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科斯滕综合征Costen's syndrome

根据美国颌面疼痛协会 (AAOP) 的定义，颞下颌关节紊乱病 (TMD) 是：
“一个统称，涵盖了一系列涉及咀嚼肌、颞下颌关节和相关结构，或两者兼有的临床问题。”（1）

过去曾使用过几个术语来描述 TMD，包括 Costen 综合征、颞下颌关节功能障碍综合征、颞下颌关节紊乱和颅下颌综合征 (1)。

大约 60-70% 的普通人群至少有一种颞下颌关节紊乱症的症状 (2)

  • 只有 5% 出现症状的患者会寻求治疗
  • 在成年早期最为常见（2），且女性比男性更常见。
  • 这些情况造成的不适是偶尔且暂时的
  • 它们经常循环发生
  • 几乎无需治疗，疼痛最终就会消失
  • 有些人会出现明显的长期症状（3）。

TMD 是一类与形态和功能畸形相关的退行性肌肉骨骼疾病

  • TMD 包括关节内椎间盘位置和/或结构异常以及相关肌肉功能障碍

这些情况主要分为三类（4）：

  • 肌筋膜疼痛
    • 这是最常见的颞下颌关节疾病
    • 它会导致控制下颌功能的肌肉出现不适或疼痛。
  • 关节内部紊乱
    • 这涉及椎间盘移位，下颌脱臼，或髁损伤。
  • 关节炎
    • 这是指一组影响关节的退行性/炎性关节疾病。

症状和体征包括疼痛的关节音、运动范围受限或偏离，以及被称为颌面痛的颅骨和/或肌肉疼痛 (5)

TMD 是一种症状复合体（即一组同时出现的、表征特定疾病的症状）

  • 颞下颌关节紊乱症的病因包括：

    • 可能是多因素的

    • 关节囊发炎或损伤以及肌肉疼痛或痉挛可能由以下原因引起：
      • 异常功能习惯（如磨牙症、咬牙、咬嘴唇）
      • 压力，焦虑
      • 关节内盘异常
      • 异常习惯可能会在某些患者的症状发作或持续过程中发挥作用
        • 因果关系仍不确定
      • 一些证据表明，焦虑、压力和其他情绪障碍可能会加剧颞下颌关节紊乱症，尤其是对于患有慢性疼痛的患者
        • 过去，人们对咬合因素作为 TMD 的致病因素的兴趣尤为广泛，但该理论后来因缺乏证据而失宠并引起争议 - 一项系统评价得出结论：“似乎缺乏进一步假设牙齿咬合在 TMD 病理生理学中的作用的证据。”（6）

短期治疗包括非常柔软的饮食和简单的镇痛治疗，可能足以治疗轻微症状：

  • 非药物治疗包括患者教育和安慰、下颌休息、软食、疼痛部位热敷和被动伸展运动（7）
    • 伸展运动和下颌运动可能会改善运动范围，但不一定能改善疼痛
  • 药物治疗（7）
    • 除非有禁忌症，非甾体抗炎药 (NSAID) 是治疗 TMD 相关急性和慢性疼痛的一线药物
    • 肌肉松弛剂，如苯二氮卓类药物
      • 可能对复发性咀嚼肌痉挛和慢性磨牙症患者有用，因为放松技术对这些患者无效
    • 三环类抗抑郁药，如阿米替林
      • 可以试用，因为它们通常对其他慢性和局部疼痛障碍有效

长期治疗可能涉及牙齿矫正或压力缓解。可能需要转诊至专科诊所：

  • 证据审查指出，中等确定性证据表明，与安慰剂或假手术相比，辅以生物反馈或放松疗法的认知行为疗法、治疗师辅助的下颌活动以及手动触发点疗法可能是缓解疼痛最有效的干预措施 (8)

笔记：

  • 颞下颌关节由双侧颞下颌关节 (TMJ) 组成
    • 每个关节由下颌髁及其相应的颞腔（关节盂和关节隆起）组成
      • TMJ 及其相关结构在以下方面发挥着重要作用：
        • 引导下颌运动
        • 分散日常活动（如咀嚼、吞咽和说话）产生的压力

参考：

 

 

According to the American Association of Orofacial Pain (AAOP) definition, a temporomandibular disorder (TMD) is:
“a collective term embracing a number of clinical problems that involve the masticatory musculature, the Temporomandibular joint and associated structures, or both.” (1)

Several terms have been used in the past to describe TMD which include Costen’s syndrome, temporomandibular joint dysfunction syndrome, temporomandibular joint disorders, and craniomandibular syndrome (1).

Around 60-70% of the general population has at least one sign of a temporomandibular disorder (2)

  • only 5% of patients with symptoms will seek treatment
  • most common in early adulthood (2) and in women than in men.
  • discomfort from these conditions is occasional and temporary
  • often they occur in cycles
  • the pain finally disappears with little or no treatment
  • some develop significant, long-term symptoms (3).

TMD are a class of degenerative musculoskeletal conditions associated with morphological and functional deformities

  • TMD include abnormalities of the intra-articular discal position and/or structure as well as dysfunction of the associated musculature

The conditions fall into three main categories (4):

  • myofascial pain
    • this is the most common temporomandibular disorder
    • it involves discomfort or pain in the muscles that control jaw function.
  • internal derangement of the joint
    • this involves a displaced disc, dislocated jaw, or injury to the condyle.
  • arthritis
    • this refers to a group of degenerative/inflammatory joint disorders affects the joint.

Symptoms and signs include painful joint sounds, restricted or deviating range of motion, and cranial and/or muscular pain known as orofacial pain (5)

TMD is a symptom complex (i.e. a group of symptoms occurring together and characterizing a particular disease)

  • aetiological factors for TMJ disorders include:

    • likely to be multifactorial

    • capsule inflammation or damage and muscle pain or spasm may be caused by:
      • parafunctional habits (e.g., bruxism [teeth grinding], teeth clenching, lip biting)
      • stress, anxiety
      • abnormalities of the intra-articular disk
      • parafunctional habits may play a role in initiating or perpetuating symptoms in some patients
        • the cause-and-effect relationship remains uncertain
      • some evidence to suggest that anxiety, stress, and other emotional disturbances may exacerbate TMJ disorders, especially in patients who experience chronic pain
        • interest in occlusal factors as a causative factor in TMD was especially widespread in the past, and the theory has since fallen out of favour and become controversial due to lack of evidence - a systematic review concluded that " seems to lack ground to further hypothesise a role for dental occlusion in the pathophysiology of TMD.." (6)

Short term treatment consists of a very soft diet and simple analgesia, and may be sufficient for mild symptoms:

  • non-pharmacological treatments include patient education and reassurance, jaw rest, a soft diet, warm compress over the region of pain and passive stretching exercises (7)
    • stretching and jaw exercises may improve range of movement but may not necessarily improve pain
  • pharmacological treatments (7)
    • unless contraindicated, nonsteroidal inflammatory drugs (NSAIDs) represent the first-line pharmacological agents used for acute and chronic pain associated with TMD
    • muscle relaxants, such as benzodiazepines
      • may be useful in patients with recurrent masticatory muscle spasm and chronic bruxism where relaxation techniques are ineffective
    • tricyclic antidepressants, such as amitriptyline
      • can be trialled as they are often effective in other chronic and regional pain disorders

Long term treatment may involve dental correction or stress relaxation. Referral to a specialist clinic may be needed:

  • an evidence review states that moderate certainty evidence shows that, compared with placebo or sham procedures, cognitive behavioural therapy augmented with biofeedback or relaxation therapy, therapist-assisted jaw mobilisation, and manual trigger point therapy are probably among the most effective interventions for pain relief (8)

Notes:

  • temporomandibular articulation is composed of bilateral, diarthrodial, temporomandibular joints (TMJs)
    • each joint is formed by a mandibular condyle and its corresponding temporal cavity (glenoid fossa and articular eminence)
      • TMJ and its associated structures play an essential role in
        • guiding mandibular motion
        • distributing stresses produced by everyday tasks, such as chewing, swallowing, and speaking

Reference:

 

 

一、 病因Aetiology

  • 颞下颌关节紊乱症的病因并不总是很清楚 (1)，但可能是由多种因素造成的 (2)
  • 这些因素可分为起始因素、诱发因素和持续因素（3）

  • 一些颞下颌关节紊乱症的可能原因包括：
    • 下颌受到严重打击造成的创伤
    • 关节退化
    • 骨关节炎
    • 类风湿关节炎
    • 椎间盘移位或脱位（4）
    • 其他形式的炎症

  • 其他可能的致病因素包括（1）
    • 牙齿错颌畸形不再被视为致病因素 - 系统评价的结论是“似乎缺乏进一步假设牙齿咬合在 TMD 病理生理学中的作用的证据。”（5）
    • 情绪压力导致咬肌痉挛
      • 对压力的反应
      • 焦虑
    • 导致下颌肌肉过度劳累的习惯，例如（1）
      • 咬笔
      • 口香糖
      • 过度热情的亲吻
    • 头部、颈部和肩部姿势不良（1）
      • 例如，使用电脑时将头向前倾或弯腰驼背
        • 这可能会拉伤与下颌肌肉和关节相关的肌肉和骨骼系统

  • 大约 75% 的颞下颌关节紊乱症患者有严重的心理异常，如焦虑症、抑郁症和其他情绪障碍 (2)。

参考：

 

  • the causes of TMJ disorders are not always clear (1) but is likely to be multifactorial (2)
  • these can be divided into initiating factors, predisposing factors and perpetuating factors (3)

  • probable causes of some TMJ disorders include:
    • trauma from a severe blow to the jaw
    • degeneration of the joint
    • osteoarthritis
    • rheumatoid arthritis
    • displacement or dislocation of the disk (4)
    • other forms of inflammation

  • other probable contributing causal factors include (1)
    • dental malocclusion is no longer considered a causal factor - a systematic review concluded that " seems to lack ground to further hypothesise a role for dental occlusion in the pathophysiology of TMD.." (5)
    • emotional stress producing masseter spasm
      • responses to stress
      • anxiety
    • habits that overwork the jaw muscles, such as (1)
      • chewing on a pen
      • chewing gum
      • overenthusiastic kissing
    • poor posture of the head, neck and shoulders (1)
      • e.g. pushing the head forward or slouching while working at a computer
        • this may strain the muscular and skeletal systems that are related to the jaw muscles and joints

  • about 75 % of patients with TMJ disorders have a significant psychological abnormality e.g - anxiety and depression disorders and other emotional disturbances (2).

Reference:

 

二、临床表现Clinical features

该疾病的三个主要特征是（1）：

  • 颌面疼痛 - 最常见的症状，可能是 (1)
    • 被描述为钝痛、单侧或双侧疼痛（2,3）
    • 经常出现在耳屏正前方
    • 疼痛可能涉及颞部、颈部和枕部 (2)，但疼痛放射至耳朵、太阳穴、脸颊和下颌骨则高度提示患有 TMD (1)
  • 关节噪音 - 咔哒声或爆裂声（3）
    • 摩擦、碾磨或嘎吱嘎吱声——骨关节炎（3）
    • 可以通过触诊或将听诊器放在颞下颌关节上来检测
  • 下颌功能受限
    • 可以描述为一种“全身紧绷感”，通常是由于肌筋膜疾病引起的，或者是一种下颌突然“卡住”、“卡住”或“锁住”的感觉，通常是由于内部紊乱引起的 (1)
      • 颌骨锁定可以是 - 张开（无法完全闭合）或闭合（无法完全张开）
    • 在张口时，关节经常会偏向下颌骨的患侧

可能存在其他非特异性特征：

  • 头痛。
  • 耳痛
  • 颈部和肩部疼痛
  • 耳鸣
  • 潜在压力、焦虑、抑郁（1、3）

放射线照相可以揭示颞下颌关节的退化。

如果怀疑患有全身性关节疾病，则需要进行血清学检查。

参考：

The three cardinal features of the disorder are (1):

  • orofacial pain - most common presenting complain, it may be (1)
    • described as a dull, unilateral or bilateral pain (2,3)
    • frequently seen immediately in front of the tragus of the ear
    • pain may involve the temporal, cervical and occipital regions (2) but pain radiating to the ear, temple, cheek, and along the mandible is highly suggestive of TMD (1)
  • joint noise - clicking or popping noise (3)
    • grating, grinding, or crunching - in osteoarthritis (3)
    • can be detected either by palpation or by a stethoscope placed over the temporomandibular joint
  • restricted jaw function
    • can be described as a “generalised tight feeling” commonly due to a myofacial disorder or as a sensation that the jaw suddenly 'catches', 'gets stuck', or 'locks' usually resulting from internal derangement (1)
      • locking of the jaw can be - open (inability to close fully) or closed (inability to open fully)
    • often the joint may deviate to the affected side of the mandible during opening of the mouth

Other non specific features may be present:

  • headache.
  • earaches
  • neck and shoulder pain
  • tinnitus
  • underlying stress, anxiety, depression (1,3)

Radiography may reveal degeneration of the temporomandibular joint.

Serological investigations are required if a systemic joint disease is suspected.

Reference:

三、 检查

 

 

体格检查可能发现以下情况：

  • 肌筋膜疼痛
    • 头部和颈部多个部位出现钝性、弥漫性、周期性疼痛（1,2）
    • 如果患者在睡觉时咬牙或磨牙（磨牙症），早晨疼痛会加剧（2）
    • 关节周围弥漫性肌肉压痛，下​​颌功能受限（2）
    • 磨牙症导致牙齿磨损（2）
  • 内部错乱
    • 疼痛持续存在，局限于颞下颌关节，并因下颌运动而加剧（1）
    • 下颌运动受限，张口和闭口时关节偏移（1）
  • 骨关节炎
    • 摩擦音或刺耳的声音
    • 颞下颌关节局部疼痛或肿胀可能提示关节内有炎症 (2)

颞下颌关节和咀嚼肌检查 (3)

  • 这应该包括仔细触诊所有结构
  • 确定肌痉挛和肌筋膜触发点
    • 这可以通过触诊咬肌或胸锁乳突肌来完成
    • 可以通过在患者张嘴和闭嘴时将手指放在颞下颌关节上或耳道内来进行
    • 张口时出现的咔哒或爆裂感可能表明下颌运动过程中关节内盘发生移位
      • 咔哒声是一种常见症状
      • 这是颞下颌关节紊乱症的诊断标准之一
      • 与疼痛严重程度或功能限制没有很好的相关性
      • 没有发出咔哒声并不是一个可靠的症状
  • 颞下颌关节局部疼痛或肿胀可能表明关节内有炎症

参考：

 

Physical examination may reveal the following:

  • myofascial pain
    • dull, diffuse, cyclic pain seen in several sites of the head and neck (1,2)
    • pain is worse in the morning in cases where the patient have been clenching or grinding (bruxism) their teeth while asleep (2)
    • diffuse muscle tenderness around the joint with limited jaw function (2)
    • wear facets on the dentition in bruxism (2)
  • internal derangement
    • pain is continuous, localized to the temporomandibular joint and is exacerbated by jaw movement (1)
    • mandible movement is restricted with deviation of the joint during opening and closing (1)
  • osteoarthritis
    • crepitus or grating sounds
    • pain or swelling localized to the TMJ can indicate intra-articular inflammation (2)

Examination of the TMJ and masticatory muscles (3)

  • this should include careful palpation of all structures
  • determining myospasm and myofascial trigger points
    • this may be done by palpation of the masseter or sternocleidomastoid muscles
    • it can be performed by placing a finger over the TMJ or into the ear canal while the patient opens and closes the mouth
    • a clicking or popping sensation that occurs when mouth opening may indicate displacement of the intra-articular disk during mandibular movement
      • clicking is a common symptom
      • it is part of the diagnostic criteria for TMJ disorders
      • it does not correlate well with pain severity or functional limitation
      • the absence of clicking sounds is not a reliable symptom
  • pain or swelling localized to the TMJ can indicate intra-articular inflammation

Reference:

 

 

四、 鉴别诊断 Differential diagnosis

颌面疼痛的鉴别诊断包括（1）：

  • 颞下颌关节紊乱
  • 牙齿原因：
  • 牙脓肿
  • 智齿萌出
  • 神经痛和神经性疼痛障碍：
  • 带状疱疹和带状疱疹后神经痛
  • 三叉神经痛
  • 乳突炎
  • 外耳炎
  • 中耳炎
  • 腮腺炎 (1)
  • 颞动脉
  • 创伤
  • 骨折
  • 位错 (2)

参考：

 

The differential diagnosis for orofacial pain include (1) :

  • TMJ disorders
  • dental causes:
  • tooth abscess
  • wisdom tooth eruption
  • neuralgias and neuropathic pain disorders:
  • herpes zoster and postherpetic neuralgia
  • trigeminal neuralgia
  • mastoiditis
  • otitis externa
  • otitis media
  • parotitis (1)
  • temporal arteriris
  • trauma
  • fractures
  • dislocations (2)

Reference:

五、管理 Management

所提出模式的目标是：

  • 1）增加下颌运动范围，
  • 2）减少关节和咀嚼肌疼痛和炎症，
  • 3）防止关节组织进一步退化，包括直接或间接的关节损伤

  • 一般而言，无论是否接受治疗，颞下颌关节紊乱症的症状和体征都会随着时间的推移而改善 (1)
  • 一年内约有 50 % 有所改善，三年内约有 85 % 有所改善 (1)

  • 保守治疗（2）
    • 自我护理实践
      • 这些步骤可能有助于缓解症状，例如：
        • 吃软食
        • 对疼痛部位进行热敷（5）
        • 避免下颌剧烈运动
        • 缓解压力的放松技巧，用于放松和减轻压力（3）
        • 进行轻柔的下颌伸展和放松运动

    • 药物
      • 非甾体抗炎药（NSAIDS），例如布洛芬，可以暂时缓解下颌不适。
      • 肌肉松弛剂
      • 抗抑郁药
        • 三环类抗抑郁药可用于治疗疼痛（包括夜间磨牙引起的疼痛）（1）
        • 用于治疗慢性疼痛综合征的抗抑郁药也可能有帮助
        • 处方选择性血清素再摄取抑制剂时应谨慎
          • 这些很少会导致磨牙症（1）

    • 稳定夹板
      • 非侵入性咬合夹板和咬合调整有助于建立咬合和颞下颌关节的平衡 (4)
        • 咬合或咬合位置是关节系统中的第三个重要元素，也是全科牙医经常关注的元素
          • 夹板和调整的最终目的是通过建立稳定性来最大限度地减少关节和咀嚼肌的疼痛
          • 夹板可用于控制磨牙症，磨牙症与牙齿磨损、错颌畸形、肌筋膜疼痛、咀嚼肌劳损、疲劳和纤维化有关
          • 这种疗法的长期有效性仍存在争议

  • 不可逆治疗 (2)
    • 外科手术
    • 植入物

有关慢性疼痛（持续时间超过 3 个月的疼痛）管理的 NICE 指导，请参阅链接项目。

参考：

 

Goals of the presented modalities are to:

  • 1) increase mandibular range of motion,
  • 2) decrease joint and masticatory muscle pain and inflammation, and
  • 3) prevent further degenerative change in articulating tissues, including direct or indirect joint damage

  • generally, the signs and symptoms of TMJ disorders improve over time with or without treatment (1)
  • about 50 % improve in one year and 85 % improve completely in three years (1)

  • conservative treatments (2)
    • self-care practices
      • these steps may be helpful in easing symptoms, such as:
        • eating soft foods
        • warm compress over the region of pain (5)
        • avoiding extreme jaw movements
        • stress-relieving relaxation techniques for relaxing and reducing stress (3)
        • practicing gentle jaw stretching and relaxing exercises

    • medications
      • nonsteroidal anti-inflammatory drugs (NSAIDS), such as ibuprofen, may provide temporary relief from jaw discomfort.
      • muscle relaxants
      • anti-depressants
        • tricyclic antidepressants can be used to treat pain (including pain from nighttime bruxism) (1)
        • antidepressants that are used in chronic pain syndromes may also be helpful
        • care should be taken when prescribing selective serotonin reuptake inhibitors
          • these may rarely cause bruxism (1)

    • stabilization splints
      • non-invasive, occlusal splints and occlusal adjustments work to establish balance in the occlusion and TMJs (4)
        • the occlusion, or bite position, is a third and important element in the joint system and is the element often addressed by general dentists
          • ultimate goal of splints and adjustments is to minimize pain in the joint and masticatory muscles by establishing stability
          • splints may be used to control bruxism, which has been associated with tooth attrition, malocclusion, myofacial pain, and masticatory muscle strain, fatigue, and fibrosis
          • long-term effectiveness of this therapy remains controversial

  • irreversible treatments (2)
    • surgery
    • implants

For NICE guidance regarding management of chronic pain (pain that lasts for more than 3 months) then see linked item.

Reference:

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