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10КОМПЛЕКСНЕ Л1КУВАННЯ ГЕНЕРАЛ1ЗОВАНОГО КАТАРАЛЬНОГО Г1НГ1В1ТУ В СТАДП
ЗАГОСТРЕННЯ
Шостенко А.А.
ДВНЗ «Буковинський державний медичний утверситет», кафедра стоматологИ дитячого в1ку, асистент
COMPREHENSIVE TREATMENT OF GENERALIZED CATARRHAL GINGIVITIS IN THE ACUTE
STAGE
Shostenko A.
HSEE "Bukovinian state medical university", department of pediatric dentistry, assistant
Анотащя
У статп проан^зовано результати вивчення особливостей мшробюценозу ясенних тканин i мюце-вого iмунiтету у 49 хворих з хрошчним i загостреним перебiгом генералiзованого катарального гiнгiвiту. Виявлено, що у хворих з загостреним перебтем генералiзованого катарального гiнгiвiту бiльш iстотнi вщмшносл в показниках мiсцевого гуморального iмунiтету на вiдмiну вiд групи пащенпв з хронiчним проявом захворювання. Виявлено значне зниження рiвнiв sIgA i IgM i, в меншiй мiрi, пiдвищення IgG. Встановлено, що умовно - патогенна стрептококова мiкрофлора займае проввдне мiсце в етюлогп хрошч-ного генералiзованого катарального гiнгiвiту, а в формуванш загострень запальних явищ в тканинах ясен домiнуюча роль належить стафiлококам та грибам роду Кандща. Розробленi програми вiдновлювального л^вання та наступних шдтримуючих лiкувально-профiлактичних заходiв, що передбачали етапне прове-дення.
Abstract
The article analyzes the results of studying the features of the microbiocenosis of gingival tissues and local immunity in 49 patients with chronic and acute generalized catarrhal gingivitis. It was found that in patients with acute generalized catarrhal gingivitis more significant differences in local humoral immunity in contrast to the group of patients with chronic disease. There was a significant decrease in sIgA and IgM levels and, to a lesser extent, an increase in IgG. It is established that conditionally pathogenic streptococcal microflora occupies a leading place in the etiology of chronic generalized catarrhal gingivitis, and in the formation of exacerbations of inflammatory phenomena in the gum tissue the dominant role belongs to staphylococci and fungi of the genus Candida. Rehabilitation programs and subsequent supportive treatment and prevention measures have been developed, which provided for phased implementation.
Ключов1 слова: генералiзований пародонтит, катаральний гшпвгг, мшробюценоз.
Keywords: generalized periodontitis, catarrhal gingivitis, microbiocenosis.
The wide spread of generalized catarrhal gingivitis among the population, especially young people, the increase in cases of its prolonged course, with frequent exacerbations of the inflammatory process in the gingival tissue and insufficiently effective treatment, represent an important, not fully resolved, problem in modern scientific and practical dentistry [1, 2 ].
Today's difficulties in complex treatment of the disease are associated with the versatility of the links and mechanisms involved in the pathological process that forms in the gingival tissue. Within the framework of the problem of generalized catarrhal gingivitis, it should be recognized that changes in the biocenosis of the periodontal gap and local immunity disorders determine the conditions for the development of the disease and its subsequent clinical manifestation [3, 4].
Numerous studies carried out recently prove that persistent opportunistic infection is the leading etiolog-ical factor that initiates and maintains the inflammatory process in the gingival tissue [5, 6].
It was also noted that these bacterial agents do not leave behind a persistent immunity, therefore, even af-
ter successfully completed antibiotic therapy and complete rehabilitation in patients with generalized ca-tarrhal gingivitis, there is a very high risk of reinfection and recurrence of the disease. In practice, violations of the normobiosis of gingival tissues occur against the background of a secondary immunodeficiency state and provoke its further development, and aggravate the further course of the disease.
Based on the foregoing, the achievement of effective and stable results of treatment of generalized catarrhal gingivitis is possible only if the biocenosis of the gum tissue is normalized and the immunity is corrected towards its restoration.
A promising method for eliminating dysbiosis can be the use of antibacterial agents in combination with the probiotic biosporin. The lack of experience in their use in patients with generalized catarrhal gingivitis dictates the need for clear recommendations for their use. It is also necessary to solve the question at what stage to carry out immunocorrective therapy, especially in patients with an exacerbated course of the disease, and also to determine the timing of repeated (prophylactic) administration of immunomodulatory drugs.
Purpose of the study: increasing the effectiveness of complex treatment, exacerbated chronic generalized catarrhal gingivitis through the staged use of professional hygiene measures, etiotropic drugs and mmune-correcting therapy.
Materials and methods. The study included 49 patients with a diagnosis of exacerbated chronic generalized catarrhal gingivitis. Young people (from 18 to 26 years old) were selected to perform the work. The ratio of the selected men and women was approximately equal. The object of the study was patients who did not suffer from other concomitant diseases. Diagnosis of exacerbated chronic generalized catarrhal gingivitis was based on generally accepted clinical and radiological data. All patients underwent an identical clinical examination, including clarification of complaints, collection of anamnesis, visual and instrumental assessment of the dental status.
Along with general clinical examination, standard digital orthopantomography was used in the work with subsequent study of the obtained images on a personal computer for a more objective assessment of the condition of the bone tissues of the alveolar processes in the area of the interdental septa.
Determination of the hygienic state of the oral cavity was carried out according to the Green-Wermillion method, and the activity of the inflammatory process in the gingival tissue according to the change, the Muhlemann bleeding index (Muhlemann HR) and the papillary-marginal-alveolar index (PMA).
The work used standard orthopantomography on a visiograph for a more objective assessment of the state of the bony interdental septa.
To determine the biocenosis of gingival tissues, the classical method of bacterial cultivation was used with the determination of the quantitative and species composition of microflora. Microbiological studies were carried out on material taken from the periodontal sulcus after rinsing the oral cavity three times with distilled water. The inoculation of the material in order to isolate the colony was carried out by the sectoral method on a Petri dish with 5% Brain Heart Agar prepared on the basis of Brain Heart Agar. The cultivation of anaerobic cultures of bacteria was carried out in an anaerostat. Biochemical identification of pure cultures of anaerobic bacteria was carried out using Farsin API test systems (France) Ruche (Germany).
Upon admission to treatment and during follow-up, the secretory humoral immune status was assessed in all patients regardless of the period of the disease (chronic course or exacerbation).
The concentration of immunoglobulins in the oral fluid was determined by the method of radial immunodiffusion in a gel according to G. Mancini 1965 [7]. Determination of secretory immunoglobulin was carried out using enzyme-linked immunosorbent assay using monospecific serum against the named immunoglobu-lin.
Based on the data of the clinical examination and in accordance with the set goal, the patients were divided into the main (27 people) and the comparison group (22 people) groups identical in age, sex and duration of the disease. Patients in the control group
(group 1) received conventional treatment: standard antibacterial therapy (topically used 2% chlorhexidine solution) along with traditional professional measures and a course of immunocorrection with an interferonogenic drug lycopid in a dosage of 1 table. per day, for 10 days.
In the long-term period (3-6 months after the end of therapy), in cases of clinical relapses, an inflammatory process in the gingival tissue, an analysis of the state of biocenosis and local secretory immunoreactiv-ity in these patients was carried out, followed by treatment according to the developed scheme. Patients of the main group (group 2) were initially treated in accordance with the method developed by us.
During the first stage of treatment, all patients of the main group underwent professional hygienic measures. After removing dental deposits, the areas of mechanical interventions were treated with a 0.2% chlorhexidine solution (Geksoral). After these procedures, a gel form "Paragel", an aseptic gel for gums, which contains 0.2% chlorhexidine biglucanate and an extract of galangal root, was applied to the affected area of the gingival tissues. To suppress fungal microflora and restore normobiosis of gingival tissues at the first stage of treatment of exacerbated chronic generalized catarrhal gingivitis, patients were prescribed Biosporin orally 2 times a day 30 minutes before meals. As an anti-inflammatory therapy, the patients of the main group were additionally prescribed Nimesil, at a dose per day, for the first 3 days. Immunological preparations were not used at the first stage of treatment, due to their inadequate corrective effect on the processes. The refusal to use them was based on the results of immunological studies carried out in the control comparison group.
The second stage of treatment in patients of the main group began after the elimination of the active inflammatory process in the gingival tissues, and included general immunotherapy with lycopid, at a dose of 1 mg per day according to the scheme once a day, for 10 days.
The third final stage included prevention of relapses of the disease in the long-term period after treatment by carrying out, according to indications, professional hygienic measures and a repeated course of general or local immunocorrective therapy. The choice of the method of immunotherapy was carried out depending on the clinical and laboratory data and the clinical state of the gingival tissues.
In patients with a renewed process, which was characterized by a chronic sluggish course, general im-munocorrection with lycopid was carried out against the background of a reduction to 5-6 days of the course of antibacterial drugs (Paragel, Biosporin).
The need for preliminary immunocorrection at the third stage in patients with intact periodontal tissues arose as a result of the detection of some deterioration in their immunological parameters by laboratory tests in comparison with those immediately after the second stage of complex treatment. In this case, preventive courses of local immunotherapy were carried out for 68 days. Likopid was administered by the application method (1 mg of the drug per 30.0 ml of saline) on a
solution moistened with a cotton swab, the duration of exposure was from 5 to 10 minutes.
Statistical processing of the results was carried out using Microsoft Excel for Windows on a personal computer with the determination of the mean and error of the mean (M ± m), calculation of the Student's t-test. When testing hypotheses, a significance level of p<0.05 was used.
Research results and their discussion. The clinical examination of patients in the main group and the control group before treatment revealed no significant differences in the severity of objective indicators characterizing the inflammatory process in the gums between the groups. This circumstance was very important in the comparative assessment of the results of complex treatment of exacerbated chronic generalized gingivitis with the traditional (group 1) and the developed method (group 2) from the standpoint of evidence-based medicine.
The hygiene index before treatment averaged 2 in patients of group 1, 3 ± 0.06, in the second 2.4 ± 0.1; bleeding index, respectively 2.5 ± 0.2 and 2.4 ± 0.18; papillary-marginal-alveolar index (PMA) - 78.7 ± 0.7% and 79.1 ± 0.7%.
When studying clinical indicators in dynamics, a positive result of complex treatment was noted in all patients of both groups, already by 3-4 visits, patients indicated an improvement in the condition of the gums. The soreness disappeared. In all groups, there was a decrease in bleeding, hyperemia and swelling in the gum area. This was confirmed and clarified by objective examination methods.
However, when comparing the effectiveness of therapeutic measures in groups 1 and 2, a delay in the elimination of the main clinical symptoms of the disease in patients treated with the traditional method was found, which was confirmed by an increase in the duration of treatment (on average by 5, 9 ± 0.3 days). The best anti-inflammatory effect in patients of the main group was achieved due to the additional introduction of the etiotropic drug biosporin and the anti-inflammatory drug Nimesil into the therapeutic complex at the first stage.
The value of the hygiene index indicated a good hygienic state of the oral cavity (0.6 ± 0.03), the indicators of the bleeding index and PMA corresponded to the norm in the group treated according to the developed method and basically approached zero values in 96.3% of patients immediately after treatment. .
At the same time, despite all the positive effects in the course of traditional treatment, after the end of therapy, the normalization of gingival indices from the baseline was observed in 81.8% of patients with exacerbated chronic generalized catarrhal gingivitis, in the rest there was only an improvement in gingival status.
This circumstance served as the basis for the continuation of treatment for such patients. Additional use of Biosporin, Nimesil and topically Likopid in them, according to the developed method for 7 days, made it possible to stop residual inflammation in all patients.
Long-term dispensary observations demonstrated that the results of complex therapy of exacerbated gen-
eralized catarrhal gingivitis achieved by using the selected drugs at different stages of treatment in patients of both groups for 6-12 months remained stable. During these periods, clinical signs of disease recurrence were absent in the overwhelming majority of patients (95.9%); there were no cases of resorption of the tops of the interdental septa. Along with clinical data, microbiological monitoring also demonstrated a higher efficiency of the developed staged therapy for exacerbated chronic generalized gingivitis compared to the traditional one. So, when conducting bacteriological studies after the treatment, it was noted that the antibacterial complex of the main group contributed to the achievement of normalization of the biocenosis of the gingival econiche in 26 out of 27 (96.3%) examined. Moreover, in these patients, the elimination of dysbi-otic disorders in the periodontal sulcus coincided with the elimination of inflammation in the gingival tissues. In the rest of the patients of the analyzed group, upon completion of the staged treatment, a pronounced positive dynamics in the change in the biocenosis of the gingival tissues was noted.
After treatment, 25 out of 27 (92.59%) patients of the main group with recovery completely disappeared staphylococci, peptostreptococci, hemolytic streptococci, fungi of the genus Candida and bacteriophages. tissues and upon completion of treatment, as in the previously mentioned, the microbiological state of the gums, practically did not differ from that in healthy people.
Under the conditions of traditional antibiotic therapy in patients of group 1, there was a decrease in the frequency and number of detection of pathogenic and opportunistic microorganisms - streptococci, staphylo-cocci, bacteroids.
Representation of bacteria stabilizing normobiosis lacto and bifidobacteria, str.viridans and str. sanginus, on the other hand, showed almost no significant upward trend. This circumstance served as the basis for the inclusion of the probiotic Biosporin in the treatment regimen. After its additional use in patients of group 1, normalization of symbiotic microorganisms in the gingival tissues was noted.
Literature data indicate a significant role of the im-munocomplex reaction in the development of generalized catarrhal gingivitis, which justified the use of im-munotherapy as an obligatory component in the treatment regimens of the disease. It is known that at the time of exacerbation of a chronic inflammatory process, it is accompanied by an increase in local and general immunity, and at the same time immunocorrective therapy has a lesser therapeutic effect, which was confirmed by our clinical and laboratory studies. Thus, in patients of the comparison group (group 1), lycopid was used at the 1st stage of complex therapy in conjunction with antibacterial therapy, depression of local immunity was revealed in patients, even with inflammation eliminated in the gingival tissue.
Based on this, we consider it expedient to carry out immunotherapy at stage 2 and subsequent, to prevent relapses of the disease. Immediately after the complex treatment at stage 1, on the contrary, there was a decrease in the levels of immunoglobulins, especially
SIgA, in more than 70% of the subjects, which affected the average values of the indices of local immunity.
Before the start of treatment of patients with exacerbated course of chronic catarrhal gingivitis, an increase in the content of immunoglobulins of all classes (sIgA, IgG, IgM) in saliva was noted (Table 2). The im-munocorrection with lycopid at the 2nd stage of complex treatment of patients with generalized catarrhal gingivitis indicated a favorable effect on the clinical condition of the gums and restoration of local humoral protection of the oral mucosa in 100% of patients.
In the 2nd group of patients with exacerbated chronic catarrhal gingivitis immediately after treatment, 6-12 months after the treatment, stable normalization of sIgA, IgG, IgM was observed, which indicated the relief of inflammation processes and the absence of relapses of the disease in 96.3% of cases.
Conclusions
1. At the first stage of treatment of exacerbated chronic generalized gingivitis, it is recommended to carry out, along with rational professional measures, local antibiotic therapy with chlorhexidine-containing agents in combination with biosporin. Under their influence, there was a decrease and complete disappearance of potential pathogens of the disease and the normalization of the biocenosis of the gingival tissue in 93% of the treated.
2. The proposed scheme of immunotherapy for exacerbated chronic catarrhal gingivitis is recommended to be carried out after elimination of active inflammation in the gingival tissue. The use of lycopid at a dose of 1 mg per day for 10 days orally at the 2nd stage of treatment and subsequently for prophylactic purposes
(locally at other stages of complex therapy) makes it possible to accelerate the elimination of the main symptoms of the disease in 96.3% immediately after im-munocorrection and persistent clinical laboratory results throughout the entire period of dispensary observation in 100% of patients.
References
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1МУНОЛОГ1ЧНА ТА МШРОБЮЛОГ1ЧНА ХАРАКТЕРИСТИКА ГЕНЕРАЛ1ЗОВАНОГО
КАТАРАЛЬНОГО Г1НГ1В1ТУ
Шостенко А.А.
ДВНЗ «Буковинський державний медичний унгверситет», кафедра стоматологи дитячого в1ку, ассистент
IMMUNOLOGICAL AND MICROBIOLOGICAL CHARACTERISTICS OF GENERALIZED
CATARRHAL GINGIVITIS
Shostenko A.
HSEE "Bukovinian state medical university", department of pediatric dentistry, assistant
Анотащя
У данш статп наведен отримаш результата дослвдження показнишв мюцевого ÎMyHrreiy та мжроф-лори порожнини рота у 42 хворих на генералiзований катаральний пнпвгт з хрошчним та загостреним nepe6iroM.
Для щентифшацп основних пародонтопатогешв застосовували полiмеpазнy ланцюгову реакщю з ви-користанням ДНК-зондiв iз зворотно1 ДНК-пбридизацп.. Бiохiмiчнy щентифжацш анаеробних бактерш, стрептокошв i грамнегативних бактеpiй проводили за допомогою тест-системи фipми АР1 (Фpанцiя).
Концентрацш sIgA, Ig G i M визначали методом pадiальноï iмyнодифyзiï в гелi по G. Manchini.
Встановлено, що проввдна роль у розвитку захворювання належить порушенню стану мюцевого iмy-нiтетy. Резидентна умовно - патогенна стрептококова мiкpофлоpа займае проввдне мiсце в етiологiï хронь чного запального процесу в тканинi ясен. У розвитку загострень - дом^ючу участь приймае стафшоко-кава та грибкова iнфекцiï в piзних асощативних взаеминах з гемолiтичними стафiлококами.
