Bai 3
VISINH VAT THUONG GAP TRONG KHOANG MIENG
PGS.TS. Nguyén Vit Trung
ThS. Pham Thj Thanh Bink,
uc TIEU
Sau khi hgc xong, sinh vién cé kha nang:
4. Trinh bay durge dc diém cla cdc nhém vi sinh vat thu’ng gp trong khoang miéng,
2. Trinh bay duge dc diém cia mét sé bénh ly thu’ng gap do vi sinh vat trong
khoang migng gay ra.
Theo két qui nghién cu cia Tring Dai hge Nha khoa Case Western Reserve ~ My thi
trong m6i tring miéng c6 khong 700 loi vi sinh vét. Chinh vi vdy, méi truémg miéng
urge vi nh mkt ng vi sinh vt cht mt ugg on vi sin vt, bao gdm c@ wi
khuén, virus, sinh vét don bao va nim. Khoang migng cé mét vi hé rat phite tap bao
gdm rit nhidu ede vi sinh vét ngoai li va ky sinh tr nbn, Céc vi sinh vat sng trong
khoang migng chung sng hai ho’ va cén bing vai vat chi, tinh trang bénh ly sé xuat
hign khi mdi quan hé nay bj pha vo.
Trong vi hé nay, vi khudn chiém da s6 v6i khodng hon 600 lodi, trong 46, hon 350 loai
44 durge dinh danh bing céc ky thuat sinh hoe phan ti.
1. VIKHUAN
1.1. Dic diém ciia vi khudn trong migng
Trong | ml nude bot c6 khodng 100 trigu vi khudn, bao gim cdc vi khudn thudng wh
trong migng va céc loai vi khudn ving lai. Con s6 nay thé hién mat d6 day dc cia
ching trong khoang migng. S6 lugng vi khuan thay d6i tt Khi sinh ra dén khi truéng
thanh va cfing phy thuéc rat nhiéu vao qué trinh vé sinh ring migng, tinh cd thé va cde
bénh Iy, dic bigt la cdo bénb ly v8 ring migng,
Mic di 1a c6 s6 Iugng 1én va mire d6 day dic nhu véy, nhumg da s6 vi khuan trong
miéng thudng khéng gay hai. Neuoc lai, thuc té, hau hét la c6 Igi boi ching gitp kiém
soat va gidt trang thai cén bing cdc thinh phin cho hé sinh thai trong migng, dam bao sr
khoé manh cho khoang miéng.
Vi khuan thudng tra trong migng thi hén tap (mixed), chi yéu gdm cdc loai vi khudn
ky ki (anaerobic) va hiéu Khi (aerobic). Vé mat sé lugng logi ky khi nhiéu gap
Khoang tir 8 dén 30 lan loai hiéu khi & mt ngudi khoé manh. Trong 46, m6t s6 logi
42
ee ee
Scanned with CamScannerchiém wu thé t6i 80% s6 lugng nhu: Streptococcus, Peptostreptococcus, Veillonella,
Lactobacillus, Corynebacterium va Actynomyces. Truc khuan hiéu khi Gram (-) (aerobic
gram negative rods) it gp & ngudi lén khoé manh; nhumg 6 ngudi gid, ngudi 6m thi loai
nay lai chiém wu thé,
‘Vio t6i migng, chiing chia nhau an néu Kh&p noi. Cé logi bam vao rang, khe ké ring; e6
Joai bam vao cdc phan mém: loi, bé mat ludi, m4, niém mac hong,... Ching sinh song
bing nhimng chat tiét 6’ migng, nhting soi thit c&, nhtmg manh rau, tai cdy nhat la chat tinh
bot va duémg, vudng mic rng, 6 loi. Chi nita gid sau khi an ma ning vun thye phim
nay khéng duge logi bé thi vi khudn sé chuyén hod va khéi dng qua trinh gay bénb.
‘Tai timg khu vue gii phdu trong migng thi c6 cdc logi vi khudn riéng chiém wu thé:
— Trén mat ring: Streptococcus sanguis, Streptococcus mutans, Streptococcus mitis,
‘Actinomyces viscosus.
— Gludi va niém mac: Streptococcus salivarius, Veillonella.
i Igi: Tap trang chi yéu 1A Fusobacterium, Pigmented, Bacteroides, Anaerobic spirochetes.
Cé hign tugng khu tr phan bé trén 1a do nhiing yéu t6 sau day:
_ ec diém gidi phu, m6 hoc khéc nhau thi tgo thinh mdi trudng s6ng wu thé cho mot
s6 logi vi khuan nhat dinh.
‘Su két dinh cia vi khuan (bacterial adherence).
— Diéu kién tai ché ca timg khu vue la khéc nhau: ap lye oxy, pH.
Sur céng sinh gitta céc vi khudn (interbacterial coaggregation).
— Site ché in nhau (microbial inhibition).
Ngoai ra con phai ké dén céc yéu t6 sau day: tudi, ché 46 &n, sy moe ring sta, hist
thude 1, sfu ring, bénh nha chu, diéu tr] khéng sinh, nfm vign chita bénb, c6 thai,
yéu 16 di truyén va ndi ging. Nhimg yéu t6 nay anh hudng én su cau tgo thanh
phan vi khudn trong miéng.
Vi kinuin c6 hai 06 thé gay ra bénh tai ché cho ring migng hoe xa hon, téi cde ving
hic cia co thé, véi cde nguyén ly khéc nhau. Theo nhiéu nghién city, cée vi khuan nay
sin xudt ra ba logi dée té: ngoai déc té dam, chat hoa tan trong nude ¢6 tée dung nh
rm6t loai enzym; ngi d6c 16, mot thir duémg da — polysaccharid nim trong ming boc vi
khudn; va cde phé phd do vi khudn chuyén hod ma thn, nhu hop chat bay hoi sulfua,
cic chat acid béo, acid propionic, acid butyric, acid lactic
1.2. Cac bgnh ly thudng gip gay ra béi vi khudn trong migng
Qua nghin ciru fim sing va thye nghigm ngubi ta di xée dinh duoc vi Khudn la nguyén
nhan hog c6 lién quan 161 cdc bénh sau day:
12.1, Bénh 6 migng
Bénh tai ch8 thudmg thy 1d mang bam ring (plaques), su rang (cavities), viém loi
(Gingivitis), viém nha chu (periodontis).
43
Scanned with CamScanner1.2.1.1. Méing bim
Ming bam li nhimg mang sinh hoe phii trén ring va gom c6 ca triéu con vi khudin, hop
chit cao phan tt cia nude miéng, céc phé phim cia vi sinh vit. Néu khéng duge lay i,
cdc mang ndy cdng ngiy cing day Ién va tré thanh cao ring (tartar), mt l6p c&n voi khg
‘edmg va la noi tri dn cba rit nhiéu vi khudn Streptococcus sanguis va Streptococcus mutans,
1.2.1.2, Séu rang
Trude kia ching ta thudng quan nigm rang an nhiéu keo, nhiéu dung sé bj sau rang,
Nhumg thye ra duéng khéng phai la thi pham, ma chi ltée nhin, hé try cho thi pham,
chinh la vi khudn. Vi khudn tiu thy durdmg (nhat [a sucrose) va tao ra acid lactic va nhiéu
phé phim c6 46 acid kha cao. Céc phé phim ndy sn mon men ring. Rang mat dan
Khodng chat, tin thuong 16 ché trén bé mat ring.
Vi khuin Streptococcus mutans la nguyén nhan hang iu cia siu rang, 81 dén Lactobaccilli,
Actinomyces va mét s6 vi khudn bién hod chét dam khdc (proteolytic bacteria).
1.2.1.3. Viém loi va nha chu
Loi 1a lép mé lién két dic va niém mgc bao quanh chén va o6 ring. Viém loi thuémg 14
do cdc mang bam 6 mat rng kich thich, lim cho sung lén, 46, chdy mau va dau. Chita
ngay, bénh sé hét nhung néu dé Iau, sé dua t6i viém nha chu véi tén thuong xuong 6
ring va rang.
‘Nha chu 1a cic m6 nang 40, bio vé va nui dudng ring. Trong bénh nha chu, eéc thanh
phan nay du bj vi khuan tan c6ng, lam ton throng
C6 sy thay d8i chuyén hudng s6 lugng (shift) tir hiéu khi Gram (+) 6 nha chu nguéi
khoé manh sang try khudn ky khi Gram (-) va Bacteroides intermedius khi c6 viém
Igi, Néu o6 nha chu viém thi c6 mit thém céc vi khudn khée Ia: ce loai Bacteroides
(B. gingivalis, B. melaninogenicus).
1.2.2, Bénh xa migng
1.2.2.1. Cée abces vit viém mé lién két ving gidi phdu sdu tai cd — mat
C6 mat cia c4 hai logi vi khudn hiéu khi va ky khi. Trung binh 6 ti 4 — 6 loai, chit yéu
1a cée vi Khun Fusobacterium, Pigmented bacteroides, Peptostreptococcus va Streptococcus.
‘Trir mét sé it ca viém nang con thi it g’p Staphylococcus aureus va vi khudn hiéu khi
Gram (-). 6 nhimg truémg hop bénh nhén nang thi loai trye khudn ky khi Gram ()
fing gip nhiéu (cdc loai Bacteroides va Fusobacterium nucleatum).
Do vay khi xét nghiém vi khudn can chi y vige lay bénh pham, van chuyén va nudi cay
vi chil yéu la loai ky khi.
1.2.2.2. Viém ni tém mac
Bénh xy ra khi vi khudn trong méu bam vao van tim bit binh thudng hoge mé tim da bi
tén thuong. Tuy rét hiém nghéo, nhung may man lé bénh it Khi xay ra 6 ngudi ¢6 trai
tim Linh manh. Nhiém huyét thuing 1d do céc vi khudin ma co thé tiép xiic trong sinh
44
—_
Scanned with CamScannerhoat thuémg 1g, di khi cing do vi khudn sau céc phdu thuat 6 migng, rut, co quan hé
hap, co quan bai tiét nue tiéu.
Vigc ding khdng sinh 48 phong bénh true khi nhé ring, léy cao rng duge ép dung khi
bénh nhan cé céc bat thurng vé cu tao tim, cé tién sir viém n6i mac tim, thay van tim
nhan tgo, bénh tim bam sinh.
1.2.2.3. Bénh & d6ng mach tim
Negoai cdc nguy co c6 dién thuéng thdy nhur cao huyét 4p, cao cholesterol, hau qua ciia hit
thuée 14, bénh déng mach tim cdn do mét s6 nguy co khéc gay ra, trong 46 06 bénh nha
chu, Két qua nhiéu nghién ciru cho thdy, ngudi cé bénh nha chu déu bj bénh tim mach
nhiéu gip 46i ngudi binh thuing,
C6 nhigu gid thuyét dé giai thich sw lién hé nay. M@t gid thuyét cho la vi khudn tir
migng lan vao ddng méu, bam vao céc mang chit béo 6 déng mach tim, tgo ra mau cue,
ngiin cin méu nudi té bao tim va dura tai con suy tim.
Gia thich khée n6i la nhimg tao phém cita viém nha chu c6 téc dung true tiép lén lop 18
bio lét déng mach, gay ra sur xo vita dng mach nay.
MOt gid thuyét nda cin cit vao vige ngudi bj nhiém tring migng thudng hay bi rung
rang. Khéng c6 rang, ho thutng trnh nhing mén &n khé nhai va tiéu thy mén Zn o6
nhigu nang lugng va chat béo. Ma nhigu chat béo 1a ri ro dura toi bénh tim mach.
1.2.2.4. Bénh phdi
Vi Khun trong migng c6 thé duge hit vio phéi r8i gay ra cde bénh hé hip nhu sung
phii, dc bigt Ia ngu’i dang bj viém nhiém Ig. Sung phdi la benh hiém nghéo,nhat 18.6
ngudi tudi cao va ngudi cé sitc dé khing suy yéu. Vi khudn thudng gap Ié Streptococcus
pneumonia, Mycoplama pneumona va Hemophillus influenza, d6i Khi ede vi Khuan ky
kh{ thude nhém Actinomyces.
Bénh nhan tigu dudng, ngudi nghign rugu thuréng bi viém gi véi cdc vi khudn nay roi
hit vi khuan vao phi.
1.2.2.5. Bénh tiéu duang
Két qua cia nhidu nghién ciru khoa hoc cho thay bénh nhan tiéu | duong ‘ype 1 thudng
hay bj viém nhiém nha chu hon 1a ngudi binh thong vi co thé ciia ho dé bj nhiém
tring. Viém nha chu cing 1a m9t trong nhigu bién chimg cia tgu duong. Nguge Iai,
bénh nha chu lam ting durémg huyét va tang hau qua xdu cia bénh chuyén hod nay.
1.2.2.6, Dé non, dé thiéu céin
Trong thoi ky mang thai, cé nhidu thay d6i hormon 6 ngudi me. Cée thay d6i niy e6 the
dura t6i viém Igi ma khong cn phai c6 cdc ming bim ring.
Theo Vign Nha khoa Hoa Ky, phy ni mang thai ma bj viém nha chu sé sinh con sém
ho&c nguy co con thiéu can cao gp 7 lan binh thudng.
1.2.2.7. Sue lién quan cita vi khudn rang migng va cdc bénh ung the
M6t sé nghién ciru da tim ra méi lién hé gitta vi khuan cé trong migng v6i cic dang ung
45
Scanned with CamScannerthy khéc nhau nhu va, tuyén tuy, thyre quan va rudt. Céc nha khoa hoc tin rang vi khudn
di chuyén vio mau théng qua vet thuong hé 6 migng va pha hong cdc mé tai nhiéu eg
quan khic nhau cia co thé.
Ung thu tuyén tuy:
Nguoi c6 nhiéu vi khudin Porphyromonas gingivalis sé 6 nguy co mac ung thu tuyén
tuy cao hon 60% so véi nhing ngubi ed mie d5 thép hon. Mot logi vi khudn khée la
Actinobacillus actinomycetemcomitan, cing lim ting gdp d6i nguy co mic ung thy
tuyén tuy. Cé hai loai vi khudn nay déu duoc biét dén 1a tha pham chinh gay ra bénh
vviém nha chu,
Ung thu rugt:
Vi khudn Fusobacterium gay ra tinh trang chay méu chan ring cé thé lam tang nguy co
mac bénh ung thu ruét. Vi khudn nay cé thé xdm nhfp vao mau téi ruét va gay ra ung
thu hodc lim trim trong thém cdc Khoi u hign 6.
Ung thw thye quan:
DA tim thdy trong migng cla cde bénh nbn bj ung thu thye quan mét loai vi khudn
duge goi la proteobacteria.
Nam 2016, céc nha nghién ctu tai Dai hoc Louisville, Kentucky (MY), cfing phat hign
a vi khudn Porphyromonas gingivalis c6 mit trén 61% bénh nhén bj ung thu thy quan.
Ung thir v
M6t nghién ciru vio nam 2015 cia Dai hoc Buffalo 6 New York (MY) 4a phat hién ra vi
Khuan lién quan dén bénh viém Ioi o6 thé gay ra ung thu vi.
Nghin ctu trén 73.000 phu nt sau min kinh, ce nha khoa hge cho biét nhing ngudi
bj viém Igi cé nguy co mic ung thu vi cao hon 14% so voi nhiing ngudi binh thudng.
Cée nha khoa hoe tin ring vi khudn tir ming xm nhap vao hé tudn hoan va tin cong
cde mé vi.
1.3. Mét sO vi khuan thudng gip trong migng
1.3.1. Cin khuiin - Staphylococci bacteria
6
Scanned with CamScannerStaphylococci la vi khudn thuémg e6 hinh cum giéng nho, Lodi tu edu duge tim théy
trong migng bao gdm Staphylococcus mutans va Staphylococcus sanguis. Cée lod vi
Kuan la thi pham cho su hinh thanh céc mang bam ring va An min cia ring. Nhiing vi
khuin nay chuyén hod dudng (tir thite an) va sin xudt ra acid, Céc acid an mon men
ring qua m6t loat cfc phan tmg hod hoc dan dén sau rng.
6 mét ly thuyét néi rang S. mutans va S. sanguis 1a vi khudn truée 46 khéng c6 hai
trong migng. Khi con ngudi bat dau sir dung duéng tinh Iuyén, cdc vi khudn phat trién
qua thdi gian sir dung dug trong sy trao déi chdt va giai phéng cdc acid. Tir cfc acid
gly Khir khodng cia men ring, vi khudn tré thanh ké thi cia con ngudi.
Nehién ciru dich t8 hoc cho thay, S. mutans 1a téc nhén chinh lién quan dén su ring
men ring ¢ tré em, thanh thiéu nién, sau bé mit chin rng 6 ngudi cao tudi, phy nit
dang cho con bu, tré so sinh. Lién cau khuan S. mutans c6 khang nguyén té bao
carbonhydrat, acid lipoteichoic, lipoprotein va protein thanh té bao. Khang nguyén /
(con duge goi Ia khdng nguyén B, SPAP hoc Pac) da va dang duge nghién cia nhigu
vi vai trd cia n6 trong diéu ché vaccin. Né gidng nhu protein SpaA cla S. sobrinus.
Neudi ta cho ring, khang nguyén I/II o6 thé lién quan dén giai doan dau trong qua trinh
gin lén bé mat ring biing cdch tuong téc véi cée thinh phin ciia mang mong nudéc bot.
Streptococcus mutans to ra c4 polysacchrid ngoai bao hoa tan va Khéng hod tan (glucan,
‘mutan va fructan) tir sucrose, céc chat nay gin lién voi sy hinh thanh mang bém va 18
te nhin ¢ kha ning gy su ring cao. S. mufans cling cé thé tong hop polysaccharid
hi trong t6 bao o6 dur thira duimg, dng vai trd nh dr tt earbohydrat va duge chuyén
4éi thanh acid trong Kkhi carbohydrat ché 46 an udng khéng 6 sin.
5. sanguinis (rude day la S. sanguis) va S. gordon 1a nhimg vi sinh vat ex tnt du tién
trén bé mat ring. Cé hai loai vi khudn nay déu sin xuét glucan ngoai bao hod tan va
khong hoa tan tir sucrose gop phan vao sy hinh thanh mang bam.
13.2. Porphyromonas gingivalis
Hinh 3.2. Pofphyromonas gingivalis ¥
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Scanned with CamScannerP. gingivalis la mét ky khi vi khudn Gram (-) gy bénh nha chu ngudi én man tinh.
P. gingivalis c6 de lye cao trong thir nghigm gay nhiém 6 dOng vat va ching sin xudt
Gt loat cfc yéu 6 gid dec lye lién quan dén sy huy hoai mé va né trénh hé théng
phong vé cita co thé vat chi. P. gingivalis cing tao ra mt haemolysin, enzym lam suy
thodi collagen, cdc chat chuyén hod gay déc té bio va v6 boc. P. gingivalis c6 fimbriae
trén bé mat té bao c6 thé gitip ching dé ding gin két véi bé mat ring.
DA cé mhieu nghién ciru cho két qua ring P. gingivalis cdn lam trim trong thém bénh
vviém khép va Alzheimer.
1.3.3, Treponema denticola
) Hink 3.3. Treponema dentcola
Day Id mét xodn khudn, vi khudn phat trién manh trong céc hoat dong bing miéng. Nh
P. gingivalis, T. denticola cing gay ra cdc bénh nha chu. Vi khuan nay la di dng hon
va c6 kha nang phan gidi protein (kha néng tiéu hod protein).
T. denticola da duge musi céy bang phurong phip thich hgp va duge chimg minh la c6 kha
"ng lim gm hoa in ca enzym, cu thé la enzym protease téuargnin (giéng trypsin).
T. denticola ciing c6 khé nang lam thodi hoé collagen va gelatin, sy xuat hign cia ching
y Jam protein bj tiéu nhiéu hon so v6i céc logi xodn khudn khéc trong khoang migng.
1.3.4, Fusospirochetes
Fusospirochetes \a céc vi khuin Gram (~) ky khi bit bude, Céc vi khudn ndy dc trumg
boi cdu trie dang soi di (chiéu dai khodng 5 - 25 mm) d6i khi la efe try Khun da
hinh thai. Céc té bao vi Khun nay sin xudt sin phim de trung la acid butyric. Day la
sin phim cuéi ciing cia sy trao di chat.
Fusobacteria o6 thé gin két véi hau hétcée vi khuén ky sinh 6 khoang migng khéc va
do d6, ching duge cho la mét phn quan trong cho cu néi gita céc vi sinh vat cur tri
6m vi mun trong qua trinh hinh thanh mang bam (két dinh va ngung kat),
Scanned with CamScannerHinh 3.4. Fusospirochetes
Nhing vi Khun hinh thoi nay séng nh sinh vat binh thu’mg trong khoang migng vi
hong gay ra bt ky téc hai. Tuy mhién, khi c6 sy hign dign ciia nhiing vét thong trong
khoang migng, Fusospirochetes gay nhiém tring cho céc khu vye bj anh huéng.
135. Veillonella
Hinh 3.5. Veillonella
Ching 1a cdu khudn Gram (-) ky khi bat buée, c6 mét s6 loai nhu V. parvula, V. dispar,
¥V. atypica, V. denticariosi (thuéng gap trong céc trudng hop sdu nga ring) va
¥- rogosae(phé bin hon trong cde trubng hop siu ring). Veilonlla spp. 48 due phiin
lip tir hiu hét cae bé mat trong khoang migng va ching xudt hign v6i s6 long cao nhat
trong mang bam rang.
Veillonella duge coi 1a mét loai vi khudn cé Igi vi né Lim chém sy phat trién cita su
ting bing céch trung hoa céc chat chuyén hod cé tinh acid ciia céc vi khuan khée nhu
5. mutans va S. sanguis.
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Scanned with CamScanner1.3.6, Actinomyces
Hinh 3.6. Actinomyces
Day 18, vi khudn Gram (+) hinh que c6 thé
Céc loai Actinomyces la thinh phan chinh cia ming bam ring, dic biét 18 & cée vj tr
xung quanh khe Igi, Ching ¢6 thé duge tim thay ¢ nhimg bénh nhan bj viém nhiém siy
6 chan rang va sé luong vi khudn niy tang khi bénh nhdn bj viém loi.
Loai dai dién phé bién nhdt trong cdu tric mang bam 1a 4. naeslundii. Loai nay duge chia
thinh hai type (A. naeshundii type 1 v8 2). Actinomyces naeslundii tao mang bém ring bing
cach gin vao bé mat cia ring bing fibrin cé rét nhiéu trén bé mat té bao.
tai trong méi trang thiéu oxy.
1.3.7. Aggregatibacter actinomycetemcomitans
| Hinh 3.7. Aggregatibacter actinomycetemcomitans
MOt téc nhdn gay bénh nha chu quan trong chinh la Actinobacillus actinomycetemcomitans.
Diy la tae nhdn gay ra bénh viém quanh ring tién trién vj thiéu nién. Hign tai, ching 48
duge xép vao chi mdi: Aggregatibacter thinh Aggregatibacter actinomycetemcomitans.
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Scanned with CamScannerA. actinomycetemcomitans sin xuat ra hang loat cic déc t8, bao gém mét leukotoxin tae