关节镜上腔灌洗术治疗中老年颞下颌关节紊乱病的临床研究

目的：评价应用颞下颌关节镜上腔灌洗术治疗临床表现为张口受限合并关节区疼痛的中老年颞颌关节紊乱病患者的临床疗效。方法：对保守治疗无效的16例颞下颌关节紊乱病引起张口受限合并关节疼痛的中老年患者,行颞下颌关节镜上腔灌洗术,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）、张口度和健侧侧向运动度变化,并通过MRI检测治疗前后关节盘位置的变化。结果：治疗后张口度35mm、健侧侧向运动≥6mm的患者占87．5％（14／16）,不同时期的张口度均较治疗前有显著差异（P〈0．001）,特别在治疗后1个月内增加明显,疼痛亦有显著缓解（P〈0．001）,无并发症的发生。MRI显示,有1例患者的关节盘部分复位。结论：颞下颌关节内窥镜下的上腔灌洗术直视下操作准确,能有效治疗颞下颌关节紊乱病的患者,明显改善张口度和缓解疼痛。颞下颌关节镜治疗技术安全有效,有临床应用价值。     

Impact of prolotherapy in temporomandibular joint disorder: a quality of life assessment

Chronic pain and functional impairment associated with temporomandibular joint (TMJ) disorders (TMD) considerably reduce oral health-related quality of life (OHRQoL). In the present study we have assessed the influence of prolotherapy in patients with TMD by the subjective measurement of QoL using the Oral Health Impact Profile-14 (OHIP-14). Twenty-five patients diagnosed with TMD (mean (range) age 38 (18 – 70) years) were included. They had all undergone dextrose prolotherapy to the TMJ at regular time intervals (four times at intervals of two weeks) using the method suggested by Hemwall-Hackett. They were asked to answer the OHIP-14 questionnaire before and two years after prolotherapy. Seven domains of OHRQoL were rated on a 5-point Likert scale from 0 (never) to 4 (very often). Domain scores and total OHIP-14 scores were compared using inferential statistics (chi squared and Wilcoxon signed rank tests). Prolotherapy was effective over time, as all the domains’ mean scores decreased considerably after treatment. The total mean score before prolotherapy was 21.20, which was extensively reduced to 13.08 after prolotherapy (p=0.001). There was statistically significant improvement in all domains, including functional limitation, physical pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap (p≤0.005 in all cases). We concluded that prolotherapy has a promising role in the improvement of OHRQoL of patients with TMD, and its beneficial effects persist at least two years after treatment.     

Imaging temporomandibular disorders: Reliability of a novel MRI-based scoring system

The aim of this study was to assess the inter- and intrarater reliability of a recently proposed scoring system for temporomandibular disorders (TMD), based upon radiological findings from magnetic resonance imaging (MRI).Patients with clinically suspected uni- or bilateral TMD, and subsequently conducted MRI examination of both temporomandibular joints, were included in this study. MRI data were independently evaluated by two experienced radiologists according to the DLJ scoring system proposed by Wurm et al., which includes assessment of the following categories: articular disk (prefix ‘D’), direction of disk luxation (prefix ‘L’), and osseous joint alterations (prefix ‘J’).60 patients (49 female and 11 male) were eligible for analysis. No significant differences were found between both observers regarding ‘D’ and ‘L’ scores (p = 0.13 and p = 0.59, respectively). Significant differences were found for the assessment of subtle osseous changes (‘J0’ category: p = 0.041; ‘J1’ category: p = 0.018). Almost perfect intra- and interrater agreements were found for ‘D’ and ‘L’ categories (intrarater and interrater agreements for ‘D’: κ = 0.92 and κ = 0.84, respectively; intrarater and interrater agreements for ‘L’: κ = 0.93 and κ = 0.89, respectively). However, the assessment of ‘J’ categories revealed only moderate interrater agreement (κ = 0.49).The DLJ scoring system based upon MRI findings is feasible for routine clinical TMD assessment, and may help to simplify interdisciplinary communication between radiologists and clinicians.     

Bland-Altman法分析甲颏距离的测量的准确性

目的:观察甲颏距离(TMD)测量的准确性及男女患者之间的区别,为临床应用提供参考。方法:由具有5年以上经验的麻醉医师通过手指触摸定位的常规方法测量TMD;由另一位麻醉医师采用超声技术定位甲状软骨切迹,并测量。采用Bland-Altman法进行分析,分别计算男性患者和女性患者触摸定位法测量TMD和超声定位测量TMD的一致性系数(Cronbach α)。结果:男性患者的一致性界限(LoA)为-7.4~6.1 mm,女性患者的LoA为-22.6~14.7 mm。男性患者的Cronbach α为0.958,女性患者的Cronbach α为0.438。结论:相对于男性患者,女性触诊法测量TMD的方法其准确性不高。     

Temporomandibular joint osteoarthritis: an open label trial of 76 patients treated with arthrocentesis plus hyaluronic acid injections

This study is an open-label trial on a sample of 76 consecutive patients with temporomandibular joint (TMJ) osteoarthritis treated with a cycle of five weekly arthrocenteses plus hyaluronic acid injections. Patients had a diagnosis of osteoarthritis according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD Axis I Group IIIb). They underwent a cycle of five arthrocenteses with injections (1 per week) of 1 ml hyaluronic acid and four follow-up assessments after the end of the treatment (at 1 week, 1 month, 3 months, 6 months). At each appointment, several subjective and objective outcome variables were assessed to test the efficacy of the treatment protocol. Marked improvements were reported for all variables during the treatment phase. The improvements were maintained over the 6-month follow-up period. The p-value of the multivariate permutation test for the efficacy of the treatment over time (with Tippett's combination) was 0.001, and significant changes at the end of the follow-up period were detected for almost all the outcome variables. Data from this study lend further support to the usefulness of serial hyaluronic acid injections performed after arthrocentesis for the treatment of TMJ osteoarthritis and for the maintenance of improvements over a 6-month follow-up period.     

Structure of Ycf1p reveals the transmembrane domain TMD0 and the regulatory region of ABCC transporters

ATP binding cassette (ABC) proteins typically function in active transport of solutes across membranes. The ABC core structure is composed of two transmembrane domains (TMD1 and TMD2) and two cytosolic nucleotide binding domains (NBD1 and NBD2). Some members of the C-subfamily of ABC (ABCC) proteins, including human multidrug resistance proteins (MRPs), also possess an N-terminal transmembrane domain (TMD0) that contains five transmembrane α-helices and is connected to the ABC core by the L0 linker. While TMD0 was resolved in SUR1, the atypical ABCC protein that is part of the hetero-octameric ATP-sensitive K⁺ channel, little is known about the structure of TMD0 in monomeric ABC transporters. Here, we present the structure of yeast cadmium factor 1 protein (Ycf1p), a homolog of human MRP1, determined by electron cryo-microscopy (cryo-EM). A comparison of Ycf1p, SUR1, and a structure of MRP1 that showed TMD0 at low resolution demonstrates that TMD0 can adopt different orientations relative to the ABC core, including a ∼145° rotation between Ycf1p and SUR1. The cryo-EM map also reveals that segments of the regulatory (R) region, which links NBD1 to TMD2 and was poorly resolved in earlier ABCC structures, interacts with the L0 linker, NBD1, and TMD2. These interactions, combined with fluorescence quenching experiments of isolated NBD1 with and without the R region, suggest how posttranslational modifications of the R region modulate ABC protein activity. Mapping known mutations from MRP2 and MRP6 onto the Ycf1p structure explains how mutations involving TMD0 and the R region of these proteins lead to disease.

ATP binding cassette (ABC) proteins are a large family of membrane proteins found in all kingdoms of life (1, 2). ABC proteins have a core structure composed of two transmembrane (TM) domains (TMD1 and TMD2) and two cytosolic nucleotide binding domains (NBD1 and NBD2) (Fig. 1A and SI Appendix, Fig. S1A) (3–5). Through ATP binding and hydrolysis at the NBDs, ABC proteins actively transport solutes across cell membranes, regulate activities of other proteins, or function as channels (1, 2). Thus, ABC proteins are involved in many biological processes, including lipid homeostasis, cellular metal trafficking, and antigen peptide transport. Mutations in human ABC proteins cause diseases such as Tangier disease, adenoleukodystrophy, cystic fibrosis, Dubin–Johnson syndrome, and pseudoxanthoma elasticum (PXE) (1, 2). Furthermore, the export of a wide range of cancer chemotherapeutics, antibiotics, and anti-fungal drugs by ABC transporters confers multidrug resistance to tumor cells, bacteria, and fungal pathogens, respectively (1, 2, 6, 7).Open in a separate windowFig. 1.Ycf1p structure. (A) Ycf1p domain arrangement. TMD, transmembrane domain; L0, L0 linker; NBD, nucleotide binding domain; and R, regulatory (R) region. The Pep4p proteolytic digestion site within the luminal loop 6 of TMD1 is denoted by a pink “*.” Phosphorylation sites in the L0 linker (S251) and R region (S908 and T911) are depicted with a “P” circled in red. (B) Cryo-EM density of Ycf1p with domains colored as in A. (C) Example of the atomic model for individual TM helices in TMD0 and the R region fit into the corresponding map densities. (D) Schematic ribbon diagram of Ycf1p colored as in A and B and with the proteolytic digestion site denoted by a pink “*.”Human ABC proteins are divided into seven subfamilies (A to G) based in part on the sequence of their NBDs and TMDs in the core ABC structure (1, 2). The C-subfamily is the most diverse and includes the cystic fibrosis transmembrane conductance regulator (CFTR), the sulphonylurea receptors that form regulatory subunits in ATP-sensitive K⁺ (K_ATP) channels, and the multidrug resistance proteins (MRPs). In addition to the ABC core, ABCC proteins contain an N-terminal extension that is either composed of an additional TM domain (TMD0) and L0 linker (Fig. 1A, orange and tan, respectively, and SI Appendix, Fig. S1A) or just an L0 tail (5, 8). A TMD0, but not L0 linker, is also found in some ABCB proteins (3, 5). These N-terminal extensions are involved in trafficking, endosomal recycling, protein interactions, and/or regulation of ABC activity (9–18). The existence of disease-causing mutations in TMD0 and the L0 linker of different ABCC proteins (8, 13, 18) indicates that these regions play important roles in protein function when present.High-resolution structural information for TMD0 is available only for the atypical ABCC protein SUR1 (19, 20), which is part of the large hetero-octameric K_ATP channel complex. In contrast, structures of monomeric ABC transporters showed only low-resolution density for TMD0 that was insufficient for building a full atomic model or lacked density for the domain altogether (14, 21–24). The vacuolar ABCC protein yeast cadmium factor 1 (Ycf1p) from Saccharomyces cerevisiae is a close homolog of human MRPs and a model for ABCC proteins that function as monomers. Ycf1p transports glutathione-conjugated heavy metals, such as Cd²⁺, from the cytosol into the vacuole, detoxifying the cell (25, 26). Human MRP1 can rescue Cd²⁺ transport activity in a YCF1 deletion strain (27).Like other ABCC proteins, Ycf1p contains a relatively long and mostly disordered linker that connects NBD1 and TMD2 (25, 28, 29) (Fig. 1A and SI Appendix, Fig. S1A). This linker contains stimulatory phosphorylation sites (25, 28), similar to the phospho-regulatory (R) region in the ABCC protein CFTR (30–32). Ycf1p also contains an inhibitory phosphorylation site in the L0 linker (33). However, how the R region interacts with the ABCC core and how its phosphorylation modulates protein function remain poorly understood for most ABCC proteins. Structural studies of Ycf1p presented here reveal how TMD0 and the R region exert their regulatory functions in MRP-like ABCC proteins.     

应用宝石能谱 CT 评估 TMD 患者的髁突位置

目的：通过应用宝石能谱CT对比分析颞下颌关节紊乱病（ temporomandibulardisorders,TMD）组和正常组的髁突位置。方法：通过参考颞下颌关节紊乱的研究诊断标准（ RDC／TMD）随机选择TMD患者与颞下颌关节正常的对照组病例各30名,均为放射科能谱CT检查的患者。通过在矢状位确定标志点后测量2组病例颞下颌关节关节窝上、前、后间隙的距离,以及关节结节倾角角度。结果：正常组和TMD组关节前间隙分别为2．44±0．49 mm和2．96±0．68 mm,两组之间关节前间隙的距离是对比差异具有统计学意义（P＜0．05）。结论：能谱CT为一种可有效诊断TMD的实用影像学方法。     

Orthognathic treatment of dentofacial disharmonies: its impact on temporomandibular disorders,quality of life,and psychosocial wellness

Aim: The objective of this literature review was to assess the effect of orthognathic surgical treatment on temporomandibular disorders (TMD), quality of life (QoL), and psychosocial wellness.

Methods: Journal articles and systematic reviews published in English between 1982 and 2015 were searched using PubMed, MEDLINE, and Cochrane database using the search terms “orthognathic,” “temporomandibular disorders,” “quality of life,” and “psychosocial.” The articles were then reviewed and discussed.

Results: Both objective and subjective parameters play a role in orthognathic treatment outcome satisfaction and QoL. Psychological factors and TMD exerted a stronger influence on patients’ QoL more than objective treatment outcome measures.

Conclusion: A paradigm shift in clinical mindset from solely objective measures to a more holistic, patient-centric approach of addressing patients’ expectations and improving QoL is warranted when treating patients with dentofacial disharmonies.     

The clinical management of awake bruxism

Background

Awake bruxism is a common clinical condition that often goes undetected, often leading to pain or damaged teeth and restorations.

Age,gender and parafunctional habits as prognostic factors for temporomandibular joint arthrocentesis

Objective: Arthrocentesis is an effective procedure for management of symptomatic patients with temporomandibular joint (TMJ) anterior disc displacement without reduction (ADDWOR), but its prognostic factors are still under investigation.

Methods: Thirty-six patients with ADDWOR underwent arthrocentesis of the TMJ and hyaluronic acid injection. They were divided into groups based on three prognostic factors: Age, gender, and the presence of parafunctional habits. The procedure outcome (success or failure) was based on pre-set criteria for improvement in pain and maximum mouth opening (MMO) one month preoperatively.

Results: Patients with parafunctional habits had a lower success rate than patients without these habits. Interesting trends were noted with age and gender as prognostic factors for arthrocentesis for patients with ADDWOR.

Conclusion: Arthrocentesis is an effective management method for symptomatic patients with ADDWOR at one-month post treatment, especially in the absence of parafunctional habits.