面部疼痛的鉴别诊断和治疗指南（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Zakrzewska JM. Differential diagnosis of facial pain and guidelines for management. Br J Anaesth. 2013;111(1):95-104.本次学习由杨聪娴副主任医师主讲。

Dworkin and colleagues published the Research Diagnostic Criteria1 for TMD in 1992 suggesting a dual axis approach, taking into account psychological factors. It has been used as a basis for research internationally. However,it is too complex for routine clinical use and has been modi-fified by others and updated (to be published in late 2013) by an international panel in order to be more clinically useful. Patients can have more than one diagnosis (e.g. muscle painwith or without disc displacement and limitation in opening).

德沃金和他的团队于1992年发表了TMD的诊断研究标准，建议采用双轴方法，将心理因素纳入，它可以被用作国际研究的基础。但是它太复杂，不适合常规临床使用，为了在临床上更有用，已被修改和更新(在2013年底出版)。一个患者可能有不止一种诊断(例如肌肉疼痛伴或不伴椎间盘位移和张口受限)。

The commonest form is an acute onset pain often relatedto prolonged opening (e.g. dental treatment or trauma).Management is reassurance, soft diet, and analgesics.Muscle pain is the commonest cause and often involves both the muscles of mastication and the neck. It is important to take a comprehensive history to elicit yellow flflags as they often result in chronicity.

最常见的形式是常与急性发作的疼痛有关延长开口(如牙科治疗或外伤)。管理就是安慰、软食和止痛剂。肌肉疼痛是最常见的原因咀嚼肌和颈部肌肉。详尽的询问病史有助于发现容易导致慢性化的伴发疾病。

The features of the masticatory form of TMD are given inTable 1. To make the diagnosis, it is crucial to appreciate that palpation needs to induce the same pain reported by the patient. Intra articular disc problems, with or without displacement, result in clicking and, if the disc does not reduce,intermittent locking. Limited opening is defifined as ,<40 mmmaximum with assisted opening (distance between the anterior incisors). Degenerative disorders present with marked crepitus (reported by the patient and detected on palpation)and are often not associated with pain. Subluxation problemsare mainly found in patients with hypermobility and areassociated with deviation of the jaws on opening. Imagingis not required for masticatory problems but can be usefulin joint disorders to confifirm the clinical fifindings; however,its use is controversial.

表1给出了咀嚼肌型的TMD的特点。要做出诊断，重要的是通过触诊复制病人的疼痛。关节内椎间盘问题，伴或不伴移位，将导致弹响，如果问题不能有效缓解，会间断发生绞索。张口受限定义为，张口至最大程度时，前切牙之间的距离小于40毫米。退行性疾病表现为明显的捻发音(由患者陈述并在触诊时发现)，通常与疼痛无关。半脱位的问题主要是在活动过度的患者中发现的，与开口时下颌部的位移有关。咀嚼肌问题时，影像学检查不是必须的，但可以发现关节功能紊乱，用以验证临床发现;然而,影像学检查是有争议的。

The aims of management are to decrease pain and functional limitation and improve quality of life. This is done through a wide range of therapies but overall selfmanagement through education needs to be encouragedas improved self-effificacy leads to fewer symptoms. Therapies range from diet, splint, physiotherapy, drugs, psychological,and surgical.

治疗的目的是减少疼痛和功能受限和提高生活质量。这样做是通过教育，鼓励广泛的治疗和全面的自我管理，因为自我效能的提高会导致症状减轻。治疗方法包括饮食、夹板、理疗、药物、心理和手术。

RCTs and systematic reviews of treatments have been published. Many studies suffer from signifificant bias,but more recent RCTs are of higher quality. The primary outcome measures in most of the studies were pain; quality of life, daily activities, and psychological statuswere rarely reported even though there is good evidencethat oral health related quality of life is impaired by TMD.

目前已有了随机对照试验和系统治疗综述。许多研究存在明显的偏倚，但近期的随机对照试验质量明显提高。大多数研究的主要结果指标是疼痛;即使有证据表面，TMD导致口腔相关的生活质量降低，生活质量、日常活动和心理状态也很少有报道。

The most common form of therapy, carried out by dentists, is the use of a variety of intraoral appliances, mainlyworn at night. There may be some effificacy for the hardfull coverage stabilization splints whereas others, which do not take into account occlusion, are prone to cause signififi-cant adverse events if misused (e.g. movement of teethand malocclusion). A recent RCT suggests that, in thelonger term, education may be more benefificial than splints. Acupuncture is of limited long-term benefifit and there is insuffificient evidence to support the use of low level laser therapy.There is currently some evidencefor the effectiveness of cognitive behaviour therapy (CBT)and physiotherapy.

最常见的治疗方式是由口腔科医生使用各种矫形器具，夜间穿戴。坚硬的全覆盖夹板可能对一些病人有效，而对另一些患者，因为没有考虑咬合的因素，会因使用不当而造成不良后果(例如牙齿移动和咬合不正)。最近的一项随机对照试验表明，在从长远来看，患者教育可能比夹板更有效。针灸的长期益处有限，低剂量激光治疗的证据有限。目前有研究证实认知行为疗法(CBT)和理疗的有效性。

A Cochrane systematic review found 11 poor-quality studies on pharmacological therapy and there is inconclusive evidence for analgesics, benzodiazepines, anticonvulsants,and other miscellaneous drugs. An open-label study of amitriptyline showed some benefifit whereas no benefifitwas noted in an RCT of Botulinum Toxin.

Cochrane系统评估发现有11个质量较差的药物治疗的研究，镇痛药、苯二氮卓类、抗惊厥药和其他药物的用药证据不足。一项开放性研究证实阿米替林有一定作用，而一项随机对照研究发现肉毒杆菌毒素无效。

If there is a functional element (e.g. crepitus, limitation inmovement), surgical therapies may be useful. The least invasive is arthrocentesis, a form of lavage performed under local anaesthesia but results are not maintained. Arthroscopy is a more invasive procedure performed under general anaesthesia and allows more exploration. It can be taken astage further to perform open surgery on the joint; this may increase functionality but relapses are common.A proposed management pathway for TMD is summarizedin Table 1.

如果有一个功能方面的因素(例如捻发音，限制运动)，手术治疗可能有用。创伤最小的是关节穿刺术，即在局麻下进行灌洗，但效果不持久。全麻下关节镜手术创伤较穿刺增加，但可以进行探查。进一步的治疗还可以进行关节开放手术，可能会改善功能，但复发是常见的。表1总结了TMD的治疗流程。