Etiologija boli i poremećene funkcije u čeljusnom zglobu i u okolnim mišićima : disertacija - Grgurević, Jakša; Knežević, Goran, stomatolog; Kobler, Pavel; Virag, Mišo (Zagreb : J. Grgurević, 1995)
Sažetak: Mnogobrojna istraživanja provedena diljem svijeta potvrđuju da je etiologija bolne disfunkcije čeljusnoga zgloba multifaktorijalna i da je pod jakim utjecajem duševnih čimbenika. Budući da je pacijenata koji nam se javljaju na pregled zbog bolova u području čeljusnoga zgloba i žvačnih mišića sve više, odlučili smo proučavati skupinu pacijenata kako bismo utvrdili čimbenike nastanka i podržavanja bolnih disfunkcijskih smetnji čeljusnoga zgloba u našoj populaciji. Istraživanje je provedeno na skupini nasumce odabranih bolesnika s bolovima i smetnjama u području čeljusnoga zgloba i žvačnih mišića koji su se javili na pregled u Ambulantu za oralnu kirurgiju Klinike za kirurgiju čeljusti lica i usta u Zagrebu. Skupina je brojila 379 bolesnika i činilo ju je 92 muškarca (24.27%) i 287 žena (75.73%) mlađe dobi.
Do 40 godina života bilo je 72.3% bolesnika. Bolesnici su temeljito anamnestički i klinički obrađeni, a prema potrebi su rađene i rendgenske snimke zgloba. Prije dolaska na pregled jedna trećina bolesnika je bila na pregledu kod raznih liječnika specijalista, što pokazuje nekarakterističnost simptoma a i nedovoljnu upućenost liječnika opće medicine i stomatologa u navedenu problematiku. Mali dio bolesnika imao je specifične bolesti koje mogu izravno zahvatiti čeljusni zglob, reumatizam (13.2%) i psorijazu (1.3%). Glavobolja, koja se javlja u 32% bolesnika, i smetnje sluha, koje se javljaju u 44% bolesnika, najvažniji su periferni simptomi bolne disfunkcije čeljusnoga zgloba. Najčešći simptom i klinički znak jest bol u području čeljusnoga zgloba. Ona se javlja u 80% bolesnika i glavni je razlog odlaska bolesnika na pregled.
U slučajevima kada je bol postojala već od početka pojave simptoma, bolesnici su se odmah javljali na pregled, 25% bolesnika već u prvih mjesec dana. U slučajevima kada se bol javila kasnije od ostalih simptoma, bolesnici su se javili vrlo kasno na pregled, 25% nakon više godina od nastanka prvih simptoma. Zbog refleksne boli, koja se je javila u 57% bolesnika, bolesnici su potražili pomoć raznih liječnika specijalista prije nego što su došli k nama na pregled; na primjer, refleksna se bol u uhu javila u 41% slučajeva. Škljocanje zgloba se javlja u 51% bolesnika i to uglavnom recipročno škljocanje, u 81% slučajeva, a ostali su tipovi škljocanja rjeđe zastupljeni. Rezultat pokazuje da 43% bolesnika ima unutarnju poremećenost zgloba. Bol u žvačnim mišićima javlja se u 47% bolesnika i to najviše u lateralnom pterigoidnom mišiću, u 32% slučajeva.
Čestoća simptoma i kliničkih znakova bolne disfunkcije čeljusnoga zgloba u naših bolesnika podjednaka je u čestoći simptoma i znakova koje su utvrdili mnogi istraživači u raznim populacijama diljem svijeta. Svi se simptomi i klinički znakovi javljaju u većem broju u žena. Prihvatljiva objašnjenja za takvu pojavu nema. Škripanje se u čeljusnom zglobu javilo u 8% bolesnika. Akutna upala čeljusnoga zgloba, arthritis, imalo je 1% bolesnika. Rendgenološki vidljive promjene u području čeljusnoga zgloba imalo je 19% bolesnika, no oštećenja je koštanih struktura čeljusnoga zgloba imalo samo 11% bolesnika. Istraživanje je razotkrilo nedovoljnu radiološku dijagnostiku u našoj sredini. U budućnosti svakako treba poboljšati radiološku dijagnostiku rutinskom uporabom tomografije i artrografije čeljusnoga zgloba, a po potrebi i CT-e i MR-a.
Iz dobivenih rezultata (dob bolesnika, čestoća škljocanja i boli u žvačnim mišićima, čestoća škripanja i rendgenološki vidljivih promjena u zglobu) vidljivo je da 90% bolesnika ima disfunkcijske smetnje, a samo 10% bolesnika ima organsku bolest čeljusnoga zgloba. Usporedbom dobivenih rezultata je uočeno: Protetski radovi koji utječu na promjenu visine okluzije pogoduju nastanku boli u žvačnim mišićima ali ne utječu znatnije na unutarnju poremećenost čeljusnoga zgloba. Na ograničeno otvaranje usta, do 40 mm interincizalnog razmaka, više utječe bol u žvačnim mišićima nego unutarnja poremećenost čeljusnoga zgloba. Stanje zubala ne može se izravno povezati s nastankom bolne disfunkcije čeljusnog zgloba.
Kako bi se točnije odredilo stanje zgloba i lakše pratile promjene u zglobu, preporučuje se da se iz kliničke uporabe isključi izraz bolna disfunkcija čeljusnoga zgloba i uvedu precizne dijagnoze za svako stanje čeljusnoga zgloba.
Summary: Numerous research all over the world confirm that temporomandibular joint pain dysfunction syndrome has multifactorial etiology which is largely due to psychological factors. The constantly increasing number of patients complaining of pain in the temporomandibular joint and masticatory muscles was the reason for studying a group of patients in order to determine the factors causing the occurrence and continuation of temporomandibular joint painful dysfunctional disorders in our population. The research was done on a group of randomly selected patients with pain and disorders in the temporomandibular joint and masticatory muscles who came to the Department for oral surgery at the Clinic for maxillofacial and oral surgery in Zagreb. The group consisted of 379 patients, 92 males (24.27%) and 287 females (75.73%).
72.3% of the total number were in the under -40 age group. The patients had a thorough anamnestic and clinical procedure, and radiography of the temporomandibular joint was performed when necessary. Before coming to us, one-third of the patients had been examined by various specialists, which points to a lack of characteristic features of the symptoms as well as to insufficient familiarity with the problem by general practitioners and stomatologists. Few patients had specific diseases which can directly affect the temporomandibular joint, i.e. rheumatism 13.2% and psoriasis 1.3%. Headache occurring in 32% of the patients, and hearing disturbances occurring in 44% of the patients, are the most significant peripheral symptoms of the temporomandibular joint painful dysfunction.
The most frequent symptom and clinical sign is pain in the temporomandibular joint, occurring in 80% of the patients, which is the main reason why the patients came for examination. In the cases where pain was present together with the occurrence of the symptoms, the patients came for examination immediately, 25% in the first month, while in the cases when the pain occurred long after the other symptoms were present, the patients came very late after the symptoms occurred, 25% of them several years after the occurrence of the first symptoms. Reflex pain occurring in 57% patients is the reason why the patients resorted to various specialists before coming to us, for example, reflex pain in the ear occurred in 41% cases.
Clicking of the joint occurred in 57% patients, and was mostly reciprocal, in 81% cases, while other cases of clicking were less frequent. The result shows that 43% of the patients have internal derangement of the joint. Masticatory muscle pain occurs in 47% of the patients, mostly in the lateral pterygoid muscle - in 32% cases. The frequency of symptoms and clinical signs of the temporomandibular joint painful dysfunction in our patients corresponds to the frequency of symptoms and sings determined by numerous studies in different populations in the world. The symptoms and clinical signs are more frequent in women, but there is no plausible explanation for this. Crepitation in the temporomandibular joint occurred in 8% patients. Acute inflammation of the temporomandibular joint, arthritis, was diagnosed in 1% of the patients.
Radiologically visible changes in the temporomandibular joint were seen in 19% patients, but bone structure damage of the temporomandibular joint was registered in 11% patients only. The research has shown insufficient radiological diagnostics in this part of the country. In the future, radiological diagnostics should be developed by introducing routine tomography and arthrography of the temporomandibular joint, together with CT and MR when necessary. The results, including the patients age, frequency of clicking, pain in the masticatory muscles, frequency of crepitation, and radiologically visible changes in the joint, show dysfunctional disorders in 90% of the patients, while organic disease of the temporomandibular joint occurs in 10% of the patients.
A comparison of the results has shown:Prosthetic replacements influencing vertical occlusal dimension considerably influence the occurrence of pain in the masticatory muscles,but do not considerably affect the internal derangement of the temporomandibular joint.Restricted mouth opening,up to 40 mm interincisal distance,is more influenced by pain in the masticatory muscles than the internal derangement of the temporomandibular joint.There does not seem to be any direct connection between the dental status and the occurrence of the temporomandibular joint painful dysfunction.In order to precisely register the state of the joint and follow up the changes in the temporomandibular joint,it is recommended to abolish the term "temporomandibular joint pain dysfunction syndrome"in favour of precise definitions for each state of the temporomandibular joint
Doktor medicinskih znanosti - stomatologija
mentor: Goran Knežević; Komisija za ocjenu: Pavel Kobler, Mišo Virag, Goran Knežević; Komisija za obranu: Pavel Kobler, Mišo Virag, Goran Knežević; datum obrane: 13.07.1995.; datum promocije: 16.02.1996.
Sveučilište u Zagrebu, Stomatološki fakultet, Zagreb, 1995
Bibliografija: str. 112-129
Summary
Keywords: Čeljusni zglob -- Etiologija boli