<<
>>

CHAPTER 4. DISCUSSION OF RESULTS OF OWN RESEARCHES

Occurrence of atypical osteonecroses of jaws and difficulty of their treatment becomes more and more actual problem of modern surgical stomatology and maxillofacial surgery.

So, osteonecroses of jaws at patients after carrying out of radial therapy in connection with presence of malignant neoplasms in maxillofacial area - osteoradionecroses [50] are known and well studied.

From the middle of XIX century there were reports on phosphoric osteonecroses of jaws at workers of match factories. The given necrosises are examples of toxic osteonecroses [62].

In the end 2000th years there were reports on osteonecroses of jaws at persons with the narcotic dependence, accepting preparations dezomorfinovogo a number and a preparation Pervitinum. In a pathogenesis of this kind of osteonecroses the leading part is played also by toxic influence on an osteal tissue of the red phosphorus used at manufacturing of these narcotic preparations [8].

Since 2003 in Europe there were reports on a new kind of osteonecroses of jaws - necrosises at the patients receiving bisfosfonaty as a part of therapy of malignant neoplasms, and also at osteoporosis treatment. The pathogenesis bisfosfonatnogo an osteonecrosis definitively is not clear till now, however leading pathogenetic factors are disturbance of normal processes remodelirovanija an osteal tissue of jaws as a result of action of preparations, presence of an occlusal overload or a trauma as a result of surgical interventions, and also presence of the dontogenous centres of the infection promoting active liberation bisfosfonatov from an osteal tissue and negative influence on normal processes remodelirovanija [30, 155].

Sick of malignant neoplasms with presence of osteal metastasises (the mammary gland cancer, a prostate cancer) and sick of a multiple myeloma most often apply now to treatment bisfosfonaty on a basis zolendronovoj acids - "Zometa", "Zoleriks", which are entered monthly (with an interval of 3-4 weeks) in the form of intravenous infusions. At carrying out of surgical interventions at the patients receiving therapy by given preparations, the risk of development of complications in the form of a jaw osteonecrosis is highest.

Insufficient knowledge of doctors-stomatologists and doctors - of oncologists of a preventive maintenance and treatment problem bisfosfonatnogo an osteonecrosis of jaws at patients with various malignant diseases leads to augmentation of quantity of cases of occurrence bisfosfonatnogo an osteonecrosis of jaws, and also to prevalence of late stages of an osteonecrosis in connection with carrying out of incorrect treatment of such patients.

We spend inspection and treatment 60 sick bisfosfonatnym an osteonecrosis of jaws (from them of 31,6 % of men and 68,4 % of women). 86,7 % of patients (52 persons) concerned age group is more senior 60 years. For the majority of patients was available accompanying somatic diseases: an anaemia in 58,3 % of cases, a various pathology from cardiovascular system (in 50,0 % of cases), a diabetes (at 13,0 % of patients), etc. Also patients received monthly courses of antitumoral therapy in connection with a basic disease. All it is contributing factors to formation immunosupressivnogo a condition characterised by depression of protective mechanisms and development is long current inflammatory processes without the expressed inflammatory reaction of surrounding tissues.

In most cases (83,3 %) to development bisfosfonatnogo a jaw osteonecrosis preceded the trauma in the form of excision of one or several teeth, however in 6,7 % of cases the reason of occurrence of an osteonecrosis was a chronic trauma a demountable prosthesis, and in 5,0 % of cases - occlusal

Overload in a combination to the centre of a chronic infection. Attempt of carrying out of surgical interventions (audit of the small cavities, a necretomy) did not bring a positive take, and, on the contrary, led to expansion of a zone of an osteonecrosis and weighting of a condition of the patient.

At bisfosfonatnom an osteonecrosis by us it has not been taped a primary lesion of a mandible, unlike a radial osteonecrosis of a jaw [50]. Localisation of the pathological centre met identical frequency both on top, and on a mandible that has been bound to localisation of a remote tooth or a configuration of a demountable prosthesis. However more frequent lesion of distal departments of jaws has been taped, that, most likely, is bound to more frequent excision of chewing group of a teeth, and also more expressed occlusal trauma.

For a clinical picture bisfosfonatnyh osteonecroses presence of the expressed inflammation is not characteristic. At the majority of patients in an oral cavity sites of the bared osteal tissue of yellow colour with a hilly surface, with poor separated, and also fistulous courses on a mucosa are defined. The expressed reaction from a periosteum, leading to jaw deformation, or formation of fistulous courses on a skin is not characteristic for the given kind of osteonecroses. At involving in process of the bottom alveolar nerve probably occurrence of proof paresthesia of a skin of a chin, a lower lip or a cheek that has been taped by us in 21,7 % of observations.

We offer working classification BONCH:

1 stage - a site of the bared osteal tissue within 1 small cavity;

2 stage - a site of the bared osteal tissue within 2 and more small cavities within one kvadranta (kvadrant - a segment of a dentition from the central incisor to last molar tooth) or 1-2 teeth within two kvadrantov;

3 stage - the site of the bared osteal tissue including three either four kvadranta, or presence of pathological fracture of a jaw or involving in process of the mandibular channel, a mandible branch, verhnecheljustnogo a sine or a bottom of a nasal cavity.

At diagnostics BONCH it is impossible to underestimate a role of radial methods of diagnostics. In modern stomatology carrying out ortopantomografii (OPTG) is the gold standard. However in 50,0 % of our observations by results of OPTG it was not possible to tap presence of the formed or generated sequesters in the field of the osteonecrosis centre. In this connection a necessary additional radiological method of research is the multispiral computer tomography (MSKT) which allows to estimate the pathological centre in all possible planes, and also on volume reconstruction. Carrying out MSKT is effective for revealing of first signs of a formed zone of an osteonecrosis (in the form of the centres of the raised density of an osteal tissue, in 96,7 % of our observations), and also definitions of the relation of the centre to the next anatomic formations: to the channel of a mandibular nerve, verhnecheljustnomu to a sine, a bottom of a nasal cavity. MSKT is an effective method of radial diagnostics both early, and late stages BONCH, and also informatively at stages of dynamic observation for an estimation reparativnyh processes at the cured patients [17].

We had been carried out the analysis of character and intensity of a pain at patients before carrying out of treatment by results of the Gillovsky painful questionnaire modified the Poppy-. The basic sensory characteristic of a pain (in 71,4 % of cases) was an aching pain, 40,5 % described character of a pain as pulling, acute character of a pain has been taped in 15,3 % of cases. The index of number chosen deskriptov (ICHVD) has made 6,14 0,6, rangovyj a pain index (RIB) -

9,8 points. At the analysis of an affective scale of pain ICHVD was 3,3 0,2, RIB - 8,14 0,8 points. The majority of patients noted exhausting character of a pain (72,5 %), definition "pain-torture" was chosen by 35,7 % of patients. At an estimation evaljuativnoj scales of pain RIB has made 3,43 0,4 points. The most part

Patients estimated the pain as strong and the strongest (41,7 % and 45,0 % accordingly). It is known, that the pain makes appreciable impact on quality of a life of patients. Thus, the pain problem is actual at patients with bisfosfonatnym an osteonecrosis.

The analysis of the immune status of patients with BONCH takes the important place in definition of an optimum way of treatment and its forecast, considering presence of an accompanying pathology at the majority of patients and carrying out of chemotherapeutic treatment on a basic disease. We had been spent an estimation of indicators of the general and local immunity at patients with BONCH. At the analysis of indicators of the general immunity depression as cellular immunity (in the form of depression of relative and absolute number TYOi V-limfotsitov at the expense of all subpopulations), and a humoral link of immunity (in the form of depression of level IgA assuming also depression of level S-IgA, providing local immunity of mucosas) has been taped. At the analysis of indicators of local immunity in an oral cavity depression of the maintenance protective S-IgA, and also oppression of cellular immunity in the form of maintenance reduction in a saliva both late, and early double neutrophils that specifies in deep oppression of local mechanisms of protection in an oral cavity has been taped. Activity and intensity of a phagocytosis also have been lowered in comparison with norm. The taped negative changes of the immune status assume development of flaccid inflammatory processes, and also call into question the positive forecast of carrying out of volume surgical interventions. Presence of an accompanying pathology, age of patients, presence of antitumoral therapy, and also oppression of the general and local immunity - was a basis for search of a method of the treatment being least invasive and leading to improvement of quality of a life of patients by means of depression of a painful syndrome and the control of an inflammation. The method meeting given demands, in our opinion, local ozonotherapy is. Absence of contraindications for treatment of patients with an accompanying pathology, neinvazivnost a method, stimulating influence on tissues and antiinflammatory effect - all it has defined our interest to the given method of treatment.

At carrying out of the analysis of indicators of local immunity at patients of 1 group after the spent treatment with application of courses of local ozonotherapy
Positive dynamics in the form of rising of activity and intensity of a phagocytosis in 1,2 and 1,7 times (r

<< | >>
Scientific source ZASLAVSKAYA NATALIA ALEKSANDROVNA. OPTIMIZATION of PREVENTIVE MAINTENANCE And TREATMENT BISFOSFONATNYH of OSTEONECROSES of JAWS At PATIENTS WITH MALIGNANT NEOPLASMS. The dissertation on competition of a scientific degree of the candidate of medical sciences. Moscow - 2014. 2014

Other medical related information CHAPTER 4. DISCUSSION OF RESULTS OF OWN RESEARCHES:

  1. THE TABLE OF CONTENTS
  2. the Table of contents
  3. the Table of contents
  4. Chapter 7 DISCUSSION of RESULTS of RESEARCH
  5. the MAINTENANCE
  6. the Chapter VI. DISCUSSION of the RECEIVED DATA
  7. THE TABLE OF CONTENTS
  8. CHAPTER 4. DISCUSSION OF RESULTS OF OWN RESEARCHES