英語晨讀 ·
山東省立醫(yī)院疼痛科英語晨讀已經(jīng)堅(jiān)持10余年的時(shí)間了，每天交班前15分鐘都會(huì)精選一篇英文文獻(xiàn)進(jìn)行閱讀和翻譯。一是可以保持工作后的英語閱讀習(xí)慣，二是可以學(xué)習(xí)前沿的疼痛相關(guān)知識(shí)。我們會(huì)將晨讀內(nèi)容與大家分享，助力疼痛學(xué)習(xí)。
本次文獻(xiàn)選自Maini, K., & Dua, A. (2020). Temporomandibular Joint Syndrome. In StatPearls. StatPearls Publishing。本次學(xué)習(xí)由趙學(xué)軍主任醫(yī)師主講。
Treatment / Management
Treatment of Temporomandibular disorders:
The identification of the disorder and management could be a challenging task. It is imperative to determine the disorder with adequate evidence before initiating the treatment. The treatment plan decision can be from among the various options available.
The first step in treating TMJ disorders is symptomatic care, which usually consists of (a) a soft diet, (b) mild inflammatory agents, (c) moist heat packs alternating with ice, and (d) voluntary disengagement of the teeth.
Further treatment modalities can group into definitive and supportive treatment.
顳頜關(guān)節(jié)功能紊亂的治療：
該病的識(shí)別和治療是一項(xiàng)具有挑戰(zhàn)性的任務(wù)，在開始治療前必須有足夠的證據(jù)來確定該病的診斷。治療計(jì)劃的確定可以從各種可用的方法中選擇。
治療顳下頜關(guān)節(jié)功能紊亂的第一步是對(duì)癥處理，通常包括（a）軟性飲食，（b）溫和的抗炎藥物，（c）濕熱敷與冰敷交替，和（d）自愿少用牙齒。
進(jìn)一步的治療方式可分為確定性治療和支持性治療。
1. Definitive treatment:
The definitive treatment identifies the disorder and treats the cause of the disorder. The various treatment methods are
a) Occlusal therapy:
The modifications in dental occlusion are the primary treatment method of TMD. This treatment focuses on altering the mandibular positioning. It identifies and removes derangements in occlusion and contact interference.
b) Emotional stress therapy:
Generally, TMD is associated with the emotional and psychological state. Muscle activities become altered due to increased levels of emotional stress.
Stress management can be with patient behavioral therapy in the following ways:
i) Patient awareness:
The patient receives education regarding the relationship between stress and muscle hyperactivity. This understanding aids in better behavioral management and improves psychological health and the condition.
ii) Restrictive use:
In the majority of TMD situations, patients complain of pain in TMJ and restricted mandibular movement. The clinician should instruct the patient to move the mandible within a trouble-free range of motion, which promotes psychological health and pain disorder.
iii) Voluntary avoidance:
The teeth contact can trigger the pain in patients. The patients must try to reduce tooth contact time. Except during mastication, swallowing, and speaking, the clinician directs patients to disengage the tooth to diminish the pain or discomfort coercively. A simple exercise of lip puffing can voluntarily disengage teeth and enhance patient health.
iv) Relaxation therapy:
Relaxation is perceptive. Among the numerous relaxation techniques, patients are encouraged to follow one that suits them to relax the muscles and promote psychological health. The stretch-relax procedure and progressive relaxation techniques are commonly followed and effective among TMD patients.
1.確定性治療：
確定性治療首先對(duì)該病明確診斷，然后針對(duì)病因進(jìn)行治療。治療方法多種多樣。
a） 咬合治療：
咬合矯正是顳下頜關(guān)節(jié)紊亂的主要治療方法，該方法主要是改變下頜骨的位置。它識(shí)別并消除咬合和接觸過程中的功能紊亂。
b） 情緒壓力療法：
一般來說，TMD與情緒和心理狀態(tài)有關(guān)。由于情緒壓力的增加，肌肉活動(dòng)會(huì)發(fā)生改變。
壓力療法可以通過以下方式與患者的行為療法相結(jié)合：
i） 患者意識(shí)：
患者接受有關(guān)壓力和肌肉過度活動(dòng)之間關(guān)系的教育。這種理解有助于更好的行為管理，改善心理健康和條件。
ii）限制性使用：
在大多數(shù)顳下頜關(guān)節(jié)功能紊亂，患者都會(huì)抱怨顳下頜關(guān)節(jié)疼痛和下頜運(yùn)動(dòng)受限。臨床醫(yī)生應(yīng)指導(dǎo)患者在無疼痛的范圍內(nèi)移動(dòng)下頜骨，這有助于促進(jìn)心理健康和疼痛障礙。
iii）主動(dòng)減少牙齒的接觸：
牙齒接觸會(huì)引起患者疼痛。患者必須盡量減少牙齒接觸時(shí)間。除了咀嚼、吞咽和說話時(shí)，臨床醫(yī)生應(yīng)指導(dǎo)患者避免上下牙齒的接觸，以強(qiáng)制性地減輕疼痛或不適。一個(gè)簡單的吹唇運(yùn)動(dòng)可以自動(dòng)地使上下牙齒分開，增強(qiáng)患者的健康。
iv）放松療法：
放松療法需要患者積極的配合方能完成。在眾多的放松方法中，鼓勵(lì)患者選擇適合自己的放松方法來放松肌肉和促進(jìn)心理健康。伸展放松法和漸進(jìn)放松法是TMD患者普遍采用的有效方法。
2. Supportive Therapy:
Patient symptom management is through supportive therapy. The cause of TMD may not be relieved with supportive treatment.
The following methods are the currently adopted approach for treating these patients:
a) Pharmacologic therapy: Analgesics, Non-steroidal anti-inflammatory drugs (NSAIDs), corticosteroids, anxiolytic agents, muscle relaxants, anti-depressants, local anesthetics can be either administered locally or systematically to reduce the patient symptoms. Typically, 10 to 14 days course of NSAIDs is the recommended course for acute pain. Muscle relaxants are an optional adjunct to treat myospasm. If a patient reports poor response in two to three weeks, tricyclic antidepressants (TCA) are another option, especially if the pain is associated with bruxism.
Invasive strategies include intra-articular long-acting corticosteroid or hyaluronic acid injections and trigger point botox injections. These interventions are recommended once conservative therapies have failed or in severe acute exacerbations. Intra-articular steroids are a recommended intervention for acute treatment of osteoarthritis of TMJ, but multiple doses can lead to the destruction of articular cartilage. There is only limited evidence regarding the efficacy of hyaluronate injections in treating acute exacerbations.Botulinum toxin injections only for painful trigger points or chronic bruxism, but a recent Cochrane study had inconclusive evidence for myofascial pain.[32][33]
b) Physical therapy: Physical therapy is commonly advocated as an adjuvant to definitive treatment. Modalities used in physical therapy involve thermotherapy, coolant therapy, ultrasound, TENS, acupuncture, and cold laser. The commonly followed manual techniques are soft tissue mobilization, joint mobilization, muscle conditioning, resistance exercises, passive muscle stretching, assisted muscle stretching, and postural training.
2.支持療法：
患者的癥狀可以是通過支持性治療來緩解，但是，顳下頜關(guān)節(jié)功能紊亂的病因可能無法通過支持治療而解除。
目前采用的治療方法如下：
a）藥物治療：鎮(zhèn)痛藥、非甾體抗炎藥（NSAIDs）、皮質(zhì)類固醇、抗焦慮藥、肌肉松弛劑、抗抑郁藥、局麻藥可局部或全身性應(yīng)用，以減輕患者癥狀。通常情況下，急性疼痛患者建議應(yīng)用10至14天的非甾體抗炎藥。肌肉松弛劑是治療肌肉痙攣的可選輔助藥物。如果患者在兩到三周內(nèi)反應(yīng)不佳，可加用三環(huán)類抗抑郁藥（TCA），尤其是當(dāng)疼痛與磨牙癥相關(guān)時(shí)。
侵入性的治療方法包括關(guān)節(jié)內(nèi)注射長效皮質(zhì)類固醇或透明質(zhì)酸，以及扳機(jī)點(diǎn)注射肉毒桿菌。一旦保守治療失敗或嚴(yán)重急性加重，建議進(jìn)行這些治療。關(guān)節(jié)內(nèi)類固醇注射是顳下頜關(guān)節(jié)骨性關(guān)節(jié)炎急性期治療的建議措施，但多次注射會(huì)導(dǎo)致關(guān)節(jié)軟骨的破壞。關(guān)于透明質(zhì)酸鈉注射治療急性加重的療效，只有有限的證據(jù)。肉毒桿菌毒素注射僅用于疼痛觸發(fā)點(diǎn)或慢性磨牙癥，但是最近的一項(xiàng)Cochrane研究沒有發(fā)現(xiàn)關(guān)于肌筋膜疼痛使用該方法的決定性證據(jù)。
b）物理治療：物理治療通常被提倡作為確定性治療的輔助手段。物理治療中使用的方法包括熱療、冷劑療法、超聲波、TENS、針灸和冷激光。常用的推拿手法有軟組織調(diào)整、關(guān)節(jié)調(diào)整、肌肉調(diào)節(jié)、阻力訓(xùn)練、被動(dòng)肌肉拉伸、輔助肌肉拉伸和姿勢(shì)訓(xùn)練。
聯(lián)系客服
