心口如一:刷牙、拔牙竟会增加心血管病风险?

2018-04-14 Major Tom 壹周冠脉

尽管对于口腔卫生与心血管病的联系已经研究了很久,但是由于之前参次不齐的口腔卫生评价标准与牙周炎诊断标准,导致两者的联系一直存在争议。

口腔卫生差,易患冠心病?

尽管对于口腔卫生与心血管病的联系已经研究了很久,但是由于之前参次不齐的口腔卫生评价标准与牙周炎诊断标准,导致两者的联系一直存在争议。

2008年《Circulation》上发表了一篇纳入了1203名无心血管病史男性的观察性研究,中位随访时间24年,一定程度上终结了争议。

该研究使用了两种方法来评估牙周炎暴露:牙槽骨X射线和全口腔的牙周袋探诊。牙槽骨X射线上的骨质损失可以观察牙周炎的进展,牙周袋探诊是诊断与随访牙周炎最重要的检查。为了尽量减少年龄对于研究的影响,研究对象被分成了<60岁和≥60岁两组。

研究发现,在<60岁的研究对象中,X线上牙槽骨骨质损失最严重的一组,是骨质损失最轻微一组冠心病风险的两倍以上(HR 2.12, 95% CI 1.26-3.60, P=0.02),并且独立于年龄、BMI、吸烟饮酒、空腹血糖、总胆固醇、甘油三酯、血压、教育程度、婚姻状况、职业与收入等已知的冠心病危险因素。

对于≥60岁的研究对象,没有牙齿组相对于骨质损失最轻微组,冠心病风险是一倍半还要多(hazard ratio 1.61, 95% CI 0.95-2.73),同样独立于其它危险因素。牙周袋探诊所获得的结论与牙槽骨X线类似。

目前可能的解释有:

1.牙周炎主要病因是病原体感染,这些病原体进入循环后,可能导致炎症反应(例如可以观察到CRP升高),而慢性炎症反应已经证明与冠心病相关。

2. 糖尿病、吸烟既促进牙周炎的产生,也可以导致冠心病。

3.对于慢性炎症性疾病敏感的遗传特质,可能促进了牙周炎与冠心病的共同产生。

2007年发表在《New England Journal of Medicine》上的一篇纳入120名严重牙周炎患者的RCT研究发现,进行了牙科处理的研究对象尽管在1天时血管内皮功能变差,但是在2个月与6个月后内皮功能较对照组都有所改善。


Tonetti M S, NEJM, 2007

但是这个研究只能推测积极的牙周炎治疗可以短期内改善血管内皮功能。至于牙周炎与冠心病之间是否明确存在因果关系,以及治疗牙周炎是否能带来心血管获益,直到目前仍然没有定论。

牙科操作可能导致感染性心内膜炎

与冠心病不同,牙科操作——从洗牙到拔牙,与感染性心内膜炎都有着明确的因果关系,因为病原体的来源就是口腔微生物。

2008年发表在《Circulation》上的一篇RCT研究,将290名研究对象分为3组:①刷牙;②服用抗生素后拔牙;③服用安慰剂后拔牙。分别在刷牙/拔牙的前中后采血进行培养,得到如下结果,曲线最高的是安慰剂-拔牙组,其次是抗生素-拔牙组,最低的是刷牙组。


Lockhart P B, Circulation, 2008

由此,我们得到了两个结论:

与常规的刷牙相比,拔牙确实是会显着提高血培养的阳性率,但是刷牙过程中竟然也会导致血培养阳性率明显提高,由0%提高至刷牙时的10%以上,的确令人惊奇,但好在之后阳性率迅速降低;

与拔牙前服用抗生素组相比,安慰剂组的血培养阳性率是明显升高的,最高可以到50%以上,这种升高可以持续到拔牙后1个小时甚至更长。

·根据2006年在法国进行的流行病学调查,大约每46000名不服用抗生素的拔牙患者就会有1位因此而换上感染性心内膜炎,如果本身就具有心脏瓣膜病变或者更换过人工瓣膜的话,这个比例还会大大增加;而如果使用抗生素进行预防的话,这个风险可以降低约70%。

·根据2015年欧洲心脏病协会的感染性心内膜炎指南,只有进行过瓣膜修复/置换,或存在发绀性先心病,或既往有感染性心内膜炎的患者应该进行预防性使用抗生素,对于不存在高危因素的患者并不推荐使用抗生素。



什么样的牙科操作需要进行预防呢?

涉及牙龈、根尖的操作以及需要穿透口腔黏膜的操作都需要进行抗生素预防。

抗生素应在操作开始前30-60分钟使用,可选择的药物包括阿莫西林、氨苄西林、克林霉素。



而尽管我们也看到刷牙可能会提高血培养阳性率,但从来没有那个指南会推荐对刷牙进行抗生素预防,毕竟目前并没有刷牙提高感染性心内膜炎发病率的证据。

而且,目前研究也发现口腔卫生状况是与感染性心内膜炎发病率显着相关,不刷牙带来的危害比起刷牙本身可能存在的风险小得多。因此,刷牙肯定还是有益的。

原始出处:

1.Dietrich T, Jimenez M, Krall Kaye E A, et al. Age-dependent associations between chronic periodontitis/edentulism and risk of coronary heart disease.[J]. Circulation, 2008, 117(13):1668.

2.Tonetti M S, D'Aiuto F, Nibali L, et al. Treatment of periodontitis and endothelial function.[J]. New England Journal of Medicine, 2007, 356(9):911.

3.Lockhart P B, Brennan M T, Sasser H C, et al. Bacteremia associated with toothbrushing and dental extraction.[J]. Circulation, 2008, 117(24):3118-3125.

4.Duval X, Alla F, Hoen B, et al. Estimated risk of endocarditis in adults with predisposing cardiac conditions undergoing dental procedures with or without antibiotic prophylaxis.[J]. Clinical Infectious Diseases , 2006, 42(12):e102.

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    2018-04-22 wxl882001

    学习一下

    0

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    2018-04-16 xre2013
  4. [GetPortalCommentsPageByObjectIdResponse(id=1644663, encodeId=1e79164466367, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Sat Mar 23 02:12:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=308281, encodeId=388a3082812d, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Sun Apr 22 19:26:37 CST 2018, time=2018-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1574227, encodeId=518f15e4227c9, content=<a href='/topic/show?id=36fc56212c6' target=_blank style='color:#2F92EE;'>#拔牙#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56212, encryptionId=36fc56212c6, topicName=拔牙)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9c5216012416, createdName=xre2013, createdTime=Mon Apr 16 06:12:00 CST 2018, time=2018-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305762, encodeId=3364305e6285, content=刷牙影响心血管.那洗头洗脸???, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:21:00 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305761, encodeId=c301305e6116, content=真够可以的, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:19:58 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305746, encodeId=5907305e460f, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sat Apr 14 17:17:08 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305740, encodeId=3db2305e402e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=40ad2312069, createdName=1222becem95暂无昵称, createdTime=Sat Apr 14 16:20:04 CST 2018, time=2018-04-14, status=1, ipAttribution=)]
    2018-04-14 怪物博士

    刷牙影响心血管.那洗头洗脸???

    0

  5. [GetPortalCommentsPageByObjectIdResponse(id=1644663, encodeId=1e79164466367, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Sat Mar 23 02:12:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=308281, encodeId=388a3082812d, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Sun Apr 22 19:26:37 CST 2018, time=2018-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1574227, encodeId=518f15e4227c9, content=<a href='/topic/show?id=36fc56212c6' target=_blank style='color:#2F92EE;'>#拔牙#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56212, encryptionId=36fc56212c6, topicName=拔牙)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9c5216012416, createdName=xre2013, createdTime=Mon Apr 16 06:12:00 CST 2018, time=2018-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305762, encodeId=3364305e6285, content=刷牙影响心血管.那洗头洗脸???, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:21:00 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305761, encodeId=c301305e6116, content=真够可以的, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:19:58 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305746, encodeId=5907305e460f, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sat Apr 14 17:17:08 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305740, encodeId=3db2305e402e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=40ad2312069, createdName=1222becem95暂无昵称, createdTime=Sat Apr 14 16:20:04 CST 2018, time=2018-04-14, status=1, ipAttribution=)]
    2018-04-14 怪物博士

    真够可以的

    0

  6. [GetPortalCommentsPageByObjectIdResponse(id=1644663, encodeId=1e79164466367, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Sat Mar 23 02:12:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=308281, encodeId=388a3082812d, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Sun Apr 22 19:26:37 CST 2018, time=2018-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1574227, encodeId=518f15e4227c9, content=<a href='/topic/show?id=36fc56212c6' target=_blank style='color:#2F92EE;'>#拔牙#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56212, encryptionId=36fc56212c6, topicName=拔牙)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9c5216012416, createdName=xre2013, createdTime=Mon Apr 16 06:12:00 CST 2018, time=2018-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305762, encodeId=3364305e6285, content=刷牙影响心血管.那洗头洗脸???, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:21:00 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305761, encodeId=c301305e6116, content=真够可以的, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:19:58 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305746, encodeId=5907305e460f, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sat Apr 14 17:17:08 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305740, encodeId=3db2305e402e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=40ad2312069, createdName=1222becem95暂无昵称, createdTime=Sat Apr 14 16:20:04 CST 2018, time=2018-04-14, status=1, ipAttribution=)]
    2018-04-14 天地飞扬

    了解一下.谢谢分享!

    0

  7. [GetPortalCommentsPageByObjectIdResponse(id=1644663, encodeId=1e79164466367, content=<a href='/topic/show?id=e3eb89e17fb' target=_blank style='color:#2F92EE;'>#血管病#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=89717, encryptionId=e3eb89e17fb, topicName=血管病)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=64bb23195917, createdName=Luyuxie_17, createdTime=Sat Mar 23 02:12:00 CST 2019, time=2019-03-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=308281, encodeId=388a3082812d, content=学习一下, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://wx.qlogo.cn/mmopen/NUyjXTCJjo6KcicAVC1MwuOgo3iaicb1Imgk1yIfnvr6oXzibcAFB6puAyNJXbzWhNuLqaFYBVRWjh7rghkvFLPxMAfD5ib3nXwVD/0, createdBy=bed21972958, createdName=wxl882001, createdTime=Sun Apr 22 19:26:37 CST 2018, time=2018-04-22, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1574227, encodeId=518f15e4227c9, content=<a href='/topic/show?id=36fc56212c6' target=_blank style='color:#2F92EE;'>#拔牙#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=36, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=56212, encryptionId=36fc56212c6, topicName=拔牙)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=9c5216012416, createdName=xre2013, createdTime=Mon Apr 16 06:12:00 CST 2018, time=2018-04-16, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305762, encodeId=3364305e6285, content=刷牙影响心血管.那洗头洗脸???, beContent=null, objectType=article, channel=null, level=null, likeNumber=80, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:21:00 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305761, encodeId=c301305e6116, content=真够可以的, beContent=null, objectType=article, channel=null, level=null, likeNumber=65, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/03/12/b047e7b7a940408d27cdc9f008613c4d.jpg, createdBy=bcec2287184, createdName=怪物博士, createdTime=Sat Apr 14 19:19:58 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305746, encodeId=5907305e460f, content=了解一下.谢谢分享!, beContent=null, objectType=article, channel=null, level=null, likeNumber=63, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=http://cdnapi.center.medsci.cn/medsci/head/2019/12/23/2f51002e1349ccda5be11c1eea1e1e60.jpg, createdBy=a22097948, createdName=天地飞扬, createdTime=Sat Apr 14 17:17:08 CST 2018, time=2018-04-14, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=305740, encodeId=3db2305e402e, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=77, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=40ad2312069, createdName=1222becem95暂无昵称, createdTime=Sat Apr 14 16:20:04 CST 2018, time=2018-04-14, status=1, ipAttribution=)]
    2018-04-14 1222becem95暂无昵称

    学习了

    0

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