TCHSA 081-2024 接受双膦酸盐治疗患者拔牙围手术期处理专家共识

ICS11.060.01CCSC05团 体 标 准T/CHSA081—2024接受双膦酸盐治疗患者拔牙围手术期处理专家共识Expertconsensusonperioperativemanagementofdentalextractionsinpatientsreceivingbisphosphonatetherapy2024-11-29发布 2024-12-29实施中华口医学会 发布T/CHSA081—2024T/CHSA081—2024II前 言本文件按照GB/T1.1—2020《标准化工作导则第1部分：标准化文件的结构和起草规则》的规定起草。本文件由中华口腔医学会归口。（T/CHSA081—2024T/CHSA081—2024IIII引 言（medication-relatedosteonecrosisofthejaw，MRONJ）MRONJ50%～80%的MRONJ后。因此，牙槽外科医生对于这类患者的拔牙手术持高度谨慎的态度[1-5]。但是，目前尚缺乏全国统一中华口腔医学会牙及牙槽外科专业委员会组织本学科及相关学科专家，对接受双膦酸盐治疗患者拔牙前的评估和准备、拔牙时的手术操作和拔牙后的随访观察进行了讨论和总结并形成了本文件。T/CHSA081—2024T/CHSA081—2024PAGEPAGE1接受双膦酸盐治疗患者拔牙围手术期处理专家共识范围本文件提出了接受双膦酸盐治疗患者拔牙前的评估和准备、拔牙时的手术操作和拔牙后的随访观察方法。）本文件没有规范性引用文件。下列术语和定义适用于本文件。药物相关性颌骨坏死medication-relatedosteonecrosisofthejaw;MRONJ8问诊（MRONJMRONJMRONJMRONJ[6-10]（激素会提高MRONJ的发生风险。恶性肿瘤患者可能接受血管内皮生长因子（vascularendothelialgrowthfactor，VEGF）（tyrosinekinaseinhibitor，TKI）（mammaliantargetofrapamycin，mTOR）MRONJ接受双膦酸盐治疗患者的口内临床检查并无特殊，但是有时可以观察到一些微小的未愈合的牙龈裂口或局部的牙龈或黏膜肿胀，这提示局部可能已经发生了早期的MRONJ。接受双膦酸盐治疗患者的影像学检查往往可观察到局灶性或广泛性的骨质硬化，广泛性的骨质硬MRONJ[11]。这些早期影像学表现往往（cone-beamcomputedtomography，CBCT）拔牙指征[12-17]MRONJ（MRONJ发生的可能性且患（）。MRONJ建议医师充分告知有双膦酸盐用药史且具备拔牙指征的患者拔牙后发生MRONJ的可能性，并结合其用药史、局部临床检查和辅助检查的情况评估并告知其发生MRONJ的风险高低。[18-21]36～12d7d～14d3～430s～1min。30s～1min。1h～2hd～71h～24hd～10d1h～48hd～14/。[22-26]（MRONJ）（MRONJMRONJ3（）麻醉推荐减量使用含肾上腺素的局麻药物，或使用不含肾上腺素等血管收缩剂的局麻药物进行麻醉[27]。翻瓣（以去骨MRONJT/CHSA081—2024T/CHSA081—2024PAGEPAGE4[21,28]MRONJ[29]MRONJ[30]d～3d、7d、14、123d～14dMRONJ通常需3～4参 考 文 献[J]2017,35(1):29-36.[2]J,2018,36(5):568-572.潘剑,刘济远.药物相关性颌骨坏死的发病机制及其防治[J].华西口腔医学杂志,2021,39(3):245-254.马燕华,王覃,李静,等.双膦酸盐相关性颌骨坏死的研究进展[J,2021,14(5):544-552.WANGQ,LIUJ,QIS,etal.Clinicalanalysisofmedicationrelatedosteonecrosisofthejaws:growingseverecomplicationinChina[J].JDentSci,2018,13(3):190-197.RUGGIEROSL,DODSONB,AGHALOOT,etal.Americanassociationoforalmaxillofacialsurgeons’positionpaperonmedication-relatedosteonecrosisofthejaws-2022update[J].JOralMaxillofacSurg,2022,80(5):920-943.VANPOZNAKCH,UNGERJM,DARKEAK,etal.Associationofosteonecrosisofthejawwithzoledronicacidtreatmentforbonemetastasesinpatientswithcancer[J].JAMAOncol,2021,7(2):246-254.ISHIMARUM,ONOS,MORITAK,etal.Prevalence,incidencerate,andriskfactorsofmedication-relatedosteonecrosisofthejawinpatientswithosteoporosisandcancer:anationwidepopulation-basedstudyinJapan[J].JOralMaxillofacSurg,2022,80(4):714-727.SRIVASTAVAA,NOGUERASGONZALEZM,GENGY,etal.Prevalenceofmedicationrelatedosteonecrosisofthejawinpatientstreatedwithsequentialantiresorptivedrugs:systematicreviewandmeta-analysis[J].SupportCareCancer,2021,29(5):2305-2317.SURYANIIR,AHMADZAII,SHUJAATS,etal.Non-antiresorptivedrugsassociatedwiththedevelopmentmedication-relatedosteonecrosisofthejaw:asystematicreviewandmeta-analysis[J].ClinOralInvestig,2022,26(3):2269-2279.MORENO-RABIéC,GAêTA-ARAUJOH,OLIVEIRA-SANTOSC,etal.EarlyimagingsignsoftheuseofantiresorptivemedicationandMRONJ:asystematicreview[J].ClinOralInvestig,2020,24(9):2973-2989.HASEGAWAT,KAWAKITAA,UEDAN,etal.multicenterretrospectivestudyoftheriskfactorsassociatedwithmedication-relatedosteonecrosisofthejawaftertoothextractioninpatientsreceivingoralbisphosphonatetherapy:canprimarywoundclosureandadrugholidayreallypreventMRONJ?[J].OsteoporosInt,2017,28(8):2465-2473.HASEGAWAT,HAYASHIDAS,KONDOE,etal.Medication-relatedosteonecrosisofthejawaftertoothextractionincancerpatients:amulticenterretrospectivestudy[J].OsteoporosInt,2019,30(1):231-239.AVISHAIG,MUCHNIKD,MASRID,etal.MinimizingMRONJaftertoothextractioncancerpatientsreceivingbone-modifyingagents[J].JClinMed,2022,11(7):1807.KWOENMJ,PARKJH,KIMS,etal.Associationbetweenperiodontaldisease,toothextraction,andmedication-relatedosteonecrosisofthejawinwomenreceivingbisphosphonates:nationalcohort-basedstudy[J].Periodontol,2023,94(1):98-107.SOUTOMES,OTSURUM,HAYASHIDAS,etal.Relationshipbetweentoothextractionanddevelopmentofmedication-relatedosteonecrosisofthejawincancerpatients[J].SciRep,2021,11(1):17226.UEDAN,NAKASHIMAC,AOKIK,etal.Doesinflammatorydentaldiseaseaffectthedevelopmentofmedication-relatedosteonecrosisofthejawinpatientsusinghigh-dosebone-modifyingagents?[J].ClinOralInvestig,2021,25(5):3087-3093.LORENZO-POUSOAI,PéREZ-SAYáNSM,CHAMORRO-PETRONACCIC,etal.Associationbetweenperiodontitisandmedication-relatedosteonecrosisofthejaw:Asystematicreviewandmeta-analysis[J].OralPatholMed,2020,49(3):190-200.KIZUBDA,MIAOJ,SCHUBERTMM,etal.Riskfactorsforbisphosphonate-associatedosteonecrosisofthejawintheprospectiverandomizedtrialofadjuvantbisphosphonatesforearly-stagebreastcancer(SWOG0307)[J].SupportCareCancer,2021,29(5):2509-2517.MAUCERIR,CONIGLIOR,ABBINANTEA,etal.Thepreventivecareofmedication-relatedosteonecrosisofthejaw(MRONJ):positionpaperbyItalianexpertsfordentalhygienists[J].SupportCareCancer,2022,30(8):6429-6440.MüCKET,DEPPEH,HEINJ,etal.Preventionofbisphosphonate-relatedosteonecrosisofthejawsinpatientswithprostatecancertreatedwithzoledronicacidAprospectivestudyover6years[J].JCraniomaxillofacSurg,2016,44(10):1689-1693.CUOZZOA,IORIO-SICILIANOV,VAIAE,etal.IncidenceandriskfactorsassociatedtoMedication-RelatedOsteoNecrosisoftheJaw(MRONJ)inpatientswithosteoporosisaftertoothextractions.12-monthsobservationalcohortstudy[J].JStomatolOralMaxillofacSurg,2022,123(6):616-621.ABOALELAA,FAROOKFF,ALQAHTANIAS,etal.TheEffectofAntiresorptiveDrugHolidaysonMedication-RelatedOsteonecrosisoftheJaw:ASystematicReviewandMeta-Analysis[J].Cureus,2022,14(10):e30485.HADAYAD,SOUNDIAA,GKOUVERISI,etal.Antiresorptive-TypeandDiscontinuation-TimingAffectONJBurden[J].JDentRes,2021,100(7):746-753.OTTESENC,SCHIODTM,JENSENS,etal.Toothextractionsinpatientswithcancerreceivinghigh-doseantiresorptivemedication:arandomizedclinicalfeasibilitytrialofdrugholidayversusdrugcontinuation[J].OralSurgOralMedOralPatholOralRadiol,2022,133(2):165-173.ADAMSAL,ADAMSJL,RAEBELMA,etal.Bisphosphonatedrugholidayandfracturerisk:apopulation-basedcohort