摘要：

药物相关性颌骨坏死（medication-related osteonecrosis of the jaw，MRONJ）目前尚缺乏国际统一的诊断“金标准”，各学术团体提出的共识或指南存在差异，导致临床诊断面临挑战，尤其是无骨面暴露的病例。根据美国口腔颌面外科医师协会（American Association of Oral and Maxillofacial Surgeons，AAOMS）2022版意见书，对于MRONJ的诊断，已将“可探及骨面的口内或口外瘘管”作为无明确骨面暴露情况下的临床表现依据。然而，临床实践中，表现为根尖区瘘管的MRONJ体征与根尖周炎高度重叠，鉴别困难；部分无骨暴露的MRONJ，其排脓通道隐匿，可位于牙周袋或上颌窦内，并不表现为典型瘘管，易导致MRONJ漏诊或误诊。针对上述问题，本文将无明确骨面暴露、存在可探及骨面的瘘管或其他隐匿性排脓通道、伴有非特异性症状及特征性影像学改变的病变类型定义为“非暴露型（non-exposed）”MRONJ。在此基础上，本文系统分析其识别难点，梳理其病史特点、临床表现及影像学表现中有助于与牙源性感染鉴别诊断的关键要点，探讨诊断性治疗的临床价值，进而提出一套实现“非暴露型”MRONJ早期识别的临床路径。需要强调的是，“非暴露型”MRONJ不同于AAOMS所提出的0期病变，亦非MRONJ的早期阶段。明确“非暴露型”MRONJ这一概念，有助于提高MRONJ的整体临床诊断率，减少因误诊、误治引发的医疗纠纷。

关键词: 骨改良药物, 药物相关性颌骨坏死, 非暴露型, 早期识别, 鉴别诊断, 诊断性治疗

Abstract:

The diagnosis of medication-related osteonecrosis of the jaw (MRONJ) currently lacks a globally unified "gold standard", with discrepancies existing among the consensus statements or guidelines of various academic societies. This diagnostic challenge is particularly pronounced for MRONJ cases without clinically evident bone exposure. According to the 2022 position paper of the American Association of Oral and Maxillofacial Surgeons (AAOMS), the diagnosis of MRONJ includes "intraoral or extraoral fistula that probes to bone" as a clinical manifestation in the absence of overt bone exposure. However, in clinical practice, MRONJ presenting with periapical fistula closely resembles periapical periodontitis, making differentiation difficult. Moreover, some MRONJ cases without bone exposure exhibit concealed drainage pathways located in periodontal pockets or the maxillary sinus, without typical fistula formation, increasing the risk of misdiagnosis or underdiagnosis. To address these issues, this article defines "non-exposed" MRONJ as a subtype of MRONJ characterized by the absence of overt bone exposure but the presence of fistulae that probe to bone or other concealed purulent drainage pathways, with non-specific symptoms and characteristic imaging changes. This article systematically analyzes the diagnostic challenges of this variant, synthesizes key differentiating features from medical history, clinical manifestations, and imaging findings to differentiate from odontogenic infections, and discusses the role of diagnostic treatment. Finally, a clinical pathway is proposed to facilitate the early identification of "non-exposed" MRONJ. It should be emphasized that "non-exposed" MRONJ is distinct from the AAOMS-defined stage 0 disease and does not represent an early phase of MRONJ. Clarifying the concept of "non-exposed" MRONJ may improve the overall diagnostic rate of MRONJ and reduce medicolegal disputes arising from misdiagnosis and inappropriate treatment.

Key words: bone-modifying agents, medication-related osteonecrosis of the jaw, non-exposed, early identification, differential diagnosis, diagnostic therapy

中图分类号: 

• 骨改良药物

• 药物相关性颌骨坏死

• 非暴露型

• 早期识别

• 鉴别诊断

• 诊断性治疗

• bone-modifying agents

• medication-related osteonecrosis of the jaw

• non-exposed

• early identification

• differential diagnosis

• diagnostic therapy