能夠以其他方法治療，像是增加其他藥物的substantivity，當牙釉質切片在體外，用螯合劑，像是草酸鹽oxalate和反丁西二酸鹽fumarate治療，接著暴露在六氯酚hexachloraphene，則牙釉質的六氯酚量會提高六到七倍，這些切片顯示，當與S. mutans培養在一起，跟對照組比較，實驗組顯著可抑制牙菌斑的生長。這些結果證明在蛀牙敏感的患者上，臨床牙釉質處理系統的臨床測試。



Taste. The usage of a topical agent in the oral cavity and especially in children requires that the agent possess a taste that is acceptable. The organoleptic properties of the agent will thus assume importance out of proportion to its therapeutic efficacy. Little information regarding the taste characteristics of antimicrobial agents is provided by the pharmaceutical industry, because this information was never important in the design of products that were used in medicine. A topical agent such as bacitracin has such an objectionable taste that some of its anticariogenic activity in animal models (See Table 8-3) could be attributed to the animals' refusal to eat food containing this agent. Other topical antibiotics, such as kanamycin, vancomycin, neomycin and puromycin, do not possess a disagreeable taste. Many of the agents used in the oral cavity, such as chlorhexidine, fluorides and iodine, have undesirable taste characteristics. Fortunately in many instances these taste(s) can be masked. More information on the gustatory sensations of these topical antimicrobial agents is needed.



味道

在口腔中使用局部用藥特別是在孩童身上，藥物需要具備可接受的味道，這些用藥的感官特性，除其治療效用外將是重點，藥物廠商提供非常少考慮到抗菌藥物味道特性的資訊，因為這些資訊在設計視為藥物的這些商品，從不是最重要的，像是崔西桿菌素bacitracin，此局部用藥就有令人反感的味道，其可歸因於一些在抗菌作用的動物模型上(查閱表8-3)，動物拒絕食用含這些藥物的食物，其他局部抗生素，像是卡那黴素kanamycin、萬古黴素vancomycin、nemycin和puromycin，就沒有這種無法接受的味道，很多使用在口腔的藥物，像是chlorhexidine、氟和碘就有此反感的味道，幸好在很多時候，這種味道可被隱藏，我們需要致力於取得更多這些局部抗菌藥物味覺的資料。



Stability. The oral antimicrobial agents should be stable at room temperatures for considerable periods of time. Most antiseptics, fluorides and some antibiotics, i.e., kanamycin, neomycin and polymyxin possess this stability. Vancomycin and bacitracin, after solubilization, remain active for only a few weeks at room temperature. Chlorhexidine can be inactivated by anionic substances, such as phosphates, carbonates, sulfates and anionic detergents. Since these compounds are often found in toothpastes, it is possible that the addition of chlorhexidine to such a delivery vehicle will render it inactive. Thus, in addition to stability, the bioavailability of the agent in various dentifrices, gels and mouthrinses will have to be determined.



穩定性

口腔抗菌藥物必須在室溫下相當的時間內保持穩定，多數的消毒劑、氟化物及一些抗生素，像是卡那黴素、neomycin和polymycin具備此穩定性。萬古黴素和崔西桿菌素，在溶解後，室溫下只能維持幾周的活躍性，Chlorhexidine因為其負離子物質，像是磷酸、碳酸、硫酸及負離子去汙劑，可以保持非活性，既然這些複合物時常發現在牙膏中，也可能加在chlorhexidine中成為傳遞媒介，使其保持非活躍性，所以，除了穩定性，必須決定在不同牙膏、牙膠或漱口水中，此藥物的生物利用度。



Safety. The safety of any oral antimicrobial agent will have to be established on the basis of animal studies and carefully monitored human trials. Chlorhexidine has been extensively used in various medical fields with no serious toxicity found. After two years of continuous use in two separate dental studies, no evidence of reduced effectiveness, bacterial resistance, yeast overgrowth or other signs of toxicity were found. Flotra et al. noted that epithelial desquamation may occur in any occasional patient. A brown stain appears unavoidable and may irreversibly discolor silicate restorations. The stain on the natural surfaces is readily removed by dental polishing.



安全性

任何口腔抗菌藥物必須以動物實驗及仔細監控的人類連續研究為基礎，chlorhexidine是最常用在不同醫學領域，且沒有重大毒性的抗菌藥物，在兩個獨立的牙科研究連續兩年的使用後，沒有證據顯示其效用減低，細菌產生抗藥性，或有酵母菌的增生，或其他毒性徵兆的產生，Flotra及其同事發現，上皮脫削可能會偶而發生在患者身上，棕色染色無可避免會發生，且含矽的填補物可能會有不可逆的變色，這些在天然正常的表面形成的染色可用牙科打磨移除。



Fluoride has a more extensive safety record, as water fluoridation and fluoride dentifrices have been used for 20 to 30 years without obvious evidence of toxicity. The dentifrices are formulated to deliver about 1 mg of fluoride per gram of toothpaste. If approximately 0.5 g of toothpaste is used per brushing, then about 0.5-1 ppm are applied to the tooth surfaces. Eighty percent of the dentifrice can be recovered in the rinsing water, so that 0.1 to 0.2 ppm are either swallowed or absorbed to oral surfaces. If the APF gels which contain 0.5 percent fluoride are used, considerably more fluoride is available both for adsorption to the teeth and for swallowing. If approximately 3 to 5 ml of gel are applied per treatment, this would contain about 15 to 25 ppm of fluoride. If eighty percent of the gel is expectorated, this leaves behind 3 to 5 ppm of fluoride. Some of this goes into the tooth, as judged by the analysis of the enamel surface, and some is swallowed. In the Cheektowaga study, over 200 applications of gels containing 0.5 percent fluoride were not associated with any signs of toxicity. Nevertheless, the use of topicals with 0.5 percent or 1.23 percent fluoride requires a prescription and should be carefully monitored. The treatment should be for short periods so as to minimize any signs of chronic fluoride toxicity. Continuous doses of fluoride in the range of 20 to 30 ppm over a period of years has been associated with osteosclerosis and thyroid changes.



氟有更大規模安全的歷史記錄，飲水加氟及含氟牙膏已使用了20-30年，並沒有發現明顯的毒性，牙膏每公克約傳遞1毫克的氟，若每次刷牙使用約0.5克的牙膏，則約0.5-1ppm會被使用在牙齒表面上，80%的牙膏可以在漱口沖掉的水中發現，所以有0.1-0.2ppm的氟不是被吞下就是被口腔表面吸收，如果使用含有0.5%氟的APF氟膠，可想而知更多的氟會被牙齒吸附或吞下，如果每次治療使用約3-5 ml的氟膠，則會包含約15-25 ppm的氟，如果80%的氟膠被咳出，這會留下3-5 ppm的氟，一些會進入牙齒，如同進入牙釉質表面?，另一些則會被吞下，在Cheektowaga研究中，多於200次0.5%的塗氟膠與任何毒性徵兆無關，然而，局部使用0.5%或1.23%的氟需要處方籤才能使用，且必須嚴格的監控，治療必須是短期才能減少任何長期氟中毒的發生，氟劑量在20-30 ppm的範圍連續使用幾年，與軟骨症及甲狀腺的病變有關。



Regulations related to safety and efficacy have proved to be a major obstacle in the development of new topical antimicrobial agents in the United States. Since 1962, when the legislation was enacted, only a toothpaste with monoflurophosphate, has been approved by the dental division of the FDA. The necessary toxicology studies in animals which must be done prior to human studies may cost about one million dollars. Most dental pharmaceutical companies are seeking approval for an over-the-counter product, which can be used frequently, if not daily. The safety requirements for a compound with such unrestricted usage have to be stringent, and this apparently accounts for the essentially zero approval rate. FDA approval for prescription-type agents that are used in individuals diagnosed as having an odontogenic infection should not be as difficult to obtain. However, neither the dental profession nor industry have approached the FDA from this perspective. Only a few clinical trails have been performed according to the specific plaque hypothesis, and these have been done with agents that had been introduced to the market prior to 1962.



與安全性及效用有關的法規證明是美國新的局部抗菌藥物發展的重要阻礙，自1962年起，當有立法制定，只有含monoflurophosphate的牙膏被FDA的牙科部門認可，必要的動物毒性實驗必須在需花費約一百萬美金的人體實驗之前完成，大多牙科藥材廠商尋求在賣場可得，不是每天但時常被使用的商品認可，這無限制使用的複合物，其安全要求必須是嚴厲且令人信服的，但顯然的其說明認可率幾乎是零。FDA對處方簽藥物的認可，使用在診斷為牙科病變感染的個體，不應該太困難取得。然而，牙科專業人士或工業皆沒有達到FDA的此觀點，在1962年之前上市的藥物，只有一些臨床連續實驗是根據特定性牙菌斑假說來實行。



Delivery of the Agent



Antimicrobial therapy should bring the drug into contact with the infecting bacteria for a time period sufficient to eliminate the bacteria, or to reduce the bacterial load to a level where host defense mechanisms can control the infection. In systemic infections, the drug is given orally or is injected. These delivery systems have not been used in dentistry, except where overt dental abscesses are present. Instead, mouthrinses and dentifrices have been almost exclusively used as delivery systems. Convenient as these may be, they fail as vehicles for therapeutic agents, except in those instances where the drug has unusual substantivity. In the discussion which follows, we will examine the various delivery systems available for oral chemotherapeutic agents.



藥劑的給予

抗菌治療必須將藥物帶到與引起感染的細菌接觸一段足夠時間來抑制細菌，或是減少細菌承載量到一定的量，宿主抵抗機制可以控制感染，當系統性感染時，藥物以口服或注射給予，除了當明顯的牙齒膿殤出現，牙科上並沒有使用這些傳遞系統，取而代之，漱口水跟牙膏幾乎是唯一的使用途徑，雖然使用方便，除了在這些藥物有不常見的substantivity情況下，它們無法做為治療藥物的傳達媒介?，在接下來的討論中，我們會檢視口腔化學治療藥物不同的傳遞媒介系統。



Dentifrices. Dentifrices are pleasant-tasting pastes containing abrasive ingredients, which were designed to be used with toothbrushes, in order to facilitate the debriding of the dentogingival surfaces of food particles and plaque. Approximately 0.5 to 1 g of dentifrice is used for a brushing which takes less than one minute. There is the possibility that the dentifrice ingredients could inactivate the therapeutic agent, as occurred in certain trials involving chlorhexidine. Dentifrices remain a popular choice for the delivery of chemotherapeutic agents, probably due to the success of the fluoridated dentifrices and the public and professional acceptance of toothbrushing as a valid oral hygiene procedure. However, toothbrushing with abrasive dentifrices should be an adjunct to antimicrobial therapy, with the brushing preceding the application of the antimicrobial agent.



牙膏

牙膏是含有研磨劑且味道良好的膏狀物，設計以牙刷使用，來促進去除牙齒牙齦表面的食物殘渣及牙菌班，使用約0.5-1克的牙膏刷牙耗時不會超過一分鐘，在一些含chlorhexidine的實驗，牙膏分子有可能會阻止治療藥物，牙膏依舊是常見的化學治療藥物傳遞媒介的選擇，可能因為含氟牙膏的成功，及大眾和專業人士接受刷牙仍是良好的口腔衛生維持的程序，然而，用研磨牙膏刷牙應該是抗菌治療的助手，伴隨刷牙動作會優於抗菌藥物的給予?。



Mouthrinses. Mouthrinses are inefficient delivery systems for a plaque antimicrobial agent because the one minute or more rinsing time is not adequate for the agent to penetrate and kill bacteria located in the deeper layers of supragingival plaque, occlusal fissures, the gingival sulcus, the periodontal pocket and the interproximal spaces. Stralfors calculated that if a mouthrinse were able to kill 75 percent of the oral flora, the original numbers would be present within one hour. This kill value is about the level which some antibacterial mouthrinses report concerning the decrease in salivary bacterial counts. Even here, the level of salivary reduction is misleading, as the salivary flora bears little resemblance to the supra- or subgingival plaque flora. Thus the reductions in the salivary flora achieved with some mouthrinses may be obtained against a group of organisms which have never been associated with caries or periodontal disease. These considerations make all the more remarkable the antiplaque and antigingivitis action of chlorhexidine and the anticaries action of fluoride when delivered in mouthrinses. Since this beneficial result is most likely dependent on the substantivity of these agents on the tooth surfaces, it may be concluded that only agents with similar substantivity can be effective when delivered in a mouthrinse.



漱口水

以漱口水作為牙菌班抗菌藥物的給予效率不高，因為1分鐘或更多的漱口時間對藥物穿透深層牙齦下牙菌斑、咬合面溝隙、牙齦溝、牙周囊袋及鄰接面空間，還有殺死細菌是不夠的，Stralfors計算，如果漱口水要能殺死75%的口腔微生物，原始數目必須存在一小時內，這能夠殺死細菌的值，約是一些抗菌漱口水考慮到降低唾液細菌數目所提出的量，甚至，因為當唾液中微生物很少與牙齦上或牙齦下牙菌斑微生物是相似的，唾液減少量是令人誤解的。所以，在一些漱口水中達到唾液微生物的降低，可能只能得到對抗一群與蛀牙及牙周並無關的微生物，這些考量，使得當以漱口水型式給予，chlorhexidine有更顯著的抗牙菌斑及抗牙周炎作用，且氟的抗蛀牙作用更明顯。所以這有利的結果，是歸功於這些藥物在牙齒表面上的substantivity，結論是只有有相似substantivity的藥物，當以漱口水給予會較有效率。



Frequent usage, such as every three to four hours, may be an effective treatment schedule for mouthrinses containing antimicrobial agents with rapid killing action and low or no substantivity. This regimen could be maintained for one to two weeks with patient cooperation, if used for treatment of a diagnosed infection. However, if used prophylactically on an open-ended schedule, the cooperation of most subjects would be difficult to obtain.



時常使用，例如每3-4小時使用一次，在含抗菌藥物的漱口水可能是有效的治療，他有快速的殺死細菌作用，且其substantivity是很低或沒有的，如果診斷為有感染情況下，這種療法可以在患者合作下維持1-2周，然而，如果預防性的沒有期限下使用，多數個體要維持合作度將是困難的。



Applicator Trays. The applicator tray is a device which fits over the coronal surfaces of the teeth. It can be individually fabricated out of plastic from a model of the teeth or can be purchased in standard sizes from certain dental suppliers. With some trays, a sponge insert can be placed in the trays so as to occlude the space between tray and tooth. The applicator is an effective way of delivering a chemotherapeutic agent to the tooth surfaces. The agent is not diluted by the saliva and has little contact with the soft tissue and tongue, thereby minimizing mucosal irritations. Applicator trays are not convenient for continuous daily usage, as would be indicated under the NSPH, and have been generally neglected by the dental profession, except as a means of giving six-month or yearly topical fluoride treatments. However, they hold great promise as a delivery system for antimicrobial agents used under the rationale of the SPH (See "Cheektowaga Study" in Chap. 18).



牙托

牙托是一個能吻合牙齒冠狀面的裝置，他可以由牙齒模型個別製造成塑膠形式，或是從某些牙材供應商得到固定尺寸的牙托，某些牙托，有海綿裝在牙托上使其佔據牙托與牙齒中間的空間，這種方式對給予牙齒表面化學治療藥物是相當有效率的方法，藥物不會被唾液稀釋，且很少與口腔軟組織和舌頭接觸，所以降低黏膜的刺激，連續性每天使用牙托是不方便的，在NSPH指示下，除了當作每半年或一年局部塗氟治療的工具，牙托一般被牙科專業人士忽略。然而，在SPH的基礎下，牙托作為抗菌藥物的傳遞媒介系統有很高的承諾?(查閱第十八章"cheektowaga研究")。



Chewing Gums, Tablets, Adherent Paste and Lozenges. Chewing gums, tablets, adherent pastes and lozenges could serve as slow-release devices that would permit the presence of an antimicrobial agent in the oral cavity for periods of five minutes or more. If the agent had an affinity for the dental surfaces, such as fluoride and chlorhexidine have, then this delivery system could be effective.




口香糖、藥片、黏著牙膏和錠劑

口香糖、藥片、黏著牙膏和錠劑可做為慢速釋放的工具，使得抗菌藥物在口腔中停留五分鐘或更久，如果藥物對牙齒表面有親合力，如同氟及chlorhexidine，則此傳遞系統將會是有效的。



Depot Devices. A more convenient and efficacious method of drug delivery would be to place the drug in a receptacle or device which can be anchored to the tooth surface. If the drug could be embedded in a matrix which is slowly solubilized in the saliva, then continuous antimicrobial levels could be maintained in the saliva for days or weeks after the insertion of the device. The receptacle would have to be small and within the physiological tolerance of the dental structures. The acceptance of orthodontic therapy would indicate that patients will tolerate a small device secured to one or more teeth. The kinetics of drug release would have to be predetermined to assure drug levels above the MIC (minimal inhibitory concentration) levels of various plaque organisms. The devices could be attached to newly erupted teeth in individuals who have a history of above-average caries experience or who have elevated levels of S. mutans of lactobacilli in their saliva. In the case of periodontal disease, the device could be placed directly into the pocket and need not be attached to the tooth.



儲存裝置

藥物傳遞更方便且有效率的方法是，將藥物放在一個可固定連結到牙齒表面容器或裝置中，如果藥物可以被包埋在一個在唾液中慢速溶解的模型，然後抗菌藥物可以在投入此裝置後，在唾液中持續維持一定濃度達幾天到幾周。此容器必須要小且在牙齒結構的生理耐受度內，根據對矯正牙齒治療的接受度指出，患者能夠接受固定一或數顆牙齒的小裝置，必須事先決定藥物動力學的釋放，來確保藥物濃度高於多種牙菌斑為生物的MIC(最低抑制濃度)，這裝置可以連結到有高於平均蛀牙率歷史，或唾液中有較高S. mutans和lactobacilli濃度的個體，其新萌發的牙齒，在牙周病中，此裝置可被放置與牙周囊袋直接接觸，且不需要接觸到牙齒。



The depot preparations represent a logical development in topical delivery systems for use in the oral cavity. Considerable clinical testing will be necessary before optimal drug levels can be determined. This development should come about cautiously and within the framework of the SPH.



此儲藏裝置準備代表使用在口腔中局部傳遞系統的合理發展，在最理想的藥物濃度確定前，必須有相當多的臨床測試，此產物必須謹慎的發展且須在SPH的框架中。



Dosages and Treatment Schedules



Topical antimicrobial agents should be delivered to the dentogingival surfaces in dosages that are adequate to yield a therapeutic result. But how do you measure a therapeutic result in the case of dental caries, when six to 24 months are necessary to determine whether the caries incidence has been reduced or stopped? Is there some clinical-pathological parameter that can be quickly changed by an effective agent(s) that is properly delivered to the caries-prone sites on the teeth? Many investigators have used plaque reduction as such an indicator. However, the plaque that is assessed is from the noncaries-prone sites at the dentogingival margin and most likely does not resemble the microbial composition found on caries-prone fissures and approximal sites. With the demonstration of the involvement of S. mutans and lactobacilli in dental caries, it became possible to use the levels of these organisms in saliva and their proportions in the plaque as a means of measuring treatment efficacy.



劑量與使用時間表

局部抗菌藥物必須以足夠達到治療結果的劑量，傳遞到牙齒牙齦表面，但是當需要6-24個月來確定是否蛀牙率有降低或停止時，要如何去測量一個蛀牙案例的治療結果呢?是否有一些被適當給予到牙齒容易蛀牙部位的藥物，可以迅速改變臨床病理變數?很多研究者使用牙菌斑減少當做指標，然而，確定評估從牙齒牙齦邊緣非高蛀牙率部位，及最高蛀牙率的溝隙和鄰接面的牙菌斑，在蛀牙中包含S. mutans和lactobacilli的證明，這證實使用這些唾液中微生物的量和他們在牙菌斑的組成，可當做測量治療效用的依據。



When S. mutans is found in levels greater than 100,000/ml saliva, active caries or a high DMFS score is usually present. When S. mutans is found in levels less than 1,000/ml saliva, active caries is usually absent. This last value could then serve as a therapeutic goal for treatment. Thus if usage of an antimicrobial agent suppressed S. mutans to levels below 1,000/ml of saliva, this treatment could be considered to be effective. In fact, such a treatment endpoint could possibly jeopardize S. mutans' survival on the teeth, as this salivary level is near the colonization threshold of S. mutans for fissures and below its colonization threshold, i.e., 10,000 CFU/ml for smooth surfaces (See "S. mutans Colonization" in Chap. 6). Accordingly, treatment which suppresses S. mutans to below 1000 CFU/ml of saliva could so reduce the chances for S. mutans to recolonize the teeth, that it could take months for S. mutans to reestablish itself in numbers that would constitute a cariogenic challenge to the teeth.



當在唾液中發現S. mutans的量大於100,000/ml時，通常可發現有活躍性的蛀牙或高DMFS分數，當唾液中S. mutans的量小於1,000/ml時，通常沒有活躍性的蛀牙，這最後的數值可當做治療的目標，所以如果使用一個抗菌藥物可以抑制S. mutans到在唾液中小於1,000/ml的量，則此治療可被視為有效的，事實上，這種治療的終點可能危及S. mutans在牙齒的存活，因為此唾液量是接近S. mutans在溝隙中形成菌落的閾值，且低於他形成菌落的閾值，例如在平滑面試10,000 CFU/ml (查閱第六章"S. mutans的菌落")，因此，抑制S. mutans到唾液中低於1000 CFU/ml的治療可以降低S. mutans在牙齒上重新形成菌落的機會，這對S. mutans來說會需要幾個月的時間重新建立足夠數目，來組成對牙齒產生威脅的量。



This ecological information was not available at the time of the initiation of the clinical trials that will be discussed in this chapter. In the absence of such a well-defined bacteriological endpoint, these clinical studies sought to determine whether various agents given in a variety of treatment schedules could simply reduce the salivary and/or plaque levels of S. mutans and/or lactobacilli. In certain studies the bacteriological findings were correlated with the subsequent caries experience of the patients.



這個生態學的資料在此章節討論的臨床連續實驗開始時還未可得，在缺少此清楚定義的細菌學終點時，這些臨床研究尋求，決定是否以不同治療時間表給予不同的藥物可以單純的降低唾液或牙菌斑中，S. mutans或lactobacilli的量，在一些研究中，細菌學的發現與患者隨後的蛀牙經驗有關。



Three treatment schedules were evident in these studies. One schedule required the patients to use the agent daily or almost daily. The only reason why these studies would not be considered as treatment according to the NSPH was the diagnosis in the patients, by clinical and/or bacteriological criteria, of a high caries risk. The second schedule also was derived from the NSPH, as it required the patients to use the medication repeatedly at regular intervals. Only the third schedule was unique to the SPH, as it involved a single short-term, intensive application of the agent.



在這些研究中，證實了三種治療時間表，第一種時間表需要患者每天或幾乎每天使用藥物，根據NSPH，為什麼這些研究不被考慮為治療的原因是，這些病患在臨床或細菌學標準的診斷是屬於高蛀牙率的，第二種時間表是源於NSPH，需要患者重複在一定的期間使用藥物，只有第三種時間表對SPH來說是獨特的，單次短暫密集的給予藥物。



CLINICAL STUDIES



Clinical studies involving a complex and chronic infection such as dental caries are fraught with operational difficulties. The studies to be described have in common that the treated patients were diagnosed as being at risk to caries. The chemical agents used, with the exception of chlorhexidine, are antimicrobials that were existent prior to the 1962 amendment to the Federal Drug Act.



臨床研究

臨床研究包括複雜且慢性的感染，例如住牙是伴隨著處理困難性的，討論到的研究，診斷有蛀牙風險來治療的患者是有相關性的，除了chlorhexidine以外，在1962年聯邦藥物管理局修正以前，使用化學藥物來抗菌就已存在。



Topical Fluorides



Anti-S. mutans Studies. Fluoride in low concentrations, especially in an acidic environment has a strong antimicrobial action mediated primarily against enolase (See Fig. 18-2). This antimicrobial effect of fluoride would occur any time a topical fluoride treatment was given.



局部塗氟

抗S. mutans研究

氟化物以低濃度，特別是在酸性環境有很強的抗菌作用，來傳達初步抗enolase (查閱圖18-2)，這個氟的抗菌作用會在局部塗氟治療中任何間點發生。



A specific effect of fluoride in vivo on S. mutans in humans was first demonstrated by Woods. He selected patients who had S. mutans in their plaques (a bacteriological diagnosis) and treated them with a dental polishing, using pastes with and without fluoride. One week later a significant decrease in the proportions of S. mutans was found in plaques taken from individuals who had been treated with fluoride. We have confirmed this result and have shown that the reduction in proportions of S. mutans can persist for up to 12 weeks after fluoride treatment. In these studies, teenage boys, living in a rehabilitation center, were randomly assigned to fluoride (1.23 percent acidulated phosphate fluoride (APF) gel) or placebo groups. Prior to getting treatment, the average values for percent S. mutans and percent S. sanguis were comparable in each group. Ten five-minute applications of either APF or placebo gels in applicator trays were given under supervision for two consecutive school weeks. No prior dental polishing was given. The proportions of S. mutans in the single approximal plaque was reduced by 50 to 70 percent in the APF group, compared to pretreatment values at each sampling period (Table 19-4). In the placebo group the proportions of S. mutans increased at each sampling period.



在人體研究氟化物在S. mutans的特別作用首先被Woods證明，他選擇在牙菌斑中有S. mutans的患者(細菌學診斷)，且使用含氟或不含氟的膏狀物來打亮牙齒治療，一個星期後，牙菌斑中發現使用氟化物治療的個體，其S. mutans有顯著的減少，我們肯定了這個結果，且顯示了在S. mutans比例的降低可以維持到氟化物治療後12周，在這些研究中，居住在一個復健中心的青少年男孩，隨機的分配到氟化物組(1.23% APF氟膠)，或安慰劑組別。在治療前，比較不同組別的S. mutans和S. sanguis平均百分比值，在學期中的連續兩個星期，在指導下，使用APF或安慰劑膠放入牙托中五分鐘重複十次，治療前沒有打滑牙齒， 在APF組別，在每個樣本時間點，與治療前數值的比較 (表19-4)，單一鄰接面牙菌斑的S. mutans比例下降了50-70%，在安慰劑組別，S. mutans比例則是在每個樣本時間點都增加。



The effect on S. mutans appeared to be selective in that the proportions of S. sanguis in the same plaque samples were not affected by the PAF treatments. In vitro testing showed S. mutans, S. sanguis and S. mitis to be equally sensitive to fluoride inhibition. This meant that the source of the specificity was not due, at least in vitro, to S. mutans having a lower tolerance to fluoride. The explanation was found by a consideration of the ecology of S. mutans and S. sanguis in the oral cavity. S. sanguis has a greater affinity than S. mutans for the tooth surfaces, owing to its ability to recognize surface receptors in the acquired enamel pellicle. S. sanguis is also present in higher numbers than S. mutans in the saliva, which is probably a reflection of its having more oral surface reservoirs which can shed into the saliva. Thus if a tooth surface has been either mechanically cleaned and/or disinfected with an antimicrobial agent, the odds are more favorable for S. sanguis to recolonize than S. mutans.



在S. mutans的作用顯然在相同牙菌斑樣本的S. sanguis比例是有選擇性的，且不被PAF治療影響?，體外測試顯示，S.mutans、S. sanguis和S. mitis對氟化物的抑制的敏感性是相同的，這表示，獨特性的來源，至少在體外，不是因為S. mutans對氟有較低的耐受性，考慮到在口腔中S. mutans和S. sanguis的生態而發現了解釋方法，S. sanguis比S. mutans與牙齒表面有較高的親合力，由於他辯認在必須的牙釉質黏體acquired enamel pellicle表面受體的能力，S. sanguis在唾液中也比S. mutans的量更多，這可能是他有更多口腔表面儲存的反應，使其能隱藏在唾液中，所以如果一個牙齒表面不是機械性清潔或用抗菌藥物消毒，S. sanguis重新形成菌落的優勢是高於S. mutans的。



This recolonization scheme could explain the beneficial results of any antimicrobial agent which is delivered to the tooth surfaces in a high enough concentration and for a time period sufficient to either disinfect or sterilize the plaque. The S. mutans to S. sanguis ratio could then be a sensitive and reliable measurement of the adequacy of treatment. In the data shown in Table 19-4, the S. mutans-S. sanguis ratio was about one prior to treatment and stayed about that value in the placebo group for the 12 weeks after the treatment period. However, in the fluoride subjects, the value decreased to 0.25 and stayed at that reduced value for at least 12 weeks. Thus by considering the directional movement of both the undesired species, such as S. mutans, and the desired species, such as S. sanguis, in a single index, a more accurate assessment of the efficacy of an antimicrobial agent, such as fluoride, can be made.



這重新形成菌落的系統可以解釋，任何抗菌藥物以夠高的濃度被帶到牙齒表面，且停留一定的時間來抗菌或消毒牙菌斑的有益結果。S. mutans和S. sanguis比例可以是一個治療適當的敏感且可靠的測量法。在表19-4顯示的數據，S. mutans-S. sanguis比例在治療前約是1，且在治療期間後，安慰劑組維持這個數值達12周，然而，在氟化物組別的個體，此數值降低到0.25且維持在此數值至少12周，所以考慮到不受歡迎的菌種，像是S. mutans，及受歡迎的菌種，像是S. sanguis的方向性移動，抗菌藥物像是氟，可更確定的評估其效用。



Anti-caries Studies. The ability of fluoride to decrease caries incidence in high-caries-active children was demonstrated by Koch. He separated nine to 11-year-old children into high and low caries groups on the basis of the number of decayed and filled surfaces (DFS). Those children with a DFS above 15 were divided into two groups, one of which received weekly oral hygiene instructions during the school year and brushed with a 0.22 percent NaF dentifrice. After one year these treated children had 60 percent less new decay than the untreated high-caries-active children and 30 percent less decay than untreated low-caries-active children (Table 19-5). Note that the benefits obtained on the occlusal surfaces were less than on the other surfaces, indicating that the fissures constitute a special situation that will require different treatment considerations. The treatment design was such that this improvement could be attributed to the combination of fluoride and oral hygiene instructions. However, other investigators have found oral hygiene per se to be of little value in curbing new caries incidence in children (See Chap. 15) or in radiation xerostomia patients (See Table 19-6). Thus the results obtained most likely were due to the high fluoride-containing dentifrice.



抗蛀牙研究

Koch證實氟化物在高蛀牙率孩童中會降低蛀牙率，他根據蛀牙及填補牙面的數目(DFS)，將9-11歲孩童分為高與低蛀牙率兩組，DFS值高於12的孩童被分成兩組，一組在學期的一年中接受口腔衛教，且使用0.22% NaF牙膏刷牙，在一年後，這些治療的孩童與其他未治療高蛀牙率的孩童比較，新蛀牙降低60%，且與未治療低蛀牙率的孩童比較，新蛀牙降低30% (表19-5)。注意到所得到的益處在咬合面小於其他面，表示溝隙構成一個特別的狀況，需要不同的治療考量，治療的設計進步可以歸功於氟化物與口腔衛教的組合。然而，其他研究者發現口腔衛生本身而言，在孩童(查閱第15章)，或放射線治療的口乾症患者中(查閱表19-6)，抑制新蛀牙的產生價值不高，所以獲得此結果多半是歸功於高濃度含氟牙膏。



An even more impressive demonstration of the ability of fluoride to suppress caries development was observed in radiation xerostomia patients. These individuals, as a result of their salivary shutdown, developed rampant caries associated with significant increases of S. mutans and lactobacilli in their plaques and salivas (See Tables 11-6 and 12-5). Driezen, Brown and their colleagues sought to prevent caries development in these individuals by the application of intensive prophylactic treatments involving oral hygiene, fluoride gels and sucrose restriction.



更令人印象深刻的是，證明氟化物在放射線治療的口乾症患者觀察到其抑制蛀牙發展的能力，這些患者，由於他們唾液腺的功能降低，發展出猛爆性蛀牙，與他們的牙菌斑及唾液中，S. mutans和lactobacilli的顯著增加有關(查閱表11-6與12-3)，Driezen、Brown及其同事尋找出在這些個體中，預防蛀牙發展是經由，加強口腔衛教、氟膠與食物中限制蔗糖量來達到的。



Fifteen patients were randomly distributed to a regimen which included the daily application to the teeth for five minutes of a gel containing a red plaque disclosing dye. Each patient was instructed and shown how to remove all dye-disclosed plaque by brushing and flossing. A second group of 15 patients received the same gel, which now contained one percent neutral NaF and were given the same instructions. A third group received both the fluoride gel and the oral hygiene instructions and in addition, had dietary sucrose restricted. These latter patients were given a list of high-sugar-containing foods and were advised not to eat these foods. During their stay in the hospital these foods were deleted from their diets and presumably there usage would remain reduced following the patients' discharge from the hospital.



15個患者被隨機分配到，包括每天給予五分鐘含紅色染色的牙菌斑顯示劑的療法，教導每個患者使用且顯示如何使用刷牙牙線移除被染色的牙菌斑，第二組的15個患者使用相同的膠包含1%中性NaF，以相同的指示進行，第三組給予氟膠及口腔衛教，另外，限制食物上蔗糖的攝取，最後一群患者給予一張含高蔗糖的食物的列表，且建議他們不要食用這些食物，在他們待在醫院的期間，他們的飲食中排除這些食物，推測在這些患者出院後，使用這些食物會保持降低的狀況。



The oral hygiene regimen was completely without benefit. Nine months into treatment these patients had 11 DMF teeth and 22.2 DMF surfaces. This contrasted markedly with the 95 percent reduction in caries experience of the patients who had received the fluoride gels with or without sucrose restriction (Table 19-6). Sucrose restriction contributed little to the caries suppression above that observed with the fluoride alone. This did not necessarily mean that the sucrose restriction was without effect, as the therapeutic efficacy of the fluoride treatment was so great, that it may have overwhelmed any other treatment effects. Nine of the 14 patients in the oral hygiene group were placed on the fluoride gel regimen and their monthly caries score was reduced to 0.05 DMFT and 0.15 DMFS (Table 19-6). The clinical results of this study are so dramatic that it is possible to state that daily fluoride gels used in this manner are curative for dental caries. A fluoride regimen of this magnitude is indicated when the risk to caries is as predictable as it is in these xerostomia patients. What is needed next is to determine whether similar results can be achieved with a less demanding treatment schedule.



口腔衛生療法完全沒有益處，九個月的治療後，這些患者有11個DMF的牙齒及22.2個DMF的牙面，這些氟化物治療的患者不管有或沒有食物中蔗糖量的限制，其對照蛀牙率有顯著95%的降低(表19-6)，蔗糖限制對蛀牙抑制貢獻不高，但高於只有氟化物治療的組別?，這不是代表蔗糖抑制是沒用的，因為氟化物治療的效用太高，所以掩蓋了其他治療效果。在口腔衛教組中，14個患者內9個併入氟膠療法，他們每個月的蛀牙分數降低到0.05 DMFT和0.15DFMS (表19-6)，此研究的臨床結果是非常卓越的，顯示每天氟膠在此方式下使用，對蛀牙有顯著的治療效用，當像在口乾症患者蛀牙的風險是可預測的時候，顯示出氟化物療法的重要性， 下一個必須達到的是決定，是否相似的結果可在較不那麼要求的治療時間表下重現。



The means by which this cure was achieved were investigated from a bacteriological perspective. The patients in the oral hygiene group exhibited an accelerated increase in plaque proportions of S. mutans so that by three months after radiation, they had significantly more S. mutans than the other patients (Table 19-7). Thereafter the proportions of S. mutans declined coincident with an increase in the proportions of lactobacilli. When these patients were switched to the fluoride gels, no further changes in the proportions of these organisms occurred. In the fluoride group the proportions of S. mutans increased during the radiation treatment to about six percent, and remained at that level until the nine-month sampling period, when they increased to 16 percent (Table 19-7). These persistent high proportions of S. mutans were not associated with caries development, although comparable proportions had been in the oral hygiene group. This anomalous situation was partially clarified by the demonstration that at least some of these S. mutans were resistant to fluoride, and the observation by others that fluoride resistance is associated with decreased acid production (See "Fluoride Resistance in S. mutans" in this chapter). Thus, these S. mutans may not have been capable of producing sufficient acid to demineralize the tooth surface. In the fluoride-sucrose restriction group, the S. mutans proportions decreased during the period of radiation therapy. This was in contrast to the other groups and suggested that the sucrose restriction was responsible, as this was the time period in which the dietary control was strictly enforced. The plaque proportions of S. mutans and lactobacilli in this group did not attain the values observed in the other groups, further indicating an effect of the sucrose restriction.



達到此治癒的方法是從細菌學觀點研究來的，在口腔衛教組別的患者顯現出在牙菌斑中S. mutans比例加速的增加，所以在放射線治療後三個月，他們較其他患者口中S. mutans有顯著的增加(表19-7)，之後，S. mutans的比例降低與lactobacilli的比例增高同時發生，當這些患者被轉到氟膠組別，這些微生物比例的轉換沒有繼續發生，在氟化物組別，S. mutans在放射線治療其間增加約6%，之後停留在這個高度直到9個月的取得樣本期間，會增加到16% (表19-7)，這個持續的高S. mutans比例與蛀牙的發展沒有關係，雖然比的上的比例也在口腔衛教組發現?。這個異常的情況，部分被以至少有一些S. mutans是對氟有抵抗性的證明來澄清，其他觀察到對氟的抵抗性是與產酸的減少有關 (查閱本章"S. mutans對氟化物的抵抗性)，所以，這些S. mutans也許無法產生足夠的酸來將牙齒表面去礦化，在氟化物合併限制蔗糖攝取的組別，在放射線治療期間S. mutans的比例降低，這與其他組別是極度對比的，且暗示了限制蔗糖的攝取是有效的，因為這個期間飲食控制是嚴格被加強的，在這個組別中，牙菌斑中的S. mutans及lactobacilli的比例並沒有達到與其他組別所觀察到的程度，進而顯示出限制蔗糖攝取的效用。



These bacteriological findings are consistent with the fluoride exerting an antimicrobial effect on the flora. However, the ability of the fluoride to remineralize the tooth surfaces and possibly to kill bacteria in situ in the white spot lesions (See "Whit Spot Hypothesis" in this chapter) would also contribute to the clinical success.



這些細菌學的發現與氟對口腔微生物發揮抗菌作用是一致的，然而，氟對牙齒表面再礦化的能力，及可能在白斑病變原位殺死細菌的能力(查閱此章"白斑假說")，也會促成臨床上的成功。



Vancomycin



Vancomycin is a polypeptide, nonabsorbable antibiotic with a gram positive spectrum of activity. The drug is relatively tasteless, is stable in nonaqueous solutions, but has a shelflife of only a few weeks when added to aqueous vehicles. Englander and Keyes reported that the topical application of vancomycin to the teeth of hamsters fed a sucrose diet, eliminated S. mutans and inhibited dental caries. This finding, plus the relatively minimal medical usage of vancomycin, led Jordan, DePaola and their colleagues to extensively evaluate vancomycin in school children or young adults infected with S. mutans. Particular care was taken to select for individuals in whom S. mutans was either prominent in the plaque or continuously present during the pretreatment period.



萬古黴素

萬古黴素是一個與格蘭氏陽性菌活動有關，聚胺基不可吸收的抗生素，這個藥物相對是無味，在非水性的溶液是穩定的，但其耐儲時間在水狀傳播媒介中只有幾周。Englander和Keyes報告局部給予倉鼠牙齒萬古黴素，餵食蔗糖飲食可以抑制S. mutans且限制牙齒蛀牙，這個發現加上相對少量萬古黴素的使用，使得Jordan、DePaola和他們的同事深入的評估萬古黴素在受到S. mutans感染的學童及年輕的成人的影響，特別用心來選擇在牙菌斑中S. mutans是顯著的或S. mutans持續在治療前存在的個體。



A series of trials were conducted in which the vancomycin was delivered via custom-fitted applicator trays, but in which the dosage and treatment schedules varied. One, three and 15 percent vancomycin gels or paste significantly suppressed S. mutans in the period immediately following treatment, but thereafter S. mutans returned. A dose-response relationship was evident, as when 15 percent vancomycin was used, S. mutans could not be detected in any patient for eight days after treatment and remained undetectable in about 60 percent of the 13 patients during the eight-week post treatment observation period. S. sanguis was observed to increase in the plaque as a result of treatment in a manner analogous to that observed with topical fluoride (Table 19-4).



一連串的連續研究以個人訂做的牙托傳遞萬古黴素來實行，但是劑量與治療時間表不同，1, 3, 15%的萬古黴素膠或膏狀物可能顯著的立即在治療時間後抑制S. mutans，但之後S. mutans又會重現。一個劑量反應的關係是明顯的，因為當使用15%的萬古黴素，在治療後八天後沒有任何患者能測到有S. mutans，在治療後八周的觀察期間內，13個患者有約60%維持無法偵測到S. mutans，與使用局部氟化物觀察到的一樣，牙菌斑中也觀察到S. sanguis有增加。



These findings demonstrated that vancomycin could suppress S. mutans for a finite period of time. In order to eliminate and/or continuously suppress S. mutans, the gel treatment would either have to remove all reservoirs of S. mutans that existed in the incipient and established carious lesions, or the gel would have to be given continuously. Jordan and DePaola chose the latter approach and conducted a trial in which a one percent gel was given daily under supervision during one school year. Under these conditions the plaque levels of S. mutans remained low during the entire treatment period and a significant reduction of caries compared to a no-treatment group was observed.



這些發現證實了萬古黴素可以在有限的一段時間內抑制S. mutans，為了抑制或持續阻止S. mutans，膠狀物治療會移除所有起初就存在或已經形成的蛀牙病灶中S. mutans的儲藏室，或是被持續的給予。Jordan和DePaola選擇後者的介入且實行一個連續的研究，1%的膠狀物在一年的學期中每天經指導下給予，在此狀況下，S. mutans的牙菌斑程度在整個治療期間中保持低下，且與沒有治療的組別比較，觀察到顯著地蛀牙減少。



These vancomycin studies fulfilled the criteria of treatment according to the SPH (See Table 14-1) in that children with a diagnosed S. mutans infection were treated so as to control that infection, and as a result, their caries levels decreased. Conceptually these investigations were more focused than the Karlstad, Ypsilanti or Cheektowaga studies. However, any treatment that requires daily supervision and yields only a reduction of about one DMF surface compared to children who received no such treatment, has to be considered cost inefficient. What is needed is not a better theory nor selection criteria, but possibly more effective agents and more cost-efficient treatment schedules.



這些萬古黴素的研究符合了根據SPH治療的標準(查閱表14-1)，治療在診斷出有S. mutans感染的孩童，結果使蛀牙程度減低，概念上，這些調查較Karlstad、Ypsilanti或Cheektowaga的研究更被重視，然而，任何需要每天指導且結果只達到與沒有接受任何治療的孩童比較，約1個DMF牙面的降低，此治療被認為其花費是沒效率的。需要的不是一個更好的理論或選擇的標準，而可能是更有效率的藥物，及花費有效率的治療時間表。



Furadroxyl



Furadroxyl appears to be such an agent, as it was associated with an impressive 75 percent reduction in the incremental DMFS rate when compared to a placebo group (Table 19-8). Dreizen and Spies selected patients with high caries activity, evidenced by a DMFS score of greater than 20 and the presence of at least five decayed surfaces. These patients were separated into furadroxyl, placebo and non-treatment groups. The furadroxyl and placebo groups were given chewing gums that differed only in the presence of 7.5 mg of furadroxyl in the treatment group. Both groups were instructed to chew one stick of gum for at least ten minutes after each meal. The no-treatment group was of similar age and caries experience but received no gums. Each subject was seen at least once every three weeks for dental examinations and for the distribution of gums to the respective groups. No attempt was made to change the dietary or oral hygiene habits of the participants.



Furadroxyl

Furadroxyl是一種可以達到與安慰劑組別比較下，其增加的DMFS率有高達75%的降低 (表19-8)，Dreizen與Spies選擇有高蛀牙活動力的患者，其DMFS分數證實有高於20且至少有五個蛀牙面，這些患者被分成Furadroxyl、安慰劑和未治療三組。Furadroxyl與安慰劑組都給予口香糖，其差別只在治療的組別含有7.5mg的Furadroxyl，兩組都被指示在每餐過後都要嚼一片口香糖至少十分鐘，未治療組患者的年齡與蛀牙率都與治療組差不多，但未治療組沒有給予口香糖，每個患者至少每三周會做牙齒檢查一次，且分配口香糖給這些患者，沒有試圖去改變這些參與者的飲食或口腔衛生習慣。



After one year the furadroxyl group averaged 0.9 new decayed surfaces, whereas the placebo group had 3.3 and the no-treatment group, 4.2 decayed surfaces (Table 19-9). Sixty percent of the furadroxyl patients had no new caries, whereas only 28 percent and eight percent, respectively, of the control groups had no new caries. When one considers that the treatment was unsupervised and there was no other intervention, save the chewing gums, the findings are remarkable and are extremely cost efficient. What then was so unique about furadroxyl, in that 30 minutes daily exposure to about 22 mg of agent could achieve this magnitude of caries reduction?



經過一年後，Furadroxyl組平均產生0.9個新蛀牙面，安慰劑組則產生3.3個，未治療組產生4.2個 (表19-9)。Furadroxyl組別的患者中有60%沒有新蛀牙的產生，分別地，在對照組各自只有28%及8%沒有新蛀牙產生。當考慮到若治療是不在指導下進行，也沒有其他介入，沒有口香糖，這個結果是很顯著且在花費上是極度有效率的。對Furadroxyl來說最特殊的是，一天30分鐘約22mg藥物的暴露可以達到蛀牙降低的重要性？



Furadroxyl is a nitrofuran derivative with the chemical formula 5-nitro-2-furaldehyde-2-semicarbazone. The nitrofurans as a group are broad-spectrum antibacterial agents that currently are used systemically for the management of urinary tract infections and topically for the treatment of skin, mucous membrane and wound infections. The compounds act as electron acceptors and inhibit enzymatic reactions in which NADH and thiamine pyrophosphate act as cofacters, thereby interfering with carbohydrate metabolism. Dreizen and Speis were aware of the Stephen curve (Figure 10-3), which demonstrated that acid production by the plaque continues for some 30 to 60 minutes following carbohydrate ingestion. Therefore, they timed the taking of the furadroxyl to coincide with those time periods in which carbohydrate metabolism in the plaque would be greatest, i.e., minutes after the ingestion of a meal, so as to achieve maximal inhibition. This solid theory was rewarded with the dramatic reductions in caries described in Table 19-8.



Furadroxyl是一個帶有化學分子式5-nitro-2-furaldehyde-2-semicarbazone的nitrofuran衍生物，nitrofuran是一群廣泛性抗菌藥物，目前以系統性使用來治療泌尿道感染，或是局部使用治療皮膚、黏膜或傷口的感染。此複合物以電子接收器來作用，且抑制NADH與thiamine pyrophophate當作協同因子的酵素作用，進而影響碳水化合物的代謝，Dreizen與Speis查覺到Stephen curve史帝芬曲線 (圖10-3)，證實了牙菌斑的酸產物會在碳水化合物消化後30-60分鐘後出現，所以，他們計算符合在牙菌斑中碳水化合物代謝最多最大的時間區間，來服用Furadroxyl，例如一餐消化後幾分鐘，已達到最高的抑制效果，這完整的理論在表19-8，以卓越的蛀牙降低被賞識。



And yet this study, reported in 1951, stands as an isolated event, without a confirming investigation. The pharmaceutical company involved was unable to obtain FDA approval for development of this agent "because a drug to be used daily as it would be in chewing gum, should be harmless under all conditions of use and misuse. The nitrofurans are too toxic for use in chewing gum." Apparently the prescription usage of this agent only in patients with high caries activity was never considered because at that time the evidence in support of the SPH was not yet in place. Because of the absence of confirmatory studies, the clinical results achieved with furadroxyl, by such a minimal intervention as the introduction of a chewing gum, constitutes a tantalizing success story but nothing more.



這個研究在1951年發表，沒有一個肯定的調查以獨立事件存在，有關的製藥廠商無法取得這種藥物發展的FDA認可，因為每天使用一種存在口香糖中的藥物，必須是在使用或誤用的任何情況下，都是無害的，nitrofuran使用在口香糖中毒性太高，顯然的，只在高蛀牙率的患者開此藥物的使用處方簽是從未被考慮的，因為當時支持SPH理論的證據還不足，因缺乏確定的研究，furadroxyl達到的臨床結果，藉由以口香糖採用很微量的介入，構成誘人的成功故事，但僅止於此。



Iodine



Various iodine preparations have long been used as disinfectants in oral and periodontal surgery and in endodontics, but they have not been employed to combat cariogenic infections. Gibbons et al. showed that an iodine solution (two percent iodine and two percent potassium iodide) applied for one to two minutes to discrete approximal surfaces was able to reduce S. mutans counts to undetectable levels in 28 of the 44 treated sites. The majority of these 28 sites did not become recolonized with S. mutans over a period of two months' observation. This finding indicated that if a caries-free smooth tooth surface can be disinfected, that the organisms which recolonize this surface most likely will not include S. mutans.



碘

各種不同碘的配置長久以來被使用來作為口腔及牙周手術還有牙髓病科的消毒劑，但是它們沒有被作為抵抗蛀牙感染的功用。Gibbons及其同事提出碘劑 (2%碘及2%碘化鉀)塗抹在分離的鄰接面上1-2分鐘可以降低S. mutans的量，在44個治療的位置有28個達到無法測出的降低量。在觀察兩個月的期間，這28個位置多數沒有成為S. mutans重新形成菌落的地方，這個發現指出如果沒有蛀牙的平滑牙面可以不被感染，則重新在此牙面形成菌落的微生物很可能不會包括S. mutans。



The situation with a fissure or incipient lesion may be different, as in these locations organisms that are within the depths of the fissure or lesion may escape the antimicrobial action of the agent and may even be selected for in the recolonization procedure (See "White Spot Hypothesis" in this chapter). The refractory nature of S. mutans in occlusal fissures was demonstrated in a second study involving topical application of iodine. In this study five subjects with salivary levels of S. mutans greater than 10,000 per ml were given a dental prophylaxis plus three treatments with topical iodine applied immediately after the prophylaxis and three and five days later. This treatment significantly reduced the occlusal proportions and salivary levels of S. mutans for four to six weeks (Table 19-9). But this same regimen significantly reduced the approximal levels of S. mutans for the entire 24-week period of observation.



溝隙或是起初的蛀牙病灶情況可能是不一樣的，因為在這些位置的微生物在溝隙的深處，或是病灶可能逃離抗菌藥物能達到的作用位置，甚至可能被選擇為重新形成菌落過程內?(查閱本章"白斑假說")，在咬合面溝隙的S. mutans，其有抵抗力的特色在包括局部塗抹碘的第二個研究中被證實。在這個研究，五個唾液中S. mutans的量大於每毫升10,000的個體，給予牙科潔牙加上潔牙後三天和五天後立即三次局部碘治療，這個治療在4-6星期後，顯著地降低咬合面S. mutans的分布，及唾液中S. mutans的量(表19-9)，但這個相同的療法在全部24周觀察期間，顯著的降低了S. mutans的鄰接量。



The reappearance of S. mutans in the occlusal plaques could represent either an outgrowth of organisms from the fissure depths which were never exposed to the iodine solution, or a new colonization by S. mutans present in the saliva. This latter possibility existed because one week after the iodine treatment the salivary levels of S. mutans averaged about 2000 organisms per ml of saliva (Table 19-9). Svanberg and Loesche had shown that sterile artificial fissures placed in the mouths of humans became infected with S. mutans provided that the salivary concentrations of this organism were 1000 per ml or higher (See Table 6-11). Thus, salivary levels of S. mutans capable of colonizing fissures were present in all subjects within a few weeks after the iodine applications. But as these salivary levels are a function of the shed rate of S. mutans from the tooth surfaces, this ascendancy of S. mutans in the saliva reflected the reemergence of S. mutans from buried reservoirs, such as the fissures, and only secondarily could these levels contribute to recolonization of uninfected fissures.



在咬合面牙菌斑中，S. mutans的再出現表示，從溝隙深處從未與碘劑接觸的微生物產生，或是存在在唾液中S. mutans新的菌落，這可能是因為在碘治療一周後，唾液中S. mutans平均每毫升約有2000個微生物 (表19-9)，Svanberg和Loesche提出將消毒過後的人工溝隙放入人類口腔中數個月，會被唾液中每毫升1000個或更多的S. mutans感染 (查閱表6-11)，所以，唾液中S. mutans量，在所有個體中碘治療後數周，是可能在溝隙中形成菌落。但是，因為這些唾液量是從牙齒表面S. mutans散佈率的函數?，這唾液中S. mutans的優勢反應了從隱藏儲藏地重新出現的S. mutans，例如溝隙中，和只有間接在未被感染的溝隙中重新形成菌落的貢獻?。



Kanamycin



The cited studies show that S. mutans cannot be easily eliminated from occlusal fissures, presumably because these fissures harbor S. mutans within their depths. If this is so, then the treatment strategy under the SPH has to include some means of gaining access to these buried reservoirs of S. mutans. One tactic would be to combine the antimicrobial regimen with the mechanical debridement of carious lesions. Results obtained when short-term usage of kanamycin was integrated with caries debridement provided further insights into the nature of the tooth surface reservoirs of S. mutans.



Kanamycin

被篩選出的研究顯示出，S.mutans無法輕易的從咬合面溝隙中被消滅，主要因為這些溝隙將S. mutans庇護在它們的深溝中，如果是這樣，則根據SPH的治療策略必須包括一些能到達這些S. mutans包埋在內的儲藏地。一個策略是包含在蛀牙病灶的機械性清創抗菌療法，結果包括短期使用kanamycin合併提供牙齒表面S. mutans儲藏地的蛀牙清創。



Children with rampant caries, as defined by having ten or more carious surfaces, were treated with either a five percent kanamycin gel or a placebo gel. The patients were instructed in how to apply the gels in applicator trays to the dentogingival surfaces twice a day for one week prior to the placement of all necessary dental restorations and again for one week after the placement of the restorations. The gel treatment was unsupervised and performed at home by the patients. Kanamycin was chosen because it has no objectionable taste, is stable and had been shown in a previous gingivitis study to inhibit plaque streptococci. The plaque was cultured from the most distal, occlusal fissure and interproximal site in each quadrant and pooled so as to give occlusal and approximal samples. These plaque samples, as well as saliva, were collected before and after each gel treatment and at the three-month recall visits.



有10個或以上的蛀牙面定義為有猛爆性蛀牙的孩童，，使用5%kanamycin膠或安慰劑膠治療，指導患者如何使用牙托放置膠在牙齒及牙齦表面，在填補所有必須填補的蛀牙前一星期，一天兩次，膠狀物治療是在沒有被指導下在家裡由患者自行使用，選擇kanamycin是因為沒有令人討厭的異味，是穩定的且在先前牙齦炎研究中能夠抑制牙菌斑中的鏈球菌，從每個象限中大部分遠心側、咬合面溝隙及鄰接面取得牙菌斑培養，且共同培養來提供咬合面及鄰接面樣本。這些牙菌斑樣本及唾液，在每次膠狀物治療之前之後及三個月的回診中被取得。



The kanamycin gel treatment given while the open carious lesions were present in the teeth lowered the levels but not the proportions of S. mutans in the plaque (Table 19-10). The placement of the dental restorations caused the proportions of S. mutans to decrease in both groups. The kanamycin was taken for a second one-week period and again while the plaque levels of S. mutans decreased, the proportions continued to increase. In fact, the proportions of S. mutans in the approximal plaques were now significantly higher in the kanamycin group than in the placebo group (Table 19-10). Closer inspection revealed that while most of the approximal samples in the kanamycin group had now proportions of S. mutans, a few samples had more than 20 percent S. mutans. This indicated that while the kanamycin reduced the plaque levels of S. mutans in most subjects, it also was capable of selecting for S. mutans in certain mouths. The biological import of this phenomenon soon became apparent in the caries scores observed at the recall visits.



在蛀牙病灶還未治療前給予kanamycin膠治療顯示降低S. mutans的量但沒有降低其在牙菌斑中的分佈 (表19-10)，牙科填補物置入後在兩個組別中都會降低S. mutans分佈，使用第二個一星期的kanamycin治療，且再次的當牙菌斑中S. mutans量會降低，但其分佈卻持續增高。事實上，在鄰接面牙菌斑S. mutans的分佈在kanamycin組別比安慰劑組別顯著的較高 (表19-10)，更仔細的檢查透露出，當在kanamycin組別多數鄰接面的樣本，其S. mutans的分佈較高，少數的樣本有高於20%的S. mutans，這顯示，當kanamycin在多數個體中降低了牙菌斑的S. mutans，但同時也能夠在幾個月中選擇出S. mutans，這個現象生物學的含意很快的在回診的蛀牙分數觀察中，變成是顯而易見的。



The number of new carious lesions was greater in the kanamycin-treated patients in the first eight to ten months after treatment (Table 19-11). This caused us to stop the entry of new patients into the study and to closely monitor the caries experience of the existing patients. Over the next one to two years, the kanamycin patients developed few new lesions, whereas the placebo patients continued to develop new lesions. When the data were eventually summarized, the kanamycin treatment was associated with a net caries reduction of about 45 percent compared to the placebo treatment. This left the need to explain how the kanamycin caused an acceleration in decay and then a burnout or quiet period, during which time the placebo group caught up to and surpassed the kanamycin group in terms of new decayed surfaces. This was done by postulating that an additional reservoir for S. mutans existed that was not accessible to either the kanamycin or the caries debriding procedures. This reservoir could either be cracks in the tooth surface and/or the white spot (incipient) lesion.



新蛀牙的病灶數目在kanamycin治療後八到十個月的患者身上較高 (表19-11)，這使得我們停止納入新患者到此研究，且密集的監測現有患者的蛀牙率，在接下來的一到兩年，kanamycin組的患者形成一些新蛀牙。當平均地總結這些資料顯示，kanamycin治療與相關的淨蛀牙降低量，與安慰劑治療比較約是45%，這留下解釋kanamycin如何造成蛀牙加速，然後一個殆盡或靜止期的需要，在同時，依據新產生的蛀牙面，安慰劑組別趕上且優於kanamycin組別，假定存在S. mutans多餘的儲藏地，kanamycin或蛀牙清創步驟無法達到此處，而達到此結果，這個儲藏地可以是牙面中的裂縫或白斑(起初的)蛀牙。



The White Spot Hypothesis. The white spot hypothesis is conceivable only in the context of bacterial specificity in the caries process. It states that the primary, or white spot, lesion represents a focal infection of S. mutans or some other organism(s), which is specifically involved in the caries process. The white spot hypothesis assumes that S. mutans or the other cariogens have already invaded the enamel and are within the depths of the white spot. When an antimicrobial agent is delivered to the tooth surface, if the agent cannot penetrate the white spot, either because of ionic charge or occlusion of the channels within the white spot by bacterial cells, those organisms within the white spot will survive. When the treatment ceases, the survivors within the white spot are able to grow out from the lesion and become dominant in the newly-forming plaque flora. If these surviving organisms include a cariogen, such as S. mutans, then the caries process is accelerated.



白斑假說

可理解的，白斑假說只在蛀牙形成中細菌特定性的背景中存在，他指出，起初或白斑的病灶，表示一個S. mutans或一些其他特定與蛀牙形成相關的微生物的病灶感染，白斑假說採用S. mutans或其他致蛀牙因子已經侵犯牙釉質，且存在在白斑的深處，當抗菌藥物被帶到牙齒表面，如果藥物因為帶電離子或在白斑被細菌細胞閉塞通道，無法穿透白斑，這些在白斑中的微生物會存活下來，當治療停止，在白斑中存活下來的微生物能夠從病灶中生長出來，且在新形成的牙菌斑菌落中占優勢，如果這些存活下來的微生物包含致蛀牙因子，像是S. mutans，則將促進蛀牙形成。



This white spot hypothesis can explain how the kanamycin treatment accelerated the rate of caries development on some surfaces while preventing the development of caries on other surfaces. In this model (Fig. 19-1), the tooth surface has three situations relative to health or disease l) the caries-free surface; 2) the primary or white spot lesion; 3) the secondary lesion of obvious cavitation. Each of these situations will respond differently to an effectively-delivered antimicrobial agent. On the caries-free surfaces, the active agent will reduce the total number of bacteria, possibly eliminating S. mutans, as is shown in Figure 19-1. This agrees with the general reduction in viable count and S. mutans seen following both periods of kanamycin therapy (Table 19-10). In the primary lesion if the agent does not penetrate into the demineralized zones, a nidus of bacteria will survive. In the reformation of the plaque these organisms will grow out of the lesion and comprise a higher proportion of the returning plaque flora. An increase in S. mutans was found in certain approximal samples after the completion of the kanamycin treatment but was not observed with the placebo treatment. This selection for S. mutans could account for the accelerated caries rate observed at the nine-month recall period in the kanamycin patients (Table 19-11). In the kanamycin group, the caries-free surfaces may be rid of a S. mutans infection and stay that way during the recall period (Fig. 19-1). In the placebo group the caries-free surfaces may remain infected with S. mutans and some will go on to become carious during the recall period. The amount of caries that develops on these initially caries-free surfaces actually determines the net caries difference between the two treatment groups.



白斑假說可以解釋kanamycin治療如何在某些牙面促進蛀牙發展率的同時，預防其他牙面蛀牙的發生，在此模型中 (圖19-1)，牙面健康或有病灶有三種情形；1)沒有蛀牙的牙面；2)初期或白斑病灶；3)明顯蛀牙窩洞的次級病灶。每個情況會對有效傳遞的抗菌藥物有不同的反應，在沒有蛀牙的牙面，活躍有效的藥物會降低整體細菌的量，可能會抑制S. mutans，如同顯示在圖19-1，這同意了可發展量整體的降低，且兩段kanamycin治療後的S. mutans的降低 (表19-10)，在初期病灶，如果藥物無法穿透進入去礦化區域，細菌在發源窩能夠存活。在重新形成的牙菌斑中，這些微生物會從病灶中發展，且構成重回的牙菌斑菌落更高的分佈，在完成kanamycin治療後的一些鄰接面樣本，其S. mutans會增加，但在安慰劑治療中並沒有發現，這個S. mutans的篩選可算是促進kanamycin患者中，在九個月回診期間的蛀牙率 (表19-11)，在kanamycin組，未蛀牙的牙面可能是沒有S. mutans感染，且在觀察回診期間維持此狀況 (圖19-1)，在安慰劑組，未蛀牙牙面可能維持被S. mutans感染且有些會在觀察期間發展成蛀牙，初期未蛀牙牙面發展成蛀牙的數量，事實上決定了兩個治療組別間的淨蛀牙差異。



The model indicates that antimicrobial treatment prior to the placement of dental restorations, or in the presence of primary and secondary lesions will be counterproductive, as such treatments will select for organisms buried within the lesions. If these organisms have cariogenic potential, such as S. mutans, then an accelerated caries attack rate might ensue. The model predicts that an antimicrobial agent that is capable of penetrating the white spot will prevent decay from being accelerated in these lesions. The failure of kanamycin to penetrate would not appear to be due to its molecular weight, since it is a relatively small molecule. But as with chlorhexidine, it has a net positive charge, which could cause it to bind at the tooth surface. Fluoride, which is known to penetrate the enamel and to be elevated in arrested lesions, has a net negative charge. Fluoride, according to the model, would penetrate the lesion, kill the bacteria in situ and should not lead to a selection for S. mutans in the newly-formed plaque nor to an accelerated caries rate.



此模型指出，在填補蛀牙後的抗菌治療，或是在初期或次級病灶發生時，會產生不良結果，因為此治療會挑選埋藏在病灶中的微生物，如果這些微生物有致蛀牙傾向，例如S. mutans，則促進蛀牙攻擊的比例會接踵而來，此模型預測，能夠深入白斑的抗菌藥物，會在這些病灶中預防窩洞形成，kanamycin無法深入病灶不是因為他的分子量，因為他相對是小分子，但是chlorhexidine，他有帶靜正電，能夠使其連結到牙齒表面，氟，已知能穿透牙釉質且在受威脅的病灶中被提高，有帶靜負電，氟，根據此模型，能夠穿透病灶，殺死在原處的細菌，且不該導致在新形成的牙菌斑中的S. mutans的選擇，也不會導致蛀牙率的加劇。



Morphological verification of bacteria in the white spot lesions was provided by Brannstrom and his colleagues. Their electron microscopic examination of white spot lesions led them to conclude that: "The presence of bacteria in small lacunae in the enamel prism, as well as deep in the enamel under white spot lesions, together with pores in the enamel surface, would seem to indicate that bacteria may penetrate the enamel at an early stage." The presence of bacteria with a coccal morphology is clearly seen in their electron photomicrographs (Fig. 19-2).



Brannstrom與他的同事提供了細菌在白斑病灶中型態學的確認，他們在電子顯微鏡下檢查白斑做出以下結論：〝細菌形成在牙釉質晶柱中小髓腔，同樣在牙釉質白斑病灶深度，與牙釉質表面孔洞，同時指出，細菌可能在初期穿透牙釉質〞，在電子顯微鏡下清楚的看見有球狀型態的細菌出現 (圖19-2)。



Testing of the White Spot Hypothesis. The white spot hypothesis was tested in rampant caries children using fluoride as the antimicrobial agent. Children five to six years of age, who had ten or more carious surfaces in the primary dentition and no erupted permanent molars, were treated with 1.23 percent neutral sodium fluoride or placebo gels. This level of fluoride was chosen because it had been shown previously to reduce the proportions of S. mutans in the plaque (Table 19-4). Neutral sodium fluoride was used because it has a less objectionable taste than either acidulated phosphate fluoride or stannous fluoride. This was important in terms of compliance, as the gels were to be taken unsupervised, at home, in applicator trays twice a day for one-week periods prior to and after the placement of the necessary dental restorations. Unlike the kanamycin protocol, the gels were readministered at about six- to eight-month intervals during the years that the patients remained in the study. These children were chosen as patients because of their high caries experience, i.e., they averaged about 22 decayed surfaces and because their first permanent molars, when they erupted, would provide a sensitive indicator of caries protection afforded by the fluoride regimen. In this manner we hoped to treat an infection in the primary dentition so as to minimize or prevent its spread to the permanent dentition.



測試白斑假說

在使用氟化物當作抗菌藥物的猛爆性蛀牙的孩童中，測試白斑假說，5-6歲的孩童，在乳牙齒列有10個或以上的蛀牙面，且沒有萌發中的恆牙，使用1.23%中性氟化鈉或安慰劑治療，選擇此氟化物濃度是因為之前顯示出，其能夠降低牙菌斑中S. mutans的分佈 (表19-4)，中性氟化鈉因為與APF或氟化亞錫比較，有較少令人討厭的異味而被選擇，這對孩童的合作度相當重要，因為氟膠是在填補蛀牙前後一周，一天兩次在沒有指導下使用牙托在家中進行，不同於kanamycin的規則，這些膠會在研究期間六到八個月後重新被給予，這些孩童因為其高蛀牙率被選取，例如平均蛀牙面約22，且因為在他們的第一大臼齒即將要萌發期間，會提供氟化物療法給予其蛀牙保護敏感的指標，在此情況下，我們希望在乳牙齒列中治療此感染，進而減低或預防其擴散到恆牙齒列。



The protocol was partially successful in that there was no selection for S. mutans by the fluoride and in fact, the fluoride-treated children had lower levels of S. mutans. More importantly, there was no accelerated caries rate in the fluoride group relative to the placebo group as there had been with kanamycin. Instead, the fluoride children exhibited one less decayed surface in the first year following treatment than did the placebo children (Table 19-12). This difference of one decayed surface per year was maintained during the second and third years of the study, so that the cumulative difference between the two groups was 3.2 surfaces (Table 19-12).



此協議草案是局部成功的，因為沒有氟化物對S. mutans的選取，且事實上，氟化物治療的孩童，有較低的S. mutans量，更重要的是，在氟治療組別，與安慰劑組別比較，沒有加劇的蛀牙率，但在kanamycin研究中是有的，反而，氟化物治療的孩童顯示在治療後第一年，與安慰劑組別比較減少一個蛀牙面 (表19-12)，這個每年一個蛀牙面的降低，在此研究的第二及第三年期間會繼續維持，所以兩組間累積降低差異達到3.2的牙面 (表19-12)。