【晨读】颞下颌关节综合征（二）
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。
Etiology
TMD etiology is multifactorial. Various theories, such as mechanical displacement, trauma, biomedical, osteoarthritis, muscle theory, neuromuscular, psychophysiological, psychosocial theory, have been proposed to cause TMD.Several factors, either alone or in combinations, are responsible for TMD.Due to multifactorial etiology, the most common factors are:
1.Predisposing factors -The factors that increase the risk of TMD or orofacial pain. It further subdivides into systemic, psychologic, structural, and genetic factors.
2.Initiating factors -The factors that cause the onset of disorder such as trauma, overloading of joint structure such as parafunctional habits.
3.Perpetuating factors -The factors that interfere with healing or complicate management such as mechanical, muscular stress, and metabolic problems.
The factors can influence each other or act together.
病因学
TMD的病因是多因素的。各种理论，如机械移位理论、创伤理论、生物医学理论、骨关节炎理论、肌肉理论、神经肌肉理论、心理生理学理论、心理社会学理论等都被提出可导致TMD。好几个因素，无论是单独的还是联合的，都与TMD有关。其病因是多因素的，最常见的因素是：
1.诱发因素-增加TMD或口面部疼痛风险的因素。它进一步细分为系统、心理、结构和遗传因素。
2.始动因素-导致疾病发作的因素，如创伤、关节过度负重等等。
3.永久性因素-影响愈合或使治疗复杂化的因素，如机械、肌肉压力和代谢问题。
这些因素可以相互影响或共同作用。
Epidemiology
Epidemiological studies from around the world confirm a very high prevalence of TMD dysfunction. Reports indicate that 39.2% have at least one symptom of TMD. The incidence rate is 3.9% among adults and 4.6 % among adolescents. Symptoms of TMD are common in all age groups. Older age groups demonstrate slightly more symptoms than the young. Women are affected more than men, observed as 2 to 1 in population-based studies, and 4 to 1 in clinical settings. No gender differences have appeared in children, but the ratio becomes 2 to 1 in young adults (female to male ratio).
History and Physical
History and examination of TMD
The objective of eliciting history and examination is to recognize the clinical signs and symptoms. The factors to be included in history are:
1) Chief complaints that include:
Location, onset, and characteristic of pain
Aggravation and relieving factors
Past treatments if any and their result
Any other pain disorders.
2) Past medical and dental history
3) General systematic assessment
4) Psychologic assessment
流行病学
世界各地的流行病学研究证实，TMD功能障碍的患病率非常高。报告显示39.2%的人至少有一种TMD症状。成人发病率为3.9%，青少年发病率为4.6%。TMD的症状在所有年龄组中都很常见。老年人的症状略多于年轻人。女性比男性受影响更大，在以人群为基础的研究中，男性与女性受影响的比例为2:1，；在临床研究中，该比例为4:1。在儿童中没有出现性别差异，但在年轻人中这一比例变为2:1（男女比例）。
病史采集和辅助检查
询问病史中的诱发因素和进行各种检查的目的是为了了解临床症状和体征。病史采集时应包括以下内容：
1） 主诉应包括：
疼痛的部位、如何发作及其特征
加重和缓解因素
过去治疗的情况（如果有）及结果
任何其他疼痛。
2） 既往病史和口腔疾病史
3） 全身健康状况评估
4） 心理评估
Physical examination findings of TMD include decreased range of motion, signs of bruxism, abnormal mandibular movements, tenderness of muscles of mastication, neck, and shoulder, pain with dynamic loading, and postural asymmetry. It is vital to perform an oral and dental examination to look for signs of tooth wear and a neurology examination to look for any cranial nerve abnormalities. A click, crepitus, or popping sensation which may accompany joint opening or closing may be associated with anterior disc displacement or osteoarthritis.Careful palpation of masticatory muscles and surrounding neck muscles may be associated with myalgia, trigger points, myospasm, or referred pain syndrome.The following baseline records should normally be part of the workup for patients suspected of having a TMJ disorder:
Clinical examination
Radiographic examination of teeth and TMJ
Diagnostic casts
The initial and most helpful study in diagnosing TMD is plain or panoramic radiography, which may reveal acute fractures, arthritis, or disc displacements. Further imaging studies like computed tomography (CT) or magnetic resonance imaging (MRI) are beneficial in severe, chronic, or suspected structural abnormalities of TMJ.Additionally, newer techniques of nerve blocks, botulinum toxin injections, arthrography, and mandibular motion data can prove to be of significant diagnostic benefit.
TMD的体格检查结果包括运动范围缩小、磨牙、下颌运动异常、咀嚼肌、颈部和肩部肌肉压痛、动态负荷疼痛和姿势不对称。行口腔和牙科检查以寻找牙齿磨损的迹象以及行神经学检查以寻找任何颅神经的异常都是至关重要的。伴随关节打开或关闭的咔哒声、捻发音或爆裂感可能与关节盘前移位或骨关节炎有关。仔细触诊咀嚼肌和周围颈部肌肉可能会发现与肌痛、扳机点、肌肉痉挛或牵涉痛有关的证据。
对于疑似颞下颌关节功能紊乱的患者以下基本检查是必需的：
临床检查
牙齿和颞下颌关节的射线照相检查
诊断依据
诊断颞下颌关节功能紊乱的、初步的、同时也是最有用的检查是X平片或X线曲面体层片，它可以显示急性骨折、关节炎或关节盘移位。进一步的影像学研究包括计算机断层扫描（CT）或磁共振成像（MRI），对于严重、慢性或怀疑颞下颌关节结构异常时帮助。此外，神经阻滞、肉毒毒素注射、关节造影和下颌运动数据等新技术在诊断上具有重要的价值。