2023 年第 6 期 第 18 卷

临床和基础联合研究药物相关性颌骨坏死

Clinical and basic joint research on medication-related osteonecrosis of the jaw

作者：张非煜1王晓庚1刘林1丁芳1董坚1薛冰2

英文作者：Zhang Feiyu1 Wang Xiaogeng1 Liu Lin1 Ding Fang1 Dong Jian1 Xue Bing2

单位：1首都医科大学附属北京安贞医院口腔科，北京100029；2首都医科大学中心实验室，北京100069

英文单位：1Department of Stomatology Beijing Anzhen Hospital Capital Medical University Beijing 100029 China; 2Central Laboratory Capital Medical University Beijing 100069 China

关键词：药物相关性颌骨坏死；唑来膦酸；颌骨坏死；动物模型

英文关键词：Medication-relatedosteonecrosisofthejaw;Zoledronicacid;Osteonecrosisofthejaw;Animalmodels

• 摘要：

• 目的  对静脉应用唑来膦酸（ZA）患者拔牙后出现药物相关性颌骨坏死(MRONJ)情况进行临床观察，并通过腹腔注射ZA结合拔牙建立MRONJ大鼠动物模型，研究相关发病机制。方法  选取2013年1月至2018年1月首都医科大学附属北京安贞医院内分泌科收治的骨质疏松使用ZA注射液患者45例，微创拔牙操作后观察伤口愈合情况。选用5周龄健康雄性无特定病原体级SD大鼠36只，完全随机分为ZA组和对照组，每组18只。ZA组对SD大鼠腹腔注射ZA（0.2 mg/ml），采用隔日1次，连续注射8周后微创拔除左侧下颌第一颗磨牙的方法建立MRONJ动物模型，对照组大鼠注射等容积0.9%氯化钠溶液并行左侧下颌第一磨牙拔除术。拔牙后继续饲养6周然后过量麻醉处死所有大鼠。取大鼠拔牙侧下颌骨，剔净软组织后行微计算机断层扫描(Micro-CT)观察影像学改变，并对感兴趣区域(ROI)骨微结构进行定量分析，再通过苏木精-伊红（HE）染色观察软硬组织结构变化。结果  临床观察中，45例患者中1例出现Ⅰ期骨坏死（极轻微型MRONJ），连续观察3年仍未痊愈。基础研究成功建立MRONJ大鼠模型，口内拔牙创口大体观察、Micro-CT及组织病理学检查均证实颌骨坏死率为77.8%(14/18)。Micro-CT对大鼠下颌骨组织ROI微结构定量分析结果显示骨微结构指标变化，ZA组大鼠拔牙创周围ROI骨矿密度、骨体积分数和骨小梁数目均高于对照组，骨小梁间隙小于对照组（均P＜0.05），提示骨的改建和愈合能力下降。HE染色显示与对照组相比，ZA组拔牙创周围出现骨坏死和炎性浸润的典型病理表现，拔牙创邻牙的牙根处牙周膜和牙髓组织出现细胞变性和坏死表现。结论  静脉应用ZA患者拔牙后可出现MRONJ。腹腔注射ZA结合拔牙的方法可成功诱导大鼠发生MRONJ样病变，并观察到大鼠的颌骨和软组织微结构发生改变。

• Objective    To observe clinically  medication-related osteonecrosis of the jaw (MRONJ) in patients undergoing intravenous infusion of zoledronic acid (ZA) after tooth extraction, establish a MRONJ rat animal model by intraperitoneal injection of ZA combined with tooth extraction, and study the relevant pathogenesis. Methods  From January 2013 to January 2018, 45 patients with osteoporosis treated in the Department of Endocrinology, Beijing Anzhen Hospital, Capital Medical University using ZA injection were collected, and the wound healing was observed after mini-mally invasive tooth extraction. A total of 36 5-week-old healthy male pathogen free SD rats were selected, and they were randomly divided into ZA group and control group, with 18 rats in each group. The MRONJ rat animal model was established in ZA group by intraperitoneal injection of ZA (0.2 mg/ml) once every other day for 8 consecutive weeks, followed by mini-mally invasive extraction of the first left mandibular molar in SD rats. The control group was injected with an equal volume of 0.9% sodium chloride solution and underwent extraction of the left mandibular first molar. After tooth extraction, the rats were fed for 6 weeks, and then all rats were killed under excessive anesthesia. The mandibular bone of the extracted side of the rat tooth was taken, and the soft tissue was removed. Micro-computed tomography (Micro-CT) was performed to observe the imaging changes, and quantitative analysis was performed on the bone microstructure of the area of interest (ROI). Then, changes in the soft and hard tissue structures were observed by hematoxylin eosin (HE) staining. Results  During clinical observation, 1 patient with stage Ⅰ bone necrosis (extremely mild MRONJ) appeared among 45 patients, and still did not recover after 3 years of continuous observation. Basic research had successfully established MRONJ rat model. Gross observation of in-traoral tooth extraction wounds, Micro-CT, and histopathology examination had confirmed that the rate of jaw necrosis was 77.8%(14/18). Quantitative analysis of the microstructure of the ROI in rat mandibular tissue by Micro-CT revealed changes in bone microstructure indicators. The bone mineral density, bone volume fraction and trabecular number of ROI around the tooth extraction wound in ZA group rats were higher than those in the control group, and the trabecular space was smaller than that in the control group (all P＜0.05), indicating a decrease in bone remodeling and healing ability. Compared with the control group, HE staining showed that typical pathological manifestations of bone necrosis and inflammatory infiltration were observed around the tooth extraction wound in the ZA group, and cellular degeneration and necrosis were observed in the periodontal membrane and pulp tissue at the root of adjacent teeth after tooth extraction. Conclusions  Patients with intravenous infusion of ZA showed MRONJ after tooth extraction. Intraperitoneal injection of ZA combined with tooth extraction can successfully induce MRONJ like lesions in rats, and changes in the microstructure of the jaw and soft tissue have been observed.