Mechanism, prevention, and treatment for medication-related osteonecrosis of the jaws

doi:10.7518/hxkq.2021.03.001

Abstract

Abstract:

The morbidity rate of medication-related osteonecrosis of the jaws (MRONJ) increased rapidly in recent years. Thusfar, the mechanism of MRONJ has no consensus. The possible mechanisms may include bone remodeling inhibition theory, angiogenesis inhibition theory, oral microorganism infection theory, immunosuppression theory, cytotoxicity-targeted oral epithelial cells, microcrack formation of maxillary or mandibular bone, and single nucleotide polymorphism. However, the efficacy of prevention and treatment based on a single mechanism is not ideal. Routine oral examination before MRONJ-related drug treatment, treatment of related dental diseases, and regular oral follow-up during drug treatment are of great significance for the prevention of MRONJ. During the treatment of MRONJ, the stage of MRONJ must be determined accurately, treatment must be standardized in accordance with the guidelines, and personalized adjustments must be made considering the specific conditions of patients. This review aimed to combine the latest research and guidelines for MRONJ and the experiences on the treatment of MRONJ in the Maxillofacial Surgery Department of West China Hospital of Stomatology, Sichuan University, and discuss the strategies to improve the clinical process.

Key words: medication-related osteonecrosis of the jaws, mechanism, prevention, diagnosis, treatment

CLC Number:

R 782.3⁺2

Pan Jian, Liu Jiyuan. Mechanism, prevention, and treatment for medication-related osteonecrosis of the jaws[J]. West China Journal of Stomatology, 2021, 39(3): 245-254.

Figures/Tables 6

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检查方式	使用建议
根尖片	可初步辅助判断，典型特征包括硬膜增厚、牙槽骨骨小梁密度增加、牙周膜间隙增宽等，但是使用较少
全景片	相对根尖片，可纳入判断的结构更多，表现为骨小梁密度增加、拔牙窝不完全愈合、骨片形成、下颌神经管或上颌窦底骨皮质增厚等，可以作为影像学检查选择之一
螺旋CT及CBCT	典型病变包括弥漫性骨硬化、骨溶解区形成、骨皮质糜烂、骨膜增生、瘘管形成及拔牙牙槽窝不完全愈合。一般来说，该影像学显示区域大于临床暴露区域。在观察骨质改变上，螺旋CT及CBCT效果相当，但CBCT的辐射相对小得多
MRI	在观察骨质改变上，与CT相当，在评估骨坏死早期骨髓变化以及围绕骨坏死区域的软组织变化方面占优势，在临床症状出现之前可出现骨髓信号强度的降低
闪烁扫描和PET	有早期核素浓集，死骨形成后会有核素摄取下降的特点，对于检测早期疾病具有高灵敏度

临床分期	临床特点	治疗建议
危险期	无任何主观症状，无骨坏死表现	无需治疗，口腔卫生宣教
0	无骨坏死或骨暴露，有非特异性临床症状，可能发生进一步病变	全身系统治疗，包括止痛药和抗生素的使用
Ⅰ	有骨暴露或骨坏死，无临床症状，无感染征兆	抗菌含漱液，临床定期随访，向患者交代病情
Ⅱ	骨暴露或骨坏死，伴局灶感染	抗菌含漱液含漱，全身抗生素治疗，控制疼痛，游离死骨表浅清创，减少软组织刺激
Ⅲ	骨暴露或骨坏死，伴疼痛感染，同时具有以下一个或多个表现：病理性骨折，口外瘘道，病灶超出牙槽骨范围的颌骨	抗生素类含漱液，全身抗生素治疗，控制疼痛，选择性局部清创或手术切除

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