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DOI: 10.1055/a-1286-8376
Orale Immunkompetenz in der Corona-Pandemie vs. Systemrelevanz der Zahnmedizin
Oral Immunocompetence in the Corona Pandemic vs. System Relevance of Dentistry![](https://www.thieme-connect.de/media/gesqm/202005/lookinside/thumbnails/10-1055-a-1286-8376-1.jpg)
Zusammenfassung
Die Covid-19-Pandemie hat das deutsche Gesundheitssystem im Jahr 2020 vor erhebliche Herausforderungen gestellt. In diesem Zusammenhang ist es bemerkenswert, dass für die Zahnmedizin kein sogenannter Rettungsschirm aufgespannt wurde. Dies bedeutet, dass nach Ansicht der Bundesregierung Zahnärzte als nicht systemrelevant eingestuft wurden und somit offiziell auch nicht zu den Ärzten gehören. Diese Annahme ist grundfalsch und gefährlich, wie im Folgenden anhand eines wichtigen Beispiels erörtert wird.
Das SARS-CoV-2-Virus führt bei infizierten Personen zu einem Beschwerdebild von leichten Erkältungszeichen bis hin zu lebensbedrohlichen beatmungsbedürftigen COVID-19-Pneumonien. Ein besonderes Risiko für schwere Verläufe haben Menschen höheren Alters sowie Patienten mit Diabetes, Bluthochdruck und anderen schweren Erkrankungen. Die Haupteintrittspforte für das SARS-CoV-2-Virus in den menschlichen Körper ist u. a. die orale Mukosa, denn die Viren reichern sich dort bevorzugt an und der ACE2-Rezeptor wird dort hochgradig exprimiert. Dieser Penetrationsweg erklärt die häufigeren schweren Verläufe bei älteren Diabetespatienten, deren Immunsystem bereits generell beeinträchtigt ist. Diabetes mellitus induziert eine chronische systemische Entzündung, die sich gerade im Mundbereich regelmäßig als Parodontitis manifestiert. Bei Diabetikern zwangsläufig oft auftretende Hyperglykämien schwächen die Mukosa-Barriere zusätzlich. Es ist daher dringend ratsam, bei Präventionsmaßnahmen für Diabetespatienten den Mund- und Rachenraum nicht zu ignorieren. Neben der parodontalprophylaktischen Betreuung ist gerade in Absenz von Zahnärzten die aktivierte Matrix-Metalloproteinase 8 (aMMP8) ein etablierter Biomarker. Die aktuellen Empfehlungen zur Prävention der SARS-CoV-2-assoziierten COVID-19-Erkrankung sollte daher um die Aspekte der Messung und Sanierung des Mund- und Rachenraums sowie einer regelmäßigen Desinfektion der oralen Mukosa erweitert werden.
Abstract
The Covid-19 pandemic has presented significant challenges for the German health system in 2020. In this context, it is noteworthy that no so-called parachute has been put on for dentistry. This means that, in the view of the Federal Government, dentists have been classified as non-systemically important and therefore officially do not belong to the doctors. This assumption is fundamentally wrong and dangerous, as discussed below on the basis of an important example.
The SARS-CoV-2 virus leads to symptoms ranging from mild colds to life-threatening COVID-19 pneumonia in infected individuals. People of older age as well as patients with diabetes, high blood pressure and other serious illnesses have a particular risk of severe history. The main gateway for the SARS-CoV-2 virus into the human body is, among other things, the oral mucosa, because the viruses accumulate there preferably and the ACE2 receptor is highly expressed there. This penetration pathway explains the more frequent severe histories in older diabetes patients whose immune system is already generally impaired. Diabetes mellitus induces chronic systemic inflammation, which manifests itself regularly as periodontitis, especially in the oral area. In diabetics, often occurring hyperglycaemias further weaken the mucosa barrier. It is therefore strongly advisable not to ignore the mouth and throat space when preventive measures for diabetes patients. In addition to periodontal prophylactic care, the activated matrix metalloproteinase 8 (aMMP8) is an established biomarker, especially in the absence of dentists. The current recommendations for the prevention of SARS-CoV-2-associated COVID-19 disease should therefore be extended to include the aspects of measurement and rehabilitation of the oral and throat space as well as regular disinfection of oral mucosa.
Publication History
Article published online:
09 November 2020
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Literatur
- 1 The Lancet. COVID-19: too little, too late?. Lancet 2020; 395: 755
- 2 Xiao Y, Torok ME. Taking the right measures to control COVID-19. Lancet Infect Dis; 2020 pii: S1473-3099(20)30152–3
- 3 Zhou P, Yang XL, Wang XG. et al. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; 579: 270-273
- 4 Xu H, Zhong L, Deng J. et al. High expression of ACE2 receptor of 2019-nCoV on the epithelial cells of oral mucosa. Int J Oral Sci 2020; 12: 8
- 5 Wu C, Zheng M. Single-cell RNA expression profiling shows that ACE2, the putative receptor of COVID-2019, has significant expression in nasal and mouth tissue, and is co-expressed with TMPRSS2 and not co-expressed with SLC6A19 in the tissues. BMC Infectious Diseses. (under review). Im Internet: https://www.researchsquare.com/article/rs-16992/v1
- 6 To KKW, Tsang OTY, Leung WS. et al. Temporal profiles of viral load in posterior oropharyngeal saliva samples and serum antibody responses during infection by SARS-CoV-2: an observational cohort study. Lancet Infect Dis. (published online). Im Internet: https://doi.org/10.1016/S1473-3099(20)30196-1
- 7 Chen L, Zhao J, Peng J. et al. 1/24 Detection of 2019-nCoV in Saliva and Characterization of Oral Symptoms in COVID-19 Patients. SSRN. (published online). Im Internet: https://papers.ssrn.com/sol3/papers.cfm?abstract_id=3557140
- 8 To KKW, Tsang OTY, Yip CCY. et al. Consistent Detection of 2019 Novel Coronavirus in Saliva. Clin Infect Dis. (epub ahead of print, 2020). Im Internet: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7108139/
- 9 Badran Z, Gaudin A, Struillou X. et al. Periodontal pockets: A potential reservoir for SARS-CoV-2?. Med Hypotheses 2020; 143: 109907
- 10 Santosh ABR, Muddana K. Viral infections of oral cavity. J. Family Med Prim Care 2020; 9: 36-42
- 11 Ortiz AP, Gonzalez D, Vivaldi-Olivier J. et al. Periodontitis and oral human papillomavirus infection among Hispanic adults. Papillomavirus Res 2018; 5: 128-133
- 12 Rocha TAH, Abreu Fonseca Thomaz EBAF, DaSilva NC. et al. Oral primary care: an analysis of its impact on the incidence and mortality rates of oral cancer. BMC Cancer 2017; 17: 706
- 13 Sanz M, Marco Del Castillo A, Jepsen S. et al. Periodontitis and Cardiovascular Diseases. Consensus Report. Glob Heart 2020; 15: 1
- 14 Preshaw PM, Alba AL, Herrera D. et al. Periodontitis and diabetes: a two-way relationship. Diabetologia 2012; 55: 21-31
- 15 de Oliveira Araújo R, Villoria GEM, Raggio Luiz R. et al. Association between periodontitis and Alzheimer’s disease and its impact on the self-perceived oral health status: a case-control study. Clin Oral Investig 2020; DOI: 10.1007/s00784-020-03489-w.
- 16 Khanagar SB, Al-Ehaideb A, Naik S. et al. Primordial-level Preventive Measures for Dental Care Providers against Life-threatening Corona Virus Disease (COVID-19). Int J Clin Pediatr Dent 2020; 13: 176-179
- 17 Passarelli PC, Rella E, Manicone PF. et al. The impact of the COVID-19 infection in dentistry. Exp Biol Med (Maywood) 2020; 245: 940-944
- 18 Khanagar SB, Al-Ehaideb A, Vishwanathaiah S. et al. Exposure Risks and Preventive Strategies Considered in Dental Care Settings to Combat Coronavirus Disease (COVID-19). HERD 2020; 1937586720950746 DOI: 10.1177/1937586720950746.
- 19 Frankenberger R. Orale Immunkompetenz – was ist das?. Quintessenz 2020; 71: 831
- 20 Wood LF, Chahroudi A, Chen HL. et al. The oral mucosa immune environment and oral transmission of HIV/SIV. Immunol Rev 2013; 254 DOI: 10.1111/imr.12078.
- 21 Embree JE, Njenga S, Datta P. et al. Risk factors for postnatal mother-child tranmission of HIV-1. AIDS 2000; 10: 2535-2541
- 22 Pfützner A, Sorsa T, Nwhator SO. et al. Warum sind Diabetiker durch das Coronavirus (CoV-2) besonders gefährdet – Möglichkeiten für die orale Diagnostik und bedarfsgerechte Prävention für Patienten und Fachärzte. ZMK 2000; 36: 350-355
- 23 Giacomelli A, Pezzati L, Conti F. et al. Self-reported Olfactory and Taste Disorders in Patients With Severe Acute Respiratory Coronavirus 2 Infection: A Cross-sectional Study. Clin Infect Dis; 2020 Im Internet: https://doi.org/10.1093/cid/ciaa330
- 24 Levison ME. Pneumonia, including necrotizing pulmonary infections (lung abscess). Isselbacher KJ, Braunwald E, Wilson JD. et al. Harrison’s Principles of Internal Medicine. 13th edn. New York: McGraw Hill; 1994: 1197-1206
- 25 Sinclair DG, Evans TW. Nosocomial pneumonia in the intensive care unit. Br J Hosp Med 1994; 51: 177-180
- 26 Toews GB. Nosocomial pneumonia. Am J Med Sci 1986; 291: 355-367
- 27 Terpenning M, Bretz W, Lopatin D. et al. Bacterial colonization of saliva and plaque in the elderly. Clin Infect Dis 1993; 16 Suppl 4 S314-S316
- 28 Scannapieco FA, Stewart EM, Mylotte JM. Colonization of dental plaque by respiratory pathogens in medical intensive care patients. Crit Care Med 1992; 20: 740-745
- 29 Scannapieco FA. Pneumonia in nonambulatory patients. The role of oral bacteria and oral hygiene. J Am Dent Assoc 2006; 137 Suppl 21S-25S
- 30 Russell SL, Boylan RJ, Kaslick RS. et al. Respiratory pathogen colonization of the dental plaque of institutionalized elders. Spec Care Dentist 1999; 19: 128-134
- 31 Lorenz KA, Weiss PJ. Capnocytophagal pneumonia in a healthy man. West J Med 1994; 160: 79-80
- 32 Zijlstra EE, Swart GR, Godfroy FJ. et al. Pericarditis, pneumonia and brain abscess due to a combined Actinomyces–Actinobacillus actinomycetemcomitans infection. J Infect 1992; 25: 83-87
- 33 Yuan A, Yang PC, Lee LN. et al. Actinobacillus actinomycetemcomitans pneumonia with chest wall involvement and rib destruction. Chest 1992; 101: 1450-1452
- 34 Shinzato T, Saito A. The Streptococcus milleri group as a cause of pulmonary infections. Clin Infect Dis 1995; 21 Suppl 3 S238-S243
- 35 Yang LC, Suen YJ, Wang YH. et al. The Association of Periodontal Treatment and Decreased Pneumonia: A Nationwide Population-Based Cohort Study. Int J Environ Res Public Health 2000; 17: 3356 Im Internet: https://doi.org/10.3390/ijerph17010356
- 36 Almirall J, Serra-Prat M, Bolibar I. et al. Risk factors for community-accquired pneumonia in adults: a systematic review of observational studies. Respiration 2017; 94: 299-311
- 37 Sands KM, Wilson MJ, Lewis MAO. et al. Respiratory pathogen colonization of dental plaque, the lower airways, and endotracheal tube biofilms during mechanical ventilation. J Critical Care 2017; 37: 45-49
- 38 El-Sohl AA, Pietrantoni C, Bhat A. et al. Colonization of dental plaques. Chest 2004; 126: 1575-1582
- 39 Sjörgren P, Nilsson E, Forsell M. et al. A Systematic Review of the Preventive Effect of Oral Hygiene on Pneumonia and Respiratory Tract Infection in Elderly People in Hospitals and Nursing Homes: Effect Estimates and Methodological Quality of Randomized Controlled Trials. J Am Geriatric Soc 2008; 56: 2124-2130
- 40 Hua F, Xie H, Worthington HV. et al. Oral hygiene care for critically ill patients to prevent ventilator-associated pneumonia. Cochrane Database of Sytem Rev 2016; 10: CD008367
- 41 Scannapieco FA, Binkley CJ. Modest reduction in risk for ventilator-associated pneumonia in critically ill patients receiving mechanical ventilation following topical oral chlorhexidine. J Evid Based Dent Pract 2012; 12: 15-17
- 42 Yoneyama T, Hashimoto K, Fukuda H. et al. Oral hygiene reduces respiratory infections in elderly bed-bound nursing home patients. Arch Gerontol Geriatr 1996; 22: 11-19
- 43 Paju S, Scannapieco FA. Oral biofilms, periodontitis, and pulmonary infections. Oral Dis 2007; 13: 508-512
- 44 Li X, Kolltveit KM, Tronstad L. et al. Systemic diseases caused by oral infection. Clin Microbiol Rev 2007; 13: 547-558
- 45 Heo SM, Choi KS, Kazim LA. et al. Host defense proteins derived from human saliva bind to staphylococcus aureus. Infection and Immunity 2000; 81: 1364-1373 Im Internet: https://iai.asm.org/content/iai/81/4/1364.full.pdf
- 46 Biesbrock AR, Reddy MS, Levine MJ. Interaction of a Salivary mucin-secretory immunoglobulin A complex with mucosal pathogens. Infection and Immunity 1991; 59: 3492-3497
- 47 Sanchez GA, Miozza V, Delgado A. et al. Determination of salivary levels of mucin and amylase in chronic periodontitis patients. J Periodontal Res 2011; 46 (02) 221-227
- 48 Gomez-Filho IS, Passos JS, Seixas da Cruz S. Respiratory disease and the role of bacteria. J. Oral Microbiol 2 1 0.3402/jom.v2i0.5811 DOI: 10.3402/jom.v2i0.5811.
- 49 Chan HH, Rahim ZHA, Jessie K. et al. Salivary Proteins Associated with Periodontitis in Patients with Type 2 Diabetes Mellitus. Int J Mol Sci 2012; 13 (04) 4642-4654
- 50 Gaeckle NT, Pragman AA, Pendleton KM. et al. The Oral-Lung Axis: The Impact of Oral Health on Lung Health. Respiratory Care (paper in print, epub ahead of print) 2020; DOI: 10.4187/respcare.07332.
- 51 Sun K, Chen J, Viboud C. Early epidemiological analysis of the coronavirus disease 2019 outbreak based on crowdsourced data: a population-level observational study. Lancet Digital Health 2020; 2: e201-208
- 52 Pfützner A, Sorsa T, Nwhator SO. et al. Warum haben Menschen mit Diabetes ein höheres Risiko für schwere Verläufe einer SARS-CoV-2-Infektion – und was könnte dies mit oraler Hygiene zu tun haben?. Diabetes Stoffw Herz 2020; 29: 234-238
- 53 Skamagas M, Breen TL, LeRoith D. Update on diabetes mellitus: Prevention, treatment, and association with oral diseases. Oral Dis 2008; 14: 105-114
- 54 Hujoel PP, White BA, García RI. et al. The dentogingival epithelial surface area revisited. J Periodontal Res 2001; 36: 48-55 DOI: 10.1034/j.1600-0765.2001.00011.x.
- 55 Groeger S, Meyle J. Oral Mucosal Epithelial Cells. Front Immunol 2019; 10: 208 DOI: 10.3389/fimmu.2019.00208.
- 56 Chi AC, Neville BW, Krayer JW. et al. Oral manifestations of systemic disease. Am Fam Physician 2010; 82: 1381-1388
- 57 Kiran M, Arpak N, Unsal E. et al. The effect of improved periodontal health on metabolic control in type 2 diabetes mellitus. J Clin Periodontol 2005; 32: 266-272
- 58 Janket SJ, Jones JA, Meurman JH. et al. Oral infection, hyperglycemia, and endothelial dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008; 105: 173-179
- 59 Sorsa T, Gursoy UK, Nwhator S. et al. Analysis of matrix metalloproteinases, especially MMP-8, in gingival creviclular fluid, mouthrinse and saliva for monitoring periodontal diseases. Periodontol 2000 2016; 70: 142-163
- 60 Schubert-Unkmeir A, Konrad C, Slanina H. et al. Neisseria meningitidis induces brain microvascular endothelial cell detachment from the matrix and cleavage of occludin: a role for MMP-8. PLoS Pathog 2010; 6: e1000874 DOI: 10.1371/journal.ppat.1000874.
- 61 Chen Y, Wang J, Pan C. et al. Microcystin-leucine-arginine causes blood-testis barrier disruption and degradation of occludin mediated by matrix metalloproteinase-8. Cell Mol Life Sci 2018; 75: 1117-1132 DOI: 10.1007/s00018-017-2687-6.
- 62 Bergelson JM. Intercellular junctional proteins as receptors and barriers to virus infection and spread. Cell Host Microbe 2009; 5: 517-521 DOI: 10.1016/j.chom.2009.05.009.
- 63 Gürsoy UK, Könönen E, Tervahartiala T. et al. Molecular forms and fragments of salivary MMP-8 in relation to periodontitis. J Clin Periodontol 2018; 45: 1421-1428 DOI: 10.1111/jcpe.13024.
- 64 Hajishengallis G. Periodontitis: from microbial immune subversion to systemic inflammation. Nat Rev Immunol 2015; 15: 30-44 DOI: 10.1038/nri3785.
- 65 Deutsche Gesellschaft für Parodontologie (DG PARO) und Deutsche Gesellschaft für Zahn-, Mund- und Kieferheilkunde (DGZMK) Gemeinsame Wissenschaftliche Mitteilung: Parodontitis-Diagnostik mit dem Entzündungs-marker MMP-8, 2015. Im Internet: https://secure.owidi.de/documents/10165/2216097/WM_DG_PARO_aMMP8_160111.pdf/14656472-5fa0-47c7-bea6-3df4a60096c2
- 66 Sanz M, Ceriello A, Buysschaert M. et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International diabetes Federation and the European Federation of Periodontology. Diabetes Res Clin Pract 2018; 137: 231-241
- 67 Sorsa T, Alassiri S, Grigoriadis A. et al. Active MMP-8 (aMMP-8) as a Grading and Staging Biomarker in the Periodontitis Classification. Diagnostics (Basel) 2020; 10: E61
- 68 Grigoriadis A, Sorsa T, Räisänen I. et al. Prediabetes/Diabetes Can Be Screened at the Dental Office by a Low-Cost and Fast Chair-Side/Point-of-Care aMMP-8 Immunotest. Diagnostics (Basel) 2019; 9: E151
- 69 Deschner J, Haak T, Jepsen S. et al. Diabetes mellitus und Parodontitis. Wechselbeziehung und klinische Implikationen. Ein Konsensuspapier. Internist 2011; 52: 466-477
- 70 Gates B. Responding to Covid-19 – A Once-in-a-Century Pandemic?. N Engl J Med 2020; 382: 1677-1679 Im Inernet: https://doi.org/10.1056/nejmp2003762
- 71 Yan Y, Chen H, Chen L. et al. Consensus of Chinese experts on protection of skin and mucous membrane barrier for health-care workers fighting against coronavirus disease 2019. Dermatologic Therapy 2020; e13310
- 72 Hobday RA, Cason JW. The Open-Air treatment of pandemic influenza. Am J Public Health 2009; 99 Suppl.2 S236-S242