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RESULTS OF CLINICAL INSPECTION OF PATIENTS WITH BISFOSFONATNYM THE OSTEONECROSIS OF JAWS (1 AND 2 GROUPS OF PATIENTS)

From 2009 for 2013 in the centre of stomatology and maxillofacial surgery MGMSU of A.I.Evdokimova it is surveyed and it is accepted on treatment of 60 patients with bisfosfonatnymi osteonecroses of jaws (31,7 % of women, 68,3 % of men).

To all patients clinical inspection under the standard scheme is spent: finding-out of complaints, the collecting of the anamnesis of a life, presence of an accompanying pathology, development of the present disease.

The condition of patients at the reference was satisfactory, patients showed complaints to presence of the bared sites of an osteal tissue in an oral cavity (40 patients; 66,7 %), presence are long not healing small cavities of a teeth after excision (7 patients; 11,7 %). Complaints to pains in the field of top or a mandible, nezazhivlenie wounds after interventions, presence of deformation of a jaw noted 13 patients (21,7 %).

All patients had in the anamnesis intravenous therapy bisfosfonatami on a basis zolendronovoj acids (Zometa, Zoleriks) in connection with presence of osteal metastasises of malignant neoplasms (a mammary gland cancer - 33 patients, a prostate cancer - 12 patients, a plural myeloma - 8 patients, a kidney cancer - 5 patients, other neoplasms - 2 patients). Distribution of patients on a basic disease and a floor is presented in table 5.

Duration of therapy bisfosfonatami at patients varied from 6 to 80 courses (average duration has made 30,6 4,4 courses), preparations were entered monthly (with an interval of 28 days) in the form of intravenous infusions.

Table 5

Distribution of patients on a basic disease and a floor

Basic disease M
n % n %
RMZH 1 1,67 32 53,33
RPZH 12 20,0 0 0
The plural

Myeloma

4 6,67 4 6,67
Kidney cancer 2 3,33 3 5,0
Others 0 0 2 3,33
IN TOTAL 19 31,67 41 68,33

All patients, besides malignant neoplasms, had an accompanying somatic pathology: an anaemia, illnesses

Cardiovascular system, a diabetes, thyroid gland diseases, etc. (Table 6).

Table 6

The taped accompanying somatic pathology at the surveyed

Patients

Somatic pathology Quantity of patients

Abs., %

Anaemia 35 58,3 %
Diseases of cardiovascular system: 30 50,0 %
• the Hypertonia 24 80,0 %
• an ischemic heart disease, a stenocardia 12 40,0 %
• the Myocardial infarction, a stroke in the anamnesis 4 13,3 %
Diabetes 2 types 13 21,7 %

Thyroid gland diseases

(A hypothyrosis, a nodal struma)

3 5 %
Diseases eyes (glaucoma) 3 5 %
Diseases of kidneys 2 3,3 %
Infectious diseases (hepatitis) 2 3,3 %

At the majority of patients (88,3 %, 53 persons) osteonecrosis development has occurred after excision of one or several teeth concerning complicated caries.

Thus patients noted long nezazhivlenie the small cavities of a remote teeth, then occurrence of a pain, a flow of pus and sites of a denudation of an osteal tissue of a jaw of grey-yellow colour with an unpleasant smell (the Drawing 9).

Fig. 9. A photo. Patient R, 69 years. The osteonecrosis centre on a mandible on the right in the field of a remote tooth 4.8.

At 3 patients (5,0 %) the osteonecrosis site has arisen in the field of an occlusal overload in a combination to presence of the centres of a chronic infection (a teeth with a chronic periodontitis), (the Drawing 10).

4 sick (6,7 %) bound occurrence of sites of the bared osteal tissue to a chronic trauma a demountable prosthesis (the Drawing 11).

Fig. 10. A photo. Patient CH, 54 years. A site of the bared osteal tissue of the top jaw in the field of a tooth 2.6.

Fig. 11. A photo. Patient I, 68 years. A mandible osteonecrosis, osteonecrosis development has occurred as a result of a chronic trauma a demountable prosthesis on a mandible. On the right defect after attempt of carrying out of a necretomy is visualised.

At 83,3 % of patients in an out-patient department where the exodontia was spent, carried out numerous attempts of audit of the small cavities, necretomies, at 3 patients
(5,0 %) with localisation of the centre of an osteonecrosis on the top jaw - a necretomy in a combination to a radical sinusotomy (Table 7).

Positive effect as a result of the interventions set forth above it has not been reached, on the contrary, in the early postoperative period the divergence of seams or occurrence of fistulous courses in the late postoperative period became perceptible, the augmentation of the sizes of a site of a denudation of an osteal tissue, formation of defects of the various size, intensifying of pains became perceptible. In connection with absence of positive dynamics from spent treatment patients addressed on consultation in TSS and CHLH MGMSU of A.I.Evdokimova.

Table 7

The interventions, spent to patients in out-patient departments on a residence, after an exodontia against therapy bisfosfonatami

Intervention type Quantity

Patients

%
Audit the small cavities/small cavities of a remote teeth (curettage) 17 34,0
Necretomy in the field of a remote teeth 30 60,0
Necretomy in a combination to a sinusotomy 3 6,0

As modern classifications bisfosfonatnyh the osteonecroses, offered by foreign experts, are bulky enough and are not convenient in application, we offer working classification of osteonecroses of jaws. In the classification offered by us for definition of a stage of an osteonecrosis we were not guided by the fact of presence or absence of an inflammation since the inflammation is secondary and after carrying out of antibacterial therapy is stopped, whereas the size of the osteonecrotic centre remains invariable, that, in our opinion, and is a defining sign for an establishment of a stage of disease.

1 stage - a site of the bared osteal tissue within 1 small cavity (the Drawing 12).

Fig. 12. A photo. Patient F, 53 years. The osteonecrosis centre on a mandible in the field of a remote tooth 4.7 (a stage 1).

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 (the Drawing 13).

Fig. 13. A photo. Patient CH, 62 years. The osteonecrosis centre on the top jaw in the field of a remote teeth 1 (a stage 2).

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 (the Drawing 14).

Fig. 14. A photo. Patient S, 67 years. The osteonecrosis centre on the top jaw, extending for a bottom of a nasal cavity and verhnecheljustnye sine (a stage 3).

Distribution of patients depending on a stage of the osteonecrotic

Process it is presented in a drawing 15. Prevalence of patients with late stages of an osteonecrosis (47 persons, 78,3 %) is characteristic.

Fig. 15. The chart. Distribution of patients on stages bisfosfonatnogo a jaw osteonecrosis.


At the analysis of localisation of an osteonecrosis it has not been taped the expressed difference in frequency of a lesion top or a mandible. However, from the results presented in table 8, it is visible, that more often osteonecrotic process is localised in distal departments of a jaw (in 85,0 % of cases).

Table 8

Distribution of patients depending on localisation

Osteonecrotic process

Localisation The top jaw Mandible Top and a mandible
Face-to-face department (in the field of a teeth 1, 3). 3 2 4
Distal departments (in the field of a teeth 1, 2, 3, 4). 21 30
IN TOTAL 24 (40 %) 32 (53,3 %) 4 (6,7 %)

For a clinical picture of an osteonecrosis presence in an oral cavity of sites of the bared osteal tissue of grey-yellow colour with a hilly surface (40 patients, 66,7 %), with formation of fistulous courses on a mucosa in 75 % of cases (47 patients), (the Drawing 16) is in most cases characteristic.

Fig. 16. A photo. Patient P, 73 years. The osteonecrosis site on a mandible on the right, is noted by a finger a fistulous course. Deformation (thickening) of a jaw is defined.

However in 10 % of cases (6 patients) at survey the small cavities of a remote teeth without cuticularization signs at which sounding of walls the painless rough osteal tissue was defined were defined only. Also in 10 % of cases (6 patients) presence of functioning fistulous courses on a mucosa of an oral cavity in the absence of the bared sites of an osteal tissue is taped. Formation of fistulous courses on a skin has been taped only in 3 cases (5,0 %) when the osteonecrosis centre settled down in the field of a bottom edge of a jaw and reached the big sizes (the Drawing 17). Presence of deformation of a jaw was clinically defined at 4 patients (in the form of a thickening).

Fig. 17. A photo. Patient P, 62 years. Fistulous courses in podpodborodochnoj areas at sick bisfosfonatnym a mandible osteonecrosis.

At osteonecrosis localisation on a mandible in immediate proximity from the channel of a mandibular nerve, paresthesia of a skin of a chin, a lower lip or the bottom departments of a cheek (at 13 patients, 21,7 %) became perceptible.

Thus, by results of clinical inspection it is taped, that larger quantity of the surveyed addressed with late stages of an osteonecrosis of the jaw localised mainly in distal departments top and the mandible, a denudation of the osteal characterised by sites
Tissues, without the expressed asymmetry of the person. Carrying out of surgical treatment in other medical institutions did not lead to a positive effect from treatment, on the contrary, caused weighting of a condition of the patient and expansion of a zone of an osteonecrosis.

3.2.

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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 RESULTS OF CLINICAL INSPECTION OF PATIENTS WITH BISFOSFONATNYM THE OSTEONECROSIS OF JAWS (1 AND 2 GROUPS OF PATIENTS):

  1. INTRODUCTION
  2. a pathogenesis, diagnostics, treatment bisfosfonatnogo an osteonecrosis of jaws
  3. RESULTS OF CLINICAL INSPECTION OF PATIENTS WITH BISFOSFONATNYM THE OSTEONECROSIS OF JAWS (1 AND 2 GROUPS OF PATIENTS)
  4. CHAPTER 4. DISCUSSION OF RESULTS OF OWN RESEARCHES