臨床医学に環境・労働の観点を

・以前歯科医のじん肺のご紹介しましたが、今回は、サルコイドーシスです。

Sarcoidosis in a dental surgeon: a case report

Luigi Checchi  

Journal of Medical Case Reports 2010, 4:259

http://www.jmedicalcasereports.com/content/4/1/259/abstract

抄録貼り付けます↓  

Introduction

Although the causes of sarcoidosis are still unknown, past and current studies have provided evidence that this disease may be associated with occupational exposure to specific environmental agents. We describe a case of sarcoidosis in a dental surgeon with long exposure to inorganic dusts. To the best of our knowledge, this is the first report of this kind in the literature.

Case presentation

At the beginning of 2000, a 52-year-old Caucasian man, who worked as a dental surgeon, presented with shortness of breath during exercise, cough and retrosternal pain. After diagnosis of sarcoidosis, a scanning electronic microscopy with X-ray microanalysis of biopsy specimens was used in order to determine whether the disease could be traced to an occupational environmental agent. Results showed the presence of inorganic dust particles within sarcoidotic granulomas, and demonstrated that the material detected was identical to that found in a powder used by our patient for several years.

Conclusions

Although these results cannot be considered as definitive proof, they do however provide strong evidence that this disease may be associated with material used by dental surgeons.

full textは↓

http://www.jmedicalcasereports.com/content/pdf/1752-1947-4-259.pdf

本文の中で，歯科医/口腔外科医が，どのような粉塵やヒュームに曝露されているかが記載されています↓

The instruments used during dental surgical procedures
produce intense heat (electrocautery, laser) and such procedures usually produce fumes containing biological material (even partially incombusted). High-speed, air-driven dental handpieces,
ultrasonic scalers, the polishing of composite and ceramic restorations and the use of the milling cutter on metallic prostheses disperse a large amount of aerosol and spatter including
fine particulate matter. During the polishing and whitening of natural teeth, chemical compounds (composed by particles of sodium di-carbonate and tricalcium phosphate) are
sprayed on the tooth surface detaching part of its enamel and dispersing microparticles in the
environment, thus exposing patients and operators at risk of inhalation. For example, a standard hygiene procedure involves the use of prophylactic material and ultrasonic and/or manual
instrumentation . The prophylaxis phase can be substituted by an artificial bicarbonate aerosol. Artificial cleaning aerosols are formed by a Mini-Clean device (Castellini, Bologna,
Italy) with air pressure set at six to seven atmospheres and water flow at one atmosphere. Each individual run lasts 20 to 30 minutes for each patient. It has been reported that 95% of the
particles measure less than five micrometers and are mainly concentrated within two meters of the patient where they can be easily inhaled by dental clinicians.

・ちなみにUpToDateには，以下のような記載があります．

Occupational and environmental exposures — It has been hypothesized that sarcoidosis is associated with several occupational and environmental exposures. However, only beryllium and its salts have been shown to produce granulomata that are similar to that seen in sarcoidosis. Despite intensive efforts, studies have largely failed to identify an external agent or agents responsible for sarcoidosis .

A case series suggested that exposure to World Trade Center (WTC) dust during the collapse, rescue, or recovery was associated with an increased incidence of sarcoidosis-like granulomatous pulmonary disease during the five years following the disaster . The series reported 26 patients who had pathologic evidence of new onset sarcoidosis following WTC dust exposure. The estimated annual incidence rate was 86 cases per 100,000 population during the first year after the WTC collapse and 22 cases per 100,000 population during the next four years. In comparison, the estimated annual incidence rate was 15 cases per 100,000 during the 15 years prior to the disaster. Eighteen of the 26 patients (69 percent) also developed findings consistent with asthma. 

参考

ＡＴＳのStatement on Sarcoidosis 

http://www.thoracic.org/statements/resources/respiratory-disease-adults/sarcoid1-20.pdf

以下日記

・現在病院で，エマーソン，レイク＆パーマーの展覧会の絵をききながらブログ書いてます．

・本日朝７時前に病院にきて，回診．１６時の夜間診まで，ずっと病棟対応でした．幸いなことに重症の患者さんがおちつきつつあります．じつは，この人が重症かしていなければ，金曜日の夜から「放浪の旅」にでようかと思っていたのですが，あきらめました．ただ，明日の朝きて，おちついていたら，旅に出ようか？

・お昼人工呼吸をしている患者さんの入浴．私が入浴中アンビューバッグ押していたのですが，浴室から病室に帰る間は，患者さん自身にバッグを押してもらいました．特にその間問題ありませんでした．（実は，毎日病室で１０回だけ，自分の呼吸に会わせてバッグをおしてもらう練習をしていました．）しかし，それを見た入浴担当の看護師さんたちは別に驚いてもいませんでした．ワタシャ，てっきり看護師さんが驚くか，感動するかと思っていましたが．．．あまりにも忙しくて，その意味がわからない？？？

・１６時～１９時３０分まで夜間診療．本日は，暇でした．で，その夜間診療後弁護士さんに頼まれていた，労災の意見書を書き，２１時頃ドラフトが仕上がりました．しかし，疲れる．ワタシャ，労災の意見書書く度に自分の寿命が縮んでいるのではないかと思います．（まるで，自分の羽をとって，織物を織るオツウの様に．ちがうかーっ！）

・昨日は，まんがライフオリジナル９月号を買いました．長女のMediGirl読んでください．（オチ，弱いけど）いつ，連載が切られないかハラハラしている私．