天津市抗骨质疏松治疗与药物相关性颌骨坏死问题的专家共识

doi:10.11958/20230147

摘要/Abstract

摘要：

骨质疏松症（OP）和口腔疾患是老年人常见的健康问题，近年来OP治疗药物相关的颌骨坏死风险日益受到相关专业医生的关注。在OP治疗前和治疗中为避免或减少药物相关性颌骨坏死的发生，需要妥善处理口腔有创性操作与OP治疗间的关系。由天津市医学会骨质疏松和骨矿盐疾病分会、天津市口腔医学会口腔颌面外科专业委员会主持，经过从事OP治疗的医生和口腔专业医生的充分交流和沟通，在循证医学基础上达成临床共识，即明确了OP和OP治疗药物相关性颌骨坏死均是具有严重不良后果的疾病，规范OP治疗可减少骨折，有利于改善老年人生活质量；在治疗期间应采取恰当措施，尽可能避免OP治疗药物相关性颌骨坏死的发生。通过两个学科医生的共同努力，以期解决由于使用OP治疗药物而影响口腔操作的临床难题，促进和保障老年人的骨骼健康和牙齿健康。

关键词: 骨质疏松, 口腔手术操作, 颌疾病, 共识

Abstract:

Osteoporosis (OP) and oral diseases are common health problems of the elderly. Recently, the risk of jaw necrosis with anti-OP medication has been increasingly concerned by relevant specialists. In order to avoid or reduce the incidence of medication-related jaw necrosis before and during OP treatment, it is necessary to properly deal with the relationship between oral invasive procedures and anti-OP treatment. It is conducted by the Osteoporosis and Bone Mineral Salt Disease Branch of Tianjin Medical Association and Society of Oral and Maxillofacial Surgery of Tianjin Stomatological Association. After full exchange and communication between doctors engaged in OP treatment and stomatological doctors, clinical consensus are reached on the basis of evidence-based medicine. It is clear that OP and OP medication-related necrosis of jaw are both diseases with serious adverse consequences, and standard OP treatment can reduce fractures and improve the quality of life of elderly. During the treatment period, appropriate measures should be taken to avoid the occurrence of OP medication-related jaw necrosis. Through the joint efforts of doctors from the two disciplines, we hope to solve clinical problems that affect oral operation due to the use of OP therapeutic drugs, and promote and protect the bone health and dental health of elderly.

Key words: osteoporosis, oral surgical procedures, jaw disease, consensus

中图分类号:

R589.5，R782.1

图/表 1

参考文献 53

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分期		骨代谢药物暴露史	临床表现	影像学表现
风险前期		未暴露	无临床症状	无特异性影像学改变
风险期		已暴露	无临床症状	无特异性影像学改变
临床前期		已暴露	颌面部无瘘管、骨暴露及死骨形成，但有非特异性临床症状，如牙齿松动、拔牙创口未愈甚至溢脓、非牙源性疼痛、感觉神经功能变化等症状	有非特异性影像学改变
Ⅰ期		已暴露	颌面部存在暴露的坏死骨或可触及骨面的瘘管	根尖周及骨髓腔内有骨质改变；下颌骨骨质改变位于下牙槽神经管或双侧颏孔连线以上区域；上颌骨骨质改变未突破上颌窦底部或鼻底
	ⅠA期			死骨与正常骨质间存在一定界线（局限型）
	ⅠB期			死骨与正常骨质间无明显界线（弥散型）
Ⅱ期		已暴露	颌面部存在暴露的坏死骨或通向骨面的瘘管，多数伴有周围软组织红肿、疼痛等感染症状	下颌骨骨质改变波及下牙槽神经管或双侧颏孔连线及以下区域，尚未累及下颌骨下缘；上颌骨骨质改变突破上颌窦或鼻底，未达到眶下孔
Ⅱ期	ⅡA期		上颌骨病变不伴上颌窦炎症	上、下颌骨局限型死骨
	ⅡB期		上颌骨病变伴明显上颌窦炎症	上、下颌骨弥散型死骨
Ⅲ期		已暴露	暴露的死骨长期不愈合，伴有剧烈疼痛和感染	下颌骨骨质改变超过下牙槽神经管或双侧颏孔连线，累及下颌骨下缘；上颌骨骨质改变突破眶下孔，累及或不累及眶底、颅底等区域，伴或不伴上颌窦炎症。可合并病理性骨折

分期		骨代谢药物暴露史	临床表现	影像学表现
风险前期		未暴露	无临床症状	无特异性影像学改变
风险期		已暴露	无临床症状	无特异性影像学改变
临床前期		已暴露	颌面部无瘘管、骨暴露及死骨形成，但有非特异性临床症状，如牙齿松动、拔牙创口未愈甚至溢脓、非牙源性疼痛、感觉神经功能变化等症状	有非特异性影像学改变
Ⅰ期		已暴露	颌面部存在暴露的坏死骨或可触及骨面的瘘管	根尖周及骨髓腔内有骨质改变；下颌骨骨质改变位于下牙槽神经管或双侧颏孔连线以上区域；上颌骨骨质改变未突破上颌窦底部或鼻底
	ⅠA期			死骨与正常骨质间存在一定界线（局限型）
	ⅠB期			死骨与正常骨质间无明显界线（弥散型）
Ⅱ期		已暴露	颌面部存在暴露的坏死骨或通向骨面的瘘管，多数伴有周围软组织红肿、疼痛等感染症状	下颌骨骨质改变波及下牙槽神经管或双侧颏孔连线及以下区域，尚未累及下颌骨下缘；上颌骨骨质改变突破上颌窦或鼻底，未达到眶下孔
Ⅱ期	ⅡA期		上颌骨病变不伴上颌窦炎症	上、下颌骨局限型死骨
	ⅡB期		上颌骨病变伴明显上颌窦炎症	上、下颌骨弥散型死骨
Ⅲ期		已暴露	暴露的死骨长期不愈合，伴有剧烈疼痛和感染	下颌骨骨质改变超过下牙槽神经管或双侧颏孔连线，累及下颌骨下缘；上颌骨骨质改变突破眶下孔，累及或不累及眶底、颅底等区域，伴或不伴上颌窦炎症。可合并病理性骨折