RU2797188C1 - Method of studying temporomandibular joint dysfunction in patients with myogenic pain - Google Patents

Abstract

FIELD: medicine, dentistry.

SUBSTANCE: invention can be used to study dysfunction of the temporomandibular joint (TMJ) in patients with myogenic pain. According to the questionnaire, markers of TMJ dysfunction, articular, muscular, neurological, are detected in the patient. The patient is asked to fill out questionnaires for assessing the quality of life according to the SF-36 questionnaire. By means of a physical examination, the symptoms of markers of joint and muscle dysfunctions accepted for diagnosis are revealed, and the state of occlusal contacts is determined. The degree of their influence on the formation of myogenic pain is assessed and the one with the greatest degree of influence is selected. The absence of a symptom of pain during movements of the lower jaw is determined. Additional studies are carried out with cone-beam computed tomography of the skull with 3D visualization, namely: examination of teeth and dentition, 3D cephalometry and screening analysis of the TMJ.

EFFECT: method provides optimization of the diagnostic process, individual approach to the choice of methods and scope of studies, the possibility of optimizing the scope and composition of research methods, optimizing the radiological scope of the study, reducing radiation and physiological loads on the patient.

1 cl, 14 dwg, 2 ex

Description

The invention relates to medicine, namely to dentistry, and can be used to diagnose temporomandibular joint dysfunction (TMJ) in patients with myogenic pain.

Dysfunction of the temporomandibular joint (TMJ) is a group of joint diseases without morphological changes in bone structures that can be detected radiologically. It is characterized by impaired movements of the lower jaw, sound phenomena when opening and closing the mouth, discomfort and periodic pain in the area of the temporomandibular joint (Ivasenko P.I., Miskevich M.I., Savchenko R.K., Simakhov R.V. "Pathology of the temporomandibular joint: clinic, diagnosis and principles of treatment. - St. Petersburg: Medi Publishing House LLC, 2007. - 80 p.; http://neostom.ru/zabolevaniya-vnchs/klassifikatsiya-zabolevaniy-vnchs.html) .

At present, the possibilities of diagnosing TMJ diseases have increased significantly due to the emergence and use of modern instrumental and technical methods. However, at present, data on the optimal choice of research methods, their scope and sequence of implementation at various stages of managing patients with TMJ diseases are not presented in the literature (Shipika D.V., Ph.D. thesis “Improving the diagnosis and treatment of diseases of the temporomandibular joints in patients with malocclusion” http://medical-diss.com/medicina/sovershenstvovanie-diagnostiki-i-lecheniya-zabolevaniy-visochno-nizhnechelyustnyh-sustavov-u-patsientov-s-anomaliyami-pri#ixzz7B506fI3B).

Currently, methods for assessing the severity of dysfunction are widely used to diagnose TMJ dysfunction.

There is a known method for determining the severity of the syndrome of dysfunction of the maxillary-mandibular joint, according to which, during a dental examination, an analysis of complaints made by patients is carried out, an anamnesis is taken. The signs are assessed: the presence of diseases of a general nature, loss of teeth and its timing, the presence of compression of the jaws during the day and night, the presence of dentures and their number, the timing of prosthetics. During an objective examination, the height of the lower part of the face, the degree of mouth opening, the amplitude of lateral movements of the lower jaw, the amplitude of displacement in the anterior and posterior directions are measured. They study the nature of the closing of the teeth, the presence of dentoalveolar anomalies, deformations and defects of the dentition. Perform an analysis of the occlusal relationships of the anterior and lateral groups. The temporomandibular joint, masticatory muscles, muscles of the neck and shoulder girdle are palpated to determine the tone and the presence of trigger points. Depending on the presence of certain clinical manifestations, there are three degrees according to the severity of the TMJ dysfunction syndrome: 10-12 points - severe; 7-9 points - a syndrome of moderate severity; 3-6 points - a syndrome of mild severity (O.N. Nikitin, A.Ya. Vyazmin "Determination of the severity of the syndrome of dysfunction of the maxillary-mandibular joint", Orthopedic dentistry, No. 1, 2000, p. 18).

There is a known method for determining the severity of musculo-articular dysfunction in patients with TMJ dysfunction, based on the method developed by the authors for a comprehensive quantitative index for assessing TMJ dysfunction and masticatory muscles (“Evaluation of the prevalence of symptoms of musculo-articular dysfunction in persons applying to a dental clinic” // Bulletin of Medical Internet conferences Science and innovation // A. R. Arushanyan, E. S. Popko, S. V. Kononov, 2015. - V. 5, No. 12. - P. 1755-17560). In accordance with the method, the criteria for assessing the severity of muscular-articular dysfunction are used: facial symmetry, amplitude of vertical movements of the lower jaw, amplitude of lateral movements of the lower jaw, protrusion of the lower jaw, symmetry of the movements of the lower jaw when opening the mouth, pain in the temporomandibular joint during movements of the lower jaw , pain in the masticatory muscles during movements of the lower jaw, palpation of the temporomandibular joint, palpation of the masticatory muscles, determination of articular noise during movements of the lower jaw. The degree of dysfunction was assessed in points: 0 points - no dysfunction; 1-10 points - mild dysfunction; 11-20 points - moderate dysfunction; 20-50 points - severe dysfunction.

One of the most common and convenient is the method for assessing the functional state of the TMJ proposed by M. Helkimo (Sweden, Gothenburg). Although the ideology of the methodology was proposed in the 70s, i.e. more than 30 years ago, it is still widely used by specialists and is considered one of the best today due to its reliability and objectivity. M. Helkimo (1974, 1976, 1979).

To determine the severity of TMJ dysfunction, three indices were proposed: anamnestic dysfunction index, clinical dysfunction index, and occlusal dysfunction index. M. Helkimo's technique takes into account the state of the joint, chewing muscles, the state of occlusal contacts. Symptoms are identified and their impact on the severity of TMJ dysfunction is assessed in points. (Helkimo, M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state / M. Helkimo // Swed. Dent. J. - 1977. - Vol. 67. - P. 101 -121).

A common disadvantage of the methods described above for diagnosing TMJ dysfunction is that they assess only the severity of TMJ dysfunction, which does not allow them to be used for making a preliminary diagnosis of TMJ dysfunction.

Currently, radiation methods for diagnosing TMJ dysfunction are widely used: traditional X-ray studies of the TMJ, which include tomography, orthopantomography, panoramic sonography;

and modern technologies - computed tomography, cone-beam computed tomography, magnetic resonance imaging.

The general disadvantage of the above methods is that they characterize morphological disorders in the TMJ and do not reveal functional disorders. In addition, often, in order to quickly obtain a diagnosis, several types of radiation studies are performed on the patient in a short period of time, for example, X-ray studies are sequentially performed: teleroentgenography (TRG) of the head in a lateral projection, followed by cephalometric analysis, orthopantomography (OPTG), CT scan of the temporomandibular joint ( CT scan of the temporomandibular joint) to detect anatomical changes in the articular head, articular cavity and violations of the relationship of bone structures. Based on the data of OPTG, TRG and CT of the TMJ, the presence or absence of anatomical changes in the bone structures is established and a preliminary diagnosis is made (RF patent, No. .2019). The lack of optimization of the radiological volume of the study creates an unreasonably increased radiation load on the patient, which adversely affects his health.

A known method for diagnosing dysfunction of the temporomandibular joint, according to which the functional state of masticatory muscles is determined by measuring blood flow parameters in the vessels in the region of the external carotid artery and in the region of the maxillary artery on the right and left sides. With indicators of the linear velocity of blood flow in the area of the external carotid artery corresponding to the age norm, and the asymmetry of the readings of the linear velocity of blood flow in the region of the maxillary artery on the right and left sides of at least 30%, dysfunction of the temporomandibular joint is diagnosed. Measurement of blood flow is performed using ultrasonic dopplerography (RF patent, No. 2322182, A61V 5/026, A61V 8/06, 20.04.2008).

The disadvantage of the known method is that the diagnosis includes only the study of masticatory muscles, while while functional disorders of the TMJ are polyetiological in nature. As a result, low information content, which reduces the accuracy of diagnosis and requires additional research, for which the volume and set of research methods remains uncertain.

A known method for early diagnosis and correction of dysfunctions of the temporomandibular joints (RF patent, No. 2445043, 03/20/2012, A61C 7/36), in accordance with which they collect anamnesis and study complaints, examine the face and oral cavity, make a preliminary diagnosis. After that, anthropometry of the face is carried out to determine the displacements of the lower jaw and changes in the height of the lower third of the face. The displacement of the lower jaw is determined in the sagittal, transversal and distal directions. To determine the distal displacement of the lower jaw, the Eshler-Bitner test is used. To determine the lateral displacements, occlusography is performed in the usual occlusion - the results are obtained using the T-Scan computer program. Orthopantomography (OPTG) is performed and the size of the joint spaces is determined. When determining secondary displacements of the lower jaw in the sagittal and/or transversal and/or distal directions, the presence of joint spaces of various sizes on the orthopantomogram and changes in the height of the lower third of the face, TMJ dysfunction is diagnosed.

In a known method, research is carried out according to the general scheme for all patients without an individual approach to the choice of methods and scope of research. As a result of the lack of optimization of the diagnostic process, an unjustified radiation load on the patient's body occurs. In addition, only articular markers of dysfunction are studied, while functional disorders of the TMJ are of a polyetiological nature, in particular, the syndrome of pain dysfunction of the temporomandibular joint in patients with myogenic nature of pain in the joint area. This reduces the information content of the method, and, consequently, reduces the accuracy of the diagnosis.

Closest to the proposed is a method for the complex diagnosis of occlusion in patients (RF patent, No. 2694175, A61V 6/00, A61V 6/03, A61V 5/0488, A61V 5/103, 07/09/2019). In accordance with the method, x-ray studies are sequentially carried out: teleroentgenography (TRG) of the head in a lateral projection, followed by cephalometric analysis in the Dolphin Imaging program 37 linear and angular parameters, orthopantomography (OPTG), CT of the temporomandibular joint (CT TMJ) to detect anatomical changes in the articular head, articular cavity and violations of the relationship of bone structures. Based on the data of OPTG, TRG and CT of the TMJ, the presence or absence of anatomical changes in the bone structures is established and a preliminary diagnosis is made. After that, electromyography (EMG) of the muscles of the head and neck is performed to study their own bioelectric potentials, the functions of the temporal, masticatory, suprahyoid and sternocleidomastoid muscles are evaluated, which makes it possible to assess the muscular complex of occlusion and supplement the diagnosis with functional disorders. Next, kinesiography of the lower jaw is carried out - a graphic recording of the movements of the lower jaw when performing tests in three planes: sagittal, frontal, horizontal. The trajectory of movements of the lower jaw, its amplitude, speed, deviations during opening and closing of the mouth, swallowing, movement of the lower jaw forward and to the sides are assessed. Based on the interpretation of the data of OPTG, TRG, CT of the TMJ, EMG of the muscles of the head and neck and kinesiography of the lower jaw, a final diagnosis is made, taking into account all violations in the components of occlusion. EFFECT: method ensures the final diagnosis, taking into account anatomical and functional disorders of occlusion, allows to draw up a comprehensive treatment plan and reduce the percentage of complications and relapses of diseases.

The known method allows you to perform the diagnosis of dysfunction of the temporomandibular joint in patients with myogenic nature of pain in the joint. However, the main disadvantage of this method is the lack of optimization in the choice of research methods individually for each patient. This causes the unreasonable use of almost all known diagnostic methods in dentistry for establishing a diagnosis: OPTG, TRG, CT of the TMJ, EMG of the muscles of the head and neck, and kinesiography of the lower jaw. This forms the maximum negative impact on the patient's body in the process of research. The radiation exposure is especially high.

From the foregoing, it follows that at present there is a problem of optimizing the scope and composition of research methods in the diagnosis of temporomandibular joint dysfunction in patients with myogenic pain.

The claimed method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain during exercise solves the problem of optimizing the volume and composition of research methods.

In addition, the claimed method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain during implementation ensures the achievement of a technical result: optimization of the diagnostic process, an individual approach to the choice of methods and scope of studies, the possibility of optimizing the volume and composition of research methods, optimizing the radiological scope of the study, reduction of radiation and physiological stress on the patient.

The essence of the claimed invention lies in the fact that in the method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain, including the study of complaints, examination of the face and oral cavity of the patient, taking anamnesis, diagnosing dysfunction, what is new is that in the process of collecting anamnesis by questioning the patient reveals the presence of markers of dysfunction of the temporomandibular joint (TMJ), causing the myogenic nature of pain, namely: the presence of markers of TMJ joint dysfunction, the presence of markers of muscle dysfunction, the presence of markers of neurological dysfunction of the TMJ, while to identify markers of articular dysfunction in a patient by surveys reveal the presence in the remote or present time of noise or clicks during various movements of the lower jaw, with each opening of the mouth, with a wide opening of the mouth and their frequency; they reveal the presence in the remote or present time of a feeling of impossibility of lower jaw movements (blocking) in the joint, the frequency and conditions under which these sensations occur: when opening the mouth, when the jaw is moved to the side or forward in one movement or with two or more movements; to identify markers of muscle dysfunction by questioning the patient, the presence of late or present fatigue and fatigue in the temporomandibular joint during chewing is detected; the presence in the remote or present of pain in the neck, occipital, temporal, parotid areas; to identify markers of neurological dysfunctions, the presence of teeth grinding is determined by questioning, whether the teeth are at rest in a closed position, the presence of an increased level of stress at work and / or at home is established, in addition, the patient is asked to fill out questionnaires for assessing the quality of life according to the SF- questionnaire 36, then by physical examination of the patient, symptoms of markers of articular dysfunctions that affect the formation of myogenic pain are detected, namely: a symptom of limitation of movements of the lower jaw, a symptom of dysfunction of the TMJ is detected, a symptom of pain is detected during palpation of the TMJ, the absence of a symptom of pain during movements of the lower jaws; identify symptoms of markers of muscle dysfunctions that affect the formation of myogenic pain, namely: identify a symptom of pain on palpation of the masticatory muscles; then, the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of articular markers is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded; evaluate the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of muscle dysfunction, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded; in addition, by physical examination of the patient, the state of occlusal contacts is determined, while examining the parameters characterizing the state of occlusal contacts that have an impact on the formation of pain of a myogenic nature: the number of teeth in the dentition; the number of contacting teeth in occlusion; occlusal interference between the posterior contact position and the central occlusion; articulation interference; after that, the degree of influence of the studied parameters influencing the formation of myogenic pain is assessed, the results of assessing the degree of influence are recorded, compared, and based on the results of the comparison, the parameters characterizing the state of occlusal contacts, which have the greatest degree of influence on the formation of myogenic pain, are selected and fixed; then additional studies are carried out by performing CBCT of the skull with 3D visualization, namely: examination of the teeth and dentition, 3D cephalometry and screening analysis of the TMJ, the results of the additional study are recorded; then the results of clinical studies obtained as a result of taking an anamnesis, the results of physical and additional examinations are analyzed, after which, based on information on the identified markers of muscle and joint dysfunction, on the basis of information on the absence of a symptom of pain during movements of the lower jaw, on the basis of information on the identified symptoms of markers muscle and joint dysfunctions that have the maximum effect on the formation of myogenic pain, based on the information obtained as a result of research on the parameters characterizing the state of occlusal contacts that have the maximum impact on the formation of myogenic pain, on the basis of information on the neurological component obtained as a result of a patient interview and the patient fills out a questionnaire for assessing the quality of life in accordance with the SF-36 questionnaire and, based on the results of additional studies, a preliminary diagnosis is made, after which, in accordance with the preliminary diagnosis, an individual study plan is drawn up for the patient, based on the results of which the final diagnosis of TMJ dysfunction is made. In addition, the degree of influence on the formation of pain of the myogenic nature of each identified symptom of a marker of articular dysfunctions, each identified symptom of a marker of muscle dysfunctions, each identified parameter characterizing the state of occlusal contacts is quantified in accordance with the criteria adopted in the methods for calculating the clinical index of dysfunction and the occlusal index dysfunction of the temporomandibular joint proposed by M. Helkimo.

In FIG. 1 shows Table 1. Example 1. The results of a survey of patient M. at the stage of anamnesis; in fig. 2 - Table 2. Example 1. Assessment of the degree of influence on the dysfunction of the TMJ identified in patient M. symptoms of markers of musculo-articular dysfunction; in fig. 3 - Table 3. Example 1. Evaluation of the range of motion of the lower jaw of patient M.; in fig. 4 - Table 4. Example 1. Assessment of the state of occlusal contacts of patient M.; in fig. 5 - the result of a myographic study of the range of motion of the lower jaw in patient M.; fig. 6 - results of myographic examination: analysis of the position of the lower jaw (displacement volume from the posterior contact position to the central occlusion) in patient M.; fig. 7 - occlusion of the patient M. before treatment; in fig. 8 shows Table 5. Example 2. The results of a survey of patient D. at the stage of collecting an anamnesis; in fig. 9 - Table 6. Example 2. Assessment of the degree of influence on TMJ dysfunction of the symptoms of markers of musculo-articular dysfunction identified in patient D.; in fig. 10 - Table 7. Example 2. Assessment of the range of motion of the lower jaw of patient D.; in fig. 11 - Table 8. Example 2. Assessment of the state of occlusal contacts of patient D.; in fig. 12 - the result of a myographic study of the range of motion of the lower jaw in patient D.; fig. 13 - results of a myographic study: analysis of the position of the lower jaw (the amount of displacement from the posterior contact position to the central occlusion) in patient D., fig. 14 - occlusion of patient D before treatment.

The solution of the identified problem and the achievement of the claimed technical result are achieved as follows.

The essential features of the invention, described in the characterizing part of the claims, namely: "A method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain, including the study of complaints, examination of the patient's face and oral cavity, history taking, diagnosis of dysfunction, ..." - are an integral part of the proposed method and ensure its feasibility, and, therefore, provide a solution to the identified problem and achieve the claimed technical result.

Dysfunction of the temporomandibular joint (TMJ) is a group of joint diseases without morphological changes in bone structures that can be detected radiographically. It is characterized by impaired movements of the lower jaw, sound phenomena when opening and closing the mouth, discomfort and periodic pain in the area of the temporomandibular joint (Ivasenko P.I., Miskevich M.I., Savchenko R.K., Simakhov R.V. "Pathology of the temporomandibular joint: clinic, diagnosis and principles of treatment. - St. Petersburg: Medi Publishing House LLC, 2007 - 80 p.; http://neostom.ru/zabolevaniya-vnchs/ klassifikatsiya-zabolevaniy-vnchs.html).

With pain dysfunction of the TMJ, there are two main causes of pain that occurs in the area of the articulation of the joint:

pain syndrome caused by muscle spasm - myogenic nature of pain;

pain syndrome emanating from the soft tissue structures of the joint, injured by the head of the lower jaw that has changed its position - the arthrogenic nature of the pain.

Myogenic pain is more often associated with a previous injury as a result of a sharp overstrain, for example, when biting off solid food, with malocclusion, with psycho-emotional arousal (stress) or with the development of myositis.

Arthrogenic pain is caused by overstretching of the intra-articular ligamentous apparatus and comes from the joint capsule or compression (compression syndrome) of the bilaminar zone when the head of the mandible is displaced posteriorly, which creates a picture of an ear disease.

The claimed method diagnoses TMJ dysfunction in patients with myogenic pain.

Functional disorders of the TMJ are polyetiological in nature. At the same time, the main factors directly related to the appearance of TMJ pathology are the state of the muscular system and the spine, the state of occlusion, the psycho-emotional state, the state of the anatomical structures of the joint.

The activity of the masticatory muscles is divided into functional (chewing, swallowing, speech) and parafunctional (clenching, grinding or bruxism). Functional disorders of masticatory muscles: discoordination in the activity of masticatory muscles, hyperactivity of individual muscles, their spasm, are leading in the development of articular symptoms (Ivasenko P.I., Miskevich M.I., Savchenko R.K., Simakhov R.V. “Pathology of the temporomandibular joint: clinic, diagnosis and principles of treatment. - St. Petersburg: OOO Medi Publishing House, 2007. - 80 p.)

According to the same authors, patients with TMJ dysfunctions are more susceptible to stress than healthy individuals. Increased levels of emotional stress not only increase head and neck muscle tone, but can also increase levels of nonfunctional muscle activity—parafunctions such as bruxism and clenching. The presence of parafunctions causes a feeling of fatigue of the masticatory muscles, their spasm and, as a result, the appearance of symptoms of TMJ dysfunction (Semkin V.A., Rabukhina N.A., Volkov S.I., "Pathology of the temporomandibular joints." - M .: Practical Medicine , 2011 - 168 p.)

Neuromuscular reflexes present during functional activity protect dental structures from damage. However, during parafunctional activity, neuromuscular defense mechanisms are not enough, resulting in damage to the structures involved. It has been proven that it is parafunctional activity that is more responsible for structural damage to the masticatory system and temporomandibular disorders than just functional activity of the maxillofacial region. It is now believed that psychosocial and psychopathological factors, rather than occlusion or anatomical abnormalities, play a leading role in the development of bruxism. There is an increase in the activity of bruxism with an increase in psychological stress. In studies of stressed patients with bruxism, an increase in muscle activity was noted depending on psychological experiences.

The presence of psychocharacterological disorders in patients with TMJ dysfunction is noted by many researchers, some of whom classify these diseases as psychosomatic, others as somatopsychic. The conducted psychodiagnostic study by V.A. Khvatova (2005) found that the majority (97%) of those surveyed have one or another neurotic disorder or a background tendency towards them.

According to the psychophysiological theory, stress causes psychovegetative stimulation of the body, which leads to an increase in the tone of the masticatory muscles, their spasm and dysfunction of the TMJ.

Thus, the emotional state of the patient can lead to the formation of muscle hypertonicity and, as a consequence, to the formation of myogenic pain syndrome.

In addition, it is known from the literature that teeth are not only the final working organs of the masticatory apparatus, but also sensitive sensory organs at the beginning of the neuromuscular reflex arc. The brainstem regulates muscle activity through muscle engrams, which are selected based on sensory input from peripheral structures. When an unexpected sensory response occurs, a protective reflex mechanism is activated, creating a decrease in muscle activity in the area of the signal. Therefore, any violation of occlusion can lead to a violation of the reflex balance and the formation of TMJ dysfunction. In case of violations of occlusion, obstacles appear for the normal movement of the lower jaw relative to the upper jaw in accordance with the canons of biomechanics. In order to eliminate these obstacles, the lower jaw changes the trajectory of its movement, the teeth are displaced into the position of forced occlusion, which leads to a violation of the coordination of the masticatory muscles. Asymmetry of movements in the TMJ, hyperactivity of masticatory muscles cause discoordination of displacements of the head and disc, determining the clinic of TMJ dysfunction. (Ivasenko P.I., Miskevich M.I., Savchenko R.K., Simakhov R.V. "Pathology of the temporomandibular joint: clinic, diagnosis and principles of treatment." - St. Petersburg: Medi Publishing House LLC, 2007 . - 80 s.)

It is known that a violation of the distribution of masticatory pressure leads to deformations of the dentition and occlusion. Deformations of the dentition and teeth reduce the range of motion of the lower jaw, causing a crushing or incomplete grinding type of chewing with limited free movement in the transversal and sagittal directions. Occlusal interferences, loss of teeth, their destruction, deformities of the dentition are risk factors for TMJ dysfunction.

Thus, the analysis of special literature indicates the relationship of occlusion disorders, in particular, the state of occlusal contacts and the presence / absence of premature occlusal contacts, with muscle discoordination, as etiological factors of TMJ dysfunction.

From the foregoing, it follows that TMJ dysfunctions can be caused by articular, muscle disorders, disorders of the state of occlusal contacts and neurological disorders in the patient's body.

In the claimed method, the diagnosis is performed based on the results of a clinical study of the patient. Currently, in the higher medical school, there is a tendency to attribute questioning and physical examination to clinical methods of examining a patient, and designate laboratory, instrumental and special methods as additional examination methods (website www.1spbgmu.ru metody_i_metodologiya_klinich_diagnostiki.pdf; "General principles of diagnosis", lecture , Bursikov A.V. "(homo89.ru> klinicheskaya-diagnostika).

A physical examination is a set of medical diagnostic measures performed by a doctor in order to make a diagnosis. All methods related to the physical examination are carried out directly by the doctor using his senses. (WIKIPEDIA).

At the first stage of clinical studies in the proposed method in the process of collecting anamnesis by questioning the patient, the presence of markers of dysfunction of the temporomandibular joint (TMJ) is detected, causing the myogenic nature of pain, namely: the presence of markers of TMJ joint dysfunctions, the presence of markers of muscle dysfunction, the presence of neurological markers dysfunctions of the TMJ, while in order to identify markers of articular dysfunction in a patient, by means of a survey, the presence of noises or clicks in the remote or present time during various movements of the lower jaw, with each opening of the mouth, with a wide opening of the mouth and their frequency is detected, the presence in the distant or in the present tense feeling of the impossibility of movements of the lower jaw (blocking) in the joint, the frequency and conditions under which these sensations occur: when opening the mouth, when the jaw is moved to the side or forward in one movement or in two or more movements; to identify markers of muscle dysfunction by questioning the patient, the presence of late or present fatigue and fatigue in the TMJ during chewing is detected; the presence in the remote or present of pain in the neck, occipital, temporal, parotid areas; to identify markers of neurological dysfunctions, the presence of teeth grinding is determined by questioning, whether the teeth are at rest in a closed position, the presence of an increased level of stress at work and / or at home is established, in addition, the patient is asked to fill out questionnaires for assessing the quality of life according to the SF- questionnaire 36.

As noted above, in the claimed method, the presence of musculo-articular and neurological markers of dysfunction of the temporomandibular joint, causing the myogenic nature of pain, is detected in the process of collecting an anamnesis by questioning the patient. As a result of performing patent information studies, a patient questionnaire was identified at the stage of collecting an anamnesis, proposed by M. Helkimo to calculate the anamnestic index to determine the severity of TMJ dysfunction (Helkimo, M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state / M Helkimo // Swedish Dent J. - 1977. - Vol. 67. - P. 101-121). According to the method proposed by M. Helkimo, at the stage of collecting an anamnesis, the patient is identified: the presence of ever noises or clicks during various movements of the lower jaw; the presence of ever fatigue and fatigue in the temporomandibular joint when chewing; having ever had difficulty opening the mouth wide; the presence of ever feeling the impossibility of movements of the lower jaw (blocking) in the joint; the presence of ever pain in the joint with movements of the lower jaw; the presence of ever pain in the temporal region.

However, in accordance with the formula of the claimed method, the authors of the invention proposed a questionnaire to identify the presence of markers of muscular-articular dysfunctions of the temporomandibular joint (TMJ), causing the myogenic nature of pain, which complements and refines the known, which distinguishes it from the known (Fig. 1, Fig. 8).

This is confirmed by the following.

In the temporomandibular joint, two types of clicks are possible: reciprocal with disc dislocation (functional TMJ pathology requiring treatment) and overrotational with habitual subluxation (this symptom requires an in-depth interpretation by the doctor, since there is an acceptable individual norm). To differentiate the type of click, it should be noted: at what volume of mouth opening a click occurs. So a reciprocal click occurs with each opening of the mouth, and an overrotational click occurs with a very wide one.

In accordance with the claimed claims, in order to increase the information content of the patient's response about the presence of clicks during movements of the lower jaw and to obtain additional information, namely: the possibility of identifying the nature of clicks in the joint, the patient, by questioning, reveals the presence of noise or clicks in the remote or present time during various movements of the lower jaw, with each opening of the mouth, with a wide opening of the mouth and their frequency.

Difficulties in opening the mouth wide may be associated with mechanical blocking in the joint or functionally incorrect muscle work - muscle hypertonicity. In the claimed method, the function of opening the mouth in detail, without fail, is examined during the physical examination of the patient to identify a symptom of limited movement of the lower jaw. Therefore, despite the fact that at the stage of collecting an anamnesis, the question to the patient about the presence of difficulty in opening the mouth wide is excluded, this does not reduce the information content of the results of the patient's survey.

The sensation of the impossibility of movements of the lower jaw (blocking) in the joint is most often associated with blocking during disc dislocation, namely: the transition of the state of disc dislocation with reduction to dislocation without reduction. To increase the initial information, clarification is required: how often and under what conditions. In the claimed method, the presence in the remote or present time of the feeling of the impossibility of lower jaw movements (blocking) in the joint, the frequency and conditions under which these sensations occur are detected: when opening the mouth, when the jaw is moved to the side or forward in one movement or with two or more movements.

Pain in the joint during movements of the lower jaw is interpreted as an arthrogenic condition, which is a sign of joint damage. In the claimed method, dysfunction of the temporomandibular joint is diagnosed in patients with myogenic nature of pain. Therefore, in the claimed method, at the stage of collecting anamnesis, this sign of TMJ dysfunction is not detected. However, in the claimed method, during a physical examination of the patient, the absence of a sign of a symptom of pain during movements of the lower jaw is determined without fail, which makes it possible to reliably determine the nature of the pain: myogenic or arthrogenic. Therefore, despite the fact that at the stage of collecting an anamnesis, the question to the patient about the presence of pain in the joint during movements of the lower jaw is excluded, this does not reduce the information content of the results of the patient's survey and, in the future, does not reduce the reliability of the preliminary diagnosis.

Fatigue and fatigue in the temporomandibular joint during chewing occurs due to the inefficient work of the masticatory muscles. This is an indirect sign of muscle disorders or the presence of muscle parafunctions and is important information for the doctor during the physical examination of the patient to decide on the need to consult a neurologist.

Pain in the temporal region may indicate hypertonicity of the temporal muscles and muscle imbalance. However, in addition to this, hypertonicity of the temporal muscles and muscle imbalance can also be indirectly indicated by pain in the parotid region, in the neck and occiput.

In the claimed method for identifying markers of muscle dysfunction by questioning the patient, the presence of late or present fatigue and fatigue in the TMJ during chewing is detected; detect the presence in the remote or present time of pain in the neck, occipital, temporal, parotid areas. As a result, the informativeness of the result of the patient's survey is increased for the doctor to perform a physical examination of the patient.

In addition, in the claimed method, in the process of collecting an anamnesis, by questioning, markers of neurological dysfunctions are revealed, which, as shown above, is important information when making a preliminary diagnosis. Establish the presence of teeth grinding, establish whether the teeth are at rest in a closed position, establish the presence of an increased level of stress at work and/or at home.

The well-known questionnaire does not reveal markers of neurological dysfunctions, which reduces the information content and diagnostic value of the results of anamnestic survey.

Thus, the questionnaire, characterized in the formula of the claimed method, differs from the one known according to M. Helkimo, is more diagnostically informative for a doctor who uses the results of anamnesis when performing a physical examination of the patient, which further increases the accuracy of the preliminary diagnosis and allows you to individualize and optimize the amount of further examinations of the patient after the provisional diagnosis.

In addition, in the process of collecting an anamnesis, the patient is asked to fill out questionnaires for assessing the quality of life according to the SF-36 questionnaire.

The SF-36 questionnaire (English The Short Form-36) is a non-specific questionnaire for assessing the quality of life of a patient, widely used in quality of life studies in Europe and the United States. It has been established to measure quality of life in Italy, France, Australia and the general US population. In Europe and the United States, studies were conducted on individual groups of people and results were obtained according to the norms for a healthy population and for patients with various chronic diseases (with distribution into groups according to age and sex).

The questionnaire reflects the general well-being and the degree of satisfaction with those aspects of a person's life that are affected by the state of health.

The SF-36 questionnaire is used to assess the quality of life in any disease; it is possible to compare the indicators of the quality of life of patients according to the SF-36 questionnaire with the data of the Russian population control for the corresponding groups; the questionnaire assesses the quality of life of patients in a complex way (including social and psychological disorders).

The SF-36 consists of 36 items grouped into eight scales: physical functioning, role-playing, bodily pain, general health, vitality, social functioning, emotional state, and mental health.

The scales are grouped into two indicators: PH (“physical component of health”) and MH (“psychological component of health”).

1. The physical component of health (Physical health - PH) physical functioning: role functioning, due to the physical condition; pain intensity; general health.

2. The psychological component of health (Mental Health - MH) mental health: role functioning, due to the emotional state; social functioning; vital activity.

Two parameters are formed from them: the psychological and physical components of health.

The indicators of each scale are compiled in such a way that the higher the value of the indicator (from 0 to 100), the better the score on the chosen scale (https://ru.wikipedia.org/wiki/SF-36#mw-head; https:// therapy.irkutsk.ru/doc/sf36a.pdf).

The authors of the present invention assessed the quality of life by questioning patients (200 people) with TMJ pain dysfunction syndrome and the presence of dento-jaw anomalies (ZCA) using the SF-36 questionnaire. The result of the survey showed that these disorders lead to a significant decrease in the quality of life in all parameters of the questionnaire scales, except for the parameter of general health. The quality of life among such patients is significantly reduced in the scales of social and role (emotional) functioning, which negatively affects the patient's neurological status, and may also indicate the impact of occlusion pathology on the patient's social activity.

Thus, from the foregoing, it follows that the detection in the process of collecting anamnesis of the presence of markers of dysfunction of the temporomandibular joint, causing the myogenic nature of pain, in accordance with the formula of the proposed method, provides an increase in information content about the signs of TMJ dysfunction markers detected at the stage of collecting anamnesis, allows already at the stage of collecting an anamnesis, draw preliminary conclusions about the etiology of joint dysfunction, which expands the volume of initial prognostic information for the doctor at the stage of physical examination of the patient, provides the opportunity to perform the most complete physical examination of the patient and increases the reliability of the preliminary diagnosis of TMJ dysfunction, and therefore allows to optimize further examination and ensures the achievement of the claimed technical result.

In accordance with the claimed claims, by physical examination of the patient, symptoms of markers of articular dysfunctions that affect the formation of myogenic pain are detected, namely: a symptom of restriction of movements of the lower jaw, a symptom of impaired TMJ function are detected, a symptom of pain is detected on palpation of the TMJ, the absence of a symptom is determined pain during movements of the lower jaw; identify symptoms of markers of muscle dysfunctions that affect the formation of myogenic pain, namely: identify a symptom of pain on palpation of the masticatory muscles; then, the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of articular markers is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded; the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of muscle dysfunctions is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded.

In addition, by physical examination of the patient, the state of occlusal contacts is determined, while examining the parameters characterizing the state of occlusal contacts that affect the formation of myogenic pain: the number of teeth in the dentition; the number of contacting teeth in occlusion; occlusal interference between the posterior contact position and the central occlusion; articulation interference; after that, the degree of influence of the studied parameters influencing the formation of myogenic pain is assessed, the results of assessing the degree of influence are recorded, compared, and based on the results of the comparison, the parameters characterizing the state of occlusal contacts, which have the greatest degree of influence on the formation of myogenic pain, are selected and fixed.

In the claimed method, when performing a physical examination of a patient to identify symptoms of markers of joint and muscle dysfunctions, as well as to identify parameters characterizing the state of the occlusal surface, use the list of symptoms of TMJ dysfunction adopted in the M. Helkimo method to calculate the clinical dysfunction index and the occlusal dysfunction index, respectively, to determine the severity of TMJ dysfunction.

According to domestic and foreign scientists, one of the most common methods for determining the severity of TMJ dysfunction is the M. Helkimo dysfunction index. The list of studied symptoms of the M. Helkimo index takes into account the state of both the joint and the masticatory muscles (Naidanova I.S. “Features of functional disorders of the temporomandibular joint and masticatory muscles in young patients with preserved dentition” 14.01.14 - dentistry / / dissertation on competition for the degree of candidate of medical sciences).

M. Helkimo proposed three indices to assess the severity of TMJ dysfunction: anamnestic dysfunction index, clinical dysfunction index and occlusal dysfunction index. (Helkimo, M. Studies on function and dysfunction of the masticatory system. II. Index for anamnestic and clinical dysfunction and occlusal state / M. Helkimo // Swed. Dent. J. - 1977. - Vol. 67. - P. 101 -121.)

The clinical indicator of dysfunction is determined during a clinical examination and makes it possible to judge the functional status of the masticatory system. The index is expressed in points, the number of which depends on the intensity of five symptoms: the degree of disturbance of the movements of the lower jaw, the assessment of the function of the TMJ, the presence of pain during movements of the lower jaw, the presence of pain during movements in the joint, pain in the masticatory muscles: 0 - no signs of disorders, 1 - moderate (medium) signs, 5 - pronounced signs, are detected and evaluated in points: the presence of a symptom of limitation of movements of the lower jaw, namely, the maximum opening of the mouth more than 40 mm, 0 points, from 30 to 39 mm, 1 point, less than 30 mm, 1 point 5 points; the maximum displacement of the lower jaw to the right more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the maximum displacement of the lower jaw to the left more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the maximum protrusion movement of the mandible more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the presence of a symptom of dysfunction of the TMJ, namely, opening and closing the mouth without deviation or with a deviation of less than 2 mm - 0 points, clicks in one or two TMJ and (or) deviation of more than 2 mm when opening the mouth - 1 point, blocking during movements of the lower jaw or subluxation - 5 points, the presence of a symptom of pain on palpation of the TMJ, namely, painless palpation - 0 points; painful palpation from the side - 1 point, painful palpation from the side and from the distal side through the external auditory canal - 5 points; the presence of a symptom of pain during movements of the lower jaw, namely, the movements are painless - 0 points; pain occurs with one movement - 1 point; pain occurs with two or more movements - 5 points; to assess the degree of influence of the symptoms of the marker of muscle dysfunction, a symptom of pain on palpation of the masticatory muscles is detected and evaluated in points, namely, painless palpation of the masticatory muscles - 0 points; pain on palpation from one to three muscles - 1 point; pain on palpation of four or more muscles - 5 points.

The occlusal index allows you to establish the state of occlusion of the dentition from a morphological and functional point of view. The index is expressed in points, the number of which depends on the intensity of the evaluated parameter that affects the state of occlusal contacts. At the same time, the degree of influence is evaluated in points, namely, 0 points - no influence, 1 point - moderate influence, 5 points - pronounced influence. To evaluate the parameter, the following are identified: occlusal interference between the posterior contact position and central occlusion, and in the absence of it or in the presence of direct symmetrical sliding from RCP to IP no more than 2 mm, 0 points are scored; in the case of unilateral contact in the RCP and during sliding in IP with a sliding distance of less than 2 mm and/or with a lateral mandibular displacement of less than 0.5 mm when sliding from RCP to IP, occlusal interference between the posterior contact position and the central occlusion is characterized as moderate interference and evaluate 1 point; with a lateral displacement of the lower jaw of more than 0.5 mm when sliding from the RCP to the IP and/or the distance between the RCP and IP is more than 2 mm, the occlusal interference between the posterior contact position and the central occlusion is characterized as a pronounced interference and rated 5 points; the absence of premature occlusal contacts is scored 0 points; the presence of premature occlusal contacts is estimated at 5 points.

Articulatory interference in the absence of violations is estimated at 0 points; in the presence of single contacts of the teeth on the working side distal to the canines and / or with unilateral contact during protrusion, articulatory interference is characterized as moderate disturbances in articulation and 1 point is assessed; in the presence of balancing contacts, articulatory interference is characterized as pronounced articulation disorders and is scored 5 points.

In the claimed method, the identification and study of a list of symptoms of TMJ dysfunction similar to the M.Helkimo method (articular, muscular, parameters of the state of occlusal contacts) and the results of assessing the degree of their influence on TMJ dysfunction are used to make a preliminary diagnosis according to the cumulative result: "... based on information about the identified markers of muscle and joint dysfunctions, based on information about the absence of a symptom of pain during movements of the lower jaw, based on information about the identified symptoms of markers of muscle and joint dysfunctions that have the greatest degree of influence on the formation of pain of a myogenic nature, based on the information on parameters obtained as a result of research, characterizing the state of occlusal contacts, which have the greatest degree of influence on the formation of myogenic pain, ... make a preliminary diagnosis. While in the M. Helkimo method, only the severity of TMJ dysfunction is determined, without linking the result with a preliminary diagnosis.

At the same time, in the claimed method, due to the assessment of the degree of influence on the formation of pain of the myogenic nature of each identified symptom of the marker of articular dysfunctions, each identified symptom of the marker of muscle dysfunctions, each identified parameter characterizing the state of occlusal contacts and the subsequent comparative assessment of this effect, it is possible to use the totality, symptoms of musculo-articular dysfunctions identified during the examination of the patient and parameters characterizing the state of occlusal contacts for diagnosis. At the same time, since they take into account the symptoms that have the greatest influence on the formation of myogenic pain, this increases the diagnostic information content of the examination results, and, consequently, increases the accuracy of the preliminary diagnosis and, as a result, provides a solution to the problem of optimizing the volume and composition of research methods and the declared technical result.

The claimed method is used to diagnose TMJ dysfunction in the presence of myogenic pain, which requires control of the type of pain: myogenic, arthrogenic. In contrast to the M. Helkimo method, in the claimed method, a symptom of articular dysfunction, namely: a symptom of pain during movements of the lower jaw, is used to identify pain of a myogenic nature, since its absence is determined, since the presence of a symptom of pain during movements of the lower jaw is a sign of arthrogenic pain. character, which indicates the presence of a joint disease with morphological changes in bone structures, detected radiologically.

In addition, in the claimed method, the absence of a sign of pain of an arthrogenic nature is also confirmed during additional studies by performing CBCT of the skull with 3D visualization, namely, “carry out ... a screening analysis of the TMJ ...”. This allows the list of symptoms of TMJ dysfunction, adopted in the M. Helkimo method for calculating the clinical index of dysfunction, to be adapted for the diagnosis of TMJ dysfunction in patients with myogenic pain, which increases the diagnostic information content of the results of a clinical study.

Thus, in the claimed method, the presence of myogenic pain in patients is controlled twice: a physical examination reveals the absence of a symptom of pain during movements of the lower jaw;

when conducting a screening analysis of the TMJ by performing CBCT of the skull with 3D visualization.

In addition, the use of the list of symptoms of dysfunction adopted in the claimed method is convenient from the standpoint of collecting, processing and interpreting data.

In the claimed method, after completion of clinical studies, additional studies are carried out by performing CBCT of the skull with 3D visualization, namely, assessment of teeth and dentition, 3D cephalometry and screening analysis of the TMJ.

Cone beam computed tomography (CBCT) allows obtaining a high-quality X-ray image of the dentition and maxillofacial region in three mutually perpendicular planes. Unlike conventional radiography, CBCT is the most informative, as it allows you to obtain images of any anatomical formations in three planes, highlight the layer of the object of interest and nearby organocomplexes with a thickness of 1 to 10 mm [Fadeev, R.A., Sheveleva, Yu.P ., Chibisova, M.A. Methodology for assessing the position of impacted teeth according to dental computed tomography (part 2) / R.A. Fadeev, Yu.P. Sheveleva, M.A. Chibisova // Institute of Dentistry. - 2013. - No. 1. - S. 30-33].

CBCT uses a single planar sensor for scanning; the generated beam is collimated in the form of a cone. During shooting, the emitter operates continuously, and information is read from the sensor several times per second. Then the information is processed in a computer and a virtual three-dimensional model of the scanned area is restored [Rogatskin, D.V. Radiodiagnostics of the maxillofacial region. Cone beam computed tomography. Fundamentals of visualization / D.V. Rogatskin. - Lvov: GalDent, 2010. - 148 p.].

As a result, CBCT allows you to perform a similar study, with less radiation exposure, compared to other radiological methods, such as OPTG, TRH, which is extremely important for patients. Radiation exposure from one CBCT study varies from 0.04 to 0.08 mSv depending on the type of tomograph. According to SanPin 2.6.1.802-99, for practically healthy individuals, the annual effective dose during preventive medical radiological procedures should not exceed 1 mSv. Based on these data, the method of cone-beam computed tomography can be attributed to low-dose studies [SanPin 2.6.1.802-99 "Hygienic requirements for the design and operation of X-ray rooms, apparatus and X-ray examinations"].

It is known from the prior art that OPTG and/or CT or CBCT of the jaws, TRG, CT of the temporomandibular joint are usually performed as part of the examination of the dentoalveolar system. However, in order to diagnose temporomandibular joint dysfunction in patients with myogenic nature of pain in the area of the articulation of the joint, when performing skull CBCT with 3D imaging, it is possible to simultaneously evaluate the teeth and dentitions, 3D cephalometry and screening analysis of the TMJ. This approach optimizes the scope of the radiological examination, which in turn provides a reduction in radiation exposure to the patient (single radiation exposure) while simultaneously providing the full amount of examination required at the stage of the clinical examination of the patient. In addition, it is cost-effective for the patient.

CBCT data make it possible to assess the position, shape, size, condition of the teeth, study the structure and obtain a digital three-dimensional image of the jaw bones, paranasal sinuses, temporomandibular joints of the patient in one study. The study is not burdensome in terms of patient positioning, non-invasive, with low radiation exposure when using CBCT, namely, when implementing this method, from 0.01 mSv (for children) to 0.05 mSv (for adults).

The use of skull CBCT with 3D visualization for additional studies, namely, assessment of teeth and dentitions, 3D cephalometry and TMJ screening analysis, in combination with other essential features of the claims of the claimed invention, allows optimizing both the scope of studies in general and the volume radiological study, namely: to exclude the use of OPTG and TRH and, with a single radiation exposure, perform the full scope of the study to formulate a preliminary diagnosis at the final stage of clinical studies.

The results of clinical studies obtained as a result of taking an anamnesis and physical examination are analyzed, after which, based on the identified markers of musculo-articular dysfunction, on the basis of the identified symptoms that have the maximum impact on TMJ dysfunction, on the basis of the information obtained as a result of research on the parameters characterizing the state of occlusal contacts that have the maximum impact on TMJ dysfunction, based on information about the neurological component obtained as a result of interviewing the patient and filling out the patient's quality of life assessment questionnaire in accordance with the SF-36 questionnaire, a preliminary diagnosis is made based on the anamnesis and physical examination data; then additional studies are carried out by performing CBCT of the skull with 3D visualization, namely, the study of teeth and dentition, 3D cephalometry and screening analysis of the TMJ, the results of additional studies are recorded; then, based on the results of additional studies, the preliminary diagnosis is clarified or confirmed, after which, in accordance with the preliminary diagnosis, an individual study plan is drawn up for the patient, based on the results of which the final diagnosis of TMJ dysfunction is made.

Thus, from the foregoing, it follows that when using the method, the collected information is sufficiently informative and allows for the analysis of the identified symptoms that have the maximum impact on TMJ dysfunction. Make a preliminary diagnosis based on the history and physical examination data Determine a set of additional laboratory and instrumental research methods to confirm (substantiate) (clarify) the diagnosis Draw up an examination plan taking into account the preliminary diagnosis Determine the prognosis, the possibility of developing emergency conditions and possible assistance with them Define goals and principles of treatment Select specific medical technologies and methods for monitoring the effectiveness of treatment.

It follows from this that the totality of the essential features of the proposed method for diagnosing temporomandibular joint dysfunction in patients with myogenic nature of pain in the articulation area, characterized in the claims, is optimal and sufficient for making a preliminary diagnosis. This, in turn, provides the possibility of an individual approach to further examination and treatment of the patient: "... in accordance with which (with a preliminary diagnosis) an individual plan for an additional study is drawn up for the patient, based on the results of which a final diagnosis of TMJ dysfunction is made." At the same time, since a preliminary diagnosis is made on the basis of a set of dysfunction symptoms that have the highest score, significant information about the etiology of dysfunction is obtained to make a preliminary diagnosis. This allows, on the basis of a preliminary diagnosis, to clarify the diagnostic criteria for additional individual studies and reduce both their volume and the set of research methods. Thus, there is an optimization of the volume of research and a set of research methods, reducing the negative physiological load on the patient's body.

Currently, there is an increased interest in the search for highly informative methods for diagnosing dysfunction, especially at the stage of preclinical manifestations. The proposed method meets this criterion.

Thus, the set of essential features described in the claims of the claimed method allows, without loss of information, to optimize the scope and set of research methods in the diagnosis of temporomandibular joint dysfunction in patients with myogenic pain. At the same time, the possibility of optimizing the diagnostic process is provided, an individual approach to the choice of methods and scope of studies is provided, optimization of the radiological scope of the study is ensured, and radiation and physiological loads on the patient are reduced.

To confirm the reliability of the choice of the list of studied symptoms of the identified markers of musculo-articular dysfunctions and the parameters of the state of occlusal contacts adopted in the claimed method, the authors of the invention performed studies of 200 patients diagnosed with TMJ pain dysfunction syndrome.

For the study, 3 groups were formed: the main group, the comparison group, the control group.

Main group (MG-1): patients aged 18-44 years. Criteria for inclusion of patients in the study group OG-1:

- the presence of symptoms of TMJ dysfunction, namely, clicks, noises, pain in the TMJ area;

- the presence of dento-jaw anomalies;

- diagnosis of temporomandibular joint pain dysfunction syndrome;

- Sanitized oral cavity.

In accordance with the ICD-10 classification, all patients with OG-1 at the stage of the clinical study were given a preliminary diagnosis of temporomandibular joint pain dysfunction syndrome.

Comparison group (GS-1): patients with dento-jaw anomalies without TMJ symptoms aged 18-44 years.

Criteria for inclusion of patients in the study group GS-1:

- absence of symptoms of TMJ dysfunction (clicks, noises, pain in the TMJ area);

- the presence of dento-jaw anomalies;

- Sanitized oral cavity.

Control group (CG-1): persons with physiological occlusion, without TMJ pathology, without indications for orthodontic treatment at the age of 18-44 years.

Criteria for inclusion of patients in the study group CG-1:

- absence of dento-jaw anomalies.

- no symptoms of TMJ dysfunction.

Patients with the following criteria were excluded from the study:

- gross morphological changes in the temporomandibular joint (TMJ) according to CBCT, MRI of the TMJ;

- post-traumatic pathology of the TMJ;

- somatic pathology in the stage of decompensation;

- systemic diseases of bone tissue and joints;

- hereditary syndromes;

- congenital anomalies of the dentofacial region (cleft lip and palate);

- Patients who refused to participate in the study at any of its stages.

When collecting a dental history, special attention was paid to the state of the dentition and jaw system: caries, reasons for the extraction of teeth, both milk and permanent, injuries of the maxillofacial region, whether orthodontic treatment was previously performed, the presence of a similar pathology in relatives, the dynamics of anomalies with age and child's growth.

Before the clinical study, all patients underwent oral hygiene and a course of professional hygiene.

The clinical study was carried out using a formalized medical history of an orthodontic patient, developed by the Moscow State Medical University of Medicine and Dentistry, and a medical record of an orthodontic patient No.

In order to identify facial signs of anomalies, facial anthropometry was performed. When examining the face from the front, the proportionality and symmetry of the development of the face and lower jaw, the severity of the nasolabial and supramental folds, the thickness and position of the lips, the nature of the closure of the upper and lower lips, the degree of visibility of the incisors of the upper jaw from under the upper lip were determined. Pay attention to the shape of the face: narrow, medium, wide, its proportionality (decrease or increase in the lower and middle height of the face). When examining the face in profile, the type of profile, the position of the upper and lower lips relative to the true vertical, the size of the middle and lower thirds of the face, the value of the nasolabial angle, and the exposure of the upper jaw incisors during smiling and talking were evaluated.

To assess the local status, a visual examination of the craniofacial TMJ, palpation of the joint and masticatory muscles were performed. During palpation of the muscles, the volume and symmetry of the masticatory muscles were determined, trigger points, the presence of symptoms of referred pain, and pain-provoking factors were identified. The volume and possible types of movements in each TMJ (rotational and translational) were assessed, the trajectory of the lower jaw movements was determined when opening and closing the mouth. Auscultation of the TMJ was also performed: the presence of a crunch and clicks was revealed.

Examination of the oral cavity was carried out according to the generally accepted method: the condition of the oral mucosa, the location of the frenulums of the lips and tongue, the size of the apical base, the location of the teeth, the symmetry of eruption, the timing of eruption, the shape of the dental arches, the presence of secondary deformities resulting from an existing anomaly of occlusion or early removal of individual teeth, the presence of orthopedic structures in the oral cavity. The hygienic state of the oral cavity and the state of hard dental tissues, the presence of caries, periodontal tissue diseases, and missing teeth were determined. The type of closure of the dentition was described using the classification of L.S. Persina (1990). When examining the dentition, the correspondence of the dental and passport age, the shape and size of the dentition, and the position of individual teeth were assessed.

Particular attention was paid to the analysis of the occlusal surfaces of the teeth. The quality of restorations, artificial crowns, made with insufficiently pronounced anatomical features of the masticatory surface, which did not provide positioning of the lower jaw, was evaluated.

At the stage of clinical studies, the analysis of the quantity, quality and uniformity of occlusal contacts, the presence of premature contacts was performed using articulation paper, for this, Bauch paper 40 µm, 8 µm was used.

Based on the clinical examination, a preliminary diagnosis was formulated according to the classification of L.S. Persina. With the help of additional research methods, the final diagnosis was established.

In the process of collecting an anamnesis by questioning the patient in patients OG-1 with the syndrome of pain dysfunction of the TMJ, complaints of pain predominated - 73%;

- for functional disorders: clicks in the joint area - 46%; restriction of mouth opening - 35%, feeling of stiffness of movements, "jamming" of the lower jaw in the joint area - 15%; tension in the masticatory muscles at rest - 45%, aggravated by eating - 23%; inconvenience when closing teeth, a feeling of "search" for the position of the lower jaw - 35%.

Aesthetic complaints in patients OG-1 were less common and were of a secondary nature: 37% for uneven tooth positioning, 29% for tooth abrasion.

Patients GS-1 mainly complained about: uneven arrangement of teeth - 90%, difficulties in oral hygiene - 10%. Among complaints of a functional nature, the most common complaint was uneven closing of teeth - 25%.

There were no active complaints among the persons of CG-1 (patients without AFA).

At the same time, in patients of the OG-1 group with pain dysfunction syndrome, the occurrence of pain was noted after a traumatic effect on the TMJ in 30% of cases, after dental treatment in 45% of cases. With active detection of complaints, signs of bruxism were detected in 85% of patients, stress and / or disruption of work and rest in 67% of cases. 38% of patients had previous orthodontic and/or orthopedic treatment.

Among patients with HS-1, there were signs of bruxism in 25% of cases. Previously, patients in this group did not undergo orthodontic treatment.

In patients of the main group, signs of dysfunction were observed in 100% of cases, and the majority (98%) had a severe degree of impairment.

The most common complaints in this group were complaints of clicks and pain in the temporal region, 54% of respondents noted restrictions in the movements of the lower jaw.

In the comparison group, only 41% had anamnestic signs of dysfunction, and most (78%) were mild.

All patients of the main group (100%) had clinical signs of dysfunction.

Among the patients of the main group, mouth opening was limited in 85.7% of cases, of which 61.9% had a slight restriction according to the Helkimo classification (30-39 mm), and 23.8% had a pronounced restriction (less than 30 mm). Mild limitation of laterotrusive movements of the lower jaw (movements of the lower jaw to the sides by 4-6 mm) occurred in 15.6%, severe (less than 4 mm) - in 3.1%. Protrusion movements with an amplitude of 4-6 mm (mild degree of limitation) occurred in 18.75%, less than 4 mm. in 3.1%, which corresponds to a severe degree.

A survey of the comparison group showed that the volume of mouth opening was impaired only in 34% of cases: insignificantly in 30% of cases, expression only in 4%. Violations of the protrusion and laterotrusion movements of the lower jaw in this group were not detected.

Among patients of the OG-1 group, the presence of premature contacts leading to displacement of the lower jaw was detected in 100% of cases, in the GS-1 group it was detected in 14%, in the GS-2 group it was detected in 4%.

In the OG-1 group:

occlusal interferences between the posterior contact position and the central occlusion were detected in 100% of cases. The most common were pronounced - 58.8% and moderate interference - 41.2%;

89% had articulation disorders with multiple premature and balancing contacts.

In patients of the GS-1 group, the displacement of the lower jaw from the posterior contact position to the position of maximum contact of the teeth occurred only in a mild form - 14% (sagittal displacement up to 2 mm, or transversal - up to 0.5 mm), there were no pronounced displacements in this group.

Particular attention was paid to the analysis of the occlusal surfaces of the teeth. The quality of restorations, artificial crowns, made with insufficiently pronounced anatomical features of the chewing surface, which did not provide positioning of the lower jaw, was evaluated.

Deviations in the preservation of the anatomical surface of the teeth were revealed in the OG-1 group in 58% (presence of extensive restorations with filling material, inlays, crowns).

The analysis of the quantity, quality and uniformity of occlusal contacts, the presence of premature contacts was carried out using articulation paper, for this purpose Bauch paper 40 µm, 8 µm was used.

In addition, the results of clinical studies were confirmed by hardware methods, namely: in the study groups, patients underwent X-ray tomography, orthopantomography, panoramic sonography, magnetic resonance imaging of the TMJ, cone beam computed tomography; functional studies were carried out: electromyography of masticatory muscles, MPI analysis - indication of the position of the lower jaw, kinesiography of lower jaw movements, analysis of occlusal contacts using the T-skan computer program.

According to the MRI of the TMJ in patients of the OH-1 group, the following were revealed: deformities of the articular disc shape in 45% of cases, dislocation of the TMJ disc with reduction in 37% of cases (dislocation of the disc without reduction was a sign of exclusion from the study group).

The studied individuals of the GS-1 and GS-2 groups did not undergo MRI of the TMJ due to the lack of indications.

According to the TMJ CBCT data, no changes in the bone tissue of the TMJ articular head were detected in patients OG-1, GS-1 (the presence of changes in bone tissue is an exclusion parameter from the study groups).

Among the examined patients OH-1 revealed distal displacement of the articular heads of the lower jaw in 67% of cases, the asymmetry of the location of the articular heads in the glenoid fossa in 45% of cases.

In patients of the GS-1 group, deviations in the positioning of the articular heads of the TMJ were noted only in 15% of cases (10% - distal displacement of the heads of the TMJ, 5% - asymmetry of the location of the articular heads).

According to the results of EMG analysis in patients of the OG-1 group, a tendency to an increase in the electrical biopotential (EBP) of masticatory muscles up to 2.0 μV, temporal muscles up to 2.1 μV was observed, which indicates the presence of hypertonicity of the studied muscles in patients with TMJ dysfunction.

In patients of the GS-2 group in the state of physiological rest of the lower jaw, the average values of the EBP of the masticatory muscles were 1.5 μV, those of the temporal muscles were 1.6 μV.

Among the patients of the GS-2 group, with the maximum volitional compression of the teeth, the following EBP values were determined: the right temporal muscle - 156 μV, the left one - 119 μV, the right chewing muscle - 185 μV, the left one - 161 μV.

In patients of the OG-1 group, lower values of muscle EBP were noted: right temporal - 77 μV, left - 82 μV, right chewing - 78 μV, left - 93 μV (Table 1). A decrease in this indicator in patients with pain in the TMJ area suggests a lower functional involvement of the muscles.

Evaluation of kinesiography data revealed that in all patients (100%) of the OG-1 group, the trajectory of movements of the lower jaw in the transversal plane was disturbed (deviation - 66.5% or diflexion - 33.5%).

In the GS-1 group, such deviations were detected only in 30% of cases. The trajectory of movement of the lower jaw in the sagittal plane in patients of the GS 2 group was disturbed only in 10%, while in patients of the OG-1 group, changes occurred 3 times more often. This may be explained by the functional displacement of the mandible and/or the presence of premature contacts when the teeth are closed.

An analysis of the position of the mandible in patients of the OG-1 group with TMJ pain syndrome in 100% revealed deviations from neuromuscular traction: displacement of the mandible in the sagittal plane in 96% of cases, in the vertical plane - 100%, in the transversal plane - 45%. In 63% of cases, the usual trajectory of the lower jaw was not parallel to the neuromuscular one.

An analysis of these parameters indicates that most patients have a forced position of the lower jaw. Thus, an analysis of EMG in patients with TMJ pain dysfunction syndrome revealed: an increase in masticatory muscle tone at rest and signs of muscle hypotonicity when teeth are closed, which may indicate a state of chronic muscle overstrain.

In patients of the SG-1 group, lower indices of the symmetry index and the “torque” parameter were determined, which indicates the presence of asymmetry in the work of the muscles and functional displacement of the lower jaw.

All patients of the OG-1 group had disorders in the trajectory of the lower jaw in the transversal plane (deviation - 66.5%, diflexion - 33.5%), 33% of the trajectory in the sagittal plane.

In the OG-1 group, analysis of the position of the lower jaw relative to the neuromuscular trajectory revealed deviations in the position of the lower jaw in 100% of cases, in 63% - not parallel to the neuromuscular trajectory.

Evaluation of the occlusion of the dentition was carried out in a fully adjustable articulator KaVo Protar 9, plastering of the models was carried out according to the intermaxillary register obtained during the neuromuscular examination. As a result of the assessment, the primary points of contact of the teeth and the direction of deviation of the lower jaw were identified to create the maximum number of interlocking teeth.

Among patients of the OG-1 group, the presence of premature contacts, leading to displacement of the lower jaw, was detected in 100% of cases; in the GS-1 group in 14%; in the CG-1 group in 4%.

When assessing the localization of occlusal contacts and the time of their occurrence, premature occlusal contacts were initially analyzed in the central ratio of the jaws, deviating the lower jaw. In the main group OG-1, primary contacts with displacement of the lower jaw were found in 83% of cases (the most common localization is the second molars and first premolars, dystopic teeth).

In the comparison group GS-1, such contacts occurred only in 17% of cases. In the control group GS-2 - were absent.

The distribution of occlusal contacts in the OG-1 group on the sides was predominantly 70:30. In the GS-2 group, the average distribution was 65:35; in the control group, the values approached the norm of 50:50.

The longest time for the formation of dense fissure-tuberous occlusal contacts was found in the main group OG-1 and amounted to 0.45 sec. The increase in time is due to the presence of premature contacts.

In the GS-1 group, the mean time was 0.37 sec. (slight increase in time), in the GS-2 group - 0.28 sec, which corresponded to the norm.

In patients with laterotrusion, among patients with symptoms of TMJ dysfunction and the presence of ACA, the group type of contacts on the canines and premolars was most common (65%), the presence of premature contacts on the balancing side was detected in 75% of cases (mediatrusive supercontacts).

Among the patients of the comparison group, group management was also most often noted (60%), however, balancing supercontacts were significantly less common - in 25% of cases.

In the control group, canine guidance occurred in 80%, the presence of mediotrusive premature contacts was noted only in 10%.

To evaluate the results of the study, the method of multifactorial mathematical analysis and statistical processing of the material was used.

The results of a hardware study of 200 patients confirm the specificity of the declared composition of symptoms as markers of TMJ muscular-articular dysfunction for patients with myogenic pain and their diagnostic effectiveness for reducing and optimizing the study volume.

Thus, it follows from the foregoing that the claimed method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain during exercise solves the problem of optimizing the volume and composition of research methods. At the same time, the claimed method for diagnosing dysfunction of the temporomandibular joint in patients with myogenic nature of pain during implementation ensures the achievement of a technical result: optimization of the diagnostic process, an individual approach to the choice of methods and scope of studies, the possibility of optimizing the volume and composition of research methods, optimizing the radiological scope of the study, reduction of radiation and physiological stress on the patient.

The claimed method for diagnosing temporomandibular joint dysfunction in patients with myogenic pain is as follows. In the process of collecting an anamnesis, by questioning the patient, the presence of markers of temporomandibular joint dysfunction (TMJ) is detected, which determine the myogenic nature of pain, namely: the presence of markers of TMJ joint dysfunctions, the presence of markers of muscle dysfunction, the presence of markers of neurological dysfunction of the TMJ. To identify markers of articular dysfunction in a patient, by questioning, the presence of noises or clicks in the remote or present time during various movements of the lower jaw, with each opening of the mouth, with a wide opening of the mouth and their frequency are revealed; they reveal the presence in the remote or present time of a feeling of impossibility of lower jaw movements (blocking) in the joint, the frequency and conditions under which these sensations occur: when opening the mouth, when the jaw is moved to the side or forward in one movement or with two or more movements.

To identify markers of muscle dysfunction by questioning the patient, the presence of late or present fatigue and fatigue in the TMJ during chewing is detected; the presence in the remote or present time of pain in the neck, occipital, temporal, parotid areas.

To identify markers of neurological dysfunctions, the presence of teeth grinding is established by questioning, whether the teeth are at rest in a closed position, the presence of an increased level of stress at work and/or at home is established. In addition, the patient is asked to fill out questionnaires for assessing the quality of life according to the SF-36 questionnaire.

Then, by physical examination of the patient, symptoms of markers of articular dysfunctions that affect the formation of myogenic pain are detected, namely: a symptom of limitation of movements of the lower jaw, a symptom of dysfunction of the TMJ, a symptom of pain on palpation of the TMJ, (detect) determine the absence of a symptom of pain during movements lower jaw.

The symptoms of markers of muscle dysfunctions that affect the formation of myogenic pain are revealed, namely: a symptom of pain is detected on palpation of the masticatory muscles.

Then, the degree of influence on (TMJ dysfunction) the formation of myogenic pain of the identified symptoms of articular markers is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of myogenic pain are selected, the result is recorded. The degree of influence on the formation of pain of a myogenic nature of the identified symptoms of muscle dysfunctions is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded.

In addition, by physical examination of the patient, the state of occlusal contacts is determined, while examining the parameters characterizing the state of occlusal contacts that have an impact on the formation of pain of a myogenic nature: the number of teeth in the dentition; the number of contacting teeth in occlusion; occlusal interference between the posterior contact position and the central occlusion; articulation interference. The degree of influence of the studied parameters influencing the formation of myogenic pain is assessed, the results of assessing the degree of influence are recorded, compared, and based on the results of the comparison, the parameters characterizing the state of occlusal contacts are selected and recorded, which have the greatest degree of influence on the formation of myogenic pain.

Then, additional studies are carried out by performing CBCT of the skull with 3D visualization, namely: examination of the teeth and dentition, 3D cephalometry and screening analysis of the TMJ, the results of the additional study are recorded.

Then the results of clinical studies obtained as a result of collecting an anamnesis, the results of physical and additional examinations are analyzed. Then, based on information about the identified markers of muscle and joint dysfunction, based on information about the absence of a symptom of pain during movements of the lower jaw, based on information about the identified symptoms of markers of muscle and joint dysfunction that have the maximum effect on the formation of myogenic pain, based on the information obtained in as a result of studying information about the parameters characterizing the state of occlusal contacts that have the maximum impact on the formation of myogenic pain, based on information about the neurological component obtained as a result of interviewing the patient and filling out the patient's quality of life assessment questionnaire in accordance with the SF-36 questionnaire and based on the results additional studies make a preliminary diagnosis, after which, in accordance with the preliminary diagnosis for the patient, an individual study plan is drawn up, based on the results of which the final diagnosis of TMJ dysfunction is made.

The degree of influence on the formation of pain of a myogenic nature of each identified symptom of a marker of articular dysfunctions, each identified symptom of a marker of muscle dysfunctions, each identified parameter characterizing the state of occlusal contacts is quantified in accordance with the criteria adopted in the methods for calculating the clinical dysfunction index and the occlusal dysfunction index proposed M. Helkimo.

EXAMPLE 1. Patient M., 27 years old, turned to an orthodontist with complaints of pain, discomfort in the TMJ area, misalignment of teeth, and absence of teeth.

History of the disease: no previous orthodontic treatment was performed. At the time of referral, the patient had been experiencing TMJ pain for approximately 4 months. Teeth 1.6, 3.6 were extracted for therapeutic indications.

The patient was diagnosed with TMJ in accordance with the claimed method of dysfunction of the temporomandibular joint in patients with myogenic nature of pain.

In the process of collecting an anamnesis, by questioning the patient, the presence of markers of dysfunction of the temporomandibular joint (TMJ) was revealed, which determine the myogenic nature of pain in the area of the articulation of the joint. The presence of markers of articular dysfunctions of the TMJ, the presence of markers of muscle and neurological dysfunctions of the TMJ were revealed. To identify markers of articular dysfunctions, a survey revealed the presence in the remote or present time of noises or clicks during various movements of the lower jaw and their frequency, revealed the presence in the remote or present time of a feeling of impossibility of lower jaw movements (blocking) in the joint, frequency and conditions, in which these sensations arose: when opening the mouth, when the jaw was moved to the side or forward in one movement or in two or more movements. To identify markers of muscle dysfunction, a survey revealed the presence of long-term or present fatigue and fatigue in the TMJ during chewing, the presence of long-term or present pain in the neck, occipital, temporal, parotid regions. To identify markers of neurological dysfunctions, the presence of teeth grinding was established by questioning, it was determined whether the teeth were at rest in a closed position. Established the presence of increased levels of stress at work and / or at home. In addition, the presence of markers of neurological dysfunctions was detected by filling in the patient's questionnaire for assessing the quality of life in accordance with the SF-36 questionnaire.

The calculation of scores for the SF-36 questionnaire was performed in accordance with the “Instructions for processing data obtained using the SF-36 questionnaire” (https://therapy.irkutsk.ru/doc/sf36a.pdf).

The authors of the claimed invention developed a questionnaire for collecting anamnesis in accordance with the claimed method. In FIG. 1, Table 1 shows an example of filling out a questionnaire for patient M., examined in accordance with the claimed method.

The patient noted pain in the chewing muscles, fatigue and fatigue in the temporomandibular joint during chewing. She also noted the presence of pain in the temporal, occipital region (associated with a static posture at work). At night, she noted intense gnashing of teeth, during the day she noted clenching of teeth during stress. Reported the presence of stress at home, at work.

According to the results of the analysis of the SF-36 questionnaire:

1) The parameter of physical functioning was 95 points - indicates that the physical is not limited to the state of health.

2) The parameter of role functioning (physical) was 50 points, which indicates difficulty in performing daily duties.

3) Pain intensity scale indicator - 51 points, which indicates a partial limitation of the patient's activity associated with pain.

4) General health 47 points

5) The scale of vital activity is reduced to 60 points

6) The parameter of social functioning was 50 points, which indicates some limitation of social contacts,

7) Role functioning (emotional) - 33.3 points.

8) The parameter of mental health was 52 points - this indicates the presence of depressive anxiety experiences, psychological discomfort.

Thus, as a result of taking an anamnesis, muscle articular and neurological markers of TMJ dysfunction were identified.

Then, by physical examination of the patient, symptoms of markers of articular dysfunctions that affect the formation of myogenic pain are detected, namely, a symptom of limitation of movements of the lower jaw, a symptom of dysfunction of the TMJ, a symptom of pain on palpation of the TMJ, (detect) determine the absence of a symptom of pain when movements of the lower jaw; identify symptoms of markers of muscle dysfunctions that affect the formation of myogenic pain, namely: identify a symptom of pain on palpation of the masticatory muscles; then, the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of articular markers is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded; the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of muscle dysfunctions is assessed, the results of the assessment are recorded, compared with each other and the symptoms that have the greatest degree of influence on the formation of pain of a myogenic nature are selected, the result is recorded.

The degree of influence on the formation of pain of a myogenic nature of each identified symptom of a marker of articular dysfunctions, each identified symptom of a marker of muscle dysfunctions, each identified parameter characterizing the state of occlusal contacts is quantified in accordance with the criteria adopted in the methods for calculating the clinical dysfunction index and the occlusal dysfunction index proposed M. Helkimo: 0 points - no effect, 1 point - moderate effect, 5 points - pronounced effect.

In accordance with the claimed method, in the exemplary implementation of the proposed method, to assess the degree of influence of symptoms of markers of articular dysfunctions in the TMJ, the following are identified and rated in points: the presence of a symptom of limited movement of the lower jaw, namely, the maximum mouth opening of more than 40 mm, 0 points, from 30 to 39 mm score 1 point, less than 30 mm score 5 points; the maximum displacement of the lower jaw to the right more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the maximum displacement of the lower jaw to the left more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the maximum protrusion movement of the mandible more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; the presence of a symptom of dysfunction of the TMJ, namely, opening and closing the mouth without deviation or with a deviation of less than 2 mm - 0 points, clicks in one or two TMJ and (or) deviation of more than 2 mm when opening the mouth - 1 point, blocking during movements of the lower jaw or subluxation - 5 points, the presence of a symptom of pain on palpation of the TMJ, namely, painless palpation - 0 points; painful palpation from the side - 1 point, painful palpation from the side and from the distal side through the external auditory meatus - 5 points; the presence of a symptom of pain during movements of the lower jaw, namely, the movements are painless - 0 points; pain occurs with one movement - 1 point; pain occurs with two or more movements - 5 points; to assess the degree of influence of the symptoms of the marker of muscle dysfunction, a symptom of pain on palpation of the masticatory muscles is detected and evaluated in points, namely, painless palpation of the masticatory muscles - 0 points; pain on palpation from one to three muscles - 1 point; pain on palpation of four or more muscles - 5 points.

After assessing the degree of influence, the symptoms of markers of joint and muscle dysfunctions with the highest score are selected and recorded.

The results of the studies in the exemplary implementation of the claimed method were recorded: in Table 2 to assess the degree of influence on TMJ dysfunction of the identified symptoms of markers of musculo-articular dysfunction (Fig. 2), and in Table 3. Assessment of the range of motion of the lower jaw of patient M. (Fig. 3) .

A clinical examination of the TMJ and masticatory muscles showed: limited mouth opening (36.9 mm), deviation of the lower jaw when opening the mouth (3.6 mm), with maximum mouth opening, pain in the joint area. On palpation of the masticatory muscles, the soreness of the temporal and masticatory muscles proper is determined on both sides, the sternocleidomastoid muscle on the right, palpation of the TMJ is painless.

When examining the patient, a slight limitation of mouth opening was revealed, which indicates a mild degree of disturbances in the movements of the lower jaw (Fig. 3, Table 3).

At the same time, the symptom of pain during the movement of the lower jaw was not detected, which confirms the myogenic nature of the pain.

By physical examination of the patient, the state of occlusal contacts was determined. At the same time, the parameters characterizing the state of occlusal contacts that affect the formation of myogenic pain were studied: the number of teeth in the dentition; the number of contacting teeth in occlusion; occlusal interference between the posterior contact position and the central occlusion; articulation interference. After that, the influence of the studied parameters influencing the formation of myogenic pain was evaluated. The results of assessing the degree of influence were recorded, compared, and based on the results of the comparison, the parameters characterizing the state of occlusal contacts, which had the greatest degree of influence on the formation of myogenic pain, were selected and recorded.

The results of the examination were entered in Table 4 "Evaluation of the state of occlusal contacts of patient M." (Fig. 4). The state of occlusal contacts of the patient M. is illustrated by the photo in Fig. 7.

As a result of examination of the state of occlusal contacts, the following was revealed (Table 4, Fig. 4).

Analysis of occlusion and articulation: closure of canines on the right according to Engdia class III, on the left according to II, incisal overlap along the sagittal 2.0 mm, vertically 1.5 mm, absence of teeth 1.6, 3.6. Narrowing of the upper dentition, shortening of the dentition. The shift of the midline on the upper jaw to the right by 3.0 mm, on the lower jaw to the left by 2.5 mm. When closing the mouth, one-sided contact of the teeth is determined with the displacement of the lower jaw from the posterior contact position to the central occlusion with a shift of the lower jaw to the left by 1.8 mm. During movements of the lower jaw, multiple articulatory interferences are determined.

After assessing the degree of influence of the state of occlusal contacts on the dysfunction of the TMJ, the signs characterizing the state of occlusal contacts were selected and recorded with the highest score, namely: pronounced violations of occlusion - 5 points and articulation - 5 points.

Then studies were carried out by performing CBCT of the skull with 3D visualization, namely, an assessment of the teeth and dentitions, 3D cephalometry and a screening analysis of the TMJ.

Screening analysis of the TMJ revealed: asymmetry in the location of the articular heads, the absence of morphological signs of TMJ disorders (preservation of the cortical layer of the articular heads on both sides). The study was carried out on a Planmeca apparatus with Romexis software.

The results of clinical studies obtained as a result of the collection of anamnesis, physical and additional examinations are analyzed. Based on information on the identified markers of muscle and joint dysfunction, on the basis of information on the absence of a symptom of pain during movements of the lower jaw, and on the basis of information on the identified symptoms of markers of muscle and joint dysfunction that have the maximum effect on the formation of myogenic pain, on the basis of the results of research information about the parameters characterizing the state of occlusal contacts that have the maximum effect on the formation of myogenic pain, based on information about the neurological component obtained as a result of interviewing the patient and filling out the patient's quality of life assessment questionnaire in accordance with the SF-36 questionnaire and based on the results of additional studies make a preliminary diagnosis.

As a result of the analysis of the results of the performed clinical examination, it can be concluded that the patient has moderate TMJ dysfunction with severe occlusal and articulatory disorders. Deformation of the dentition, occlusal and articulation disorders could be the cause of the displacement of the lower jaw, which led to the formation of a muscular type of dysfunction.

In accordance with the preliminary diagnosis, an individual study plan is drawn up for the patient, based on the results of which the final diagnosis of TMJ dysfunction is made.

Patient M. was assigned an instrumental examination of the masticatory muscles (myography), which resulted in a final diagnosis. The results of myographic studies are shown in Fig. 5 and FIG. 6: at rest, there was an asymmetry of the electrobiopotential of the masticatory and temporal muscles during mowing, hypertonicity of the left temporal muscle and hypotonicity of the right masticatory muscle with slight closing of the teeth. Asymmetry and decrease in the tone of the chewing muscles with the maximum closing of the teeth, a decrease in the tone of the temporal muscles (improving the distribution of biopotential between the temporal and chewing muscles) muscles when closing on cotton rolls. Myography was performed on a K7 Myotronics machine. Further recommended:

1) Consultation and treatment of a neurologist

2) Normalization of the position of the lower jaw with an occlusal splint

3) Orthodontic treatment to eliminate deformations of the dentition

4) Prosthetics in the area of missing teeth.

EXAMPLE 2. Patient D., 30 years old, went to the orthodontist with complaints of pain in the area of masticatory muscles and TMJ.

The patient was diagnosed with TMJ dysfunction in accordance with the claimed method for diagnosing temporomandibular joint dysfunction in patients with myogenic pain, similar to Example 1.

In the process of collecting an anamnesis, by questioning the patient, the presence of markers of dysfunction of the temporomandibular joint (TMJ) was revealed, which determine the myogenic nature of pain in the area of the articulation of the joint.

Anamnesis of the disease: earlier orthodontic treatment was carried out on a full fixed technique (bracket system for both jaws). At the time of treatment, the patient noted pain in the TMJ area for approximately 6 months. With active detection of complaints, gnashing of teeth at night, clenching of teeth during the day was revealed. The patient also notes severe stress on the eve of the onset of pain.

The patient underwent a clinical examination in accordance with the claimed method for diagnosing temporomandibular joint dysfunction in patients with myogenic pain, by analogy with Example 1.

In the process of taking an anamnesis, by questioning the patient, the presence of markers of temporomandibular joint dysfunction (TMJ) was revealed, which determine the myogenic nature of pain in the area of the articulation of the joint, namely: the presence of markers of TMJ joint dysfunctions, the presence of markers of muscular and neurological dysfunctions of the TMJ were revealed. To identify markers of neurological dysfunctions, the presence of teeth grinding was established by questioning, it was determined whether the teeth were at rest in a closed position. Established the presence of increased levels of stress at work and / or at home. In addition, the presence of markers of neurological dysfunctions was detected by filling in the patient's questionnaire for assessing the quality of life in accordance with the SF-36 questionnaire.

Results of the analysis of the SF-36 questionnaire:

1) The parameter of physical functioning was 90 points - it indicates that physical activity is not limited by the state of health.

2) The parameter of role functioning (physical) was 75 points, which indicates difficulty in performing daily duties.

3) Pain intensity scale indicator - 51 points, which indicates a partial limitation of the patient's activity associated with pain.

4) General health 67 points

5) The scale of vital activity is reduced to 65 points

6) The parameter of social functioning was 75 points, which indicates some limitation of social contacts,

7) Role functioning (emotional) - 33.3 points.

8) The parameter of mental health was 56 points - this indicates the presence of depressive anxiety experiences, psychological discomfort.

The results of the studies at the stage of collecting anamnesis were entered into a table (Fig. 8, Table 5).

After analyzing the results of the studies listed in Table 8 (Fig. 8), articular and muscle markers of TMJ dysfunction were identified, and symptoms of neurological dysfunction were identified, which indicates a pronounced nature of TMJ dysfunction.

Then, by physical examination of the patient, the symptoms of markers of articular dysfunctions that affect the formation of myogenic pain are revealed. A physical examination of the temporomandibular joint and masticatory muscles was performed (Fig. 9, Table 6; Fig. 10, Table 7): mouth opening is not limited, movements of the lower jaw are smooth, painless. On palpation of the masticatory muscles, the soreness of the temporal and masticatory muscles on both sides is determined, palpation of the temporomandibular joint is painless.

Symptom with the greatest degree of influence: a symptom of pain on palpation of the masticatory muscles: pain on palpation of 4 or more muscles - 5 points.

At the same time, the symptom of pain during the movement of the lower jaw was not detected, which confirms the myogenic nature of the pain.

Analysis of occlusion and articulation (Fig. 11, Table 8): closure of canines and molars on the right according to Angle class I, on the left according to II, incisal overlap along the sagittal 2.0 mm, vertically 3.0 mm.

The shift of the midline on the lower jaw to the left by 2.0 mm. When closing the mouth, one-sided contact of the teeth is determined with the displacement of the lower jaw from the posterior contact position to the central occlusion with a shift of the lower jaw back by 2.5 mm.

Thus, the analysis of the state of occlusal contacts (Fig. 11) revealed severe violations of occlusion - 5 points and articulation - 5 points.

When performing CBCT of the skull with 3D imaging, assessment of the teeth and dentition, 3D cephalometry and screening analysis of the TMJ were performed.

Screening analysis of the TMJ revealed: distal displacement of the articular heads of the TMJ, the absence of morphological signs of TMJ disorders (preservation of the cortical layer of the articular heads on both sides). The study was carried out on a Planmeca apparatus with Romexis software.

According to the results of clinical studies, it can be concluded that the patient has a moderate degree of predominantly muscular dysfunction with severe occlusal and articulation disorders, with the presence of neurological markers. Deformation of the dentition, occlusal and articulatory disorders, stress and signs of bruxism (night grinding of teeth, clenching of teeth during the day) could be the cause of the formation of a muscular type of dysfunction.

Taking into account the identified features, the patient was assigned an instrumental study of the masticatory muscles - myography (Fig. 12, Fig. 13). At rest, there was an asymmetry in the electrobiopotential of masticatory and temporal muscles. Hypertonicity of the left and right (to a lesser extent) temporal and left masticatory muscles; hypotonicity of the right masticatory muscle with slight closing of the teeth. Decrease in the tone of the masticatory muscles with the maximum closing of the teeth, an increase in the tone of the masticatory muscles when closing on cotton rolls.

Myography was performed on a K7 Myotronics machine.

Examination of the patient revealed no disturbances in the movements of the lower jaw, which indicates the preservation of the function of the TMJ proper and confirms the myogenic nature of the pain.

During movements of the lower jaw, multiple articulatory interferences are determined.

The following diagnosis was made: distal occlusion, shortening of the dentition, anomalies in the position of individual teeth, midline shift in the lower jaw to the left by 2.0 mm, functional displacement of the lower jaw, bruxism.

The patient is advised:

1) Consultation and treatment by a neurologist,

2) Normalization of the position of the lower jaw with the help of an occlusal splint,

3) Repeated orthodontic treatment fixing the lower jaw in a new position.

Claims (1)

A method for studying dysfunction of the temporomandibular joint in patients with a myogenic nature of pain, including the study of complaints, examination of the face and oral cavity of the patient, the collection of anamnesis, the diagnosis of dysfunction, characterized in that in the process of collecting anamnesis, by questioning the patient, the presence of markers of dysfunction of the temporomandibular joint is revealed (TMJ), which cause the myogenic nature of pain, namely: they reveal the presence of markers of TMJ joint dysfunctions, the presence of markers of muscle dysfunction, the presence of markers of neurological dysfunctions of the TMJ, while to identify markers of articular dysfunction in a patient, by means of a survey, the presence of noises or clicks in real time is detected during various movements of the lower jaw, when opening the mouth; reveal the presence in the present time of the feeling of the impossibility of movements of the lower jaw in the joint, the frequency and conditions under which these sensations occur: when opening the mouth, when the jaw is moved to the side or forward in one movement or in two or more movements; to identify markers of muscle dysfunction by questioning the patient, the presence of real fatigue and fatigue in the temporomandibular joint during chewing is detected; the presence in the present of pain in the neck, occipital, temporal, parotid areas; to identify markers of neurological dysfunctions, the presence of teeth grinding is determined by questioning, whether the teeth are at rest in a closed position, the presence of an increased level of stress at work and / or at home is established, in addition, the patient fills out questionnaires for assessing the quality of life according to the SP-36 questionnaire , then by physical examination of the patient, the symptoms of markers of articular dysfunctions, muscle dysfunctions and parameters that determine the state of occlusal contacts, which affect the formation of pain of a myogenic nature, are revealed, and the degree of their influence is assessed in points, while in order to identify symptoms of markers of articular dysfunctions, the following is determined: the presence of a symptom of limitation movements of the lower jaw, with a maximum mouth opening of more than 40 mm, 0 points, from 30 to 39 mm, 1 point, less than 30 mm, 5 points, the maximum displacement of the lower jaw to the right, more than 7 mm, 0 points, from 4 to 6 mm, 0 points 1 point, from 0 to 3 mm score 5 points, the maximum displacement of the lower jaw to the left more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points, the maximum protrusion movement of the lower jaw is more than 7 mm score 0 points, from 4 to 6 mm score 1 point, from 0 to 3 mm score 5 points; identify and evaluate in points the presence of a symptom of a dysfunction of the TMJ, namely: opening and closing the mouth without deviation or with a deviation of less than 2 mm - 0 points, clicks in one or two TMJ and / or deviation of more than 2 mm when opening the mouth - 1 point, blocking during movements of the lower jaw or subluxation - 5 points, the presence of a symptom of pain on palpation of the TMJ is detected and evaluated in points, namely: painless palpation - 0 points, painful - palpation from the side - 1 point, painful palpation from the side and from the distal side through the external auditory passage - 5 points, the presence of a symptom of pain during movements of the lower jaw, namely: the movements are painless - 0 points; pain occurs with one movement - 1 point, pain occurs with two or more movements - 5 points; determine the absence of a symptom of pain during movements of the lower jaw; the results of assessing the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of markers of articular dysfunctions are compared with each other and the symptoms that have the greatest degree of influence are selected, the result is recorded; then, the symptoms of markers of muscle dysfunctions that affect the formation of myogenic pain are identified and evaluated in points, namely: the symptom of pain on palpation of the chewing muscles is identified and evaluated, namely: painless palpation of the chewing muscles - 0 points, pain on palpation from one to three muscles - 1 point, pain on palpation of four or more muscles - 5 points; the results of assessing the degree of influence on the formation of pain of a myogenic nature of the identified symptoms of muscle dysfunctions are compared with each other and the symptoms that have the greatest degree of influence are selected, the result is recorded; in addition, by physical examination of the patient, the state of occlusal contacts is determined and evaluated in points, while examining the parameters characterizing the state of occlusal contacts that affect the formation of myogenic pain, namely: the number of teeth in the dentition, the number of contacting teeth in occlusion , occlusal interference between the posterior contact position and central occlusion, articulation interference, while the degree of influence is evaluated in points, namely: 0 points - no effect, 1 point - moderate effect, 5 points - pronounced effect, while occlusal interference between the posterior contact position and central occlusion in case of its absence or in the presence of direct symmetrical sliding from RCP to IP no more than 2 mm, score 0 points; in the case of unilateral contact in the RCP and during sliding in IP with a sliding distance of less than 2 mm and/or with a lateral mandibular displacement of less than 0.5 mm when sliding from RCP to IP, occlusal interference between the posterior contact position and the central occlusion is characterized as moderate interference and evaluate 1 point; with a lateral displacement of the lower jaw of more than 0.5 mm when sliding from RCP to IP and / or the distance between RCP and IP is more than 2 mm, occlusal interference between the posterior contact position and central occlusion is characterized as severe interference, 5 points are assessed; in the study and assessment of the degree of influence on the formation of pain of the myogenic nature of articulation interference, the absence of premature occlusal contacts is estimated at 0 points; the presence of single contacts of the teeth on the working side distal to the canines and / or one-sided contact during protrusion is scored 1 point; the presence of balancing contacts is 5 points, the results of assessing the degree of influence of the state of occlusal contacts that affect the formation of myogenic pain are compared with each other and, based on the results of the comparison, the parameters characterizing the state of occlusal contacts that have the greatest degree of influence are selected and fixed; then additional examinations of the patient are carried out by performing cone beam computed tomography (CBCT) of the skull with 3D visualization, namely: examination of the teeth and dentition, 3D cephalometry and screening analysis of the TMJ.

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