Temporomandibular disorders. 1. Clinical evaluation

The treatment of temporomandibular disorders continues to provide dental practitioners with a difficult challenge that has yet to overcome numerous major obstacles. In this, the first of a series of three articles, an overview of the current understanding of the diagnosis of temporomandibular disorders will be presented. The subsequent two articles will present an overview of the management strategies that have appeared in the literature in recent years.     

种植体周围炎的非手术治疗方法

随着口腔材料和相关技术的不断发展,种植已成为缺失牙的修复方案之一。种植体周围炎作为种植修复后的常见并发症之一,发生因素较为复杂,治疗手段也较为多样化。常用治疗方法主要包括机械治疗、激光治疗、抗生素的应用、化学药物治疗及手术治疗。该文主要利用文献检索并描述种植体周围炎的非手术治疗方法。     

Non-surgical periodontal treatment: where are the limits?

In the present scanning electron microscopic study, the possibilities and limitations of non-surgical root planing were investigated. 10 single-rooted teeth from 4 patients with advanced periodontitis were studied. The root surfaces were cleaned and planed without flap reflection, using fine curettes. The teeth were then extracted and the root surfaces were systematically examined by scanning electron microscopy (SEM) for the presence of residual bacteria and calculus. 29 of 40 curetted root surfaces were free of residues, if they were reached by the curette. On the remaining 11 surfaces, only small amounts of plaque and minute islands of calculus were detected, primarily at the line angles and also in grooves and depressions in the root surfaces. Instrumentation to the base of the pocket was not achieved completely on 75% of the treated root surfaces, however. The primary reason for this was the extremely tortous pocket morphology on the teeth selected for study. In conclusion, it may be stated that during non-surgical root planing in cases of advanced periodontitis, surfaces that can be reached by curettes are usually free of plaque and calculus. However, in many cases the base of the pocket will not be reached. It is for this reason that deep periodontal pockets should be treated with direct vision, i.e., after the reflection of conservative flaps.     

Temporomandibular disorders. Part 3. Surgical treatment

Surgery of the temporomandibular joint has a small but nonetheless important role in the overall management of temporomandibular disorders. Appropriate case selection is the mandatory requirement for successful surgical intervention in order to achieve the desired outcome of treatment, such as relief of symptoms and improved function. In this, the third article in the series, a general overview of the current surgical treatment modalities for temporomandibular disorders will be presented.     

Temporomandibular disorders: the past,present, and future

This article traces the history of the development of the current diagnostic and therapeutic approaches to the management of temporomandibular disorders, with emphasis on the mistakes or misconceptions that occurred during their development and the lessons that can be learned from these errors. It also makes recommendations for future areas of investigation, and methods for facilitating such studies, in order to improve the future treatment of these patients. Based on a lecture entitled “Temporomandibular Disorders: The Past, Present and Future” presented at the 1st International and 19th Annual Meeting of the Japanese Society of the Temporomandibular Joint, Nagoya, Japan, July 19, 2006.     

Temporomandibular disorders and mandibular vertical asymmetry

Objective To analyze the association between mandibular vertical asymmetry and the presence of TMD in adult patients.

Methods This case-control study recruited patients from the orthodontic clinic at FEBUAP. Patients were classified on the basis of diagnostic criteria for temporomandibular disorders (DC/TMD). Panoramic radiographs were measured to determine mandibular vertical asymmetry indices according to criteria described by Kjellberg and Habets. Both methods (DC/TMD and index criteria) were standardized a priori.

Results A total of 56 patients were analyzed, of whom 25 (44.6%) met the inclusion criteria and were divided into two groups (TMD group, n = 15; non-TMD group, n = 10). The highest asymmetry index was observed in the condylar neck, followed by the total condylar asymmetry index, but without significant differences between groups (p > .05).

Conclusion There is no association (p > .05) between temporomandibular disorders and mandibular vertical asymmetry.     

红外偏振光治疗各类颞下颌关节紊乱病的疗效分析

目的:探讨红外偏振光对不同类型颞下颌关节紊乱病的临床疗效,为临床正确选择这种理疗技术的适应证提供依据。方法:对426例颞下颌关节紊乱病患者(657侧关节)进行了红外偏振光理疗。结果:发现红外偏振光理疗对各类型颞下颌关节紊乱病引起的关节或肌肉区的疼痛症状有明显的疗效;对咀嚼肌紊乱疾病类引起的肌肉区疼痛的疗效(94%)高于对有关节结构紊乱疾病类引起的关节疼痛症状为主的疗效(72%);对非绞锁关节张口度的改善具有良好的疗效;经治疗后,在疼痛明显减轻的同时,关节弹响的发生率反而提高;对关节结构紊乱疾病类引起的下颌绞锁运动没有显著疗效,绞锁关节张口度在治疗前后没有显著性差异;近期观察关节内骨关节病类改变没有明显差异。结论:红外偏振光理疗对各类型颞下颌关节紊乱病引起的关节或肌肉区的疼痛症状有良好的疗效,并可以改善张口度。对可能由关节结构紊乱引起的弹响及下颌绞锁运动没有明显疗效,在有下颌绞锁运动的情况下,对张口度的改善亦不明显,对关节内骨关节病类改变没有明显近期疗效。     

正畸治疗与颞下颌关节症状的相关研究

目的：探讨正畸治疗和颞下颌关节紊乱病（TMD）的关系。方法：设计正畸组、错[牙合]组和正常组的调查表,用Visual Foxpro6．0建立相应的数据库,对173例已正畸治疗者、95例有错[牙合]畸形但未治疗者和32例正常对照进行TMD症状、体征及相关情况的问卷调查和专科检查,所得结果用基于Helkimo指数改良设计的数据库进行分析,采用SPSS10．0软件包进行成组设计两样本比较的秩和检验。结果：正畸组和错[牙合]组在主诉症状指数、临床症状指数和咬合指数的分布上存在显著差异（P〈0．001）;正畸组和正常组在主诉症状指数和临床症状指数的分布上有显著差异（P〈0．001）,但在咬合指数的分布上无显著性差异（P〉0．05）。结论：正畸治疗后患者在一定时期内易出现颞下颌关节紊乱病的症状和体征。     

Dental treatment as perceived etiology of temporomandibular disorders

ABSTRACT

Objective: To characterize patients who believe their temporomandibular disorders (TMD) symptoms are caused by their prior dental treatment.

Methods: A sample of 337 patients were selected and classified into dental treatment-related and non-dental treatment-related groups, according to their personal belief of their TMD etiology. The relationship between patients’ perceived etiology and patient characterization was analyzed using Chi-square and t-test.

Results: One-hundred and thirty-one patients perceived that the cause of their TMD was dental-related. Within this group, 27.5% of the 131 patients considered that their TMD was specifically caused by prior dental treatment. These patients possessed significantly greater disability (self-reported work disability, family interference, and higher level of depression) compared to the patients who did not believe their TMD was caused by dental treatment.

Conclusion: Dentists should recognize that their dental treatments could possibly be the cause of patients’ TMD symptoms, according to patients’ beliefs.     

颞下颌关节紊乱病伴内倾性深覆正畸治疗前后相关指数分析

目的研究伴有内倾性深覆的颞下颌关节紊乱病患者正畸治疗前后症状的变化,探讨内倾性深覆与颞下颌关节紊乱病的相关性。方法伴内倾性深覆的颞下颌关节紊乱病患者40例,定量计算每例患者正畸治疗前后的Fricton颞下颌关节紊乱指数（craniomandibular index,CMI）,比较其治疗前后的变化。结果伴内倾性深覆的颞下颌关节紊乱病患者经正畸治疗后,内倾性深覆均得到解除,恢复良好的外形及咬合关系,临床症状均得到改善,治疗后2年时评价发现,颞下颌关节功能障碍指数、肌肉压痛指数和CMI分别由治疗前的0.321±0.091、0.020±0.015、0.171±0.053下降为0.062±0.021、0.003±0.004、0.033±0.012,差异均有统计学意义。结论伴内倾性深覆的颞下颌关节紊乱病患者经正畸治疗解除内倾性深覆后,颞下颌关节紊乱症状可明显改善,内倾性深覆与颞下颌关节紊乱病关系较为密切。     

Temporomandibular disorders among Brazilian adolescents: reliability and validity of a screening questionnaire

Temporomandibular disorders (TMD) screeners assume significant item overlap with the screening questionnaire proposed by the American Academy of Orofacial Pain (AAOP).

Objective

To test the reliability and validity of the Portuguese version of AAOP questions for TMD screening among adolescents.

Material and Methods

Diagnoses from Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD) Axis I were used as reference standard. Reliability was evaluated by internal consistency (KR-20) and inter-item correlation. Validity was tested by sensitivity, specificity, predictive values, accuracy and receiver operating characteristic (ROC) curves, the relationship between the true-positive rate (sensitivity) and the false-positive rate (specificity). Test-retest reliability of AAOP questions and intra-examiner reproducibility of RDC/TMD Axis I were tested with kappa statistics.

Results

The sample consisted of 1307 Brazilian adolescents (56.8% girls; n=742), with mean age of 12.72 years (12.69 F/12.75 M). According to RDC/TMD, 397 [30.4% (32.7% F/27.3% M)] of adolescents presented TMD, of which 330 [25.2% (27.6% F/22.2% M)] were painful TMD. Because of low consistency, items #8 and #10 of the AAOP questionnaire were excluded. Remaining items (of the long questionnaire version) showed good consistency and validity for three positive responses or more. After logistic regression, items #4, #6, #7 and #9 also showed satisfactory consistency and validity for two or more positive responses (short questionnaire version). Both versions demonstrated excellent specificity (about 90%), but higher sensitivity for detecting painful TMD (78.2%). Better reproducibility was obtained for the short version (k=0.840).

Conclusions

The Portuguese version of AAOP questions showed both good reliability and validity for the screening of TMD among adolescents, especially painful TMD, according to RDC/TMD.     

����ؽ����Ҳ�ҧ�ϰ�����

颞下颌关节紊乱病(TMD)的保守治疗方法很多,本文重点介绍了目前临床上常用的有关TMD保守治疗的咬合板的类型、作用和适应证。咬合板治疗是临床治疗TMD的首选疗法,但目前缺乏设计完善的临床试验以证实其疗效。建议推行临床试验透明化,实施临床试验注册制度和高质量的随机对照试验(RCT),以便于总结咬合板治疗TMD的临床证据,提高TMD临床治疗水平。     

错矫治治疗颞下颌关节紊乱病临床疗效分析

目的 分析并评价矫治错(牙合)同时治疗颞下颌关节紊乱病(TMD)的临床效果。方法 采用直丝弓技术矫治各种错(牙合)畸形伴TMD患者42例,详细记录治疗前、治疗6个月、治疗结束、治疗结束后2年的牙(牙合)情况及TMD症状、体征变化、颞下颌关节(TMJ)X线片情况。结果 30例患者TMD症状及体征基本痊愈,占71.4％;好转7例,占16.7％;无效或加重5例,占11.9％。结论 错(牙合)畸形伴TMD的年轻患者经正畸矫治可以恢复咬合或作(牙合)重建,建立(牙合)平衡,使颞下颌关节、下颌回复到正常解剖位置。但已经发生器质性损害或TMJ解剖结构不对称的患者,治疗效果有待于进一步观察。     

偏侧咀嚼对大鼠颞下颌关节滑膜影响的研究

目的：研究偏侧咀嚼对大鼠颞下颌关节滑膜的影响。方法：30只大白鼠随机分为6组,实验组间断磨除右上、下颌磨牙牙冠至龈下,对照组末做处理,饲养条件相同。实验1组磨除牙冠后4周末、实验2、3组磨除牙冠后10、16周末处死动物,取其双侧TMJ进行光镜切片检查,结果与对照组对照。结果：实验1、2、3组双侧颞下颌关节滑膜均出现受损的病理变化。结论：偏侧咀嚼可引起颞下颌关节滑膜损伤,是颞下颌关节紊乱病的病因之一。     

颞下颌关节紊乱病磁共振诊断的研究

目的:研究MRI对颞下颌紊乱病诊断的准确性和可信性.方法:利用MRI对19例单侧关节疼痛颞下颌关节紊乱病(TMD)患者38侧关节完成开闭口斜矢状位T1和T2加权成像,观察盘突关系、盘形态改变及关节腔内积液情况.利用关节镜诊断为金标准判定MRI诊断的准确率.同期行灌洗术治疗,分析治疗前后不同时期患者的疼痛值(疼痛直观模拟标尺VAS)变化.结果:MRI检查结果显示在患侧89.47%(17/19)显示不可复性关节盘移位,10.53%(2/19)显示可复性关节盘移位,47.37%(9/19)关节上腔前隐窝出现积液.在健侧15.79%(3/19)显示可复性关节盘移位,无不可复性关节盘移位和腔内积液出现.通过关节镜手术对患侧进行检查,关节盘移位在MRI片上均得到证实,MRI检查的准确率为100%,灌洗术后疼痛100%有显著缓解(P<0.001).结论:颞下颌关节紊乱病与关节盘移位和腔内积液密切相关,通过MRI检查可以准确有效的对颞下颌紊乱病进行诊断,灌洗术对关节疼痛治疗效果显著.     

Non-surgical periodontal treatment of cyclosporin A-induced gingival overgrowth: immunohistochemical results

Aim:  The present study was planned to analyze the effects of a 12-month non-surgical periodontal treatment on histologic and immunohistochemical features of cyclosporin A (CsA)-induced gingival overgrowth (GO).
Materials and methods:  Gingival samples were collected from 21 liver transplant subjects exhibiting CsA-induced GO prior to, and 12 months after non-surgical periodontal therapy including oral hygiene instructions, scaling and 2-month recall appointments, and also from 18 healthy control subjects. Gingival biopsy specimens were stained with hematoxylin–eosin and monoclonal antibodies for vimentin, CD3 (T-lymphocytes), CD20 (B-lymphocytes), CD34 (endothelium) and Ki-67 (fibroblasts proliferation rate), using a streptavidin-biotin-peroxidase complex method.
Results:  Total inflammatory cells, gingival vessels and fibroblast proliferation rate demonstrated significant reduction after non-surgical periodontal treatment ( P  < 0.0001) in overgrown gingiva, while B- and T-lymphocytes remained nearly unchanged ( P  = 0.61 and 0.33, respectively). At the 12-month evaluation no significant differences were found when comparing the gingival biopsies from CsA-treated patients and those from healthy controls ( P  > 0.05).
Conclusions:  Control of clinical inflammation by means of non-surgical periodontal treatment results both in lowering of inflammatory infiltrate and in changes in connective tissue composition. Thus, plaque-induced inflammation would seem to modulate the drug-gingival tissue interaction.
Clinical relevance:  A strict plaque control program play a pivotal role in the management of transplant patients exhibiting cyclosporin A-GO.     

利用Florida探针评价牙周炎非手术治疗的疗效

目的利用Florida探针评价牙周炎的非手术治疗的疗效。方法选择100例牙周炎患者为研究对象,进行牙周非手术治疗,采用Florida探针检测患者在治疗前和治疗结束后1个月时的探诊深度（PD）和附着丧失（AL）。检测位点为患者所有天然牙的近中颊、颊正中、远中颊和舌正中4个位点。将全口牙分成前牙组、前磨牙组、后牙组和所有牙组4组,比较4组间、4个位点间以及PD<5 mm和PD≥5 mm的位点间治疗前后PD和AL的变化。结果前牙组、前磨牙组、后牙组和所有牙组治疗后PD和AL与治疗前相比均有明显改善（P<0.05）,PD明显下降,且有牙周附着再获得;其中前牙的改善较磨牙和前磨牙更明显。PD<5mm和PD≥5mm的牙周位点间PD的恢复有统计学差异（P<0.05）,治疗后明显好转;而AL在治疗前后无统计学差异（P>0.05）。4个位点间改善程度的比较无统计学差异（P>0.05）。结论Florida探针能够较准确、客观地评价牙周状况。牙周非手术治疗对牙周炎具有良好的治疗效果,前牙疗效更为明显,同一牙齿不同位点的疗效基本一致。