薬剤関連顎骨壊死のステージ別の治療戦略

出典
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1: Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline.
著者: Noam Yarom, Charles L Shapiro, Douglas E Peterson, Catherine H Van Poznak, Kari Bohlke, Salvatore L Ruggiero, Cesar A Migliorati, Aliya Khan, Archie Morrison, Holly Anderson, Barbara A Murphy, Devena Alston-Johnson, Rui Amaral Mendes, Beth Michelle Beadle, Siri Beier Jensen, Deborah P Saunders
雑誌名: J Clin Oncol. 2019 Sep 1;37(25):2270-2290. doi: 10.1200/JCO.19.01186. Epub 2019 Jul 22.
Abstract/Text: PURPOSE: To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.
METHODS: Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included.
RESULTS: The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting.
RECOMMENDATIONS: Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
J Clin Oncol. 2019 Sep 1;37(25):2270-2290. doi: 10.1200/JCO.19.01186. ...

口腔内アセスメント表

歯科への連携を検討する際の、歯科への依頼の緊急度をトリアージするための簡便なアセスメント票。
  1. スコア3（一項目でもスコア3があるもの）
  1. 早急に歯科受診を促す
  1. スコア2（一項目でもスコア2があるもの）
  1. 緊急性は低いが、口腔内のリスクがあがっている可能性あり
  1. スコア2が長く続くようであれば歯科を受診させる
  1. スコア1（すべてのスコアが1）
  1. 口腔内の管理は良好。このままケアを継続する

がん治療による口腔粘膜炎発症頻度

がん治療の内容によって、口腔粘膜炎の発症頻度や重症度は異なる。

口腔粘膜炎の発症頻度が高い抗がん剤

口腔粘膜炎の発症リスクが高い薬剤を、特に赤字で示す。

殺細胞性抗がん剤による口腔粘膜炎

右頬粘膜に発症した抗がん剤による口腔粘膜炎
出典
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1: 著者提供

頭頸部放射線治療による口腔粘膜炎

頭頸部がん化学放射線治療時に発症した広範な口腔粘膜炎
出典
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1: 著者提供

骨髄抑制期の歯性感染症の急性化

口腔内の清掃不良に起因する、歯肉の局所感染症。広い範囲の歯肉に発赤・腫脹を認める。
出典
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1: 著者提供

口腔カンジダ症

頭頸部放射線治療中に発症した口腔カンジダ症。口蓋・頬粘膜・舌・口唇裏面の粘膜に、広範に白色の偽膜形成を認める。
出典
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1: 著者提供

ヘルペス性口内炎

薬物療法中に発症した口唇のヘルペス感染症。小水疱を形成後、破れて潰瘍を形成している。二次感染を併発し、口唇の腫脹を伴う。
出典
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1: 著者提供

薬剤関連顎骨壊死　

ビスフォスフォネート製剤の長期使用後に発症した、重度の薬剤関連顎骨壊死。下顎骨が腐骨化し、広範に露出している。
出典
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1: 著者提供

口腔乾燥症

著明な口腔乾燥により、粘膜に乾燥した痂皮が固着している。
出典
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1: 著者提供

口腔粘膜炎の重症度評価

NCI-CTCAE Ver.5.0　口腔粘膜炎の重症度評価
 
参考文献：有害事象共通用語規準 v5.0 日本語訳 JCOG 版（http://www.jcog.jp/doctor/tool/CTCAEv5J_20180730_v21_0.pdf）. 10/43ページより
出典
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1: 著者提供

薬剤関連顎骨壊死　ステージング

参考文献：
American Society of Clinical Oncology：Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline. J Clin Oncol. 2019 Sep 1;37(25):2270-2290, PMID：31329513

OAG（Oral Assessment Guide）

看護師が口腔内環境のアセスメントを行う際に用いられる。
出典
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1: 著者提供

口腔粘膜炎の症例

a：初診時　下顎と下唇
b：初診時　上顎歯槽部
出典
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1: 著者提供

清掃器具

出典
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1: 著者提供

歯性感染症の症例

a：初診時　口腔内
b：ケア介入1週間後の口腔内
出典
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1: 著者提供

口腔粘膜炎の重症化のカスケード

口腔粘膜炎の治療戦略は、重症化のカスケードを踏まえて癌治療への悪影響を抑制することである。
出典
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1: Updated clinical practice guidelines for the prevention and treatment of mucositis.
著者: Dorothy M Keefe, Mark M Schubert, Linda S Elting, Stephen T Sonis, Joel B Epstein, Judith E Raber-Durlacher, Cesar A Migliorati, Deborah B McGuire, Ronald D Hutchins, Douglas E Peterson, Mucositis Study Section of the Multinational Association of Supportive Care in Cancer and the International Society for Oral Oncology
雑誌名: Cancer. 2007 Mar 1;109(5):820-31. doi: 10.1002/cncr.22484.
Abstract/Text: Considerable progress in research and clinical application has been made since the original guidelines for managing mucositis in cancer patients were published in 2004, and the first active drug for the prevention and treatment of this condition has been approved by the United States Food and Drug Administration and other regulatory agencies in Europe and Australia. These changes necessitate an updated review of the literature and guidelines. Panel members reviewed the biomedical literature on mucositis published in English between January 2002 and May 2005 and reached a consensus based on the criteria of the American Society of Clinical Oncology. Changes in the guidelines included recommendations for the use of palifermin for oral mucositis associated with stem cell transplantation, amifostine for radiation proctitis, and cryotherapy for mucositis associated with high-dose melphalan. Recommendations against specific practices were introduced: Systemic glutamine was not recommended for the prevention of gastrointestinal mucositis, and sucralfate and antimicrobial lozenges were not recommended for radiation-induced oral mucositis. Furthermore, new guidelines suggested that granulocyte-macrophage-colony stimulating factor mouthwashes not be used for oral mucositis prevention in the transplantation population. Advances in mucositis treatment and research have been complemented by an increased rate of publication on mucosal injury in cancer. However, additional and sustained efforts will be required to gain a fuller understanding of the pathobiology, impact on overall patient status, optimal therapeutic strategies, and improved educational programs for health professionals, patients, and caregivers. These efforts are likely to have significant clinical and economic impact on the treatment of cancer patients. Cancer 2007;109:820-31. (c) 2007 American Cancer Society.
Cancer. 2007 Mar 1;109(5):820-31. doi: 10.1002/cncr.22484.

薬剤関連顎骨壊死のステージ別の治療戦略

出典
imgimg
1: Medication-Related Osteonecrosis of the Jaw: MASCC/ISOO/ASCO Clinical Practice Guideline.
著者: Noam Yarom, Charles L Shapiro, Douglas E Peterson, Catherine H Van Poznak, Kari Bohlke, Salvatore L Ruggiero, Cesar A Migliorati, Aliya Khan, Archie Morrison, Holly Anderson, Barbara A Murphy, Devena Alston-Johnson, Rui Amaral Mendes, Beth Michelle Beadle, Siri Beier Jensen, Deborah P Saunders
雑誌名: J Clin Oncol. 2019 Sep 1;37(25):2270-2290. doi: 10.1200/JCO.19.01186. Epub 2019 Jul 22.
Abstract/Text: PURPOSE: To provide guidance regarding best practices in the prevention and management of medication-related osteonecrosis of the jaw (MRONJ) in patients with cancer.
METHODS: Multinational Association of Supportive Care in Cancer/International Society of Oral Oncology (MASCC/ISOO) and ASCO convened a multidisciplinary Expert Panel to evaluate the evidence and formulate recommendations. Guideline development involved a systematic review of the literature and a formal consensus process. PubMed and EMBASE were searched for studies of the prevention and management of MRONJ related to bone-modifying agents (BMAs) for oncologic indications published between January 2009 and December 2017. Results from an earlier systematic review (2003 to 2008) were also included.
RESULTS: The systematic review identified 132 publications, only 10 of which were randomized controlled trials. Recommendations underwent two rounds of consensus voting.
RECOMMENDATIONS: Currently, MRONJ is defined by (1) current or previous treatment with a BMA or angiogenic inhibitor, (2) exposed bone or bone that can be probed through an intraoral or extraoral fistula in the maxillofacial region and that has persisted for longer than 8 weeks, and (3) no history of radiation therapy to the jaws or metastatic disease to the jaws. In patients who initiate a BMA, preventive care includes comprehensive dental assessments, discussion of modifiable risk factors, and avoidance of elective dentoalveolar surgery (ie, surgery that involves the teeth or contiguous alveolar bone) during BMA treatment. It remains uncertain whether BMAs should be discontinued before dentoalveolar surgery. Staging of MRONJ should be performed by a clinician with experience in the management of MRONJ. Conservative measures comprise the initial approach to MRONJ treatment. Ongoing collaboration among the dentist, dental specialist, and oncologist is essential to optimal patient care.
J Clin Oncol. 2019 Sep 1;37(25):2270-2290. doi: 10.1200/JCO.19.01186. ...

口腔内アセスメント表

歯科への連携を検討する際の、歯科への依頼の緊急度をトリアージするための簡便なアセスメント票。
  1. スコア3（一項目でもスコア3があるもの）
  1. 早急に歯科受診を促す
  1. スコア2（一項目でもスコア2があるもの）
  1. 緊急性は低いが、口腔内のリスクがあがっている可能性あり
  1. スコア2が長く続くようであれば歯科を受診させる
  1. スコア1（すべてのスコアが1）
  1. 口腔内の管理は良好。このままケアを継続する