RU2745476C1 - Method for the treatment of drug-associated osteonecrosis of the jaw - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to dentistry and surgery, and for the treatment of drug-associated osteonecrosis of the jaw. To do this, the boundaries of sequestrectomy are determined by registering microcirculation parameters using laser Doppler flowmetry, sequestrectomy is performed, and an APRF clot is placed on the bottom of the bone wound. The wound is sutured tightly using plastic techniques with local tissues. In the postoperative period, antibiotic prophylaxis with drugs of a wide spectrum of action is carried out, and after reducing the edema at the edges of the wound, injections of autologous plasma are carried out according to the scheme 1 injection in 7-8 days, 4-5 times.

EFFECT: method provides effective treatment and reduction of the number of complications due to precise definition of sequestrectomy boundaries and acceleration of regeneration processes.

1 cl, 1 ex

Description

The invention relates to medicine, in particular to dental surgery and maxillofacial surgery, and is intended for the treatment of drug-associated osteonecrosis of the jaw.

Drug-associated osteonecrosis has a specific clinical and radiological picture, which differs from typical osteomyelitis - a primary chronic course, severe pain before the appearance of clinical signs, the absence of classical signs of sequestration on radiographs, a discrepancy between the radiological and intraoperative picture, and frequent relapses.

As a rule, this disease is a complication of therapy with osteomodifying agents (bisphosphonates, denosumab), which, according to the recommendation of the Association of Oncologists of Russia and foreign oncological associations and societies, are the standard in the treatment of patients with bone metastases of malignant neoplasms of various localizations.

The pathogenesis of the disease is based on many factors - a violation of bone remodeling, toxic effects on soft tissues, including directly on the oral mucosa, infectious agents and dysfunction of general immunity. Osteomodifying agents inhibit angiogenesis by inhibiting the formation of blood vessels, endothelial cells, fibroblast growth factor, and endothelial growth factor, impairing endothelial cell function. Histological examination of the tissue revealed a decrease in p63 gene expression, which indicates a decrease in basal cell precursors, and may lead to impaired healing of the oral mucosa.

Thus, the main factors in the treatment of surgical treatment of drug-associated osteonecrosis of the jaw, affecting the reduction of postoperative complications and recurrent diseases, are, firstly, effective removal of the entire area of necrotic bone and, secondly, optimal stimulation of local regenerative processes (use of drugs of general actions can provoke continued growth of the primary tumor).

According to the data of domestic and foreign researchers, one of the most accepted criteria for removing a site of necrotic bone is the surgeon's intraoperative impression. However, the problem is that the exact boundaries of such necrosis are difficult to determine "by eye", which means that a clear delineation of necrotic bone is difficult to achieve.

The use of methods of radiation diagnostics (computed tomography) is proposed to be carried out before the operation. Taking into account the peculiarities of the clinical and radiological picture (the absence of a clear demarcation zone of sequestration), this technique is not sufficiently effective for surgical treatment.

The closest analogue adopted for the prototype is a method for the treatment of drug-associated osteonecrosis of the jaw, in which tetracycline is administered to the patient a few days before the operation, during the operation, the boundaries of sequestrectomy are determined by the method of bone fluorescence, in which the bone segment is studied in relation to the intensity of its fluorescence. In bones, tetracyclines form insoluble complexes, especially in areas of intense remodeling. Intraoperative imaging is performed with a Velcoscope; viable bone shows greenish fluorescence. After that, sequestrectomy and suturing of the bone wound are performed (Pautke C, Bauer F, Bissinger O, Tischer T, Kreutzer T, Steiner T, Weitz J, Otto S, Wolff KD, Sturzenbaum SR, Kolk A. Tetracycline bone fluorescence: a valuable marker for osteonecrosis characterization and therapy. J Oral Maxiofac Surg. 2010 Jan; 68 (l): 125-9. doi 10.1016 / j.joms. 2009.05.442).

The disadvantage of this method is the high risk of postoperative complications. In addition, the method is complicated by the need to administer the drug 10 days before the operation. Also, the use of expensive equipment significantly complicates the use of the method intraoperatively.

The problem of the claimed invention is the development of an effective method for the treatment of drug-associated osteonecrosis of the jaw.

The technical result is an increase in the effectiveness of treatment of drug-associated osteonecrosis of the jaw, a decrease in the number of complications.

To achieve the claimed technical result in the method of treatment of drug-associated osteonecrosis of the jaw, the boundaries of sequestrectomy are determined by registering microcirculation parameters using laser Doppler flowmetry, in which the Doppler channel at a wavelength of 0.8 μm measures the bone tissue perfusion index and a conditional line drawn through the points of reaching the maximum stable perfusion indices from the center of the necrosis focus, is the boundary of sequestrectomy, after which an APRF clot is placed on the bottom of the bone wound, the wound is sutured tightly using plastics with local tissues, antibiotic prophylaxis with broad-spectrum drugs is carried out in the postoperative period, and after reducing the edema at the edges of the wound, autologous plasma injections according to the scheme 1 injection in 7-8 days, 4-5 times.

Determination of the sequestrectomy border by registering microcirculation parameters using laser Doppler flowmetry allows you to accurately and objectively determine the sequestrectomy zone boundaries during surgery, which allows you to remove the entire infected bone area, thereby reducing the risk of recurrence.

The use of autologous plasma in the treatment of drug-associated osteonecrosis is the most optimal way to stimulate local regenerative processes, which reduces the risk of postoperative complications.

The method is carried out as follows.

Using the device of laser Doppler flowmetry "LAKK-OP" set the boundaries of sequestrectomy. The device for laser Doppler flowmetry consists of an analyzer unit with a laser at a wavelength of 0.8 μm, a light guide probe and a personal computer. Under endotracheal anesthesia, after aseptic processing of the operating field, an incision is made in the mucous membrane of the alveolar process of the jaw, wider than the supposed boundaries of osteonecrosis, the osteonecrosis focus is skeletonized within the visible boundaries. The light guide probe of the apparatus is installed in the center of the visible necrosis focus and is gradually moved around the periphery in three directions - downward, leftward, right (on the lower jaw), or upward, leftward, rightward (on the upper jaw) until the maximum stable perfusion rates are reached.

Mathematical processing of the LDF signal was carried out using the LDF_3w_ software (2012-04-10).

Sequestrectomy is performed along a conventional line drawn through the points with the maximum stable perfusion indices.

Next, an APRF clot is placed on the bottom of the bone wound, which is preliminarily prepared as follows. In a test tube coated with silicon oxide, 9 ml of peripheral venous blood is taken, which is centrifuged for 13 minutes at 2600 rpm. Then the clot is removed from the test tube, separated from the red fraction and placed on the bottom of the bone wound. The wound is sutured tightly using plastic techniques using local tissues (additional incisions "poker", moving the flaps).

In the postoperative period, antibiotic prophylaxis is performed with broad-spectrum drugs (amoxiclav 1000 × 2 times a day intravenously for 5 days). After reducing the edema at the edges of the wound, autologous plasma injections are performed according to the scheme 1 injection every 7-8 days, 4-5 times.

For the production of autologous plasma, 9 ml of peripheral venous blood is taken into a test tube with an anticoagulant, which is centrifuged for 3 minutes at 3300 rpm. Next, the average portion of the obtained plasma is taken into the syringe.

Clinical example

Patient C. 78 years old.

He complained of pain in the upper jaw on the right, the presence of a bared area of bone on the upper jaw on the right, bad breath.

To the patient, 6 months before going to the dental clinic, tooth 1.5 was removed, after which the hole did not heal for a long time. The curettage of the wells was carried out several times. There were severe pains in the upper jaw on the right, radiating to the eye. Sent for consultation with a maxillofacial surgeon, performed CT scan, diagnosed with drug-associated osteonecrosis of the upper jaw. Hospitalized for surgical treatment.

Previously received OMA (zoledronic acid) for bone metastases for 2 years. The primary focus is the prostate.

At the time of treatment, the face is symmetrical, the skin is physiological. Regional lymph nodes are not palpable. Opening the mouth in full. Partial secondary adentia. On the upper jaw, a single standing tooth 2.3. On the alveolar process of the right upper jaw there is a defect in the mucous membrane in the projection of the tooth 1.5, with a diameter of about 1.5 cm. The edges of the defect are made with granulation tissue, in the defect there is a gray bone. In the projection of the 1.6 tooth, there is a fistulous course with insignificant purulent discharge. The intensity of pain according to the VAS scale is 8 points.

On CT, the osteosclerosis focus is visualized in projection 1.6 - 1.5 without clear boundaries.

Diagnosis - Drug-associated osteonecrosis of the right upper jaw, stage 2.

The treatment was carried out according to the claimed method. Under endotracheal anesthesia after aseptic treatment of the operating field, an incision was made along the crest of the alveolar process of the upper jaw from projection 1.7 to 2.1, the mucoperiosteal flap was detached, and a necrosis focus (gray bone) was found without a demarcation zone. The sensor of the laser Doppler flowmetry apparatus was installed in the center of the lesion, which was moved in three directions: upward, medially and laterally. When the maximum perfusion indicators were reached (on average, 15.2 Pf units), resection was performed along a conditional line drawn through these points (in this case, from tooth projection 1.6 to tooth projection 1.1). At the bottom of the bone wound, an APRF clot prepared according to the indicated technique was placed. The wound on the mucous membrane was sutured tightly using plastic techniques with local tissues. In the postoperative period, broad-spectrum antibiotics were prescribed (amoxiclav 1200 × 2 times a day intravenously for 5 days).

In the postoperative period, after edema reduction (on the 4th day), autologous plasma was injected into the edges of the postoperative wound (made according to the above method). The stitches were removed on the 9th day. The wound healed by primary intention with a slight divergence of the edges from the distal pole. The patient was discharged from the hospital. Pain intensity at the time of discharge 0 points on the VAS scale.

At the outpatient stage, 4 injections with an interval of 7 days of autologous plasma were made into the edges of the postoperative wound. The wound is completely healed. The intensity of pain syndrome at the end of the course was 0 points on the VAS scale. Control CT examination revealed no new foci of necrosis.

At the follow-up examination after 6 months, the patient showed no complaints, the intensity of the pain syndrome was 0 points on the VAS scale. On the mucous membrane of the alveolar process of the right upper jaw, there is a postoperative scar, pink, painless. The control CT examination of new foci of necrosis was not revealed, the closure of the cortical plates is determined.

After 8 months, the patient received a removable denture for the upper jaw.

Claims (1)

A method for the treatment of drug-associated osteonecrosis of the jaw, including determining the boundaries of sequestrectomy by registering microcirculation parameters using laser Doppler flowmetry, in which the Doppler channel at a wavelength of 0.8 μm measures the bone tissue perfusion index, and a conditional line drawn through the points of achieving the maximum stable perfusion parameters from the center of the necrosis focus, is the border of sequestrectomy, after which an APRF clot is placed on the bottom of the bone wound, the wound is sutured tightly using plastic techniques with local tissues, antibiotic prophylaxis with broad-spectrum drugs is performed in the postoperative period, and after edema reduction, autologous plasma is injected into the wound edges scheme 1 injection in 7-8 days, 4-5 times.