【晨读】颞下颌关节综合征（四）
英语晨读 ·
山东省立医院疼痛科英语晨读已经坚持10余年的时间了，每天交班前15分钟都会精选一篇英文文献进行阅读和翻译。一是可以保持工作后的英语阅读习惯，二是可以学习前沿的疼痛相关知识。我们会将晨读内容与大家分享，助力疼痛学习。
本次文献选自Maini, K., & Dua, A. (2020). Temporomandibular Joint Syndrome. In StatPearls. StatPearls Publishing。本次学习由赵学军主任医师主讲。
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.
颞颌关节功能紊乱的治疗：
该病的识别和治疗是一项具有挑战性的任务，在开始治疗前必须有足够的证据来确定该病的诊断。治疗计划的确定可以从各种可用的方法中选择。
治疗颞下颌关节功能紊乱的第一步是对症处理，通常包括（a）软性饮食，（b）温和的抗炎药物，（c）湿热敷与冰敷交替，和（d）自愿少用牙齿。
进一步的治疗方式可分为确定性治疗和支持性治疗。
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.确定性治疗：
确定性治疗首先对该病明确诊断，然后针对病因进行治疗。治疗方法多种多样。
a） 咬合治疗：
咬合矫正是颞下颌关节紊乱的主要治疗方法，该方法主要是改变下颌骨的位置。它识别并消除咬合和接触过程中的功能紊乱。
b） 情绪压力疗法：
一般来说，TMD与情绪和心理状态有关。由于情绪压力的增加，肌肉活动会发生改变。
压力疗法可以通过以下方式与患者的行为疗法相结合：
i） 患者意识：
患者接受有关压力和肌肉过度活动之间关系的教育。这种理解有助于更好的行为管理，改善心理健康和条件。
ii）限制性使用：
在大多数颞下颌关节功能紊乱，患者都会抱怨颞下颌关节疼痛和下颌运动受限。临床医生应指导患者在无疼痛的范围内移动下颌骨，这有助于促进心理健康和疼痛障碍。
iii）主动减少牙齿的接触：
牙齿接触会引起患者疼痛。患者必须尽量减少牙齿接触时间。除了咀嚼、吞咽和说话时，临床医生应指导患者避免上下牙齿的接触，以强制性地减轻疼痛或不适。一个简单的吹唇运动可以自动地使上下牙齿分开，增强患者的健康。
iv）放松疗法：
放松疗法需要患者积极的配合方能完成。在众多的放松方法中，鼓励患者选择适合自己的放松方法来放松肌肉和促进心理健康。伸展放松法和渐进放松法是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.支持疗法：
患者的症状可以是通过支持性治疗来缓解，但是，颞下颌关节功能紊乱的病因可能无法通过支持治疗而解除。
目前采用的治疗方法如下：
a）药物治疗：镇痛药、非甾体抗炎药（NSAIDs）、皮质类固醇、抗焦虑药、肌肉松弛剂、抗抑郁药、局麻药可局部或全身性应用，以减轻患者症状。通常情况下，急性疼痛患者建议应用10至14天的非甾体抗炎药。肌肉松弛剂是治疗肌肉痉挛的可选辅助药物。如果患者在两到三周内反应不佳，可加用三环类抗抑郁药（TCA），尤其是当疼痛与磨牙症相关时。
侵入性的治疗方法包括关节内注射长效皮质类固醇或透明质酸，以及扳机点注射肉毒杆菌。一旦保守治疗失败或严重急性加重，建议进行这些治疗。关节内类固醇注射是颞下颌关节骨性关节炎急性期治疗的建议措施，但多次注射会导致关节软骨的破坏。关于透明质酸钠注射治疗急性加重的疗效，只有有限的证据。肉毒杆菌毒素注射仅用于疼痛触发点或慢性磨牙症，但是最近的一项Cochrane研究没有发现关于肌筋膜疼痛使用该方法的决定性证据。
b）物理治疗：物理治疗通常被提倡作为确定性治疗的辅助手段。物理治疗中使用的方法包括热疗、冷剂疗法、超声波、TENS、针灸和冷激光。常用的推拿手法有软组织调整、关节调整、肌肉调节、阻力训练、被动肌肉拉伸、辅助肌肉拉伸和姿势训练。