Резюме
Ємельянова Н.Ю., Калашнік Д.М., Каменір В.М. Екстрапульмональні прояви у хворих на хронічні обструктивні захворювання легенів.
Стаття присвячена актуальній проблемі стоматології та пульмонології, а саме змінам у порожнині рота хворих, які страждають на хронічне обструктивне захворювання легенів (ХОЗЛ). Незважаючи на те, що основну увагу у визначенні ХОЗЛ акцентують на бронхолегеневих проявах, все частіше обговорюється роль екстрапульмональних проявів, у тому числі змін у порожнині рота. Доведено, що хворі з ХОЗЛ у 100% мають стоматологічні скарги, та більш ніж у 90% страждають на запальні захворювання пародонтального комплексу. Патогенез існуючих змін у порожнині рота обумовлений не тільки наявністю соматичної патології, а ймовірно, дисбалансом між захисними й агресивними факторами в наслідок застосування лікарських засобів для лікування основного захворювання. Детальне та цілеспрямоване дослідження у даному напрямку може стати корисним для оптимізації методів лікування та профілактики захворювань порожнини рота у даної категорії хворих.
Ключові слова: хронічне обструктивне захворювання легенів, пародонт, інгаляційні глюкокортікостероіди.
Резюме
Емельянова Н.Ю., Калашник Д.М., Каменир В.М. Экстрапульмональные проявления у больных хроническими обструктивными заболеваниями легких.
Статья посвящена актуальной проблеме стоматологии и пульмонологии, а именно изменениям в полости рта пациентов, которые страдают хроническими обструктивными заболеваниями легких (ХОЗЛ). Несмотря на то, что основное внимание в определении ХОЗЛ акцентируется на бронхолегочных проявлениях, все чаще обсуждается роль экстрапульмональных проявлений, в том числе изменениям в полости рта. Доказано, что пациенты с ХОЗЛ в 100% имеют стоматологические жалобы, та более 90% страдают воспалительными заболеваниями пародонтального комплекса. Патогенез существующих изменений в полости рта обусловлен не только наличием соматической патологии, а возможно, дисбалансом между защитными и агрессивными факторами вследствие использования лекарственных средств для лечения основного заболевания. Детальное и целенаправленное исследование в данном направлении может стать полезным для оптимизации методов лечения и профилактики заболеваний полости рта у данной категории больных.
Ключевые слова: хроническое обструктивное заболевание легких, пародонт, ингаляционные глюкокортикоиды.
Summаry
Emelyanova N.Y., Kalashnik D.N., Kamenir V.M. Extrapulmonary manifestations in patients with chronic obstructive pulmonary disease.
Article is devoted to the problem of dental and pulmonology, namely changes in the oral cavity of patients who suffer from chronic obstructive pulmonary disease (COPD). Despite the fact that the focus of the definition of COPD is focused on the broncho-pulmonary manifestations, increasingly discussed the role of extrapulmonary manifestations, including changes in the oral cavity. Demonstrated that patients with COPD in 100% have dental complaints, that more than 90% suffer from inflammatory diseases of the periodontal complex. Pathogenesis of existing changes in the oral cavity caused not only by the presence of somatic pathology, and possibly an imbalance between aggressive and protective factors through the use of drugs to treat the underlying disease. Detailed and focused research in this area may be useful for optimizing the treatment and prevention of oral diseases in these patients. inhaled glucocorticoids.
Key words: chronic obstructive pulmonary disease, periodontium, inhaled glucocorticoids.

УДК 616.31: 616.24 – 007.272 – 036.12

ГУ «Национальный институт терапии им. Л.Т. Малой НАМНУ» 61039 Украина,г. Харьков,пр. Постышева, 2-а
GI «L. T. Mala National Therapy Institute of the NAMS of Ukraine», 61039 Ukraine,Kharkov,Postyshev Avenue, 2-а

vikakamenir@yandex.ru gdftherapy@mail.ru

Chronic obstructive pulmonary disease (COPD) is one of the leading causes of morbidity and mortality in modern society and is a significant economic and social problem, which so far has no tendency to improvement. According rows studies, the prevalence of COPD in the world in people over age 40 is 10,1% (11,8% in men and 8,5% in women) [3]. COPD is regarded as a disease with progressive lung dysfunction and is associated with an inflammatory reaction of lung tissue to stimulation by various pathogenic agents and gases [7]. The focus in the definition of COPD emphasize bronchopulmonary manifestations. However, in recent years, increasingly debated role extrapulmonic manifestations, such as systemic inflammation, skeletal muscle dysfunction, cardiovascular disorders, weight loss, osteoporosis, anemia, changes in the periodontal tissues and hard tissues of teeth [4,8 -9]. In connection with the presence of symptoms to determine extrapulmonic COPD, as a systemic disease [7]. In recent years, widely discussed mechanisms of close association of COPD and cardiovascular disease (CVD). Large epidemiological studies have shown that the leading cause of mortality of patients with mild-moderate COPD course is not respiratory failure, as traditionally assumed, and cardiovascular disease (CVD) - coronary heart disease (CHD) and heart failure (HF) [2,6, 8]. According to population studies in patients with COPD risk of cardiovascular death increased by 2-3 times and is about 50% of the total number of deaths [8]. The cause frequent association of COPD and CVD may be common risk factors - smoking [2,6], and persistent systemic inflammation, chronic infection, taking certain medications that increase the activity of the sympathetic nervous system (β2-agonists) and others [11]. Currently accumulate more and more data that chronic persistent systemic inflammation present in COPD, contributes to the pathogenesis of atherosclerosis and CVD in patients with COPD.

In the current research a great place on the study of periodontal tissues for respiratory diseases, including chronic obstructive pulmonary disease (COPD) and bronchial asthma (BA) [4]. Epidemiological data of systematic reviews have shown that inflammatory disease and oral tissues may be independent predictors of the risk of COPD. In some studies conducted indicates the detected link between gum disease and respiratory diseases in subjects at high risk. Authors of studies using microbiological and epidemiological tests have shown that in case of unsatisfactory oral hygiene in raid colonized potential respiratory pathogens, which when joined other risk factors such as smoking, cause the development of COPD. Aggravation and progression of COPD depends on the initial colonization of pathogens on the surface of the pharynx. Enzymes aspirate pathological influence on receptor cells of the mucous membranes of the mouth, which improves adhesion and increases colonization of pathogens. In addition, bacterial products aspirate can induce the production of cytokines respiratory epithelial cells increases susceptibility to epithelial mucosal infection by pathogenic bacteria. Evaluation of the role of hormonal regulation of the functional state of periodontal tissues have long attracted the attention of researchers. However, there are quite a controversy about the development of periodontal disease in different hormonal imbalances. Also not fully known data on the impact of corticosteroids on bone turnover [1,5]. Of generalized periodontitis when using inhaled glucocorticoids (IUC) is characterized by inhibition of phagocytosis and intensity, decreased serum levels of IgA and IgA and sIgA in oral fluid, and decreased activity suktsenatdehidrohenazy neutrophil tissue indicates decompensation protective factors and reduce the possibility of forming an adequate response to microbial antigens and metabolic disorders [10-12].

The aim - to explore the features of clinical symptoms oral cavity in patients with COPD.

Materials and Methods:

The study was conducted in the clinic of  Institute of therapy by the name of  .T.Malaya of the National  Academy of Medical Scienes of Ukrain. Related studies randomized 101 patient: 36 women (35.6%) and 65 men (64.3%), whose average age was (63,4 ± 1,6) years. The diagnosis of "COPD + CHD" had 40 patients, "COPD" - 36, "CHD" - 25 patients (Table 1).

Table 1

Clinical characteristics of individuals surveyed three groups     

Notes: * P <0,05 (I and III) 2. Δ p <0,05 (II and III)

Exclusion criteria from the study were: exacerbation of COPD, chronic heart failure IV FC, acute heart failure, serious heart rhythm abnormalities, hormonal dysfunction of the thyroid gland, tuberculosis history, malformation of the lungs, bronchial asthma, insulin-dependent diabetes mellitus.

Diagnosis of COPD placed under orders from the Ministry of Health of Ukraine № 128 of 12.03.07, and provisions set out in the document GOLD (Global initiative for Chronic Obstructive Lung Disease), based on history,  overall clinical examination, ECG, Echo CS, X-ray   of the chest, determination of respiratory function (DRF). According to the recommendations of the European Society of Cardiology established diagnosis of coronary artery disease based on clinical (anginal pain), load tests (stress echocardiography with dobutamine, bicycle ergometry), XM ECG, coronary angiography.

In order to determine the dental status of 45 patients were: Group 1, patients with COPD and CHD  (20 patients), group 2 - patients with CHD  (10 patients), Group 3 - patients with COPD (15 patients). The control group consisted of 10 somatically healthy patients representative by age and gender. Patients performed a clinical dental examination with determination CPU index (K - carious teeth, P - sealed teeth, R - removed teeth), oral hygiene index (Green-Vermylon) and the state of periodontal tissues (papillary - marginally - alveolar index (PMA) on Parma%, comprehensive periodontal index (KPI) for Leus, index bleeding on Muchlemann). Changes in periodontal tissue diagnosed on the basis of systematics M.F.Danilevskoho (1994).

Statistical analysis of the results of clinical and laboratory tests carried out on a computer using the «Microsoft Office Excel 2003". Check distribution dates for compliance with the law normally performed using the Shapiro-Uilki. Results are presented as M ± m (M-arithmetic mean, m-error mean). Comparison of mean values ​​was performed using Student's t test.

The results:

1 stage COPD were 22.3% (17 patients). Patients with stage II and III COPD were approximately equal numbers of 38.1% (29 patients) and 35.5% (27 patients), patients with stage IV COPD was only 3.9% (3 people), so statistical analysis this group of patients was involved. Patients with COPD received baseline and symptomatic therapy: of course COPD I-II degree - m - anticholinergics or beta-2-agonists, long-acting, if necessary - short-acting bronchodilators. Patients III and stage IV COPD to basic therapy added inhaled steroids.

In all patients with coronary disease observed stable angina I-II FC, CH I-IIA stage with preserved left ventricular systolic function. All patients treated with coronary artery disease according to the recommendations of the Ukrainian Society of Cardiology: acetylsalicylic acid (Cardiomagnyl), beta-blockers (NEBILET or Ivabradyn), statins (Vabadyn, atorvastatin), ACE inhibitors or angiotensin receptor antagonists-2 (kardosal). In 8 patients had coronary conducted in 78 patients - VEM-test and in 15 patients - stress echocardiography. In the study group were 47 patients who had myocardial infarction. Individuals of all three groups did not significantly differ by age and gender (p <0,05). Patients with COPD in conjunction with coronary artery disease and COPD were compared to the frequency of the factor of cardiovascular risk as smoking (p <0,05).

At the initial examination 15 (75 ± 9,7%) patients of group 1, 7 (70 ± 14, 5%) patients group 2, and 15 (100%) with COPD complained of bleeding gums, swelling and intermittent itching in the gums, mobility teeth and rapid emergence of dental plaque. It should be noted that the most intense complaints were characteristic of patients with COPD, in which 8 (53.3%) patients indicated the bleeding when brushing teeth, and 7 (46.7%) - the bleeding while taking solid food. Among the group of somatically healthy only 2 patients complained of bleeding gums and the presence of dental accretions. Data distribution of complaints by groups of patients are presented in Table 2.

On examination of the oral mucosa in 37.7% of patients drew the attention of insufficient moisture of the mucous membrane, a small swelling of the oral mucosa, including mucous tongue and cheeks. Tongue in 8 (17.8%) patients had increased in size, there were prints of teeth on the sides. In 11 (55.0%) patients of COPD + CHD than dry buccal mucosa with teeth imprints increased keratinization of the oral mucosa. Also in 5 (50.0%) patients with coronary artery disease group was marked swelling of the tongue with atrophy and hypertrophy of filiform papillae.

Table 2.

Distribution of the nature of complaints investigated in experimental and control groups  (M ± m,%)

        Notes:   * - Difference likely than control p <0,05

An objective study of oral referred patients rate CPR significantly different not only from the control group (healthy), and between the first, second and third groups. The highest rate was registered in the group of patients with COPD + CHD - 10.4 due to the increased number of carious lesions cervical and wedge-shaped defects. In a detailed study of periodontal tissue indicated that the most pronounced changes were observed in patients with COPD, and were presented with chronic generalized periodontitis of different degrees of severity (redness and swelling of the gums, bleeding when probing, the presence of periodontal pockets, tooth mobility). In this group of patients with periodontal status changes were observed in 14 (93.4%) patients, of whom 1 degree of periodontitis was inherent in 7 (46.7%) patients, the second stage 5 (33.3%), and the third - 2 (13 3%) individuals. All clinical changes confirmed index figures. Thus, the index stood at 30.7 PMA and KPI-1, 54.

Thus, the clinical picture of the oral cavity of patients in most cases characterized by the development of dental disorders. Intensity non-caries lesions indices PMA and KPI statistically significant different in patients with this pathology unlike stateless somatic diseases. Thus, the pathogenesis of disorders in the oral cavity in COPD is complex. It is due, above all, an imbalance between aggressive and protective factors that fully meets the clinical picture. A certain part of the clinical manifestations of the disease, its course and possible complications add some medicines used for somatic treatment of such patients. Therefore, detailed and focused research in this area, taking into account all factors of influence on organs and tissues of the oral cavity can be useful to optimize treatments in these patients.

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