RU2394497C1 - Method of estimated clinical, functional, morphological disorders in temporomandibular joint dysfunction and effectiveness monitoring of therapeutic process - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgical and orthopaedic dentistry, orthodontics and maxillofacial surgery. Substance of the method consists that prior to initiation of treatment, an individual abnormality coefficient (K_iac) is calculated by formula: K_iac=PS+IE+FD+MC; where, PS is a score of pain syndrome; IE is a score of inflammatory events; FD is a score of functional disorders; MC is a score of morphological changes. A formalised estimate of each parametre is based on a four point scale: no changes or disorders manifested - 0 points, mild changes or disorders observed - 1 point, moderately expressed changes or disorders observed - 2 points, full-blown changes or disorders observed - 3 points. In process of treatment, an individual dynamic factor K_idf is calculated by formula: K_idf=(C_n-1-C_n)/C_n-1, with frequency rate in 5, 10, 15 days from the date of the initial visit, where C_n is a score calculated by formula K_iac in current patient examination, C_n-1 is score calculated by the same formula in previous patient examination. If after repeated examination, K_idf is zero or more or after two successive measurements, it is -0.2 or more, upward change of treatment tactics is recommended.

EFFECT: use of the given invention allows for differentiated estimation of a state of the temporomandibular joint in dysfunction prior to treatment.

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Description

The invention relates to medicine, namely to surgical and orthopedic dentistry, orthodontics and maxillofacial surgery. The method can be used in practical work for an objective and comprehensive operational assessment of the dynamic parameters of the clinical, functional and morphological state of the temporomandibular joint (TMJ).

A known method for the differential diagnosis of TMJ diseases (application 2006144506 RU from 2006.12.13), in which sound signals are studied in the range from 30 to 5000 Hz, when detecting mainly in the range 1 from 30 to 300 Hz, joint arthrosis is diagnosed, with a range of 2 from 30 to 600 Hz - arthritis, with a range of 330-5000 Hz - dysfunction of the temporomandibular joint.

A known method for determining pathological changes in the TMJ (US Pat. No. 2198599 RU from 2003.02.20), where they use the diagnostic capabilities of detecting changes in the spatial and topographic orientation of the articular heads of the lower jaw during computed or magnetic resonance imaging. Determining the degree of lateral pterygoid muscle hypertrophy by 0.3 or more cm, the initial manifestations of TMJ arthrosis are determined (I-II art.).

There is a known method for visualizing the TMJ (Pat No. 2269932 RU from 2006.02.20), in which an ultrasound scan of the TMJ is performed, which allows you to visualize the trajectory of the TMJ in real time, and also eliminates the radiation load on the patient and the medical staff.

Known methods for assessing the functional state of TMJ (Pat. No. 2102927 RU, patent application No. 2006120330; No. 2005102318 RU), which use only one of the possible methods of monitoring the condition of the joint: either reography in the field of chewing teeth of both jaws with a diagnosis of inflammation to reduce tone periodontal vessels, or the functional state of the masticatory muscles and the asymmetry of the linear velocity of blood flow in the maxillary artery on the right and left sides, at least 30% are diagnosed with TMJ dysfunction, or palpation in projection B ES and in the presence of severe pain of acute, while slowly increasing mouth opening, TMJ diagnosed disease and the lack of pain is the test end of treatment.

A known method for the diagnosis and effectiveness of treatment of TMJ by examining the pain threshold with a strain gauge at certain points in the skull. Manual therapy is then carried out, the measurement results are compared before and after it, and the effectiveness of manual therapy in the treatment of TMJ dysfunction is determined by increasing the pain threshold.

A known method for diagnosing pathology of TMJ (US Pat. No. 2168934 RU from 2001.06.20), which consists in using the projection of paired points of symmetry of the skin of the face on the joint area relative to the vertical line of symmetry of the face and measuring the bioelectromagnetic reactivity indices. The joints are subjected to a functional load, a second measurement of bioelectromagnetic reactivity indices is carried out, the coefficient of the functional state of the joints is calculated according to the results of the measurements by the formula K = (1-V1 / V2) × 100%, for V1 less than V2, or K = (1-V2 / V1 ) × 100%, for VI, greater than V2, where K is the value of the coefficient of the functional state of the joints, expressed as a percentage; V1 = Z1 * / Z1, V2 = Z2 * / Z2, where Z1, Z2 is the arithmetic mean of the bioelectromagnetic reactivity indices measured at the pair of symmetry points on the left and right sides of the face to the functional load of the joints, and Z1 *, Z2 * - after the functional load, respectively, then the functional state of the joints is assessed by the value of the K value, while for the values of K from more than 15 to 30% the functional state of the joints is assessed as compensated, and for the values of K from 0 to 15% and more than 30% the functional state of the joints is evaluated like a subcom retired.

The disadvantage of this method: the authors used to assess the condition of the joints only one objective indicator - the bioelectromagnetic reactivity index, which cannot fully and objectively reflect such a complex condition as joint inflammation and morphological state.

An analysis of the above methods for diagnosing and evaluating the effectiveness of TMJ treatment allows the following conclusions.

Diagnostic methods currently known do not allow a comprehensive and objective assessment of the clinical, functional and morphological state of the TMJ according to the main parameters: pain, inflammation, functional disorders, morphological changes; do not allow to distinguish groups of patients for differentiated treatment with an assessment of its effectiveness; do not allow monitoring by a set of parameters characterizing the effectiveness of treatment of inflammation of the TMJ. Known methods are focused on determining pathological changes in TMJ according to one criterion, which cannot objectively characterize clinical, functional and morphological disorders (CFM) of TMJ.

The purpose of the invention is the development of a method for differentiated and individualized assessment of the condition of the temporomandibular joint based on a combination of clinical data, functional disorders and morphological changes and the possibility of monitoring the effectiveness of the treatment process.

Achieving the technical result involves the step-by-step implementation of research and clinical work.

First of all, a scale was developed and cluster groups were formed according to the criteria of the main parameters for assessing clinical, functional, morphological disorders (MPSF) with TMJ dysfunction.

In particular, evaluated (table 1):

clinical manifestations in the form of a pain syndrome based on the patient's sensations;

inflammatory phenomena on the basis of clinical, instrumental and laboratory methods;

functional disorders based on instrumental, clinical methods;

morphological changes based on instrumental, radiation research methods.

Each parameter is formally evaluated on the basis of a four-point scale: there are no manifestations of either changes or violations - 0 points; slightly expressed - 1 point; moderately expressed - 2 points; significantly expressed - 3 points.

To systematize and streamline the clinical characteristics of conditions designated as slightly, moderately, or significantly pronounced manifestations, criteria have been developed for evaluating and assigning the degree of CMF to the corresponding group for TMJ dysfunction (Table 2).

table 2 Criteria for a formalized assessment of the degree of clinical, functional and morphological disorders in TMJ dysfunction Formalized criteria for registration in points Slightly expressed Moderately expressed Significant 1 point 2 points 3 points Pain syndrome (anamnestic data, complaints) No spontaneous pain Recurrent spontaneous pain Constant spontaneous pain Low intensity with movements of the lower jaw Moderately pronounced intensity during movements of the lower jaw Significantly expressed intensity during movements of the lower jaw Short time (several minutes) By time up to several hours a day By time - constantly Pain syndrome (clinical examination) Pain on palpation of the muscles in the following anatomical areas (chewing muscle, temporal, tendon of the temporal muscle, sublingual, stylohyoid, lateral pterygoid) in two areas with pain intensity 1 on a three-point scale Pain on palpation of the muscles in the following anatomical areas (chewing muscle, temporal, tendon of the temporal muscle, sublingual, stylohyoid, lateral pterygoid) in two areas, with pain intensity 2 on a three-point scale Pain on palpation of the muscles in the following anatomical areas (chewing muscle, temporal, tendon of the temporal muscle, sublingual, stylohyoid, lateral pterygoid) in two areas with pain intensity 3 on a three-point scale Pain on palpation of the joint area from the outside or behind is extremely slight (on the one hand). Pain on palpation of the joint on both sides (through the external auditory canal) is moderate Pain on palpation of the joint from two sides (through the external auditory meatus) is significantly pronounced Pain during movements in the joint in one direction (when opening the mouth, moving the jaw to the side or forward) is insignificant. Pain in two directions of movement (when opening the mouth, moving the jaw to the side or forward) is moderate. Pain with two or more movements (when opening the mouth, moving the jaw to the side or forward) is significantly pronounced. Inflammation Soft tissue swelling in the joint area is absent Slight swelling of the soft tissues in the joint area Severe soft tissue swelling in the joint The skin is not changed Slight hyperemia of the skin in the joint Hyperemia of the skin in the joint Endaural palpation is slightly painful. Endaural palpation is moderately painful. Endaural palpation is significantly painful Functional impairment Single clicks when opening Reciprocal clicks (when opening and closing), clicks with lateral and protrusive movements Reciprocal clicks, clicks during lateral and protrusive movements (a history of periods of clicks with their disappearance and a sudden sharp restriction on opening the mouth) Mouth opening over 40 mm, lateral and anterior movements 4-6 mm Mouth opening greater than 30 mm, lateral and anterior movements 4-6 mm Self-opening mouth less than 30 mm Opening and closing the mouth in the midline (deviation up to 2 mm is permissible) Displacement of the lower jaw to the side when opening more than 2 mm Displacement of the lower jaw to the side when opening more than 2 mm

Table 2 (continued) Slightly expressed Moderately expressed Significant 1 point 2 points 3 points Functional Disorders (continued) Opening the mouth with the help of a doctor exceeds the amount of independent opening by a value of 4 mm or more The presence of articular noise during palpation examination There are periods of sudden restriction of mobility (in particular, in the mornings, fast-passing) Opening a mouth with a doctor’s aid exceeds self-opening by less than 3 mm The presence of parafunctions (bruxism) Morphological changes There is no deformation of the head and articular fossa No deformation of the head and articular fossa Foci of osteosclerosis and bone marrow edema of the articular head, smoothness of the articular tubercle are noted No cartilage damage Thinning of articular cartilage noted Articular cartilage thinning Displacement of the anterior anterior degree I Displacement of the disk anterior to I or II degree Displacement of the anterior anterior degree II (complete dislocation of the disk from the joint space with the loss of contact of the posterior pole with the head) Self-repositioning of the disc during opening / protrusion movement Self-repositioning of the disc during opening / protrusion movement Self-repositioning of the disc during opening / protrusion movement does not occur No signs of disk damage Signs of damage to the disc (flattening, sagging) Damage to the articular disc (thinning, sagging, deformation) The range of motion is not limited. Hypermobility of the articular disc (anterior displacement in the position of the open mouth) Noted as a limitation of range of motion (the head is at the foot of the articular tubercle), and hypermobility (habitual dislocation) of the articular head There are no indirect signs of lateral pterygoid muscle overload Moderate indirect signs of overload and degenerative changes in the lateral pterygoid muscles Pronounced indirect signs of overload and degenerative changes in the lateral pterygoid muscles

Systematization, unification and formalization of parameters, consisting in a point assessment of the degree of violations, allows you to give an objective quantitative assessment of the level of QPSF TMJ.

Next, you need to determine the individual coefficient of deviation from the norm (K _icons ) by the formula:

To _icons = BS + VYA + FN + MI,

where BS is the score for the magnitude of the pain syndrome; VY - a score for the magnitude of inflammatory phenomena; FN - scoring of functional impairment; MI - scoring of the magnitude of morphological changes.

In the absence of TMJ VJS, the total score is - 0, the most pronounced CMV of TMJ is 12 points.

The study was conducted using data from 58 patients with TMJ diseases. According to the severity of KMFN TMJ patients are divided into 3 groups for a differentiated choice of treatment tactics (table. 3).

Table 3 Formalized indicators of the individual coefficient of deviation from the norm and the group of patients for the appointment of differentiated treatment with CPMF TMJ To the _icons (points) Groups for diff. treatment one one 2 3 four 5 2 6 7 8 9 3 10 eleven 12

Next, determine the individual dynamics coefficient (K _ikd ) to assess changes in the treatment process according to the formula:

K _ikd = (C _n-1 -C _n ) / C _n-1 ;

C _n is the sum of the points determined by the formula K of _icons during the current examination of the patient, C _n-1 is the sum of the points determined by the same formula with the previous examination of the patient.

To evaluate the effectiveness of treatment, it is necessary to calculate the dynamics coefficient with a frequency determined by the doctor, for example, after 5, 10, 15 days from the time of the initial treatment, and also calculate the dynamics of the indicator not only relative to the level before treatment, but also relative to the level of the previous examination.

The next stage of the study is to determine, depending on the change in the number of points during the initial and multiple examinations, the dynamic characteristics that we designate as negative dynamics (O), without dynamics (B), weakly positive (SP), positive (P), clearly positive ( OP). Table 4 shows the change in the coefficient of dynamics and its ratio in percent relative to the initial level in the process of differentiated treatment.

Table 4 Distribution of dynamic changes in multiple studies of TMJ of TMJ relative to the level before treatment Dynamic Change Assessment Groups K _ikd (units) Percentage change Group 1 - negative dynamics (O) more than 0 0 2 group - without dynamics (B) 0 0 Group 3 - weakly positive dynamics (SP) from - 0.1 to -0.2 8.33% - 35.3% 4 group - positive dynamics (P) from - 0.21 to -0.65 35.4% - 77.7% Group 5 - distinctly positive dynamics (OP) less than 0.66 77.8% - 100%

If in multiple studies of TMJ _{VJS, the ICd is} greater than or equal to zero and the percentage of point changes is greater than or equal to zero, or with two consecutive multiple examinations, the dynamics coefficient is more than 2 points, and the percentage of dynamic changes is less than 8.33%, then treatment tactics should be increased effectiveness.

Example 1. Monitoring of individual indicators of patient A. with MPSF TMJ at the stages of treatment and after a course of therapy with an assessment of the effectiveness of differentiated treatment tactics.

Diagnosis: TMJ pain dysfunction on the right. The _icons before treatment are equal to ten points, including three points according to the parameters of the BS, VY one point, FN three points, MI three points, the patient is assigned to the 3rd group of differentiated treatment.

On the fifth day after the comprehensive K _{icon, it} dropped to eight points, respectively, K _ikd was 0.2, which corresponds to a weakly positive dynamics. Percent changes relative to the initial state + 20%, that is, there was a decrease of only one point of inflammatory phenomena and one point of functional impairment, which required a change in treatment tactics in the direction of increasing intensity.

On the tenth day K _icons amounted to five points; To _ikd relative to the level before treatment was 0.5, relative to the level of the previous examination - 0.37, which corresponds to a positive trend.

On the fifteenth day K _icons amounted to two points; To _ikd relative to the level before treatment -0.8, relative to the level of the previous examination -0.6, which corresponds to a clearly positive trend

This technique allows you to determine the individual coefficient of deviation from the norm and the individual coefficient of dynamics in a comprehensive assessment of clinical, functional and morphological disorders of the temporomandibular joint; prescribe differentiated treatment and determine the degree of its effectiveness; quantify dynamic changes at the stages of treatment; timely change the intensity of treatment in case of insufficient effectiveness.

Claims (1)

A method for assessing clinical, functional, morphological disorders in the dysfunction of the temporomandibular joint and monitoring the effectiveness of the treatment process, characterized in that prior to the start of treatment, an individual deviation coefficient (K _icons ) is determined by the formula: K _icons = BS + VYa + FN + MI ; where BS is the score for the magnitude of the pain syndrome; VY - a score for the magnitude of inflammatory phenomena; FN - scoring of functional impairment; MI - scoring of the magnitude of morphological changes; at the same time, each parameter is formally evaluated on the basis of a four-point scale: manifestations of either changes or violations are absent - 0 points, slightly expressed - 1 point, moderately expressed - 2 points, significantly expressed - 3 points; in the course of treatment, the individual dynamics coefficient K _{ikd is} calculated with a multiplicity of 5, 10, 15 days from the moment of initial treatment, according to the formula: K _ikd = (C _n-1 -C _n ) / C _n-1 ; where C _n is the sum of the points determined by the formula K of _icons during the current examination of the patient, C _n-1 is the sum of the points determined by the same formula with the previous examination of the patient; if during the second examination, the value of K _{ikd is} greater than or equal to zero, or with two consecutive measurements, its value is greater than or equal to 0.2, then a recommendation is made to change the treatment tactics in the direction of increasing effectiveness.