RU2599976C1 - Method for diagnostic of internal disorders in temporomandibular joint - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to dentistry, and can be used in diagnostics of internal disorders in temporomandibular joint. Time of occurrence of noise audio signals and phases of opening and closing a mouth arising during mutual displacement of the articular surfaces by means of electronic stethoscope are registered. Phonogram record is started in the “joint front view” mode, when after audio signal, a patient slowly opens and closes the mouth once for 15 seconds. At that, the first movement a patient always starts to the right, in case of noise audio signal occurence a doctor fixes the time and the phase of opening or closing the mouth using time intervals on the phonogram: up to 7.5 s - opening the mouth, from 7.5 to 15 seconds - closing the mouth; from 1 to 2.5 seconds - initial phase of opening the mouth, from 2.5 to 5 seconds - medium phase of opening the mouth, from 5 seconds to 7.5 s - final phase of opening the mouth; from 7.5 seconds to 10.0 seconds - initial phase of closing the mouth, from 10.0 seconds to 12.5 - medium phase of closing the mouth, from 12.5 to 15 seconds - final phase of closing the mouth. When detecting reciprocal click, in the form of high amplitude tooth on the phonogram within the initial phase of opening the mouth in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth in the time interval from 12.5 to 15 seconds - diagnosis of front settable displacement of articular disk. When detecting reciprocal click, in the form of high amplitude tooth and crepitation in the initial phase of opening the mouth in the form of multiple repeating low amplitude teeth in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth from 12.5 to 15 seconds - diagnosis of front settable displacement of articular disk and secondary osteoarthrosis.

EFFECT: method enables to diagnose internal disorders in temporomandibular joint at the early stages of disease, perform long-term record of audio signals for survey in dynamics of clinical course of pathological process in the TMJ, to assess the treatment efficacy, to document data of examination and treatment in a patient's medical history properly due to fixation of time at closing and opening the mouth when detecting reciprocal click, crepitation on the phonogram.

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Description

The invention relates to medicine and can be used in dentistry for the diagnosis of internal disorders in the temporomandibular joint (TMJ) in patients with diseases of the temporomandibular joint with the aim of early detection of pathology, dynamic monitoring of the course of the disease and evaluation of the effectiveness of the treatment.

It is known that from 40 to 60% of the population have various diseases of the temporomandibular joint (TMJ) (Khvatova V.A. Clinical gnatology. - 2005. - M., "Medicine". - P. 127). Internal disorders account for 70 to 82% of all TMJ diseases; this term refers to changes developing in the temporomandibular joint, including displacements, defects, deformations of the articular disc, ruptures of the articular ligaments diagnosed by modern radiation methods (P. Ivasenko I., Miskevich M.I., Savchenko R.K., Simakhov R.V. Pathology of the temporomandibular joint: clinic, diagnosis and treatment principles. — St. Petersburg, 2007. - P. 22).

A known method for recording noise in TMJ diseases, including auscultation using an electronic stethoscope with a phonendoscope with a piezoelectric accelerometer and an acceleration sensor (Iordanishvili, A.K., Potapov, A.I., Bobunov, D.N. Application of an electronic phonendoscope - stethoscope in dental arthrology // Institute of Dentistry. - No. 1. - 2006. - S. 92-93).

The closest analogue is the method described in the source - RU 2351280 C1, 04/10/2009 (Iordanishvili A.K., Makeev B.L., Bobunov D.N., Potapov A.N., Soldatova L.N. Differential diagnostic method diseases of the temporomandibular joint, RF patent 2351280).

The essence of the known method for the differential diagnosis of diseases of the temporomandibular joint by studying the noise sound signals arising from the mutual movement of the articular surfaces is that they study signals in the range from 30 to 5000 Hz and diagnose them mainly in the range from 30 to 300 Hz arthrosis of the joint, in the range from 301 to 600 Hz - arthritis, in the range above 600 Hz - dysfunction of the temporomandibular joint.

However, the known method is difficult to use, it does not allow to diagnose internal disorders of the temporomandibular joint, since the apparatus itself is quite bulky, it is inconvenient to use in practice.

Existing methods for diagnosing noise in the temporomandibular joint are characterized by the complexity of differential diagnosis of various pathologies, the difficulty of processing and interpreting the data.

The technical result of the application of the invention is to increase the efficiency of differential diagnosis of noise in patients with internal disorders of the temporomandibular joint due to the expansion of the studied parameters by the method of auscultation of the temporomandibular joint using an electronic stethoscope.

The essence of the method for diagnosing internal disturbances in the temporomandibular joint by recording the time of occurrence of noise sound signals and the opening and closing phases of the mouth arising from the mutual movement of the articular surfaces using an electronic stethoscope consists in starting the phonogram recording in the “front view joint” mode , the patient slowly opens and closes his mouth 1 time within 15 seconds after the sound signal, then the time of occurrence of noise sound signals and the opening and closing phase are recorded mouth in the “joint rear view” mode with lateral movements of the jaws, while the patient always starts the first movement to the right, with the appearance of noise sound signals the doctor records the time and phase of opening or closing the mouth; and when registering a reciprocal click in the initial phase of opening and the final phase of closing the mouth of the patient, it is possible to diagnose the anterior controlled displacement of the articular disc on the right, when registering the reciprocal click in the initial phase of opening the mouth and the final phase of closing the mouth on the left and crepitation allows the diagnosis of anterior controlled displacement of the articular disk and secondary osteoarthrosis of the TMJ.

New in achieving the technical result is that the main role in the diagnosis of patients with internal disorders of the temporomandibular joint is assigned to fixing the time of noise in the temporomandibular joint and the phase of opening and closing the mouth, documenting the data obtained in the medical history.

The method is as follows.

Audio diagnostics is carried out using an Littmann electronic stethoscope (3M ESPE), which is installed in the projection area of the temporomandibular joint in patients with pathology of the temporomandibular joint. Phonograms are recorded in the position of the patient sitting without the support of the head, patients retain its natural position. The technique of auscultation of the temporomandibular joint is as follows:

First, they launch the program, turn on the stethoscope and enter the patient’s last name, first name and patronymic;

then the recording duration mode is selected and due to the fact that the program is not adapted for use in dentistry, the “joint” on the right is selected in the program;

the Littmann electronic stethoscope sensor (3M ESPE) is installed on the outer surface of the zygomatic process near the ear tragus on the right;

set the "front view joint" mode and ask the patient to slowly open 1 time and 1 time slowly close his mouth after a beep for 15 seconds;

phonograms are recorded and, when a click or crepitation occurs, the doctor records the time and phase of opening the mouth using the time intervals proposed by the authors on the phonogram: up to 7.5 seconds - opening the mouth, from 7.5 to 15 seconds - closing the mouth; from 1 to 2.5 seconds - the initial phase of opening the mouth, from 2.5 to 5 seconds - the average phase of opening the mouth, from 5 seconds to 7.5 seconds - the final phase of opening the mouth; from 7.5 seconds to 10.0 seconds - the initial phase of closing the mouth, from 10.0 seconds to 12.5 - the average phase of closing the mouth, from 12.5 to 15 seconds - the final phase of closing the mouth;

a stethoscope sensor is installed on the outer surface of the zygomatic process near the tragus of the ear on the other side (left) and the procedure is repeated to identify the TMJ pathology on both sides;

the phonogram obtained in the course of the study is stored in a computer database;

the doctor includes the “Playback” function in the computer program to repeat the sounds recorded by the computer program during the study to clarify the nature of violations in the TMJ.

The diagnosis is made on the basis of a computer analysis of phonogram records - they fix the time of occurrence of noise sound signals and the phase of opening and closing the mouth, in which sound phenomena occur.

Registration of a reciprocal click in the form of a high-amplitude tooth in the initial phase of opening in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth from the time interval of 12.5 to 15 seconds in the patient allows the diagnosis of anterior regulated displacement of the articular disc during registration reciprocal click, in the form of a tooth of high amplitude, and crepitation in the form of multiple repeating teeth of low amplitude in the initial phase of opening the mouth in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth from 12.5 to 15 seconds allows you to diagnose anterior regulated displacement of the articular disc and secondary osteoarthritis of the TMJ.

The results of the study of the temporomandibular joint using an electronic Littmann stethoscope (3M ESPE) are presented in the phonograms (Fig. 1 and 2). In FIG. 1 - on the phonogram of the right TMJ when opening and closing the mouth - articular noise in the form of a “click” is visible as a large amplitude tooth in the initial phase of opening at 1 second and the final phase of closing of the patient’s mouth at 14 seconds, which indicates the diagnosis of anterior regulated displacement of the articular disk on right. On the phonogram of the left TMJ, when opening and closing the mouth, 2 articular sounds in the form of a “click” are detected, which are visible as large-amplitude teeth in the initial phase of opening the mouth at 1 and 2 seconds, and 3 articular artifacts in the form of a “click” that are recorded on the phonogram as teeth of large amplitude in the final phase of closing the patient’s mouth, occurring at 12, 13 and 14 seconds, which indicates the presence of anterior regulated displacement of the articular disc to the left.

In FIG. 2 - on the phonogram of the right TMJ when opening and closing the mouth - articular noise in the initial phase of opening the mouth at the first second and the final phase of closing the mouth at 14 seconds in the form of a tooth of large amplitude and crepitus in the form of multiple repeating teeth of low amplitude, which indicates the presence anterior corrected displacement of the articular disc and secondary osteoarthritis of the TMJ on the right. In the phonogram of the left TMJ, when opening and closing the mouth, there are 2 high-amplitude clicks at 1 and 2 seconds of opening the mouth and 1 click of the amplitude at 14 seconds in the final phase of closing the mouth, which indicates the presence of anterior regulated left displacement of the articular disk to the left.

Clinical example 1

Patient K., 26 years old, came to the dental clinic with complaints of clicks in the temporomandibular joint on the right.

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Clinical examination revealed prognathism in combination with a deep bite, narrowing of the lower jaw, crowded teeth in the anterior lower jaw, tension and tenderness of the masticatory muscles on the right. Palpation of the temporomandibular joint area is painless. Auscultation data using a Littmann electronic stethoscope (3M ESPE): FIG. 1 - in the phonogram of the right TMJ when opening and closing the mouth - articular noise in the form of a “click” is visible as a large amplitude tooth in the initial phase of opening at 1 second and the final phase of closing of the patient’s mouth at 14 seconds, which indicates the presence of anterior regulated displacement of the articular disk on right. On the phonogram of the left TMJ, when opening and closing, 2 articular clicks are detected in the form of a “click”, which are visible as large-amplitude teeth in the initial phase of opening the mouth at 1 and 2 seconds, and 3 articular sounds in the form of a “click”, which are visible as large teeth amplitudes in the final phase of closing the patient’s mouth, occurring at 12.13 and 14 seconds, which indicates the presence of anterior regulated displacement of the articular disc to the left.

When using the additional method of axiography, this patient showed a mismatch between the trajectories of opening and closing the mouth over the upper third of the path length in both directions. The patient underwent the electromyography method, and data were obtained that showed pronounced asymmetry of the masticatory and temporal muscles, as well as a change in the index of lateral displacement of the lower jaw. The patient underwent psychological testing using an individual typological questionnaire (ITO), the patient had scores above the norm on a scale of anxiety, sensitivity, which indicates maladaptation, nervous strain. Based on the analysis of the recorded noise, a diagnosis was made of anterior regulated displacement of the articular disc of the TMJ to the right and left, confirmed by the history and clinical examination.

Magnetic resonance imaging (MRI) confirmed the diagnosis.

The patient underwent complex treatment: orthodontic treatment, rational prosthetics, selective grinding of teeth, splint therapy (kappa on the teeth of the lower jaw) was used to normalize the tone of the masticatory muscles. The patient was advised to limit the wide opening of his mouth while eating and talking. Due to high anxiety and sensitivity, the neuropathologist prescribed drugs for psychological correction, and it was recommended to attend a course of group auto-training classes. A positive therapeutic effect from the use of the complex of therapy occurred after 6 months. Sound phenomena in the TMJ area have disappeared, which was confirmed with an electronic stethoscope. Relapse of pain and pathological sounds in the TMJ was not observed.

Clinical example 2

Patient S., 32 years old, came to the dental clinic with complaints of clicks, a crunch in the temporomandibular joint on the left, fatigue with prolonged chewing. According to the patient, a physician with a diagnosis of joint hypermobility is observed, with an echocardiographic study, mitral valve prolapse, abnormally located left ventricular chords were diagnosed.

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Clinical examination revealed a deep incisal overlap in the patient. On palpation according to R. Slavichek, tension and tenderness of the masticatory muscles on the left are noted. Palpation of the temporomandibular joint region on the left is painful. To the left is articular noise, determined by palpation, and a lateral displacement of n / h by 2 mm at the end of the opening of the mouth. When using the auscultation method using an electronic Littmann stethoscope (3M ESPE), a reciprocal click is recorded in the phonogram of the right TMJ when opening and closing the mouth in the initial phase of opening the mouth at the first second and the final phase of closing the mouth at 14 seconds in the form of a large amplitude tooth and crepit in the form of multiple repeated low-amplitude teeth, which indicates the presence of anterior regulated displacement of the articular disc and secondary osteoarthritis of the TMJ on the right. In the phonogram of the left TMJ, when opening and closing the mouth, there are 2 “clicks” of high amplitude at 1 and 2 seconds of opening the mouth and 1 “click” of high amplitude at 14 seconds in the final phase of closing the mouth, which indicates the presence of anterior adjustable left displacement of the articular disc. When using the axiography method, this patient showed a mismatch between the trajectories of opening and closing the mouth over the upper third of the path length in both directions.

Based on the study of the temporomandibular joint on the right with a Littmann electronic stethoscope (3M ESPE) for registering a reciprocal click in the initial phase of opening the mouth in the form of a large amplitude tooth and crepitus - in the form of multiple repeating low amplitude teeth, we diagnosed anterior corrected displacement of the articular disc, secondary osteoarthrosis of the TMJ on the right. Based on the study of the temporomandibular joint on the right with a Littmann electronic stethoscope (3M ESPE) on the phonogram of the left TMJ when opening and closing the mouth, registration of 2 “clicks” of high amplitude in the initial phase of opening the mouth and 1 “click” of high amplitude in the final phase of closing the mouth, which indicates the presence of anterior regulated displacement of the articular disc on the left. Based on the analysis of recorded noise, a diagnosis was made of anterior corrected displacement of the articular disc, secondary TMJ on the right, anterior regulated articular displacement of the left, confirmed by anamnesis and clinical examination.

Magnetic resonance imaging (MRI) confirmed the diagnosis.

The method was tested on the basis of the department of propaedeutic dentistry SBEI HPE "Smolensk State Medical University of the Ministry of Health of the Russian Federation" in the functional room. We examined 60 patients (32 - women, 28 - men) aged 19 to 35 years. The examined were divided into 2 groups. The 1st group included 30 patients with pathology of the temporomandibular joint, the 2nd group included 30 patients without signs of pathology of the temporomandibular joint and history of it, which made up the comparison group. The following examination methods were used: axiography, electromyography, magnetic resonance and computed tomography, tests for psychological testing, audio diagnostics was carried out using an electronic Littmann stethoscope (3M ESPE) connected to a computer with the specified software. Diagnosis: internal disorders of the temporomandibular joint was confirmed by clinical studies (patient complaints, medical history and clinical examination) and additional research methods. Comparison in the studied groups was carried out in pairs using nonparametric methods using the Mann-Whitney test. Differences in the comparison were considered significant with a probability of more than 95% at p <0.05. To automate the calculations used the software package Exel. 1 year after treatment, a comprehensive examination of patients of group 1 was carried out to assess the effectiveness of the treatment, which included rational prosthetics, manufacture of mouth guards and psychological correction.

Research results

In all examined group 1, changes were detected in the phonograms of both joints, expressed to varying degrees. Reciprocal click was revealed in 30 examined patients with pathology of the temporomandibular joint, and in 21 patients it appeared in the initial and final phases of opening and closing the mouth and was characterized by a short sound of large amplitude for a short duration. The phonogram is presented in the form of a tooth of large amplitude, while in the comparison group, sound phenomena in the TMJ were not recorded.

Diagnosis: anterior corrected displacement of the articular disc in 21 patients was confirmed by magnetic resonance imaging. Differences with the comparison group were significant with a probability of more than 95% at p <0.05.

With a prolonged course of internal disorders in the joint, irreversible dystrophic and necrobiotic changes develop in the articular disc, articular cartilage, leading to destruction and deformation of the bone tissue of the head of the lower jaw, which is manifested by crunch (crepitus). As a result of the studies, crepitation was detected in 9 patients, which is a characteristic sign of arthrosis, and in 7 patients it was observed in all phases of opening and closing the mouth, and elongated recording of high-frequency noise and amplitude at constant sound pressure was also determined.

Diagnosis: secondary osteoarthritis in the examined patients was confirmed by magnetic resonance imaging and computed tomography. In 3 patients, a combination of various sound phenomena was diagnosed in different phases of opening the mouth. The phonogram showed a burst of medium amplitude followed by nonspecific noise of low amplitude and medium frequency.

Identified violations in the temporomandibular joint using the method of audio diagnostics correlated with magnetic resonance imaging.

Conclusion: The data obtained by TMJ audiography using an Littmann electronic stethoscope (3M ESPE) allow you to set the time and phases of opening and closing the mouth in which sound phenomena occur and their nature (“click”, “crepitation”), which allows you to determine the type of internal disorders of the temporomandibular joint and make the correct diagnosis. The presence of clicks and crepitus in all examined patients of group 1 and the absence of sound phenomena in TMJ in patients of the comparison group confirm the information content of this diagnostic method. The disappearance of a click in 86.5% of patients after complex treatment, including the use of mouthguards, rational prosthetics and psychological correction, indicates the possibility of dynamic observation using an electronic stethoscope.

The application of the proposed method provides the following advantages.

Auscultation using an electronic stethoscope allows you to detect small-amplitude sound signals, amplify them and perform frequency selection, and the ability to transfer information to a personal computer and store it in a database allows dynamic monitoring at different stages of complex therapy. Using the proposed protocol of audiographic research facilitates and improves the diagnosis of internal disorders of the temporomandibular joint, makes it possible to evaluate the course of the disease in dynamics, as well as the effectiveness of the therapy at its various stages, which ultimately shortens the treatment time and improves the quality of life of patients.

The method allows to diagnose internal disorders in the temporomandibular joint in the early stages of the disease, to conduct long-term recording of sound signals for research in the dynamics of the pathological process in the TMJ, to evaluate the effectiveness of the treatment, to correctly document the examination and treatment of the patient in the history of the disease.

Claims (1)

A method for diagnosing internal disturbances in the temporomandibular joint by recording the time of occurrence of noise sound signals and the opening and closing phases of the mouth arising from the mutual movement of the articular surfaces using an electronic stethoscope, characterized in that the phonogram is started in the “front view joint” mode, when after a sound signal the patient slowly opens and closes his mouth 1 time within 15 seconds, while the first movement the patient always starts to the right, when a noise occurs O signals physician records the time and phase of opening or closing the mouth, using the time slots on the phonogram: 7.5 seconds - the mouth opening, from 7.5 to 15 seconds - the closing of the mouth; from 1 to 2.5 seconds - the initial phase of opening the mouth, from 2.5 to 5 seconds - the average phase of opening the mouth, from 5 seconds to 7.5 seconds - the final phase of opening the mouth; from 7.5 seconds to 10.0 seconds - the initial phase of closing the mouth, from 10.0 seconds to 12.5 - the average phase of closing the mouth, from 12.5 to 15 seconds - the final phase of closing the mouth; when registering a reciprocal click, in the form of a high-amplitude tooth in the phonogram in the initial phase of opening the mouth in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth in the time interval from 12.5 to 15 seconds, the diagnosis is anterior regulated displacement of the articular disc, when registering a reciprocal click, in the form of a high-amplitude tooth and crepitus in the initial phase of opening the mouth in the form of multiple repeating low-amplitude teeth in the time interval from 1 to 2.5 seconds and the final phase of closing the mouth from 12.5 to 15 seconds - diagnosis of anterior regulated displacement of the articular disc and secondary osteoarthritis.

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