双磷酸盐相关性颌骨坏死的循证诊治  

An Evidence-based Diagnosis and Treatment for Bisphosphonate-related Osteonecrosis of the Jaw

作　　者：黄伟[1,2] 曾宪涛 倪小兵 冷卫东[1,2] 郭毅[3] 李祖兵[4] 

机构地区：[1]湖北医药学院附属太和医院口腔医学中心,湖北十堰442000 [2]湖北医药学院口腔颌面外科研究室,湖北十堰442000 [3]武汉大学公共卫生学院流行病学教研室,湖北武汉430071 [4]武汉大学口腔医学院.口腔医院口腔颌面外科,湖北武汉430079

出　　处：《湖北医药学院学报》2013年第1期17-23,共7页Journal of Hubei University of Medicine

基　　金：湖北省自然科学基金面上项目(2012FFB03902);湖北省教育科学"十二五"规划2012年度重点课题(2012A050);湖北医药学院2011年度优秀中青年科技创新团队项目(2011CXX04);十堰市科学技术研究与开发项目(201300X)

摘　　要：目的:运用循证医学的方法,为一例疑似骨转移的牙槽骨坏死患者确诊并选择合理的治疗方案。方法:根据循证实践的方法,提出问题,检索收集相关证据,对所获证据进行评价,并结合患者意愿制定治疗方案。结果:共纳入1个随机对照试验,5个临床指南,4个前瞻性对照研究,10个病例报道和1个专家意见。证据结果表明:⑴双磷酸盐相关性颌骨坏死(BONJ)是2003年开始发现的因使用双磷酸盐药物导致的疾病,随着病例报道日渐增多而引起国际关注,国内对此病种缺乏认识;⑵目前BONJ的致病机制尚不明确,诊断标准也未统一,普遍参照的是美国口腔颌面外科协会制定的诊断标准;⑶BONJ的治疗方案可根据临床分期确定;早期主张非手术治疗;保守治疗无效和出现游离死骨时行清创术;必要时行颌骨切除;⑷X线等影像学检查有助于BONJ的早期诊断和预防;⑸双磷酸盐的半衰期长,停药并不能缓解症状和进程,在清创和牙槽手术期间停药有利于伤口愈合,是否停药视具体情况由医患双方协商确定;⑹使用双磷酸盐前应接受全面的口腔检查并及时处理病灶;对易感者要告知BONJ的症状和风险,使用含漱剂保持口腔卫生,避免牙槽手术等创伤。根据以上证据结合患者意愿,行右上颌病灶局部清创术清除部分死骨。患者因义齿修复需行双侧上颌隆突修整,在告知BONJ症状和风险后予以牙槽骨修整。至今随访14个月,患者基本痊愈。结论:BONJ是一新出现的疾病,目前其病因尚不明确,诊断标准和治疗方法也未统一,采用循证治疗的方法制定合理方案,可有效提高治疗效果。Objective To diagnose and perform individualized evidence-based treatment for a patient with alveolar osteonecrosis who is suspected of bone metastases.Methods Based on the clinical questions we raised,the relative evidences were collected and critically assessed,patient's preferences were also taken into account in the decision-making treatment.Results There were 1 randomized controlled trial,5 clinical guidelines(based on case reports or expert opinion analysis),4 prospective controlled trials,10 cases reports,and 1 expert opinion were considered eligible.The evidences indicated that:⑴cases of bisphosphonate-related osteonecrosis of the jaw(BONJ) were first described in 2003 as a potentially serious complication related to the use of bisphosphonates(BP).As more cases were reported,the disease has received much international attention.⑵The pathogenesis and the best way of managing BONJ remains unknown.There is currently no consensus on the exact diagnostic criteria,the criteria given by the American Association of Oral and Maxillofacial Surgeons(AAOMS) is used most widely.⑶Non-surgical management is recommend at early stage;a surgical approach mainly including debridement is based on the exposed bone;radical management refers to resection of bone beyond the alveolus and is recommended where there is large segment of necrotic bone or pathological fracture.⑷Radiographic evaluation can be helpful for prevention and diagnosis of early BONJ.⑸Because of long half-life of BP,discontinuation of BP therapy can not relieve the symptoms but may be good for wound healing after alveolar surgery.Modification or cessation of BP therapy should be done in consultation with the physician and the patient.⑹There is some consensus for the need for careful dental preparation of patients prior to BP therapy.Patients should be instructed in the clinical signs and symptoms of BONJ and avoid alveolar surgery during BP therapy.The individualized treatment plans were developed based on the available evidence and the patient's p

关 键 词：颌骨坏死 双磷酸盐 循证实践 循证诊断 循证治疗 

分 类 号：R782.1[医药卫生—口腔医学]