双磷酸盐相关性颌骨坏死的循证治疗:附3例报道

Evidence-based diagnosis and treatment of bisphosphonate related osteonecrosis: report of 3 cases

目的：探讨双磷酸盐相关性颌骨坏死的循证治疗。方法：针对3例双磷酸盐用药患者出现的拔牙创不愈、牙周肿痛、溢脓等症状，提出临床问题，检索收集并评价相关证据，帮助制订治疗方案。结果：共纳入相关文献39篇，结果显示①双磷酸盐相关性颌骨坏死的致病机制不明：诊断标准普遍参照美国口腔颌面外科医师协会的临床指南。②治疗方案为早期有骨坏死或暴露而无明显感染时．先行抗感染、镇痛等非手术治疗：感染症状复发时，行局部清创术；出现大段骨坏死或病理性骨折时．行大范围骨切除。③组织病理学诊断标准尚未建立；影像学检查有助于早期诊断和牙槽骨手术前评估。④停药并不能缓解症状和进程．但在清创和牙槽骨手术期间有利于伤1：3愈合，是否停药由医患双方协商确定。根据以上证据．对3例患者先行保守治疗，效果不佳后行局部清创术，随访6～12个月，疗效良好。结论：双磷酸盐相关性颌骨坏死是近年新出现的疾病。目前致病机制不明，诊断和治疗方法未统一。循证治疗可制定合理方案．有效提高治疗效果和生存质量。

PURPOSE： To explore the diagnosis and treatment of bisphosphonate-related osteonecrosis of the jaw （BONJ） from the view of evidence based medicine. METHODS： For the symptoms of three patients with BONJ, including persisting socket, sore gums, fistula and pyorrhea, the clinical questions were raised, the relative evidences were collected and critically assessed. RRSULTS： Thirty-nine related references were included. The evidences indicated that ①The precise pathogenesis of BONJ remains unknown. The diagnostic criteria proposed by the American Association of Oral and Maxillofacial Surgeons is used widely. ②Non-surgical management is recommended at early stage when there is exposed or necrotic bone without obvious infection symptoms, including antibiotic therapy and pain control, etc. Local debridement is adopted when the infection is uncontrolled or recurrent. Resection of bone beyond the alveolus is performed where there is large segment of necrotic bone or pathological fracture. ③Diagnostic histopathological characteristics of BONJ have yet to be established. Radiographic images can help diagnosing early and assessing the risk before alveolar surgery. ④ Discontinuation of BP therapy can not relieve the symptoms but may be good for wound healing after alveolar surgery, which should be done in consultation with the physician and patient. Based on the available evidence, individualized treatment plans were developed. After a invalid conservative treatment, local debridement was performed and proved to be effective during follow-up. CONCLUSION： As a new disease, the exact mechanism of BONJ has not been completely elucidated.There is currently no consensus on the diagnostic criteria and the best way of trerapy. The treatment efficacy has been improved by determining an individualized treatment according to evidence-based approach.