灼痛问题：晚期痴呆患者因双膦酸盐给药不当继发的口腔溃疡。

文献信息

中文摘要

背景： 口服双膦酸盐是骨质疏松症的一线治疗，但当片剂滞留而未正确吞咽时，可引起黏膜化学性损伤。在存在吞咽困难或难以遵守给药指南的认知功能受损老年人中，这一风险更高。病例介绍：一名73岁女性养老院居民，患有晚期血管性痴呆，因口腔疼痛24小时、进食减少、嗜睡和新发面部肿胀就诊。她已接受每月一次伊班膦酸150 mg治疗两年，有吞咽片剂困难的记录，但未进行正式吞咽评估。检查显示左下唇和前舌溃疡，伴轻度前庭肿胀。临床检查排除了血液学营养缺乏和骨坏死；根据分布、临床特征及与近期给药的时序关联，创伤性、苔藓样、水疱大疱性和肿瘤性病因被认为可能性不大。医院牙科服务诊断为双膦酸盐相关化学性黏膜损伤。停用伊班膦酸，开始局部治疗，溃疡在三周内愈合。鉴于患者吞咽困难和认知状态，改用地舒单抗。讨论：本病例支持现有文献，即不当给药——常与吞咽困难或身体功能障碍相关——是口服双膦酸盐相关溃疡的主要原因，通常累及舌和 lower lip。伊班膦酸相关病例报道罕见，可能反映处方频率而非风险较低。当前指南缺乏针对吞咽困难或认知状态在处方决策中的明确建议。结论：在口服双膦酸盐治疗前和治疗期间，应评估是否存在吞咽困难及认知状态。新发口腔疼痛、溃疡或面部肿胀应促使进行口腔检查和药物审查，当口服给药受损时，应考虑替代性抗骨吸收药物。

英文摘要

Background: Oral bisphosphonates are first-line osteoporosis therapy but can cause mucosal chemical injury when tablets are retained rather than swallowed correctly. This risk is heightened in cognitively impaired older adults with dysphagia or difficulty complying with medication administration guidelines. Case Presentation: A 73-year-old female nursing home resident with advanced vascular dementia presented with 24 h of oral pain, reduced intake, lethargy and new facial swelling. She had received monthly ibandronic acid 150 mg for two years, with documented difficulty swallowing tablets but no formal swallowing assessment. Examination showed ulceration of the left lower lip and anterior tongue with mild vestibular swelling. Clinical investigations excluded haematinic deficiency and osteonecrosis; traumatic, lichenoid, vesiculobullous and neoplastic causes were considered unlikely based on distribution, clinical features and temporal association with the recent dose. Bisphosphonate-associated chemical mucosal injury was diagnosed by hospital dental services. Ibandronic acid was discontinued, topical treatment initiated, and ulcers resolved by three weeks. Denosumab was substituted in view of the patient's dysphagia and cognitive status. Discussion: This case supports the existing literature identifying inappropriate administration-often linked to dysphagia or physical impairment-as a leading cause of oral bisphosphonate-associated ulceration, typically affecting the tongue and lower lip. Ibandronate-related cases are rarely reported, likely reflecting prescribing frequency rather than lower risk. Current guidelines lack explicit recommendations addressing dysphagia or cognition in prescribing decisions. Conclusions: Presence of dysphagia and cognitive status should be assessed before and during oral bisphosphonate therapy. New oral pain, ulceration or facial swelling should prompt oral examination and medication review, with alternative antiresorptive agents considered when oral administration is impaired.